Health - Vital Signs: Patterns: For Heart Risk, No Telltale Body Shape

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• Vital Signs: Patterns: For Heart Risk, No Telltale Body Shape
• National Briefing | Health: American Life Span Edges Longer
• Insurer to Forgo Rate Rise
• The Big Picture: Hoping to Avoid the Knife
• Skin Deep: Warmed-Over Atkins? Don’t Tell the French
• Well: Time to Focus on Sad Dads
• Well: What Makes a Hospital Great
• The New Old Age: The Curtain Rises on the Class Act
• Prescriptions: California Insurer Retreats on Raising Rates
• Recipes for Health: Spinach and Goat Cheese Quesadillas
• With Quest to Cool Fuel Rods Stumbling, U.S. Sees ‘Weeks’ of Struggle

Vital Signs: Patterns: For Heart Risk, No Telltale Body Shape Posted: 16 Mar 2011 10:13 PM PDT A major new analysis challenges the long-held idea that obese people who carry their extra weight mainly around the middle — those with an “apple” shape — are at greater risk for heart disease than “pears,” whose fat tends to cluster on their thighs and buttocks. Related More Vital Signs Columns The new report, published online on Friday in The Lancet, pooled data from 58 studies about more than 220,000 people, with a mean age of 58. During the time they were followed, more than 14,000 suffered a heart attack or stroke. Conventional risk factors like blood pressure, cholesterol, diabetes and smoking were accurate predictors of a heart attack or stroke, but additional information about weight or body shape (ascertained by measuring waist circumference or waist-to-hip ratio) did not improve the ability to predict risk. “Whatever your shape is doesn’t really matter,” said Dr. Emanuele Di Angelantonio, a lecturer at the University of Cambridge and a member of the Emerging Risk Factors Collaboration, which carried out the study. He emphasized that being overweight or obese is one of the main modifiable risk factors for cardiovascular disease, and is often an early sign of future risk. But he said, “Whatever form of obesity or overweight you have is all the same.”

National Briefing | Health: American Life Span Edges Longer Posted: 16 Mar 2011 11:40 PM PDT Life expectancy in the United States has hit another high, rising above 78 years. The estimate of 78 years 2 months is for a baby born in 2009, and comes from a preliminary report released by the Centers for Disease Control and Prevention. Experts do not believe there is one simple explanation for the increase, but better medical treatment, vaccination campaigns and public health measures against smoking are believed to be having an impact. The infant mortality rate hit a record low of 6.42 deaths per 1,000 live births, a drop of nearly 3 percent from 2008. Male life expectancy is roughly 75.5; for females, it is about 80.5.

Insurer to Forgo Rate Rise Posted: 16 Mar 2011 10:03 PM PDT Blue Shield of California, a nonprofit insurer, on Wednesday withdrew its request to seek higher rates this year for individual policies amid stiff criticism from regulators and consumers. Add to Portfolio Citigroup Inc Go to your Portfolio » Some people would have experienced rate increases as high as 87 percent if Blue Shield had gone ahead with all of its planned increases. Blue Shield’s retreat echoed moves last year by WellPoint, the large commercial insurer whose proposed premium increases were met with stiff resistance that spread across the country and even evoked denunciations from President Obama. In making its announcement, Blue Shield emphasized its role as a nonprofit organization in seeking to provide insurance to as many people as possible. “By agreeing not to raise rates this year, we are helping to make coverage more affordable for our members during tough economic times,” said Bruce Bodaken, Blue Shield’s chairman and chief executive, in a statement. But the reversal could also make it more difficult for other insurers in California, as well as other states, to raise premiums sharply, according to some analysts and advocates, even if companies offer evidence that justifies the increases because of the higher cost of providing medical care to their customers. Under the one-year-old federal health care law, state regulators are required to play closer attention to what insurers are charging for policies, and some advocates say the reversal is early proof that the law will help keep premiums reasonable. “What it shows is that scrutiny matters,” said Anthony Wright, the executive director of Health Access California, a consumer advocacy group that is in favor of greater oversight of the health insurers. Blue Shield, however, asserted that an independent review of the proposed increases supported the higher rates. Like other insurers in the state, Blue Shield says it loses money on selling individual coverage. It estimated its decision to keep premiums steady would save policy holders $35 million to $40 million this year, although some customers will still see an increase in their rates. The company acknowledged that it abandoned its quest for higher rates after encountering such fierce opposition. “We were very frustrated by the negative attention we were getting,” said Tom Epstein, a spokesman for the insurer, which has been a vocal proponent of many of the changes required by the federal health care law. The law will succeed only if people can afford to buy coverage under the new system, he said. Blue Shield’s decision also illustrates how the insurers are able to absorb the losses associated with selling individual coverage because they are generating profits in other markets, like selling coverage for employers. “It’s a reflection of how well Blue Shield and the industry are doing in their overall business,” said Carl McDonald, an industry analyst for Citigroup. The question is whether state regulators reviewing the rate requests by other insurers will look beyond the economics of selling individual coverage to determine whether to approve sharp increases. In Connecticut, for example, WellPoint had sought a double-digit increase but was rebuffed by state regulators. Still, the fact that Blue Shield initially asked for higher rates may make other increases more palatable, according to Roger Collier, an industry consultant. “If Blue Shield had simply not raised rates or requested a small increase, that would have made life difficult for everyone else,” he said. While both state and federal regulators praised the insurer’s decision, they also signaled that they continued to favor heavy oversight of the rates insurers can charge. The federal law allows review of proposed rates, but only some states have gone further to give regulators the authority to deny any increases they view as excessive or unreasonable. California, for example, is currently weighing proposed legislation to expand regulators’ powers. Blue Shield’s decision, which was made while California regulators were still reviewing its proposal, “is very welcome news,” said Dave Jones, the state insurance commissioner, “but it underscores the need here in California to give the insurance commissioner the authority to reject excessive rate hikes.” While Blue Shield had agreed to his request to delay the increases, insurers can go ahead and raise rates, regardless of whether they are justified. “At the end of the day the health insurers hold all of the cards. They get to decide,” he said. Secretary Kathleen Sebelius of the Department of Health and Human Services also emphasized the need for states to grant their regulators the power to deny rate requests, in a statement responding to Blue Shield’s announcement. “We believe that insurance commissioners should have rate approval authority and will continue to support states’ efforts to review premium increases and protect consumers,” she said.

The Big Picture: Hoping to Avoid the Knife Posted: 16 Mar 2011 10:03 PM PDT In November, the prestigious Cleveland Clinic hailed a “scar-less” weight-loss surgery as one of the top 10 medical innovations expected this year. Enlarge This Image G.I. Dynamics G.I. Dynamics of Lexington, Mass. has approval in Europe for the EndoBarrier, which mimics part of bypass surgery. Even the devices approved in Europe are several years from the market in the United States. More Photos » The Big Picture Elusive Remedies Articles in this series are examining the campaigns and research efforts to combat obesity. Multimedia Slide Show Fat Monkeys Related Diet Plan With Hormone Has Fans and Skeptics (March 8, 2011) Today’s Lab Rats of Obesity: Furry Couch Potatoes (February 20, 2011) F.D.A. Approves Band Device for Less Obese (February 17, 2011) Panel Votes to Expand Surgery for Less Obese (December 4, 2010) Patient Money: After Surgery to Slim Down, the Bills Can Pile Up (January 1, 2011) Abbott Labs Withdraws Meridia From the Market (October 9, 2010) F.D.A. Declines to Approve Diet Drug (February 2, 2011) Enlarge This Image IntraPace A gastric pacemaker from IntraPace delivers electrical pulses said to create a feeling of fullness. More Photos » Developed by a company aptly called Satiety Inc., the procedure shrinks the stomach by using a stapler inserted through the mouth, rather than by cutting open a person’s belly. But when the results of a clinical trial came in, the procedure resulted in the shedding of far fewer pounds for patients than the company had hoped. Venture capitalists who had invested $86 million in Satiety over a decade shut the company down. The failure of the procedure, called transoral gastroplasty, pushes back the availability of any incision-less procedure to millions of obese Americans for several years, a disappointment to companies trying to find the next best thing to major surgery. The setback also further restricts options for those who are overweight, because it is occurring on top of federal rejections of a new generation of diet pills. These defeats are not for lack of effort. Entrepreneurs are developing all manner of odd and ingenious ideas aimed at replacing bariatric surgery. These include a pill taken before meals that would swell up in the stomach, pacemakers that deliver jolts of electricity to the stomach wall, and tubes that line the inside of the small intestine, letting food slide through without being absorbed. Device makers hope that by going in through the mouth using an endoscope, they can eliminate the infection risk from incisions, and possibly the need for general anesthesia, thereby lowering the current $12,000 to $30,000 cost for bariatric surgery. If weight loss could be made less forbidding and less expensive, many more people might undergo such procedures, including people who are less than severely obese. Even though more than 20 million Americans are heavy enough to qualify for bariatric surgery, only about 200,000 have the operation each year. “There’s definitely a need for something for the other 99 percent,” said Hugh Narciso, chief executive of Baronova, whose experimental device slows the movement of food out of the stomach. But bringing a device to market can be difficult. The digestive tract, with all its acids and movements, is an inhospitable place for a medical device. Bariatric surgery, meanwhile, has become safer because it is now done through tiny incisions. Just recently, the Food and Drug Administration lowered the weight requirement for Allergan’s Lap-Band, making more than 26 million additional people eligible to have it implanted. Other companies besides Satiety have had problems. Leptos Biomedical went out of business last year. Industry executives say that ReShape Medical has cut many workers; company executives and directors did not return calls. Gastric pacemakers from EnteroMedics and Transneuronix failed in clinical trials. The Transneuronix failure occurred only months after the company was acquired by the device giant Medtronic for $269 million. “Right now, it doesn’t look like anything is on the horizon that will replace surgery,” said Dr. Ninh Nguyen, chief of gastrointestinal surgery at the University of California, Irvine. There are two main types of surgery. The gastric bypass, which restricts the stomach and bypasses part of the small intestine, can cause people to lose as much as 80 percent of their excess weight. In many cases it can also quickly resolve diabetes, a frequent companion disease to obesity. Gastric banding, like the Lap-Band, involves putting an inflatable ring around the stomach to restrict food intake. It is less complicated than bypass, with a fatality rate during surgery of about one in 1,000, or about one-third that of bypass. But banding does not result in weight loss as significant as that of bypass, and carries potential complications after surgery. A third approach, sleeve gastrectomy, is starting to gain popularity. The procedure involves stapling the stomach into a narrow tube so that less food can be ingested. The excess part of the stomach is then cut out. A potential improvement on sleeve gastrectomy is gastric imbrication or plication. The stomach is narrowed by folding and sewing it in place, much like the pleating used to narrow a pair of pants. Those tucks eliminate the need to remove the excess stomach. Still, entrepreneurs hope that devices through the mouth will be safer and cheaper. Perhaps the simplest idea is a balloon inserted through the mouth and inflated in the stomach, creating a sense of fullness. Allergan and some other companies sell balloons in Europe, where rules for device approval are easier. But balloons lose their effectiveness over time, because the stomach expands to accommodate them. And there are risks. A balloon used in the 1980s in the United States caused complications, including potentially fatal blockages, when it accidentally deflated and traveled into the small intestine. Spatz FGIA of Jericho, N.Y., is developing an adjustable balloon that can be inflated further after the stomach has expanded, providing another jolt of weight loss. It also has an anchor to keep the balloon in the stomach should it deflate. Gelesis, a start-up in Boston, is testing a capsule that would be swallowed before meals. The capsule contains particles that swell to hundreds of times their size in the stomach by absorbing water, then eventually shrink and are excreted. In a demonstration, a spoonful of the particles was put into a glass of water. A few minutes later, the glass was filled with a heavy slush. One big challenge for this idea is that someone anticipating a delicious feast might simply skip the pill. HourGlass Technologies of Redwood City, Calif. is trying to mimic banding from within. Instead of clamping a ring around the outside of the stomach, it inserts a device through the mouth that sucks in the stomach and clamps it in place. GI Dynamics of Lexington, Mass., has approval in Europe for the EndoBarrier, which mimics part of bypass surgery. It is a tube, inserted through the mouth, that lines the inside of the small intestine. Food going through the intestine cannot pass through the intestinal wall. 1 2 Next Page »

Skin Deep: Warmed-Over Atkins? Don’t Tell the French Posted: 17 Mar 2011 12:00 AM PDT PARIS Enlarge This Image Ed Alcock for The New York Times Chloe Château, a Paris researcher on the Dukan diet. Well Share your thoughts on this column at the Well blog. Go to Well » Related Beauty Spots (March 17, 2011) Enlarge This Image Pool photo by Stefan Rousseau Among the media-labeled Dukannistes: Carole Middleton, Kate's mom. 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 Dukan diet book 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 via Facebook and Twitter, 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 of carbohydrates a 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 at Harvard University’s School of Public Health and chairman of the American Heart Association Nutrition 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. 1 2 Next Page »

Well: Time to Focus on Sad Dads Posted: 17 Mar 2011 12:47 PM PDT

Well: What Makes a Hospital Great Posted: 17 Mar 2011 03:00 AM PDT

The New Old Age: The Curtain Rises on the Class Act Posted: 17 Mar 2011 08:22 AM PDT

Prescriptions: California Insurer Retreats on Raising Rates Posted: 16 Mar 2011 01:11 PM PDT

Recipes for Health: Spinach and Goat Cheese Quesadillas Posted: 15 Mar 2011 09:00 AM PDT Many types of greens would be delicious in these quesadillas. Spinach is the quickest to wilt and the easiest to find. Recipes for Health Martha Rose Shulman presents food that is vibrant and light, full of nutrients but by no means ascetic, fun to cook and to eat. See All Recipes for Health » Visit Recipes for Health on Facebook. Related Recipes for Health: Fast Food for Harried Days (March 14, 2011) Recipes for Health: Broccoli and Red Onion Quesadillas (March 15, 2011) Recipes for Health: Black Bean and Goat Cheese Quesadillas (March 16, 2011) Recipes for Health: Mushroom Quesadillas (March 17, 2011) 1 6-ounce bag baby spinach or 1 bunch spinach, stemmed 1 tablespoon extra virgin olive oil 1 to 2 garlic cloves (to taste), minced Salt and freshly ground pepper 4 corn tortillas 2 ounces goat cheese, crumbled (1/2 cup) 1. Wash the spinach but do not dry. If using bunch spinach, chop coarsely. Heat the olive oil over medium heat in a large, heavy frying pan. Add the garlic. Cook until fragrant, about 30 seconds, then stir in the spinach. Raise the heat, and stir just until the spinach wilts. Remove from the heat. Press down on the spinach with the back of your spoon, and drain off any water in the pan. Season to taste with salt and pepper. 2. In a microwave: Place a corn tortilla on a plate. Top with half the spinach, and spread in an even layer. Sprinkle on half the cheese, and top with another tortilla. Press down gently, then microwave for 1 to 1 1/2 minutes, until the cheese has melted. Remove from the microwave, cut into quarters or sixths, and serve. Repeat with the remaining ingredients. In a pan: Place a corn tortilla in the pan. Top with half the spinach, and spread in an even layer. Sprinkle on half the cheese. Turn the heat to medium-high, and heat until the cheese begins to melt. Place another tortilla on top of the cheese, and press down lightly. Flip the quesadilla over in the pan, and heat for about 30 seconds or until the cheese has melted. Flip back over, and remove to a plate. Cut into quarters or sixths, and serve. Repeat with the remaining ingredients. Yield: Two quesadillas. Advance preparation: The cooked spinach will keep for a couple of days in the refrigerator. Reheat gently before assembling the quesadillas. Nutritional information (per quesadilla): 272 calories; 8 grams saturated fat; 1 gram polyunsaturated fat; 7 grams monounsaturated fat; 30 milligrams cholesterol; 17 grams carbohydrates; 3 grams dietary fiber; 211 milligrams sodium (does not include salt to taste); 13 grams protein Martha Rose Shulman is the author of "The Very Best of Recipes for Health."

With Quest to Cool Fuel Rods Stumbling, U.S. Sees ‘Weeks’ of Struggle Posted: 17 Mar 2011 01:04 PM PDT TOKYO — Amid widening alarm in the United States and elsewhere about Japan’s nuclear crisis, military fire trucks began spraying cooling water on spent fuel rods at the country’s stricken nuclear power station late Thursday after earlier efforts to cool the rods failed, Japanese officials said. Multimedia Interactive Feature Evacuation Zone around Nuclear Plant TimesCast | Inside a Nuclear Reactor TimesCast | Inside a Nuclear Reactor Close Video See More Videos » Interactive Feature Status of the Nuclear Reactors at the Fukushima Daiichi Power Plant Interactive Feature How a Reactor Shuts Down and What Happens in a Meltdown Photographs The Aftermath in Japan Photographs High Radiation Hinders Emergency Work to Cool Nuclear Plant Interactive Feature: Video: Japan’s Natural and Nuclear Disasters Related News Analysis: Dearth of Candor From Japan’s Leadership (March 17, 2011) Scientists Project Path of Radiation Plume (March 17, 2011) Nuclear Agency Tells a Concerned Congress That U.S. Industry Remains Safe (March 17, 2011) Misery and Uncertainty Fill Up Shelters (March 17, 2011) Crews Scour Tsunami Zone for Victims (March 17, 2011) The Lede Blog: Japan Earthquake and Tsunami: How to Help (March 11, 2011) Times Topic: Japan â€" Earthquake and Tsunami (2011) Related in Opinion Room For Debate: What Aid Makes Sense for Japan? Room for Debate: Japan's Nuclear Crisis: Lessons for the U.S. Enlarge This Image Asahi Shimbun, via Reuters A woman was screened for radiation on Wednesday after being evacuated from an area near the Fukushima Daiichi nuclear plant. More Photos » The United States’ top nuclear official followed up his bleak appraisal of the grave situation at the plant the day before with a caution that it would “take some time, possibly weeks,” to resolve. The developments came as the authorities reached for ever more desperate and unconventional methods to cool damaged reactors, deploying helicopters and water cannons in a race to prevent perilous overheating in the spent rods of the No. 3 reactor. Moments before the military trucks began spraying, police officers in water cannon trucks were forced back by high levels of radiation in the same area. The police had been trying to get within 50 yards of the reactor, one of six at the plant. The five specially fitted military trucks sprayed water for about an hour, but the full impact of the tactic was not immediately clear. The Japanese efforts focused on a different part of the Fukushima Daiichi Nuclear Power Station, 140 miles northeast of here, from the reactor — No. 4 — depicted in Washington on Wednesday as presenting a far bleaker threat than the Japanese government had offered. The decision to focus on the No. 3 reactor appeared to suggest that Japanese officials believe it is a greater threat, since it is the only one at the site loaded with a mixed fuel known as mox, for mixed oxide, which includes reclaimed plutonium. Western nuclear engineers have said that the release of mox into the atmosphere would produce a more dangerous radioactive plume than the dispersal of uranium fuel rods at the site. The Japanese authorities also expressed concern on Wednesday that the pressure in the No. 3 reactor had plunged and that either gauges were malfunctioning or a rupture had already occurred. After the military’s effort to cool the spent fuel atop the reactor with fire trucks, Hidehiko Nishiyama, deputy director-general of the Nuclear and Industrial Safety Agency, said it was too early to assess the success of the attempt. Mr. Nishiyama also said that radiation of about 250 millisievert an hour had been detected 100 feet above the plant. In the United States the limit for police officers, firefighters and other emergency workers engaged in life-saving activity as a once-in-a-lifetime exposure is equal to being exposed to 250 millisieverts for a full hour. The radiation figures provided by the Japanese Self-Defense Force may provide an indication of why a helicopter turned back on Wednesday from an attempt to dump cold water on a storage pool at the plant. A White House statement late Wednesday said that President Obama had “briefed Prime Minister Kan on the additional support being provided by the U.S., including specialized military assets with expertise in nuclear response and consequence management.” On Thursday a Pentagon spokesman, Col. David Lapan, said the military expertise made available to the Japanese included a nine-person assessment team that has or will shortly arrive there to work with the Japanese military and government. The team members, Colonel Lapan said, will then recommend whether additional American military forces are needed to assist in the effort. The American military is also gathering information on the damaged nuclear power plant. Officials said that a Global Hawk drone was flying missions over the reactor. In addition, U-2 spy planes were providing images to help the Japanese government map out its response to the quake and tsunami. Earlier Thursday Japanese military forces tried to dump seawater from a helicopter on Reactor No. 3, making four passes and dropping a total of about 8,000 gallons as a plume of white smoke billowed. The Japanese government said that the reactor typically needs 50 tons of water, or about 12,000 gallons, a day to keep from overheating. 1 2 3 Next Page » Norimitsu Onishi reported from Tokyo, and David E. Sanger and Matthew L. Wald from Washington. Keith Bradsher contributed reporting from Hong Kong, Hiroko Tabuchi from Tokyo, Alan Cowell from London, and Thom Shanker from Washington.

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