Rate of Childhood Obesity Falls in Several Cities

Jessica Kourkounis for The New York Times

At William H. Ziegler Elementary in Northeast Philadelphia, students are getting acquainted with vegetables and healthy snacks.

PHILADELPHIA — After decades of rising childhood obesity rates, several American cities are reporting their first declines.

The trend has emerged in big cities like New York and Los Angeles, as well as smaller places like Anchorage, Alaska, and Kearney, Neb. The state of Mississippi has also registered a drop, but only among white students.

“It’s been nothing but bad news for 30 years, so the fact that we have any good news is a big story,” said Dr. Thomas Farley, the health commissioner in New York City, which reported a 5.5 percent decline in the number of obese schoolchildren from 2007 to 2011.

The drops are small, just 5 percent here in Philadelphia and 3 percent in Los Angeles. But experts say they are significant because they offer the first indication that the obesity epidemic, one of the nation’s most intractable health problems, may actually be reversing course.

The first dips — noted in a September report by the Robert Wood Johnson Foundation — were so surprising that some researchers did not believe them.

Deanna M. Hoelscher, a researcher at the University of Texas, who in 2010 recorded one of the earliest declines — among mostly poor Hispanic fourth graders in the El Paso area — did a double-take. “We reran the numbers a couple of times,” she said. “I kept saying, ‘Will you please check that again for me?’ ”

Researchers say they are not sure what is behind the declines. They may be an early sign of a national shift that is visible only in cities that routinely measure the height and weight of schoolchildren. The decline in Los Angeles, for instance, was for fifth, seventh and ninth graders — the grades that are measured each year — between 2005 and 2010. Nor is it clear whether the drops have more to do with fewer obese children entering school or currently enrolled children losing weight. But researchers note that declines occurred in cities that have had obesity reduction policies in place for a number of years.

Though obesity is now part of the national conversation, with aggressive advertising campaigns in major cities and a push by Michelle Obama, many scientists doubt that anti-obesity programs actually work. Individual efforts like one-time exercise programs have rarely produced results. Researchers say that it will take a broad set of policies applied systematically to effectively reverse the trend, a conclusion underscored by an Institute of Medicine report released in May.

Philadelphia has undertaken a broad assault on childhood obesity for years. Sugary drinks like sweetened iced tea, fruit punch and sports drinks started to disappear from school vending machines in 2004. A year later, new snack guidelines set calorie and fat limits, which reduced the size of snack foods like potato chips to single servings. By 2009, deep fryers were gone from cafeterias and whole milk had been replaced by one percent and skim.

Change has been slow. Schools made money on sugary drinks, and some set up rogue drink machines that had to be hunted down. Deep fat fryers, favored by school administrators who did not want to lose popular items like French fries, were unplugged only after Wayne T. Grasela, the head of food services for the school district, stopped buying oil to fill them.

But the message seems to be getting through, even if acting on it is daunting. Josh Monserrat, an eighth grader at John Welsh Elementary, uses words like “carbs,” and “portion size.” He is part of a student group that promotes healthy eating. He has even dressed as an orange to try to get other children to eat better. Still, he struggles with his own weight. He is 5-foot-3 but weighed nearly 200 pounds at his last doctor’s visit.

“I was thinking, ‘Wow, I’m obese for my age,’ ” said Josh, who is 13. “I set a goal for myself to lose 50 pounds.”

Nationally, about 17 percent of children under 20 are obese, or about 12.5 million people, according to the Centers for Disease Control and Prevention, which defines childhood obesity as a body mass index at or above the 95th percentile for children of the same age and sex. That rate, which has tripled since 1980, has leveled off in recent years but has remained at historical highs, and public health experts warn that it could bring long-term health risks.

Obese children are more likely to be obese as adults, creating a higher risk of heart disease and stroke. The American Cancer Society says that being overweight or obese is the culprit in one of seven cancer deaths. Diabetes in children is up by a fifth since 2000, according to federal data.

“I’m deeply worried about it,” said Francis S. Collins, the director of the National Institutes of Health, who added that obesity is “almost certain to result in a serious downturn in longevity based on the risks people are taking on.”

Read More..

Rate of Childhood Obesity Falls in Several Cities

Jessica Kourkounis for The New York Times

At William H. Ziegler Elementary in Northeast Philadelphia, students are getting acquainted with vegetables and healthy snacks.

PHILADELPHIA — After decades of rising childhood obesity rates, several American cities are reporting their first declines.

The trend has emerged in big cities like New York and Los Angeles, as well as smaller places like Anchorage, Alaska, and Kearney, Neb. The state of Mississippi has also registered a drop, but only among white students.

“It’s been nothing but bad news for 30 years, so the fact that we have any good news is a big story,” said Dr. Thomas Farley, the health commissioner in New York City, which reported a 5.5 percent decline in the number of obese schoolchildren from 2007 to 2011.

The drops are small, just 5 percent here in Philadelphia and 3 percent in Los Angeles. But experts say they are significant because they offer the first indication that the obesity epidemic, one of the nation’s most intractable health problems, may actually be reversing course.

The first dips — noted in a September report by the Robert Wood Johnson Foundation — were so surprising that some researchers did not believe them.

Deanna M. Hoelscher, a researcher at the University of Texas, who in 2010 recorded one of the earliest declines — among mostly poor Hispanic fourth graders in the El Paso area — did a double-take. “We reran the numbers a couple of times,” she said. “I kept saying, ‘Will you please check that again for me?’ ”

Researchers say they are not sure what is behind the declines. They may be an early sign of a national shift that is visible only in cities that routinely measure the height and weight of schoolchildren. The decline in Los Angeles, for instance, was for fifth, seventh and ninth graders — the grades that are measured each year — between 2005 and 2010. Nor is it clear whether the drops have more to do with fewer obese children entering school or currently enrolled children losing weight. But researchers note that declines occurred in cities that have had obesity reduction policies in place for a number of years.

Though obesity is now part of the national conversation, with aggressive advertising campaigns in major cities and a push by Michelle Obama, many scientists doubt that anti-obesity programs actually work. Individual efforts like one-time exercise programs have rarely produced results. Researchers say that it will take a broad set of policies applied systematically to effectively reverse the trend, a conclusion underscored by an Institute of Medicine report released in May.

Philadelphia has undertaken a broad assault on childhood obesity for years. Sugary drinks like sweetened iced tea, fruit punch and sports drinks started to disappear from school vending machines in 2004. A year later, new snack guidelines set calorie and fat limits, which reduced the size of snack foods like potato chips to single servings. By 2009, deep fryers were gone from cafeterias and whole milk had been replaced by one percent and skim.

Change has been slow. Schools made money on sugary drinks, and some set up rogue drink machines that had to be hunted down. Deep fat fryers, favored by school administrators who did not want to lose popular items like French fries, were unplugged only after Wayne T. Grasela, the head of food services for the school district, stopped buying oil to fill them.

But the message seems to be getting through, even if acting on it is daunting. Josh Monserrat, an eighth grader at John Welsh Elementary, uses words like “carbs,” and “portion size.” He is part of a student group that promotes healthy eating. He has even dressed as an orange to try to get other children to eat better. Still, he struggles with his own weight. He is 5-foot-3 but weighed nearly 200 pounds at his last doctor’s visit.

“I was thinking, ‘Wow, I’m obese for my age,’ ” said Josh, who is 13. “I set a goal for myself to lose 50 pounds.”

Nationally, about 17 percent of children under 20 are obese, or about 12.5 million people, according to the Centers for Disease Control and Prevention, which defines childhood obesity as a body mass index at or above the 95th percentile for children of the same age and sex. That rate, which has tripled since 1980, has leveled off in recent years but has remained at historical highs, and public health experts warn that it could bring long-term health risks.

Obese children are more likely to be obese as adults, creating a higher risk of heart disease and stroke. The American Cancer Society says that being overweight or obese is the culprit in one of seven cancer deaths. Diabetes in children is up by a fifth since 2000, according to federal data.

“I’m deeply worried about it,” said Francis S. Collins, the director of the National Institutes of Health, who added that obesity is “almost certain to result in a serious downturn in longevity based on the risks people are taking on.”

Read More..

Health Centers Find Opportunity in Brownfields

PHILADELPHIA — The community health center rising on a derelict corner here in West Philadelphia never would have broken ground if not for the asbestos inside the building that was demolished to make way for it. Because of the contamination, Spectrum Health Services received a $2 million federal cleanup grant, the first piece of a $14 million construction financing puzzle.

When complete, the 36,000-square-foot building will provide a new home for a health center that has been squeezed into a deteriorating strip mall nearby for decades. It will also be the latest in a nationwide trend to replace contaminated tracts in distressed neighborhoods with health centers, in essence taking a potential source of health problems for a community and turning it into a place for health care. In recent years, health care facilities have been built on cleaned-up sites in Florida, Colorado, New Hampshire, Minnesota, Oregon and California.

“These health care providers are getting good at it,” said Elizabeth Schilling, policy manager for Smart Growth America, an advocacy group. “They have internalized the idea that this is an opportunity for them.”

Because these sites are contaminated, many qualify for government tax credits and grants, providing health centers with vital seed money to build. Community health centers, by design, exist to serve populations in poor neighborhoods, where there also tend to be available but contaminated properties like old gas stations, repair shops and industrial sites.

In fact, many of the country’s 450,000 contaminated sites, known as brownfields, are in poor neighborhoods, according to the Environmental Protection Agency. These tracts are disproportionately concentrated in poor communities because contaminated sites are more difficult to redevelop if property values are depressed. Banks are often reluctant to finance construction on a property that might require a costly cleanup.

“In communities where the real estate market isn’t working that well, you end up with a brownfield,” said Jody Kass, executive director of New Partners for Community Revitalization, a brownfield advocacy group.

“It’s a Catch-22,” said Phyllis B. Cater, chief executive of Spectrum Health Services. “The environmental issues are significant and yet there are scarce resources for communities to do the cleanup and remediation that’s required.”

But if the state or federal government provides the first piece of financing, other funders are more likely to fall into step.

Community health centers, in particular, are under pressure to grow. By 2015, the number of Americans who rely on community health centers for care is expected to double to 40 million from the 20 million who relied on the centers in 2010, according to the National Association of Community Health Centers. The Affordable Care Act allocated $11 billion to expand these centers. Of that, $1.5 billion was allotted to construction.

But finding a viable site is not always easy. It took Spectrum 15 years to find its new home on Haverford Avenue. The original building, an aging medical office, went up for auction in 2007 after the owner was arrested on a tax evasion charge. Spectrum bought the property for $650,000. Ms. Cater speculated that if Spectrum hadn’t bought the site, it most likely would have fallen into disrepair like the decaying row houses and the dilapidated bodega across the street that Spectrum hopes to redevelop eventually.

Spectrum currently occupies 10,000 square feet in a rundown strip mall four blocks away. The center is divided among three crowded spaces, so employees must walk outside to get from the medical offices to the billing department. The treatment rooms are dreary and cramped, with holes in the drywall and collapsing ceiling panels.

“I’ve seen better centers in rural Mississippi. This is not how you support a community,” Ms. Cater said.

When it opens next summer, the new, three-story center will have 34 exam rooms, eight dental rooms, a spacious community center and a full-service laboratory. It will also employ twice as many people as the current facility, adding 66 jobs to Spectrum’s payroll.

The 50-year-old building was in poor shape, but it was the presence of asbestos that allowed Spectrum to qualify for the critical first piece of financing: a $2 million brownfield redevelopment grant from the federal Department of Housing and Urban Development. The organization also received an additional $2 million H.U.D. loan that was tied to the brownfield grant, a $1.7 million redevelopment grant from Pennsylvania and $3.45 million in other loans.

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Moscow Journal: Book Gives Russians Close-Up of American Minutiae

MOSCOW — After 20 years of opining on weighty bilateral issues like NATO expansion and ballistic missile defense, the political analyst Nikolai V. Zlobin recently found himself trying to explain, for an uncomprehending Russian readership, the American phenomenon of the teenage baby sitter.

In Russia, children are raised by their grandmothers, or, if their grandmothers are not available, by women of the same generation in a similar state of unremitting vigilance against the hazards — like weather — that arise in everyday life. An average Russian mother would no sooner entrust her children’s upbringing to a local teenager than to a pack of wild dogs.

But of course much in everyday American life sounds bizarre to Russians, as Mr. Zlobin documents meticulously in his 400-page book, “America — What a Life!”

It seems strange, 20 years after the fall of the Iron Curtain, that ordinary Russians would still be hungry for details about how ordinary Americans eat and pay mortgages. But to Mr. Zlobin’s surprise, his book — published this year and marketed as a guide to Russians considering a move abroad — is already in its fifth print run, and his publisher has commissioned a second volume.

With the neutrality of a field anthropologist dispatched to suburbia, Mr. Zlobin scrutinizes the American practice of interrogating complete strangers about the details of their pregnancies; their weird habit of leaving their curtains open at night, when a Russian would immediately seal himself off from the prying eyes of his neighbors. Why Americans do not lie, for the most part. Why they cannot drink hard liquor. Why they love laws but disdain their leaders.

“The secret is that everyone wants to know what America is without its ideological blanket,” said Mr. Zlobin, who has lived in the United States on and off for 20 years and serves, at times, as an informal consultant to the Kremlin. “Originally I thought you had to watch the important issues, but it turns out what matters are the very basic ones.”

He is not the first Russian to engage in this exercise. In 1935, Ilya Ilf and Yevgeny Petrov, Soviet satirists, embarked on a road trip across the United States. Their book, “One-Story America,” described its residents’ earnestness (“Americans never say anything they do not mean”) their provinciality (“curiosity is almost absent”) and the ubiquity of advertising, which, they wrote, “followed us all over America, convincing us, begging us, persuading us, and demanding of us that we chew ‘Wrigley’s,’ the flavored, incomparable, first-class gum.”

That book, published less than two decades after the Bolshevik Revolution, was a touch subversive because it did not focus on the class struggle, then the Kremlin’s central talking point about the United States.

Mr. Zlobin is writing at a moment when state-controlled television casts the United States as a global bully, releasing waves of turbulence on the world and covertly undermining President Vladimir V. Putin. Mr. Zlobin does not make much effort to advance that thesis, instead suggesting, in his soft way, that Russian leaders would benefit from understanding what Americans are like.

“I often get appeals for help in Washington — ‘Get to know so and so,’ they tell me, naming some public figure, ‘We need to solve this problem,’ ” he writes. “It is difficult to explain that in the United States, in most cases, problems are not solved this way.”

Mr. Zlobin, who has lived in St. Louis, Chapel Hill, N.C., and Washington, finds his answers in middle-class neighborhoods that most Europeans never see. Readers have peppered him with questions about his chapter about life on a cul-de-sac. Most Russians grew up in dense housing blocks, where children ran wild in closed central courtyards. Cul-de-sac translates in Russian as tupik — a word that evokes vulnerability and danger, a dead end with no escape.

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Thefts a Concern as Holiday Deliveries Increase

Librado Romero/The New York Times

A driver in Midtown Manhattan on Friday. U.P.S. expects to deliver more than 500 million packages this season, leaving some to fear a rise in thefts.

A pair of brown leather boots was snatched last week from a doorstep in the suburbs of Chicago. A computer disappeared from a front porch in Fort Worth last month, and an iPad case was stolen outside a Long Island home this week.

As the peak of the holiday gift-buying season approaches and more people are ordering online, here is the downside: Grinch-like bandits are swiping the deliveries from doorsteps when families are not home. Some thieves follow U.P.S. and FedEx trucks along their routes and nab the gifts, while others simply drive through residential neighborhoods looking for packages.

In River Forest, Ill., where the police arrested two young men last week, accusing them of stealing deliveries from homes, plainclothes police officers trail U.P.S. trucks to ferret out thieves who may be following them, Cmdr. Jim O’Shea said.

“This is common at this time of year,” Commander O’Shea said. “We’re trying to take a proactive approach to curtail this.”

So far this holiday season, Americans have spent $21.4 billion online, up 14 percent from last year, according to comScore, a research company. U.P.S. alone expects to deliver more than 500 million packages, and with many of them being left on doorsteps, there could be ample opportunity for thieves to strike.

The Better Business Bureau now recommends that customers be proactive, asking their shipping companies for tracking numbers and requiring signatures upon delivery. If they are not at home, customers should ask for their packages to be held at a lobby desk or at a local shipping center, advised Claire Rosenzweig, the president of the group’s New York chapter.

 

There are no national statistics on doorstep thefts, but reports of local episodes abound. In Burbank, Calif., with five reported incidents this year, compared with one last year, two teenagers were arrested last month after they were found trailing a U.P.S. truck. One young man was released, while the other person, Ararat Gevondyan, 19, was charged with receiving stolen property, with his bail set at $10,000.

“It’s a crime of opportunity,” Sgt. Darin Ryburn of the Burbank Police Department said. The burglars are “going through these packages for items that could be resold,” he said.

On Long Island, two young men were arrested this week, suspected of stealing headphones, an iPad case and two pairs of Skechers shoes from homes in the Bay Shore area.

A few of the thefts have been caught by home surveillance cameras set up to catch or deter vandals. A television station in Pasadena, Calif., showed a video of a woman taking a package from a doorstep. The homeowner said she never got the Paula Deen electric salt-and-pepper shaker her sister had sent her.

While it may seem extreme to install cameras to keep an eye on packages, this type of home surveillance has become more common in recent years, said Marc Horowitz, a spokesman for Brickhouse Security. The company’s sales for home security cameras have more than doubled in the past year, he said, as the cameras have become less expensive. A simple motion-activated porch camera costs about $100.

Some camera customers fear the culprit is closer to home, breaking that commandment of the cul-de-sac, Do Not Covet Thy Neighbor’s Flat-Screen TV.

Mr. Horowitz said he had heard reports from his sales representatives that some customers were buying cameras because they suspected neighbors of pilfering packages (or newspapers and plants).

U.P.S. started a program last year called U.P.S. My Choice, which allows a customer to receive an e-mail or text message before a package arrives and reroute it if no one is going to be home.

U.P.S. drivers are also trained to leave packages out of sight, said Natalie Godwin, a company spokeswoman. Ms. Godwin was with a driver in Atlanta on Tuesday when he decided not to leave a package on someone’s stoop because it was clearly an expensive computer monitor. He dropped it off nearby at the apartment complex’s office.

Drivers leave notes telling the tenants where to find packages, Ms. Godwin said. Often, she added, “They’ll use their own judgment.”

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Mind: A Compromise on Defining and Diagnosing Mental Disorders

They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations.

But the effort itself was a valuable guide for anyone who has received a psychiatric diagnosis, or anyone who might get one.

This month, the American Psychiatric Association announced that its board of trustees had approved the fifth edition of the association’s influential diagnostic manual — the so-called bible of mental disorders — ending more than five years of sometimes acrimonious, and often very public, controversy.

The committee of doctors appointed by the psychiatric association had attempted to execute a paradigm shift, changing how mental disorders are conceived and posting its proposals online for the public to comment. And comment it did: Patient advocacy groups sounded off, objecting to proposed changes in the definitions of depression and Asperger syndrome, among other diagnoses. Outside academic researchers did, too. A few committee members quit in protest.

The final text, which won’t be fully available until publication this spring, has already gotten predictably mixed reviews. “Given the challenges in a field where objective lines are hard to draw, they did a solid job,” said Dr. Michael First, a psychiatrist at Columbia who edited a previous version of the manual and was a consultant on this one.

Others disagreed. “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry,” wrote Dr. Allen Frances, the chairman of a previous committee who has been one of the most vocal critics, in a blog post about the new manual, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM5.

Yet many experts inside and outside the process said the final document was not radically different from the previous version, and its lessons more mundane than the rhetoric implied. The status quo is hard to budge, for one. And when changes do happen, they are not necessarily the ones that were intended.

The new manual does extend the reach of psychiatry in some areas, as many critics feared it might. Hoarding is now a mental disorder (previously it was considered a symptom of obsessive-compulsive behavior). “Premenstrual dysphoric disorder,” a severe form of premenstrual syndrome, is also new (it was previously in the appendix).

And binge-eating disorder (also formerly in the appendix), a kind of severe, highly distressing gluttony, is now a full-blown diagnosis. This one by itself could tag millions of people considered healthy, if often overindulgent, with a psychiatric label, some experts said.

But the deeper story is one of compromise. It is most evident in how the committee handled three of the thorniest diagnoses in psychiatry: autism, depression and pediatric bipolar disorder.

The group working on depression declared early on that it wanted to eliminate the so-called bereavement exclusion, which stated that grieving the loss of a loved one should not be considered a clinical disorder, though it shares many of the same outward signs. Grief has always been a normal reaction to death, not a kind of depression.

Advocacy and support groups, such as those representing people who have lost a child, objected furiously to the idea that the bereaved might be given a diagnosis of depression.

“This was just astonishing, that they would eliminate the exclusion, and a distortion of the research on the subject,” said Jerome Wakefield, a professor of social work and psychiatry at New York University, who did not work on the manual.

In the end the committee cut a deal. It eliminated the grief exclusion but added a note in the text, reminding doctors that any significant loss — of a job, a relationship, a home — could cause depressive symptoms and should be carefully investigated.

“It’s like they took it all back,” Dr. Wakefield said. “I don’t like the way it was done — in a footnote — but it’s there.”

The debate over autism was even more furious, and it resulted in a similar rapprochement.

From the outset, the committee intended to tighten the definition of autism and simplify it, eliminating related labels like Asperger syndrome and “pervasive developmental disorder not otherwise specified,” or PDD-NOS. The rate of diagnosis of such conditions has exploded over the past decade, in part due to the vagueness of the definitions, and the committee wanted to draw clearer boundaries.

It proposed a single “autism spectrum disorder” category, with stricter requirements.

Some outside researchers raised concerns. In January one of them, Dr. Fred Volkmar of the Yale School of Medicine, who had quit the committee in protest, presented research suggesting that 45 percent or more of people who currently had an autism or related diagnosis would not have one under the proposed revision.

Autism groups reacted immediately, fearing that the change in the diagnosis would deny services to children and families who need them.

The committee countered with its own study, suggesting that the new definition would exclude about 10 percent of people currently with a diagnosis. And again, the experts took a half step back.

The new, streamlined definition was approved, but with language that took into account a person’s diagnostic history. “It’s explicit that anyone who’s had an Asperger’s or autism or PDD-NOS diagnosis before is now included,” said Catherine Lord, a committee member who worked on the new definition and who is director of the Center for Autism and the Developing Brain in New York. “Essentially everyone gets in.”

Pediatric bipolar disorder posed a different challenge.

In the 1990s and 2000s, psychiatrists began giving aggressive, explosive children a diagnosis of bipolar disorder in increasing numbers. The trend appalled many patient advocates and doctors.

Bipolar disorder, which is characterized by episodes of depression and mania, had previously been an adult problem; now the diagnosis is given to children as young as 2 — along with powerful psychiatric drugs and tranquilizers that also cause rapid weight gain. The committee wanted to stop the trend in its tracks, said experts who were involved.

Most of the children treated for bipolar disorder did not have it, recent research found. The committee settled on an alternative label: “disruptive mood dysregulation disorder,” or D.M.D.D., which describes extreme hostility and outbursts beyond normal tantrums.

“They essentially wanted to have some place for these kids, and D.M.D.D. was all they had in their kit,” said Dr. Gabrielle Carlson, a child psychiatrist at Stony Brook University Medical Center, who provided some outside consultation. “These are mostly kids who have A.D.H.D. or what we would call oppositional defiant disorder, but with this explosive feature. They need help; you can’t wait forever. The question was what to call it, without pretending we know enough to saddle them with a lifelong diagnosis” like bipolar disorder.

D.M.D.D. has its own problems, as many experts were quick to point out. It could be a symptom of an underlying condition, as Dr. Carlson argues. It could “medicalize” frequent temper tantrums. It’s brand new, and no one knows how it will play out in practice.

But it is now in the book — because it was the best solution available, experts inside and outside of the revision process said.

From beginning to end, many experts said, the process of defining psychiatric diagnoses is very much like finding the right one for an individual: it’s a process of negotiation, in many cases.

“That’s one of the take-aways from all this, and I think it’s a good one,” Dr. Carlson said. “A diagnosis is a hypothesis. It’s a start, and you have to start somewhere. But that’s all it is.”

One of the committee’s most ambitious proposals was perhaps the least noticed: a commitment to update the book continually, when there’s good reason to, rather than once every decade or so in a giant heave. That was approved without much fanfare.

Read More..

Mind: A Compromise on Defining and Diagnosing Mental Disorders

They plotted a revolution, fell to debating among themselves, and in the end overturned very little except their own expectations.

But the effort itself was a valuable guide for anyone who has received a psychiatric diagnosis, or anyone who might get one.

This month, the American Psychiatric Association announced that its board of trustees had approved the fifth edition of the association’s influential diagnostic manual — the so-called bible of mental disorders — ending more than five years of sometimes acrimonious, and often very public, controversy.

The committee of doctors appointed by the psychiatric association had attempted to execute a paradigm shift, changing how mental disorders are conceived and posting its proposals online for the public to comment. And comment it did: Patient advocacy groups sounded off, objecting to proposed changes in the definitions of depression and Asperger syndrome, among other diagnoses. Outside academic researchers did, too. A few committee members quit in protest.

The final text, which won’t be fully available until publication this spring, has already gotten predictably mixed reviews. “Given the challenges in a field where objective lines are hard to draw, they did a solid job,” said Dr. Michael First, a psychiatrist at Columbia who edited a previous version of the manual and was a consultant on this one.

Others disagreed. “This is the saddest moment in my 45-year career of practicing, studying and teaching psychiatry,” wrote Dr. Allen Frances, the chairman of a previous committee who has been one of the most vocal critics, in a blog post about the new manual, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM5.

Yet many experts inside and outside the process said the final document was not radically different from the previous version, and its lessons more mundane than the rhetoric implied. The status quo is hard to budge, for one. And when changes do happen, they are not necessarily the ones that were intended.

The new manual does extend the reach of psychiatry in some areas, as many critics feared it might. Hoarding is now a mental disorder (previously it was considered a symptom of obsessive-compulsive behavior). “Premenstrual dysphoric disorder,” a severe form of premenstrual syndrome, is also new (it was previously in the appendix).

And binge-eating disorder (also formerly in the appendix), a kind of severe, highly distressing gluttony, is now a full-blown diagnosis. This one by itself could tag millions of people considered healthy, if often overindulgent, with a psychiatric label, some experts said.

But the deeper story is one of compromise. It is most evident in how the committee handled three of the thorniest diagnoses in psychiatry: autism, depression and pediatric bipolar disorder.

The group working on depression declared early on that it wanted to eliminate the so-called bereavement exclusion, which stated that grieving the loss of a loved one should not be considered a clinical disorder, though it shares many of the same outward signs. Grief has always been a normal reaction to death, not a kind of depression.

Advocacy and support groups, such as those representing people who have lost a child, objected furiously to the idea that the bereaved might be given a diagnosis of depression.

“This was just astonishing, that they would eliminate the exclusion, and a distortion of the research on the subject,” said Jerome Wakefield, a professor of social work and psychiatry at New York University, who did not work on the manual.

In the end the committee cut a deal. It eliminated the grief exclusion but added a note in the text, reminding doctors that any significant loss — of a job, a relationship, a home — could cause depressive symptoms and should be carefully investigated.

“It’s like they took it all back,” Dr. Wakefield said. “I don’t like the way it was done — in a footnote — but it’s there.”

The debate over autism was even more furious, and it resulted in a similar rapprochement.

From the outset, the committee intended to tighten the definition of autism and simplify it, eliminating related labels like Asperger syndrome and “pervasive developmental disorder not otherwise specified,” or PDD-NOS. The rate of diagnosis of such conditions has exploded over the past decade, in part due to the vagueness of the definitions, and the committee wanted to draw clearer boundaries.

It proposed a single “autism spectrum disorder” category, with stricter requirements.

Some outside researchers raised concerns. In January one of them, Dr. Fred Volkmar of the Yale School of Medicine, who had quit the committee in protest, presented research suggesting that 45 percent or more of people who currently had an autism or related diagnosis would not have one under the proposed revision.

Autism groups reacted immediately, fearing that the change in the diagnosis would deny services to children and families who need them.

The committee countered with its own study, suggesting that the new definition would exclude about 10 percent of people currently with a diagnosis. And again, the experts took a half step back.

The new, streamlined definition was approved, but with language that took into account a person’s diagnostic history. “It’s explicit that anyone who’s had an Asperger’s or autism or PDD-NOS diagnosis before is now included,” said Catherine Lord, a committee member who worked on the new definition and who is director of the Center for Autism and the Developing Brain in New York. “Essentially everyone gets in.”

Pediatric bipolar disorder posed a different challenge.

In the 1990s and 2000s, psychiatrists began giving aggressive, explosive children a diagnosis of bipolar disorder in increasing numbers. The trend appalled many patient advocates and doctors.

Bipolar disorder, which is characterized by episodes of depression and mania, had previously been an adult problem; now the diagnosis is given to children as young as 2 — along with powerful psychiatric drugs and tranquilizers that also cause rapid weight gain. The committee wanted to stop the trend in its tracks, said experts who were involved.

Most of the children treated for bipolar disorder did not have it, recent research found. The committee settled on an alternative label: “disruptive mood dysregulation disorder,” or D.M.D.D., which describes extreme hostility and outbursts beyond normal tantrums.

“They essentially wanted to have some place for these kids, and D.M.D.D. was all they had in their kit,” said Dr. Gabrielle Carlson, a child psychiatrist at Stony Brook University Medical Center, who provided some outside consultation. “These are mostly kids who have A.D.H.D. or what we would call oppositional defiant disorder, but with this explosive feature. They need help; you can’t wait forever. The question was what to call it, without pretending we know enough to saddle them with a lifelong diagnosis” like bipolar disorder.

D.M.D.D. has its own problems, as many experts were quick to point out. It could be a symptom of an underlying condition, as Dr. Carlson argues. It could “medicalize” frequent temper tantrums. It’s brand new, and no one knows how it will play out in practice.

But it is now in the book — because it was the best solution available, experts inside and outside of the revision process said.

From beginning to end, many experts said, the process of defining psychiatric diagnoses is very much like finding the right one for an individual: it’s a process of negotiation, in many cases.

“That’s one of the take-aways from all this, and I think it’s a good one,” Dr. Carlson said. “A diagnosis is a hypothesis. It’s a start, and you have to start somewhere. But that’s all it is.”

One of the committee’s most ambitious proposals was perhaps the least noticed: a commitment to update the book continually, when there’s good reason to, rather than once every decade or so in a giant heave. That was approved without much fanfare.

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DealBook: U.S. to Sell Last Holdings of A.I.G. Common Stock

The Treasury Department said on Monday that it planned to sell its remaining holdings of common stock in the American International Group, essentially ending taxpayers’ four-year ownership of the bailed-out insurer.

The Treasury Department said that it had begun a public offering of its 15.9 percent stake in A.I.G., amounting to about 234.2 million shares. It is the latest in a string of sales by the federal government, which has quickly reduced taxpayers’ holdings over the last two years.

All that would be left is a relatively small number of warrants that give the department the right to buy additional shares in A.I.G.

If completed, the sale would represent the achievement of a long-held goal of both the Obama administration and A.I.G. itself: ending the government’s ownership of the insurer. For the Treasury Department, it would signify a complete exit from perhaps the most controversial rescue struck during the financial crisis of 2008. In return for making up to $182 billion available to the company, the government received a stake that at its peak represented 92 percent of the company.

And for A.I.G., it would represent an unambiguous transformation into a fully private enterprise, an insurer that has clambered back from the brink of annihilation. Over the last four years, the company has sold off a number of assets in an effort to repay its bailout.

While the Treasury Department did not outline a timetable for its latest stock offering, the sale is expected to be completed quickly. Unlike in previous offerings, A.I.G. is not expected to buy back any of the shares being offered.

A spokesman for A.I.G. declined to comment.

The offering is being run by Bank of America Merrill Lynch, Citigroup, Deutsche Bank, Goldman Sachs and JPMorgan Chase.

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Fear of Fighting Haunts Once-Tranquil Damascus

Muzaffar Salman/Reuters

Damascenes cling to the hope that the ethnic strife that has deepened when fighting has reached other areas will not arise in their city.

DAMASCUS, Syria — Business has been terrible for Abu Tareq, a taxi driver, so last week, without telling his wife, he agreed to drive a man to the Damascus airport for 10 times the usual rate. But, he said later, he will not be doing that again.

On the airport road, he could hear the crash of artillery and the whiz of sniper fire. Dead rebels and soldiers lay on the roadsides. Abu Tareq saw a dog eating the body of a soldier.

“I will never forget this sight,” said Abu Tareq, 50, who gave only a nickname for safety reasons. “It is the road of the dead.”

Damascus, Syria’s capital, is one of the world’s oldest continuously inhabited cities, a touchstone of history and culture for the entire region. Through decades of political repression, the city preserved, at least on the surface, an atmosphere of tranquillity, from its wide downtown avenues to the spacious, smooth-stoned courtyard of the Umayyad Mosque and the vine-draped alleys of the Old City, where restaurants and bars tucked between the storehouses of medieval merchants hummed with quiet conversation.

Now, though, the rumble of distant artillery echoes through the city, and its residents are afraid to leave their neighborhoods. Cocooned behind rows of concrete blocks that close off routes to the center, they huddle in fear of a prolonged battle that could bring destruction and division to a place where secular and religious Syrians from many sects — Sunni, Shiite, Alawite, Christian and others — have long lived peacefully.

For more than a week, Syrian rebels and government forces have fought for the airport road, as the military tries to seal off the capital city, the core of President Bashar al-Assad’s power, from a semicircle of rebellious suburbs. Rebels have now kept the pressure on the government for as long as they did during their previous big push toward Damascus last summer. This time, improved supply lines and tactics, some rebels and observers say, may provide a more secure foothold.

But the security forces wield overwhelming firepower, and while it has been unable to subdue the suburbs, some rebel fighters say they lack the intelligence information, arms and communication to advance. That raises the specter of a destructive standoff like the one that has devastated the commercial hub of Aleppo.

“Damascus was the city of jasmine,” Mahmoud, 40, a public-school teacher, said in an interview in the capital. “It is not the city I knew just a few weeks ago.”

Car bombs have ripped through neighborhoods, their targets and perpetrators only guessed at. Checkpoints choke traffic, turning 20-minute jaunts into three-hour ordeals. Wealthy residents find it quicker and safer to drive to Beirut, Lebanon, for a weekend trip than to the Old City.

Shells have been fired from Mount Qasioun overlooking Damascus, a favorite destination from which to admire the city’s sparkling lights. West of downtown, where the palace stands on a plateau, things are relatively quiet. But from the mountain, puffs of smoke can now be seen over suburbs in an arc from northeast to southwest.

Mahmoud, unable to find heating oil and medicine for his sick wife, said his grocer has lectured him daily on shortages and soaring prices. The once-ubiquitous government, he said, now appears to have no role beyond flooding streets with soldiers and security officers, “who are sometimes good and sometimes rude.”

People with roots in other towns have left, he said, “but what about me, who is a Damascene, and has no other city?”

The sense of claustrophobia has grown as rebels have declared the airport a legitimate target and the government has blocked Baghdad Street, a main avenue out of the city. On Sunday, it blocked the highway south to Dara’a.

In some outlying neighborhoods and nearby suburbs, the front lines seem to be hardening.

On the route into Qaboun, a neighborhood less than two miles from the center of Damascus, the last government checkpoint in recent days was near the municipal building. Less than a quarter-mile on, rebels controlled the area around the Grand Mosque.

An employee of The New York Times reported from Damascus, Syria, and Anne Barnard from Beirut, Lebanon. Neil MacFarquhar contributed reporting from Beirut.

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Browser Wars Flare Again, This Time for Phones and Tablets

SAN FRANCISCO — When Google took a video camera to Times Square in 2009 and asked passers-by what a browser is, most of the answers were hilariously incorrect, from “a search engine” to “broadband” to “Yahoo.”

But even if consumers are not so sure what Web browsers are (programs like Internet Explorer and Firefox), they have become a crucial business for tech companies like Google and Microsoft. That is because they are now the entry point not just to the Web but to everything stored online, like Web apps, documents and photos.

And as the cloud grows more integral, both for businesses and people, the browser companies are engaged in a new battle to win our allegiance that will affect how we use the Internet.

It’s an echo of the so-called browser wars of the 1990s, when Internet Explorer and Netscape Navigator fought for dominance on the personal computer. This time, though, the struggle is shaping up to be over which company will control the mobile world — with browsers on smartphones and tablets. Entrenched businesses are at stake. Google’s browser-based business apps, for instance, threaten Microsoft’s desktop software, and mobile Web apps threaten Apple’s App Store.

“Twenty years ago, we didn’t know how the Internet was going to get used by people, and we for sure didn’t know about mobile or tablets,” said Marc Andreessen, co-founder of the first major browser, Netscape Navigator, and an investor in Rockmelt, a browser start-up. “Mobile is a whole new level of reinvention, so it feels like we’re in the most fertile time of invention since the early ’90s.”

Browsers give Web companies more control over how people use their products, and data about how people use the Web, which they can use to improve their products and inform advertisers. Faster browsing leads to more Web activity, which in turns leads to more revenue for Web companies — whether searching on Google or shopping on Amazon.com, which built a Kindle browser, Silk.

As Mr. Andreessen put it, “Why let something be between us and our users? Let’s have as much control of the user experience as we can have; make sure our services are wired in.”

Google’s Chrome browser, for example, makes Google searches faster and simpler because people can enter search queries directly into the address bar. And its apps — like Gmail, Drive for file storage and Docs for word processing — are all accessible through any browser.

“Chrome makes it much easier for you to search, browse the Web and use Drive, Docs and apps, and we are fortunate to be in a position where when people do those things, we do better,” said Sundar Pichai, senior vice president of Chrome at Google. “Chrome is a platform, the underlying layer on which all our cloud operations run.”

Most people use either Chrome, Microsoft’s Internet Explorer, Mozilla’s Firefox or Apple’s Safari. In the biggest disruption to the market in 15 years, Chrome last spring toppled Internet Explorer as the most popular browser in the world, despite the fact that it does not come loaded on computers as Explorer and Safari do. It now has 36 percent of the global market, while Internet Explorer’s share has dived to 31 percent, according to StatCounter, which tracks browser market share.

A host of smaller companies, like Rockmelt and Opera, are also trying to grab market share, largely by focusing on mobile devices.

Browsers themselves are not lucrative businesses. Some, like Firefox, earn money from search engines like Google and Microsoft’s Bing that pay when people use the search bar built in to the browser.

“No one is doing a browser to make money,” said David B. Yoffie, a professor at Harvard Business School who was co-author of a book about the first browser wars. “Suddenly now, the browser has become the interface for the cloud more broadly, not just for traditional Web sites.”

In their search for dollars, browser companies are redesigning their products to follow consumers to mobile devices, social networks and cloud-based apps.

For example, new mobile browsers let people swipe through tabs with their fingers, automatically resize or zoom in on Web pages so they fit a phone’s screen and load pages faster than older mobile browsers. Some also sync with other devices, so things like most-visited Web sites, passwords and credit card numbers are available everywhere.

Nonetheless, browsing the Web on a mobile device is still inferior to using the desktop Web or smartphone apps. Apps, like those downloaded from Apple’s App Store and Google Play for Android devices, have more exciting features, are faster to load and are better optimized to small screens.

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