This post is in the “totally bonus” category. This short, summarized description of a proposed highly- and ultra-processed food definition is for scientists and policy makers familiar with this important issue as well as anyone with an interest. So if you missed the first version of this piece a couple of days ago, maybe because it was a lot longer, here is a chance to hear the essence of it. And some of the ideas have been revised or clarified since then.

If you feel done with HUPF for the moment, a podcast on coffee production in the mountains of Panama is coming in the next few days. I recently had an interesting visit there and got to ask about the role of the indigenous people on the coffee plantations.

Back to HUPF:

A federal definition of Highly- and Ultra-Processed Food (HUPF) is coming. How HUPF is defined is important to two opposing interests: Big Food with its future profits at stake is certainly lobbying hard on the issue with the Trump administration, and the American people with their health in jeopardy have the voice of RFK, Jr., who has been badly losing on the HUPF fight to date.

Using the original definition by Carlos Monteiro from 2009, 55% of the calories Americans eat are HUPF and those HUPF calories have strong links to chronic disease. If a clear, strong definition is achieved, it could provide the basis for policy that grows in effectiveness over time and minimize the opportunities for Big Food to lobby and connive its way out of regulation.

A durable, strong definition will be clean and simple, which I suggest is best achieved by identifying the technology that is essential to the creation of HUPF and using the historical timeline a technical framework provides.

This timeline is easy to determine. All HUPF is a product of innovations in technology in the last two hundred years. It was the Second Industrial Revolution (mid-19^th to mid-20^th centuries) and Third Industrial Revolution (the post-World War II Digital Age) that enabled the creation of new food products and additives that humans had not previously encountered or consumed. The great bulk of these have been created in the Third Industrial Revolution since 1945. Of course, we are continuing to create new food substances and additives in the 21^st century as we enter what some have termed a Fourth Industrial Revolution, but it may be too early to define the current era.

The proposed definition is:

Highly- and ultra-processed food is produced from food or chemicals modified or newly created with methods of the Second or Third Industrial Revolution, or moderately processed food that has become a health risk because it is mass produced with new technology and can now be over-consumed.

That is a strong, simple, working HUPF definition in 46 words.

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There are several tenets to this working definition:

1. HUPF is unnatural food.

2. Everything that is natural food predates the Second Industrial Revolution and has been consumed by humans for a long time. (This claim bears checking, but I can’t think of a natural food that was created after the Second Industrial Revolution began.)

Intuitively, hundreds of millions of humans have manipulated their available natural foods with any tools and chemical processes at their disposal over the course of human history. Invention of moderate food processing techniques to create new foods and additives – many fermented foods are ancient examples – will have played itself out by the time of the Second Industrial Revolution.

3. Because of our accumulated cultural experience, natural food tends to be healthy, how we tend to eat it.

4. HUPF is not, by this working definition, unhealthy, but for most of the thousands and thousands of HUPF substances, healthiness is not well certified.

This definition provides room for nutritionists to weigh as appropriate to each implementation the healthiness of individual substances and categories, some of which may be ambiguous, like bread with reconstituted whole wheat flour and the category of seed oils.

Everything that is HUPF is a new industrial invention, or it is a food that is a new risk because of mass production, which is made possible by a high level of processing. Newly over-consumed substances like refined sugar, highly refined flour, salt, and white rice are in this sub-category of HUPF.

5. While the beginning of the Second Industrial Revolution likely marks the point after which any newly created food or additive is HUPF, it seems reasonable to assert that any food substance or additive created after 1945, approximately the beginning of the Third Industrial Revolution, is HUPF. This includes most HUPF, thousands of which have not been identified, catalogued, or certified by our government.

We can say no new natural foods have entered human food environments since at least 1945 and any food or additive created after 1945 is HUPF. Some HUPF is older. Hydrogenated vegetable oil, for example, was invented in 1901. It’s possible the watershed date should shift 100 years earlier.

6. Any definition of HUPF, simple or complex, will require exceptions when implemented in law, policy, regulations, or programs. Exceptions will be added based on the circumstances of jurisdiction, institutional setting, nutritional needs, economic and financial dictates, or political influences. In order to have a defensible policy, the exceptions should be added to the language of the implementation and not be part of the main definition. In definitions offered and enacted so far, exceptions have been embedded in the definition – where they invite argument. I cannot think of any exceptions inherent to the simple working definition offered.

7. The proposed HUPF definition is in harmony with the original 2009 definition of Monteiro that has been the foundation of most research on the effects on health of HUPF. This compatibility provides an evidence-base for policy that could be implemented using the simple definition.

It was the youthful Hippies in the late 1960s who intuited that during their short lives our food environment had gone bad, with our diets co-opted by lab-created, unnatural products. The Sixties Counterculture’s insight into the dichotomy of natural/unnatural food is fundamental to understanding what HUPF is. Ironically, the Hippies valuable contribution, aimed at restoring the health of our food environment, has been co-opted by the commercial sector, with 557 Whole Foods stores worldwide stocked with aisles of HUPF.

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The health risks are bad, but the economics favor HUPF. In every implementation of an HUPF definition, policy makers may consider that HUPF can provide convenient, cheap calories, whether it is the increased costs of reduced-HUPF school lunches in California or the cost of calories in vegetables versus the cost of soda calories when sugar-sweetened beverage taxes are formulated.

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Thank you for reading. Your comments, likes, and shares are always valued.

It’s vacation travel season, so I thought I might be helpful sharing a preventative health tip I recently became aware of. It involves eating.

A chance encounter with the wrong bacteria or virus can create an unpleasant GI problem even here in America, so I always travel with Pepto-Bismol.

But it turns out the pink tablets are good for more than just treating a tummy problem. They can be a very effective preventative.

Imodium is always in by toiletry kit as well, just in case things get bad, or I have to be on a plane or somewhere else I can’t be guaranteed of getting to a restroom quickly. Pepto-Bismol is sufficient in most cases, but Imodium is the quick lock-down solution when needed. Pro tip: To avoid constipation, stop Imodium as soon as relief is found, and keep drinking plenty of water throughout the whole episode. Also, step up the fiber after stopping Imodium.

You likely know all this.

Perhaps, like me, you didn’t know that taking two Pepto-Bismol tablets every three hours during eating hours is very good at preventing diarrhea. Pepto-Bismol has an anti-bacterial and anti-viral effect, which has a chance to work - most of the time -because the Pepto-Bismol also helps your body absorb water from the intestines. In order for it to work best, take the Pepto-Bismol on schedule so it is in your GI tract when you eat. Take a maximum of 8 tablets every 24 hours.

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For Eating in America friends around the world or those looking for help after the fact in a farmacia in Latin America or a drugstore in Africa, you can ask for bismuth subsalicylate. Kaopectate in America also contains bismuth subsalicylate. Imodium’s generic name is loperamide.

Although bismuth subsalicylate is effective for indigestion and nausea as well as diarrhea, you’ll want to limit your use of it. It’s banned or very restricted in Western Europe because bismuth is a heavy metal, although research shows it has low toxicity. I don’t worry, but I wouldn’t take it regularly for indigestion.

Bismuth subsalicylate when taken as a prophylactic is mostly protective. In a randomized-control trial of American students who stayed for three weeks in a country where Americans often have traveler’s diarrhea (I won’t tell you about when I was there a few months ago and who on the trip had it) those on the placebo were three times as likely to get diarrhea as those on the full preventative dose of Pepto-Bismol. Forty percent of the students on the placebo got diarrhea!

Whether you take Pepto-Bismol or not, greatly reduce your chance of getting diarrhea when outside the U.S., Canada, Australia, Japan, and Western Europe, by never eating uncooked vegetables (including those bits of lettuce on your sandwich), fruit you don’t peel yourself, or street food. Never drink water or allow ice in your drink that you are not sure is purified. Be sure your food is freshly made and steaming hot, and avoid those sauces that have been on the table for hours or days. I know everyone has heard this advice or most of it, but a lot of people don’t fully follow it, and, when I travel, I have seen most of those people get sick.

Finally, if you’re traveling someplace more “iffy,” especially if you’ll be any distance from reliable medical care, you might ask your doctor for an antibiotic prescription to have on hand just in case of a real emergency.

Pay attention to all drug precautions, check in with your doctor with your status and questions, and remember my advice cannot replace that of a trained medical professional.

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And send photos.

Thanks for reading. You’re the best.

Please note that a small portion of the text of this podcast is taken from an Eating in America Note, published on EatingInAmerica.co this week.

I propose a new, simple definition for highly- and ultra-processed food, the definition of which shouldn’t be, but nonetheless has become, perhaps the most important nutrition issue of 2026. It has been made an issue as a tactic of delay by the Big Food lobby, which will exploit any opening to postpone the possibility of regulation of highly- and ultra-processed food.

You haven’t heard from me as much as usual lately because I have been working on this definition intensely over the last few weeks. My hope is to provide a fresh perspective that provides a framework for the clearest, simplest, most durable way forward.

Highly-processed food = ultra-processed food

Highly-processed food and ultra-processed food are two terms for the same thing. This is supported by the new Dietary Guidelines, which uses the term highly-processed instead of ultra-processed. I will use the abbreviation HUPF, standing for highly- and ultra-processed food.

HUPF and disease

HUPF has been linked to many chronic diseases, including obesity, heart disease, cancer, diabetes, and dementia.

The Tobacco Playbook: the chapter about delay.

Big Food knows HUPF as a category is bad for our health and that it will be increasingly regulated at various levels of government. But Big Food has had close ties to the tobacco industry, so, like Big Tobacco, they have learned all the tricks and moves to fight regulation, including those in the chapter about delay in the mythical but often cited Tobacco Playbook. This is the set of schemes and strategies that has been used not only by Big Food, but the alcohol industry and opioid manufacturers, and is being employed now by the gambling industry.

To interfere with the growing momentum toward regulation, the question of a viable definition of ultra-processed food has been pushed by the HUPF food lobby, America’s biggest. RFK, Jr.’s Health and Human Services department and the USDA have been struggling to settle on a definition of ultraprocessed food that can be used for writing policy and regulations. Kennedy says the definition is finished and is awaiting the approval of Trump now. This holding pattern means Big Food is not done lobbying on the issue.

A simple definition of HUPF is needed

I predict the Trump administration will come out with a not-simple, maybe even tricky, definition that is as favorable as possible to Big Food while maintaining the appearance of addressing the concern with HUPF that is a core issue of Trump’s important constituency, the Make America Healthy Again movement.

The Big Food lobby and HUPF

However, what Americans actually need is a clear and simple definition of HUPF that can’t be corrupted by Big Food.

I can ‘t know for sure that the federal HUPF definition will be compromised by Big Food’s influence but, given the record of this administration and the record of success and power of the Big Food lobby, it is a safe bet that industry profit will be considered at least equally with public health in the forthcoming Health and Human Services and USDA definition.

For examples of the power of Big Food, their lobby got the word “ultra-processed” taken out of this year’s Dietary Guidelines, even though RFK, Jr. is an avowed enemy of HUPF. And the Make America Healthy Again Strategy Report, of September 2025, mentioned ultraprocessed only once, in the context of the need for a definition.

Before RFK, Jr. and the USDA issue their Big Food-compromised definition, I have a proposal.

First, some background.

Carlos Monteiro, the scientist who invented and popularized the term “ultraprocessed food,” did the world a huge service in identifying how the food we are eating is industrial, formulated to be addictive, heavily marketed, all about profitability, and not healthy. Monteiro defined ultraprocessed as generally bad and not ultraprocessed as where the good lies, which is all true. But his definition of ultra-processed was too inclusive and not simple and clean enough to be used for policymaking.

Clarity from an unlikely source

I respectfully offer a simpler way to view what has happened to our food environment and how it happened, a clear dichotomy that was popularized in the late 1960s by none other than the Hippies.

Without the benefit of science or research, the love-beaded, bell-bottomed folks of the Counterculture Revolution intuited that the direction the food environment had gone was all wrong. They understood American diets were being co-opted by the marketing and lab-created, unnatural products of Big Food. They said, “What was the matter with the way we were eating before?”

The natural food movement blossoms

And so the natural food movement was born in earnest. In the words of Crosby, Stills, Nash, and Young from 1969’s Woodstock, “…we’ve got to get ourselves back to the garden.”

Suddenly un-sugared granola and un-sugared plain yogurt were to be found in small urban food co-ops along with raw milk, whole grains, nuts, honey, molasses, organic vegetables, lentils, brown rice, tofu, and sprouted beans. Highly- and ultra-processed food were rejected. To the youth of the Counterculture, this was an entirely new way of eating, but to the grandparents of those Hippies and their grandparents and their grandparents, this was just the way food was supposed to be. Except for the tofu, of course, which was “far out, man.”

The end of World War II and the beginning of the HUPF Era

These twenty-somethings had been born in the years surrounding the dropping of the first nuclear bombs in 1945, ending World War II and beginning the Atomic Age, and the Anthropocene Epoch proclaiming the most pronounced human impact on our planet, and, not coincidentally, the HUPF era.

It is no coincidence that the HUPF era directly follows World War II. The needs of the Allied war machine had driven both the development of new HUPF food products for our soldiers and chemical design and manufacturing that fueled the rapid rise of commercial HUPF after the war.

HUPF harms? We happily swallowed the problem.

Why did it take until the early 21^st century, 60 years after the start of the HUPF era, for concern about the radical change in our food environment to come to the forefront in American society? Money, marketing, and our indulgence and belief in the delightful wonders of HUPF, perhaps. You could say we swallowed the problem. Fortunately, the now almost extinct human subspecies called Hippies – I say that with love and peace – seems to have been created on earth to detect the unnatural change in our food that had occurred and to call out the alarm.

The Hippies’ natural foods is now a commercial sector

We are five plus decades beyond the start of the “back to natural foods” movement. That movement is now a fully commercialized sector of our food system with 557 Whole Foods stores globally. And despite the array of HUPF products in Whole Foods stores, the Hippies did start us on a healthy way forward.

The stark division identified by the Counterculture between new food and natural food is the true way to think about ultra- and non-ultra-processed food and the best starting point for a definition of HUPF.

A new proposed definition

Highly- and ultra-processed food is produced from food or chemicals modified or newly created with methods of the Second or Third Industrial Revolution. That is my definition of HUPF in 23 words.

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There are several tenets to the definition

1. HUPF is unnatural food. Natural food, if processed or modified, is done so with methods that predate the Second Industrial Revolution* (see the footnote for an explanation of the dates and the nature of the first three Industrial Revolutions), and in the case of techniques like fermentation, by thousands of years.

EXAMPLE

Yogurt is a food that can be very healthy in its natural form but is now sold mainly in a modified form with post-industrial ingredients, making it HUPF in those cases. Yogurt is the example almost always cited (to the delight of the HUPF lobby) when the Big Food-inflated problem of defining HUPF is discussed. The question always posed is “What about yogurt with its additives? It’s healthy food!” The answer is “Okay, although healthier in its natural form, but if you want to make a law banning HUPF while making an exception for yogurt: fine, help yourself.”

2. Everything that is natural food has been consumed by humans for a long time. Humans have learned what to eat and what not to eat over millennia. We have adapted some food to our biological needs, or, in some cases, our biology has adapted to the available food. What we eat, works for our health.

EXAMPLES

First, we have developed genetic adaptations in some cases. Lactose intolerance develops in children as a way to force their weaning from mother’s milk in order that their new baby siblings can get adequate nutrition. In northern cultures where animal milk is common, lactose intolerance has evolved out of the genetic pools, allowing more resilience to famine. Second, a traditional Inuit diet, which is all protein and fat and lacks vegetables and fruit, adapts the available food by including raw organ meat like seal liver and caribou brain which is rich in vitamins. Furthermore, evolution within the Inuit genes allows the metabolization of fat from their hunted food in a way that reduces bad cholesterol and heart disease.

3. Everything that is HUPF is a new or relatively new industrial invention, or it is a food that is a new risk because of mass production allowed by a high level of processing.

a. All of the many thousands of food products and additives created after 1945 are HUPF. Keep in mind, please, that 1945 is not a hard and fast date, pending further investigation and discussion of how far back it could be pushed. For now it is a safe and convenient date to mark the watershed after which no new natural food could have been created. We can say no new natural foods have entered human food environments since at least 1945 and any food or additive created after 1945 is HUPF.

b. Some HUPF is older.

EXAMPLE

Hydrogenated vegetable oil, or transfat, as in margarine or Crisco shortening, was invented in 1901. It was marketed as a healthy alternative to butter, but in reality, is very toxic to heart health.

c. Second Industrial Revolution processes made some moderately processed food into HUPF. These foods had been tolerated without great harm in small amounts in our diets, but they became significant health risks when they became widely and cheaply available by virtue of mass production, made possible by a high degree of processing. The nutritional and structural character of these foods was the same as it was in the pre-industrial age, but industrial processing and mass production lowered cost and allowed over-consumption.

EXAMPLES

Refined sugar, highly refined flour, salt, and white rice are in this sub-category of HUPF.

4. Where natural food is available in sufficient quantity and quality, it is sufficient nutritionally. In such an environment, HUPF brings few nutritional advantages to the table.

The health risks are bad but the economics favor HUPF.

HUPF is an overwhelmingly negative nutritional contributor to diet but has economic value on the basis of convenience and cost per calorie. Policies addressing the pervasiveness of HUPF in our food environment have to deal with these economic factors, whether it is in the potential increased cost of school lunches -- as in California’s HUPF school food ban -- or when creating sugared beverage taxes, which have the greatest effect on lower-income households.

Policy makers are aware that when the choice is between sufficient HUPF calories or insufficient healthier calories, having sufficient calories must win every time. Hungry children, and there are many in America, are not okay. The cost of healthy food is the greatest and broadest nutrition policy challenge in America.

We have to acknowledge that HUPF is not by definition harmful.

Some HUPF substances are toxic. Some might be fine in low doses found in normal consumption but toxic in high doses. But for most HUPF we don’t have safety data, and it would be very difficult to get. Some HUPF likely have benefits outweighing any risks. For example, seed oils are good replacements for animal fats. Some preservatives like nitrites and nitrates reduce levels of dangerous bacteria but present their own carcinogenic risks. I would suggest the sensible default, where we can afford it, is to pass over HUPF unless there is strong evidence it is safe.

HUPF may never be removed from our food supply, but it will hopefully be reduced in many helpful steps and stages.

California leads the way, as usual

Impatient with delays addressing the health harms of HUPF, some states have proceeded with their own definitions and laws. California leads the way, as usual, using Monteiro’s 2009 definition as a basis.

Monteiro’s definition has been widely used in research for approaching 20 years, but it is overly descriptive and inclusive. Nutritionists and policy makers, joined by a happy chorus from the Big Food lobby, have been in consensus that the Monteiro definition is not well-suited for regulatory, law-making, or program-design use.

Complexity and exceptions weaken definitions proposed to date

Other nutrition scientists have offered their definitions, hoping to provide a more independent, scientific perspective than any that will come from Health and Human Services and USDA. Typically, these HUPF definitions are not simple and have exceptions built in. Any complexity and any exceptions will be examined by Big Food for an opportunity either to argue that certain HUPF products are not covered or to re-design their products to avoid coverage by regulation. A simple, solid definition presents less openings for argument and so can be more impervious to corruption by Big Food.

Also, any definition of HUPF, simple or complex, will require exceptions when implemented in law, policy, regulations, or programs. Exceptions will always be added based on the circumstances of jurisdiction, institutional setting, nutritional needs, economic and financial dictates, or political influences. In order to have a defensible policy, the exceptions should be added to the language of the implementation and not be part of the main definition.

EXAMPLE

The usefulness of simplicity is seen in the FDA smoking control regulations where the target was defined simply as nicotine in combustible tobacco products. The streamlined approach to defining the problem helped create an extremely effective regulatory framework for tobacco control.

Conclusion

HUPF consists of thousands and thousands of substances created mostly in the decades since the end of World War II and the beginning of the Third Industrial Revolution.

Most of these modified foods and additives have no substantial certification of their safety on record. They are not sold to us for our health. They are produced to profit the corporate coffers of Big Food. The quick creation of an effective regulatory framework for HUPF, beginning with a strong and durable definition, would reduce health harms and deaths from diseases that are linked to HUPF and point to a possible return to a healthy food environment.

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Footnote

*The First Industrial Revolution, from the late-18^th to mid-19^th centuries, was about the transition from the agrarian economy to industrial employment, mainly in textile factories in England. Industrial innovation for the production of HUPF occurred mainly with the Second and Third Industrial Revolutions. The Second Revolution was from the mid-19^th to mid-20^th centuries and saw massive leaps in technology and communications with the dawn of electricity, steel, telephone, internal combustion engines, and expanded railways. The Third Industrial Revolution was, in essence, the Digital Revolution, which began after World War II.

Trump suppressed a major government-led study on alcohol, health, and risk of death meant to guide the writing of the 2025 Dietary Guidelines for Americans. Although a draft of the report had been released for public comment, this was, nonetheless, a big win for the alcohol industry.

This week the scientists who did the research published the results that Trump, Republicans in Congress, and the alcohol industry don’t like. The paper appeared in the peer-reviewed Journal of Studies on Alcohol and Drugs.

We’ll walk through what the research says, and, I’m sorry, it may not be good news if you enjoy alcohol, as I and most Americans do.

But first, here’s what has happened.

The Interagency Coordinating Committee on the Prevention of Underage Drinking, a group with expert scientists endorsed by the USDA, Health and Human Services, and many agencies, was tasked in April 2022 with studying the effect of alcohol on health. Later in 2022 Congress passed a law mandating a similar report from the National Academies of Sciences, Engineering, and Medicine. On paper, the two studies were meant to be complementary and to inform recommendations on alcohol intake in the 2025 Dietary Guidelines. But the National Academies research was tainted from the outset by the strong financial links of some of its scientists to the alcohol industry.

Congress attacks the work of the Interagency Committee

During their nearly three years of work, the integrity of the Interagency Committee process was assaulted by Republican Congressmen acting in tandem with the alcohol lobby, who feared the tightening of the 2020 Dietary Guidelines, which recommended limiting alcohol to two drinks per day for men and one drink a day for women. The lobby also feared the Interagency Report would state that alcohol was a cause of cancer, since that evidence had already been solidified in the scientific literature.

Representative James Comer, Republican from Kentucky, home of Bourbon whiskey, led an aggressive congressional investigation into the work of the Interagency Committee. In January 2025, at the release of the draft report, Comer issued press releases from the House Oversight Committee on Reform accusing the Committee of work that was unlawful, biased, and wasteful, and executed with a predetermined outcome using cherry-picked data.

Meanwhile, the National Academies of Sciences report had been released a month earlier, in December 2024.

National Academies report finds drinking causes breast cancer

The National Academies of Sciences found that drinking was a cause of breast cancer. This was bad news for the alcohol industry but represented the minimum about cancer the Academies report could say, given the mounting evidence. The National Academies scientists also reported there was what they called “mid-grade” evidence, not strong but not weak, that moderate drinking, defined as one drink per day or less, resulted in a 16% decrease in risk of death compared to non-drinkers. The alcohol industry liked this.

Interagency Committee report finds drinking causes seven types of cancer

On the other hand the Interagency Committee draft report found “… the risk of dying from alcohol use begins at low levels of average use” and from there, the more alcohol the more the risk. In contradiction of the 2020 Dietary Guidelines, the Interagency report said men generally have the same level of risk as women, which is a one in 1,000 risk of dying from alcohol use if consumption is more than 7 drinks per week. The risk increases to one in 100 with more than 9 drinks per week. The Interagency Report also found that seven types of cancer, not just breast cancer, were causes of alcohol-related deaths.

These Interagency Committee results were not at all friendly to the alcohol industry, or, frankly, to the many people who drink in what is considered moderation. If the Dietary Guidelines were going to be written in alignment with this study by Health and Human Services and the USDA, the new Guidelines would need to lower the 2020 Guidelines’ recommended limit on alcohol of two drinks per day for men and one for women and add a warning that alcohol is a cause of cancer.

The Interagency report is 86’d

But the Trump administration took office two weeks after the Interagency draft was released and the report was never finished and published.

The 2025 Dietary Guidelines on alcohol are toasted by the alcohol industry

When the 2025 Dietary Guidelines were finally finished and released in January 2026, based on a new made-to-order, quasi-scientific report, the alcohol lobby was flush with success. The new Guidelines removed the recommended limit on drinking and instead simply advised, if drinking, to drink in moderation. Going against the science in both the Interagency and the National Academies reports, the Guidelines made no mention of cancer.

The Interagency research re-surfaces in a peer-reviewed journal

This week the six original authors of the Interagency report, joined by 19 additional co-authors, published a paper with the results of the Interagency research. Their original findings stand that low levels of drinking don’t have a protective effect – a little alcohol isn’t necessarily bad, but it isn’t good for you. A little more alcohol and then the risk of disease, including cancer, and death becomes apparent. At 8.5 drinks per week the risk of an alcohol-related death becomes one in 100, for both men and women. At the previous recommended limit of 14 drinks per week for men, the risk of an alcohol-related death is one in 25.

The publication of this paper is important. It stood up to independent peer review, has four times the number of authors as the original report, and can now be cited by other scientists, policy makers, and program designers going forward.

100,000 cancer cases annually due to alcohol

Studies have found about 20,000 to 25,000 annual American cancer deaths due to drinking. 83% of these deaths could be prevented by drinking within the 2020 Dietary Guidelines of a maximum of two drinks per day for men, one for women. In thinking about the meaning of this statistic for your own choices, remember that these are just cancer deaths, and that cancer cases due to alcohol total about 100,000 annually. Any case of cancer tends to have a bad impact on life.

These two reports raise somewhat different levels of alarm, but both make clear cancer is a risk with drinking.

That alcohol causes cancer has so far escaped the knowledge of 60% of Americans. There will be better awareness of alcohol’s relationship to cancer if and when a warning is incorporated in the Dietary Guidelines, as it should have been this year.

Informing Americans about the risk

The word is getting out there despite the power of the alcohol lobby. In January 2025, just before Trump took over, the U.S. Surgeon General’s office issued a report saying alcohol is a leading cause of preventable cancer. And, don’t tell Trump this, the CDC still has a web page listing the seven cancers caused by alcohol and advising that reducing drinking lowers cancer risk. By the way, the CDC takes the trouble to point out that red wine (or white, for that matter) carries the same risk as beer and hard liquor.

Making personal choices

Given that the National Academies group had financial links to the alcohol industry and was engaged by Congress to provide a counter to the work of the Interagency group, I lean toward the findings of the more worrisome Interagency Committee study. Of course, neither endorses drinking as a safe habit. As someone who enjoys alcohol, I am still weighing my own, personal level of concern.

I do know I am thankful for the work of all the genuine, independent scientists and public health officials publishing and acting on this issue and that the findings of the Interagency Committee and the National Academies were able to be brought into the open despite the efforts of the Trump administration to repress science it doesn’t like. Let us know what you think in the comments!

Thank you for reading.

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Elon Musk and Joe Rogan, eat your hearts out.

In today’s game, three doctors walk into a Fox TV studio for a taping of Survivor, Surgeon General. Two of them work for Fox. Two of them got their medical degrees at schools in the Caribbean. One of them lies about her qualifications. Two of them are selling supplements. One of them isn’t really a doctor and is a recent stockholder in tobacco. Two of them are not completely pro vaccine. Which of these three are qualified to be the U.S. Surgeon General? Who will be voted out? You decide, because you are a whole lot more qualified than the President who nominated them.

Candidate #1

To recap our game so far, Donald Trump named Dr. Janette Nesheiwat as his nominee for Surgeon General two weeks after being elected to his second term. In his statement, the President-Elect repeated Nesheiwat’s lies about being double-board certified and a graduate of the University of Arkansas School of Medicine. In fact, her medical degree is from a Caribbean university, which as a group are best known for accepting those who fail to get accepted into a U.S. medical school. For many though, the Fox commentator’s real fault was that she was pro vaccine and science. People who wanted someone who could be trusted to speak the truth about everything, not just vaccines and science, objected to the nomination, and everyone else wanted someone who would not speak the truth about science, so they objected, too.

“YOU’RE FIRED!”

Warming our hearts with his famous Apprentice reality TV show catchphrase, in May 2025 the President told Nesheiwat, “You’re fired!” as the Surgeon General nominee.

Candidate #2

Next up, vaccine skeptic, supplement seller, tobacco investor, and not-an-actual-doctor Casey Means was the second nominee for the nation’s top doctor. Means is a darling of the MAHA movement, and they love everything about her -- except MAHA folks didn’t mention her holdings in tobacco giants Altria Group and Philip Morris.

With everything else to complain about with Means, the tobacco investments did not get much attention, but to me it was a serious red flag. Surgeons General through the years have played a huge role in turning public attitudes about smoking toward the negative, but there is still a long way to go with tobacco. Smoking remains the leading preventable cause of death in America with a half-million deaths annually. We can’t have a Surgeon General nominee who profits from tobacco.

“YOU’RE FIRED!”

But it was the not-a-real-doctor thing and her vaccine skepticism that tanked Means’ nomination in her confirmation hearing. Trump said, “You’re fired!”

Candidate #2

Trump’s third nominee hoping to be named “Survivor, Surgeon General,” is Dr. Nicole Saphier. Like Nesheiwat, Saphier both graduated from a Caribbean medical school, yup, and was a commentator on Fox News. Like Means, Saphier sells supplements and has expressed ambiguity about vaccines.

Let me be clear, ambiguity about FDA- and, more importantly these days, W.H.O.-approved vaccines is completely inappropriate in a Surgeon General. But since Eating In America is about what we consume in our bodies, I will object to Saphier on the basis that she is yet another snake oil selling nominee, who claims science where there is none, makes health promises where there is no or insufficient evidence or expert scientific consensus, and takes money for products where there is no proven efficacy but there are serious concerns about safety.

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Outrage #1: Saphier proposed as Snake Oil General

Saphier, in addition to her job as a radiologist and work on Fox, is a maker and vendor of a line of wellness supplements. Her company, Drop Rx, sells four elixirs, she calls them tinctures, for about $10 an ounce. They are named “Focus,” “Calm,” “Soothe,” and “FemmeX.” Saphier makes unsupported health claims for these formulations of unquantified herbs and ultraprocessed ingredients and one of them contains an ingredient, kava, that is banned in the U.S. military.

I will come back to this outrage, and the even bigger outrage of the way the U.S. handles supplements, in a moment.

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Don’t mess with the Chinese sea snake

We all may have become familiar with the term “snake oil salesman” by watching American Westerns where men in bowler hats sold cure-all elixirs out of the back of a covered wagon. There is a surprising origin story to these early wellness hucksters.

180,000 Chinese laborers brought the oil of the Chinese sea snake, the extremely venomous black-banded sea krait, when they came to build railroad lines in the American West in the mid-1800s. This traditional medicine is very rich in eicosapentaenoic acid, or EPA, an anti-inflammatory omega-3 oil. The snake oil might have provided some relief for aches from pounding stakes into railroad ties all day and the other difficult and dangerous work these men were doing. There is some evidence that EPA can help with joint pain. But I can’t help speculating if the crates of snake oil didn’t also contain some bottles of snake venom wine, also a traditional Chinese medicine and a more powerful treatment for pain than snake oil.

The Rattlesnake King

In any case, inspired by the widespread Chinese use of sea snake oil, a man named Clark Stanley showed up in Chicago in 1893 dressed as a cowboy and carrying live rattlesnakes and bottles of supposed snake oil that actually contained only mineral oil, beef fat, red pepper, turpentine, and Stanley’s false claims of healing powers. But Stanley was a good hawker, and the snake oil business took off.

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Snake oil elixir, a new law, and a $20 fine

A surge in snake oil and other elixir sales was part of the reason for the passage of the Pure Food and Drug Act of 1906. That law was the basis in 1917 for fining Stanley $20 for his false health claims. The fine didn’t hurt Stanley, but the bad publicity resulted in him having to shut down his factories and, in fact, his whole operation.

Defining a supplement: food, drug, or a little of neither?

Skipping ahead to 1994, the new Dietary Supplement Health and Education Act categorized supplements as food, not drugs. As a subcategory of food, supplement makers don’t have to prove their products work or are even safe before putting them on the market. Further, while food items aren’t allowed to make unapproved health claims, food supplements are given a lot more leeway. They are not supposed to make health claims, but, well, they do.

The American snake oil supplement system

The system we have is deficient. Americans spend $60 billion a year on supplements that are not reviewed for their health claims or safety.

Some of these supplements are meant to be nutritional, like vitamins, minerals, omega-3 fatty acids, or whey powder protein, for example. These should be regulated like food and held to the same strict FDA standard for food health claims.

Other supplements are, in essence, over-the-counter drugs. These include products containing psychoactive ingredients. Some supplements in this group are meant to calm us, like bacopa monniera, or make us alert, like ginseng. The other supplements in this group are advertised as being associated with a range of health benefits such as stress relief, inflammation reduction, or soothing digestive issues. Like any drug with a health claim, these should be treated by the FDA as over-the-counter medications and verified for safety and the validity of their claims.

Surgeon General hopeful Saphier’s supplement

Let’s check one of Surgeon General nominee Saphier’s Drop Rx products, “Calm.” “Physician formulated. A clean product you can trust. Experience the power of nature, backed by science.”

So, a doctor designed it, Drop Rx says we can trust its safety, and science says it works. Well yes, there is some science that supports the psychoactive calming effect of ingredients, including kava, in Calm. But there hasn’t been the rigorous testing that should accompany any psychoactive product that is, in essence, a drug.

Kava, unfit for service

But, worse, the science also points to kava’s risk of liver damage, which is the reason the U.S. military, UK, France and Switzerland have banned kava, and the FDA published advisories about its potential toxicity in 2002 and 2020.

There is some confusion about the kava in Calm. In two places the Drop Rx website shows the presence of kava in Calm and in two other places on the website the kava is missing in favor of another psychoactive ingredient. But regardless of the quality, safety, and efficacy of Saphier’s elixirs, the fact that she is selling supplements is the basic issue.

What we need in a Surgeon General

We need a Surgeon General who is deeply committed to solidly scientific approaches to saving lives and improving our health, with a desire to communicate about the effectiveness and safety of vaccines, the need to control tobacco and addictive substances including ultraprocessed food, along with addictive media and digital and instantaneous gambling, the need to treat unhealthy weight in Americans, and the urgent need for diligence in the face of new global health threats due to both climate change and the ease of pandemics to spread.

As long as Trump puts forward candidates as inappropriate and unqualified as Saphier, we can only hope the game of Survivor, Surgeon General will go on. But, for better or worse, it seems that the lack of an actual Surgeon General is not going to stop the Surgeon General’s office from issuing Surgeon General advisories. This past week RFK, Jr. went ahead and signed and released a Surgeon General’s report warning about excessive screen time for kids.

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Here’s a story that is so scary and sobering that only a science fiction writer could make it up. Only it is not fiction.

And while a mere epidemiologist like me could not have conceived this story – it is too outrageous given what we know today – the story does provide us, and by us, I mean scientists including epidemiologists, media, and the public, at least several sobering lessons.

I love food history stories. They can be so informative. Here we go.

The butter part of this story started maybe 10,000 years ago, perhaps when some nomads put goat milk into a bladder, and as the nomads walked the bladder bounced around and churned the milk into butter.

Butter has been loved ever since.

The margarine story started in France in 1869. It was not love at first taste. Napoleon III wanted a cheap, hardy alternative to butter to send to sea with the Navy and to feed the bottom ranks of the working class. The resulting margarine didn’t work out for the Emperor. Neither the Navy nor the poor wanted it. But the idea of a cheap butter substitute was too good to throw away, and in 1901 a chemist invented partially-hydrogenated vegetable oil. Crisco, which was 100% partially-hydrogenated vegetable oil, came on the market ten years later in 1911, and by 1930 margarine was made with partially-hydrogenated vegetable oil.

Let’s pause for a reminder. Partially-hydrogenated vegetable oil is a horror story of its own. It is toxic with trans fats, and trans fats can increase the risk of death by a third. 34% to be exact. Trans fats raise the risk of heart attack, stroke, Alzheimer’s, and cancer.

Nutritional epidemiologist Walter Willet and others found solid evidence that trans fats were bad for the first time in 1990. However, the FDA, with its cumbersome process combined with pressure from the ultraprocessed food industry, took until 2015 to revoke the GRAS, or Generally Recognized As Safe, status of industrially made trans fats, banning them from food only eight years ago, in 2018. And yes, partially-hydrogenated vegetable oil can be seen as a very early poster child of the ultraprocessed food industry.

Back to our story, the butter shortages during World War II conditioned the American public to eating margarine, and the gap between butter and margarine consumption narrowed. In the post-war years, the margarine industry saw a bright future.

Convincing the public of margarine’s healthiness with biased-science and media

In the most audacious industry funding of research I know of, around 1945 the National Association of Margarine Manufacturers gave funding to three scientists at the University of Chicago and the University of Illinois to compare the health effects of margarine versus butter.

That grant in itself was not audacious, but it might have been innovative. We think of industry funded research as part of the playbook written by the tobacco industry, which passed the practice on to the ultraprocessed food, opioid, cannabis, and gambling industries. But, in fact, this was a case of the ultraprocessed food industry funding research eight years before the tobacco industry started its massive effort in 1953 to co-opt the science linking smoking to cancer.

Of course, no matter who conceived of the idea of funding science to get advantageous and respectable-seeming results, or, in the case of tobacco, just to cast doubt on the good science coming out, the priorities were always the same, profits before science before health.

The audacious piece is what the Chicago scientists were paid to do. Previously all the research on the healthiness of margarine versus butter was done on animals, almost always lab rats. This grant was to do human research.

To put this in context, this money was delivered three years before German doctors were put on trial in Nurenberg for their concentration camp medical experiments on prisoners. This money came in the middle of the 40-year course of the Tuskegee Syphilis Study which withheld antibiotics from infected men who were Black. This was nine years before the NIH became the first institution to require a review of human subjects research it conducted. By the way, the NIH review program was only to provide itself legal protection, not primarily as a matter of ethics.

Here’s the thing. The doctors in Chicago were paid to conduct their research on orphans in two orphanages. One orphanage ate butter and the other ate margarine. The research went on for two years and was done on 350 children from 2 to 17 years old. They were weighed monthly and their heights were recorded, with blood draws to measure their red blood cell count and hemoglobin. Medical records were checked only to see if one orphanage was seeing a difference in health compared to the other. In their resulting paper the doctors seemed strangely excited the margarine eating children were much healthier than those that ate butter, although they took care to say in the paper that the very good health was certainly not “simply because” of the margarine.

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It was a poor study with a poor design, written up with bias in favor of its funder, but of course the outrageous, nowadays unthinkable aspect is that forcing this study on these children was seen as acceptable. Children cannot give their consent to being subjects of research. Furthermore, these toddlers and kids and teenagers were wards of the state and in an institution where one might imagine they were experiencing some level of trauma or emotional distress on a daily basis. The margarine research equated them to lab rats with human metabolisms.

Having no consciousness about the possible harms of this research to its subjects paid off for everybody but the children. Especially the margarine industry, which saw a favorable paper, “Margarine And The Growth Of Children,” published in the Journal of the American Medical Association, one of the world’s top medical research journals. The very influential TIME Magazine picked up the story, quoting the scientists’ conclusion that “Margarine is a good source of table fat in growing children…”

Within a couple of years as much margarine was being eaten as butter. Margarine continued to grow in popularity, becoming consumed twice as much as butter by 1970.

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Today, Institutional Review Boards, or IRBs, in the U.S., or their equivalent in Europe and elsewhere, but not China or Russia, carefully screen all proposed research plans at universities or any organization doing federally funded research or FDA regulated trials, to ensure strict ethical standards are met. The margarine study would not have passed IRB review.

Are our problems with unethical research solved in the U.S.? Apparently not in RFK, Jr.’s department, home to the FDA, NIH, and CDC, three agencies that fund or review a lot of human subjects research.

At the end of 2025 it was revealed that the CDC had given a no-bid contract to Danish researchers to test the effect of hepatitis-B vaccines on newborns vs. 6-week old babies in Guinea-Bissau in Africa. The researchers are friendly with anti-vaxxers aligned with RFK, Jr. Kennedy has strongly praised one of the researchers. A leaked protocol for the study points to an intention on the part of the researchers to show that withholding the vaccine for six weeks is safer than giving it at the same time as other newborn vaccines. The World Health Organization is clear that withholding the hepatitis-B vaccine at birth is dangerous, risking the long-term development of serious illness and death due to transmission of hepatitis-B from the mother during birth. 18% of adults in Guinea-Bissau have hepatitis-B.

In sum, Kennedy disregarded procedure to give a contract to researchers who designed a study to exploit the high prevalence of a disease in an African nation. The leaked protocol revealed that their intent was to support the CDC’s dismissal under Kennedy of the hepatitis-B vaccine recommendation for newborns. There was no review by an IRB at the CDC of this research. The study has been decried as unethical by the World Health Organization and research ethicists and scientists, and it has been likened to the Tuskegee Syphilis Study. As of March 2026 the study was on permanent hold.

While this began as a horror story about industry-funded, completely unethical research that found that margarine was as healthy as butter, again not true, we ended with another scary story of highly unethical research. Only this latter study was funded by a government politician, RFK, Jr., who happened to be in charge of a group of prestigious scientific agencies and yet had the goal of supporting his own dangerously wrong and unscientific ideas about vaccines.

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This month Lela Nargi in an article in The Guardian wrote about one of the studies I led that, together, examined, among other things, the use of cars vs. buses vs. walking to shop for healthy food. I told Ms. Nargi that I thought buses were a terrible way to have to go to get groceries, at least compared to going in a car.

As part of the access to healthy food research, we surveyed community leaders in the three communities in Rhode Island where the data collection took place.

One woman’s response spoke for many bus users and made a lasting impression on me. She was a shopper who uses a wheelchair, but her comments apply equally to those fully able to walk:

If you are allowed to take a small travel cart onto the bus often you have trouble getting it on and off the bus and are in the way of other patrons, so a lot of bus drivers will refuse you service if you try. Many of the bus routes do not go to where there are less expensive markets, and if you want to go to one of them you have to walk quite far. If you find sales in different locations, it’s not worth the effort and extra expense of travel time. Also, the weather is a factor – rain, snow, extreme heat – keeps many people from making the hike to the bus. Sometimes bus routes are a couple of blocks away. If this is the only choice you have, making your way to the market usually means going two-three times a week. There are many people who have to take taxis just to get their groceries home, which is expensive. Most often we are elderly or disabled and must shop on our own, consuming much of our day. When I’m told how lucky I am to be on a bus route, I like to tell people what I must go through to get a few days of groceries, and I prefer to use my electric wheelchair and lug my groceries home on the footrest of my chair.

As one community member lamented, the food system was “designed for drivers.”

There are a number of studies that measure physical access to food by car, but not many that attempt to measure access by transit bus. It’s difficult, and no one had figured out how to accurately estimate the number of people who could reasonably access a given supermarket or other location (like a health center, for example) by bus. It’s important for policy and planning to see how many people can get to a service location or potential location in a reasonable amount of time. But it’s very tricky to do that.

To use a bus, the shopper has to walk to the stop, wait for the bus, ride, and then get off and shop. This assumes there is a bus stop close to the supermarket, which is often the case. Coming back the shopper has a wait for the bus, ride, and walk home from the stop. Walking takes a fairly standard amount of time; bus stop waiting times range from none at all to who knows, depending on the spacing between buses and when exactly the shopper arrives at the stop; and usual bus speeds vary according to the time of day, usually being slowest during rush hours.

There aren’t any great software tools to put all these segments together to give the best estimate of how far away a supermarket or pantry could be for a shopper on a time budget, so I had to invent a new method. I won’t bore you with the details, but to see how many people in a community live close enough to reach a supermarket in a reasonable amount of time, you have to figure out what a reasonable amount of time is.

For this we depended on a group of community leaders who told us that, if you have a car, a round trip of 18 minutes is reasonable. Let me stop right here for a spoiler alert.

Basically, in all three communities, anyone with a car for shopping was within reach of at least one affordably priced supermarket and one healthier food pantry, given a time budget of 18 minutes for the round trip driving. If you had a car, physical access to affordable food for most people was no problem.

For those using a bus, the community leaders said a reasonable time budget for the traveling part of the shopping excursion was 36 minutes. This makes sense in these urban or semi-urban communities. It is mostly a given that using a bus is going to take longer than driving a car for food shopping.

What doesn’t make sense, when you think about it, is doing the calculation for how accessible food is by bus for a community when you start with the assumption that bus users have twice the time budget to do shopping. I don’t think bus users can be assumed to have more time on their hands than car drivers, but that is the approach taken by other studies like ours, and that is the way we did it.

Ours was an inherently inequitable, unequal measure for comparing healthy, affordable food access by car versus by bus.

I led the research, and I own that flaw in equity.

As you will see, if we had analyzed the data using the same time budget for shopping by bus as for shopping by car, the result would have been dramatic.

Perhaps it is dramatic enough to find that given a 36 minute round trip, only half of the people in the three communities had access to an affordable supermarket. Only one out of five could reach a food pantry that offered produce.

However, if we had cut the bus round trip budget by half to the 18 minutes allowed for a car round trip, the estimate of the number of people in each community with access to healthy food would have fallen to zero. All of the 18 minutes would have been consumed by walking to and from the bus stop and waiting for the bus on each end, leaving no time to actually ride on the bus

There is no perfect method for assessing food access, but the grand lesson is that, apart from all the hassles of using the bus, the time required for shopping by bus is never going to be the same as for driving, no matter how little time you have for shopping because the adults in your household have multiple jobs or you have multiple children to manage.

We found out some other interesting stuff. First, supermarkets and some food pantries were the only sources of a reasonable amount of healthy food in our study area. The seventy convenience, corner, and dollar stores in the three communities, and we surveyed them all, did not come close to clearing our low bar for having enough healthy food.

Second, the results of our cost analysis of shopping at the accessible supermarkets was a shock. We priced a selection of produce and dry and can goods at each store. The food we checked at the most expensive store cost twice what the same food did in the least expensive store. Shoppers who could access one of the three discount supermarkets could buy twice as much food compared to those who only had access to the most expensive store. The ability to make the food dollar go twice as far makes a world of difference to a family on a limited income, and about 10% of the population of the three communities lives in poverty

Buses can be somewhere between tolerable and great for commuting to work. When I was in college, I got up at 4 am every morning for a two-hour ride on two buses to get to my summer job in a cardboard box factory. Even that was tolerable, if just for a summer. But grocery shopping by bus can be hard.

What are the grocery shopping solutions for people who don’t have a car, don’t live within a short walk of a supermarket, and can’t afford delivery or a car service for their shopping? Unfortunately, I don’t think there are any easy, global solutions with something so unwieldy as transit systems, but maybe there are some smaller scale solutions, custom fit for the needs of local communities.

Maybe it sometimes involves government encouragement of retail food outlets, something that is already in action in several American cities, in addition to myriad government programs that are already in the food business, like assisting or funding food banks, pantries, farmers markets, indoor markets, military commissaries, soup kitchens, taxi voucher programs, and food deliveries for shut-ins.

Thanks for reading.

What are your thoughts about bus access to healthy food?

Coming up this week, I’ll share what I found doing a study in Rhode Island on the use of buses vs. cars to access healthy food. If you haven’t had to do it, and I’m glad I have never had to, it might be a little hard to imagine how hard it is to shop for groceries relying on the bus.

Medicare says yes to Ozempic and Zepbound

But first, there are a couple of big GLP-1 things to talk about. Beginning July 1, people who have Medicare Part D and qualify medically will be able to get GLP-1s to treat unhealthy weight with only a $50 monthly copay, much less than available discounted prices. Currently, Medicare does not cover any weight loss treatment.

The benefit is being offered by the Centers for Medicare and Medicaid Services, or CMS, as a pilot program that will end after a year and a half, on December 31, 2027. At that time CMS hopes a permanent program will be in place to continue benefit coverage.

A body mass index, or BMI, of 35 provides automatic medical qualification. A BMI of at least 30 in combination with diastolic heart failure, uncontrolled hypertension, or Stage 3a chronic kidney disease also qualifies. Finally, a combination of a BMI of at least 27 and either cardiovascular disease or prediabetes reaches the threshold of medical qualification.

To receive the prescribed GLP-1, patients with these conditions must receive prior authorization through Humana, the CMS contractor who will administer the pilot program.

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Possible and and proven GLP-1 benefits grow and grow

While the inclusion of GLP-1s in Medicare benefits will reduce the risk from unhealthy weight for many, the bigger, long term GLP-1 story is that many of these newly covered Americans will experience other GLP-1 associated health benefits, as might anyone using GLP-1s.

At first scientists had it wrong. GLP-1 is a hormone that is produced in the gut in response to eating. The initial belief was that drugs like Ozempic worked for weight loss by supercharging our natural gut GLP-1, and the abundance of GLP-1in the gut made us feel satiated with less food than normal. Turns out that appetite suppression through signaling with GLP-1s seems to happen mainly in the brainstem, which produces GLP-1 in addition to the gut.

Also, GLP-1s slow the pace of stomach emptying and that contributes to a reduced desire to keep eating and also helps slow down metabolism. Carbohydrates are digested slower, turning into sugar less rapidly, tamping down glycemic spikes. So, by contributing weight loss and a reduction in blood sugar spiking, GLP-1s are good for control of prediabetes and diabetes.

The science and the public embrace of GLP-1s for conditions beyond unhealthy weight and diabetes are unfolding quickly. The benefit of GLP-1s to reduce the risk of cardiovascular events like heart attacks and strokes and for the treatment of sleep apnea is well documented, to the degree these are standard conditions qualifying patients with unhealthy weight but not obesity to receive GLP-1s under many health insurance plans.

Losing unhealthy weight is good for your heart health, but, as you may have heard, GLP-1s are good for your cardiovascular system independent of any weight loss.

GLP-1s are in love with cytokines. It’s complicated.

Cytokines are chemical messengers in our body involved in regulating our immune system. Too much cytokine production is associated with autoimmune disease like rheumatoid arthritis. On the other hand, doctors sometimes inject cytokines to fight cancer or serious infection.

The actions of the many cytokines, and their interactions with GLP-1s, are complex, but we know that the way that GLP-1s, working through cytokines, tamp down immune reactions in the body that are causing inflammation is key to benefits GLP-1s provide beyond weight loss.

Inflammation can save our life but is also involved in so many of our health problems.

To put this in plainer English, GLP-1s can reduce bad levels of inflammation in our organs without turning off immune reactions entirely. Liver and kidney disease and immune system dysfunction can benefit. Arthritis and female and male fertility are being researched in connection with GLP-1s.

Nervous system disorders are being investigated, although evidence has been disappointing or mixed in Parkinson’s and Alzheimer’s trials. However, dementia treatment research will continue with GLP-1s and newer, related drugs.

Meanwhile promising research has begun on the use of GLP-1s to treat traumatic brain injury. The availability of pill versions of GLP-1s offer additional hope for treatment in this regard. Orforglipron from Eli Lilly, which just came on the market, uses a small molecule structure which can penetrate the blood-brain barrier more easily than injectable versions that use full peptide proteins that are much larger. This not only means better transport of the medicine to the site of trauma but more availability to GLP-1 receptors deep in the brain, so potentially these oral medicines could have more effectiveness for controlling satiety.

A very interesting area of research is the often observed effect of GLP-1s on the reduction of addicted or disordered behavior. Many GLP-1 users report a sudden disinterest in drinking alcohol. Disordered gambling, shopping, sex behavior, and eating can be reduced, including simple food addiction and binge and anorexic behaviors. GLP-1s can be associated with reductions in the use of nicotine, opioids, cannabis, and cocaine.

Addictions are not a choice we make

I have to pause here because I just listed a number of what we think of as “bad things.” I always like to remind myself that these are just “things.” While all of these things can be bad for us, they are things I and other people are given by genetics, environment, and happenstance, and don’t choose. It’s good to remember that every one of these obsessions comes to us a product for sale, so someone stands to profit from our obsession.

We are fortunate to have an increasing arsenal of medical and behavioral treatments, now including GLP-1s, to rid ourselves of these things, and it may be that our society is making some progress in ridding itself of some of the stigma around these things.

A tremendous amount of research needs to be done to understand how GLP-1s work and to invent new ones and understand them as well. We are yet to sort out how much of a miracle these drugs are and to discover any risks to using them that may still be hidden.

But we may be at the start of a new era with regard to GLP-1s. The health benefits are so evident, and for some people the body image changes are important and apparent. Popular interest in GLP-1s has been extremely high. One in eight American adults is on or has tried a GLP-1. What’s more, dieting and medical treatments are both areas in which Americans as a group have repeatedly shown a willingness to try anything, and that is certainly the case with GLP-1s, be they compounded off-brand GLP-1s made in America or even much, much sketchier next generation GLP-1s like the experimental retatrutide compounded under unknown conditions in China and available on the gray market online.

It’s important that RFK, Jr., the FDA, and Trump take an aggressive approach to keep up with the American public, not just with approving new GLP-1s, as they seem intent on doing as fast as possible, but with ensuring GLP-1 safety and clamping down on sources of unregulated substitutes. And with making these medicines affordable to all Americans.

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Turns out RFK, Jr. could be called today’s James Delaney, the congressman who gave us the Generally Recognized As Safe, or GRAS, system. Kennedy has been voicing many of the exact same nutritional concerns that Delaney expressed – two years before Kennedy was born. And, in the same way that Delaney struggled with the power of what was to become known as the ultraprocessed food industry, Kennedy is struggling today. Because of the influence of Big Food and the lack of will in Congress to properly fund the FDA, the Delaney Act and its GRAS system in 1958 failed to effectively regulate the addition of chemicals to our food. Given the enormous size and power of the ultraprocessed food industry today, Kennedy has a challenge on his hands in reforming it, as he would like to do, for the benefit of the public’s health.

So what’s going on with the FRESH Act collision in the House? First, I noticed, as did the nutrition watchdogs Center for Science in the Public Interest and the Environmental Working Group, the appearance of Florida Republican Kat Cammack’s FRESH and Affordable Foods Act. Both CSPI and EWG termed the Act not fresh but rotten.

Cammack’s FRESH Act is, in full, the FDA Review and Evaluation for Safe, Healthy and Affordable Foods Act. Cammack and her food industry friends would use it to further eviscerate an already weak food additive safety system. The Environmental Working Group’s Melanie Benesh said, “I did not think it was possible to make our food system even weaker, but this proposal does it.”

Cammack’s draft bill was discussed this past week in subcommittee. There is a large amount of doubt about whether it, or any of the several congressional proposals currently in committee that are intended to reform GRAS in a positive, public health direction, will succeed in this session.

Cammack’s FRESH act was introduced on April 22^nd in draft version. Another Republican, Julia Letlow from Louisiana, an avowed MAHA mom, introduced her own FRESH Act on April 29^th. Representative Letlow’s bill, H.R. 8578, the Food Reform for Effective and Sustainable Health Act of 2026 does just two things. This FRESH Act makes the new inverted pyramid Dietary Guidelines into law, and it requires each new Dietary Guidelines to be approved by a new law in Congress. Letlow’s proposal is not as horrible as Cammack’s law, but it isn’t good. It inserts Congress into a supposedly scientific process that is already thoroughly corrupted by politics.

Cammack’s aberration is the story, but I mention Letlow’s bad idea because it seemed to me far too unlikely to have two Republican nutrition proposals named the FRESH Act coincidentally introduced in the House seven days apart. Perhaps it is just an attractive name for a bill. There was yet a different nutrition-oriented FRESH Act introduced last year.

Maybe I’m just overly suspicious of what goes on in Congress these days, but it seems plausible that the name of Letlow’s bill is meant to be confused and amplified by the anti-MAHA FRESH Act introduced by fellow House Republican Cammack. Letlow is strongly aligned with MAHA and RFK, Jr. and is the deep underdog in a fight for the Senate seat of Louisiana’s incumbent Senator Bill Cassidy. Cassidy, a pro-vaccine physician, is seen as a traitor by Trump and MAHA for torpedoing Trump’s nominee for Surgeon General, MAHA darling Casey Means. With her FRESH Act, Letlow could be undercutting Cammack’s bill and gathering MAHA energy and attention in her Senate fight. Neither FRESH Act is good for public health and science, so another crack in the anti-science, anti-public-health Republican Party is okay from my perspective as a public health scientist.

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Meanwhile, a year ago RFK, Jr. directed the Health and Human Services Department to begin a rule-making process to close the GRAS loophole through which the ultraprocessed food industry has self-certified as safe thousands of chemicals – without providing the FDA or the public any information. However, experts have doubts that Kennedy’s rule-making will be able to circumvent congressional involvement and, in the end, changing GRAS will require a law.

At least RFK, Jr. is acting and some members of Congress have moved to address the GRAS mess. It is an uphill battle against the ultraprocessed food lobby, the biggest in Washington.

The ultimate problem with any proposed solution is that the FDA is and always has been underfunded, and the already inadequate staffing has been slashed by Trump. These cuts are badly affecting food safety in all areas, not just additives. One estimate of the cost of establishing the safety of a food additive is 2.5 to 5 million dollars and thousands of substances have already been introduced which have no published safety evidence.

An obvious solution is to put the cost of this proof on the manufacturers who would profit. If this means we have a much reduced number of food additives, we should consider the effects of that on an individual basis. We humans coped without these added chemicals in our food for thousands of years. We now have the science to create these complex substances, but we should also use our science to truly understand the health effects of these additives and newly imagined foodstuffs before we sell them.

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…the survival of the country, as well as its democracy, depends on the health of its citizens. The shocking number of our young men who cannot meet the … physical requirements of our armed services must make each of us ask the reasons for this reservoir of ill health in the midst of such a varied and abundant food supply.

It wasn’t Abe Lincoln with regard to the Union forces or Franklin Roosevelt at the outset of World War II, although it very much applied then. Nor was it Robert F. Kennedy, Jr. in his run for the presidency.

The quote above is from U.S. Representative James Delaney in 1951, the year following the start of Delaney’s House Select Committee’s years long investigation into the glaring lack of safety in food additives.

Delaney is known today for giving us the Generally Recognized As Safe, or GRAS, system of food additive safety assurance or, most would say, lack of assurance. But Delaney’s words sound as though they came from the lips of RFK, Jr. And what Delaney told us was bad in 1951 is still bad, 75 years later.

The congressman, increasingly alarmed about what his Committee was finding, wanted to spread the word to the public and build support for a battle with the increasingly powerful food industry. He wrote an article for American Magazine with scary, but not exaggerated, examples of the public at risk from toxic food additives and unregulated pesticides and of the food industry’s eagerness to capitalize on preferences of the human palate while ignoring nutritional needs. The congressman’s condemnation of the food additive practices of the industry, the lack of regulatory oversight, and the sad nature of the food environment as a whole, could have been written today.

The date I give for the start of the ultraprocessed food era is 1953. Somewhat arbitrary, but it marks the introduction of Swanson TV dinners, Kraft Cheez Whiz, frozen French fries, Tony the Tiger and Frosted Flakes, and McDonald’s franchises. Delaney’s article provides context for that moment and deepens our understanding of the history of today’s food environment and the rise of ultraprocessed food.

First, Delaney told about a peach packer who learned that adding a little of the industrial chemical thiourea would keep his peaches perfect, so he treated a shipment and sent them off. A fellow packer decided to try the same trick except, fortunately, had FDA inspectors test the thiourea first. The rats who were fed it died. When, by lucky chance, the inspectors learned of the first packer’s shipment, a frantic race to find and recall the peaches followed. Fortunately, they were all recovered before any were eaten.

Also in the late 1940s, lithium chloride was put on the market as a salt substitute for people on low-salt diets. Little safety testing had been done, and three people died before the lithium chloride was withdrawn.

Delaney goes on to rail against the national distribution of beer sterilized with poisonous hydrofluoric acid by a Massachusetts brewery and an Indiana manufacturer substituting butter with yellow-colored mineral oil labeled “edible fat” in popcorn sold all over the U.S. The mineral oil was found to be eliminating all the fat-soluble vitamins from people, many of them children, and causing vitamin deficiencies.

Delaney wrote that chickens (and later it was sheep, pigs, and cattle, too) were being treated with a new hormone called “stilbrestrol” to make them fat and faster growing. Then, despite the FDA’s oversight of pharmaceuticals, stilbrestrol was given to pregnant women, to prevent miscarriage and premature birth, up until 1971, when the practice was stopped because stilbrestrol is a strong carcinogen and causes infertility.

Delaney’s list went on. Many chemicals had been newly added to foods in the 1940s. For example, there was a shortage of shortening in 1947, and bread makers began to add emulsifiers and other substances, cutting the amount of shortening by 50% and making the bread softer. 10 million pounds of chemicals like polyoxyethylenes such as Polysorbate-60 were sold to bakers in America in 1949. Delaney was concerned about adding all these untested additives, but he also asked the simple question, ‘Why make the bread white and take out the nutrients?’ That was some far too uncommon common sense for the 1950s.

Delaney saw the increased role of soft drinks like Coca-Cola in our diet and worried about the phosphoric acid in it, citing U.S. Navy research that human tooth enamel is dissolved in 24 hours by phosphoric acid. That story seems like it is out of the way-back-machine, but 75 years later Coke still contains phosphoric acid as a main ingredient and great-grandchildren who inherited the practices of the dentists of 1951 are still filling cavities of people who drink Coke.

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And Delaney worried about the explosion of new pesticides, including the highly toxic chlordane, finally banned in 1988, and DDT. The congressman was concerned DDT was being found in high quantities in meat in supermarkets. Soon, DDT was found stored in the fat of almost all Americans.

From a nutritional standpoint, Delaney could be a golden hero of the MAHA movement. In 1951, the Korean War had started, and the congressman decried the state of our food environment as the cause of so many American men being physically unfit for military service, words echoed today by RFK, Jr., who wasn’t born when Delaney said it. The congressman even wondered if the increased number of people with mental illness was related to the new chemicals in the food supply, far before RFK, Jr. gave voice to that concern.

In my next post, I’ll discuss how Delaney found it hard to translate into law his clear vision of what needed to be done to fix the American food environment. It wasn’t until 1958 that the Delaney Act, officially the Food Additives Amendment to 1938’s ineffectual Food, Drug, and Cosmetic Act, was passed. The Delaney Act made advances in food safety, but industry lobbying created a giant loophole to allow thousands of chemicals - for which the public has no safety information - into the food supply. Nutrition scientists and food safety advocates have long complained about the Generally Recognized As Safe, or GRAS system, in which the ultraprocessed food industry largely self-certifies the safety of food additives. It is in RFK Jr.’s hands to try to close that loophole. However, a law, the FRESH Act, to reform the GRAS system, has been introduced in Congress by a House Republican — but the FRESH Act grossly reforms GRAS to the favor of the ultraprocessed food industry. We’ll see what happens, but first we’ll discuss it next time.

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Yes, I know it is Eating in America, not “Smoking in America”, but today’s news is important, and I had to cover it, given the conclusion this week of EiA’s four-part series on cannabis. Think of this as a little bonus, since I already wrote this post for the Notes social media-ish stream of Substack. (If you are not familiar with Notes, you can find EiA’s Notes collection on the website EatingInAmerica.co. Many of my Notes extend or synopsize EiA posts and podcasts and there are thousands of worthwhile Notes from other authors.)

Cannabis has been reclassified today to a Schedule III drug for medical purposes. The Drug Enforcement Administration within the Department of Justice made the change, presumably on the basis of a scientific finding from RFK, Jr.’s Department of Health and Human Services. All of this avoids the further exasperation of Donald Trump, who expressed frustration a few days ago that the rescheduling had not yet occurred after he had ordered it in December.

From the public health perspective, the two major benefits of reclassification are the greater ease of doing medical research on a Schedule III substance and the potential for the FDA to regulate cannabis products. The direct health benefits of national regulation could be huge.

Today’s ultra-high potency products are linked to increased health risks including cannabis use disorder, cannabis hyperemesis syndrome, and psychosis. Any national regulation at this moment would apply only to medical uses, since recreational cannabis will remain fully illegal in federal law. However, according to Reuters, the Department of Justice has scheduled hearings to begin June 29 with the aim of reclassifying cannabis for all purposes.

Too bad Trump rescheduled cannabis for medical purposes without first putting together a coordinated program of research and FDA regulation, but as usual he appears to be acting in response to personal appeals and the widespread opinion of potential voters, and not from a public benefit (health and safety, in this case) perspective. If, following the hearing process beginning in June, recreational cannabis is reclassified, that is another moment the administration could embrace setting up national regulation of cannabis and pumping up the research.

However, stocks for cannabis-related companies rose sharply yesterday with leaked word of the rescheduling. A windfall of tax savings will occur as medical dispensaries will, for the first time, be able to take tax deductions for their expenses, including rent and payroll. The cannabis business is likely to be suddenly much more profitable.

A portion of those profits are certain to appear in increased lobbying power in Washington, D.C., almost certainly fighting against needed national regulations, like potency caps, that could help reduce the risk of harms such as cannabis use disorder. Following the tobacco, opioid, and ultraprocessed food playbooks, Big Cannabis is likely to fight hard and with lots of cash lubrication against regulatory control of qualities of its product, like high potency, which are linked to the tendency of frequent users to use even more frequently than they might want.

Rescheduling and any other step to federal legalization offers an opportunity to provide a carefully designed, scientifically-based policy framework for cannabis’s place in our society, including limits on product potency along with testing, labeling, and safety requirements. A smart strategy, one that has been tested country-wide in Uruguay, is to allow a reduced-risk level of cannabis potency that is still satisfying to recreational users, with the goal of displacing cannabis sourced from criminal enterprises in favor of standardized and more trustworthy products from legal dispensaries and pharmacies.

From my public health point of view, national cannabis legalization for both recreational and medical use is a step I hope will happen, but only in coordination with ample support of rigorous research and a well-designed and closely monitored program of regulation based on that research.

Thanks for reading. I would love to read your thoughts, opinions, and experiences, if you care to share.

There’s more on the interesting and unfolding story of cannabis in America with my new four-part series on the subject on Eating In America.

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This week Eating in America has ventured out the kitchen door to the living room to explore something that might be on the coffee table of 44 million Americans in the last month. That is to say, cannabis.

Cannabis has become widely legal but also highly potent, and regulations are loose and vary by jurisdiction. Enforcement is sometimes loose. There is increasingly good evidence about the risks of cannabis use while at the same time it has become highly accepted as a mostly safe part of our recreational landscape, joining alcohol in that regard. It is also felt by millions of Americans to provide medical benefit that is mostly not available to them from the traditional medical system.

What should be medical cannabis look like going forward when each state that has medicalized it has a different system? How big is the money around cannabis today, and how is that influencing policy and public perceptions? And what are some policy changes that would help address safety and public health issues while aligning cannabis use and regulation with both science and public attitudes?

And what role does the continuing black market play as regulations are created and refined?

POTENCY

Higher levels of potency are linked to higher rates of cannabis use disorder, where an individual’s control over use begins to slip while some facet of life – health, relationships, work - is being negatively affected.

Growing technique boosted black market cannabis strength from 2% THC content, THC being the high-producing chemical in cannabis, in the 1960s to 17% by 2017. But it was the legalization of recreational cannabis in 24 states and Washington D.C. that spurred the creation of ultraprocessed cannabis now available in legal dispensaries and on the gray market. Extracted cannabis products in dispensaries are on offer at THC levels above 90%.

With legality has come not only potency but big money, with an estimated market of $47 billion in sales in 2026. Has the big money in cannabis found Big Tobacco’s playbook? Have they studied the page about encouraging the addictive effects of their products yet not acknowledging them? The gray market producers of high-level THC products made from low-THC hemp, a $24 billion industry, have taken advantage of the lack of age restrictions for hemp products and are blatantly marketing to minors, packaging THC-infused candy and treats in child-friendly packages. Getting them while young was an important chapter in the Big Tobacco playbook.

In the 1980s Big Tobacco acquired the ultraprocessed food companies General Mills, Kraft, and Nabisco and brought their playbook with them. The main premise of ultraprocessed food is hyperpalatability, the sense that a food is so good it is hard to stop eating. Addictive qualities and the targeting of children have been key to making ultraprocessed food a $2 trillion dollar industry.

The federal government joined with the states in the public health effort to control tobacco and together they have had great success reducing smoking rates. There remains much more to be done, and we can’t tolerate any more U.S. Surgeon General nominees like Casey Means, who owned stock in Big Tobacco.

But a framework in which ultraprocessed food could be limited has begun to be constructed, although controlling a $2 trillion dollar industry will demand a prioritization of public health that administrations so far have not been able to make.

The federal government’s position with Big Cannabis is actually better than it was with tobacco or ultraprocessed food. Cannabis is still illegal at the federal level. Loosening the cannabis law to a level of tight regulation will be easier than creating restrictions on largely unregulated markets, as was the case with tobacco and will hopefully be the case with ultraprocessed food.

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Here are seven recommendations for federal cannabis policy.

Acknowledging that recreational cannabis use can be safe and is widely popular and that medical cannabis is regarded as uniquely beneficial by patients who use it, a public health first approach would call for, minimally:

1. Copious support for research into all aspects of cannabis use, including medical use for physical and mental health conditions.

2. Legalization and full regulation at the federal level, including strict product testing for contaminants and chemical components and full labeling of those components. Regulation would cover both recreational and medical products.

3. A minimum federal age requirement and safety labeling that would align with the development of scientific evidence about brain development concerns as it becomes available.

4. Federal marketing regulation that would require front of package safety labeling, forbid packaging that targets youth, and forbid health claims that are not fully supported by scientific evidence.

5. Creation of a window for transition of medical cannabis from state licensed dispensaries to pharmacies, with federal approval of the efficacy of a product allowing insurance coverage and lowered prices for patients.

6. Adherence to the November 2026 federal deadline to ban manufacturing and sale of hemp-based products with more than a non-intoxicating level of THC.

7. Critically, the setting of maximum strength levels across all types of cannabis products. These potency caps would need to be set at a conservative level until research could prove equivalent safety in higher dose products – or at least provide reliable estimates of increased risk with increased doses upon which to decide ultimate cap levels.

On this last point, researchers have proposed the need for potency caps, and others, including recently the New York Times Editorial Board, have proposed cannabis taxation based on product strength. In the same way as whiskey is taxed more than beer, products with higher concentrations of THC would be taxed more than lower THC products.

Tiered taxation might be warranted but only if done in combination with caps. It would be irresponsible to allow continued sales of THC concentrations that exceed amounts required for enjoyment by most people. Putting a government stamp of approval on high-doses is not in the public interest. Just as alcohol consumers can drink themselves into inebriation, so can cannabis users continue to consume cannabis until reaching a state of mind (or lack of it) equal to that reached more quickly with high-potency cannabis. They would still have the freedom to take that risk.

The result of implementing these measures would be a cannabis landscape somewhat similar to that for alcohol sales. Standards would be set at the federal level and licensing and most enforcement would remain at the local level. Taxation would occur at both the federal and state level, as with alcohol.

THE BLACK MARKET

The continued activity everywhere of the black or illicit market for cannabis is an important consideration in setting regulatory standards in a legalized environment.

Canada had good success in reducing illegal sales, which by 2023 had dropped from 88% to 24% of total sales in the five years following recreational legalization in 2018. (It’s noteworthy that along with recreational legalization, medical sales in Canada decreased from 12% to 4% of total sales.)

In 2014 Uruguay became the first country to legalize cannabis, taking an approach that allowed cannabis clubs that could grow their own, home growing, and pharmacy sales of state-controlled and -priced product.

Initially the illicit, organized crime-controlled market in Uruguay remained dominant because of overly strict regulations for legal cannabis that included limiting THC levels to just 3%. To increase uptake of the government produced cannabis sold in pharmacies, maximum allowed THC levels were increased to 9%, then 15%, and currently 20%. The organized crime-controlled market is now only 7% of the total, although a gray market of distribution from home growers is estimated at 30% of the market.

Uruguay seems to demonstrate a model where potency caps can be put in place while keeping the least safe black market purchases, those from criminal enterprises, small in volume.

In the U.S., the volume of black market sales in legalized states varies, influenced by state taxes and regulations and local conditions. California is repeatedly mentioned as a state with significant black market and unlicensed retailer sales.

THE CREATION OF BIG CANNABIS

The political and countercultural revolution of the 1960s was the turning point for wide acceptance of cannabis in America. The advocacy group NORML was formed in 1970, and the call for legalization began and continued unabated with the work of activists and the funding of various pro-cannabis organizations and efforts by benevolent donors.

With the beginning of recreational legalization in 2012, corporate money took over the funding of activists and has also paid for political lobbyists. Large donations to legislators began to correspond closely to “yes” votes for legalization. Congressional efforts to legalize cannabis in 2021 attracted $4 million in lobbying by the cannabis industry and large expenditures by Big Tobacco and beer manufacturers.

The cannabis industry might exceed hundreds of billions of dollars in sales in the next decade. Just as with the explosion of ultraprocessed food beginning in the 1970s, the prospect of large cannabis profits has unleashed intense lobbying, in the case of cannabis for legalization and relaxed regulation.

The regulatory position of the cannabis industry is strengthened by the happiness of recreational use states which are enjoying the large cannabis tax revenues they are collecting: $4.4 billion in 2024, for example. In 2021, in 11 states with legal cannabis sales, cannabis taxes brought in more revenue than alcohol taxes by 20%.

As legalization pushes forward and the need for greatly increased regulation becomes more apparent, the flow of billions of dollars in sales and tax revenues will tend to make further increasing revenue a priority for states and a continued number one priority for the cannabis industry. Public health concerns will need active voices and strong defending.

That’s the conclusion of our series “Ultraprocessed Cannabis: Potency, Policy, and Public Health in America.” You can find the first three articles in the series at EatingInAmerica.co.

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Usually Eating in America is about what we eat and what people like RFK, Jr. are doing or not doing to make it healthy. But EiA is near the end of four-part series on cannabis, something Kennedy and Trump could help make less of a threat to health, and today we touch on another big failure of Kennedy and the current administration, this time with regard to a smokable substance with strongly negative health effects: tobacco.

Look for the final part of my cannabis series in two days, on April 21. We get into black market cannabis, the effect of big money in cannabis, and policy ideas to move forward balancing public health and public opinion.

First, the smoking gun.

A lot has been going on with Trump, RFK, Jr., and public health in America since the new administration began last year, so it went somewhat unnoticed that in April’s decimation of the CDC, all 120 Office on Smoking and Health staff were fired. The federal government has effectively ended its effort to prevent initiation to tobacco and reduce use.

Meanwhile, nearly a half-million Americans continue to die annually from tobacco use.

The obliterated Office had been formed in 1978 and has led effective national anti-smoking campaigns, written the Surgeons General’s many reports on tobacco, and run and analyzed the annual National Youth Tobacco Survey, a key tool to monitor smoking among adolescents and older youths. The Surgeons General’s reports had to be restored to public access by court order but are now deep-sixed in an archive, including the last one, 2024’s “Eliminating Tobacco-Related Disease and Death: Addressing Disparities.”

Fortunately, the National Youth Tobacco Survey data from 2025 has been released by the FDA, although without comment or analysis that was usually provided by the Office of Smoking and Health.

Statnews reported that former Office of Smoking and Health Director Tim McAfee called the closing of the office “the greatest gift to the tobacco industry in the last half century.”

Foundayo

Good news in the world of GLP-1s, the new daily orforglipron pill from Eli Lilly got very fast fast-track approval on April 1 from the FDA. Eli Lilly, confident that their application would be approved, had started manufacturing the drug months ago, and it is already available for purchase.

The pill, brand name Foundayo, can be taken without regard for time of day and with or without food. The other new GLP-1 pill, Novo Nordisk’s Wegovy, must be taken first thing in the morning a half-hour before consuming anything. For those of us who cannot cope with waiting 30 minutes for their first cup of coffee, that might be a deal breaker.

The Wegovy pill became available in January. Trials showed average weight loss of 16.6% with Wegovy, about 3% more than the average loss achieved with Foundayo. Side effects are typical of GLP-1s with both pills, but the effect profiles may be better with the Wegovy. Their head-to-head costs are competitive and somewhat less expensive than the injectable version of Wegovy or Eli Lilly’s Zepbound.

Both manufacturers are optimistic about uptake on their pills. There is speculation that the pills might work out as a weight maintenance option for many people who create their weight loss with an injectable Wegovy or Zepbound regimen for some months or years but would prefer to take pills for lifelong maintenance of the weight loss.

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The Gorske dilemma

When I was a young man and beginning to collect random ideas about healthy eating, NPR played a story in which a farmer declared he was a vigorous 98 years old and had eaten bacon every day of his life. I was happy to realize eating fried, fatty, salted pork would not automatically result in my death warrant going out to the grim reaper.

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Eating in America is typically about what’s on our plate: what we’re eating. However, in this series we’re examining something that is not on everybody’s plate but was consumed by 44 million Americans in the last month. Cannabis is very much “in the air” these days, so to speak, especially if you live in a state where it is decriminalized and the smell of cannabis is easily found on the streets.

Cannabis use is not unrelated to our consumption of food and to the food environment. The pleasure people find in cannabis taps into the dopamine pathways in our brain that help us choose what to eat. And the parallels to alcohol use are often pointed out.

On Eating in America, we talk a lot about how ultraprocessed food has taken over our food environment. Has ultraprocessed cannabis taken over its world?

THC levels in cannabis have exploded in the last 25 years, going from around 5% in illegal cannabis in the 1970s to over 90% for some legal products in today’s recreational dispensaries. Cannabis use disorder is growing along with the potency of products, and research is clarifying that some claims of benefits don’t hold up. Instead, a number of risks are being confirmed.

The status of alcohol has often been used as a reference point when discussing cannabis legalization and regulation. While there are natural parallels between alcohol and cannabis distribution and consumption in our culture, there are important differences. On the one hand, alcohol and cannabis are the two recreational substances that are consumed in significant amounts by large percentages of our population. They are both, for the most part, widely available for purchase at prices that most people can afford.

However, their effects on the body and mind are very different. Because of its long status as a legal substance, the risks associated with alcohol have been much more researched than the risks associated with cannabis. For example, we now know a heightened risk of cancer begins with the consumption of any alcohol. The World Health Organization and the 2020 U.S. Dietary Guidelines Scientific Advisory Committee are among the groups who have found that the only safe level of alcohol consumption is zero.

While far too little research has been done on cannabis with regard to biological safety, research has begun to make clear that there is not much benefit for the mental health conditions for which cannabis is often recommended and good evidence of mental health risks.

A new review published in The Lancet analyzed existing randomized controlled trials, the gold standard of cause-and-effect research, and found no difference in outcome with cannabis treatment for anxiety, anorexia, psychotic disorders, PTSD, and opioid use disorder. Cannabinoids in cannabis actually increased cravings in those with cocaine use disorder.

The Lancet review did find some evidence that cannabis “can reduce symptoms of … insomnia, tic or Tourette’s, and autism spectrum disorder.” There was insufficient or no data to make conclusions about other mental health conditions like ADHD, bipolar disorder, and depression.

While evidence of the mental health benefits of cannabis is limited to a few conditions, the evidence has been mounting about mental health risks. A new Journal of the American Medical Association Internal Medicine review finds cannabis linked to psychosis, cannabis use disorder, and self-harm in adolescents with mood disorders. However, the JAMA review did find some evidence that the main non-psychoactive chemical in cannabis, CBD, by itself, without THC, the part of cannabis that is psychoactive, might help relieve anxiety, although more research is needed.

THE ALCOHOL COMPARISON

Alcohol is highly regulated at a national level and cannabis is not well-regulated. The amounts of alcohol in a product are clear and well-understood by consumers. While alcohol percentages are not regulated, for fermented products like beer and wine, they are controlled by the biology of yeast, and for distilled products like hard liquor and brandy, they are controlled by manufacturers adhering to convention and optimizing taste.

On the fully natural to ultraprocessed spectrum, the process of distilling fermented grains or grapes puts hard liquors and brandy in the processed category of consumables. Beer and wine, the precursors of whiskey and brandy, are lightly processed.

There are always trends in alcoholic beverages, but, as a consumable substance, the field as a whole is mature.

ULTRA-POTENT AND ULTRAPROCESSED

In contrast, cannabis products now sold on the black market, in medical dispensaries, and particularly in recreational dispensaries, are very far removed from the relatively low-powered cannabis used by the Chinese in 2,700 BC and in the hippie world of Haight-Ashbury in the 1960s. But in the 70s, a steep upward curve of potency began as a Mexican drug gang in Sinaloa, soon to be a cartel, discovered that isolating the unpollinated female cannabis plant, called sinsemilla, tripled cannabis THC levels, from 2% to 6%.

Due to breeding, cloning, and cultivation innovations, THC contents of black market cannabis rose further to 17% on average, by 2017.

New products, some found in dispensaries and some, avoiding regulation and law, found on the gray market in gas stations and convenience stores, have further increased potency using THC extraction and concentration methods employing solvents. THC levels for dispensary products can be 90% or more. Some solvents used for extraction are toxic, and incomplete residue removal in substandard manufacturing processes might pose a risk to consumers.

With extraction methods creating new ultra-high potency levels, cannabis has entered the era of the ultraprocessed.

Ultraprocessed gray market gummies and other products with intoxicating levels of THC are a particular concern. In 2018 Congress deregulated hemp, or cannabis without an intoxicating amount of THC. The intent was to allow hemp-based products containing CBD to be sold without regulation. However, the law did not forbid the conversion of the CBD in hemp into THC through chemical processing.

Soon colorful bags of candies and treats with high levels of THC were showing up in gas stations, convenience stores, and smoke shops. Some of these products were packaged to closely mimic popular brands like Frito-Lays and Cheetos or children’s gummies. With no age restrictions, or restrictions of any kind, reports began to come in of children hallucinating at school.

Colorful cans of beverages containing THC-derived from hemp have become popular outside of dispensaries, often being used as a substitute for alcoholic drinks. The THC in beverage products has a quick effect compared to edible products like gummies, although not as quick as smoked cannabis.

A handful of states banned all hemp products containing THC and last November Congress inserted a provision into the legislation that reopened the government. The law will limit the THC content in hemp products and ban the conversion of CBD into THC. The law gave the $28 billion hemp products industry a year before the restrictions go active this coming November, but lawmakers are proposing a one year extension. Meanwhile, the regulated cannabis industry has been lobbying for the restrictions to protect their businesses. Meanwhile, THC candies and snacks remain on shelves in many jurisdictions in states like Massachusetts without any restrictions or enforcement against purchase by minors.

Both cultivation practices and chemical extraction have greatly increased the potency of cannabis. And there is now good evidence that higher potency cannabis is associated with increased risk of psychosis and cannabis use disorder.

Ironically, with the reality of psychosis risk with today’s high potency cannabis, a dose of truth has been bestowed on 1937’s laughable propaganda film “Reefer Madness,” although it seems to me unlikely that there were a large number of cases of psychosis with the low potency cannabis of almost a hundred years ago when “Reefer Madness” was being made.

There is cannabis madness today in that there is far too little cannabis science and far too little regulation. As a result, we have a chaotic landscape of cannabis sales, quality, and use. This shouldn’t be the case. Alcohol has been an important point of comparison when the loosening of laws and regulations has been argued for cannabis. However, the marketing, sale, and quality of alcohol is very well-defined, and its use is not confused by dual systems of lightly regulated recreational and medicinal alcohol.

On the other hand, the cannabis sanity is in the wide recognition that the fun, stupefying, euphoric, or calming effects of cannabis aren’t a threat to our communities and that, as with the risks associated with alcohol, the risks of cannabis consumption can be reasonably weighed by adults for themselves. But, going forward, the science and regulation deficits have to be fixed.

Thank you for reading. In Part Four of “Ultraprocessed Cannabis: Potency, Policy, And Public Health In America,” we check on the continued black market in cannabis, look at how big money in cannabis has become a powerful influence, and propose seven policy and regulation recommendations to bring the public’s comfort with cannabis together with public health moving forward.

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In Part One of this series, we have a look at the surprising history of cannabis in America. Did you know the Puritans brought it here, and by law they had to raise it because it was so valuable for hemp fiber to make rope and sails? We also discuss medical cannabis, cannabis use disorder, and the increased appearance in emergency rooms of people with uncontrollable vomiting and screaming stomach pain from too much cannabis, in Part Two.

You can find all that at EatingInAmerica.co.

What are your thoughts and experiences with cannabis, unregulated hemp-based THC products, and the way forward? Please share your comments! Your support for this post and podcast are appreciated. Peace.

Cannabis was legal in America well into the 20^th century and medical cannabis products were manufactured by pharmaceutical companies and widely prescribed and used. Of course, it’s important to keep in mind that this was before modern medicine: before aspirin even.

Thirty years after medical cannabis was first re-legalized in California in 1996, what is the role of medical cannabis today?

The flip side of cannabis as a medical or mental health treatment is when cannabis use is disruptive, harmful, and risky. What is cannabis use disorder, and is today’s increase in cannabis use disorder related to the potency of cannabis now? Related to this, which is greater: the number of people who drink alcohol almost daily or the number of people who use cannabis almost daily?

Cannabis became common in American medicine beginning in 1840 when knowledge of medical uses was brought from India, but medical beliefs and practice around cannabis began to turn in the 20^th century. In 1915 California became the first state to make cannabis illegal. Of course, always the eager trendsetter, California was also first to reverse course and re-legalize cannabis for medical purposes in 1996.

Medical re-legalization pulled some people away from black market cannabis, allowed professional medical supervision of cannabis treatment, and added to the number of products tailored or specified for treatment of conditions including cancer, chronic pain, multiple sclerosis, nausea, vomiting, epilepsy, PTSD, and arthritis.

Now, patients seeking cannabis help in the 40 states with comprehensive medical cannabis programs, along with the District of Columbia and Puerto Rico, can have their need certified by a doctor and then usually pay a fee for a state medical card. Today, around 3 million patients are certified for medical cannabis purchases or home-cultivation.

Medical cannabis programs have requirements for lab testing, which increases safety and standardization of doses for patients and lets patients avoid the unknowns of black market cannabis. However, widely varying methodology between labs and cherry-picking of samples submitted to labs have sometimes made test results unreliable and variable according to the lab, putting patients at risk of misdosing. State regulatory oversight has increased over time, but it remains uncertain whether medical cannabis is well-tested for impurities and the cannabinoid content well-quantified at all times in every jurisdiction.

Nonetheless, medical dispensaries provide relative safety assurance compared to the black market, where pesticide, heavy metal, and fungal contamination is untested and deliberate adulteration of cannabis with dangerous substances such as fentanyl sometimes occurs.

Yet cannabis in a medical dispensary is lightly regulated compared to federally regulated pharmaceuticals. For example, all non-prescription over-the-counter drugs, such as pain relievers and cold medicine, must conform to strict standards published by the FDA. We are far from that with medical cannabis.

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THE ECONOMICS OF MEDICAL CANNABIS

Most medical cannabis is not taxed, while recreational cannabis is heavily taxed in some states. However, most patients seeking cannabis face fees for a doctor’s certification and for the state medical card.

Medical cannabis patients are more frequently low-income and tend to be older and in worse health compared to recreational users. Perhaps this has to do partly with the more limited access these groups have to traditional medical care.

Medical dispensaries risk losing customers to recreational dispensaries in states with both, while paying higher operating costs. While some states with recreational cannabis continue to see increases in the number of medical patients, it may be that more dual-licensing states have a decreasing number of medical patients. However, patients typically don’t find specialized cannabis formulations to treat their chronic conditions in recreational dispensaries, which tend to focus on products with high levels of the psychoactive ingredient, THC, the part that makes users high. Products for medical purposes usually have lower THC doses and, often, high ratios of CBD, a non-psychoactive ingredient, to THC.

CANNABIS USE DISORDER

This substance use disorder is defined with 11 criteria that include craving, unsuccessful effort to cut down, and interference with work or relationships. Meeting two or three of these 11 criteria constitutes a mild case of cannabis use disorder and having six or more is a severe case. In 2024, 7% of Americans 12 and up, that is 21 million people, had cannabis use disorder of some severity. Within those numbers, 5% of adolescents and 16% of young adults had cannabis use disorder. That’s 1.2 million kids age 12 to 17 and 5.5 million adults age 18 to 25.

Related to cannabis use disorder, the number of people who use cannabis on a daily or near daily basis has been climbing rapidly over the last 20 years, and in 2022 the number of frequent users of cannabis surpassed the number of frequent users of alcohol in America. In the same way that near daily use of alcohol has a statistical association with alcohol use disorder, so does near daily use of cannabis have a statistical association with cannabis use disorder. I find the rapid increase in near daily use of cannabis worrying.

The reason that there are now more people who use cannabis near daily compared to those who drink near daily is unknown. I have seen that the 2024 study that reported the increased near daily use did not take into account that medical use of cannabis is frequently on a daily or near daily basis (42% in one study), which would tend to increase the reported overall number of daily or near daily cannabis consumers.

Decriminalization of cannabis is, of course, likely the biggest contributor to the increase of near daily use, but it’s concerning that frequent use has been found to be associated with the use of stronger cannabis at the individual level.

Both frequent use and stronger cannabis are related to Cannabis Hyperemesis Syndrome, or CHS. Emergency room visits for CHS have risen in the last 10 years. CHS presents in the emergency department as severe nausea, cyclic vomiting, and very bad stomach pain, conditions that can continue up to a week.

Some people might have heard a frequently cited estimate of how common CHS is. That estimate is a large number, but, to me, the methodology for making the estimate is very suspect, so I won’t quote it. But, even if on further research the risk turns out to be relatively small, for those who get it, CHS is very, very not fun.

Despite cannabis still being listed as a Federal Schedule 1 drug with no accepted medical use, like heroin and LSD, the FDA has approved four THC- or CBD-based drugs. These are for the treatment of nausea from chemotherapy, anorexia, and seizures from two rare forms of epilepsy. The FDA seems to have an encouraging posture towards applications for additional cannabis-based medicines.

Alcohol and cannabis are both used by many people to self-medicate. That is unlikely to ever stop. While there is often a difference between what makes people feel better and what science says is the most effective treatment to make them better, there is a validity to both perspectives. After all, even placebos without any biologically active ingredient can be effective. If a benefit is perceived, a benefit is received.

Why, what, and how we eat is all about our neurological reward circuits, the dopamine pathways that control so much of what we do. These are the channels tapped, to our detriment, by the designers of ultraprocessed food. They are also the paths that lead to pleasure when we drink, smoke a cigarette, or eat a weed gummy.

In this four-part series I’m going to expand the scope of Eating In America a little bit and look at one of the non-food items consumed by 44 million Americans in the last month: cannabis.

We begin with a surprising history of ye olde cannabis.

It was the Puritans and ye other olde colonists from England that brought cannabis, otherwise known as hemp, to America. It was so valuable for making rope, sails, and clothing, hemp was used as currency. Jamestown was growing it from the start in 1607, and in a while the Virginia, Massachusetts, and Connecticut colonies passed laws that farmers had to grow it. Yes, it was illegal not to grow cannabis, although the cannabis strains in question were industrial hemp, bred for fiber without enough THC content for intoxication.

Medicinal use of cannabis began in the 1840s and became very common and widespread. Cannabis was in many medicines, including tonics, tinctures, and extracts. Parke-Davis, one of the world’s largest pharmaceutical companies, was among the drug manufacturers producing cannabis products.

The weight of medical opinion began to turn against cannabis in the late 1800s. In 1915, California, always ahead of the times, was the first state to make recreational cannabis illegal. Ironically, later in the century California was the first state to make cannabis legal again.

By 1937, 23 states had made possessing cannabis illegal, which is, with almost perfect symmetry, nearly the number of states that have re-legalized recreational cannabis today.

In 1937 Congress made cannabis illegal for the first time across America by passing the “Marihuana Tax Act.” Motivated by its own racism, Congress called the drug marijuana, its Mexican name, to promote anxiety and fear about the large number of Mexicans who had come to the U.S.

1937’s “Reefer Madness” is an outrageous anti-cannabis propaganda movie intended to stoke the building fear about cannabis. Of course, in the 1970s “Reefer Madness” was resurrected and became a cult classic: a terrible film but amusing for many when sufficiently stoned.

I’m using the term “cannabis” throughout this series instead of “marijuana” or a slang term. “Cannabis” is the scientific name for the plant and what the drug was called before the 1930s.

In Part 3 we will look at how the hemp form of cannabis has recently been exploited to make high THC content products that have been marketed to youths by unscrupulous producers outside the regulated cannabis industry.

So on to our investigation of today’s cannabis environment. Cannabis madness or long-awaited sanity? There are many questions that need addressing.

What are the dramatic changes that have occurred in cannabis itself in the last 25 years? What does the evolving legal landscape for cannabis look like in America? How chaotic is the regulatory landscape? What is the role of medical cannabis? How can and, indeed, should medical cannabis dispensaries remain a part of the landscape?

Why do more people today use cannabis on a daily or near daily basis than drink alcohol? Yes, since 2022 more people are frequent cannabis users than frequent alcohol consumers!

What are the new and increasingly dominant economics of cannabis? And what are some policy changes that would help address safety and public health issues while aligning cannabis use and regulation with both science and public attitudes?

Let’s get to sorting out the madness.

Tetrahydrocannabinols, or THC, are the psychoactive chemicals in cannabis that are the reason it is so popular as a consumable. THC content in cannabis stayed fairly level at around 5% from the 1970s into the early 2000’s. Since then average levels have climbed steeply to around 20%, a four-fold increase.

Cannabis bought on the black market today is often not as strong as that bought in a dispensary, but it can be. And there are concentrated products in dispensaries that can go over 90% THC content.

High content extracts are made using solvents. The chemicals used in producing extracts, both regulated and black or gray market, are not well identified, but solvents commonly used in making black or gray market extracts include alcohols, acetone like in nail polish remover, and toxic petroleum-based chemicals.

Safely produced or not, these extracted products are ultraprocessed, and so cannabis has joined the food we eat in the era of the ultraprocessed.

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A visit to a recreational dispensary makes evident that connoisseurs are a part of today’s cannabis culture, not dissimilar to the way connoisseurs are a part of wine culture. There is a lot to know about the psychoactive effects of various cannabis cultivars, blends, and forms of administration. While the Indica plant species label denotes a sedative effect and the Sativa species an energizing or cerebral effect, those are somewhat outdated terms, in that there are many compounds in cannabis called terpenes, each of which has a different psychoactive effect.

And then there are the 120 plus cannabinoids, the most well-known two being the psychoactive Delta-9 THC and the not-psychoactive cannabidiol, or CBD. The THC and CBD quantities are stated in products displayed in recreational dispensaries.

However, CBD will create differing effects of the THC, depending on the overall blend of compounds, the form of administration, quantities, and the consumer’s biology. For example, sometimes the high is enhanced or muted, or unwanted effects of THC, like anxiety, are reduced. To the uninitiated, trying to figure out the offerings in a dispensary and what a product will be like when consumed can be more guess work than shopping the Burgundy section at a high-end wine shop.

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So where can cannabis be bought legally today?

Cannabis is fully legal in 24 states and Washington D.C. with recreational and medical dispensaries in all of them except for Virginia, where sales will likely be allowed this year. Fifteen more states and Puerto Rico allow only medical cannabis sales, and six more states allow sales of CBD oil with a low level of THC. You will not find any kind of cannabis for legal sale or consumption in Idaho, Wyoming, Nebraska, North or South Carolina.

Most states with recreational dispensaries allow a limited amount of home growing, typically 3 to 6 plants per person. Only a few states that allow sales of cannabis solely for medical purposes also permit home cultivation.

Cannabis’s illegal status at the federal level has resulted in highly variable regulation and enforcement, ranging from inadequate to, at times, grossly inadequate, as states have legalized cannabis one by one. The patchwork quilt of regulation has two layers since essentially every state that has recreational cannabis started with medical legalization, requiring dual-levels of regulation per state for the co-existing channels of dispensing.

Estimates date the growing of Cannabis sativa to 10,000 BC, likely as a grain food and for its useful fiber. The first known medical uses are attributed to the Chinese emperor Shen Nung, around 2,700 BC. Since then, medicinal cannabis has been used and researched around the globe and widely used here in America in the 19^th century.

However, as we have seen, quoting science writer Stephanie Pain, “In the twentieth century, prescription gave way to proscription.” What was once recommended, became forbidden.

Despite cannabis’s illegal status over the last 100 years or so, Americans suffering physical or mental ailments have long sought the return of medicalized cannabis as an adjunct or alternative to federally-approved medicine or treatment.

Thank you for reading. In Part Two of “Ultraprocessed Cannabis: Potency, Policy, And Public Health In America,” we take the pulse of medical cannabis and consider the rise of cannabis use disorder.

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You’ve got a healthy weight, or you are not interested in weight loss, or at least in weight loss using available medical paths like GLP-1s or bariatric surgery – why should you care about GLP-1s?

GLP-1s are a factor in the continued fast rise in health care costs in America. If you don’t need them or take them but you have medical insurance or just pay federal taxes, you are likely still affected by the cost and popularity of GLP-1s. (I might point out that most people don’t ever have cancer, but their insurance payments help save the lives of those who do. Maybe it can be seen as a sort of actuarial scientist’s form of karma.) No matter our personal stance, GLP-1s are having an impact on the health and economic well-being of America.

I was writing today’s update on GLP-1s when I noticed a Boston Globe Editorial that mused about how the City of Boston wants to control the cost of GLP-1 medications for its employees, how that dilemma was common now across employers and insurers throughout government and industry, and what could be done to control GLP-1 pricing. The end of this podcast is what I posted in the Globe as comment both on its Editorial and the other comments of Globe readers.

Also, today, many GLP-1 questions are popping up. GLP-1s and muscle mass – worry or no worry? Stretching out the GLP-1 dose schedule when a patient’s target weight level is reached would be a great way to save money…but does it work without weight re-gain?

Also, what is happening with GLP-1 pricing, new products, and Ozempic patent expirations? And could GLP-1s really be made for only $3 a dose? There’s a lot going on.

To our questions.

If you are using or contemplating using a GLP-1 you have likely been made to worry about the fact that dieting causes loss of the soft tissue we like, such as muscles, along with loss of fatty tissue, which we don’t like. A lot of the anxiety about GLP-1 muscle loss is generated by social influencers and nutrition and conditioning hawkers. Not to worry…but do step up with the strength conditioning.

The bigger you are the more muscle you need to support and control your weight. Strength and conditioning is always important, but especially so during weight loss. And, unlike dieting, where will-power is a very poor tool for permanent results, I do recommend putting will-power into play as much as possible if strength exercises are not your thing. Improvements can be seen from workout to workout, whether in the gym or your living room. The important thing is to start and continue on a regular basis, finding as many ways to enjoy yourself and take pride in your gains as possible.

A small study has found that once some patients reach their target weight on a GLP-1 they can reduce the frequency of their doses without regaining weight. This finding is hopeful for GLP-1 patients having difficulty with the long-term cost of the medication, but much more research is needed to understand the risks and conditions required for success in any reduced dosing approach. We do know that a complete stopping of GLP-1 treatment is strongly linked to weight regain. Proceed with caution if thinking about a reduced dosage and be sure to consult your health care provider.

The Trump administration’s work to reduce GLP-1 costs is welcome but, so far, not a huge game changer. Continued pressure on pricing may come from the introduction of competing medications, but manufacturers other than Novo Nordisk and Eli Lilly have not yet made application to the FDA for any product approvals.

But there is room for improvement. A new study released in preprint found that semaglutide, the ingredient in Wegovy and Ozempic, could be sold for $12 a month in generic liquid form for injection and $36 a month in generic pill form, a dramatic savings over the cost of the Novo Nordisk brands.

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With Novo Nordisk semaglutide patents expiring this year in China, India, Brazil, Canada, Turkey and five other countries, and no patent protection in 150 other countries, theoretically by the end of this year 85% of the world’s population with the disease of obesity could be living in a country with a generic semaglutide medication available.

Meanwhile, Novo Nordisk just received fast-track approval for a high-dose form of Wegovy in a pen. The dose in Wegovy HD is three times greater than the highest dose in regular Wegovy and average weight reduction is 21%, compared to 15% with regular Wegovy.

Novo Nordisk has also just put its Wegovy pill on the market. Eli Lilly has applied on the fast track for approval for its new GLP-1 pill, Orforglipron. Unlike the Wegovy pill which must be taken on an empty stomach at least 30 minutes before eating anything, Orforglipron can be taken with or without food.

That’s a rundown of the some of the biggest news in GLP-1s.

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The following is based on my response to the Boston Globe Editorial on GLP-1 coverage for City of Boston employees. The Editorial advocated compromises that could result in some people who were already on a GLP-1 being removed from coverage for their medication. The comments featured a lot of folks who were of the mind that will-power and exercise were all that is required for weight loss.

Quote: I’m a nutritional epidemiologist and publish EatingInAmerica.co. I have studied the obesity epidemic in America, what has caused it, and the GLP-1 drugs. These highly effective medications are saving lives and reducing chronic disease, including obesity, diabetes, cardiovascular disease, kidney disease, osteoarthritis, and sleep apnea, and generally making life better for millions of Americans.

Because of the arbitrarily high prices of GLP-1 medications in America, the point at which health care savings from GLP-1s exceed their costs is somewhere in the future, requiring the decision to cover them at this moment to be based in large part on difficult estimates of the value of these medications to the quality of life of a patient.

There is still stigma on these medications because of some remaining popular belief, evidenced in many of the comments to the Boston Globe Editorial, that GLP-1s are the easy way out of unhealthy weight and that all that is required to restore a healthy weight is will-power and exercise. My personal opinion is that because of this remaining attitude it is easier for insurers and employers to restrict coverage to GLP-1s and save money.

But why are we thinking about the use of medications to control weight at all? Best would be if we could roll back the clock 50 years to the beginning of the obesity epidemic, or 60 years to when ultraprocessed food was allowed to start taking over our food environment and put strong protections in place against the making and marketing of unhealthy food.

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This post and podcast are about what’s in our food and who’s in charge of making it healthy. While RFK, Jr. and his Department of Health and Human Services are getting a lot of attention when it comes to federal action or inaction on making our food healthy, in many ways it’s the USDA, the Department of Agriculture, that’s more in charge of the healthiness of our food.

For example, the USDA is responsible for the safety and inspection of our food. The Department is a full partner with Health and Human Services in writing the Dietary Guidelines that this year famously featured the upside-down food pyramid.

But, more importantly, the 2026 USDA budget is $458 billion – nearly half of a trillion dollars. Most of that money flows to agriculture through consumers who receive food assistance like SNAP in order to put food on their tables. Folks being able to afford to eat and not go hungry is certainly a big factor in health. But also, how SNAP and the other programs allow that money to be spent in the store influences the healthiness of the food that is produced. As Jerold Mande in our interview today points out, a lot of states are now beginning to put restrictions on SNAP dollars being used to buy unhealthy products like Coca-Cola.

However, a lot of money flows through the USDA to directly support agriculture in this country, and whether that money goes to the production of fruits and vegetables that are in short supply in American diets, which it mostly doesn’t, or whether that money goes to help produce corn for ethanol, feed for cattle and pigs, or ingredients for ultraprocessed food, which are the places most of the money goes, makes a tremendous amount of difference to what our American food environment looks like.

Perhaps no one knows more about these issues and how the USDA handles them then our guest on Eating in America today, Jerold Mande.

Interview - Introduction

Jerold R. Mande is a nationally recognized expert in public health, nutrition, policy. He’s an adjunct professor of nutrition at the Harvard Chan School of Public Health and CEO of Nourish Science, an NGO dedicated to greatly increasing nutrition research, putting bite and muscle (my words) into the FDA’s regulation of food ingredients and additives, including the regulation of ultra-processed food and modernizing SNAP food assistance.

This is all towards the overarching Nourish Science mission to change the federal nutrition goal to “ensuring every child reaches age 18 at a healthy weight and in good metabolic health.”

Mande has served three presidents in senior policymaking positions at USDA, FDA, and OSHA. He has shaped nutrition, food safety, and tobacco control programs. He led the Nutrition Fact Label Design Team at FDA for George H.W. Bush.

And first but not least, Mande started his career with Al Gore in Congress, helping Gore write America’s organ donation laws.

Transcript (lightly edited for clarity)

RB: “Jerry Mande, it is such a pleasure and honor to have you on Eating in America.”

JM: “Ric, thanks for having me.”

RB: “So I get sent frequent press releases from the USDA, as I’m sure you do. And I want to save a few minutes in this discussion to get your interpretation about what’s going on with all the program and policy initiatives and media events from the USDA these days.

“But first, one of the press releases that I passed over very quickly said the USDA is closing a couple of buildings in Washington DC and Alexandria, Virginia. But that closure had a lot of meaning for you. Will you explain please Jerry, what has happened with those buildings?”

JM: “So these closures are core facilities of USDA and represent a demolishing of the culture that makes USDA such a remarkable agency, fulfilling the goal of President Lincoln, who created the agency’s mission to make it “the people’s department.”

“First, the Braddock Building in Alexandria is the home of the Food and Nutrition Service. That’s the agency within the USDA that manages 80% of the USDA budget, feeds one in four Americans each year, and houses programs such as SNAP, the Food Stamp Program, the School Meals Program, and the Women Infants and Children, or WIC, program.

“The South Building in D.C. proper is attached to the USDA main headquarters building, the Witten Building. It’s the only federal department that is actually on the mall. It’s a short walk from the White House and right next to the Washington Monument. Actually the South Building should be the headquarters building because it’s many times larger. But the headquarters is the Witten Building. It’s a beautiful building.

“The South Building when it was built in 1936 was the largest office building in America. It held that distinction until the Pentagon was built. And still today, it’s the second largest.

“So the announcement you mentioned, it doesn’t scream out that there’s a problem in getting rid of those buildings. And what they’re doing in getting rid of those buildings is moving those programs somewhere else.”

RB: “Well, it occurs to me that USDA Deputy Secretary Vaden, when he announced the closures, said Trump’s idea is to control this sprawling federal bureaucracy. But to control it, they’re actually sending it away to many far, far away places. And that seems the opposite of actually controlling sprawl!”

JM: “Just a little bit of background to help explain the impact of these closures. Earlier in my career, I worked at the Department of Health and Human Services, particularly the FDA. These were great agencies, I thought.

“And indeed, I thought that the Department of Agriculture was sort of the bad guys because of the industry influence on the issues I worked on, like food labeling, where we had to fight the USDA at every step to get the Nutrition Facts Label that we have in place today. But when I worked at HHS, something just didn’t stand out to me at all.

“The HHS, because it was cobbled together over many administrations and literally decades and decades, was scattered all across the country in different buildings and agencies. There is a big building a block off the mall. The secretary works there, but none of our agency heads work there because their agencies are scattered all across the country. I thought it was always a bit dysfunctional, and there were a lot of challenges. But I figured, this is just life in the federal government and that’s as good as it gets, I guess.

“But then in the Obama administration, I was invited to join the Department of Agriculture. And it was just this remarkable eye-opening experience that, wow, this agency operates so much better than anything I’ve ever experienced before. And it was because of the culture created by the proximity of all of the staff.”

“Secretary Vilsack, the secretary then, and all of his undersecretaries, which are the equivalent of these HHS agency heads, were literally on the same hallway in the Witten building, and all of their staff were right behind them in the big South building. As a result, we met all together, face-to-face, in-person every week. This, what I’ll call the subcabinet, and the physical proximity of all the agencies and the secretary, created just a much more effective culture.

“So the [Trump] administration is going to the HHS model: wanting to destroy the culture of the USDA and move its agencies all over.

“They began that in their first term. They ran an experiment. They took two of the smaller but important agencies at USDA, the Economic Research Service and the National Institute of Food and Agriculture, both research agencies, and decided they were going to move them to Kansas City. They did and it had the desired effect.

“People quit. People didn’t pick up and move to Kansas City. So the elite quality of those agencies was destroyed. The Biden administration tried to build them back, but they still haven’t been as strong and as effective as they had been in the past.

“The Trump administration took that lesson to heart. If you try to just get rid of an agency altogether, well, that’s up to Congress to do and people go to court and the administration loses. But they said, gee, it’s within our authority to just tell an agency they have to relocate somewhere else. If we can do it within our budget, it seems to be legal, and it’s going to have the net effect of destroying that agency, essentially.”

RB: “I think almost two thirds of the Economic Research Service just declined to move to Kansas City, as nice as Kansas City might be.”

JM: “No, they have their families, their careers, their lives in Washington. And so four years wiser and learning from their first time, the Trump administration came back and said, just move the agencies someplace different. They’ll explain it that the agencies need to be closer to the people, but you have to say “if it’s not broke, why do you?”

“So you have this extraordinary agency with a really remarkable culture that Abraham Lincoln literally put in place and that’s operated at an elite level for 150 plus years. But they came armed with a blueprint of how to demolish that, and that’s what they’ve embarked on. And that’s what these closures represent.”

RB: “Thank you for that insight and perspective. The contrast you have drawn between HHS and USDA couldn’t make things clearer.

“The other thing I wanted to look at a little bit is what’s going on with the programs. I’m a recent subscriber to the press releases from the USDA. I see a lot of program initiatives. Big ones, like $38 billion in conservation money, $12 billion in Farmer Bridge Assistance, $16 billion in Supplemental Disaster Assistance, and smaller ones, too. And then lots of media events.

“What’s going on? Am I incorrect in getting the sense that the USDA is making a push to shore up farm and ranch support in this somewhat chaotic environment for the country and agriculture and ranching?”

JM: “Well, they are trying to support our farmers, our ranchers, and should, right? We rely on only 2 % of the population to feed us all. So it’s a very important thing to do.

“But they’re actually good on the food and nutrition issues, particularly the diet quality issues that I’ve devoted my career to.

“Food and nutrition, I will divide broadly into three buckets, all equally important. Food justice has to do with making sure Americans who are poor have the support and food that they need, but also that the workers in the system are taken care of.

Then there’s diet quality, which is my issue, making sure that the food we eat helps us thrive and certainly doesn’t make us sick or cause a chronic disease. And then, climate and sustainability, agriculture plays a big role in that.

My whole career is devoted to the diet quality piece. All three buckets are large areas and equally important. I strongly support work in all of them. I just chose to work in diet and health. It’s the one that most inspires and animates me.

“This administration has been remarkable on the diet and health part of food and nutrition. They’re actually doing a great job on MAHA, Make America Healthy Again, particularly SNAP, which is something that I oversaw.

“When I was with the USDA for six years, we were trying to make changes, or at least test some changes in pilots about how SNAP could be used as a lever with big food to improve diet quality. We couldn’t get a single state pilot started. They now have 22, which is just remarkable. Twenty-two states no longer sell soda to SNAP recipients [using SNAP dollars], which I think is a great idea.

“But on the food justice side and on sustainability and climate, they’re really breaking those things. That’s not their priority, and they’re doing a poor job.

“For me, it’s challenging. There are some areas where they’re doing a really great job. The dietary guidelines they put out are a sort of a microcosm of both [the good and the bad]. They’ve said some things that just don’t follow the science. They seem to be heading down the path about eating more red meat. That really is fine. People can eat red meat, but we don’t need to eat more of it. In fact, people should eat less of it. But then at the same time, they’ve said people shouldn’t be eating ultraprocessed foods, which is great - and something a second Biden administration probably would not have said.

“So it’s a very unpredictable time and something we’re all trying to still figure out.”

RB: “Thank you so much Jerry Mande for your perspective on the direction of the USDA these days: both the favorable things that are happening and things that are still, perhaps, lacking in their direction.

“I wish we could talk forever because there’s a wealth of knowledge there and some great ideas. What’s the website for folks who want to learn more about your efforts?”

JM: “It’s NourishScience.org. And Ric, thank you for having me. I enjoyed this and if you invite me back, I promise to come.”

RB: “All right! I will do that! Thanks so much!”

RFK, Jr. has gone full publicity blitzkrieg about his success enlisting U.S. medical schools to teach more about nutrition. The Health and Human Services Department is selling it as a great victory for Kennedy’s Make America Healthy Again Movement. However, the omission of a very important item from Kennedy’s proposed nutrition curriculum topics for doctors has hit a very sensitive nerve with me today.

First, the background.

As Eating in America reported last fall, the Trump administration and the USDA have killed the annual U.S. Food Security Report. After thirty years of continual monitoring of American household food security, the final report was quietly issued, two months late, on December 30.

Over the decades, the Food Security Report has been crucial to guide food assistance programs like SNAP and to measure our progress, or lack of it, in reducing hunger in America. Most of us have never had to worry about hunger or food security, but in 2024 one in seven households, 41 million Americans, experienced food insecurity. That was measured at 13.7% of households, a little more than in 2023, but not statistically different.

In 2024, 5.4% of households had very low food security compared to 5.1% in 2023, but still not statistically different. Very low food security means sometimes being hungry, skipping a meal, or not eating for a whole day because of lack of money for food.

Children experienced food insecurity in 3.3 million households and very low food security in 318,000 households.

Why does Trump want to let the fact that hunger is still found in America be hidden? Does he not want to address it? Is he aware that his policies and actions are likely to increase food insecurity and hunger, and he would rather not see statistics proving the rise of food insecurity and hunger in adults and children?

Trump’s lack of support for SNAP benefits during last fall’s federal shutdown and his tightening of eligibility requirements make it highly likely that food security, if it were still being measured, would show a downturn and hunger an upturn in the first year of his administration.

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This masking of hunger in America reminds me how rich coffee plantation owners in Central America, where the use of enslaved people was forbidden, essentially created a system of slavery by maintaining a state of food deprivation on their plantations in order to force the indigenous people to work (Coffeeland, Sedgewick, 2020). Families were tied to the plantation. There were no other source of work and no other source of food. The indigenous laborers were nominally free – there was nothing to rebel against - but because they and their families were hungry, they were subdued, controlled, and subservient.

When I see the prevalence of hunger in Americans and the fact that hunger will be officially hidden by our government going forward, I cannot help but see hunger as a device of repression against poor Americans in the hands of Trump and his minions. And in recent months outside of America, Trump has weaponized the hunger of civilians in Gaza and Cuba.

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So what has this to do with the addition of nutrition to a medical education?

I’m getting there.

There are two kinds of malnutrition in America, and increasingly around the world: undernutrition and overnutrition.

I have only heard RFK, Jr. talk about overnutrition. Overnutrition as expressed in unhealthy weight is all around all of us. Kennedy, Trump, and MAHA advocates and siblings Calley and Casey Means, the latter Trump’s nominee for Surgeon General, all grew up in privilege, moving in elite circles and with exposure mainly to people like themselves, many of whom had issues of overnutrition. Maybe I am wrong, but meaningful exposure to the real lives of Americans with food insecurity and, worse, undernutrition, might never have been part of Kennedy, Trump, and the Means’ real-world education.

However, real doctors and health experts, not unqualified people like Casey Means or Kennedy, should be, need to be, attentive to the fact that some of their patients and constituents may be experiencing food insecurity.

Doctors in training need to learn that there are quick food security screeners that can be administered in the doctor’s office. The best known is the simple Hunger Vital Sign tool: a two-question validated screener developed by Children’s Health Watch in Boston. It is based on the Trump-killed U.S. Food Security Survey. The doctor or professional simply asks for an “often” or “sometimes true” versus “never true” response to two statements: First, “Within the past 12 months we worried whether our food would run out before we got money to buy more.” Second, “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.” A response other than “never true” flags the need for a doctor to assist in assuring that the patient’s food security is addressed.

So why would teaching the use of a food security screening tool like the Hunger Vital Sign not be at the very top of the list of things about nutrition that a doctor should be taught? It boggles my mind, but food security screening is not explicitly on the list of 71 nutrition competencies Kennedy recommends be addressed in medical education.

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Kennedy’s list is billed as being based on an expert list of 36 competencies published in the Journal of the American Medical Association in 2024, but it bears little resemblance. The JAMA list puts food security screening as the #2 item, behind #1 “Provides evidence-based, culturally sensitive nutrition and food recommendations to patients for the prevention and treatment of disease.” In general, the JAMA list is written to make doctors-to-be aware and sensitive to nutritional issues and competent to address nutrition in partnership with dedicated nutrition professionals. I like the JAMA list a lot.

The Kennedy list is, on the other hand, more like a curriculum for doctors who want to become social media influencers and snake oil peddlers, like our unlicensed-doctor-waiting-to-be-Surgeon-General, Casey Means. For example, recommended core competency #58 is learning how to recommend a wide range of “nutraceuticals” or food and herb-derived supplements like Means sells. And then there are bizarre recommendations for the training of a doctor, like competency #67: “Regenerative agriculture immersion: participate in on-site learning at farms including soil sampling, composting, crop rotation.”

The single competency on Kennedy’s list that pops out as a genuinely valuable addition to JAMA’s list of two years ago is #55: “GLP-1 agonists counseling with diet and lifestyle guidance.” In other words, doctors should be familiar with the growing arsenal of GLP-1 and related medicines, how they work, their powerful intended and side effects, real world food needs stemming from taking GLP-1s, effects - real or feared - on muscle mass, and that there should be no stigma attached to taking GLP-1s. Well, of course, yes.

There has long been a push for more nutrition training in medical school. As doctors watched the obesity epidemic explode and attendant chronic diseases increase in America, the nutrition training gap in medical school became undeniable. More awareness and understanding in the medical profession were required, even if effective treatment tools to curb the symptoms of the disease of obesity were not yet widely available.

I didn’t understand until I read JAMA’s 2024 recommended nutritional competencies that the need was not for doctors to learn more facts about fats and carbohydrates but to learn how to treat people with respect, understanding, and thoughtful guidance when those people are just coping with the effects of living in a terrible food environment that is allowed to prey on their biology.

Fifty-three out of the approximately160 medical schools in the U.S. have capitulated to Kennedy’s somewhat extortionate push to incorporate more nutrition training. The use of any of Kennedy’s 71 competencies is, fortunately, not required by the medical school agreements with Kennedy, and it might be embarrassing to see any medical school work from a list grounded in Kennedy’s personal bias and not in science. However, the list is described by Kennedy as “recommended”, not merely “suggested.”

So despite my long-held belief and advocacy for more nutrition training for doctors, I stand with those who are upset by Kennedy forcing the issue on medical schools. Our federal government does not place science and the health of its people above all else. Opening any door to future federal dictates for medical training is scary, given the current administration.

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Red meat consumption is down, and chicken consumption is up.

While the consumption of beef, the most popular red meat, continued to grow in the prosperous years after World War II, it peaked in the 1970s and has rapidly declined since. On the other hand, chicken consumption has been growing steadily since World War II. During the Great Recession of 2007 to 2009, chicken overtook beef as the most consumed animal protein.

Shunned by some and loved by others, pork is classified by the USDA as a red meat but was famously and successfully marketed from 1987 to 2011 as “the other white meat.” Observers remarked that the white meat ad campaign contradicting the USDA was paid for by a tax on pig sales organized by the USDA.

In fact, pork can be quite lean like poultry, but the fat content of both beef and pork depends on the cut and can vary greatly in both cases. As a nutritionist, I agree with the USDA, and even RFK, Jr., that pork is red meat.

Pork’s fortunes have taken small ups and downs, particularly in the Great Depression of the 1930s and during the beef boom of the mid-1970s, when it took a big dip, but consumption has generally grown slowly over time.

Altogether, Americans eat a lot of protein, before we even get to plant protein and dairy. According to USDA data there were about 200 pounds of trimmed, boneless meat of various types available for each American in 2021.

Those 200 pounds consist of chicken in the number one position at 68 pounds; beef at 56; pork, 48; turkey, 12; and about 20 pounds of fish. That’s over a half-pound of meat, poultry, and fish per American per day.

The reason that many Americans have been reducing their red meat consumption is that they’ve received the message about red meat being bad for your health. The true science is very clear on three points: red meat is linked to cancer, red meat in general has a lot of saturated fat which is linked to heart disease, and most Americans get more than the recommended level of protein.

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Groups concerned with the environment have long publicized the heavy climate burden of cattle. Livestock, mostly cattle, are responsible for 15% of human-created greenhouse gas from their burps and production of manure. Additional sources of emissions are due to the loss of forest for pasture, the production of feed, and manure storage. However, survey data indicate that environmental concerns are not, for most people, a big motivator in their reduction of red meat consumption.

Apart from health, the other key factor in reduced red meat consumption, is cost.

Since the pandemic beef has led all food products in cost increases: roasts have gone up 74%, steaks 57%, and ground beef 53%. But while alarm bells have been ringing with the price of round roast hitting $9 a pound at the end of 2025, round was at $11 a pound – adjusted for inflation – in 1980, a few years after the peak of beef consumption in the mid-70s.

In short, beef got very popular and then very expensive and as the demand fell, prices fell, but now they’re back up despite only a very slow growth in demand over the last decade. It may be a difficult task for RFK, Jr. and the USDA to boost consumption much at this point.

And, despite the scientific consensus around the increased health risks associated with red meat, Kennedy wants us to eat more for our health. He believes we need more protein, while most nutritionists agree that generally we eat much more than we need.

Kennedy’s beliefs coincide with the mission of the USDA to support the cattle industry. Kennedy embrace of this symbiotic relationship was demonstrated in his February address to the National Cattlemen’s Beef Association, “begging” them to vastly expand the size of their herds to accommodate increased consumer demand and drive prices lower.

RFK, Jr.’s comment on herd expansion alarmed environmentalists. According to reporting in The Guardian, The World Resources Institute has calculated that to expand the American herd by 25 million head of beef cattle, 100 million acres of arable land would be required in the U.S. There are currently 86 million head of cattle in beef production, a 75 year low. The conversion of 100 million acres, about the size of California, would come at great cost in methane gas emissions and loss of land that would otherwise be a carbon sink or produce lower-burden plant protein.

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Will Kennedy succeed?

Not only will RFK, Jr. and the USDA be fighting the widening understanding of the health risks linked to red meat and the price of beef at the supermarket, but they will also be fighting demographics. A 2023 study analyzed CDC National Survey data from 2015 to 2018 and found that 12% of American adults eat half of the beef we consumed.

That highest consuming population tends to be in the 50- to 65-year-old range. They were kids at the peak of beef consumption in the 1970s.

Foods we are exposed to at an early age make a biological imprint on us as part of the creation of our culinary compass. A large component of this early setting of food preferences is our family’s food culture. In short, children and teens fed a lot of meat, as many were in the 1970s, were tending to learn a lifelong meat habit. In coming years, as those heavy meat eaters age out of the population, the beef marketers are going to have to work even harder to bolster sales.

Plant protein and grain

When we hear the advice to eat more plant protein, we may think first about whether we could eat more beans like soy or many others. We may also tend to increase consumption of plant-based meat alternatives, like Impossible Burgers. We may not be conscious that on average 31% of the protein Americans eat already comes from plants, mostly from grains. Our diet is in contrast to the average diet in lower-income countries where 70% of protein comes from plants.

What about plant-based meat alternatives?

A 2025 study found plant-based, what I call “pretend,” meat had just 1.4% of the retail meat market share in the U.S.

It may be difficult to evaluate any health benefits of plant-based meat alternatives compared to actual meat or to plant protein sources in grains or beans, as plant-based meat alternatives are ultraprocessed foods with a wide variety of mixes of ingredients. These highly-promoted, lab-designed and manufactured products are convenient and likely more healthy than red meat products they replace, although pretend chicken or turkey replacements for organic poultry are a hard health sell for me.

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If you believe in the greater certainty of the health benefits of real food, for additional concentrated plant protein, minimally processed ingredients like beans or moderately processed foods like tofu or tempeh might make sense.

Moving forward

So no, for pressures of cost, health, and the increasing difficulty of political and agricultural policy leaders in denying the climate crisis, I don’t think we are going back to the beef consumption America saw in yester year.

The cowboy and beef, and the heightened, comfortable machismo state they have evoked in our culture, are becoming saddle sore, encroached, and endangered in America.

In fact, let me be the first, or perhaps among the first, to propose a rational but radical idea. States and localities have authority to regulate and tax unhealthy substances, think tobacco, alcohol, marijuana (for those states where it is legal), and has been attempted in a few places, sugar-sweetened beverages. Tax revenues from these sources can be and sometimes have been used to pay for health expenses incurred by the state because of these substances. What brave state will be the first to tax red meat? Or ultraprocessed food, for that matter?

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My dream is that nutrition will be an apex science some day: treated as one of the foremost disciplines in maximizing the health of humans. Then, having written the codex spelling out how our bodies metabolize food and how to eat healthy, nutrition can take a seat next to Newtonian physics: always fundamental, exerting its rule every moment of our lives, but just part of life. No need to think about it. In my dream gastronomy will become very simple like basic physics: apples fall from trees, and we eat them… and other real foods.

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