Eating in America Podcast

Cannabis was legal in America well into the 20th 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 20th 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.

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.

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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.

Thank you for reading. In Part Three of “Ultraprocessed Cannabis: Potency, Policy, And Public Health In America,” we do a health reality check for and against cannabis; discuss cannabis in relation to America’s other favorite recreational substance, alcohol; and follow the path of ultra-potent to ultra-high to ultraprocessed.

If you haven’t already, be sure to check out the first part of our series, where we look at how cannabis got so strong and how the U.S. got a hodge-podge of cannabis regulation. You can find that at EatingInAmerica.co.

Your support of Eating in America is so helpful to this Substack’s growth. Please let me know your thoughts about cannabis in the comments. Thank you!

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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.

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.

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 19th 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.

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.

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.

With today’s video podcast, you have your full choice: watch, listen, or, as most do, read Eating in America. Anyway you do it, we are glad to have you here.

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.

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“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?”

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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.”

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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!”

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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.

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.

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.

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.”

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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.

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.

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.

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?

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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Excess unhealthy weight is a risk factor for serious chronic diseases, including heart disease, stroke, diabetes, osteoarthritis, and cancer. A new study reveals trends in obesity among people who are Black, White, and Hispanic. The projected trend for the next ten years, through 2035, does not look good for any of these groups.

In 1990, a little less than 20% of American adults had a BMI of 30 or more, which is the standard, although imperfect, measure of obesity. By 2022, that percentage had risen to 45%. Obesity in the U.S. had more than doubled in 22 years.

While all the groups analyzed fared poorly, the levels of obesity among groups ranged from 40% in males who were either White or Black to 60% in females who were Black. Hispanics of both sexes had the biggest jumps in obesity from 1990: 25% increases in both males and females, with 2022 levels of almost 50% in females and 43% in males.

Obesity is highest in people who are

GLP-1 coverage shrinks as demand grows

As costs rapidly rose in the last few years due to expanded coverage of GLP-1s like Ozempic, Wegovy, and Zepbound, insurers began to respond with medication management programs and restrictions on coverage. Many GLP-1 patients prescribed for obesity or excess unhealthy weight have struggled to maintain coverage, pay increased costs for coverage, or find the money to buy their medicine without insurance help.

GLP-1 medications are highly effective for not only treatment of excess unhealthy weight but for treatment of diabetes. Patients with diabetes have experienced cutbacks in coverage, too, but not to the same extent as those being treated for obesity.

Of course, Zepbound and the others are very expensive. A study by authors at Yale, Harvard, King’s College Hospital London, and Doctors Without Borders, estimated that the full price of Ozempic is more than 200 times the cost of manufacturing. But the two major GLP-1 makers, Novo Nordisk and Eli Lilly, operate in an unregulated near-monopoly market in the U.S., where one of eight adults are prescribed a GLP-1.

CVS Caremark, an Aetna company, dropped GLP-1 coverage for obesity in July, but is facing a class-action lawsuit to restore it. Many other commercial insurers and large, self-insured employers have dropped GLP-1 coverage for obesity or imposed restrictions or larger shared costs.

Three states recently dropped Medicaid coverage for patients to receive a GLP-1 for obesity. Now only thirteen states provide coverage, which is sad given that Medicaid patients are among the most impoverished and a population heavily afflicted by the disease of obesity.

It is disturbing to see patients pulled away from access to a highly effective medication which is likely providing substantial health improvement and for which there is no equivalent substitute.

Worst are the manipulative processes used by GLP-1 management programs such as EnCircleRx, a cost control program started in 2024 by EverNorth, a prescription insurance company under the Cigna umbrella. In the face of GLP-1 coverage cost increases of as much as 40% a year hitting some plan sponsors in the insurance market, EverNorth offered employers EnCircleRx, with a guaranteed 15% cap on cost increases, year-to-year. EnCircleRx manages costs by creating barriers erected at the prior authorization stage and then finds additional savings with its lifestyle support program.

In the first year, eleven million patients were enrolled in EnCircleRx to get their GLP-1. As part of the process most are required to engage at least once a week with a program called Omada Health. Omada provides required nutrition, exercise, and behavioral health education and weigh-ins which are instantly uploaded from a connected digital scale provided by Omada. As beneficial as healthy eating and exercise are, these are likely things these patients have already tried unsuccessfully on their own for losing weight: interventions that science has proven do not work for most people in the long run. However, if a patient stops engagement with Omada, their EnCircleRX GLP-1 coverage can be taken away, and they will have to pay the market cost or drop the medication.

The value of a program like Omada for increasing weight loss while on a GLP-1 is questionable. There has come to be considerable medical consensus that these sorts of GLP-1 add-on programs are important for weight loss, and it seems, sort of, like it makes sense, but a good randomized controlled trial proving that assumption is hard to find.

Actual nutrition modifications and exercise are not required as part of Omada and similar programs, just receiving the message that they are important. If there was good fact-based evidence that eating changes and physical activity were essential, it seems to be these lifestyle plans would require them.

In addition to burdening patients with this sort of “use-or-lose” nutrition and exercise counseling regimen, there are reports of programs like EnCircleRx rejecting patients for coverage out-of-hand, at least until the patient puts in an appeal, even though they meet the requirements for high BMI or elevated BMI in combination with other chronic conditions which can benefit from weight loss like high-blood pressure, high cholesterol, cardiovascular conditions, sleep apnea, or diabetes.

Weaker or stronger bones with GLP-1s?

Patients who take a GLP-1 to lose unhealthy weight or treat diabetes should be warned that weight loss, especially the sometimes-dramatic losses that can come with GLP-1 use, warrants regular exercise to stem the potential loss of muscle mass. A lot of muscle can be consumed as the body seeks to replace the calories it’s not getting from food by instead burning skeletal muscle along with the targeted fat. Strengthening through resistance work is very important, but vigorous aerobic exercise should be added to the regimen as well.

Tangible reductions in strength can be felt with muscle mass loss. What is not tangible, is unseen, and is seldom discussed are changes in bone mass density that may occur with weight loss and GLP-1 use. Weight loss without GLP-1 use is linked to decreasing bone mass density, meaning weaker bones and more susceptibility to fractures. However, studies have reported conflicting results about weight loss caused by GLP-1 use. GLP-1s might provide limited help in increasing bone mass density while losing weight – or they might not. A 2024 randomized controlled study found that the GLP-1, liraglutide, sold as Saxenda for weight loss, reduced bone mass density along with body fat and weight. Exercise combined with liraglutide roughly cut in half the loss of bone mass density.

So, for those of us prescribed a GLP-1, in addition to the effect of heavy resistance exercise in stemming the loss of muscle, we have yet another reason to be at the gym.

New GLP-1 medications coming

Three new GLP-1s may reach the market this year, according to the Journal of the American Medical Association. Eli Lilly, maker of Zepbound and Mounjaro, expects fast track FDA approval of a new semaglutide pill, Orforglipron, targeted at those reluctant to self-inject. Trials of the pill, to be taken daily, delivered an average weight loss of 11% in patients with obesity but not diabetes after about a year and a half.

Novo Nordisk has a high-dose version of Wegovy that is also on FDA fast track. The new injectable will have three times more semaglutide in it than Wegovy. Trials in patients with obesity but not diabetes indicate an average 19% weight loss, only about 3% more than Wegovy delivers.

Novo Nordisk has also applied for approval of a new injectable, this time combining semaglutide with cagrilintide. The new drug, CagriSema, is on a par for efficacy with the high-dose Wegovy, with trials providing 20% weight loss in patients with obesity but not diabetes. However, CagriSema also registered slightly more side effect reports than Wegovy.

Other more powerful GLP-1s and related drugs are in the works. One of the objectives of coming products will be more weight loss but we also might find medications coming which are intended to cause less side effects, which are an important limitation for some folks trying to stay on a GLP-1.

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Everyone on Earth has one food in common, milk. We all drank it as our first meal, even if it was just the milk contained in formula.

Breast milk is the most perfect food: the ultimate personalized nutrition. I envy all moms and dads who have experienced breast feeding and its joy and love. Of course, breastfeeding is great if it can happen, but, in the interest of inclusivity, I wasn’t breastfed and I turned out fine.

Milk has been in the news a lot lately with full fat milk being promoted in the new Dietary Guidelines and the Whole Milk for Healthy Kids Act signed this month, so I am going to share the answers, many of which I think you will find interesting or useful, to the questions I have had about milk.

First, guess the answer, which is better for hydration, water or milk?

Full fat milk is 87% water and skim is 90%. A 2016 study found that both full fat and skim milk were better than water for hydration of adults. In fact, milk was more effective than any tested fluid. Oral hydration solution, like Pedialyte or the equivalent homemade solution mixed with the correct balance of sugar and salt, was also effective, as was orange juice. Plain water was on a par with, surprisingly, Coca-Cola, tea, coffee, beer, and Powerade. That’s right, water is just as good as a sports drink for hydration…but not as good as milk.

In a small sample of participants, a 2014 study found that milk was better than Powerade for re-hydration after vigorous exercise. The dairy industry has made much out of some small studies that show milk outperforms water for rehydration after heavy sweating. This evidence is weak, but milk does have the electrolytes calcium, potassium, and sodium, which water has little of. More research is needed, but, since milk does deliver protein and good hydration, you might find it a good option after a workout, as I do.

Okay, let’s deal with what is in RFK Jr.’s head, and I mean his thoughts about milk, raw and whole.

RFK, Jr. says raw milk is good for you. He drinks it.

Raw milk can carry Salmonella, E. coli, and Listeria. The USDA, CDC, and FDA all strongly warn against drinking it.

Testing has refuted the argument that raw milk is better than pasteurized nutritionally. There is a minor reduction in some vitamins from pasteurization, but not nearly enough to risk a serious illness. The CDC found that from 1998 through 2018, 2,645 people became ill from raw milk, with 228 hospitalizations.

However, hard cheese made from raw milk is safer than fluid raw milk. One study found that raw milk hard cheese can meet European Union standards for bacterial safety, but that a rigorous production process is needed, so safety is not guaranteed. Softer cheeses are not as effective in reducing pathogen loads as hard cheese, so beware. Also, FDA research in 2024 and 2025 found that Avian Flu virus, H5N1, can survive the raw milk hard cheese aging process. However, the FDA has found that milk pasteurization does kill the H5N1 virus.

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Should I buy ultra-pasteurized milk?

First Louis Pasteur discovered that the beer fermenting process was caused by yeast, and then he invented pasteurization to kill off the unwanted microbes that could cause beer to go bad. Having revolutioned the beer industry, Pasteur figured out how to pasteurize milk – 161 years ago in 1864.

I have a hard time heating milk on the stove for hot chocolate without making a skin on the surface. Have you ever wondered how milk is pasteurized without being ruined? The High Temperature/Short Time method is the common way. Milk is heated to 161°F for just 15 seconds. Milk pasteurized this way is coded for removal from grocery shelves 16 to 21 days after bottling or boxing.

Ultra-pasteurized milk, on the other hand, is flash-heated with injected steam to 280°F and then rapidly vacuum chilled. A box of ultra-processed milk can last for months, often without refrigeration. Very convenient, but there is a slightly sweeter, “cooked” taste, and some folks might prefer regular pasteurized milk for some uses. After it is opened the shelf life of ultra-processed milk is similar to that of regular pasteurized milk.

The Whole Milk for Healthy Kids Act and the case for whole milk

Trump signed the Whole Milk for Healthy Kids Act this month, allowing schools in the National School Lunch Program to serve full and 2% fat milk. This policy is heartily approved by Trump and RFK, Jr.’s MAHA followers.

But as Yasmin Tayag points out in the Atlantic, whole milk also connects Trump’s MAGA constituency back to a bucolic, pure, but imaginary American past that appeals to the right and far right. Social media posts by Trump and Kennedy of them with milk mustaches are reminiscent of the dairy industry’s “Got Milk” campaign of the 20th century.

And Trump’s post of himself as a milkman further reinforces this connection to a white American past. The milkman image goes way back to Trump’s childhood and reminds us that milkmen delivered milk bottles to doorsteps in the early through the mid-20th century. At one time almost a third of all the milk we drank in America was home delivered. Milkmen were the original Uber Eats, but without the app.

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Framing Trump as a restorer of an old version of America is strong messaging built on a weak basis.

The effort to promote whole milk is meant to benefit farmers who hope to sell more, as milk sales continue a 50-year decline. Whole milk is more expensive than reduced fat milks (by which I mean 2%, 1%, and skim milk) because of its fat content, which can be used in other products like butter and cream. So if some people switch from lower fat to full fat milk, that’s good for the dairy industry.

What types of milk sell the most?

My analysis of USDA 2025 data through November shows that full fat milk is 47% of sales, skim is just 6%. In between are 2% fat, which has 34% of sales, and 1%, which has a modest 13% of sales.

In fact, there was a little shift in 2025 with all the buzz about whole milk. Regular full fat milk was up about one percent over 2024, but milk sales as a whole were down about two percent. So despite the promotion of whole milk, for the moment the industry continues to slip in volume.

Flavored milk is 11% of all non-organic milk sales. About 2/3 of flavored milk consumed is chocolate, both at school and at home. A survey of 51 flavored milks sold in schools found they all contained added sugar, ranging from 6 to 16 grams worth.

Organic milk, by the way, is 7% of all milk sales.

Is organic better?

How much healthier is organic milk for you than conventional? Pesticides are in conventional cow milk, mainly from cows eating contaminated feed and forage. Most conventionally farmed cows are treated with growth hormones and antibiotics that also show up in their milk.

Organic is a little better nutritionally because forage results in somewhat better milk than than the feed mixtures provided to intensively-raised indoor cows. While many conventionally producing cows are allowed to graze, factory farming counts for about 70% of milk production, and the number of small dairy farms dropped by almost half in the last ten years.

It would be an easy choice between organic and conventional milk if price weren’t a factor, but this week in the U.S. the average advertised cost of a gallon of organic, $8.16, is exactly three times that of a gallon of conventional milk.

Other motivators for organic dairy purchases are the public health benefits of not introducing pesticides and antibiotics into the environment, and the presumption that cows are happier being out grazing in a pasture at least three months a year, as required by the USDA for organic milk cows, as opposed to those many cows that spend their life inside where welfare issues are a concern.

Another hopefully interesting statistic: cow milk is almost 100% of American animal milk production, but, worldwide, cow milk is about 80%, followed by buffalos at 15%. Goats, sheep, camels, yaks, horses, reindeers, and donkeys together are responsible for 5% of milk production.

Will school kids actually drink more milk if full fat milk is available?

Blind taste test studies indicate kids will maybe, maybe not drink more full fat milk than lower fat milk on the basis of taste. One study found consumers can’t tell the difference between milk types by taste alone, while a recent one found a taste preference for full fat milk.

Saturated fat?

There is new debate among nutrition scientists about whether saturated fat in milk has the same risk-increasing effect on heart health that saturated fat in, say meat, does. More research is needed.

It seems very likely to me that if a kid is a milk drinker of whatever fat content, that alone is a win for health, as long as the milk is unflavored and not raw. Milk’s health benefit is further increased if the milk is consumed in place of less healthy juice or sugar-sweetened beverages.

Doesn’t removing fat from milk remove vitamins?

Calcium absorption in the intestines can’t effectively happen without vitamin D. The vitamins dissolved in the milk fat, A and D, are removed along with the fat in lower fat milk, but they are, by regulation, replaced with 2,000 IU of vitamin A in all lower fat milk.

Further, since about 1933, vitamin D has been added to milk. Vitamin D fortification is the primary reason that rickets, the crippling bone disease, is rare in America, 100 years after it was epidemic in northern industrial cities and the poor South. Almost eliminating rickets in America was a big public health and nutrition win.

However, rickets has begun to reappear, with a disease rate in the early 2000’s ten times what it was twenty years previously: still very low but unacceptable. Those affected have been primarily poor, dark-skinned children in the South who did not receive vitamin D supplements when breast feeding past six months.

Your skin is a vitamin D factory when you get sun exposure. If you are dark-skinned or above the 37th parallel, which runs roughly from San Francisco to Tulsa to southern Virginia, you are likely getting less vitamin D production from the sun than might be optimal.

What about the extra calories in full fat milk?

A large study, part of the Framingham Heart Study, found no relationship between drinking lower fat versus full fat milk on weight gain. So probably no worries there.

Calcium, the wondrous white metal we all need a lot of

Calcium quantities are the same in full and lower fat milk, so this is not part of the whole milk debate. Since calcium is a metal, when you think of it, our bones are made of metal, although a soft one! Calcium is critical to our bone health but also lets our blood clot, muscles contract, and heart beat. We lose calcium all the time through our nails, hair, urine, and feces. If it is not replaced in our food, our body takes calcium from our bones. There are a lot of factors that affect loss of bone mass and microstructure, but studies have shown dairy consumption is a protective factor: it decreases the risk of bone fractures.

Milk, yogurt, and cheese are not the only things that can benefit bone health. Physical stress delivered to your bones through exercise helps them strengthen and reduces the risk of osteoporosis. That goes for everyone. There might not be an upper age limit on the benefit of exercise to bone health.

For dairy-free consumers, in addition to exercise, to reduce the risk of osteoporosis calcium can be obtained by eating nuts and seeds, kale, broccoli, some lettuces, collard, Brussel sprouts, and cabbage.

Many people have good reason to avoid dairy. There is an interesting history to that.

It used to be that during childhood everyone in the world gradually lost the ability to digest milk - until about 8,000 years ago when dairy animals were domesticated in Turkey. My theory is that the body’s development of lactose intolerance was nature’s way of forcing the weaning of older children so that young ones could have their turn at the breast.

However, along came cow farming, and a genetic mutation that kept lactase production going in the human body through adulthood gradually spread. Then 3,000 years ago dairy herders in Northern Europe experienced selection for the lactase gene during famines – when dairy was the most reliable food source. Those who had the mutation were more likely to live through crop failures.

Everyone quotes a 2017 study that found 36% of Americans have lactose intolerance. The rate worldwide according to the study is 68%, but the study’s methods were off, and it was retracted last year. So perhaps we don’t have a reliable figure, but we know a lot of Americans have trouble with milk. Yogurt, by the way, tends to be less troublesome for lactose intolerant folks, since the fermentation process reduces the lactose content in yogurt.

The plant milk solution

While about 10% of the animal and plant milk market combined is lactase-treated milk for the lactose intolerant, about 15% is comprised of plant-based milks, mainly almond. In 2022 almond milk had about 60% of the market. Oat milk had 20% of sales, with coconut and soy milk each taking about 10%. Almond and oat milk lead sales because of their taste, which is preferred by many.

Plant-based milks have good nutrition, and although sugar is added to some, it can be less sugar than the lactose in milk. However, lactose in cow milk is a slow-digesting sugar compared to fast-digesting sucrose in plant-based milk, so expect less glycemic control with plant-based milks.

Oxalic acid is in a lot of foods. Be aware that the high oxalic acid content in almond milk significantly reduces the uptake of calcium from the milk. So when an almond milk claims it has more calcium than cow milk, the reason is that it needs to start with more calcium to try to match the ultimate calcium delivery of cow milk.

Milk allergy

Milk allergy is one of the most common allergies for children. Reactions vary from mild to severe. Happily, most kids outgrow it.

Trump’s disgust and dismissal of breastfeeding

First, in 2011 Trump called a lawyer in a deposition hearing who requested a break to pump milk “disgusting.”

Second, for decades the misleading marketing of infant formula in developing countries has caused untold infant deaths due to the use of contaminated water mixed with the powder. Formula use in these places is also associated with nutritional issues and economic stress for impoverished women who are misled into buying formula. America, the World Health Organization, and nutrition and public health experts everywhere had agreed for 40 years that breast feeding was the best source of nutrition to keep infants healthy.

However, in 2018, on the order of Trump, who was acting in the interest of formula manufacturers like Nestlé, the U.S. delegation to the World Health Assembly tried to block a resolution to promote breastfeeding and clamp down on inaccurate formula marketing. The U.S. forced Ecuador to withdraw the resolution by using trade threats and threats of withdrawing military assistance for the armed conflict on Ecuador’s border with Columbia. Many other intimidated nations refused to sponsor the resolution until Russia finally did, at which time it overwhelmingly passed.

That year, I was in Malawi to gather formula samples to test for contamination. I saw Nestlé formula marketing everywhere. I stood in line at a market behind a clearly low-income woman with a baby. She had one item: formula. She was not buying clean water…

I wonder how the U.S.’s own, already subpar, infant mortality rate will fare under Trump?

Got Milk?

In the face of 50 years of declining sales, the dairy industry has heavily marketed milk as an essential part of the diet to the American public. There are a lot of pluses to milk consumption, full fat or lower fat: great calcium and hydration, a substitute for unhealthy beverages, and it’s got low-cost protein. This may be a too-rare instance of a food industry interest roughly aligning with a public health interest. So, “Got milk?” Heck, yeah!

I appreciate your reading. Let me know if you didn’t find 8 interesting facts... Please share, like, or comment at will, and be sure to subscribe at EatingInAmerica.co.

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Oh, and a…

Conflict of interest disclosure. I had an early career in milk nutrition. In 3rd grade I was in charge of bringing the crate of little milk cartons to the classroom where we ate lunch. I was very proud. I think the milk cost 3 cents.

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The long reach of USAID across the globe, saving lives, making friends for America, and elevating this country’s place in the world, ended in 2025. This morning I came across a photo of a food pyramid poster I took at the health headquarters in Nampula Province in Mozambique while I was doing USAID-funded research in 2018 on childhood stunting caused by aflatoxin in mold on staples like maize and cassava.

The poster was in Portuguese and focused on a healthy diet for people with diabetes. Nutrition science has corrected its simplistic “fats are bad, carbs are good” stance since the original 1992 American pyramid from which this Mozambican one was derived, but I love the local adaptation with its beautiful cassava, maize, pineapples and papaya.

However, I am still not a fan of the pyramid shape to depict a healthy diet. All parts of the diet should be healthy and work together. No food type should be at the pinnacle.

It is both surprising and dismaying how the 1992 pyramid has not only re-emerged in America with the new, RFK, Jr. upside-down food pyramid, but that it spread so far around the globe it never really went away.

My prediction, and I feel pretty confident here: the new U.S. food pyramid will not achieve the universality of the original. First, I have to think that our global credibility in the realm of health and nutrition has been damaged enough in the last year that many other nations will no longer be ready to accept on face value the science and messaging that has poured out of our country for the last 75 years since the end of World War Two.

Second and third, the new pyramid does not make sense graphically or provide the best advice nutritionally.

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Ok. Enough food pyramid talk for a while, but, in a completely different realm of pyramids, ones you can’t eat, a quick tip that if you happen to be in Austin, Denver, Chicago, DC, Edmonton, Quebec, Montreal, Lisbon, Sydney, or Utrecht, go at once to the Horizons of Khofu. This totally unique, virtual reality experience of the Giza Pyramid in Egypt is at once both realistic and surreal! I went in New York while it was there. Very, very different and very cool.

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