January 2010

Filet on the bone, as prepared by Dan Silverman at the Standard Grill, is seasoned with salt before and after cooking.

Ever since Mayor Michael R. Bloomberg announced his salt reduction initiative this month, people on all sides of the issue have developed a case of high blood pressure. Some scientists have gone on as though that white powdery substance were the most dangerous biological weapon on the planet. Meanwhile, some chefs and diners have responded as though the city were stationing armed police officers in kitchens and bodegas lest anyone make a move for the Doritos.

CONSULTING A PROFESSIONAL Dan Silverman, head chef at the Standard Grill, talks to the City Critic about how salt is used at the restaurant.

People, relax. In the right amounts, salt is a fine thing. And as for the guidelines, which focus on “packaged and restaurant foods,” they’re voluntary.

Packaged foods are an easy target, often so gunked up by chemicals that it takes a pile of salt to get any flavor at all. As for restaurants, the salt initiative seems to be aimed at fast-food joints, but salt plays an important role in nicer kitchens, too ? the kind where actual human beings cook actual food.

“A lot of really great chefs tend to have a heavy hand with salt,” said Caroline Fidanza. She ought to know. She’s one of the chef-partners at the popular restaurant Saltie in Williamsburg, Brooklyn. “I think that 99 percent of why people don’t think of themselves as good cooks is that they’re reluctant to use salt at home.”

As an experiment, I picked up some signature dishes at popular New York spots. I got the works at Shake Shack. A New York strip steak with creamed spinach at Michael Jordan’s Steakhouse. From Ollie’s, the Chinese chain, cumin-flavored lamb (“I eat that and need to consume about a gallon of water afterward,” one foodie warned me). A slice of candy bar pie from Momofuku Milk Bar, because a sprinkle of salt gives desserts there an edge. House-made saffron pappardelle with braised rabbit at the Standard Grill, because it looked so luscious. The corned beef at Katz’s Delicatessen, because, well, how could you not?

At Two Boots, I could have ordered the vegetarian Earth Mother pizza, but I opted for the Dude, a Cajun bacon-cheeseburger pie. “I’ll have two Dudes,” I told the guy behind the counter. “We’re the only two dudes you need,” he said, gesturing to his friend at the register. That seemed pretty salty.

Instead of indulging, I put the dishes into Ziploc bags and sent them off to Certified Laboratories in Plainview, on Long Island, to be tested for sodium. Then I had to wait for the results.

When a chef cooks in what Mark Erickson, the dean of culinary education at the Culinary Institute of America, called a “fresh-prepared food environment,” salt is only one of the many tools ? along with garlic or citrus or fresh herbs, say ? she can use to build flavor. But if you’re stirring a huge vat of goo in an industrial food factory a mile below the earth’s surface, salt is one of the only tricks you have, so you have to use it a lot.

But at least in fast-food chains you can know what you’re getting: in New York, they are required to post nutritional information, which they more or less stick to. Better restaurants rely on the palate of not just the chef who creates the dish, but also the line cook who executes it. “When we say ‘season to taste,’ ” Mr. Erickson warned, “if you’ve been slaving in a hot kitchen your taste might be different from someone who’s been sitting at a desk in an air-conditioned office all day.”

And the stronger the flavors in a dish, he added, the harder it may be to guess how much salt it contains.

The Food and Drug Administration recommends a maximum of 2,400 milligrams of sodium per day, 1,500 for people who have hypertension, are African-American (who are at higher risk of hypertension) or are beyond an unspecified middle age.

So how did New York’s favorite dishes fare? The yellow ribbons of pasta from the Standard Grill delivered maximal flavor without maximal salt: 745 milligrams of sodium, less than a third of the suggested daily dose. That drought-inducing lamb at Ollie’s? A thousand milligrams.

At Shake Shack, a Double ShackBurger, fries and a peanut butter shake pack 1,980 milligrams ? a lot of sodium, yes, but goodness, a lot of food. (If that’s your idea of lunch, you might consider carrot sticks for dinner.) The two slices from Two Boots came to 2,240 milligrams: as predicted, more Dude than necessary. A large take-out container of Manhattan clam chowder at the Oyster Bar weighed in at a scary 3,100 milligrams. And Katz’s?

Katz’s justifiably famous corned beef sandwich, with mustard but only two of the six pickles the counter guy gave me (along with his number), came to a truly remarkable 4,490 milligrams of sodium. That’s about two whole days’ worth in one sandwich, nearly the equivalent of 10 McDonald’s hamburgers.

For decades, Katz’s motto has been “Send a salami to your boy in the Army.” Perhaps it ought to come with a Purple Heart.

E-mail: citycritic@nytimes.com

Altria, home to Philip Morris and its popular Marlboro cigarette brand, was a corporate pariah for years, blamed for the death of millions of people and sued for hundreds of billions of dollars.

FOR years, Altria, home to Philip Morris and its popular Marlboro cigarette brand, was a corporate pariah blamed for the deaths of millions of people and sued for hundreds of billions of dollars by attorneys general in every state. After eventually acknowledging, like others in its industry, that cigarette smoking was, indeed, addictive and caused disease, Altria went a step further. It broke from the Big Tobacco pack and began supporting legislation that would ultimately put the company under the regulatory thumb of the Food and Drug Administration.

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Michael Szymanczyk, Altria’s chief, supported regulation of tobacco but is urging the government to allow more marketing of smokeless products.

Altria’s motives for submitting to strict oversight have long been a mystery. Did the company and its executives, who were internally pursuing a strategy of “societal alignment,” suddenly embrace a true partnership on public health? Or was this a case, as its longtime foes and competitors have argued, of Altria seeking to generate good P.R. or lock in its market dominance by cozying up to a regulator that could restrict rivals from marketing new products?

Another possible answer was highlighted this month, as the federal government began fine-tuning aspects of a law that President Obama signed last summer that gives the government sweeping new powers to regulate the production and marketing of tobacco products.

A series of letters that Altria submitted to the F.D.A. as part of that process argues that the government should, effectively, sign off on the notion that smokeless tobacco products are less harmful than cigarettes ? and that Altria and other companies should be allowed to market them as such to consumers.

It is a pivotal and divisive claim. While public health doctors agree that the smokeless products are far less hazardous to individuals than cigarettes, they still have concerns because all tobacco products contain nicotine and carcinogens. They also contend that promoting smokeless products ? some in tiny packages in the shape of cigarette packs ? would attract new, perhaps younger customers and maintain the addiction for smokers who might otherwise quit. They note that Altria is adding flavorings to its smokeless products that have long been used in candy.

Furthermore, critics say, Altria’s suggestion to the F.D.A. that it be allowed to market its products as less risky is part of an effort to dodge indoor-smoking laws (which are credited with encouraging more smokers to quit) and to encourage smokers to use oral tobacco products as supplements.

“If you look at how they’re marketing smokeless now, they’re marketing for dual use, and to protect the cigarette market, which is their big money maker,” says Stanton A. Glantz, a professor of cardiology and a specialist in tobacco research at the University of California, San Francisco.

UNDER its gregarious chief executive, an occasional smoker named Michael E. Szymanczyk, Altria is treading carefully when it comes to talking about its business strategies or its relationship with the F.D.A. After its letters to the regulator made headlines this month, the company canceled interviews for this article with top executives at its headquarters in Richmond, Va.

An Altria spokesman says the executives declined to comment because “we don’t want to be perceived as leading the discussion” on the regulatory front.

Brendan J. McCormick, another Altria spokesman, says the company supported the legislation enacted last summer because it believed that the F.D.A. offered the best way to settle the debates about tobacco use and marketing, which have raged for decades. He says the company believes that F.D.A. standards will create more predictability in the industry and a level playing field for competitors.

Moreover, he says, the F.D.A. provides a forum to evaluate products that are potentially less harmful ? and if the agency agrees with its argument, the company could market them with a federal imprimatur.

Mr. McCormick says Altria doesn’t agree with criticisms that the new tobacco law and the company’s willingness to work closely with its regulator cement its market dominance. “This is a dynamic industry,” he says.

And Altria is a changing company. It spent $11.7 billion last year to acquire UST, formerly the United States Tobacco Company and home to popular snuff brands like Copenhagen and Skoal.

The merger made Altria the biggest cigarette and chew company in the country, controlling 50 percent of the cigarette market and 55 percent of the smokeless market.

The deal also solved several quandaries facing the company. The biggest was that, after its spinoff of Kraft Foods and the less-regulated, faster-growing Philip Morris International units in recent years, Altria had become a stand-alone domestic cigarette company in a declining industry. Bans on indoor smoking, along with rising federal and state excise taxes, have accelerated a long-term decline in the volume of domestic cigarette sales.

Volumes may be declining, but cigarettes remain Altria’s biggest business by far, accounting for $14.4 billion in revenue in 2009. (Smokeless brought in $1.2 billion.) Cigarette profits are growing thanks to price increases and a customer base of people who haven’t kicked the habit. About 70 percent of the nation’s 46 million smokers say they want to quit, government surveys show, and about 40 percent try every year. But only 2.5 percent succeed, the surveys say. The government estimates that 400,000 Americans die of smoking-related diseases each year.

Critics and public health officials contend that in focusing the F.D.A.’s attention on smokeless products, a much smaller but growing industry, Altria and other tobacco companies are diverting regulators’ attention from the source of the real public health problem: cigarettes.

Consider so-called light cigarettes, which have captured nearly 90 percent of the United States market, based largely, analysts say, on the false perception among consumers that they are safer. (Many studies have shown that smokers inhale those cigarettes more deeply.) While manufacturers are required by the new law to drop words like “light,” low” and “mild” from their labels by this summer, the companies may still be able to use pale blue, green or silver packaging, which critics say signifies the same thing to consumers.

“They’re taking the F.D.A. debate and making it on smokeless rather than ‘light’ cigarettes, which is where the real harm is,” says Gregory N. Connolly, a professor at the Harvard School of Public Health who was head of tobacco control for Massachusetts. “It’s brilliant, in a way.”

WHEN Mr. Szymanczyk joined Philip Morris as head of sales in 1990, the company was No. 2 on Fortune magazine’s list of America’s “most admired” companies. Four years later, it had fallen to No. 204, after taking a bashing in court and in the press.

Mr. Szymanczyk, who started his career selling bar soap at Procter & Gamble, faced a huge clean-up job when he was handed the reins to the domestic cigarette business in 1997.

He grew up in Lansing, Ill., a working-class town not far from the steel mills of Gary, Ind. Physically imposing at 6-foot-8, he attended Indiana University on a basketball scholarship.

He graduated from college in 1971, married and started a job at Procter & Gamble ? all in the same week, according to court testimony he provided during the tobacco wars. He is a veteran of those battles. One Christmas, an anti-tobacco choir led by Michael Moore, the documentarian, decorated a tree outside his home with Marlboro boxes.

Endorsing vaccines as the world’s most cost-effective public health measure, Bill and Melinda Gates said Friday that their foundation would more than double its spending on them over the next decade, to at least $10 billion.

The change could save the lives of as many as eight million children by 2020, Mr. Gates calculated. He said he hoped his gift would inspire other charities and donor nations to do the same.

“Vaccines are a real success story,” Mr. Gates said in an interview before the announcement, which he made at the World Economic Forum in Davos, Switzerland. “The cost is tiny, and yet it saves more lives than any other component of a health care system.”

Julian Lob-Levyt, the executive secretary of the GAVI Alliance, a partnership among drug companies, health agencies and charities bringing vaccines to poor countries, said he “hugely welcomed” the announcement.

“If other donors follow the lead of the Gates Foundation and step up their funding for vaccines,” Dr. Lob-Levyt said, “GAVI has the ability to immunize millions of children against the world’s two biggest childhood killers, pneumonia and diarrhea.”

Vaccines already get more financing from the Gates Foundation than any other cause, and Mr. Gates said no money would be shifted away from other projects, like improved crops, assistance to small businesses and, on the domestic front, schools and libraries. Instead, he and Warren Buffett will increase their annual gifts to the foundation, and about 30 percent of all spending, up from 20 percent, will be for vaccines.

In calculating that eight million lives could be saved, Mr. Gates cited a computer model developed for the foundation by public health specialists at Johns Hopkins University.

Whether such an optimistic prediction comes true depends on several factors that are still uncertain.

For starters, Mr. Gates wants to make sure that 90 percent of the world’s children get shots for routine childhood diseases like measles, diphtheria, whooping cough and polio. Right now, almost 80 percent do. But with 134 million children born each year, it is a constant struggle to keep up, and efforts can be interrupted by factors like war, natural disasters, bad roads and corrupt officials.

Then he assumes that two new vaccines against rotavirus and pneumococcal disease, which are major killers of malnourished children, are adopted as routine immunizations in most poor countries and reach 80 percent of all children by 2020. Even in wealthy countries, the introduction of any new vaccine can be tricky because of bureaucratic and logistical delays and because unexpected rumors can spring up, like the persistent one that polio vaccine is a plot to sterilize Muslim girls.

Mr. Gates’s model also assumes that a malaria vaccine now in development by GlaxoSmithKline will be approved and will by 2014 reach at least some of the one million children, mostly in Africa, who die annually of the disease.

Yet the vaccine, known as RTS,S, is still in the testing phase. And as Mr. Gates acknowledged, “you can always be surprised” during clinical trials.

On the pessimistic side, his model assumes that no vaccine against AIDS or tuberculosis will be licensed during the decade ? something that virtually all public health specialists ruefully agree with because progress on those has been very slow.

Endorsing vaccines as the world’s most cost-effective public health measure, Bill and Melinda Gates said Friday that their foundation would more than double its spending on them over the next decade, to at least $10 billion.

The change could save the lives of as many as eight million children by 2020, Mr. Gates calculated. He said he hoped his gift would inspire other charities and donor nations to do the same.

“Vaccines are a real success story,” Mr. Gates said in an interview before the announcement, which he made at the World Economic Forum in Davos, Switzerland. “The cost is tiny, and yet it saves more lives than any other component of a health care system.”

Julian Lob-Levyt, the executive secretary of the GAVI Alliance, a partnership among drug companies, health agencies and charities bringing vaccines to poor countries, said he “hugely welcomed” the announcement.

“If other donors follow the lead of the Gates Foundation and step up their funding for vaccines,” Dr. Lob-Levyt said, “GAVI has the ability to immunize millions of children against the world’s two biggest childhood killers, pneumonia and diarrhea.”

Vaccines already get more financing from the Gates Foundation than any other cause, and Mr. Gates said no money would be shifted away from other projects, like improved crops, assistance to small businesses and, on the domestic front, schools and libraries. Instead, he and Warren Buffett will increase their annual gifts to the foundation, and about 30 percent of all spending, up from 20 percent, will be for vaccines.

In calculating that eight million lives could be saved, Mr. Gates cited a computer model developed for the foundation by public health specialists at Johns Hopkins University.

Whether such an optimistic prediction comes true depends on several factors that are still uncertain.

For starters, Mr. Gates wants to make sure that 90 percent of the world’s children get shots for routine childhood diseases like measles, diphtheria, whooping cough and polio. Right now, almost 80 percent do. But with 134 million children born each year, it is a constant struggle to keep up, and efforts can be interrupted by factors like war, natural disasters, bad roads and corrupt officials.

Then he assumes that two new vaccines against rotavirus and pneumococcal disease, which are major killers of malnourished children, are adopted as routine immunizations in most poor countries and reach 80 percent of all children by 2020. Even in wealthy countries, the introduction of any new vaccine can be tricky because of bureaucratic and logistical delays and because unexpected rumors can spring up, like the persistent one that polio vaccine is a plot to sterilize Muslim girls.

Mr. Gates’s model also assumes that a malaria vaccine now in development by GlaxoSmithKline will be approved and will by 2014 reach at least some of the one million children, mostly in Africa, who die annually of the disease.

Yet the vaccine, known as RTS,S, is still in the testing phase. And as Mr. Gates acknowledged, “you can always be surprised” during clinical trials.

On the pessimistic side, his model assumes that no vaccine against AIDS or tuberculosis will be licensed during the decade ? something that virtually all public health specialists ruefully agree with because progress on those has been very slow.

Migraines may be right up there with root canals and childbirth as one of life’s more painful experiences. But unlike childbirth or dental surgery ? which can be dulled with standard pain medications ? migraines are notoriously tricky to treat.

Dr. Joel Saper, director of the Michigan Headache and Neurological Institute, says treatments for migraines should vary. “What might be a miracle drug for one person could be a dud for another,” he said.

Those who suffer from these disabling headaches often try a dozen or so medications before they find something that works. What’s more, many migraines do not get properly diagnosed, according to the doctors and researchers I spoke with. That can lead to a lot of extra pain ? and expense ? for the afflicted.

A reason migraines are so maddeningly elusive is that they are not simply bad headaches. They stem from a genetic disorder (yes, you have your parents to blame) that afflicts 36 million Americans and manifests as a group of symptoms that besides head pain may include dizziness, visual disturbances, numbness and nausea.

Some of the symptoms resemble those from other disorders, like sinus headaches, epilepsy, eye problems or even strokes. And to further complicate matters, sufferers react in varied ways to medications.

“What might be a miracle drug for one person could be a dud for another,” explained Dr. Joel Saper, director of the Michigan Headache and Neurological Institute, a treatment and research center in Ann Arbor. “There is no universally effective therapy.”

If that sounds murky, one thing is not: early intervention is important. If you get a migraine every few months and can cope by taking an over-the-counter med, great ? you’ve got the problem somewhat under control. But if recurring pain is not responding to your own efforts, seek expert help.

“Some early data suggests that if you let headache pain go without treatment it can lower your threshold for pain down the line,” Dr. Saper said. In other words, untreated headaches can make you more vulnerable to pain.

On the other hand, if you are taking over-the-counter or prescriptions painkillers two to three days a week for months on end, the medications you are taking to dull pain could worsen your condition. You may then start to experience medication-overuse headaches ? a risk for migraine sufferers.

Researchers are learning that pain and the medications used to treat pain can potentially change the biology of the brain.

Receiving good treatment can help you function more effectively, and will probably also save you money over the long term. And if you have health insurance, it should cover most of the relevant medical evaluations and treatments.

Here are suggestions for getting help.

EVALUATION If you have chronic or disabling headaches that your primary care physician has not been able to manage, see a neurologist who has expertise in treating headaches.

Be sure to ask beforehand about that expertise. Not all neurologists have experience treating migraines.

You might want to see a certified headache specialist. Doctors with this new certification have passed board exams in their area of specialty as well as one on headaches. You can find a list of the approximately 200 certified headache doctors on the Migraine Research Foundation’s Web site.

Before you make an appointment, ask your potential doctor’s assistant, by phone, a few key questions. Find out about the doctor’s experience. And be sure to ask how long the first meeting will last.

“A good doctor will spend at least an hour with you,” said Dr. David W. Dodick, a neurologist at the Mayo Clinic in Arizona.

It’s important for a doctor to take time to listen to your issues, said Claire Louder, 44, who has had migraines since she was 12. She said she has seen a half-dozen doctors over the years.

“The best ones pay attention to what you say,” said Ms. Louder, who is a chamber of commerce executive in Maryland. “One doctor I saw had a treatment plan in mind before I’d said a word. Then she kept telling me my migraines were due to stress, which was an oversimplification.”

A good doctor should be creative and willing to try a variety of treatments.

At your first visit, the doctor will make sure that your headaches are not caused by an underlying illness, like Lyme disease or a brain tumor. Once the doctor is satisfied that your condition is indeed what are called primary migraines, the doctor will ask you detailed questions about your attacks, take a thorough medical history, and probably have you keep a diary of your migraine patterns.

STRATEGIES VARY Be prepared for a multi-tiered approach.

Doctors typically prescribe a triptan drug or an ergot-related drug to help people control infrequent migraine attacks. Both of these drug types influence brain cell reactions that are part of the migraine process.

There are seven types of triptans. Ms. Louder tried five before she found one, rizatriptan ? sold under the brand name Maxalt ? that worked for her. The best-seller Imitrex (sumatriptan) is available in an affordable generic version.

Triptans are far more popular, but many people who do not respond well to triptans do well with the ergots, such as D.H.E. (dihydroergotamine), Dr. Saper said.

If you have migraines at least weekly your doctor may prescribe a preventative medicine to reduce the frequency of attacks.

“Prescription preventatives are grossly underutilized,” Dr. Dodick said. “They can be extremely effective for some people.”

Preventive medicines, which you must take every day, include anti-seizure drugs, beta blockers and tricyclic antidepressants. Ms. Louder started taking Topomax (topiramate), an antiseizure drug, five years ago and says it has helped to reduce the frequency of her migraines from once a week to once a month.

Your doctor might suggest some relatively inexpensive natural remedies too ? like vitamin B2, coenzyme Q10, magnesium or butterbur, an herb that is sold under the name Petadolex ? which some specialists say can help reduce both the frequency and intensity of your headaches. These supplements are not covered by insurers but all are relatively inexpensive.

LIFESTYLE CHANGES “Migraines are built into the biology of the brain,” Dr. Saper said.

Sufferers inherit a hypersensitivity to physical and emotional events ? like stress, noise, certain foods and even bad weather. Learning to identify the circumstances that can set off an attack is an important part of migraine management.

Dr. Dodick said, “Recognizing triggers can prevent attacks from occurring.” After keeping a diary, Ms. Louder learned, for instance, that low-pressure storm systems, meats with nitrates and many other preservatives induced her migraines.

“Migraine patients don’t respond well to change,” Dr. Dodick said.

Sometimes just keeping one’s patterns and habits predictable can reduce attacks. Lack of sleep, erratic schedules and lots of plane rides are disorienting for even the hardiest people, but they can literally send migraine sufferers to their beds, or worse, to the E.R.

WASHINGTON ? President Obama drew sustained laughter from Congress, especially Democrats, on Wednesday when he declared in his State of the Union speech that “by now it should be fairly obvious that I didn’t take on health care because it was good politics.”

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But after spending 2009 emphasizing that a health care overhaul was his top domestic priority, Mr. Obama gave it much less prominence in his address. He did not mention it until more than half an hour in ? a sign of how imperiled the bill has become.

In the last week, Democrats have vigorously debated among themselves how to salvage the legislation. Speaker Nancy Pelosi suggested Wednesday that the Senate would have to take the next step and make substantial changes in its bill before the House would act again.

Senate aides said the changes recommended by Ms. Pelosi could add $300 billion to the cost of the legislation, which already carries a 10-year price tag of nearly $1 trillion.

House Democrats disputed the $300 billion figure.

Even if Democrats can resolve their internal disputes, they must contend with opposition from Republicans, who have been emboldened by their victory in a special Senate election last week in Massachusetts.

“If anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors and stop insurance company abuses, let me know,” Mr. Obama said. “Let me know.”

Hearing that invitation, the House Republican leader, Representative John A. Boehner of Ohio, raised his left hand high.

Mr. Obama’s speech did nothing to resolve differences between the House and the Senate or to clarify the way forward. Just 20 weeks ago Mr. Obama stood in the same place and made an urgent plea to a joint session of Congress. “The time for bickering is over, the time for games has passed,” he said on Sept. 9.

“Now is the time to deliver on health care,” he said then.

But on Wednesday health care was wedged into a catalog of presidential priorities, which included jobs, the economy, education, bank regulation, energy independence, deficit reduction and the war in Afghanistan.

The change highlighted the risks for Mr. Obama in staking more of his political capital on legislation whose fate in Congress is uncertain ? a bill that divides the Democratic caucus, that is reviled by Republicans and that makes many independent voters nervous.

In his speech Wednesday, Mr. Obama put health care in the context of his economic agenda, saying, “It is precisely to relieve the burden on middle-class families that we still need health insurance reform.”

Mr. Obama acknowledged that he had not convinced the American people of the merits of his plan. He traced his failure to communication problems and to the opposition of special interests, not to flaws in the proposal.

“The longer it was debated, the more skeptical people became,” Mr. Obama said. “I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, the process left most Americans wondering what’s in it for them.”

But Mr. Obama stood behind his proposals, which he described as a vast improvement over the status quo. “As temperatures cool,” he said, “I want everyone to take another look at the plan we’ve proposed.”

In a speech last week in Ohio, Mr. Obama said his campaign for major health legislation had run into “a little bit of a buzz saw,” with the Republican victory in Massachusetts. The president blamed “special interests and armies of lobbyists and partisan politics.”

But Mr. Boehner, the House minority leader, said Wednesday: “That buzz saw was not lobbyists and special interests. That buzz saw was the American people saying, ‘Stop, we’ve had enough of this.’ ”

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WASHINGTON ? Democratic leaders in Congress voiced resolute optimism on Thursday that they would adopt major health care legislation this year, and they said that doing so was a crucial element of President Obama’s broader agenda to create jobs, revive the economy and reduce federal budget deficits.

Senator Harry Reid on Thursday discussing President Obama’s State of the Union speech at a news conference on Capitol Hill.

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But legislative leaders conceded that they did not have an immediate strategy for advancing a health care measure and described their time frame as open-ended.

Speaker Nancy Pelosi, at a news conference in the Capitol, said House Democrats had begun exploring the possibility of breaking out pieces of the comprehensive bill they passed in November and moving forward on smaller measures.

“It means, we will move on many fronts, any front we can,” Ms. Pelosi said. “We’ll go through the gate. If the gate’s closed, we’ll go over the fence. If the fence is too high, we’ll pole-vault in. If that doesn’t work, we’ll parachute in. But we’re going to get health care reform passed for the American people, for their own personal health and economic security, and for the important role that it will play in reducing the deficit.”

Aides said that a first candidate for a stand-alone measure could be the proposal to eliminate the exemption from federal antitrust law that health insurance companies have long enjoyed. Such a proposal was incorporated in the larger House health care bill.

The Senate considered a similar proposal but did not include it in the bill it passed on Dec. 24.

In keeping with the tone of Mr. Obama’s State of the Union address, the Senate majority leader, Harry Reid of Nevada, placed health care in the context of a broader agenda focused on jobs and the economy.

Mr. Reid met Thursday with his top advisers and Senate committee chairmen to discuss the health care legislation, but made no decisions about how to proceed, aides said.

“We’re going to do health care reform this year,” Mr. Reid said at a news conference. “The question is, At this stage, procedurally, how do we get where we need to go.”

The Republican victory in the Massachusetts special Senate election last week means that Democrats will soon lose their 60-vote majority, which they need to overcome Republican filibusters. But even if they could surmount Republicans opposition, Senate and House Democrats have yet to bridge the differences between their bills.

“We’re not talking about minor tweaks,” Ms. Pelosi said. “It’s more serious than that.”

Though tensions between the two chambers have been running high, Ms. Pelosi did not criticize the Senate.

“The rules of the House enable more expeditious passage of legislation,” she said. “The Senate takes longer. That’s what our founders built into the system.”

So, Ms. Pelosi added, “I don’t want to waste any energy on criticizing the Senate.”

The speaker said the health care legislation would create four million jobs over 10 years. “We must pass health care reform,” she said. “We cannot sustain financially the current system.”

At a town-hall-style meeting in Tampa, Fla., on Thursday, Mr. Obama said he was intent on winning passage of a health care bill this year.

“If you are serious about reducing our deficit and debt,” he said, “you cannot accomplish it without reforming our health care system, because that’s what’s gobbling up more federal dollars than anything else.”

The House Republican leader, Representative John A. Boehner of Ohio, said he detected no material change in Mr. Obama’s approach.

“Unfortunately,” Mr. Boehner said, “the president does not appear to have listened to what the people in Massachusetts have said.”

One potential route for Democrats would be to have the Senate adopt changes to its health care measure as part of a budget bill, which could be approved with a simple majority vote.

But some centrist Democrats, like Senators Evan Bayh of Indiana and Blanche Lincoln of Arkansas, have said they oppose that approach.

Another centrist Democrat, Senator Ben Nelson of Nebraska, said Thursday that he, too, would oppose use of the expedited budget procedure. He urged Senate Republicans to work with him instead.

“If Republican colleagues are serious about fixing our health care system and want to avoid using the reconciliation process,” Mr. Nelson said, “then I will go to the negotiating table with them. If Republican senators join me at the table, we can use bipartisanship for health reform rather than use reconciliation, which needs only 50 votes.”

Four-year-olds practice brushing their teeth at the Basic Beginnings center in Haverhill, Mass.

HAVERHILL, Mass. ? The twelve 4-year-olds sat in a corner, small hands clasping toothbrushes. Isaac and Aaron brandished them like swords, stabbing each other in the side. Jacky rubbed his into the carpet. Abigail squirmed, and Chayleece jumped up and down.

“You ready? Start brushing!” said Massiel Diaz, their teacher at the Basic Beginnings day care center. “Brush, brush your teeth ? at least two times a day. Clean, clean, clean ? fighting tooth decay,” Ms. Diaz sang out, as the children moved the brushes up, down and around, connecting with teeth occasionally but also with their face and nose.

And then they swallowed the pea-size dots of toothpaste ? bubblegum-flavored “Dora the Explorer” Colgate.

Massachusetts is the first state to add toothbrush time to the color-nap-snack-and-play routine of preschools, requiring that all children who eat a meal at day care, or attend for more than four hours, brush their teeth during class and be educated about oral health.

The regulations, which went into effect last week, are being praised by some parents and caregivers while causing a tempest in a toothbrush for others, according to schools and chat rooms.

“I don’t want someone’s hand in my child’s mouth,” said Sarah Brodsky, a teacher at First Path Day Care in Watertown and mother of 4-month-old Noah. “It’s a little too much” government intervention, Ms. Brodsky added.

“JG,” posting on Boston.com’s blog Moms Nation, agreed that the government might have overstepped its bounds: “We don’t need the state mandating every little thing in our lives. Let parents be parents,” adding, “The kids can’t even reach a sink.”

Parents who feel strongly about the regulation can opt out, said Sherri Killins, commissioner of the Department of Early Education and Care, which oversees day care centers and established the regulations to help stem dental disease. According to a 2003 state study, one in four Massachusetts kindergartners have dental disease.

“Poor dental care is the most common, chronic childhood ailment, and if untreated can result in pain, infection and other devastating impacts on a child’s health,” Ms. Killins said.

At the Basic Beginnings Learning and Development Center here, about 40 miles north of Boston, the director, Deborah Ramos, started training her charges in early January, so glitches would be worked out by the time the regulations went into effect.

Staff members use a soft bristle to swab the gums of infants. Like other day care centers statewide, Basic Beginnings is choosing to apply so little toothpaste that it is safe for children to swallow, a practice used in Head Start programs, which mandated tooth brushing in 2006.

Ms. Ramos said there was some apprehension, but teachers quickly worked brushing into the postlunch routine.

Dr. David S. Samuels, a periodontist in Andover and president of the Massachusetts Dental Society, which supports the rule, said in order for the program to be effective, teachers need to help children without the motor skills do it correctly. He is also worried about the spread of germs through toothbrushes and spitting.

Alexandra Picus, director of the First Path Day Care in Watertown, said she was still working out the details of how they will herd 60 preschoolers into position. “We need to start early,” Ms. Picus said. “We’re supposed to have rest time, and now we have to eat a little earlier so there’s enough time for the children to brush their teeth. It’s not the happiest moment.”