Eating in America Podcast

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.

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.

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.

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.

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.

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.

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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.

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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.

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Thanks for reading.

What are your thoughts about bus access to healthy food?

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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.

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.

What do you think about what might be the awakening of the age of GLP-1s in America? Let us know!

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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 22nd in draft version. Another Republican, Julia Letlow from Louisiana, an avowed MAHA mom, introduced her own FRESH Act on April 29th. 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.

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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Guess who said:

…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.

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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.

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.

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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.

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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.

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.

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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.

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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.

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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.

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.

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.

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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.

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.

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