Weight-loss regimen a preferred choice for countering diabetes

After all those well-intentioned New Year's resolutions have yielded to the force of habit, many of the nation's 79 million obese adults will have a day of reckoning with their primary care physicians.

Lose weight and get active, the doctor will order, or risk developing diabetes. Then the MD will scribble a prescription.

For most patients, the prescribed treatment will not be a pill. It will be a 12-week program aimed at preventing Type 2 diabetes by getting obese adults to shed as little as 10 pounds and exercise for a little more than 20 minutes a day.

That regimen — the Diabetes Prevention Program — may soon become the blockbuster prescription medicine you've never heard of. In 2013, it is poised to become the envy of pharmaceutical companies, a new rival to programs such as Weight Watchers, and a target of opportunity for healthcare entrepreneurs.

Led by a trained coach, it is a testament to the power of a mentor and of setting modest goals in spurring healthful behavior. And it may be a crucial first test of the Affordable Care Act's focus on preventive health.

In nearly 30 clinical trials, scientists have established that the program is far more effective at helping people lose weight and prevent or delay the onset of diabetes than "usual care" — essentially, a doctor telling a patient to slim down and get active, and then sending him on his way. But the program hasn't been packaged in a form that healthcare providers can simply and cheaply offer to patients, said Dr. Jun Ma of the Palo Alto Medical Foundation Research Institute, who studies diabetes prevention.

The Diabetes Prevention Program is not rocket science. In 12 weekly sessions, a coach teaches obese subjects at high risk of developing diabetes to set goals for losing 5% to 7% of their body weight, limit the fat and calories they consume, track their food intake, get at least 150 minutes of exercise each week, and devise strategies to avoid gaining back lost pounds.

In trials, subjects who attended the tightly scripted sessions and followed the regimen were far more likely than those who were on their own to reach their weight-loss goals in three months — and to keep that weight off for more than a year. By doing so, they drove down their risk of developing Type 2 diabetes by 58%, according to a landmark report published in the New England Journal of Medicine in 2002.

The program, in short, is powerful medicine.

"If you could take it as a pill, it would definitely be commercialized," said Sean Duffy, a software designer and former Google employee who launched an online version of the program about a month ago.

In June, a panel of physicians and public health experts that advises the Department of Health and Human Services gave the program a mighty push into everyday medical practice. The U.S. Preventive Services Task Force recommended that doctors refer their obese patients to "intensive, multicomponent behavioral interventions" designed to promote weight loss and physical activity. It cited only one that met its strict standards: the Diabetes Prevention Program.

Under the Affordable Care Act, that carries significant weight. Starting in June, most health insurers will be required to make proven weight-loss and behavior-modification programs available without a copayment to obese customers with a doctor's referral.

No one knows whether expanded coverage of such programs can save money and head off a public health disaster. But without it, experts believe a tidal wave of Type 2 diabetes and heart disease — with a 20-year price tag estimated at $550 billion in the U.S. alone — is a virtual certainty.

For all its promise, the program has remained little more than a good idea — and a pretty expensive one at that — for years. The researchers who developed it at the University of Indiana pegged the cost of the trial's intensive 12-week phase and nine months of maintenance at about $1,300 per patient. To make it cheaper and more accessible, they trained a few YMCA chapters to deliver the program.

Today, about 75 chapters in 28 states and the District of Columbia offer it. The Centers for Disease Control and Prevention, which has been charged with broadening access to "lifestyle change" programs, disbursed $6.75 million in 2012 to encourage health insurers, public health advocates and employer groups to offer versions of the program.

But with more than 78 million people potentially in line to get it, demand far outstrips supply.

Researchers like Ma have been working on ways to use technology to make the program more widely available. In a study published last month in the Archives of Internal Medicine, she and her colleagues found that putting the 12-week curriculum on an inexpensive DVD and assigning a coach to answer questions and offer support helped 37% of obese participants lose 7% of their body weight — a rate more than twice as high as for those who got no help at all.

In a related study published in the same journal, researchers gave obese volunteers a personal digital device to monitor their weight, diet and physical activity and had them check in with a coach every other week. The volunteers lost more weight than trial subjects who were on their own.

The UnitedHealth Group's Diabetes Prevention and Control Alliance in Minnetonka, Minn., has worked to make the Diabetes Prevention Program available on demand to Comcast cable subscribers nationwide. UnitedHealth Group physicians and public health specialists worked with a TV production crew to create a reality-show version of the program. After the pilot aired last year in Philadelphia and Knoxville, Tenn., it took just three weeks to get 700 people to volunteer for a clinical trial of the TV-based program. The results of that will be published soon, said Dr. Deneen Vojta, chief clinical officer for the UnitedHealth program.

"These people lost a ton of weight," she said.

The growing scientific consensus around the diabetes program has not been lost on one of the nation's most ubiquitous and respected weight-loss programs, Weight Watchers. With 20,000 meetings a week across the United States, Weight Watchers International has the infrastructure that the Diabetes Prevention Program lacks. Like the diabetes program, its groups are run by coaches who give advice and encouragement and teach members to track their intake. The company has steadily added features — most recently a spate of food-tracking apps — as clinical trials showed their value.

Weight Watchers has been lobbying the government to recognize its programs as an effective tool for diabetes prevention. The stakes are huge: If insurers were required to cover the costs of patients' Weight Watchers memberships, the customer base could expand by leaps and bounds.

In Britain, the National Health Service will pay for the company's initial 12-week course, said David Kirchhoff, chief executive of Weight Watchers International in New York City. Given the program's widespread presence in the U.S. and evidence of its effectiveness in clinical trials, it makes sense for insurers here to pay too, he said.

Entrepreneurs are also getting in on the act. Duffy's San Francisco-based startup, Omada Health, launched an online version of the Diabetes Prevention Program called Prevent that may be the first of many digital spinoffs.

Designed to win the CDC's seal of approval, Prevent resembles a Facebook version of the Diabetes Prevention Program while preserving the privacy of customers who prefer it. Incoming members are matched to a group, and everyone works toward a goal of losing 5% to 7% of their body weight in 12 weeks under the supervision of a coach. Members' weights are transmitted to the coach by a digital scale upon enrollment and weekly thereafter.

Early testing has shown that as groups jell, members learn from — and lean on — one another, Duffy said. He plans to sell the program at about $120 per month for four months, primarily to insurers and companies for use by their customers and employees.

Payment will be due only after users show results, he said.

melissa.healy@latimes.com

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European businesses slow to go online: study

BRUSSELS (Reuters) – European businesses are not doing enough to use the internet to grow their customer base and promote products, Belgian database and marketing firm Email-Brokers said after studying 13 million websites.

Belgium, Germany and the Netherlands have the highest proportion of companies online but even in these countries 40 percent of business have no internet presence, it found.

The European Commission has estimated that companies which exploit the full potential of the internet create, on average, more than twice as many jobs.

“It is one of the ways to create employment and economic growth and it is not Star Trek, it exists today,” Email-Brokers head William Vande Wiele said.

Britain and Liechtenstein were the most advanced in terms of e-commerce – defined as being able to process orders and payments, with 16 percent and 17 percent, respectively, of business sites offering it, compared with 6 percent in Belgium and 9 percent in Austria, Germany and the Netherlands.

Vande Wiele said many corporate websites were badly designed, and did not provide basics such as adequate contact information or company details.

In Belgium, 91 percent of all corporate websites did not meet such basic standards, compared with about 20 percent in Luxembourg and France, the study concluded.

“Sites which do not comply with such minimum standards do not inspire confidence and before buying something online a user will need a minimum level of confidence,” Vande Wiele said.

Many websites are not kept up to date, the study also found, with more than 80 percent of business sites in Belgium, Greece, Italy and Spain not updated for more than a year.

(Reporting by Robert-Jan Bartunek; Editing by Dan Lalor)

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Beyonce, Clarkson to perform at Obama inauguration

WASHINGTON (AP) — Beyonce will sing the national anthem at President Barack Obama's inauguration ceremony.

The committee planning the Jan. 21 event also announced Wednesday that Kelly Clarkson will perform "My Country 'Tis of Thee" and James Taylor will sing "America the Beautiful" at the swearing-in ceremony on the Capitol's west front.

Richard Blanco, the son of Cuban exiles, is the 2013 inaugural poet, joining the ranks of Maya Angelou and Robert Frost to have served in that capacity. Blanco's works explore his family's exile from their native country and "the intersection of his cultural identities as a Cuban-American gay man," the inaugural planners announced.

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Gaps Seen in Therapy for Suicidal Teenagers

Most adolescents who plan or attempt suicide have already received at least some mental health treatment, raising questions about the effectiveness of current approaches to helping troubled youths, according to the largest in-depth analysis to date of suicidal behaviors in American teenagers.

The study, in the journal JAMA Psychiatry, found that 55 percent of suicidal teenagers had received some therapy before they thought about suicide, planned it or tried to kill themselves, contradicting the widely held belief that suicide is due in part to a lack of access to treatment.

The findings, based on interviews with a nationwide sample of more than 6,000 teenagers and at least one parent of each, linked suicidal behavior to complex combinations of mood disorders like depression and behavior problems like attention-deficit and eating disorders, as well as alcohol and drug abuse.

The study found that about one in eight teenagers had persistent suicidal thoughts at some point, and that about a third of those who had suicidal thoughts had made an attempt, usually within a year of having the idea.

Previous studies have had similar findings, based on smaller, regional samples. But the new study is the first to suggest, in a large nationwide sample, that access to treatment does not make a big difference.

The study suggests that effective treatment for severely suicidal teenagers must address not just mood disorders, but also behavior problems that can lead to impulsive acts, experts said. According to the Centers for Disease Control and Prevention, 1,386 people between the ages of 13 and 18 committed suicide in 2010, the latest year for which numbers are available.

“I think one of the take-aways here is that treatment for depression may be necessary but not sufficient to prevent kids from attempting suicide,” said Dr. David Brent, a professor of psychiatry at the University of Pittsburgh, who was not involved in the study. “We simply do not have empirically validated treatments for recurrent suicidal behavior.”

The report said nothing about whether the therapies given were state of the art or carefully done, said Matt Nock, a professor of psychology at Harvard and the lead author, and it is possible that some of the treatments prevented suicide attempts. “But it’s telling us we’ve got a long way to go to do this right,” Dr. Nock said. His co-authors included Ronald C. Kessler of Harvard and researchers from Boston University and Children’s Hospital Boston.

Margaret McConnell, a consultant in Alexandria, Va., said her daughter Alice, who killed herself in 2006 at the age of 17, was getting treatment at the time. “I think there might have been some carelessness in the way the treatment was done,” Ms. McConnell said, “and I was trusting a 17-year-old to manage her own medication. We found out after we lost her that she wasn’t taking it regularly.”

In the study, researchers surveyed 6,483 adolescents from the ages of 13 to 18 and found that 9 percent of male teenagers and 15 percent of female teenagers experienced some stretch of having persistent suicidal thoughts. Among girls, 5 percent made suicide plans and 6 percent made at least one attempt (some were unplanned).

Among boys, 3 percent made plans and 2 percent carried out attempts, which tended to be more lethal than girls’ attempts.

(Suicidal thinking or behavior was virtually unheard-of before age 10.)

Over all, about one-third of teenagers with persistent suicidal thoughts went on to make an attempt to take their own lives.

Almost all of the suicidal adolescents in the study qualified for some psychiatric diagnosis, whether depression, phobias or generalized anxiety disorder. Those with an added behavior problem — attention-deficit disorder, substance abuse, explosive anger — were more likely to act on thoughts of self-harm, the study found.

Doctors have tested a range of therapies to prevent or reduce recurrent suicidal behaviors, with mixed success. Medications can ease depression, but in some cases they can increase suicidal thinking. Talk therapy can contain some behavior problems, but not all.

One approach, called dialectical behavior therapy, has proved effective in reducing hospitalizations and suicide attempts in, among others, people with borderline personality disorder, who are highly prone to self-harm.

But suicidal teenagers who have a mixture of mood and behavior issues are difficult to reach. In one 2011 study, researchers at George Mason University reduced suicide attempts, hospitalizations, drinking and drug use among suicidal adolescent substance abusers. The study found that a combination of intensive treatments — talk therapy for mood problems, family-based therapy for behavior issues and patient-led reduction in drug use — was more effective than regular therapies.

“But that’s just one study, and it’s small,” said Dr. Brent of the University of Pittsburgh. “We can treat components of the overall problem, but that’s about all.”

Ms. McConnell said that her daughter’s depression had seemed mild and that there was no warning that she would take her life. “I think therapy does help a lot of people, if it’s handled right,” she said.

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Nissan Adding Cheaper Leaf as U.S. Battery Car Assembly Begins

Nissan Motor Co., the world’s largest seller of electric vehicles, said it’s adding a lower-priced version of the rechargeable Leaf as production of the car begins in Tennessee.

For 2013 the company adds an entry level S grade Leaf that’s cheaper than the SV and SL models sold in the U.S. since late 2010, Nissan said in a statement today, without providing prices. All 2013 Leaf models have improved electric range, and recharge time for SV and SL grades falls to four hours from a 220-volt outlet from about seven hours currently, Nissan said.

“The refinements and enhancements for 2013 hit at the core of customer requests during Leaf’s first two years,” Al Castignetti, Nissan’s vice president of U.S. sales, said in the statement. Those include faster charger time, better range and optional leather seats and high-end audio systems, he said.

Nissan is trying to boost U.S. sales of the battery-powered hatchback that have so far fallen short of the company’s ambitions. Leaf deliveries to U.S. drivers grew 1.5 percent in 2012 to 9,819, less than half of Chief Executive Officer Carlos Ghosn’s 20,000-unit target.

U.S. production of the car has begun at Nissan’s Smyrna, Tennessee, plant. The Yokohama, Japan-based company late last year opened the largest lithium-ion battery plant in Smyrna, funded with a federal loan from the Obama administration worth as much as $1.4 billion.

Base prices for the 2012 SV and SL Leafs are $35,200 and $37,250, respectively, before a $7,500 federal tax credit. Nissan introduced a new Leaf to the Japanese market late last year that was priced 11 percent less than the previously cheapest one.

Range for the 2012 models averages 73 miles (117 km) per charge, according to the U.S. Environmental Protection Agency.

Pricing of the 2013 model Leafs is to be announced later, said Travis Parman, a company spokesman.

Nissan’s North American operations are based in Franklin, Tennessee.

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LAPD force exceeds 10,000 for the first time, officials say

For the first time in the city's history, Los Angeles' police force now exceeds 10,000 officers, city officials said Monday.

Appearing with LAPD Chief Charlie Beck to discuss the continued drop in crime last year, Mayor Antonio Villaraigosa said the department is budgeted for 10,023 officers, up from the 9,963 authorized over the last three years, during a deep budget crisis.

The staffing increase took effect Jan. 1, when 60 sworn officers moved into the LAPD from the General Services Department, which patrols parks, libraries and other municipal buildings, said Villaraigosa spokesman Peter Sanders. Those officers will continue to patrol city facilities, budget officials said.

Some questioned the significance of the staffing milestone, since the overall number of sworn officers employed by the city hasn't grown.

"It's an increase for show," said Kevin James, a candidate for mayor in the March 5 election who has questioned Villaraigosa's LAPD hiring goals. "The mayor really wanted to get to 10,000 one way or the other before he left office, and this was the way he could do it under the current budget constraints."

Los Angeles experienced a 10.5% decrease in gang crime and an 8.2% drop in violent crime last year, compared with 2011. The city had the lowest number of violent crimes per capita of any major city, including New York and Chicago, Villaraigosa said.

The mayor attributed those numbers — and a decade-long decline in crime — in large part to the expansion of the police force.

Villaraigosa originally promised to add 1,000 new officers to the department during the 2005 election campaign, criticizing then-Mayor James K. Hahn for failing to do so. Since then, he has succeeded in adding 800 officers, Sanders said. On Monday, Villaraigosa suggested that the addition of the final 200 will not be achieved until after June 30, when he leaves office.

"I would hope that the next mayor would, as we get out of this economic crisis, increase our Police Department to that 1,000," he said.

While Villaraigosa has been pushing for continued hiring at the LAPD, Beck has warned in recent weeks that the LAPD would lose 500 officers if voters fail to approve Proposition A, a half-cent sales tax measure on the March 5 ballot. That would represent more than half of the LAPD buildup accomplished by Villaraigosa.

Despite Beck's warnings, Villaraigosa said he is not ready to endorse Proposition A until the council makes a series of cost-cutting moves, such as turning over operation of the city zoo to a private entity.

Since Villaraigosa took office, homicides have decreased 38% and gang crime has dropped by a similar amount. The number of slayings has stayed largely the same over the last three years, with 297 homicides in 2010, 297 in 2011 and 298 last year. Overall crime dropped 1.4% last year. Property crimes, which are more numerous than violent crimes, increased for the first time in several years — driven in part by a 30% increase in cell phone thefts, officials said.

With little money to pay officers for overtime, the department has been compensating them with time off. The resulting staffing loss has been the equivalent of about 450 officers at any given time, according to department figures — a hit that has complicated crime-fighting strategies.

Preserving LAPD funding has become increasingly challenging for council members. For nine months they have debated whether to lay off dozens of civilian LAPD employees while continuing to hire enough police officers to maintain current staffing levels.

Councilman Paul Koretz, who opposed the layoffs, said the movement of the 60 building patrol officers to the LAPD was "a little smoke and mirrors." He questioned whether the LAPD buildup in the Villaraigosa era was financially sustainable.

"It just seems like we really never did the analysis to see if we could afford it," he said.

A defeat of the sales tax increase, which is projected to generate roughly $215 million in new revenue, would leave council members no choice but to roll back the size of the LAPD, Koretz said.

But Villaraigosa warned that would be dangerous, saying other California cities have seen upticks in crime after cutting back on officers.

"I know some people think that 10,000 cops is a magical illusion, a meaningless number, that more officers don't necessarily lead to a reduction in crime," said the mayor, adding: "Those critics talk a lot, but they're just plain wrong."

david.zahniser@latimes.com

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Conn. lawmaker apologizes over Facebook post

HARTFORD, Conn. (AP) — A Connecticut lawmaker has apologized after saying in a Facebook post that shooting victim and former Arizona U.S. Rep. Gabrielle Giffords should “stay out of my towns.”

Giffords last week visited Newtown, Conn., where a gunman killed 20 young children and six adults at an elementary school last month. The Democrat, who met with families of the victims, was critically wounded two years ago in a deadly mass shooting in Tucson, Ariz.

The Hartford Courant posted images Sunday showing Republican state Rep. DebraLee Hovey‘s Facebook comments. In one dated Friday she says, “Gabby Giffords stay out of my towns!!”

Hovey released a statement Monday saying her comments were insensitive and that she apologizes if she offended anyone.

Hovey had said in another post that the visit was political.

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'Downton,' 'Girls,' 'Idol' and more this January

NEW YORK (AP) — Where once the post-holiday schedule was a blizzard of chilly reruns, January is aburst with premieres and finales.

Already, the much-adored British miniseries "Downton Abbey" has made its much-awaited season return Sundays on PBS.

On IFC on Fridays, the hilarious "Portlandia" is back for its third season of sketch comedy poking fun at the peculiarities of Portland, Ore., starring Fred Armisen and Carrie Brownstein.

And NBC's mystery melodrama "Deception" has arrived on Mondays. Meagan Good stars as a detective going undercover at the home of a rich family with whom she was once friendly, to investigate a murder within the clan.

On Tuesday, PBS' "American Experience" begins a three-week documentary miniseries, "The Abolitionists," spotlighting Frederick Douglass, William Lloyd Garrison, Harriet Beecher Stowe, John Brown and Angelina Grimke.

Also on Tuesday, the FX drama "Justified" is returning for its fourth season of Kentucky hill-country crime-fighting led by Deputy U.S. Marshal Raylan Givens (series star Timothy Olyphant).

On Thursday, comedic action centers at the White House with the premiere of NBC's "1600 Penn." Josh Gad ("The Book of Mormon") stars as the goofball son of the incumbent U.S. president (played by Bill Pullman) who keeps the first family in a stir, yet manages to make everything turn out all right by the final fade-out.

The Gallaghers of "Shameless" are a much different family. In this dark comedy, William H. Macy stars as the boozy single father of a brood of kids who manage their ragtag Chicago homestead in spite of Dad's overindulgences. Also starring Emmy Rossum, it returns Jan. 13 for its third season on Showtime.

Also on Jan. 13, HBO's comedy "Girls" returns for a second season sure to be at least as ballyhooed, discussed and argued about as the first. Lena Dunham (who also writes, produces, directs and created the series) stars as one of a quartet of twentysomething gal pals in New York.

Right after "Girls," HBO launches the second season of "Enlightened," an affecting comedy starring Laura Dern as a confused New Age-y activist who's bent on changing the world.

What was Carrie Bradshaw like before Sarah Jessica Parker and "Sex and the City"? Find out on "The Carrie Diaries," which debuts on the CW on Jan. 14. AnnaSophia Robb stars as the high-school era Carrie in this likable prequel.

"American Idol" returns on Jan. 16 on Fox. Veteran judge Randy Jackson will be joined by Mariah Carey, Nicki Minaj and Keith Urban. Ryan Seacrest, as always, is the affable host.

After five seasons, Fox's lovably inscrutable sci-fi series "Fringe" concludes its head-scratching run on Jan. 18. Stars include Anna Torv, Joshua Jackson and John Noble.

Fox's bloody suspense drama "The Following" premieres Jan. 21. Kevin Bacon stars as a former FBI agent drafted back into service to chase a serial murderer and his vicious disciples.

My, how Spartacus' army has grown! Commanding thousands of freed slaves, Spartacus is primed to bring down the entire Roman Republic as the final season begins for "Spartacus: War of the Damned," Jan. 25 on Starz. Liam McIntyre plays the rebel leader.

The world of "Dallas" will be rocked during its second season with the death of arch-villain oilman J.R. Ewing (played, of course, by Larry Hagman, who passed away in November while the series was in production). Also starring Patrick Duffy and Linda Gray, this rebooted (so to speak) version of the long-running CBS prime-time soap returns on TNT on Jan. 28.

FX weighs in with an edgy new drama "The Americans" on Jan. 30. It stars Matthew Rhys and Keri Russell as two KGB agents posing as the heads of a normal American household in the 1980s, as they work tirelessly to bring down the U.S. on behalf of Mother Russia.

On Jan. 31, NBC unveils a new medical drama "Do No Harm." Steve Pasquale ("Rescue Me") stars as a neurosurgeon with a great bedside manner who inconveniently shares a body with his sociopathic alter ego.

The same night, NBC closes the book on the brilliant mockery of "30 Rock." This Tina Fey comedy wraps seven seasons of making fun of pop culture, modern life and especially its own real-life broadcast network — which, like the rest of the TV universe, has even more midseason goodies in store come February.

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EDITOR'S NOTE — Frazier Moore is a national television columnist for The Associated Press. He can be reached at fmoore(at)ap.org and at http://www.twitter.com/tvfrazier

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The New Old Age Blog: Who Should Receive Organ Transplants?

Joe Gammalo had been contending with pulmonary fibrosis, a scarring of the lungs, for more than a decade when he came to the Cleveland Clinic in 2008 seeking a lung transplant.

“It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told me in an interview. “I didn’t expect to live.”

Lung transplants are a dicey proposition, involving a huge surgical procedure, arduous follow-up, the lifelong use of potent immunosuppressive drugs and high rates of serious side effects. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the clinic’s lung transplant program.

Only 50 to 57 percent of all recipients live for five years, she noted, and they will still die of their disease. But there’s no other treatment for pulmonary fibrosis.

Some medical centers would have turned Mr. Gammalo away. Because survival rates are even lower for older patients, guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.

But “we are known as an aggressive, high-risk center,” said Dr. Budev. So Mr. Gammalo was 66 when he received a lung; his newly found buddy, Clyde Conn, who received the other lung from the same donor, was 69.

You can’t mistake the trend: A graying population and revised policies determining who gets priority for donated organs, have led to a rising proportion of older adults receiving transplants.

My colleague Judith Graham has reported on the increase in heart transplants, but the pattern extends to other organs, too.

The number of kidney transplants performed annually on adults over 65 tripled between 1998 and last year, according to data from the Scientific Registry of Transplant Recipients. In 2001, 7.4 percent of liver transplant recipients were over 65; last year, that rose to 13 percent.

The rise in elderly lung transplant candidates is particularly dramatic because, since 2005, a “lung allocation score” puts those at the highest mortality risk, rather than those who’ve waited longest, at the top of the list.

In 2001, about 3 percent of those on the wait list and of those transplanted were over 65; last year, older patients represented almost 18 percent of wait-listed candidates and more than a quarter of transplant recipients. (Medicare pays for the surgery, though patients face co-pays and considerable out-of-pocket costs, including for drugs and travel.)

The debate has grown, too: When the number of adults awaiting transplants keeps growing, but organ donations stay flat, is it desirable or even ethical that an increasing proportion of recipients are elderly?

Dr. Budev, who estimated that a third of her program’s patients are over 65, votes yes. As long as a program selects candidates carefully, “how can you deny them a therapy?” she asked. So the Cleveland Clinic has no age limit. “We feel that everyone should have a chance.”

At the University of Michigan, by contrast, the age limit remains 65, though Dr. Kevin Chan, the transplant program’s medical director, acknowledged that some fit older patients get transplanted.

“You can talk about this all day — it’s a tough one,” Dr. Chan said. Younger recipients have greater physiologic reserve to aid in the arduous recovery; older ones face higher risk of subsequent kidney failure, stroke, diabetes and other diseases, and, of course, their lifespans are shorter to begin with.

Donated lungs, fragile and prone to injury, are a particularly scarce commodity. Last year, surgeons performed 16,055 kidney transplants, 5,805 liver transplants and 1,949 heart transplants. Only1,830 patients received lung transplants.

“What if there’s a 35-year-old on a ventilator who needs the lung just as much?” Dr. Chan said. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” Yet, he acknowledged, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”

These questions about who deserves scarce resources — those most likely to die without them? or those most likely to live longer with them? — will persist as the population ages. They’re also likely to arise when the International Society for Heart and Lung Transplantation begins working towards revised guidelines this spring. (I’d also like to hear your take, below.)

Lots of 65- and 75-year-olds are very healthy. Yet transplants themselves can cause harm and there’s no backup, like dialysis. Without the transplant, they die. But when the transplant goes wrong, they also die.

More than four years post-transplant, the Cleveland Clinic’s “lung brothers” are success stories. Mr. Conn, who lives near Dayton, Ohio, can’t walk very far or lift more than 10 pounds, but he works part time as a real-estate appraiser and enjoys cruises with his wife.

Mr. Gammalo, a onetime musician, has developed diabetes, like nearly half of all lung recipients. But he went onstage a few weeks back to sing “Don’t Be Cruel” with his son’s rock band, “a highlight of both our lives,” he said.

Yet when I asked Mr. Conn, now 73, how he felt about having priority over a younger but healthier person, he paused. “It’s a good question,” he said, to which he had no answer.

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Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Is Facebook worth it? Film execs confide they may cut movie ads

Hollywood's friendship with Facebook is showing signs of strain.

The entertainment industry was among the first to embrace the Silicon Valley phenomenon. Studio executives thought the giant social network held great promise in reaching moviegoers for less money than traditional advertising such as trailers and TV ads. Facebook's origins even became fodder for the 2010 Academy Award-winning movie "The Social Network."

These days, major studios are taking a hard look at the cost of winning friends on Facebook. Some industry executives are increasingly skeptical that Facebook ads and promotional campaigns that ask users to "like" a movie can deliver big box-office returns.

"For people who are actually looking at the research and are looking for return on investment, for metrics that indicate specifically what Facebook's role is in the movie marketing equation, the jury's still out," said Jim Gallagher, a movie marketing consultant who formerly oversaw marketing for Walt Disney Studios.

Fred Leach, Facebook Inc.'s head of entertainment measurement, said the Menlo Park, Calif., company is working more closely than ever with Hollywood studios to help them target the right audience for a film, including giving studios more data showing the connection between ads and movie ticket sales and more tools to track the effectiveness of Facebook campaigns.

In Hollywood, few are openly critical of the world's biggest social networking company.

"Facebook continues to be an important advertising partner," said Dwight Caines, president of worldwide digital marketing at Sony Pictures Entertainment. "They are on every campaign we do today."

But other film executives confide privately they are considering cutting their spending on Facebook ads, just as carmaker General Motors Co. did last year, when the nation's third-largest advertiser dropped its annual $10-million Facebook campaign after deciding the ads didn't help sell cars.

The skirmish with Hollywood comes at a sensitive time for Facebook. The company, under pressure from Wall Street to grow revenue after its initial public stock offering in May, is competing with other social media for a share of the estimated $1.5 billion a year each major studio spends promoting movies globally.

Part of the problem is that studios are being asked to pay for the exposure they once got for free.

For years, studios have set up Facebook fan pages to connect with moviegoers, sending photos, video clips and other updates to the News Feed of users who "liked" a particular film, at no cost to the studios.

Then, in September, Facebook made a change to the algorithm that decides what users see in their News Feed. Facebook says it made the shift because users were tagging posts with negative feedback.

Major brands, including Hollywood studios, have seen a dramatic decline in the number of fans who see their messages.

For example, 72% of movies and network TV shows experienced a drop in the number of people who saw new Facebook posts after the new algorithm launched, according to BlitzMetrics, a Facebook marketing firm that analyzed 9 billion page posts generated over a 60-day period before and after the change.

That decline took a toll on two factors marketers watch closely: reach and engagement.

Twenty-three percent of the biggest studio pages saw a reduction in "engaged" users — people who click on a post, share it with friends or write a comment — because of decreased exposure in the News Feed, BlitzMetrics found. The drop in "reach" — the number of people who saw these updates from the most popular film and TV sites — was even sharper: 45%.

The change in the algorithm coincided with a push from Facebook to get studios to buy ads in the News Feed.

Social media experts say studios will have to find new ways to appeal to users and interact with them more. Pages that get a lot of likes and comments are favored by Facebook's algorithm.

Some studios are responding by bringing in their own writers and production teams to help create more engaging campaigns. Studios will also have to place ads to recapture the attention of their audience on Facebook, the experts said.

"The days of free traffic are over," said Dennis Yu, founder of BlitzMetrics. "Facebook has been trying to educate marketers on how to be social — to post the most engaging content — so as not to be penalized by their algorithms."

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