We have talked about empires before, from the ancient ones to the British, but nothing prepares you for the vastness of the Pacific ocean. This was POlyneasia, and we are looking at how a people built a civilization and what they packed for it.

Someone, somewhere on one of those islands, decided to take a canoe out and explore. Finding another island, or two, or three. Later someone said,
“hey, our island is getting crowded, we need to make a new colony somewhere else".

You may have heard ancient stories about “an island” from passed on as stories were. Perhaps someone was there before and returned with stories of another island that could be future home. Complete with freshwater, and fresh tropical drinks like a daiquiri.

Looking at those distances, even by today's standards, all I can think about is a long flight across the Pacific. The seats are uncomfortable, the food isn’t particularly good. I’d hope for an upgrade that might give a little more legroom, and perhaps a meal that doesn’t come wrapped in plastic. Of course, I would hope the Wi-Fi works. Because someone on X is wrong.

The ancient Polynesians crossed this same ocean in canoes. Navigation before GPS (seriously, no Google Maps). Probably larger seats, and their Wi-Fi was the stars, the currents, and finding seabirds meant land and home.

Over centuries, voyagers reached those islands and settled them.

It is hard to imagine how extraordinary this is. My Western mind is blown to think that this is before Europeans crossed the pond.

The Polynesians didn’t just carry provisions for the voyage. They transported what they needed to settle an island. And the food is what was a constant.

They were bringing the means to make those places habitable. And that makes me think of another enormous frontier that humans are only beginning to explore. Space. The final frontier (where is Captain Kirk).

Their Pacific, Our Universe

“Space, the final frontier,” I was about ten when that TV show came out, and it was one of my favorites. “Boldly going where no man had gone before.”

For us to go to space, we either need to be a billionaire, or a government. But for the people of the Pacific, they needed a few friends to build a boat. We have to have thousands of pounds of rocket fuel, lots of thrust just to escape earth’s gravity and get into orbit. They needed a push from the beach and they were on the ocean in their vessel.

Now comes the important question. What do we eat when we get there? This is a question NASA is still trying to answer. If you read the Martian, potatoes were the answer, and some of that came from the folks who used them.

Right now, the International Space Station receives regular deliveries of food from Earth, it was the first Instacart. I’ve had the pleasure of trying some of this food, and I must say, I prefer it over American Airlines fare.

If you are in a canoe, you can bring food along for a journey. If you will inhabit a new island, you need to bring the plants to grow, the pigs, and whatever else to establish a colony. Same with Mars. On Startrek, they had a machine that looked like a fancy vending machine, turn a button, and out came clam chowder. They avoided the messy background of how this got assembled, was it pre-made, or magically put together and transported like the transporter room that Bones McCoy hated to get in.

NASA has already experimented with growing lettuce, peppers, and other plants in space, using relatively little water and without conventional soil. Biosphere was an experiment done in the desert to see how people did in a version of space - just as barren, but still a windshield away from the real earth. In that and many other experiments, NASA, as well as many of earth’s engineers and farmers, work with plants to see what might work. Our friends in Polynesia had done those same experiments.

They didn’t have to create life-support systems on an uninhabitable planet. They were moving familiar food-producing organisms into unfamiliar environments.

You could eat a coconut, and plant one. The time to plant a tree is 100 years ago, the next best time is now. Same with a yam and breadfruit. Bring some to eat, some to plant.

We think of space and we don’t rely on just NASA. Biosphere was privately funded like SpaceX. In fact, I am writing this with help from those satellites now. We have lots of private financing not specifically looking to go to space but consider this: we are making artificial meat in a lab. Why? Some want the taste without the cow. Bringing a cow to Mars might make a carnivore happy, but it isn’t practical. We have water engineers saving water and trying to grow crops in the most inhospitable places on earth. They aren’t thinking of Mars, or beyond, they are thinking of feeding a hungry planet.

Each of our ingredients, breadfruit, yams, coconuts were not part of a grand experiment to find a new island. But something that had worked for centuries feeding a people, and some learned to grow them to make it easier. Like all of our civilizations. They learn to grow something then they can grow it elsewhere, and civilization spreads.

Breadfruit: What Do You Do With It?

Breadfruit, it isn’t bread, and doesn’t look like the fruit most of us know. You can see in the photo it is a bumpy green ball about the size of a grapefruit,. Cut it open and you’ll find pale, starchy flesh.

Roast breadfruit and the aroma and texture are a bit like freshly baked bread. I think that is more imagination than I have, perhaps it was so long at sea. To me it is more like a roasted potato than a loaf of sourdough.

In our series we have seen that early farmers take a wild plant and learn how to grow it for the village. They plant some wheat in the spring, harvest in the fall. But every year it needs to be planted again. The soil for wheat or rice was often rich soil with water nearby.

The soil on most islands is not great for growing rice or wheat. It is often volcanic, or sandy, or a mix. But this Breadfruit trees can be planted in volcanic soil, or even sandy soil, and in five to seven years the tree is producing fruit. It thrives on that volcanic soil with good drainage and lots of rain that the South Pacific has.

Chopped is one of the Food Networks game shows where chefs are given a surprise basket of ingredients to make a meal of in a short period of time. On occasion breadfruit shows up. If the breadfruit is firm, it is mature and mostly starch, like a potatoe. Something you can cut, deep fry or mash or boil and add some olive oil to (the Polynesians didn’t have olive oil, or even Popeye).

If the breadfruit is fully ripe,the flesh is. soft, creamy, sweeter, and almost custard-like. This would be a custard, or maybe throw it in the ice-cream machine. The ice cream machine on Chopped is a trap, it almost always goes on the brink, like McDonald’s.

But that mature breadfruit tree can produce hundreds of pounds of fruit during a season. And unlike an annual grain crop, a breadfruit tree can continue producing for decades. Just like wheat and rice provided a dependable source of carbohydrates, or the potato, the breadfruit was the source for these islanders.

You could go to an island, plant some trees, come back later and start to colonize it. You could start with a small number of people, and as the trees harvest grew, as well as the harvest from the ocean, you could gradually sustain a larger population.

Taro, Yams, and the South American–New Zealand Express

Taro is one of those vegetables you might have seen in an Asian market It looks like a hairy, unattractive potato.Cut it open and there is a starchy interior, creamy white, sometimes flecked with purple.

Taro is the foundation of poi. And since it seems every strip mall in California has some poi you probably had one of the essential foods of Polynesia. Yes poki and poi, coming to a mall near you.

You cannot eat Taro raw because it contains calcium oxalate crystals (if your body makes these they are called kidney stones). Those crystals will irritate your throat and esopaphagus.

Yams were another useful crop. And before someone sends me an angry message from the sweet potato industry, a true yam is not a sweet potato. This is one of those facts you will see someone talk about at Thanksgiving. Yes, we know. and I am assured that the Polynesians did not have marshmellows.

Some yams grow into enormous underground tubers. They can be stored for considerable periods, much like you can store potatoes, making them valuable when fresh food is scarce.

A South American Passenger

Sweet potatoes used by the Polynesians originated in the Americas. And that means that there was a trade route between those civilizations. In fact, the Polynesians were growing yams before Europeans reached the Pacific.

The precise movements of people and plants, and the dates and routes involved, we can only guess. Who knows who reached whom first. The result of that trade was that the sweet potato became part of the food system of the Pacific all the way to New Zealand.

The South American–New Zealand Express. Enter the Māori

The Polynesian ancestors , the Māori ,reached New Zealand around the late thirteenth century.

New Zealand was much colder than the tropical islands. Breadfruit trees and coconuts didn’t grow well in New Zealand. But the sweet potato, called kūmara in Māori, did.

They developed storage pits to preserve the harvest through colder seasons. Much like your root cellar.

Coconuts: Food, Water, and a Hardware Store

My first view of the coconut was a television program based on James Michener’s Tales of the South Pacific. Otherwise, coconut was something mom used to bake some food. Speaking of which, I make an amazing almond tort (click here).

Maybe you saw the silly Tiktok video where Paul Saladino brings coconuts through airport security to serve as his liquid. He says he doesn’t want the microplastics from the bottled water they sell after security, and I agree. But most of us bring a steel refillable water bottle, but Paul brings a sack of coconuts. Where does he have room for that, and how on earth do you open them? Not with a machete, good luck bringing that through security.

The Polynesians, however, had a far more practical reason to carry coconuts. They serve as food, where the young coconut provides liquid and soft flesh. The older mature coconut provides more fat and calories — oh that just hit me. Yes, we gain a bit of fat as we age.

Coconuts have more use than food. The shell makes a cup, or clothing. The leaves can be woven into baskets and roofing. And the fibrous husk can be made into rope.

And what did they use that rope for? Well, ask any man who has a garage and we have rop. Men have collected ropes long before we had drawers full of cords that provided electricity to a used electronic device no longer made. But for the Polynesians, ropes are needed for canoes.

Imagine crossing thousands of miles of ocean in a vessel whose wooden components are held together with rope made from coconuts. No Home Depot, but you had the makings of a rope. And when the tropical rains came, there was work to be done. No internet, so you had to do something, and they would sit under shelter and braid coconut fibers into rope.

Here in America, when it rains, we tend to stay inside and Netflix and chill. At my age, that means watching a movie and relaxing on the couch. I understand the younger generation has given that phrase an entirely different meaning. Ah, to be young again.

But let’s not dwell on life after sixty.

We look at coconuts and think of a tropical drink. They looked at coconuts and saw food, drink, building materials, and a hardware store. All growing on a tree, no hook in a garage or drawer.

Pigs, Chickens, and the Noah’s Ark of the Pacific

The islands the people went to were not small, little desert islands. There are plenty of those in the South Pacific. But those don’t have the water, soil, or area to be anything more than a camping site for young lovers. Think of the Hawaiian Islands, all large, able to support not only the breadfruit, taro and coconuts. They are also large enough to have ranches for another source of food, as well as their hides, hooves and etc.

But those islands didn’t come equipted with the plants or the animals to support a new colony. Those creatures, along with the plants, had to be brought.

Polynesians were not vegetarians. There is plenty of evidence they brought with them pigs, chickens, and maybe a few other creatures. In Alaska, among my people, the Athabascan, vegetarians are given another name: bad hunters.

Polynesians also had pets. When we move, we take our pets. I have moved several times with my Golden Doodle, Lucky. The golden doodle goes through the same phases as humans. Until age five, they are a whackadoodle, endless energy. Then, Doodles at the age of five discover they can lay down, and one day they transform from an energetic dog into the Great American Sloth. Dogs have been faithful companions for almost all humans’ existence. In fact, we probably evolved to simply serve the dog.

Now, anyone who has traveled with a dog knows it requires food and water. You also have to share your sleeping quarters with them. And you have to clean up after them.

For food, there were pigs and chickens. There may have been others, and probably were, but let us think about taking a canoe ride with some pigs and chickens. Imagine the larger, and sometimes cantankerous pig. Or several pigs. Chickens would be easier, they take up less space. But they can still be a pain. I suppose they would have taken the smaller pigs on the boat, have the larger one for the going away party.

Why go to all this trouble? Because one pig is dinner. A breeding pair of pigs could eventually mean pork for an entire village. Chickens reproduce a little faster than pigs. If you have ever been to the island of Kauai, chickens roam freely, and have been here for longer than Europeans. I see them running around and think Coq au vin.

The Pacific rat traveled with people across much of Polynesia. Some were probably deliberately transported as food, while others may have simply helped themselves to passage. Others went to New York, where they still dominate the city and are well served by the politicians.

Every civilization started with a farm, something to grow that could sustain people, allow them to settle down, form villages, towns, governments, and of course taxes. Different parts of the world provided ingredients that fostered those civilizations.

We went from hunter-gatherers to civilizations, because foods allowed us to do that. Civilization is more than just planting enough to get by. These are the lessons we have learned from our previous episodes of coffee, salt, tea, and spices.

If you ever thought about Mars, think about the planning of the Polynesians and what was done here on earth. Take a look at the size of the water they ad to cross. In our next section - what it might take to inhabit another planet.

What Would You Pack to Colonize Mars?

This is more than a thought experiment, it is an active area of research as we consider outposts in our solar system and beyond. Who wouldn’t want to snowboard in Uranus.

But what do you bring and how do you start that process. Well, here are a few ideas.

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We like villains. Smoking is a good villain. We who don’t smoke, we hate the smell of it. That it can lead to cancer, heart disease, and bad breath means we can point to this and say - here is a cause of many problems.

We want to point to one thing that explains rising obesity, diabetes, and pick anything else. Sugar has been at the top of that list for years.

The sugar industry hasn’t helped. As you read in my last column, sugar is responsible for a large part of the Caribbean slave trade, overthrowing the Hawaiian monarchy, and bad teeth. So what else can we blame sugar for?

You probably heard people blame sugar for diabetes. It doesn’t cause diabetes, and that seems odd to most, because blood sugar levels rise with diabetes. Some blame sugar for heart disease, inflammation, premature aging. The sugar industry paid some researchers in the 1960’s and they wrote a piece saying that fats more than sugars are to blame for heart disease.

So what is the data about sugar in all its forms? Is it the pure white poison that makes cocaine look tame?

Yes, sugar has it’s share of the blame, but like Murder on the Orient Express, there is more than one guilty party. This week, we will go into the detail about the sugar wars.

So I promised my paid subscribers a short primer about sugar and biology. The arguments and the data about what sugar does - besides being delicious

There is no doubt that most western countries consume too much sugar, and too much leads to more things than cavities. But sugar is the universal currency of your metabolism. Your body preferentially uses sugar for energy. That does not exonerate sugar, but let me give you a few facts:

Glucose is the form of sugar your body uses for metabolic currency.

Your brain relies on sugar. As much as the keto people would love to convince you that you don’t need sugar, and your brain can survive with ketones alone, that is misleading. If your brain glucose goes below forty mg/dl you will lose consciousness, no matter how many ketones you have in your blood stream.

Your body can make sugar out of almost every macronutrient, from carbohydrates, to protein, to fat, and even alcohol. Those metabolic pathways show how important sugar is to you.

Too much of a good thing isn’t a good thing. Too much sugar and there are consequences.

Let’s take apart the keto experts, the carb-insulin hypothesis, with the goal that you will not feel guilty about having dessert.

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The Most Misunderstood Hormone in Dieting

It is insulin. The keto enthusiasts concluded that insulin’s primary purpose is to make you fat. Time to learn its role, which is rather complex, unlike the pithy conclusions of a keto enthusiast.

Read more

Sugar helped build the British Empire, financed fortunes on both sides of the Atlantic, and contributed to the enslavement of millions of Africans. It made tea palatable to the British, encouraged the development of an extraordinary global trading network, and eventually gave British dentists plenty of work.

It was so valuable that Napoleon made the sugar beet famous, because he didn’t want to import from the UK. . Sugar interests helped bring down the Hawaiian monarchy. And long before the United States was worried about communism in Cuba, American businessmen were deeply interested in Cuban sugar.

All of this from a plant that is essentially an overgrown tropical grass.

A grass worth more than gold

Sugarcane was first cultivated thousands of years ago in what is now New Guinea. It was brought through Southeast Asia and into India, where we converted the sweet juice into something we would recognize as sugar granules.

Sugar was not the first sweet taste homo sapiens encountered. We had honey, ripe fruit, and sweet plant juices. Our attraction to sweetness signals a source of energy.

India is where sugar extraction improved. From India, Arab traders brought sugar to the Middle East, North Africa, the Mediterranean and Europe.

The European wealthy household offered sugar as a sign of its importance. Ordinary people had little access to it. The pattern is something we’ve seen before with both spice or salt. is fashionable first in the royal court. It becomes a trickle down phenomenon, as production drives down the price or improved trade routes come online.

The empire in a teacup

That cup of tea, so famous in Britain, was imported first from China, then from India. Likewise, the sugar came from the other side of the world, and even that cup, porcelain, from the East.

But going to London, I do what millions of tourists do, I find a place for “high tea.” That is far from the traditional high tea. High tea was originally a working class supper, featuring meat pies, not cucumber finger food. But still sitting in a fancy hotel, being served some Jing second flush Darjeeling tea, with sugar, seems so British.

As an aside, what we are participating in is actually a version of “low tea.” Invented by a Dutchess because dinner was served after 8 pm, she became hungry at around 4 pm.

Plantation Life

If you go to the Virgin Islands or anywhere there were sugar plantations, you will probably buy a straw hat, drink some rum drink, and find someplace to get away from the humidity. It is a sultry, pleasant vacation. While there, visit a plantation where sugar was harvested, and see how brutal conditions were.

Similar to the slavery in the Southern states, sugar plantations were only good to the owners. The slaves toiled in dangerous conditions, where the cane had to be cut, crushed, boiled, and refined. The slave labor was needed due to the growing European taste for sugar.

In the British acquired colonies of Barbados and Jamaica, merchants made fortunes from sugar, while slaves’ lives were cut short from the horrific conditions. Industries spawned from sugar included shipping companies, insurers, investors. Taxes from sugar benefited the treasuries of Britain.

We cannot forget Rum, even though a night of Rum might want you to forget. Rum comes from Molasses, a byproduct of sugar production, which was fermented and distilled.

By the nineteenth century, the increased supply of sugar drove down its price to where the working class could afford sugar. The sweetened tea, jam, biscuits, and other foods that would once have been considered luxuries became common.

Increased sugar’s first health issue appeared first in the mouth. The British began losing their famous association with dentistry. Sugar helped build the British Empire. It also did wonders for the future of dentistry.

Fossil records of early humans show many died from tooth infections. The widespread use of sugar in the diet began to show up as a chronic disease, spawning yet another industry, dentistry. Other chronic diseases from sugar would follow.

When refusing sugar became a moral decision

In 1791, a group of British abolitionists began organizing a boycott of sugar because of the brutal conditions in the British West Indies. This might have been one of the first consumer boycotts of note, because the year after organizing the boycott, an estimated 400,000 British consumers participated.

Women couldn’t vote for members of Parliament, but they could influence what their households purchased. They encouraged people to buy East India sugar as an alternative to sugar produced by enslaved Africans in the West Indies.

In museums, you can find sugar bowls bearing antislavery messages. Imagine that. Your sugar bowl telling visitors something about your moral convictions. Today we have bumper stickers.

Sugar Beets

Sugar beets are the alternative to cane sugar. To be clear, your body doesn’t care where the sugar comes from, corn cane, or a beet, but it became important to Napoleon.

Imagine being at war with Britain, something France does as a pastime, and having to import sugar from the place you are at war with. Sounds like oil doesn’t it?

In 1801, sugar beets were harvested, and the first factory was established to extract sugar in Prussia. When Napoleon occupied Prussia in 1807, he noted the industry. In 1811, Napoleon promoted large-scale beet sugar cultivation in France to replace imported cane sugar.

This also led to the proliferation of beet salads, something useful for composts and Californians. Okay, I live in California, but I find beets taste like dirt, and that is a hill I shall occupy.

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Lest We Lose our Humility

I enjoy making fun of the British, even though I love London. But we Americans have our own bad relationship with sugar on the political side. And certainly, our proliferation of hyper-processed foods would have been nothing without sugar. And while Britain has dentistry and tooth problems, we took to sugar with our own chronic diseases, obesity and diabetes.

Hawaii became a state not because we liberated the Native peoples, but because we wanted sugar cane. We overthrew a recognized government, not because we wanted a lei, but the sugar. That was our Marines backing up an industry like the East Indian Company, which had their own military.

Now, while some blame sugar entirely for obesity, and have elaborate explanations of the carb-insulin hypothesis, I will have another article about this later this week about sugar and what it does.

Suffice to day - the carb insulin hypothesis is a model that is simplistic and incorrect. And while I normally would attach a paid section to this, going through the chemistry and biochemistry of sugar, I will instead have an entire article for the paid members coming out this next week.

Until then, listen to sugar on my podcast FORK U.

If you have been on the standard American diet, you need fiber. If you introduce fermentable fiber too quickly, it can be like a champagne pop - without the cork, but lots of internal bubbles that can bloat and cause discomfort.

There is plenty of evidence that fiber is healthy for you, and promotes the kind of bacteria in your colon that you want.

The standard recommendation for fiber is about 25 grams daily for women and 38 grams for men through age 50, with lower age-adjusted targets of 21 and 30 grams after 50.

Fiber, Constipation, Diarrhea

One major role for fiber is to prevent constipation. Fiber can not only decrease constipation, but also firm up stools if your stools are a bit loose. On a GLP-1, one can get enough fiber, and last week we showed how to start fiber in the morning with some good breakfast.

What About Supplements

There are many fiber supplements out there. More and more are coming daily, but I want to talk about the more common ones. There is nothing wrong with taking a supplement, because we are not perfect, and sometimes taking a supplement is a good way to keep things moving along. Now my brain is thinking “old man River, it just keeps moving” - while a boat is quietly going down the Colonic River.

Metamucil (Psyllium)

This is probably one of the most commonly sold fibers in the US, and a favorite of many gastroenterologists. The fiber forms a gel, moves things along in the colon, and has a lot of good evidence for improving stool consistency, decreasing constipation, and even will lower your LDL cholesterol a bit.

When starting this supplement, bloating and discomfort can happen if you are starting from a regular diet. Introduction of any fiber can cause this. So start slow and work your way up.

Metamucil must be taken with 8 ounces of water. If you don’t take it with water or other liquid, the fiber can expand in the throat or stomach and cause a blockage, not to mention nausea, vomiting, and even a visit to the ER.

Metamucil is contraindicated for people with bowel obstructions, difficulty swallowing, undiagnosed rectal bleeding, or known psyllium allergies.

Citrucel (methylcellulose)

This was probably the most common supplement I have recommended to my patients, because it causes the least bloating. It is soluble, like Metamucil, but it is less fermentable, hence less discomfort. Kind of tastes like Tang, that breakfast drink for those of us who grew up in the 60’s and 70’s.

Benefiber (Wheat Dextrin)

Unlike psyllium husk, Benefiber does not thicken into a gel, or become gritty, making it able to mix into water, coffee, juice. Some even put it into foods like yogurt and oatmeal.

It ferments slowly, less bloating. Although any fiber can cause bloating.

Traditional vs New Types

Traditional fiber supplements are a single type of fiber molecule (e.g., 100% psyllium husk or 100% wheat dextrin). Effective for their specific tasks (like gelling or softening stool). Different fibers feed different populations of bacteria, and some bacteria benefit from the products made by others. This is another reason we like having various fibers in your diet. From a supplement standpoint, this is partially accomplished by combining different fibers. Early indications suggest this approach may support a broader range of bacteria than relying on a single fiber.

Loam, the new kid on the block

This was formulated by a friend of mine, Karan Rajan, a fellow surgeon from the UK. Like most of us surgeons, fiber intrigued him, but wanted something better than was on the market. I am on his scientific advisory board. I do not receive money for endorsing Loam.

Loam is a bland blend of six prebiotic fibers. It even has a small, placebo-controlled study showing changes in the microbiome, including increased microbial diversity.

This is a higher fiber per serving, about ten grams. When I heard that some people put it into coffee, I didn’t believe it. Okay, I partially believed it because most of the UK has awful coffee. So if Karan put it in his coffee, who could blame him? Then I put it in my coffee. No change in taste, didn’t form a gel, and made my morning coffee a healthier drink. Now I put it in my coffee.

If I were to make a daily drink with vitamins, electrolytes, and fiber for GLP-1 patients (okay, I am working on this), I would include this type of a multi dimensional fiber.

For the future of fiber therapy, these types of multi-fiber prebiotic blends will be the way to go. Although for treatment of constipation, bulk fibers like Metamucil are effective.

The Ileal Brake

The Ileal Brake isn’t a new electric bike addition, it describes how your small bowel and fiber help you feel full.

The ileum is the last part of your small intestine, just before the colon. When the partially digested food reach the ileum, it triggers a signal that slows the movement of food through the digestive tract. Partly mediated by GLP-1 but also fiber..

Protein is often described as the food that keeps you satisfied. And it does. But consider this: most protein is digested in the first foot of the small intestine. Fiber when it arrives in the distal small bowel produces an effect of satiety.

Isn’t it interesting that the hyper-processed food available contains little to no fiber and is so easy to consume without feeling full? Tell me you can’t just eat one.

Let’s Talk About Poop

Constipation is one of the more common side effects of GLP-1 medications. Most of the time, it is a nuisance. Sometimes, it becomes a serious problem.

First, what is constipation? Some people think that if they don’t have a bowel movement every morning, something is wrong. First, consider you are eating less so you will have less poop. You may go from having a regular bowel movement daily, every morning at 5 am before you wake up at 7 am. To having one every few days. The key is if you feel comfortable, your stools are easy to pass..

When stools become hard, dry, or difficult to pass, you are constipated. You can even have a bowel movement every day and still be constipated. See those little rabbit turds in the bowl, yup, you need more liquid in your diet.

Why GLP-1 Medications Can Cause Constipation

There are several reasons for constipation when taking a GLP-1 medication.

We went over eating less. It is the one most people tend to forget. But when eating less, you also get less water in your diet. If twenty percent of your water comes from food, and you are eating less food, you will slowly get less fluid. Your body may not need the calories from the food, but you always need the same amount of liquid to compensate for the liquids you lose daily, in sweat, tears, stool, urine, etc.

The chances are you are drinking less. Some people taking GLP-1 medications experience less thirst, we discussed this last week. I never had a water bottle as a kid, except when hiking or camping, then we had a canteen - one my dad had during World War 2, now I wish I still had that. Otherwise, there was a hose outside, fountains with free water in Rome, and a glass by the sink.

One of the “jobs” of your colon is to absorb water from stool. It does that no matter how long the stool remains in the colon. The longer it is there, the more water it absorbs.

When Fiber Helps

Since 90 percent of people are fiber deficient, the symptoms of constipation are likely to come forward as constipation when you take a GLP-1. Increasing fiber is a reasonable place to start. Mind you, if you have abdominal pain, bloating, then you need to chat with your doctor before trying fiber maxing (a new term I understand).

Psyllium, like Metamucil, is useful because it forms a gel and helps retain water in the stool. That gel is resistant to the colon sucking out water and works well to keep things moving along. It has good evidence for treating chronic constipation.

Remember, you need to drink 8 ounces of liquid with the Metamucil, and if you have mild constipation, increasing liquid in your diet is a first step. I don’t care what color your urine is, just drink more - slowly over time, not gulping huge amounts at once. There are some of you with fluid restrictions. Here is where you need to sit with a registered dietician, always a good option, and go through your diet.

When More Fiber Makes Things Worse

If stool is moving slowly through the bowel, adding more bulk may increase bloating, discomfort, and the feeling that something is stuck.

More fiber isn’t always better. If you are already constipated and becoming increasingly uncomfortable, repeatedly adding more fiber may worsen your situation. Think Grizzly bear (see the last article about fiber). You don’t want a butt plug of fiber.

I want to emphasize this again: if you have severe abdominal pain, vomiting, marked abdominal swelling, or difficulty passing gas, don’t take more fiber. Talk to your doctor.

When to Use Something Other Than Fiber

For uncomplicated constipation that isn’t improving with food, fluids, and fiber, there are medications that can help.

MiraLAX (polyethylene glycol or PEG) is often a good choice. It is an osmotic laxative, meaning it retains water in the stool, making it softer and easier to pass. Unlike fermentable fiber, it doesn’t work by feeding your intestinal bacteria.

It has better evidence for treating chronic constipation than fiber supplements alone. It won’t work overnight. It generally takes one to three days to work.

Senna and bisacodyl (Dulcolax) are stimulant laxatives. They increase intestinal activity. They are good for occasional constipation. They can cause cramping and diarrhea. Typically Dulcolax works in eight hours, so I recommend people take this at night.

Magnesium-based laxatives are another option, but they require caution in people with kidney disease, because magnesium can accumulate in the body. For some of you who have decided to take magnesium supplements, you may have already experienced your bowels working too well.

The evidence that stool softeners like Colace work are weak, and I do not recommend these.

You should not need laxatives just to have a bowel movement. If you do, it is time to discuss a longer-term plan with your doctor.

When to Call Your Doctor

Most episodes of constipation can be handled without a medical visit. But there are times when you should call.

If you have persistent constipation despite reasonable treatment, develop a significant change in your usual bowel habits, or repeatedly need laxatives, it is time to get some professional help. No, don’t go to the people offering colonic hydrotherapy - coffee is best given through the mouth.

Increasing the dose of a GLP-1 can lead to constipation, and then I’d go through the algorithm outlined above. Increase water or other fluids, consider a laxative, and slowly increase fiber.

Severe or persistent abdominal pain, repeated vomiting, a swollen abdomen, or an inability to pass gas requires urgent evaluation, particularly when they occur together. And please, if you have any blood in the stool, rectal bleeding, fever, or unexplained weight loss, please get prompt medical assessment.

The Goal Is to Have a Comfortable Bowel Movement

If you can doom-scroll while sitting on your toilet because you are waiting, you need more fiber and more water.

Sometimes, the most important thing you can do for your colon is stop adding fiber and call your doctor.

Let’s Have Lunch

Last week, we started with breakfast and overnight oats. I also mentioned lentil soup, and you can find my recipe at terrysimpson.com.

But lunch doesn’t have to involve cooking soup, or even cooking at all. For those of us taking GLP-1 medications, lunch is often smaller than it once was. Getting enough protein is important, but we also need to think about fiber.

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But there is some encouraging news. A new obesity drug, petrelintide, targets a different hormone pathway and may offer another option for patients who struggle with GLP-1 side effects.

This week on Dr. Simpson Unfiltered, we look at the science behind these headlines, what we know, what we don’t, and why it matters.

People seem to think a bit of salt, pepper, maybe onions and garlic provide the spices one needs. Perhaps it is because some associate spice with heat. Mostly because many have never experimented with some of those great warm spices available. A pinch of coriander, some freshly ground cumin, a little cardamom, or a touch of cinnamon can turn an ordinary dish into something remarkable. And the most astonishing part is that these spices financed voyages around the world, built cities, created fortunes, and caused people to kill one another.

Without the spice trade, it is safe to say that the United States, as we know it, would be vastly different than we are now. The money loaned to the United States, when we were a fledgling country, came from the wealthy spice merchants from what was considered one of the great hyper empires of the world - based in Amsterdam.

But before we go to the birth of the United States, let me take you to the meatball.

Today’s Meatball is a bit boring

When I went to the states for college, the meatballs in the continental US were boring. Many are just combinations of beef and pork, and often the meat is overcooked, leaving the meatball dry, although that is often hidden in the sauce (tomato sauce if you are making spaghetti, or a gravy sauce for others). One recipe had frozen meatballs from the grocery store placed into a crock pot with a vat of grape jelly (it wasn’t bad, it was ghastly).

Most meatballs are like having only the meat from a burger without the crunch and sour of the pickle, the sweetness of the tomato, and that touch of bitterness from the onion. I didn’t understand why my grandmother’s and mom’s meatballs were so delicious, and these were so dull. Over time, I had received recipes from different people who made meatballs, and they were all versions of the same until history showed me the ingredients I was missing.

In Search of the Mighty Meatball

While there may have been other reasons to visit Turkey, Norway, Italy, and Sweden — there was always project meatball. Finding a meatball that tasted like my mom’s. I can’t ask mom about this, her dementia didn’t let me crack that code, so I had to travel the world to find the secret to unlock the flavors in her meatballs.

The Swedish Meatball’s Origins in Turkey

If you go to Stockholm, consider taking a “food tour.” Not only will you learn about the history and culture of the country, but you will also eat well. Then, if looking for recommendations, they know the city and its food like no other. In this case, I wanted a meatball. The traditional meatball as served in Stockholm.

But when talking to the food historians in Sweden, the meatball did not originate in Sweden. The meatball was brought to Sweden by King Charles XII in 1714. He was forced into exile in the Ottoman Empire (now Turkey) after losing a war to Russia in 1709. For five years, he was a guest of the Sultan, and besides trying to get the Ottoman Empire to go to war against Russia, he enjoyed the Ottoman cuisine. After five years, the Sultan became tired of Charles scheming and tossed Charles out of Turkey.

Charles returned to Sweden with two cuisine items: the meatball and coffee.

The Meatball in the Ottoman Empire

Istanbul is the western world’s second cosmopolitan city. This was the last city of the Roman empire, until the Sultans conquered it in 1453, which began the Ottoman Empire. But today I was walking in The Spice Market. This market has been in business since 1664. You can imagine when Charles XII came here, and his nose was filled with aromas from around the world. Aromas he never smelled before.

Lets start counting world hyper powers. The Ottoman Empire was one. It was built not just on military conquests, but spices. The spice road, silk trail, ended here and from here money was made selling these goods to Europe.

Food Charles had never eaten before. When I was there, the smell of the spices was so abundant and so fresh that my nose was overjoyed. Just outside the spice market, as everywhere, are people who will sell you lamb cooked simply over fire, and to that lamb is added lemon zest, salt, zaatar, as well as nutmeg.

There was something comforting about the smell in the spice market. I didn’t realize my brain was remembering food aromas from home.

Putting ground meat with spices isn’t an original idea. In the Roman Empire, the cookbook author Apicius (25BC–37AD) describes meats from chicken to fish being ground with spices added. Almost every culture has a variation of a meatball (ground meats roasted with some spices). Rome is our second major global power. Yes, we learned the conquest of the world but where did Rome make its money? Trade. It conquered not to force people into a religion or a political system, but to secure trade routes. What made a lot of Rome’s money? Spices and food.

For the Ottoman empire, the meats they used were lamb and poultry. No pork (they were Muslim and pork was forbidden). The flavor came from the variety of spices available to the Ottomans. The Ottomans, it turned out, had all the known spices of the Western World. The spices from Asia and Indochina were traded to Europe through the Silk Road, which began in modern day Xi’an and ended in Istanbul.'

The Swedish Version

Until the mid 1800’s meatballs were mostly consumed by the wealthy in Sweden. Charles didn’t have meatballs as a meal, but would eat them as a snack with coffee (coffee being the other Turkish product he introduced to Sweden). Meatballs were first mentioned in Cajsa Warg’s 1754 Swedish cookbook. She described meatballs as chopped meat (calf, sheep, or ox) with grated bread and eggs. The seasonings were pepper, salt, and nutmeg. Nutmeg, for a time, was worth more per weight than gold.

By the 1850s, the meatball became common food for the Swedes. Much like fashion trends are set by the famous today, the meatball was the fashionable food and became a beloved dish of Sweden.

But let us get back to spices and the world.

A Night in Amsterdam

Many years ago, I stayed in the Waldorf Astoria, Amsterdam. The hotel is made up of six canal houses, once owned by some of the city’s wealthy residents.

In the seventeenth century, Amsterdam was the center of one of the great commercial empires in history. That empire was based on spices

Tea and pepper were the commodities that allowed Britain to become an empire. Notice a pattern here. Trade, often involving spices, but stable trade, which was backed by a navy. A different group of spices for Amsterdam, Nutmeg Cloves, Cinnamon, and Pepper. Amsterdam became one of the wealthiest cities in the world from spice trades. In fact, so wealthy it is considered one of the great hyper empires of the world. Along with the Roman Empire, British Empire and the United States.

Most look at Amsterdam during this period and have called it a global power, and this would be our third global power. s

A Young Republic

If you are in Amsterdam, you can find the house where John Adams lived. As ambassador, Adams secured loans to our fledgling republic, helping keep it afloat when the US was nearly bankrupt. All because the world loved the taste of nutmeg.

Amersterdam Wasn’t the First

Spices were a way to display wealth and status. If you wanted to impress your guests, you served them a meal filled with spices.

One of the first spices traded was pepper. Pepper was valuable because it was small, durable, easy to transport, and in tremendous demand. In medieval London, a pound of pepper could cost the equivalent of a week’s wages for an ordinary laborer.

The Price of Nutmeg

The Banda Islands, now Indonesia, were once the world’s source of nutmeg and mace. The islanders traded these spices with Asian merchants for centuries before Europeans arrived.

In 1621, Dutch forces under Jan Pieterszoon Coen conquered the Banda Islands. Much of the indigenous population was killed, expelled, or enslaved, and the islands were reorganized around spice production for corporate profit.

New York City is sometimes referred to as New Amsterdam, because Amsterdam laid claim to the big apple. Britain gained New York in exchange for a small spice island, Run. The exchange was one of those moments when the spice trade and New York intersect.

Today, you can buy spices for a fraction of what they were. And yet, most of those spices are underused in kitchens.

Many of those spices have medicinal properties: turmeric is anti-inflammatory, cinnamon helps regulate blood sugar, and pepper improves bioavailability of many compounds. Adding spices to your cooking not only improves flavor, but also your health.

But without spices, many global powers would never have been. Today we have counted Rome, the Ottmans, Britain, Amsterdam and the United States might never have been. There may never have been a reason to cross oceans, develop corporations like The Hudson Bay, or Dutch East India. The United States is now a major power. Spices are cheap, and the seas are defended to allow them to move freely. That is why we are mighty - it is the mighty spice

So don’t let the great explorers of the past lives be for naught - add some spice to your cooking.

Coming Home Through Food

They say you travel the world to find paradise in your backyard. In this case I had gone to four countries in Europe to find the meats and spices used to make the meatball in my grandmother’s cookbook. But we have to add a twist — we have more spices available, so here is my version of the meatball. Made, tested, and even JJ approved.

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Those fibers that need gentle introduction to your body, those are the fermentable fibers. And your gut will ultimately get used to them, like them, but before that happens, let me tell you a story.

I used to have breakfast with one of my favorite GI doctors. Wanting to leave a good impression on her, I ordered the steel cut oatmeal. The first day, I felt a bit of rumbling. The second day, which was a surgery day, I had a lot of gas. The third day, while in clinic, I lit a candle on my office desk while answering the phone, and opened the window. Answering a phone call, I turned around, and then noticed smoke. The papers had crossed over the candle, set the desk on fire, and I had to stop the call, put out the fire. For the many years I owned that desk, the burn mark gave me a vivid reminder of what happens when you introduce certain fibers too soon. My week of breakfast meetings ended with eggs. She didn’t have a sense of humor when I related that story to her. She asked me why it took me many years to get that kind of fiber in my diet. Alas, some GI doctors have no sense of humor.

Why did a perfectly respectable bowl of steel-cut oatmeal cause so much trouble, and how do we introduce fiber without repeating that experiment?

Half of the steel cut oatmeal’s fiber is soluble, it doesn’t get broken down, and then it reaches the colon, intact. It then becomes powerful, and I mean a powerful source of food for the bacteria in the colon.

The bacteria ferment the fiber. Instead of saying they digest the fiber, we use the word “fermentation.” Fermentation is the name of the digestion, where bacteria consume food and grow in an oxygen free environment, like your colon or a champagne bottle. That is how I want you to think about it. You eat oatmeal, it ferments in the colon, and like champagne, it pops out. I know, it is odd to think of our gut as fermenting and causing us distress, but that is what is happening. Hence, fiber that reaches the gut, and these bacteria consume it. That is fermentable fiber. Or champagne fiber. And the gas pops out.

The gases produced include carbon dioxide, methane, hydrogen sulfide and others.

There is a war in your colon, and bacteria are competing for space. Trillions of them. There is also some yeast in that microbiome. The bacteria who win the war are the ones who eat well. It turns out the more efficient the bacteria are at fermentation, the less gas they create.

Start feeding your gut more oatmeal, and those efficient bacteria multiply. Over time, eat enough steel cut oatmeal, and your gut microbiome will have the bacteria that produce less gas. Here is the good news: the bacteria that love fiber are the bacteria associated with less heart disease, less cancer, and better health.

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A Grizzly Bear and Constipation

Before a grizzly hibernates, it begins to consume fibrous material. Things like sticks. Lots of it, and so much so that it forms a plug in its colon, so that when it sleeps, it does not need to move its bowels. The material is in the colon and not going anywhere. At least that is the story we were told.

Bears develop fecal plugs during hibernation. The traditional story is that they eat roughage, leaves, and other fibrous material to plug themselves up. Nice story, but in reality, during hibernation, the fecal material sits in the colon, while the colon continues to absorb water. That is one of the main functions of the colon, to absorb water from stool.

For the Grizzly, that fecal material becomes a plug, hard and dry. Hair and plant debris can be present, but the plug isn't simply made of sticks and berries. You wonder why when bears wake up, they are grumpy. That has to be one tough time. But there is a similarity to a GLP-1 patient.

On a GLP-1, the colon doesn’t move as fast as it once did. Because fecal material sits longer in the colon, and the colon still absorbs water, and fecal material becomes more of a plug. Yes, Lamaze might help, but seriously, it can be a problem.

What about fiber to help move things along?

Metamucil is one of the more common fibers commercially available. It is made from a seed husk (psyllium) and is part soluble. Metamucil absorbs water and holds onto it. So the colon doesn’t absorb that bulk. This allows Metamucil to help move things along. It is not very fermentable, would not make good champagne. About 1/3 of it is fermentable, leading to far less gas. Most who get bloated with Metamucil are because they did not drink enough water with it. Keeping hydrated is one of the cornerstones in avoiding constipation.

When dealing with fiber, we have to have hydration. Without hydration, you become a grizzly bear. Without the winter sleep. Adding more fiber to a slow moving colon that absorbs the water from stool can make one miserable.

So why do we say more fiber is needed? This sounds like a trap. Too much champagne and you have misery. Too much grizzly fiber and you are stuck.

Then there are the studies. People who have fiber in their diet have less heart disease, less colon and rectal cancer, and longer lives. Best of all, you will have less constipation and enjoy a wider variety of foods.

The best diet for people on a GLP-1 is the Mediterranean diet. Its benefits aren’t solely due to fiber, but fiber is part of the package, or it might be the package.

For paid subscribers, we’ll get practical. And of course, a recipe.

There is a way to enjoy the champagne without becoming a bear.

Here are the keys: There are two reasons fiber will give you an issue. One is that you have fermentable fiber, and your colon isn’t used to it yet. The second is that you have a fiber not accompanied by enough water or other liquid. Fixing those issues is not difficult, but now you know a bit more about fiber.

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Why?

We will start with RFK Jr. and the anti-vaccine people he panders to. For years, he has objected to the infant dose of hepatitis B. He has claimed this vaccination leads to autism - it doesn’t. RFK Jr. also claimed it increases the risk of chronic diseases like autoimmune diseases - again, no evidence. And he has had friends, including researchers in Denmark, who agree with him.

Those researchers in Denmark were awarded a grant of $1.6 million of your tax dollars to test it.

The test is being done in West Africa, Guinea-Bissau, where hepatitis B is common. To be clear, when an infant becomes infected, there is a 90 percent chance they carry that virus for life.

Babies have a particular problem with this virus. While most healthy adults clear an acute hepatitis B infection about 88 percent of the time, the infant immune system cannot fight this virus off well.

That child may appear healthy for years, even decades, before developing cirrhosis or liver cancer.

The researchers want to know whether the hepatitis B vaccine has additional effects on health beyond preventing hepatitis B. Their entire field of study is other effects of vaccines.

To be clear, I have no objection to studying vaccine safety. We want to know not only short term effects, but long term effects. But there is one long term effect we know about with hepatitis B - chronic infection.

But why do this by assigning newborns to wait six weeks for a vaccine the WHO recommends within 24 hours of birth?

The researchers argue that six weeks is already the routine schedule in Guinea-Bissau. They’re not taking away a vaccine those children would otherwise receive. In fact, half the children in their trial would get a birth dose they wouldn’t ordinarily receive.

That’s their argument. Except Guinea-Bissau decided to join WHO recommendations for getting the vaccine the first day of life, as 115 other countries, including the United States.

Their logic is similar to finding we have an effective drug to treat something and it will come to market, and we know it will come to market, but we decide to investigate delaying that effective treatment just to see what happens. That is unethical.

The WHO has raised substantial objections to the study, including whether the additional scientific questions justify the risks. The researchers have modified their protocol to screen mothers for hepatitis B and exclude babies born to infected mothers. It shocks me they had to include that and such was not in the original proposal.

Here is the problem: maternal screening doesn’t eliminate household transmission, nor does it prevent a child from acquiring hepatitis B from someone else during those first six weeks. Like the caregivers of that child.

Caregivers were responsible for over half the transmission of hepatitis B to infants in the Alaska study. The auntie, grandmother, sister, cousin, or friend who will love and handle that infant, can transmit it. While adults transmission of hepatitis B is blood borne or sexually transmitted, infants immune system are undeveloped and transmission to them is far easier.

And the children who become chronically infected won’t necessarily show the consequences during the study. Liver cancer can develop twenty or thirty years later. By then the grant will be over and the researchers will have moved on.

The children won’t have.

How They Got the Money

If you’ve ever applied for a federal research grant, it is a multi-step process where lots of people examine your proposal. They then rank your ideas, your previous work, and score your proposal. If you reach above a certain score, your grant is funded.

This one didn’t go through an open competition. The Danish researchers submitted an unsolicited proposal to the CDC. Meaning the CDC didn’t ask for people to send in proposals, and they didn’t submit it through normal channels. According to the agency’s own Federal Register notice, the university received a single-source, noncompetitive award of $1.6 million over five years.

The CDC says it performed an objective review and determined that the proposal was meritorious. It is odd that the two people granted this proposal are from The University of South Denmark, in Denmark. Further, these research scientists have been highly praised by RFK Jr.

This, out of the box grant, given to a foreign university, happens when the NIH, under RFK Jr decision, terminated over 2000 grants. Many of those grants involved research of diseases that happens to Americans.

Let me introduce you to the researchers, Peter Aaby and Christine Stabell Benn. Their research focuses on the broader health effects of vaccines. Kennedy has praised their work, and Benn has participated in American discussions about hepatitis B vaccine policy.

Every drug, vaccine, and medical device undergoes initial phase 1-3 testing but continues ongoing vigilance. In this case, they are denying a vaccine that has proven ability to work and are testing it against - nothing. No provision to protect the child against hepatitis B.

Besides, there is a better way this can be done. But to do that let me tell you about Alaska and hepatitis B.

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What About Alaska?

Hepatitis B outbreak in Alaska was discovered in 1973 during a medical study in remote Alaska Native villages.

Doctors went into two remote Alaskan Eskimo villages to figure out why so many people were getting sick with liver issues. They took blood samples from 418 residents and used a brand-new, highly sensitive lab test to look for the virus. The results shocked the medical world. They found over half the village (54.8%) had been infected with hepatitis B at some point in their lives. Even more concerning, 14% of the population were “active carriers,” meaning they were contagious.

We used to believe hepatitis B spread through blood transfusions, sex, or shared needles. These studies in Alaska showed that if one person in a house had the virus, almost everyone else in the house got infected too. The worrisome discovery that children could get the virus just from playing with things in the household. This is because the virus can live on surfaces (like toys, tables, or cups), little kids were accidentally passing it to one another while playing or sharing things.

Alaskan Emergency

The discovery of the epidemic of hepatitis B led to the CDC having a permanent outpost in Alaska. Cooperation between my Alaska Native community and the CDC led to the vaccination campaign and awareness.

Hepatitis B among Alaskans led to some of the highest rates of childhood liver cancer in the world. Children were acquiring hepatitis B, developing chronic infections, and sometimes dying from liver cancer before they had much chance to live.

In the early 1980s more than 53,000 Alaska Native people were screened, tens of thousands were vaccinated, and newborn vaccination became part of the program. But it didn’t stop there. We have continued to follow people who were screened and those who were vaccinated. This has been ongoing for more than 40 years.

The early results were spectacular, Hepatitis B infections declined dramatically. Childhood liver cancer nearly disappeared. A 2025 study reported no hepatocellular carcinoma among Alaska Native people aged 20 or younger since 1999 in the population under surveillance.

Another study examined people vaccinated in 1981 and 1982. Forty-one years later, approximately 91% still showed evidence of protection, and none of the participants with documented breakthrough infections developed chronic hepatitis B.

Those are extraordinary results, and they’re not based on a computer model or predictions. They’re what happened after we vaccinated an actual population and followed it for decades.

Our own CDC participated in documenting those outcomes.

Then There Are the Ethics

Suppose investigators came to us and proposed a study in a community with endemic hepatitis B. They wanted to assign newborns to receive a proven vaccine at birth or wait six weeks, in order to investigate possible unrelated effects of the vaccine.

Having served on both ethics committees and Institutional Review Boards such a study would not be approved in the United States.

Guinea-Bissau’s own health minister initially suspended the trial over ethical concerns. There are also questions about the longstanding relationships between the researchers and Guinea-Bissau’s public health establishment. Oddly, when that official had the appointment at the University of Southern Denmark the suspension was overturned. But I’d like to know what changed between the suspension and the approval, who reviewed the revised proposal, and how possible conflicts of interest were handled.

It is of no surprise that four members of the Danish university’s ethics committee reportedly resigned in protest.

The WHO’s has also protested the study, stating it was unethical. The reason is pretty straightforward. Withholding Proven Care: Hepatitis B is highly prevalent in Guinea-Bissau, affecting nearly 1 in 5 adults. The WHO strongly mandates a birth dose of the vaccine because it is up to 95% effective at preventing mother-to-child transmission. Denying it to 7,000 infants risks giving them lifelong, incurable chronic infections that lead to liver cancer and cirrhosis.

Violation of the Declaration of Helsinki: The researchers defended the trial by stating that Guinea-Bissau’s under-resourced local healthcare system doesn’t routinely offer the birth dose anyway (relying instead on a 6-week dose), meaning no child would get “worse care” than local standards. However, international bioethics rules state that human trials must provide the best proven global intervention, regardless of local poverty or resource shortages

And the fact that an intervention isn’t routinely available in a poor country doesn’t automatically make it ethical to withhold it in a research trial.

We have American taxpayer money, researchers from a wealthy European country, and newborn babies in West Africa bearing the risks. We should all find that arrangement deeply troubling. Would we approve the same experiment if these were newborns in the United States, or in Denmark?

Medical ethics don’t become less important because the research subjects live in a poorer country.

The children in Guinea-Bissau deserve nothing less than the best protection the world can afford them. Because long after RFK Jr leaves office, and the study is over, those infants who develop hepatitis B will be suffering the consequences.

Protein is not magic, more protein is not better, but protein becomes important as food intake falls.

Why Protein Matters on a GLP-1

Before you ever started a GLP-1, you probably never thought about getting enough protein for the day. In fact, seeing people with protein deficiency isn’t something you probably saw - unless it was someone with a severe disease like cancer, end stage AIDS, anorexia, or other horrific diseases.

Simply put, protein helps preserve muscle mass during weight loss. It provides the building blocks for your body constantly making and turning over new cells. Protein also helps keep you satisfied. And since your body goes through periods of recovery, like after the flu you need protein to help with that.

Weight loss will cause you to lose some “lean mass.” That is any weight loss, whether from a diet, medication, surgery, or any form of calorie restriction. The goal is to minimize unnecessary loss and not pretend it can be prevented.

Some studies showing lean body mass loss are missing the point - we expect some loss. That is normal with weight loss. More later.

How much protein do you actually need?

So there is a minimum amount you need, which is quoted as 0.8 grams per kilogram of ideal body weight per day. So, if your ideal body weight is 70 kilograms - about 150 pounds - then you need 56 grams of protein. But if you actively lose weight, especially older adults (over 60) you should aim higher.

1 to 1.2 g/kg/day - so for our ideal weight of 150 lbs, the person needs 70-85 grams a day. And higher amounts depending on age, activity level, if you are ill.

What if you get more? Is more better? More is not better. More will not hurt, but you have a limited plate size, and there are other things your body needs besides more protein.

Protein is only half the muscle story

If you do not exercise, you will not build muscle. No matter how much protein you eat, without exercise, your muscles will not grow. Doesn’t matter if you eat chicken breasts, tuna, or steak - your muscles grow with movement and resistance.

That guy in the gym spends hours a day working on those muscles, and they need the protein. Chances are not spending hours at the gym.

You should do resistance training, and that can be things like lifting weights. I do yoga, some like other forms. It has to be something you like and will repeat. Exercise classes can give you community, which is also nice, but your job is to bank the muscle now, so that you have it in a dozen years if you need it.

Protein is not Aspirin

Hitting a protein target is just that. It is a target. You will mostly eat more protein than you need, but you do not have to hit a number every day. Instead of thinking - I have to make 200 grams of protein - think about your plate. It isn’t a drug, a pharmaceutical that you have to hit that dose.

Food should come with a healthy variety of fruits, vegetables, fish, legumes and whole grains. All of which contain protein.

Fish and Seafood

Great healthy protein sources, which are easy on the stomach. Many find that fatty red meats are hard on the stomach. But fish, which is a different kind of fat, tends to digest easily and is considered one of the better protein sources. Today I had some salmon with my lunch. Others like shrimp, tuna, white fish. It is an easy way to get in a lot of protein. I had a small filet of salmon, and it had about 25 grams of protein.

Dairy

One of the easier ones. I have been on a kefir kick lately. Kefir is fermented milk. I like it because it concentrates on the protein in milk and has little to no lactose in it. On mornings when I am up before my stomach is awake, having a bit of kefir is easy on the stomach and gets me about 10 grams of protein. I have been using oat milk and kefir for my morning smoothie.

Greek yogurt has about twice the protein as Kefir, and is an easy breakfast.

Some love cottage cheese. It has a bit more protein in it. I know, cottage cheese is not a cheese, and it is just a curd to me.

And don’t forget milk. I do, lactose intolerant, so for me milk is something I drank as a kid.

Eggs are also a great source of protein. Single egg is about 6-7 grams, most have two to three eggs. I prefer mine with lots of good red sauce on them and some beans - ok, huevos rancheros.

Legumes

These are one of my favorite proteins. Beans. Last week, I gave a simple recipe that I use when I cook chicken. Chickpeas are an easy air fried snack. One cup of beans has about 15 grams of protein, also a great source of fiber and little fat.

Soy Foods

Living in California, I have had a lot of tofu, tempeh, and edamame. Vegetarians and vegans grow here more than cows. I will have some tofu recipes in another episode, and I do a monthly TikTok, Instagram (and we put it on here) short cooking show with Chef Ray where we cook with these ingredients.

Do You Need Protein Shakes

Sometimes you do. If your appetite is low, breakfast isn’t going to go down, or you want convenience. Sometimes days are rough after some injections, and these are helpful. Some nights for dinner, all I want is something, and a protein shake works great.

Collagen

Collagens contain protein, but they do not contain all the protein someone needs. This should not be the center of your protein strategy. The data for collagen preserving your skin has been re-examined, and there is no reason to recommend collagen over other sources of protein.

Whey protein induces more muscle building.

What about eating too much protein?

The main issue is you are not getting enough of other things on your plate. You still need fiber, fruits, vegetables, and other micronutrients that you get from a Mediterranean style diet.

And if you have kidney or liver disease, you need specialized medical advice from a registered dietician familiar with your condition (not a chiropractor).

Here is on of my favorite recipes - a quick and easy Lentil based Dahl - and a two minute video of how to make this.

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More than a million people in Great Britain are vaping who never smoked a cigarette. In America, millions are vaping nicotine and cannabis, while nicotine pouches are becoming the latest way to get a nicotine fix. But are we reducing harm or simply finding new ways to become addicted? From lung injuries and transplants to THC gummies and nicotine pouches, Dr. Terry Simpson takes an unfiltered look at what the science tells us, what we still don’t know, and how to reduce risk without the usual hysteria. Because vaping may be safer than smoking, but safer doesn’t mean harmless.

Watch almost any British television series, and tea appears whenever you enter someone’s home or office. Tea, apparently, is not only a beverage, but also medication for both mental and physical issues.

Oh, turns out someone has died? Put the kettle on. Yes, at some point Gin or whisky will be involved, but there is always tea. Were you shot at? Tea. Your spouse has left you? Tea. Need to discuss a murder? Tea.

I have been watching Slow Horses, one of the great detective series about MI5. From this I have learned that British intelligence can tolerate treason, Russian assassins, and Gary Oldman’s personal hygiene, as long as there is tea.

It does not matter the hour, morning, afternoon, evening. And I am always shocked that nobody ever looks at the clock and says, “Perhaps this caffeine will interfere with my sleep.” No. Kettle on. Could be 2 am, and you just showed up to tell them bad news, are hiding from a shooter, or you broke up with your significant other - tea it is.

It is not like Americans who offer coffee to everyone, but close. Tea is offered regardless of time, circumstances, or whether you even like the person. I am convinced that if you do not offer tea to a Brit, you will be breaking a royal command.

Civilizations and Tea

In this series about foods that built civilizations, we have covered foods from wheat to salmon, allowing civilizations to settle and develop.

Tea is different. Nobody survived a winter because they had enough tea. But tea, like coffee, helped build civilizations, providing a gathering spot. But the love of tea allowed for two wars, espionage and ritual.

The Chinese Had Tea First

The legend is that the Chinese Emperor Shen Nong discovered tea when some leaves blew into his hot water almost 5,000 years ago.

By the eighth century, during the Tang dynasty, Lu Yu had written The Classic of Tea, an entire book about cultivating, preparing and drinking tea.

Black and Green Tea

I’ve always thought green tea tasted like pond water. And despite the many health benefits of green tea, it never appealed to me. Black tea is my preference, and it amazes me that black and green tea come from the same plant, Camillia sinensis.

Green tea leaves are heated quickly by steaming or pan-firing right after harvesting to stop oxidation. This keeps the leaves green. Black tea leaves are withered, rolled, and left to fully oxidize in the air, which turns them dark brown or black. Same plant. Different processing.

Then the British Discovered Tea

When tea first arrived in Britain in the 17th century, it was a luxury item, as all new imports are. Catherine of Braganza, the Portuguese wife of Charles II, helped make tea fashionable at the royal court.

Expensive and exotic, the sort of imported luxury you drank because other people couldn’t afford it.

The tea moved from court to wealthy households and eventually into ordinary homes. Taxes on tea were high, which had the predictable effect of creating a thriving smuggling business.

By the eighteenth century, Britain was buying enormous amounts of tea from China. This left a large trade imbalance. China was not importing many British goods, so the Brits had to pay in silver. Silver went east. Tea went west. This was an excellent arrangement if you were China. The British were less enthusiastic. Then they discovered that China would import opium.

Things Get Ugly

The East India Company discovered an appetite for opium. Despite China wanting to stop the drug, opium provided a tidy profit for the East India Company. Drug wars have had a similar problem. Opium also solved the trade deficit.

When China responded by restricting opium, and when you limit the profit of a Brit, you have war. The so-called opium wars began in 1839.

Britain did not go to war because somebody was late delivering Earl Grey. There was more to the wars than a tea trade deficit. But tea was at the center of the trade imbalance. History is almost never as simple as the sentence we remember from school.

While the Brits were successful in the opium wars, war is costly, even when you win. Ongoing war takes a bite out of profit.

So a fine idea developed. Instead of buying all this tea from China, they might grow it somewhere they already controlled. Like India.

India Already Had Tea

This is one of those parts of history that becomes more interesting when you stop telling it entirely from the British perspective.

Tea was already growing in Assam. Indigenous people, including the Singhpho, grew the tea, but it was not to the British taste. Brits preferred the taste of the Chinese varietals. The Chinese had a different method to cultivate and process tea. But they were not forthcoming in offering their knowledge or plants to the Brits. War can make people a bit selfish.

So the East India Company decided to steal the plants and knowledge

And for that, the East India Company hired Scotsman, Robert Fortune.

The Original Tea Thief

Between 1843 and 1861, the East India Company sent Robert Fortune on multiple trips to China. His mission was to obtain tea plants, seeds and knowledge, and bring them to India. Then develop an Indian tea industry solving the trade imbalance.

Fortune traveled into areas closed to foreigners, sometimes wearing Chinese clothing and adopting a Chinese appearance. Since he did not speak Chinese, his companions would tell people that he came from across the Great Wall.

He visited tea-growing districts, collected plants and seeds, and learned how the Chinese processed tea. He also helped settle the European misconception that green tea and black tea came from entirely different species.

Over those years, he brought 20,000 plants out of China. After trial and error, Fortune discovered tea grew best in the province of Darjeeling. Located in West Bengal, this high-altitude region became the perfect home for the tea Fortune smuggled out of China. The steep terrain and cool mists were the perfect environment. Much like Paso Robles is a perfect environment for some wines. Fortune birthed the famous, highly prized “Darjeeling tea” industry.

While a native wild tea variety (Camellia sinensis var. assamica) had been discovered in Assam, India, Fortune’se brought expert Chinese tea masters and workers to the Assam plantations. These workers taught the locals how to properly ferment, roll, and dry the leaves. The Assam district now made tea to the liking of the Brits.

My Tea

One of my two current teas is a Darjeeling second flush from JING. Second flush is picked later than the delicate first flush and produces a fuller tea with the flavor tea people describe as muscatel. I'm not going to hold the cup under my nose and tell you that I'm getting notes of Himalayan stone fruit, leather and a summer rain falling on the eastern slope of a mountain. When I was in London, I tried various teas. One morning, this one appeared during breakfast at the Langram. It has become a favorite.

Somehow, I also imported a small stockpile of the tea in that brief period, when Prime Minister Keir Starmer and Donald Trump seemed to have no tariffs between them. I think it lasted about twenty minutes.

Tregothnan

The place is called Tregothnan, an estate in Cornwall where the local microclimate is just warm and humid enough for Camellia sinensis. They planted their first tea bushes in 1999 and began selling English-grown tea in 2005.

Naturally, I purchased some.

But the irony is that now tea can be grown in the UK. While the estate in Cornwall produces about 10 to 15 tons per year. Consider London drinks about 13,000 tons per year.

Still, going to war with China over tea. Hiring a spy to bring it to India, and all that effort, and they could have grown tea in their backyard.

Boston Tea Party

You remember the story from grade school, the cry of “Taxation without representation.” Brave colonists standing up against the British Empire.

On December 16, 1773, men, disguised as Native Americans, dumped 342 chests of East India Company tea into Boston Harbor.

That isn’t the whole story. Because the Tea Act threatened the people selling tea in America. One of the men was a wealthy Boston merchant John Hancock.

We remember the liberty. We don’t talk nearly as much about the profit margins. And that is where the tea gets really interesting.

John Hancock and the Business of Liberty

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We now know that bacteria was responsible for the plague, and it has a name. Yersinia pestis. Today plague is uncommon, recognizable, and treatable with antibiotics.

The story developing in Siberia involves a young laboratory worker. One story says she broke a vial that contained live Yersinia pestis. She died quickly. Russian officials say of pneumonia of uncertain origin. About 200 people were placed under observational quarantine.

So before we decide the Black Death has returned, let’s separate the biology from the headlines.

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The three forms of black death

When we talk about the plague, we have divided it into three types. Bubonic plague, septicemic plague, and pneumonic plague. All of them are caused by the same organism, and all of them treatable with antibiotics. But they manifest differently.

Bubonic plague is the form most people associate with the Black Death. These bacteria usually enter through an infected flea bite and travel to nearby lymph nodes. Lymph nodes turn dark or black because of internal bleeding and dead tissue. They become large and painful, and we have a unique name for them. We call these lymph nodes “buboes”. Without treatment, about 30 to 60 percent of people will die. Person-to-person transmission of bubonic plague itself is uncommon.

Pneumonic plague is the form relevant to the current concern in Siberia. This form of plague infects the lungs and can progress quickly. Symptoms include fever, profound illness, shortness of breath and cough, sometimes with bloody sputum. Pneumonic plague spreads directly from person to person through respiratory particles during close exposure. Untreated, it can be fatal within 18 to 24 hours after even minor symptoms begin.

Septicemic plague occurs when the bacteria multiply in the bloodstream. Patients rapidly develop shock, along with bleeding, tissue necrosis and organ failure. Untreated septicemic plague is fatal. This is usually the final step before death, and often started as bubonic or pneumonic plague.

That is why plague is one of those infections where physicians treat before we have the final test result.

The CDC states that if plague is suspected, besides the usual, obtaining cultures is to begin antibiotics immediately.

In the United States, gentamicin and fluoroquinolones are the recommended antibiotics used for 10 to 14 days.

The World Health Organization recommends close contacts be identified, monitored, and given seven days of preventive antibiotics. Healthcare workers directly exposed to pneumonic plague patients also receive antibiotics.

That explains some of what we are seeing in Russia.

A 28-year-old woman working in a laboratory in Irkutsk developed a rapidly progressive pneumonia and died. Something all sources agree upon. However, one report says she broke a vial containing live Yersinia pestis. Russian federal officials say she died from pneumonia of uncertain origin, and no work-related pathogen was identified.

Meanwhile, about 200 people who had contact with her were placed under observation, and several hospitals went into quarantine. Quarantining a hospital does not mean everyone in the hospital has plague or been exposed to it. If authorities believe someone has had a pneumonic plague, they can trace and isolate contacts while they sort out what happened. And of course, begin antibiotics.

Biologic Weapons - not a conspiracy

The Soviet Union had a large biological-weapons program. Former program officials said some of the work with Yersinia pestis included efforts to produce antibiotic-resistant strains.

We do not know if this woman was exposed to a resistant or “engineered” strain. But if a plague was involved in a laboratory accident, one of the first questions I would want answered is which strain was it, and what antibiotics is it susceptible to?

Unlike what terrified medieval Europe, we have antibiotics, laboratories, infection control, contact tracing, and the ability to recognize what we are looking at. Not just a mask with some incense.

Just in Time for Halloween

For more information, see below:

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The guidance about what to eat while taking a GLP-1 ranges from “just eat less,” to “eat better” to someone trying to sell you their favorite diet. And eat better doesn’t come with a guide. Yes, more vegetables, bla bla.

It reminds me of the noise my weight-loss surgery patients faced.

That is one reason I became certified in Culinary Medicine. After years of operating on people for obesity, I realized that telling someone to “eat less and eat better” wasn’t particularly useful. Better how?

For years, I gave patients the same general advice many of my colleagues did. Others had their own answer: low-carb forever. Arg.

I wanted something more useful than that. I wanted to know what pattern of eating had evidence not simply for losing weight, but for living longer and healthier.

The Mediterranean Diet

Simply put, the Mediterranean Diet has some of the best long-term health data of any dietary pattern.

The Mediterranean Diet is not “eat whatever people living around the Mediterranean eat.” Pizza in Naples does not automatically become health food, because Naples is on the Mediterranean. McDonald’s in Rome isn’t better than the one in LA. Although, I like Rome.

Plus, people in that region today are eating more ultra processed foods than before.

Here is the technical definition. The Mediterranean Diet is a pattern, named after traditional eating patterns from parts of the Mediterranean region. It is scored based on how much or little of different food groups. OK, that sounds way too complicated. And rather than make this complicated, I like to reduce it to nine points.

Think of it as a scorecard, not a religion. The more points you get, the better health outcomes you have.

1. Vegetables

To score one point for vegetables, you must eat at least 250 grams (about 9 ounces) of vegetables per day. We count based on the raw food. So two medium carrots are about 6 ounces or 170 grams. Have a salad filled with chopped vegetables, and you’ve made the nine ounces.

Not just lettuce. Tomatoes, peppers, carrots, broccoli, greens, eggplant, onions, squash — whatever vegetables you actually enjoy enough to eat repeatedly.

2. Legumes

I have fallen in love with beans lately. Simple bean dishes are so easy to make from canned beans (recipe below). Adding beans or making them the center provides protein with fiber and low saturated fat. Some of my favorite beans come from Rancho Gordo.

To get a point, you need two ounces of legumes a day. By the way, peanuts are a legume, so a serving of peanut butter might count. No, Reese’s might not be the best source, but hey.

Beans, lentils, chickpeas and peas.

They bring fiber, protein, minerals and remarkable versatility. And no, they don’t have to come from Greece. Dal fits beautifully. So do black beans.

3. Fruit and Nuts

Fruit is food, not candy. Yes the low carb people think fruit is horrific, even though the data shows the opposite.

This is another 9 ounces (250 grams) to make a point. Not difficult to do. An apple is about 5 ounces. Twenty grapes is about 100 grams. And I love having frozen grapes for dessert.

Add nuts and you get another source of fiber, unsaturated fats and protein. You don’t need exotic berries harvested under a full moon.

4. Whole Grains and Cereals

To get one point, you need nine ounces, but how do you get that?

What is a serving of whole grains? It seems confusing, especially since some products are a mix of both whole and refined grains. In the Mediterranean Diet, you might notice 9 ounces, but is that grain when it is dry or wet or both? So it turns out there is a whole grain council that has done the work for you, and they tell you right on the package. See the symbol below.

This makes your math simple. You either need three stickers of the 100% whole grain or six of the other stickers.

Ways to incorporate whole grains. Use whole grain pasta, whole grain breads, popcorn is a whole grain, and overnight oats in the morning is a great way to start the day (on my commuter mornings, I sometimes take overnight oats to drink in the car). Whole grain rice works, although it takes a bit longer to cook.

5. Fish and Seafood

Think Sushi! OK, I want sushi

Two servings of fish per week. That might be a tuna fish sandwich one day, and salmon another day. It might also be shellfish, like crab, or maybe a serving of clam chowder.

Allergic to fish and seafood? Well, it is one point you won’t make, but that is just one.

Fish appears regularly in this pattern, particularly in place of some red and processed meat.

6. Dairy

The Mediterranean diet emphasizes fermented dairy products, yogurt and cheese. . To get a point for dairy on the Mediterranean Diet Score, and limit sugar, I like plain Greek yogurt and add fruit (blueberries, strawberries).

Other fermented products include cheese. My favorite cheese is still the Norwegian goat cheese that I grew up with as a child.

The key with dairy is that there is an upper limit. In this case about 1 cup per day. This allows some modest cheese and yogurt.

I’ve discovered Kefir lately (which I tend to pronounce like my son’s childhood friend but and told I should pronounce it Kah Fear. I am lactose intoleratant and on a GLP-1 this is an easy drink, fermented, and gives me high quality protein on those days when solids don’t go down well.

Dairy is a point on the Mediterranean Diet Score, and more points are not a bad thing. The studies were clear that yogurt and low fat milk had a reduced risk of metabolic syndrome (Babio N, et al. Consumption of Yogurt, Low-Fat Milk, and Other Low-Fat Dairy Products Is Associated with Lower Risk of Metabolic Syndrome Incidence in an Elderly. Mediterranean Population.J Nutr. 2015 Oct;145(10):2308-16. for link click here.)

7. Meat

The Mediterranean diet limits one to about 4 ounces of red meat a day. If you don’t eat red meat, you get a point. Have beans instead of meat, you get a point. Four ounces isn’t that much, but here are two facts for you. Your body will only absorb as much iron as is in 3 ounces of red meat. More will not increase iron absorption (unless you have hemochromatosis). People with hemochromatosis must limit red meat intake. Four ounces is anywhere from 20-35 grams of protein, but probably not your only protein source for the meal.

Red meat has some health disadvantages in large quantities over time. So having other sources of protein seem to work out better.

8. Fats and Oils

One point if most (sixty percent) of your fats come from olive oil. This isn’t difficult, and it is delicious. I like California Olive oils because they have some of the highest purity standards for extra virgin olive oil in the world. You can argue with the taste (I love olive oil from Liguria) but you cannot argue chemistry.

9. Alcohol

If you drink 5 ounces a day of wine, or one beer, or one drink, you get a point. Less you get a point. No alcohol, you get a point. More, you lose the point. No, you cannot store your points for the weekend.

As much as alcohol has had a disappointing result for health, I still have the occasional glass of wine - and I enjoy it.

GLP-1 greatly reduced my desire for alcohol. I used to drink wine with dinner most nights, now I have it on the occasional weekend. It has also made me appreciate some wines more than others.

Some of my Favorite Dishes and Examples of Mediterranean Points

Sometimes you just want examples of how you can get these points. There isn’t an app, but it isn’t that difficult. But incorporating this eating plan into your life has health benefits.

One study showed that higher adherences (five points out of nine per day consistently) led to a 9 percent increase in longevity. Another study of over 1.5 million people showed a 22 percent reduction in cardiovascular disease. Another study showed decreased incidence of cancer.

Hence, health is cusine. Weight loss is chemistry.

Weight loss is the GLP-1 (Ozempic, Zepbound, Retatrutide, etc). We found that. No more dieting. But we want long-term health.

This is where the Mediterranean Diet comes in. You can eat a fish taco and get Med points?

Whole grain taco - 1/4 of a point

Fish - 1 point

Cabbage for crush 1/4 point

Salsa - real good salsa, not the canned red stuff - 1/4-1/2 point

Add beans - 1 point

In one meal you have 2 - 2.5 points .

None of that is traditional Mediterranean, but all of it is great, and that is the point to getting points.

Ok, here are some of my favorites:

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Does GLP-1 cause hair loss, or does weight loss cause hair loss, or is it a nutritional deficiency?

It happens to about 8 percent of women. Three to four months after starting GLP-1, they start noticing hair loss. Just when as they feeling good about the weight loss.

First, a bit more hair in the shower drain. Then it comes out in clumps.

About 8 percent of women report hair loss on GLP-1 medications. For men, there is somewhat less than 1 percent.

Telogen Effluvium

It is such a great word, and is the condition that describes the most common cause of hair loss for people who lose weight. Whether weight loss is from diet, weight loss surgery, or GLP-1 use. TE is responsible for more than 90 percent of the hair loss, and occurs at the level of the hair follicle when the follicle is “stressed.” Essentially, the hair follicle stops making hair and takes a rest.

It can also happen after other major stressors, pregnancy, job change, divorce, new relationship, having a teenager.

Anatomy of a Hair Follicle and why it stops making hair

A hair follicle is a tiny, pocket-shaped tube in your skin that grows hair. a miniature hair factory.

Every hair on your body grows out of its own follicle. You are born with about 5 million of them all over your body, except on the palms of your hands and the soles of your feet. Well, some do have hair follicles on their palms, but that is a rare wolf like condition.

Hair follicles normally cycle through four phases: growth, transition, rest, and shedding. The hair on your head has a growth cycle (anagen phase) that can last from two to seven years. The shorter the growth cycle, the shorter your hair is. Those people with a nice long hair have much longer hair cycles. Once the hair cycle has completed, or is forced to stop, the follicle goes into a transition and rest phase, and the hair will shed. As people age, the growth cycle shortens.

Several things will force the hair follicle into a resting phase. One is major hormonal disruptions, like pregnancy or people who are given some exogenous hormones.

Everyone responds differently to stress, but for some, their hair follicles respond to stress by stopping growth and entering into a 3-month resting phase. People who go through a stressful event (like weight loss or childbirth, high fever) don't lose their hair immediately. The shedding hits right on cue 3 months later, once that resting phase wraps up.

If you begin a GLP-1 in January, then sometime in March or April you suddenly wonder why your bathroom looks like a golden doodle exploded in it.

Hair loss after weight surgery happens even more than people on GLP-1 medications. Up to 57% of people with weight surgery,

The Supplement Rush

Some people think they will avoid hair loss by taking lots of biotin, vitamins, and extra protein shakes. And while a lack of nutrients can cause hair loss, most of the time it is just TE.

But during the panic time, as the hair brush and sink fill, people look to the internet to buy biotin (not a good idea and rarely a reason for hair loss) or add more protein powder into their lives. Please resist this rush. Also resist those who say, “I took this supplement before I started and never lost a hair.” Anecdotes are not evidence.

Typical hair loss (or it is really shedding) during the first several months after a large weight loss or operation is classic telogen effluvium. Then three to four months after the initial shedding, the hair returns, often richer and fuller than before.

Persistent Hair Loss

If the hair doesn’t come back after a few months, that is when we think about other diagnoses.

Could GLP-1 Cause Hair Loss?

I suppose it could. But there has been no evidence that the drug itself causes this as an issue.

People on these drugs eat less, lose weight rapidly, and sometimes don’t eat well.

“I started Zepbound and my hair fell out” does not necessarily mean Zepbound attacked the hair follicle.

It may mean: Zepbound led to much less appetite and not enough nutrients. That is the logic that the salesmen of supplements and scams depend on.

Male and Female Pattern Baldness

These happen to men, and women, in their 20’s. A person could have both TE and pattern baldness. Rapid shedding can expose that you have fewer hairs providing cover (or comb over).

Most of the time it is temporary

Classic telogen effluvium is generally non-scarring and temporary.

The follicle isn’t dead. Stress has just reset the follicle. And it takes about 3 months for that new hair to show itself on the scalp.

Once the triggering physiologic stress settles, hairs can cycle back into growth. The American Academy of Dermatology notes that normal fullness typically returns over six to nine months.

That doesn’t make watching your hair come out any less disturbing.

Don’t overtake supplements. Protein powder probably won’t hurt you. If concerned, have your doctor look at your scalp, and maybe get some blood work.

What I Would Actually Do About GLP-1 Hair Loss

Here’s where we leave social media medicine and do some medicine.

First: Look at the Pattern

Diffuse shedding all over the scalp beginning a few months after substantial weight loss?

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MesoAmerica and Chocolate

In our series looking at foods that built civilizations,today we are going to stay in the Americas with chocolate.

Chocolate has been used as currency, consumed by kings, incorporated into religious ceremonies, and prescribed as medicine. Today, it is a multibillion-dollar industry that wants you to believe that eating chocolate is an act of preventive cardiology.

I mean, why not? They convinced us to give chocolate to people we love, eat it when we are happy, when we are sad when only the dog understands us. Don’t feed chocolate to your dog.

And we have done all this with a bitter seed that most of us would probably spit out if we tasted it straight from the tree.

Ancient Harvest and production of Cacao

Archaeological evidence from Ecuador indicates people used cacao about 5,300 Valentines ago.

Football-shaped pods were cut from large branches of the Theobroma cacao tree. The pods are sliced open and have 30 to 40 seeds encased in a sweet, sticky white pulp. The seeds and pulp were scooped out and placed into piles or baskets covered in banana leaves to ferment for 3 to 7 days. During fermentation, yeasts broke down the pulp, killed the seed germ, and began developing the chocolate flavor.

After fermentation, the beans were spread on mats and left in the sun for about a week. Workers periodically turned them until they were dry and brown. At this point, the beans were shelf-stable, light, and portable. They were bagged and used as currency across Mesoamerica. Imagine growing your currency.

To make the cacao drink, the beans were toasted on a griddle over an open fire, which loosened the papery outer husks. They then crushed the shells and blew away the husk, revealing the inner cacao nibs.

These were then ground, like maize, by rubbing a stone rolling pin back and forth over the nibs. The friction and a small controlled fire under the stone would melt the natural cacao butter. As a result, the solid nibs transformed into a rich, glossy, flowing chocolate paste.

They mixed this pure cacao paste with water, cornmeal (to thicken it), spicy chili peppers, wild vanilla, allspice, and fragrant flowers.

To serve it, they would pour the liquid from jars into bowls until a thick, froth formed on top. That was considered the most prized part of the sacred drink.

The Maya used cacao in ceremonies, Aztecs collected cacao as tribute, and the beans were used as currency. Just like we used to use the Hershey’s bar as currency on the playground. Imagine using chocolate to pay taxes. That chocolate would be as bitter as taxes are today.

Europe Meets Chocolate

The first time Cortez drank cacao, they hated it, describing it as a drink fit for swine. But then they began to experiment with the recipe by removing the chili peppers and cornmeal and adding lots of cane sugar. Do we know what Cortez said exactly? Not really, although I think of him as one of the nastier characters on The Princess Bride.

Then they added cinnamon, vanilla, and anise, instead of using the local herbs. And they served it hot, instead of cold.

The Spanish court kept this sweetened "hot chocolate" recipe a state secret for nearly 100 years. By the 1600s, the recipe leaked to the royal courts of France, Italy, and England, becoming the ultimate luxury status symbol for the European elite, and Starbucks fans everywhere. It is a good story, and some even think it is true.

The difference between cacao and cocoa is sometimes described as the difference between the original cold Aztec drink and the modern Spanish one. But it was probably a misspelling by the English traders on ships manifests. But if you want to sound cool, you use cacao.

Mother’s Day, 1990

It was Sunday, Mother’s Day, and I was a surgical resident on the vascular service. I was thinking about driving down to Portland to visit my mom when I received a call from Dr. Raker.

There was a patient who needed vascular surgery to save his leg. There went my Mother’s Day plans. Over the course of the next six hours We operated, bypassed the aneurysm, and saved Charlie’s See’s leg.

Charlie had tasted more chocolate than probably anyone alive, and he didn’t like most American chocolate. Some Belgian choclolate, maybe.

He told me about the Guna people of Panama, who drank six cups of chocolate a day. And they didn’t have heart disease. He had tried, but didn’t like that drink. His expressed regret was that if he had consumed more chocolate, maybe he wouldn’t have needed vascular surgery. That is unlikely, but lets find out why the people in that area of Panama have lower blood pressure.

Chocolate Flavonols

The bioactive ingredient in chocolates is flavanols. These have several effects: they reduce blood pressure directly through nitric oxide, they have mild anti-clotting effect, and they are anti-inflammatory.

Nitric oxide causes the muscles in blood vessel walls to relax. When those muscles relax, your blood pressure goes down. The lower your blood pressure is, the less strain on your heart, the less risk of developing atherosclerosis, and the longer a person lives. Of course, we don’t want it too low.

All that from drinking chocolate. But not so fast. We often have mechanisms in biology that do not translate to eat chocolate and decrease your risk of heart attacks and strokes. But what a sweet experiment to try, so they did.

COcoa Supplement and Multivitamin Outcomes Study, aka COSMOS.

COSMOS followed 21,000 Americans for over 3.5 years to see if the cocoa flavonols decreased the risk of heart attacks and strokes. Subjects were fed either a placebo or 500 mg of flavonols daily.

They found that the group who took flavonols had a 27% lower risk of death from heart disease, and about a ten percent lower risk of all cardiovascular disease.

Perhaps had they had the content of the bean, as in a chocolate bar, or even received the drink that the Kana (Guna) people drank, it might have had a different result.

Is it Dessert or a Health Food

One way to describe nutritional information is those who are splitters - finding the ingredient in the food that causes the reaction and focus on that. And there are lumpers, but the food together in a matrix and see what that matrix does that a single ingredient might not.

We know that eating blueberries, seeds, nuts, other fruits and vegetables provide improved health outcomes across all studies that have examined these. That is the backbone of the Mediterranean diet. Building a diet around those healthy foods.

Chocolate has not been on the list for the Mediterranean diet. Again, just because chocolate originated in Mesoamerica does not mean it cannot be a part of a Mediterranean diet.

However, you can make chocolate an important part of the Mediterranean diet, and not be dessert. I will have a few of my favorite recipes below, like adding them to my son’s favorite “taco” soup.

When you get a chocolate bar that is 70 percent or more “dark” chocolate, that does not translate into the amount of active flavonols in the chocolate. How the chocolate is processed will determine the amount of flavanols in the chocolate, not the percent of dark chocolate. So if you enjoy chocolate as dessert, enjoy it. Don’t fool yourself into thinking it is a health food.

But you can add a healthy dose of chocolate to beans, stews, sauces, and add a richness to a dish that are perfectly healthy. This is much like the mole sauces of Mexico, rich, but with more of an Italian-Sardinian twist.

As for our people from Panama - they still drink the bitter cocoa. When they move from their village to the city, they drink less and tend to develop the same diseases as the city folk, high blood pressure, heart disease and stroke. I might add this confounding variable: while in their village, they eat more fish, almost no ultra processed food, and filled with other fruits and vegetables (kind of like a good Mediterranean diet - or if you want to rename it to the DASH or MesoAmerican diet, you can).

Now, what if I told you that one of my favorite ways to eat chocolate is with beans? Below, I'll show you how cocoa makes my son's favorite taco soup taste better, how I use chocolate with coffee to make a crust for tri-tip, and which cocoa you buy in the baking aisle matters more than you might think. Finally, why that really dark candy bar may not be as healthful as a Reese’s.

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Recently Andrew Huberman stated the risk of going blind from GLP-1 was roughly the same risk as going blind from masturbation. That is a reassuring soundbite. But I don’t want a soundbite.

The current headlines of people suing GLP-1 manufacturers because they went blind. From this are two sub-headlines: those who say it isn’t a big deal and barely rises above the noise from those who have diabetes and go blind. The second group are the GLP-1 skeptics, who will magnify any negative side effects and say if you buy their coaching plan, you won’t go blind.

There is a real medical condition behind the headlines. Rare as it might be, that isn’t a zero risk. There is also an anatomical predisposition to this effect.

I have taken tirzepatide since October of 2024. Going from over 225 pounds, losing 50 and maintaining, I am happy. It has had a positive impact on my health, from all my labs, it has changed food noise. But would I make that trade if I knew I would go blind? What risk would I accept?

What is this blindness everyone is talking about?

The condition is called nonarteritic anterior ischemic optic neuropathy, mercifully abbreviated NAION. It is an injury to the optic nerve caused by inadequate blood supply to the portion of the nerve where it enters the back of the eye. Don’t worry - let me explain.

The optic nerve is the cable that carries visual information from the eye to the brain. The fiber for the internet that sends information. But that fiber is a living tissue and needs a blood supply to keep it alive. If the blood supply is lost, you go blind, that fiber is frayed and cannot transmit information.

If the blood flow to the nerve is decreased, you may damage the nerve to lose some sight. Meaning, you don’t have perfect vision, like having a bad cable, you don’t have great internet. You may lose some vision on the side of the eye, or in the center, or things can get fuzzy. The loss of sight is usually described as sudden and painless loss.

Most often, this happens in one eye, and the amount of vision lost varies. This condition does not mean a person becomes completely blind. Often that is not the case.

This is not the same as diabetic retinopathy, where diabetes damages the blood vessels of the retina. The retina is at the back of the eye. It is what converts light into the electrical signals. Think of it as the keyboard. Diabetic retinopathy is like having a bad keyboard, where you can lose some keys or all of them, or they don’t work as well. So retinopathy is a different condition.

NAION has been known about for a long time, long before GLP-1 medications. NAION is like a heart attack to the arteries that feed the optic nerve. Anything that can cause damage to a blood supply can cause this condition. Mostly diabetes, but also high blood pressure, sleep apnea, high cholesterol, etc.

This is part of what makes the current controversy difficult to sort out. Many people taking GLP-1 medications already have some of the conditions associated with NAION. If someone taking Ozempic develops this problem, did the medication cause it, contribute to it, or was it something that would have happened anyway? This is not a question to dismiss based on someone with pre-existing conditions. The question is more, what is the additional risk of partial or complete visual loss added by GLP-1 medications?

The anatomy of the problem

Andrew Huberman’s says there is a specific anatomy (a crowded optic disc) that leads to NAION. While Huberman is not a physician, he happens to be a specialist in the nerves in the eye. So here is what he is talking about.

Where the optic nerve goes from the eye into the brain is called the optic disc. Think of it as all the cables coming together, forming that nerve and bringing that information to the brain.

If blood flow to the optic nerve becomes decreases, swelling can develop within that confined space. Anytime you get a loss of blood flow swelling takes place. Ever put a rubber band around a finger, and you see it swell. That is what happens if there is blood loss in this area. When the area swells, the nerve gets damaged. Just as if you left the rubber band long enough on the finger, the finger would become damaged. The difference is with the finger, you have nerves that tell you it is painful. In the eye, you don’t have those pain fiber nerves, which is why this is painless and you don’t see it coming (sorry).

Some people have a smaller area, and they are far more susceptible to NAION. But the real question is what caused the original interruption in blood supply.

A person can have a crowded optic disc for decades without developing NAION. In fact, most people with a crowded disc never experience the condition.

We see this throughout medicine. Having a predisposition to a problem does not mean you will get the problem. You can smoke for years and never get lung cancer or heart disease. A person may have coronary artery disease for years, and never have a heart attack. You can have a narrow spinal canal (spinal stenosis) and never have back pain (go yoga).

What did the regulators find?

In June 2025, the European Medicines Agency reviewed the evidence linking semaglutide to NAION. They concluded that NAION should be recognized as “a very rare adverse effect of semaglutide.” They state this includes Ozempic, Wegovy, and Rybelsus.

The agency estimated approximately one additional case of NAION for every 10,000 people treated with GLP-1 for one year. One in ten thousand. But it is not zero.

The agency also reported that people with type 2 diabetes had approximately twice the risk of NAION in people taking semaglutide compared with those who were not. That makes sense when you realize that diabetes damages arteries far more than any other underlying condition.

A doubling of a rare event is still a rare event. But rare is not zero. And if you suffer from partial or complete blindness, it is hardly comfort. Just like if a shark bites you, a rare event, you still have an injury (this is why I scuba), I have a pathologic fear of sharks, so I wanted to overcome it).

The European regulators recommended that semaglutide’s prescribing information include NAION as an adverse effect. I would agree, informed consent requires this.

What about Zepbound?

There is one more distinction before we get into the studies.

Semaglutide and tirzepatide (Zepbound) are not the same drug.

The European regulatory determination specifically concerns semaglutide. We cannot automatically apply the same risk to every medication that acts on the GLP-1 receptor. It may not be the GLP-1 receptor, but we simply don’t know. Yes, it seems logical, but as we have seen in medicine before, what seems logical does not work when applied to medicine. We have to see. Not that human beings aren’t logical, we are not, but lots of great theories and models don’t automatically apply.

So what do we do? That is one of those deeply personal reflections and questions you have to ask yourself. I have my vision checked yearly by an optometrist for my glasses. This year, an ophthalmologist will check it for a more in-depth look at my retina and optic disc. But to be clear - having a non-crowded optic disc does not guarantee you won’t have an issue -here is where Huberman was wrong.

I will go more into detail in the paid section below.

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It is difficult to imagine that thousands of years ago people constructed large buildings, managed rivers, built monuments, and created art. We have glimpses of these civilizations through stories, archaeology, and the structures they left behind, but much of their history has been lost. Imagine, we don’t even know where Cleopatra or Alexander the Great are buried, yet we know their stories.

As European powers conquered Indigenous peoples, their languages, cultures, and oral traditions were suppressed. When a language disappears, so are the stories preserved within it. Our clues come from archaeology when we uncover a monument, a building, or an ancient settlement.

In the Andes, the potatoes they cultivated were not the Russets, Yukon Golds, or fingerlings you find in the store today. Different colors, shapes and textures. Adapted to survive the elevations, temperatures, and growing conditions.

Biodiversity protected their food supply against frost, disease, and changing environmental conditions. If one variety failed, another might survive. The ancient wisdom of diversity that Andean farmers developed over thousands of years was lost when the potato eventually reached Ireland.

Preserving Potatoes

They even developed a method to freeze - dry the crop. They exposed the potatoes to repeated cycles of freezing and thawing. Then they pressed them and allowed them to dry. The result was called chuño.

The freeze-dried potatoes could be stored for years. When rehydrated, they were used in soups and stews.

I wonder if they ever thought about freeze-drying the coffee berry. Perhaps there was an ancient people called the Sanka.

Tiwanaku: Farming at the top of the world

The civilization flourished for centuries, before it declined around the end of the first millennium CE. Near Lake Titicaca, in what is now Bolivia, the Tiwanaku civilization developed an agricultural system that allowed people to grow food in one of the most challenging environments on Earth. This pre-Inca civilization had monumental stone buildings, elaborate sculpture, and an extensive network of agricultural settlements. Its buildings and agricultural remains are still there. These people had an advanced civilization before the Inca. It is amazing to think the Inca were not the first to build a sophisticated society in the Andes.

They developed raised agricultural fields, known today as waru waru. Water-filled channels surround these elevated planting beds. The channels helped moderate temperature fluctuations, reducing the risk of frost damage to crops, while the raised beds improved drainage and growing conditions.

The Inca: An empire built on agriculture

The Incas inherited thousands of years of agricultural knowledge

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The empire depended on the ability of crops to grow at different elevations. Food was collected, stored, and distributed through their kingdom. Potatoes were important in the highlands, while maize, quinoa and other plants supported populations in different environments.

Machu Picchu sits high in the Andes. Its buildings, terraces, and water systems demonstrate advanced engineering. It is on most travelers bucket list.

When the Spanish arrived, they encountered an unfamiliar vegetable, a product of thousands of years of agricultural experimentation. They would carry that vegetable across the Atlantic.

The Irish Lumper: The Potato That Fed a Nation

The most famous potato, the Irish Lumper. When the Lumper arrived in Ireland, it thrived, even in poor soil, and produced enough food to sustain a family on a small plot of land. The Irish Lumper was a large, knobby, rather homely potato with pale skin and yellowish flesh. It wasn't known for its flavor. Historical accounts describe it as watery, bland, and sometimes soapy. It produced enough yield to feed your family. Add a little milk or buttermilk, and you had a diet that could sustain people doing hard physical labor.

Small land owners and sharecroppers throughout Ireland depended on the Lumper for their primary source of food. Then the blight came, crossing from America. It was Phytophthora infestans arriving in 1845, and harvests failed. Ireland's dependence on potatoes, combined with inadequate government relief, turned an agricultural disaster into a human catastrophe. Even while Ireland exported some grains to the UK. Approximately one million people died, and another million emigrated, many to America.

As with all waves of immigrants, they encountered discrimination, but ultimately helped shape the country's economy, literature, culture, and political life. Their wave of immigration led to a long sustained economic boon for America.

Today a group has reconstituted the Lumper, and you can buy one today. It is ok, not my favorite. For that, we have the simple boiled potato from Norway.

The French Fry: From Belgium to McDonald's

For generations, the French and Belgians have argued about who invented the French fry. A popular Belgian story claims that people living along the Meuse River traditionally fried small fish, but when the river froze, they cut potatoes into the shape of fish and fried them instead.

Fried potatoes became popular in Belgium and France during the nineteenth century. Belgians perfected the technique of cooking them twice: first at a lower temperature to cook the potato through, then again at a higher temperature to create that wonderful crisp exterior.

Belgian fry shops used animal fats, from beef tallow to horse fat from a horse’s kidneys. Yes, some will even tell you that horse fat from the kidney makes the best fries - I wouldn’t know.

The French fry eventually crossed the Atlantic and became an American institution. For decades, McDonald’s cooked its fries in a mixture containing beef tallow and vegetable oil.

In 1990, the company announced it would switch to vegetable oil, a decision influenced by growing concerns about saturated fat and a persistent Omaha businessman named Phil Sokolof. Many attribute this change to physicians, but it was really from this first food influencer. Taking out full page advertisements in major newspapers claiming saturated fat from the fries was bad for the heart. Alas, that “debate” continues.

But changing the frying fat didn’t change the fundamental technique. Commercial French fries are generally cooked once, frozen, and then cooked again before serving. That is why my favorite tip for making good fries at home is to buy the frozen ones that have already been partially cooked. Finish them in the oven or air fryer, and you can get that crisp exterior and fluffy interior without turning your kitchen into a Belgian fry shop. No horse required

Fear Not the Potato. Fear the Person Who Fears the Potato.

The potato wars: From carbohydrates to beef tallow

Today, the potato is at the heart of several nutritional controversies. From those who say it is one of the evil whites that leads to obesity, to those who think potatoes should be fried in beef tallow. These are the controversies we will address for our paid members.

Blood Glucose and the Potato

Potatoes are primarily starch, which your body will break down into glucose. Eating a potato will raise blood glucose, although the magnitude of that response depends on the type of potato, how it is cooked, how much you eat, and how well your pancreas works. It also depends on what other foods you eat with it.

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From California to the interior of Alaska, salmon, a staple allowed people to settle into villages, develop complex social networks, art, and trade routes. Those trade routes are as large as the ones in the Mediterranean. Some tribes built communal homes and developed complex art and language. Some were Seagoing tribes with canoes up to sixty feet long that traveled oceans.

All because there was a fish that would return in large numbers to streams and rivers, reliably, predictably. So predictable, the people could build their lives around salmon runs. So much so that some built a calendar not only with lunar cycles, but also with the return of the salmon.

Civilizations have always gathered around food and water. The Mediterranean connected people who grew wheat and olives, giving people time to make wine, mine copper, build ships, trade with their neighbors, and occasionally went to war with them.

Asia had rice and grain near the great river systems. Because of reliable calories with rice and grain, it allowed the villages to become cities and travel on the water to trade.

Today we are going to my home - from the Ventura River in California to my home state of Alaska.

The Crop That Swam Home

Different than the other civilizations, no one had to plant this crop. They didn’t have to tend the crop. It literally swam home every year. Different times for different types of salmon.

When the first Europeans saw these fish, the river was so crowded they joked you could walk on their backs, crossing the river and never get wet.

Ketchikan, The Salmon Capital of the World

I grew up in Ketchikan, Alaska. A city founded upon salmon. Some say Ketchikan stands for smelly fish, apparently after the large spawn as the fish died, it left quite an odor - you can only imagine thousands of dead salmon.

Everyone has their favorite type of salmon. The large ones, the King Salmon, also called Chinook, typically start their run to the creeks and rivers in April. Youcould catch them reliably in late May and June, or even later. We had a King Salmon derby, usually in late May to early June. The record salmon was 79 pounds for that derby. The largest King I ever caught was 26 pounds, and I cannot imagine catching one larger.

For a fish that was the livelihood of many of my neighbors, the stocks have become so low that the derby I grew up with was cancelled. Global warming has devastated salmon runs.

The above totem is either an eagle or a man, depending on who you ask. The clam has caught it and the tides roll in and the man, or eagle sings a song. Note the amazing carving, and a story as old as time itself.

These are Chilkat blankets, or dancing blankets. They take up to five years to create. Made from a combination of inner cedar bark combined with mountain wool to make the foundation. The colors are mostly dyes of four natural pigments: black (hemlock bark/copper oxide), yellow (wolf moss), blue-green (copper soaked in urine), and the creamy white of natural undyed goat wool.

Non Nomadic People

Because of the abundance, both in terms of the salmon runs, other marine mammals, berries, they didn’t have to forage. So they were able to build villages with communal living - they were SF before SF was.

An intense harvest in the late spring and summer led to a winter of art, ceremonies, and the potlatch. The potlatch is a giant party where the hosts not only displays their wealth, but gives it away. The richer you are the more you would give and that would be the nudge for the neighbor to do the same.

Large villages and communal houses when encountered by the first Eruopeans isn’t something they were expecting. There was an entire civilization, clans, tribes, alliances. People who made treaties, made war, and played games.

In Ketchikan these were rebuilt during the Depression. Here you can see my brother and I being kids - but it also gives you an idea of the large size of these communal homes and totems.

They did travel through large canoes.