My friend Dr. Zachary Rubin is eating lettuce again, but I am waiting a bit.

I have known Zachary from social media for a few years, and we have become friends. It turns out his father and I went to medical school together.

Dr. Rubin and I fight the same battles on social media against misinformation. On a side note, he is one of the kindest people you can know.

So if he and his wife come to the central coast of California, I look forward to taking them to dinner. Which means, for the moment, we are going somewhere that serves locally grown lettuce. I really don’t want dinner to end with me prescribing antibiotics. Ever been to a dinner where you hear your guests stomach rumbling? Yes, I’ve had that happen to me.

Dr. Ruben wrote an excellent piece explaining why he returned to salad. Like myself, he spent much of summer avoiding lettuce and explosive diarrhea. His central point is correct: The lettuce sitting in a restaurant in September is not necessarily the lettuce we were eating in June. The iceberg lettuce implicated in this summer’s outbreak has been recalled and should no longer be in stores or restaurants. Any leftover has long since wilted.

I worry less about the date than about the water

September 1 is not my lettuce liberation day. I prefer lettuce when it is less dependent on irrigation.

Lettuce is grown not far from where I live in California. If you drive from Phoenix to California, you will see miles of lettuce farms.

And irrigation is my main concern. For example, the 2018 romaine lettuce outbreak came from E. coli O157:H7. That contaminant was traced to canal irrigation (well, one portion of the canal ).

I love the canals of Arizona, some of which have their origins, a thousand years ago from the Ho Ho Kam. The supply from the Colorado River was guaranteed because of the political power of Arizona’s congressional staff, Senator Hayden and Congressman Rhodes. This provided Arizona with plenty of water for its farmers. Thus, you will see canals going through Arizona. Not quite Venice, no masks (maybe Zorro).

Hence my admittedly peculiar lettuce rule

I wait to get lettuce from the store, or a taco with lettuce, when the canals provide less water for the lettuce.

And yes, I did eat a Caesar salad recently.

Before my friend accuses me of violating my own embargo, the lettuce was locally grown. One loves a restaurant that sources from small local farms.

So I ate it. Besides, it was a Caesar salad. There are limits to the sacrifices science should demand. And of course, the dressing was made in house, with a coddled egg, with anchovies, and with California olive oil. Okay, my keyboard is now irrigated with saliva. A true Caesar salad - by the way, the best one I ever had was at Marx Brothers in Anchorage, Alaska - which sadly closed because the owner decided to retire.

But I am not yet back to casually ordering lettuce everywhere.

Summer is not the whole story

Cyclospora has a strong seasonal pattern, traditionally occurring during the warmer months. But leafy greens have repeatedly demonstrated an annoying refusal to obey simple seasonal rules.

E. coli O157 outbreaks tend to peak during summer, during peak irrigation. Yet when investigators have looked specifically at outbreaks involving leafy vegetables, many begin in the fall. Because the summer harvested lettuce, is available in the fall.

Labor day may be the last day you wear white, but it is not the first day I get salad from Ralph’s Grocery.

So who is right?

Probably both of us. My friend is making a perfectly reasonable evidence-based decision. The implicated product has left the market. The agricultural supply chain is changing. There is no justification for treating every head of lettuce in America with that degree of suspicion.

Where we differ is simply how much residual uncertainty we are willing to tolerate. Medicine works like this all the time. Two physicians can look at exactly the same evidence, agree about the facts, and come to different diagnoses.

And since his father and I survived medical school together, I feel a certain obligation to keep the next generation healthy.

So when clan Rubin comes to the Central Coast of California for dinner, I’ll happily buy. I’ll even let him order the salad. Of course, the restaurant will have lettuce from a local supplier, it is the least I could do.

Now if he comes when the rains have returned, alas, lettuce entertain you.

The last thing I need to explain to my medical school classmate is that I sent his son and wife home with antibiotics instead of leftovers.

By the way - please subscribe to my friend, Dr. Rubin.

In our series of foods that built civilizations, we turn to the Americas before Europeans arrived.

Long before Europeans arrived, civilizations in the Americas had developed writing, calendars, monumental architecture, cities, trade networks, irrigation systems, pottery and sophisticated agriculture. Corn, or maize, fed the Maya, Inca, and Aztec worlds.

In what is now the American Southwest, Pueblo peoples built multi-story communities in the desert, while Mississippian societies built towns and enormous earthworks along the great river valleys.

It began with Corn, or Maze

It all began with a grass called Teosinte (pronounced “tA-O-‘sin-tE”). Teosinte does not look like corn today, but the DNA shows they are alike, and it was this grass that Native Americans 10,000 years ago began to engineer. In fact it wasn’t until a few years, 2005, ago that modern molecular geneticists discovered that this grass, Teosinte, was the father of corn. For years, people who study plants, botanists, assumed the evolutionary predecessor had long since become extinct. And while Teosinte is widely spread throughout Central America, it was not even considered in the same family as corn.

The original ear of Teosinte is 2-3 inches long with 5-12 kernels. The kernels were hard, and most human teeth would break trying to eat them. Teosinte is inedible for many people. Contrast Teosinte with modern corn with a cob. A cob is 12 inches long, with over 500 kernels. The coating on the kernel was selectively bred from the rock-hard protecting seed to, now, where corn has an easily chewable, paper thin, but still indigestible membrane. This was breeding at its finest.

Ten thousand years ago, there was no plant that anyone would recognize as corn. In fact, there was no corn. By 4500 years ago, corn was throughout all the Americas, with carbon dating of kernels in Arizona from over 3000 years ago, Canada 700 years ago. Corn allowed the Mayan people to go from a people who foraged, to a people who could stay and cultivate.

You can see from the photos how as time went on corn changed: both Teosinte and corn have the same number of chromosomes, they have the same genes that code for the same proteins. Teosinte and corn can be bred, because they are so close genetically. The difference between the grass, Teosinte, and modern corn is about a few genes. Corn didn’t “evolve” early Native Americans bred corn. Generation of corn after generation, they bred the crop that tasted better, chewed easier, and survived well.

In what is now El Salvador, some have said the Mayans discovered corn in the mountains of Chalatenango. Recently, a damn revealed a village in the area, which was one of the original four Lake Island villages of the Mayans. On this land, one can see the range of corn from the grass to the modern corn. If you hike there, you can see places where the Mayans would grow special crops, where they would harvest the Teosinte with the kernels they could eat, and over time they would breed it and cross breed it until they had an agricultural system based on this plant.

So sacred was corn, that they called it the “grain of the gods.” To this day, the people in Santa Ana, in western El Salvador, still plant little plots of primitive corn that they called something like “ulupiche”. This is not to eat, but simply to please the ancestors. It is from these Mayans that corn was selectively bred, or genetically engineered for better taste, different colors, and ability to withstand pests.

Corn moved quickly, finding its way to Mexico 7000 years ago, South America 6800 years ago, and to North America nearly 4000 years ago. Once Europeans arrived, corn spread even more rapidly through the rest of the world.

The First Tupperware Party

Edible Tupperware, that would bring new life into a product that seems to have gone the way of Department Stores and home parties hosted by your neighbor to get you to buy something.

The first squash probably used to carry water, food, grain. Vessels such as these were radioactive-dated nearly 11,000 years ago in Hondorus. These gourds were hard, the inside was bitter, but they were efficient to carry water, perhaps cook food, and store nick knacks (the first junk drawer was a squash). But get hungry enough, and even bitter food can be tasty (not Brussels sprouts).

The squash family (Cucurbitaceae) was domesticated about the same time. Those squash were related to zucchini, yellow summer squash, acorn squash, delicata, many pumpkins, pattypan, and crookneck squash. And as much as zucchini feels Italian, these squash were grown and consumed in Mexico thousands of years before Rome existed.

Multiple types of edible squash were cultivated in different geographic regions, and ultimately traded.

The Bean

The last of the sisters was the bean. Indigenous peoples domesticated several species of beans in the Americas. The most familiar is Phaseolus vulgaris, the ancestor to black beans, kidney beans, pinto beans and navy beans. But there wasn’t just one ancestor to all the beans.

Indigenous farmers domesticated at least five species of Phaseolus. Today, we know their descendants. Besides the black and pinto beans. There was a different region that grew lima beans, and yet others were the scarlet runners and tepary beans.

Europeans had been eating beans for thousands of years before Columbus. Original old world beans included fava beans, peas, lentils and chickpeas. From America, Europe obtained kidney beans, black beans, pinto beans., and cannellini beans. Yup, those favorite beans I put on Paella originally were groomed in America.

The Three Sisters

When the first European settlers arrived, they noted the agricultural habits of Iroquois with the three sisters. The corn provided the pole, the beans fixed nitrogen into the soil, and the squash provided a ground cover that kept away pests.

The works not only from the perspective of good land use, but also provides a complete protein. You do not have to eat corn and beans in the same bite to create a “complete protein.” But across a diet, their amino-acid profiles complement each other beautifully. Corn gives abundant energy and some protein. Beans add protein, particularly lysine. And, squash adds micronutrients through the seeds, fat and additional protein.

The agricultural system worked, and because it worked, it was copied throughout the Americas. The nutrition also worked, without a Registered Dietician telling them.

Civilizations

We have historic records of what happened to some civilizations, which gave us written languages, weights, measures, amazing architecture, Mayan calendars. The tragedy of the indigenous peoples of what is now North and South America has been well documented. We have no idea what we have lost.

Yet what remains is the food. What always seems to remain is the food, and now when you eat your tomato on the pizza, or have cannelloni beans on Paella, you are eating history from the major continents that all had their own civilizations whose contribution was great pizza, paella, and food.

Every one of the ancient civilizations has disappeared. Their food remains. We read about the Greeks eating whole grains and pulses. We tour Machu Picchu. We marvel at the Code of Hammurabi. We look at the terracotta soldiers guarding the tomb near Xi’an. All while enjoying the food that allowed them to settle and make a civilization.

Some monuments survived, but the food is still here. I still don’t know why we kept Brussels sprouts.

Yes, a cult. You can eat low carb, lose weight, and improve some blood work. But low carb has developed a movement, champions, villains, and apostates. I am the latter.

David Hume wrote that “a wise man, therefore, proportions his belief to the evidence.” The low-carb movement too often does the reverse. You know their model: sugar raises insulin, insulin stores fat, therefore sugar (or carbs that become glucose) makes you fat.

The model is simple (5th grade level), sounds sophisticated, easy to explain, and therefore popular.

My Adventures in Low Carb

I know because I followed it for a bit. Lost weight felt great, and when I gained weight, I could blame the 90 calories slice of bread instead of the 1800 calorie steak.

Then I did what no cult member should do. I read. Then got a formal education in nutrition when I trained for and obtained certification in Culinary Medicine. You know, those woke colleges with their education.

The low carb model doesn’t explain everything, so it is time to abandon it.

This terrifies the faithful, because when another diet succeeds, there is always an explanation for why it does not count. When epidemiology favors Mediterranean eating, epidemiology is hopelessly fake science.

When epidemiology favors low-carb, we adopt it again. Kind of like music is bad unless it is from our hymnal.

They go to lengths to justify their eating. The “lipid model” is outdated, because our low carb LDL is “large and fluffy.” Inflammation is the key, because god forbid keto makes us more vulnerable to heart attacks. Oh, and let’s abandon the red meat and cancer literature entirely.

On the internet, simplicity sells. Low-carb, calorie counting and plant-based eating dominate nutrition coaching, roughly in that order, and the easiest model is also the easiest to monetize.

Yes, low carb can sound erudite,. A gym bro can teach low-carb between sets, sell the workout, sell the meal plan and sell the supplement without once troubling the audience with uncertainty. Chiropractors love low carb because they sound like they know human physiology beyond a subluxation.

MD on Low Carb is the new hero

The internet audience awaits authority figures with degrees. If you have a MD, or Ph.D., and declare yourself keto, you now have an audience.

Look at the quality of the MD’s and you find a group of individuals far from the ivy towers, and often write things like “lies medical school taught me.” Who doesn’t like a good conspiracy from the voice of an “insider.” Even if the insider had lost their medical license.

Other Heros and Apostates

Gary Taubes is the darling of low carb. First, he is an excellent writer. But when the research went against carbohydrate-insulin claims, he kept finding ways to preserve the model. And now his writing to preserve what is, at best, science fiction.

Denise Minger became a star after critical evaluation of The China Study, through data analysis. Denise kept reading and encountered evidence to the contrary, such as Walter Kempner’s rice-and-fruit diet, that did not fit neatly into the low-carb model. She is now avoiding radical dietary “isms.”

Peter Attia evolved too and managed a softer landing in longevity medicine. He was the scientific advisor under Taub’s experiments. Apparently Peter read and agreed with the data, and Gary did not.

Have Degree - Welcome Friend

Craving authority figures in comes a new addition. Nick Norwitz. Truly impressive credentials, Oxford PhD and Harvard MD. Oddly, Dr Norwitz did not go on to residency, clinical practice or a research lab.

He is full on influencer, having stepped into a movement primed to celebrate those credentials.

Forks over Cholesterol Code

Now a group of the low carb elite have come up with a new film. The Cholesterol Code (available wherever you can buy it for a few bucks). It is remarkably similar to another move from the vegan group. Forks Over Knives.

I can imagine Dave Feldman (a low carb fanboy) and his friends saw Forks over Knives while drinking bone broth with his buddies, said, “Hey, we can do this.” And the Cholesterol Code was born.

Same format, testimonials, fighting the system, coming up with an answer. And using the fifth grade reading level appealed to a wide audience, who will feel as if they got an education. They didn’t. It was a movie, marked as a documentary. Fair note, I didn’t see the movie, I relied on my friend Simon Hill of The Proof podcast. Although oddly, I guessed the plot line with remarkable accuracy.

The danger is that their movie came after their penultimate paper was retracted. Alas, they say they retracted the paper, not the journal (yes, you resigned, you were not fired).

Make Heart Disease Healthy Again

There is always a danger to diet cults. Leave science behind, and sometimes you leave the importance of diet in health. In this case, forgetting that we had five times the number of heart deaths when we ate more butter. Keto and low carb want to return to the 1950’s.

To protect themselves from biology, they’ve identified a group: the lean mass hyper-responders. Their theory, that if you have a lean mass (not obese), and eat keto, and develop, predictably, very high LDL you will be immune from laws of biology. They wrote a paper about it, many people widely criticized it, and was retracted. Oddly, 20 percent of these chaps had accelerated atherosclerosis.

I like red meat

Some of my best friends are red meat: especially lamb. But I do limit it now. When I did Atkins, keto, then Paleo, I noticed my LDL rose. My arteries seemed to gain the fat that my belly lost. Not a great trade off for someone whose family tends to have heart attacks in their 50’s. Yes, I am on a statin.

Sustainability

The second issue with low carb is sustainability. I was so tired of bacon and eggs. I remember ordering it again, and thinking “what is wrong with yogurt and granola?” Okay, I know granola is dessert, but come on. To this day, the only way I can look at an egg is if I put hot sauce on it and have beans surrounding it.

Any diet works as long as one remains permanently faithful. Falling away is a sign of weakness, because apparently keto takes away all cravings and provides complete satiation. It doesn’t.

And of course, falling off low carb means you didn’t have willpower. You were not faithful, you didn’t pray enough.

The model isn’t perfect

The problem begins when partial truth becomes total explanation. The more nutrition literature I read, the less elegant the model became. The more you read about Ancel Keys, and read his works, the more you realize he was amazing.

The more you read about Mediterranean, DASH, and MIND (a diet of DASH and Mediterranean), the more you realize that Mediterranean (or DASH) is better and sustainable. The problem is it is more of a 12th grade reading level, so hard for social media types to grasp.

Faith vs Science

The model doesn’t work. The model is dangerous. The model is unsustainable. And cave men did not eat just animals. That is your holy trinity.

Low carb is a cult, or maybe a religion. It has its faithful, it has its cult leaders, and it will explain away anything that holds up a mirror.

But then if you get out and see the world, you will realize that people eat rice daily, are thin as a rail, relatively healthy, and have some of the longest lives on the planet.

Today we will make sense of the madness of rice.

Looking East

While people in the Mediterranean were mostly illiterate, in Asia they had developed writing, laws, philosophy, governments with elaborate testing for civil servants and gunpowder. In addition, the evidence shows they circumnavigated the oceans, found a larva that could make silk cloth, and developed fine porcelain. They did this while we were drawing crude paintings in caves. Some of our ancestors looked east, and even wrote about this “strange” but highly advanced civilization.

This was all possible by grass, we call rice.

Yangtze River Basin

Along the basin of the Yangtze river, and elsewhere, was an edible grass that ultimately became rice. You can imagine it was simply gathered until someone learned how to plant it.

Wild rice then would drop the edible seed as it matured. Replanting those which kept their seed on the plant longer meant the rice was easier to gather. Planting and gathering meant staying in one area, then with abundance, one had to build storage, and eventually a civilization around rice. Weights, measures, laws, buildings. Once people can exchange for rice, you develop professions, art, philosophy.

River basins have great soil, but the unpredictability of floods, so management of the river, canals, and all because of a simple grain.

I realize carnivores like to hunt large game as their primal food, but chasing mammals doesn’t lead to a civilization, or a brain beyond hunting. Also true today, although the hunting is reserved for which type of beef is better, and which store has better prices. Modern carnivore hunters prefer Costco beef, gyms, testosterone, and making fun of people who take statins. One needs a granary to build a civilization.

Rice Roads

The ability to grow rice led to the first trade routes as rice and the dishes that accompany it. From Bryani, to Pilaf and Risotto, to Paella Rice, made its way through trade routes around the world. And with each region, their dishes were accompanied with rice. Spice roads developed on the trails originally made by rice traders, and one might think the spices were there to make the rice even better.

Today, we all have our favorite rice dishes. Mine vary between sushi and paella. Every culture accepted rice and made their own dish.

Some regions even claim their rice came not from the east, but locally.

Rice and Medicine

The first peer reviewed diet for a chronic disease was the Rice and Fruit Diet, popularized by Walter Kempner out of Duke University. He developed the diet for malignant hypertension, the disease that President Roosevelt died of. This disease was almost uniformly fatal within six months from diagnosis. Kempner's developed this low-sodium diet of white rice and fruit. In trials it not only lowered blood pressure, but also improved survival.

In the 1960’s the diet became popular for weight loss, and throughout the United States, “Rice Houses” became a place for weight loss. Many Hollywood celebrities swore by them.

Vitamin B1 was arguably the first vitamin

Today, we know that thiamine deficiency leads to Beriberi, which was a common, and often fatal disease in the Japanese Navy. Kanehiro Takaki noticed sailors who preferred polished white rice, almost exclusively for food developed beriberi. while officers eating a more varied diet generally did not. Hanehro Takati is credited with saving the Navy by changing their diet. Polished rice removes the husk and endosperm of the rice which is the main source of fiber and nutrients.

Vitamin A is also unavailable in polished white rice. Vitamin A deficiency remains a preventable cause of childhood blindness. The World Health Organization estimates that 250,000 to 500,000 vitamin-A-deficient children become blind every year, and about half die within twelve months of losing their sight.

To overcome this, rice was genetically modified to produce a precursor of vitamin A. The rice takes on a deep yellow color, hence the name “golden rice.” Unfortunately, the objection to a genetically modified organism was brought to court and stopped golden rice from being used. While this sits in litigation, these children are still going blind and dying.

Why note use brown rice? White rice is shelf stable for years. Brown rice will quickly become rancid, so it has a limited shelf life.

How to Eat Rice without Losing Your Mind - and should you buy the $400 Rice Cooker?

When writing about rice, there is a lot of heat and not much light. Influencers warn about blood sugar levels, arsenic, while some claim brown rice is perfect and white rice is evil.

Others, in an attempt to sound like they know science, refrigerate rice overnight and claim it is now transformed into perfection. Let’s go through those claims, as well as the fancy rice cookers I see on the market.

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Nothing makes the anti-vaccine crowd angrier than news reports of deaths from a preventable disease. They are angry because in the starkest terms, a death happens that could have been prevented by vaccination. In this case measles. From the anti-vaccination playbook, they will argue the person didn’t die of measles, but of pneumonia, or medical mismanagement, anything but measles.

This week, the Center for Disease Control (CDC ) reported that two people in Lancaster County, Pennsylvania, had died with measles. The report was generated from the Pennsylvania Department of Health (DOH). They stated they reported the deaths to the CDC, after “the epidemiology team thoroughly investigated and verified both individuals tested positive for measles. The information was not reported to the public until the results of the epidemiological investigations were confirmed.”

One of the deaths was an infant, who died in childbirth. The coroner reported the infant died with a ruptured spleen. Because he didn’t say it was measles immediately, the anti-vaccine crowd roared that this was deliberate misinformation.

Spleens and Measles

How can a child die from a ruptured spleen if they have measles?

The expert for that would be Dr. Paul Offit, a pediatric infectious-disease physician at Children’s Hospital of Philadelphia, director of CHOP’s Vaccine Education Center, and the Maurice R. Hilleman Professor of Vaccinology. He stated that measles can involve lymphoid tissue and produce splenic enlargement. An enlarged spleen is more vulnerable to rupture, especially during childbirth. Measles doesn’t just kill from its infection. It can kill from pneumonia, neurologic damage, and apparently a ruptured spleen.

Aaron Siri (an anti-vaccination attorney) and Robert F. Kennedy Jr. seized on the Lancaster County coroner’s comments and immediately treated uncertainty as exoneration.

I reported the infant death when Pennsylvania announced it, and even discussed Dr Offit’s mechanism involving the spleen.

Kennedy and Siri then opened the anti-vaccine playbook. Accusing Governor Shapiro of playing politics with measles. The evidence for measles was properly reported to the CDC. They dismissed the DOH findings, and based their “case” on the lack of a corner, stating it was “measles.”

The coroner gave the proximate cause of death - a ruptured spleen. He did not provide the secondary issue, measles from an unvaccinated mother.

Our hearts go out to the mother, who, had she been vaccinated, would have passed that immunity through the placenta. That does not answer whether measles contributed to the conditions that led to that rupture.

That is the revealing part of this story. It is not simply a disagreement over one infant’s death. It is a difference in how we look at the world. In medicine, we look at evidence (lab tests, etc). But in the world of anti-vaccine lawyers, they use rhetoric. They have the answer they want, and will fight to prove it. In medicine, we know we can be wrong, but when we make a statement, we at least have laboratory tests for receipts.

The coroner emphasized that the spleen was not enlarged at autopsy. But once a spleen has ruptured and hemorrhaged, gross size after the event does not necessarily tell us what the organ was like beforehand. More importantly, Paul Offit was not inventing a novel explanation. He is a pediatric infectious-disease physician and vaccinologist who has seen measles-associated splenic involvement before.

What we have here is a clinical history of measles followed by splenic rupture, a pattern that is not unprecedented. What we do not have, at least publicly, is evidence of a traumatic birth that otherwise explains the rupture.

For medicine to blame measles, it requires virology, pathology, epidemiology and a causal chain.

For lawyers to exonerate measles requires a lawyer, a microphone and a hunch.

How Fermentation Built Civilization

We were selecting a microbiome without knowing it. Bacteria, yeast and molds. Feed the ones that worked, keep the conditions they liked, and do it again.

Your grandmother may have kept the bowl that made better bread. She saved some of yesterday’s dough to start tomorrow’s. Others learned that milk mixed with a bit of salt and kept in a goat’s stomach became yogurt or cheese instead of something that had to be thrown away.

In Asia, they salted cabbage, put it into a jar, and buried it, and it allowed them to survive the winter. And perhaps in what is modern day Iran, they learned that when they crushed grapes, stored them in special containers, they made wine. And in Mesopotamia (now Iraq), ancient Sumerians left written recipes of barley brewing dating back over 5,000 years that was probably beer.

There were no microscopes, or bacterial cultures. We didn’t know that yeast metabolized sugar into alcohol and carbon dioxide, or that lactic-acid bacteria changed the chemistry of cabbage and milk.

But what they didn’t see was a colony of bacteria, yeast, and mold, creating environments in which organisms thrived, and transformed foods into something more edible and even stable for preservation.

Those microorganisms gave us bread, beer, wine, cheese, kimchi, vinegar and eventually penicillin.

What Did Ancient Beer Taste Like?

We are fascinated by what people before us ate and drank.

From the Midas Tomb in ancient Phrygia, now Turkey, they discovered that people had made a fermented drink from barley, grapes and honey. It was probably beer, wine and mead in the same cup.

Based on a chemical analysis of these vessels, Dogfish Head Brewery used modern yeast to make a beer called Midas Touch. But I wished we could have cultured the yeast and bacteria from one of those vessels?

As much effort as Dogfish used to reproduce the ingredients on the basis of chemical analysis, the beer is not the same. The barley, grapes, and even the water are different. Some of those grape varieties may not even exist anymore. The temperature and storage conditions we are guessing at best. And the microbes undoubtedly changed over the three thousand years while waiting to resume their shift.

Dogfish Head analyzed ingredients from pottery in China. That 9000 year old pottery once held a fermented beverage made from rice, honey and fruit. This was being drunk years before the Great Wall was built. Which makes me think, the Great Wall was the velvet rope, seeing if your name was on the list for the rice wine party.

But consider it like this: even pizza lovers from New York will tell you that without the NY water, or coal fired oven, you cannot make a true NY pizza.

The yeast we use now are descendants of those used by our ancestors. But the microbiome changes, they reproduce, mutate, mix with other organisms from the flour, the grain, the fruit, the hands and the environment. Yeast today are more different from their ancestors than we are from ours.

But we are never drinking the exact same beer. We are drinking what became of that ancient experiment. Just like you never step in the same river twice.

Then We Finally Saw Them

Then came Antonie van Leeuwenhoek, who developed the first microscope. He was not a physician. He was not a professor of microbiology. There was no microbiology. He was a fabric salesman with an obsession for making good lenses. When he put those lenses together, he saw a world no one knew existed. He pointed it at everything, water, tooth scrapings and eventually beer. He saw tiny living things moving around in a world humans had never seen. Leeuwenhoek called them animalcules, little animals. He even looked under his microscope and wine and beer.

France Has a Wine Problem

By the middle of the nineteenth century, France had been through revolution, empire, monarchy, another revolution, republic, and empire again. The country had plenty of political problems. But there was one problem that could unite almost any Frenchman. They didn’t know why sometimes their wine would spoil. Yes, there is the occasional bottle that is “corked” and that is an inconvenience. But losing the entire batch is a disaster.

Louis Pasteura chemist was commissioned to help solve this problem. Leeuwenhoek could see them. Pasteur wanted to know what the hell they were doing. They were doing the chemistry. The yeast was associated with alcoholic fermentation. Other organisms were associated with lactic fermentation. Different microorganisms produced different outcomes. And suddenly all those odd instructions from your grandmother made sense. Use this bowl. Save some of that dough. Keep a little from the good batch. Don’t use that barrel again.

Pasteur found that gently heating wine could prevent some of these microbial problems without boiling or ruining the wine. Which gives us one of my favorite historical details: pasteurization was developed for wine before it was used for milk. The raw-milk crowd should put that on the T-shirt.

My Great-Great-Uncle Changed Surgery

James Young Simpson — my grandfather’s uncle — helped transform surgery with chloroform anesthesia.

Anesthesia meant surgeons could finally operate without four people holding the patient down. Unfortunately, patients could survive the operation and still die several days later from infection.

That is where Joseph Lister enters the story.

Lister read Pasteur’s work on fermentation and putrefaction, and wondered if microorganisms could spoil wine, perhaps they could also spoil wounds.

Fermenting grapes can be wonderful. Fermenting wounds, not so much

Lister began using carbolic acid to treat wounds, instruments and surgical infection rates fell. That became the start of modern, safe surgical technique.

Pasteur was worried about spoiled wine. Lister was worried about dead patients.

In your kitchen, you practice microbiology.

Fermented Foods, Probiotics, Prebiotics and Keeping Your Gut Healthy

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Salt helped preserve food, provision armies, build economies, and prevent iodine deficiency. Then we figured out how to put it everywhere. If you like this, please find FORK U wherever you download podcasts.

Roman soldiers were paid in salt.

You may have heard that Roman Legionairs were partially paid in salt. It’s supposedly where we get the word salary, and the saying that someone is “worth his salt.”

There’s a problem with that wonderful story, is it is a myth.

The Romans had money.

If you ever collected coines, getting a Roman coin isn’t very expensive. The reason is Romans minted enormous quantities of coins. Roman coins are found throughout what was once the Empire, particularly around military installations such as the forts along Hadrian’s Wall. Because, Roman soldiers were paid in money, not salt

I’d love the thought of some Roman quartermaster standing beside the imperial salt lick, handing each legionary his monthly scoop. It didn’t happen.

Here is some truth that underlies the legend. The Latin word for salt is sal. Rome had the Via Salaria aka the Salt Road. The Latin salarium, from which our word salary ultimately derives, was associated with salt.

But the fact that generations found the story believable tells us that salt really was valuable.

Before Rome, There Was the Salt Lick

Humans have always sought salt. We can argue that the evolutionary (teleological) reason for the salt taste bud’s redeeming value.

Forgive me, chemistry nerds, but I will use salt and sodium interchangeably here. To be precise, sodium is a positively charged cation. I remind myself of this, because my son is taking 10th-grade chemistry, and I have to keep up. Combine sodium with the negatively charged chloride anion, and you get sodium chloride—table salt.

Sodium is essential for human physiology. Sodium is involved in countless processes in the body from nerve transmission to muscle function. If your sodium level gets too low, like if you over drink water, you can get brain swelling and die. If your sodium level gets too high, as can happen with some brain injuries or other pathologic processes, you will also die. Hence, our bodies, mostly kidneys, regulate blood sodium levels tightly. Too much and too little is too bad.

Animals also seek salt. Elephants visit mineral deposits, they never forget. Hoofed animals gather at salt licks. Some mineral licks have been used by generations of animals. You can imagine the conversation:
”Yes, my grandfather brought me to this same salt lick when I was just a baby chimp.”

But taste alone doesn’t explain why salt became valuable enough to shape civilizations. Salt had another trick.

Salt Gave Us Time

Imagine killing a large animal without refrigeration. I can picture a woman at the mouth of a cave saying, “You can’t bring that in here.” Turns out, that was one of the cartoons made for a book I wrote years ago.

Imagine you just killed this large beast, knowing you can only eat so much before it spoils. Bacteria don’t particularly care that you were hoping to save some of that animal for February.

Early man developed several preservation solutions; We dried food, smoked food, fermented food, and we salted it.

Salt helps to draw the water out of tissues, making it difficult for bacteria to take hold. It also helps dry the chicken skin for when you bake a chicken.

Cheese is one of our great food-preservation stories, we discussed this previously. Fresh milk is highly perishable. Fermentation, removal of whey, reduction of moisture and the use of salt transform it into concentrated nutrition that, depending upon the cheese, can last for months or even years.

The Pharaoh Wasn’t Exactly Salted

The Egyptians understood preservation extraordinarily well. Not only did They salt and dry foods, including fish, but they also used sodium salts to preserve something considerably more valuable to them: their dead.

Egyptian mummification employed natron. Natron is sodium rich soil that comes from salty lake beds once some of the water evaporated. Much like putting Kosher salt on your chicken skin and drying it out before cooking, these sodium solutions dried out the bodies.

The Pharaoh wasn’t technically salted like a cod. But sodium chemistry helped give us the mummy, or the daddy.

At the ancient Chehrabad salt mine in modern Iran, archaeologists have recovered well preserved bodies of miners killed there centuries ago. Salt preserved them quite well

Then Governments Discovered Salt

If almost everyone needs and wants something, eventually a government will discover it can tax it. Never fails.

Salt taxes became major source of state revenue. Ancient Chinese governments were some of the first to impose a salt tax. France eventually imposed the famously unpopular gabelle. That famous salt tax helping lead to the French Revolution.

And centuries later, British control and taxation of salt in India provided Gandhi with one of the most powerful symbols of the independence movement: the Salt March.

Refrigeration Changed the Equation

Refrigeration removed one of reasons humans needed large quantities of salt. Refrigeration allowed food to be transported, salt free.

Meat could remain cold, Fish could be frozen. Milk refrigerated. Food could be shipped, via railroads, hundreds of miles without being salted.

Technology changed, our taste buds didn’t.

The era of ultra processed food has its foundation in salt. Salt not only provides an inexpensive way to preserve food, it also tickles the tongue and makes any snack delicious.

We went from spending thousands of years trying to find enough salt to where sodium excess, from food, has become a major public health problem.

Excess sodium in the diet, contributes to heart disease, strokes, and cancer. And in the era of processed foods, excess salt is a problem.

And much of that sodium isn’t coming from somebody standing over dinner with a salt shaker. The majority of the salt in our diet comes from processed food. Depending upon the country and diet, major sources include instant noodles, canned soups, frozen meals, and even restaurant food.

The Time We Put Something Useful Into Salt

Imagine the early pioneers coming to the Middle West and seeing the rich black soil, often referred to as black gold. This soil grew amazing vegetables. What they didn’t know was that this soil was deficient in iodine. Iodine deficiency led to goiter, and that part of the middle west became known as the goiter belt.

Goiters are large abnormal growths of the thyroid gland, in the neck. These goiters would grow to large sizes, because the thyroid was trying to compensate for a lack of iodine. Goiters became so large they interfered with swallowing and even breathing. The only solution was to operate on them.

Goiters became a major problem, and operating on them was fraught with danger. One clinic became known for safe and careful thyroid surgery, The Mayo Clinic.

To fix this, one only needs to add a little iodine to the diet. At first public health officials gave iodine as a supplement, and iodine worked. What didn't work was getting everybody to take it. Then the brilliant idea of putting iodine into salt led to iodized salt.

On May 1, 1924, iodized salt appeared on grocery shelves in Michigan. Morton introduced iodized salt nationally later that year. The intervention was voluntary in the United States, inexpensive and effective. So much so that one no longer sees those large goiters except in medical textbooks or third world countries.

Which makes our modern fascination with expensive “mineral salts” particularly amusing.

Your Celtic Salt Is Not a Multivitamin

Maldon flakes taste great on a tomato, providing unique texture. Different salts have different crystal structures, moisture and cooking properties. I use Kosher salt to season meats before they are cooked.

Celtic salt and Himalayan salt are frequently promoted because they contain magnesium, calcium, potassium and dozens of other trace minerals. The operative word is trace. Pink salt often touted as having magnesium, but to get 80 mg of magnesium, you would need to consume about 3.4 cups of salt.

Some influencers sell you their version of salt, usually as an electrolyte solution, touting the trace minerals of the pink salt. They don’t tell you a better solution is to eat an ounce of almonds . One ounce provides about 80 milligrams of magnesium along with fiber, protein and unsaturated fat.

There is an additional irony here. Many fashionable specialty salts aren’t iodized. The inexpensive table salt with iodine was deliberately added to fix a nutrition problem

From Salt Tablets to Gatorade

Of course, there are circumstances when people genuinely lose substantial amounts of sodium. Being ill, like vomiting or severe diarrhea, is the most common way people need salt.

Someone working for hours in extreme heat, fighting a wildfire, running a marathon or playing football in August can lose considerable amounts of both water and electrolytes through sweat. For years, one response was the salt tablet. The thinking was simple, you sweat out salt, Therefore, replace salt.

In 1965, University of Florida nephrologist Robert Cade and his colleagues developed a drink containing water, salts and sugars to replace what the college football players were losing. That became Gatorade.

We’ve discussed electrolyte solutions before, and how the intestine given both sugar and salt improve the absorption of not only the electrolytes but also the water. When someone tries to sell you “no sugar” electrolyte solution, they are going backwards in time to the old salt tablet.

Most people do not need replacement electrolytes (of which the major one is salt) unless they are sick. An hour or two in the gym is not going to cause problems that simple water won’t fix.

Himalayan Salt Is Still Salt

Himalayan pink salt has some brilliant branding.

The name conjures up pristine crystals gathered from some inaccessible Himalayan mountaintop in time to refill your electrolyte bottle.

In reality, Himalayan pink salt is mined in Pakistan.

Its beautiful pink appearance comes from trace mineral compounds, including iron as well as the algae.

There is no health benefit to pink salt, or sea salt, or any salt. Chemically, salt is 99 percent sodium chloride. Your kidneys don’t know that the package has a mountain on it.

Again, buy it because you like it. Not because you think pink sodium chloride has become a different nutrient from white sodium chloride.

Blood Pressure Matters

The effect of excess sodium is increased blood pressure. We have lots of data showing that reducing sodium intake leads to lower blood pressure. The health benefits are remarkable: lowering systolic blood pressure (the top number) by two points can decrease your risk of a heart attack by ten percent in ten years, and stroke by seven percent in ten years.

One of my favorite diets is the DASH (Dietary Approach to Stop Hypertension) diet. They fed people a diet limiting salt to 2300 mg per day, and increasing fruits and vegetables. This led to a drop in blood pressure equal to one blood pressure pill. I’ve had a FORK U episode about DASH previously, episode 46.

Your Stomach Also Gets a Vote

The discussion about sodium is usually reduced to hypertension, but that’s not the only reason to care about high salt intake.

High dietary sodium is also associated with gastric cancer. WHO explicitly includes gastric cancer associated with high sodium consumption.

That doesn’t mean salting your scrambled eggs causes cancer. Excess salt in ultraprocessed food leads to adverse outcomes.

So Should I Throw Away My Salt Shaker?

No.

If you’ve followed my work for any length of time, you know where this is going. Cook food. Vegetables , beans and fish taste better when it’s seasoned. And by seasoning, we mean adding salt to the food.

The advantage of cooking is that you use other ingredients for flavor, beside salt. Such as garlic, herbs, spices, lemon and vinegar.

We Solved the Salt Problem

The history of salt is really the history of solving one problem and getting another. Our ancestors sought mineral deposits and saline springs because salt tasted good. Then we discovered salt preserves food.

Salt allowed fish and meat to travel. It helped turn milk into cheese. It provisioned armies and ships. People mined it. Governments controlled it. Governments taxed it. Gandhi marched over it.

We even fortified salt to deliver iodine and prevent a genuine deficiency disease.

And now, having reached the point in human history when the average American consumes too much sodium. Then to top it off, we’ve created an industry devoted to convincing people that their water bottle needs more of it through electrolytes. I wonder if they call it “electrolytes” to avoid pointing out they are loading you with sodium?

Sometimes you need electrolytes. Sometimes you need sodium. Most of the time, you need water.

Just don’t confuse culinary pleasure with nutritional magic. For the magnesium, eat almonds.

A friend of mine showed me the designs for the stone walls of the Atria Health Institute, part of their nearly 30,000 square foot office. The Atria Center opened their Beverly Hills branch, and was founded by entrepreneur Alan Tisch. This was not a stone for the wall, the entire wall was one solid piece of stone, cut carefully by a computer to be part of the office for people paying tens of thousands of dollars a year to get tested, prodded and prescribed the latest luxury packaging of concierge-preventive-longevity medicine.

This business is booming, I thought, as a boomer. In an economy plunging for most people, the wealthy flock to try to touch the immortal. All I could think of is that we have these insufferable individuals around for longer. Atria’s clients are paying tens of thousands of dollars for services available from a good primary care physician, or what that physician can refer you for.

If someone is offering to make you live past 100 and they are 40, you should probably dismiss them. Instead of trying to live to 150, focus on what we actually know: how to function well for as long as possible.

Or, as the old line goes, “I would have taken better care of myself if I knew I was going to live this long.”

Taking Longevity Advice from People younger than I am

The world is filled with longevity experts, like Bryan Johnson. Trying to find ways to sell you his protocol. He was born 20 years after I was. Sometimes he gets the blood products from his son to find some Draculan way to boost his longevity.

He will sell you his Blueprint Longevity Protein and other supplements. Johnson takes some 50 to 100 a day, and can be yours for $449 per month (the Big Stack Box). Of course, there are other (less expensive) options. He even sells olive oil - his brand of course.

I’m 69, and I’m doing just fine

Oddly, I’m doing fine at 69 years old. For the past few years, I have seen what happens when people of my age don’t take simple steps to take care of themselves. You don’t need to spend $20,000 to $70,000 a year to implement these steps and improve your life and health span. Human lifespan has increased, but what I am more interested in is extending my period of healthy functioning.

People in the luxury business of longevity target upper middle class individuals. They convince them to buy the “regenerative farm olive oil” that doesn’t use pesticides, costing many times more than standard olive oil. They make their money targeting high-income people with solutions inaccessible to most Americans. Making these solutions seem “exclusive.” The solutions are not exclusive. Even with the “inexpensive” $20,000-a-year package, most of what matters for your health span is available through a good primary care physician and the specialists they refer you to.

A Good Primary Care Physician

When I renewed my Crestor, my doctor from the UCLA system spent ten minutes, of which nine filled out information on the computer. The rest was a quick look at me, stating, “How are you doing?” and then “Probably time for a colonoscopy.”

In contrast, my primary care doctor in Alaska, now retired, closed his laptop after looking at my labs and said, “So, Terry, what is going on in your life?”

This is the reason many people who can afford it flock to places like Atria. Time with a doctor, time to be seen, heard and probed with the latest gadget to feel as if they are getting the best. You don’t need to spend that money to get quality care and a quality primary care physician.

Think of healthcare in two systems: one is the preventive, primary care side that takes care of your medications, screens you for diseases (breast cancer, colon cancer, heart disease, etc). And directs you to be as self sufficient as possible for your health.

The other is the hospital system. This is for when things fall apart. You need surgery, whether to remove a gallbladder, repair your aorta or replace your knee. Your job is to stay out of that system, but if you must interact with it you want to find the best in the business.

I chose UCLA for the second reason. Perhaps my years in surgery led me to worry about the worst that might happen, and which hospital system do I want to take care of that issue. UCLA is a good answer, while their primary care doctor is marginal.

In contrast, my producer (20 years my junior) has her care from the Kaiser network, where she loves her primary care doctor, if not occasionally constrained by a system that demands she stay within it. Her job is to stay out of the hospital system and have a good PCP (primary care physician) to do that.

I travel a lot, so while I appreciate the Kaiser system, I want flexibility wherever I go. Kaiser, if you need their tertiary care, has excellent physicians and facilities.

The primary care physician can assist you with daily living. For most of your care, this is who you need to interact with, and finding one who will know you, take their time with you, and keep you out of a system or prevent problems from turning into emergencies is what you are looking for. If they are associated with a system you like, that is great. That is not a requirement, however.

When my friend needed a knee replacement, I knew who to recommend. The surgeon had great outcomes, but his personality is one you would never invite into a social circle because he is boring. Most important, he is an excellent technician, with a great support staff. You want a primary care doctor who knows their system, or you want to go to a system so uniformly excellent that it is unlikely to have a bad choice.

Stress Comes From People

I spent a stressful career as a surgeon, and I loved the operations, the trauma call, and the technical aspect of surgery. What bothered me were those things I could not control: always involving people, because as my late brother told me, no matter what you do, the stress comes not from your job, but from the people you work with. Surgeons are, for the most part, assholes. Hospital administrators took our playbook and perfected it. Surgeons are aggressive; administrators are passive-aggressive. We tell you exactly what we think. They nod thoughtfully, tell you they hear your concerns, and quietly wonder whether your suggestion will affect their seven-figure bonus. I say this, telling you that one of my best friends is a surgeon. Unfortunately, I fall into the surgeon’s personality.

My brother was a pipe fitter. His greatest stress was people, and he imparted on me that wisdom that no matter what job you have, your stress will come from people. Those who don’t pull their weight, those who are officious, those who think being an “inspector” gives them a license to harass with impunity.

I live in a community where my friends retired early to avoid the stress of the job, and yet the stress they have is from some of the people they have to deal with. Be that the HOA “Karen” or the “Chads”, the city government officials who need to put in a stop sign where there have been five accidents in the last year, the neighbor with the dog who barks too loud, or the overcompensating friend who talks over everyone and knows everything.

Yes, you can love your job, and be around people that are stressful. My job was stressful, but it was never the blood I saw that bothered me. It was the blood I heard.

There is no supplement that will make those people change. There is no meditation that will give you “serenity now.” Change jobs, careers, locations, and all that is fine - expect the people around you will have their own Chads and Karens.

Take Care of Yourself - Don’t Smoke, or if you do, stop.

For all my brother’s wisdom, he smoked, since he was 14 years old. The happiest of kids, the most popular guy who everyone loved. At his funeral, people who knew him as a kid paid their respects. He was a good man who everyone loved.

But his life was cut short - not because he didn’t take the BJ supplements, but because his lungs, having survived Hodgkins and being irradiated when he was younger, found some cells that became malignant, and by the time they were discovered, had metastasized throughout his body.

I stopped working in hospitals several years ago, and now do wound care at nursing homes, helping those with wounds, ulcers, sores get them better. I see people who are my age or younger, that didn’t do well. They smoked.

When I meet someone older than I am, who is in good health, I ask if they smoke, but I know they don’t. Some had quit, most never started. I don’t see active smokers in their 80’s and 90’s - and I am sure there are some, but they are rare.

One of my favorite patients died last week. I’d known him for several years. He had suffered a devastating stroke years ago, and couldn’t speak but a few, but could understand, and was one of those people who always smiled, always remembered you, and made you feel better. He continued to smoke. Several times a year, I would ask if he would quit, and he would laugh and shake his head. He indicated that his lot in life now, unable to use half his body, unable to express himself well, was just relegated to people like me coming by and talking to him, and he was waiting to die. He got his wish, sadly he was confined to his bed the last few weeks, and I am sure the one thing he wished he could do was go outside and have a cigarette. Tortured by your habit.

Mind your blood pressure

This is an easy one. You won’t feel your blood pressure, so you have to measure it. If your blood pressure is high, get it under control. You think your blood pressure is fine and you only have “white coat syndrome.” You don’t you have high blood pressure.

Practical Advice From Someone Who Isn’t in Their 40s

How to Find a Good Doctor, Avoid Chad and Karen, Stop Smoking, and Check Your Damn Blood Pressure

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Coffee was once thought to be bad for the heart, and then we tested it. It turns out that coffee is good for your health. So much so that some elevated coffee “super food” status. Of course, that means the shirtless salesmen of supplements and scams will want to sell you some extract or put butter in the cup. Yes, seriously, if you wanted saturated fat in your coffee, use proper cream. But coffee is indeed good for many parts of you. But historically, coffee gave us not only a beverage to keep us up late, but also coffee houses.

In my podcast series, FORK U, I’ve had episodes about how bread gave civilization calories, beans gave it protein, olive oil gave it light. In the latest episode, coffee, the beverage that gave civilization somewhere to meet, and a reason/mechanism to stay awake.

Before the Coffeehouse: The Happy Goats

Legend has it that a goat herder named Kaldi noticed when his goats ate the coffee berries, the goats danced. Kaldi tried the coffee berry, and he felt more alert. It is a nice story.

Coffee originated somewhere in the Middle East, some say Ethiopia. My mom would say it began in Norway, then spread to Yemen, and perfected in the Ottoman empire. It was not perfected at Starbucks. Becoming not just a drink to keep awake for nighttime devotions, but providing a beverage around which people would gather and chat. Coffee became so important that a potential bride would have to make a satisfactory cup for her future in-laws. If she could make a good cup of coffee, the wedding would take place. Some traditions are worth bringing back.

The Coffee House

Want to foment a revolution - start a coffee house. No, not the type with WIFI where everyone sits in their cubby and watches a computer. But one where people talk, and not to mispronounce your name when they call your cup of “black coffee.”

Coffee houses began in the Middle East, becoming public gatherings. On the occasion when ideas counter to governments were discussed. , various sultans, kings, and officials tried to ban them. Clearly, it didn’t work.

While many scholars no longer use the term “dark ages,” I define it as the western world before coffee. Once coffee came, we had a renaissance. Coincidence?

My favorite were the penny coffee houses, which started in Oxford and London. People would pay a penny, drink coffee, read newspapers and talk politics. They were sometimes called Penny Universities. Today, those university coffee houses exist, but we would call them 100,000 dollar coffee houses.

Before commercial real estate, people gathered in coffee houses to discuss everything from weather to shipping lanes. Edward Lloyd started one in 1686, near the docks, and provided information about ships, weather, pirates. Ultimately, this information became important for insuring ships, and that is where Lloyds of London came. Not tea, but coffee.

The Scandinavian love of coffee comes from when Sweden lost to Peter the Great and their King Charles XII sought refuge in the Ottoman empire. He fell in love with their coffee. Returning to Sweden, he brought coffee, some say meatballs, and the Swedish word Fika - or the world’s first sanctioned coffee breaks. Have coffee, have a cardamon roll, and talk to family and friends.

Today many a first date are at a coffee shop, replacing dinner or a bar. Some rebelled at such an idea, but wouldn’t you want to know what your “potential” partner thinks when their brain is fully wired? After all, if you cannot discuss Hume with your first date, there is no reason for a second. If your date puts everything in the coffee, making it a functional desert, you know it is time to find someone with serious taste buds.

The Science of Coffee

The first twin experiment was invoked by King Gustav III when he took a set of twins, condemned to death, allowing them to live if they would take part in his study. One would drink three pots of coffee a day, and one would drink three cups of tea a day and see who would live. They outlived the two doctors, and King Gustav. Yes, the tea drinker died first. Gustav, assassinated before the result was clear, felt coffee consumption was bad.

Most of us think about coffee and waking up or staying awake.

Wake Up Brain

The brain uses energy in the form of ATP, as the ATP (adenosine triphosphate) is metabolized, one component left is adenosine. As the day drags on, and you metabolize more ATP, your brain level of adenosine rises. That adenosine doesn’t just float around your brain fluid, it binds to an adenosine receptor. The more adenosine binds to the receptor, the more the brain slows down a bit, and then you get tired. By the end of a 16 hour day, your receptors are saturated and you fall asleep.

Drink coffee, the caffeine crosses the blood brain barrier and will also bind to those adenosine receptors. But instead of slowing down the brain, it stimulates things. Think of the adenosine receptor like a light switch (brain sleepy switch), caffeine turns the brain on, adenosine turns it sleepy.

Caffeine does a few other things, causes a burst of activity from your adrenal glands, and enhances dopamine function. So when you have coffee and a sweet, you get a bigger hit (and don’t forget the date at the coffee shop).

The adenosine is still around, and once the caffeine is metabolized, you will fall asleep. Some call this a caffeine crash. You still have to pay the piper. Caffeine metabolism varies greatly between people based on how much coffee they drink, drugs they take, smoking, and many other factors. My dad would wake up at 2 am, drink a cup of coffee, because it helped him sleep. I drink coffee after 2 in the afternoon, and I have lots of trouble falling asleep hours later.

Which brings us to the most important practical point: caffeine cannot replace sleep. If you slept four hours last night, a cup of Joe may convince your brain that things are going well for a while. But you still need your sleep.

While drinking that first morning cup, caffeine starts to cross into your brain, temporarily assisting your wake up. Which brings us to my favorite myth.

Coffee, Cortisol and the 90-Minute Myth

Some on social media say one should put off drinking coffee for 90 minutes, because it will increase your cortisol level. First, I cannot imagine anyone telling me not to drink coffee for the first 90 minutes of the day. If the world had adopted this, we would have already had WW3.

There is no study anywhere showing that waiting 90 minutes makes it healthier, or improves health, alertness, sleep, cortisol dynamics or long-term outcomes.

This is classic - we have a mechanism and we will guess the outcome. Happens a lot.

The other classic - we know coffee can increase heart rate and increase blood pressure. So for years cardiologists would tell their patients to avoid coffee. Then we actually studied patients who drank coffee. The first batch confirmed coffee was bad. Then we separated out those who smoked cigarettes, and the coffee drinkers actually did better than non-coffee drinkers.

Many social media types find a mechanism, make a click bait headline, and try to make people suffer (they clearly are not coffee drinkers, so I don’t trust them).

More Health Benefits of Coffee

Coffee is more than brown water with caffeine. Those berries contain a complex mix of anti-oxidants, polyphenols, and other words that when you say them will make you feel important.

Among other benefits, lower risk of liver failure and cirrhosis. One of my favorite hepatologists (a doctor who takes care of patients with liver problems) recommends her patients drink at least three cups of coffee a day (yes, Dr. Richards, your patient’s love you for it). She isn’t alone, coffee drinkers have less problems with their liver.

And fatty liver is a major problem in America, not with alcohol, although that was the primary cause, but because of the rise of metabolic disease from obesity. Fatty liver disease is now the most common reason for liver transplants. Coffee, while not an answer, is certainly an adjunct.

One to four cups of coffee is not associated with the cardiovascular catastrophe once feared, and is indeed associated with favorable outcomes. Still, there is always the warning to speak to your cardiologist before embarking on a new habit.

Type 2 diabetes has better outcomes in coffee drinkers, even among those who drink decaf - proving coffee is more than brown water with caffeine.

So what coffee should you actually drink—and does the way you make it matter?

Paper filtration, as it turns out, is a key to one of the health benefits of coffee. As is how the coffee is made, the type of coffee you buy, and how much you drink. Yes, the coffee apparatus matters. And there are two ingredients in coffee that will raise your cholesterol, but they can be mediated.

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Earlier this week, I asked a broad substack audience if they wanted to know if their primary care doctor was not up to date with COVID. 87% said they wanted to know, 13% said no. Yes, we want to know if our doctor might be a vector for COVID infection.

Some hospitals and clinics are asking whether healthcare workers who have direct contact with patients should continue receiving the annual updated COVID vaccine. It is a fair question.

Unlike the early days of the pandemic, we now have six years of experience and data. We know that COVID vaccines are not perfect, but do they reduce risk enough to justify requiring them for healthcare workers who care for vulnerable patients?

Wastewater surveillance is currently showing increasing circulation of SARS-CoV-2 in many communities. Emergency departments around the country are seeing an uptick in patients with COVID infections. The virus continues to circulate and evolve.

COVID and Influenza

That the last COVID surges have been relatively mild does not mean the next surge will be. That being said, COVID is three times more likely to cause death than influenza, especially among the many vulnerable patients we care for, from the elderly to those whose health is compromised. If we believe annual influenza vaccination is worthwhile for those caring for vulnerable patients, it is reasonable to ask whether we should apply that same standard to a virus that continues to cause substantially more severe disease.

Like influenza, COVID has settled into a seasonal pattern, and some years COVID will have far more hospitalizations and deaths. We cannot predict whether the next variant will be milder or more severe, only that the virus will continue to mutate.

Semmelweis to Lister Reducing Risk

Nearly two hundred years ago, Ignaz Semmelweis noticed that mothers delivering babies in the physicians’ maternity ward died at rates approaching 10 to 18 percent. In the neighboring ward staffed by midwives, mortality was only 2 to 3 percent. “Why?” he wondered.

It came down to hand washing, especially when the physician went from the autopsy room to the delivery room. Semmelweis had data, not only from his hospital, but also from two other colleagues. Despite the data, Semmelweis’s interventions were dismissed. Semmelweis was ultimately proved correct, but sadly years after he died.

Joseph Lister studied the use of antiseptics in the operating theater to reduce surgical wound infections. The spray of carbolic acid in the operating theater was a bit noxious to the staff. In spite of good and careful data, there were many who pushed back on his data.

Early risk reductions were dramatic. Lister showing a reduction of death after amputations from 50% down to 15%. But as further changes occur, the reductions in morbidity and mortality would show some diminishing return.

Incremental Changes

When you look at drawings of Lister operating, I have to smile. He was wearing his suit and tie, no gloves, no mask. You can still see the machine used to spray carbolic acid into the operating theater. The operating room bears little resemblance to what we know today. Yet beside him sits the one piece of equipment that changed surgery forever: the carbolic acid spray apparatus.

It was far from perfect.

The spray irritated everyone’s eyes and lungs. It was messy. Many surgeons thought it was unnecessary. But as the evidence accumulated, Lister’s methods spread throughout Britain, Europe, and eventually the world. The spray apparatus became so iconic that it can still be found in surgical museums from Edinburgh to Ohio.

One of Lister’s greatest students was William Macewen. Macewen realized that instead of killing bacteria after they entered the wound, perhaps they should never enter the operating room. He shifted surgery from antisepsis, killing bacteria with carbolic acid, to asepsis, keeping bacteria out to begin with.

Instruments were first sterilized by boiling, but Macewen soon introduced steam sterilization. Surgeons had boiled instruments in the Roman Republic, and this fact was lost from Rome’s fall until Macewen’s reintroduction.

He championed one-piece steel instruments, replacing the wooden-handled instruments that harbored bacteria in tiny cracks and crevices. Not long ago, we discovered a few wooden-handled surgical instruments tucked away in a hospital storage room. They hadn’t been used in generations, but they were a reminder of how far surgery had come.

The operating room itself was changing. Surgeons began wearing dedicated operating room clothing, replacing the business suit with the first version of scrubs, and they were all white. For years, surgeons referred to them simply as “the whites.” FIGS eventually arrived and proved that operating room attire could have some style without bringing back the bacteria.

Macewen also championed the ritual every surgeon knows well: the surgical scrub. Long before alcohol hand rubs and modern antiseptic solutions, surgeons spent ten minutes meticulously cleaning their hands before every operation.

The operating room was becoming cleaner by design, rather than by rescue. As aseptic technique matured, the famous carbolic acid spray apparatus disappeared from operating rooms, replaced by a philosophy that prevented contamination, rather than trying to disinfect it after the fact.

In America, William Halstead introduced gloves to the operating room, not to decrease infection. He did it to protect his chief nurse, who ultimately became his wife (surgeons and nurses - a long story), as her hands were suffered from skin damage from harsh antiseptic soaps.

Each step in the operating room presented changes, the first ones like Semmelweis and Lister were dramatic, and with every incremental step increased the costs.

If you have ever peeked into an operating room while an orthopedic surgeon replaces a hip or knee, you probably wondered why everyone appears to wear space suits. Those helmet systems are more than costumes. They are body exhaust suits with filtered air designed to reduce contamination of the surgical field.

Hospitals invest millions in laminar airflow operating rooms, surgical helmet systems, and disposable body exhaust suits, all to reduce the risk of infection after joint replacement by less than one percent. Why? Because when an artificial joint becomes infected, the consequences are devastating. Patients often require multiple operations, months of antibiotics, prolonged disability, and sometimes never regain normal function.

No hospital administrator walks into an orthopedic operating room and says, “The benefit is less than one percent. We can’t justify the expense.” Okay, I am sure some hospital administrators have tried that.

We accept those costs, because every infection prevented matters. Technology has changed. The principle has not. Our responsibility is still the same: reduce the chance that we become the source of a patient's infection.

Now Back to COVID

As surgeons, we don't accept preventable infections simply because they cannot all be eliminated. We work relentlessly to reduce risk. The same principle applies to COVID-19. We want to reduce the likelihood that an infected healthcare worker brings the virus to a vulnerable patient, because that transmission may lead to hospitalization, prolonged illness, or death.

A 2026 JAMA Network Open study found that individuals who had received a COVID vaccine within the previous six months were 43% less likely to transmit SARS-CoV-2 to close contacts than those whose vaccination was more remote. Like immunity against infection itself, that protection declined over time. Rather than being an argument against boosters, it is the rationale for timing them before the winter respiratory virus season, when COVID transmission predictably increases and our patients are at greatest risk.

If we introduced a new device that reduced hospital-acquired infections by 43 percent during the months it was most effective, no hospital would hesitate to adopt it. Infection prevention committees would recommend it. Hospital administrators would find the funding. Physicians would ask why it wasn’t already available.

One of the silly arguments I heard is that since the vaccine wears off, we shouldn’t require it. You know hand washing wears off, but we require that between every patient's room. The effect of wearing gloves wears off after two hours, and we recommend surgeons change gloves if their case lasts more than two hours, we don’t recommend they forego wearing gloves.

Why should we view a vaccine differently?

No intervention in medicine is perfect. The protection from a COVID booster wanes over time. That is true. But COVID is also seasonal. The largest waves predictably occur during the late fall and winter, after holiday travel, family gatherings, and people spending more time indoors. If a yearly booster provides its greatest reduction in transmission during precisely the months when our patients are at greatest risk, then that is exactly when we should want our healthcare workforce to have that protection.

Medicine has never advanced, because we found one perfect intervention. It has advanced because we stacked one evidence-based improvement upon another. Semmelweis gave us hand washing. Lister introduced antiseptic surgery. Macewen brought aseptic technique. Halstead introduced surgical gloves. Every generation accepted another layer of protection, because each layer reduced risk for the patient.

COVID vaccination for healthcare workers belongs in that same tradition.

We also do it for our workforce

Protecting patients is the primary reason to keep healthcare workers up to date with COVID vaccination. But it isn’t the only reason.

Healthcare workers are among the most likely to be exposed to SARS-CoV-2. During every seasonal surge, they care for infected patients day after day. When they become infected, they are required to stay home, precisely when hospitals and clinics need them the most.

A large multicenter study found that healthcare workers who remained up to date with COVID vaccination missed, on average, about two fewer days of work for each COVID illness than those whose immunity had waned. Two days may not sound like much for one person. Across an entire hospital system, however, those days translate into hundreds of thousands of dollars in staffing costs, overtime, temporary personnel, and reduced clinical capacity. More importantly, fewer absences mean more experienced nurses, physicians, therapists, and support staff are available to care for patients during the very weeks when demand is highest.

This is one reason virtually every major infectious disease and infection prevention organization continues to recommend that healthcare personnel remain up to date with COVID vaccination. The Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the Pediatric Infectious Diseases Society (PIDS), the HIV Medicine Association (HIVMA), the Society of Infectious Diseases Pharmacists (SIDP), and the Society for Post-Acute and Long-Term Care Medicine (AMDA) issued a joint consensus statement concluding that COVID vaccination should be a condition of employment for healthcare personnel in U.S. healthcare facilities.

In contrast, an updated COVID booster is inexpensive. It reduces transmission, reduces healthcare worker absenteeism, and helps protect the patients entrusted to our care.

Healthcare workers have long accepted requirements designed to protect patients. Most hospitals require immunity to diseases such as measles, mumps, rubella, varicella, and hepatitis B, and many require annual influenza vaccination. COVID should not be viewed differently, simply because it has become politically controversial. The same standard should judge it we apply to every infection prevention measure: does it meaningfully reduce risk? The answer is unambiguous, not perfect, but none of our interventions are.

Surgeons Live With the Consequences

As surgeons, we accept dozens of mandatory infection control measures without complaint, because they protect the patient. We don't "educate" people about sterile instruments, and then let them choose whether they want to use them. We require them because the patient has entrusted us with their life.

Our operating rooms are held to the highest standards of sterility, because our patients expect nothing less. If the circulating nurse tells me the sterilization indicator on an instrument tray failed to change color, we do not start the operation. I will inwardly curse, because that is twenty minutes of my day, but no surgeon would suggest we proceed anyway. That autoclave is the direct descendant of William Macewen’s steam sterilizer. It represents more than a century of learning that meticulous attention to seemingly small details prevents devastating infections.

Before every operation, I scrub my hands. I am assisted to properly put on the sterile gown and gloves. The patient’s skin is prepped with an antiseptic solution, and every member of the operating team follows this, almost as if it was ritual. While each individual step is imperfect, and reduces risk by an infinitesimally small amount, together they have created one of the safest environments in medicine because our patients have placed their trust in us.

As a surgeon, I go through the journey with the patient when there is a wound infection. The hospital administrator doesn’t. So when I hear someone suggest we “educate” healthcare workers about COVID boosters, rather than require them to do this as part of direct patient care, I wonder why we make that distinction. We don’t educate surgeons about instrument sterilization, and then allow them to decide whether they feel like using an autoclave today. We don’t educate nurses about hand washing and leave it as a matter of preference. We establish standards because the consequences of failure are borne not by the administrators, not by a governing board, but by the patient - the customer-owner, as we say in Alaska.

Education is essential, but education alone has never been the standard for infection prevention. We educate healthcare workers, and then we establish standards that protect patients.

Those of us who cared for patients during the pandemic have not forgotten what it looked like when someone could no longer breathe on their own. None of us wants to stand at another bedside wondering whether a preventable transmission occurred because someone in the healthcare system chose not to take advantage of a safe, inexpensive intervention. We cannot eliminate every infection. But we have a professional obligation to reduce the ones we reasonably can.

Every major healthcare organization involved in infectious diseases, hospital epidemiology, and infection prevention continues to recommend that healthcare personnel remain up to date with COVID vaccination. COVID remains a major cause of morbidity and mortality among our patients. If we have an opportunity to reduce the chance that the infection comes from us, we should take it. That has been the philosophy of medicine since Semmelweis asked a simple question, “Why?” It remains the philosophy that should guide us today.

In my recent FORK U podcast, I discussed the family known as legumes or The Leguminosae. Or, as botanists now call them, the Fabaceae.

It wasn’t ribeyes, protein powder, or soy that built the bodies that came to define the word gymnasium, and today we seem to forget. The typical diet of the Roman or Grecian was fruits, vegetables, puls, and sometimes a bit of fish if they were near the coast.

Sometimes people have said beans are the “poor man’s meat.” I would suggest it is the other way around: for most of human history, meat was the rich man’s bean.

Daniel and the Meat Vs Bean Argument

You may remember the story of Daniel, captive of King Nebuchanezzar. You probably remember the “Daniel and the lion’s den” story, but I prefer the other one. Daniel was told to eat the food from the king’s table, the King’s meat and wine. But Daniel asked to be excused. He asked if he and his companions could eat their simple diet of beans - and probably for that region it was a pea (same family). After ten days, they were to be judged, and indeed, the “fairest” were those who ate the simpler diet.

This was not the first controlled nutritional experiment, this was just scripture and a story. But that metaphor was asking the universal question - what diet leads to better health.

Every Civilization had their Legume

When we look to the Romans and the Greeks, they had puls, but every civilization had some form of legume that became the important source of protein.

Legumes are easy to grow, in fact they are good for the soil, putting nitrogen back into the soil. Legumes are easy to store, they are inexpensive compared to meat, and they are a good source of protein and fiber.

In America, the Native American peoples discovered the three sisters: beans, corn and squash.

Vegetarians Rise in America

Vegetarians used to be a rare in America. Growing up in Ketchikan, Alaska, every Fourth of July, the local Seventh-day Adventists had a booth where they sold what they proudly called “Shamburgers.” They were bean burgers.

Let’s just say...they weren’t exactly culinary masterpieces. Fortunately, vegetarian cooking has come a long way.

There are now some outstanding bean burgers. My personal favorite comes from the Hillstone Restaurant Group, perhaps Houston’s in some parts of the country.

Years ago, though, eating vegetarian at most restaurants was an exercise in compromise. Your choices were usually a salad, a baked potato, steamed broccoli, or some unfortunate combination of the three. Vegetarianism may have been growing, but restaurant menus hadn’t quite caught up.

Today, that’s changed dramatically. Entire restaurants celebrate plant-based cooking, and chefs have discovered what much of the world has known for centuries: vegetables and legumes don’t have to imitate meat to be delicious.

In fact, once a month, Chef Ray joins me on Instagram and TikTok—together we’re the Elder Brothers—and we cook a plant-forward meal.

Long before “plant-based” became fashionable, beans were already doing the heavy lifting. They were the original protein for people who chose not to eat meat. And after thousands of years, they’re still one of the healthiest, most economical, and most delicious sources of protein you can put on your table.

Bread, Olive oil, Beans

Bread supplied the calories that fueled civilization. Bread allowed cities to be built, armies to march, and people to invent trade routes.

Olive oil not only gave us a delicious way to roast fish, vegetables, and legumes, but also provided light for homes, temples, and cities.

But beans, peas, and their family provided a source of protein low in saturated fat, high in fiber, rich in protein, and provided not only great food, but also satiety.

Between the bread, olive oil, and legumes, you have the foundation for the Mediterranean diet. Simple, rustic, and delicious.

Twenty Thousand Plants

The bean family (Fabaceae or Leguminosae) contains about 20,000 species (older texts often say 18,000 or 19,000; modern taxonomy is just over 20,000). Most of these are not edible.

Some of the most obvious of this family you are familiar with: Chickpeas, lentils, peas, soybeans, fava (broad) beans, lima beans, mung beans, black-eyed peas (which are actually beans), adzuki beans, and lupins. Nature liked the bean so much she invented it over twenty thousand different types. We only eat about a hundred of them—and most of us rotate through six.

If you think the bean family begins with kidney beans and ends with chickpeas, think again. Peanuts aren't nuts, black-eyed peas aren't peas, green beans are immature bean pods, and snow peas and snap peas are all legumes. Jicama, licorice, mesquite, tamarind, carob, fenugreek, and even alfalfa all belong to the same botanical family. I think that's a pretty good endorsement.

Surprised? One of the defining characteristics of the bean family is that they package their seeds inside a pod. Nature is remarkably practical. Instead of scattering seeds across the ground, legumes wrap them in a protective case until they're mature (no, kangaroos are not a legume, but I see why you think that). We call those seeds beans, peas, lentils, or chickpeas, depending on the species.

Sometimes, like green beans and snap peas, we get impatient and eat the whole pod before the seeds are fully mature. Sometimes we wait for the pod to dry, shell out the seeds, and that's what ends up in our soup or chili. Sometimes we throw the pod on the floor and call it a western restaurant. I remember one restaurant in Chicago, long since gone, where you toss your peanut shell on the floor and it was considered OK. Years later, I encountered another such place in Arizona (now closed). Well, better than a spittoon, and what a way to celebrate a legume.

In 1967, Margaret and Ancel Keys (yes that one) wrote one of my favorite books about the bean.

Today, when we are looking for better and healthier ways to eat, I submit, you don’t need protein powder, you don’t need ribeyes. Consider the bean, and like heirloom tomatoes, there are even people bringing back some great beans.

Beans Deserve Better Marketing and Two Recipes Worth Learning (and a look into my pantry)

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This is the first of a two-part series. In this installment, I want to talk about something we rarely discuss: what happens when the scale finally stops moving. In part two, I will write about maintaining your weight if you reduce or stop a GLP-1 medication.

Maintaining the Plateau

I have maintained my current weight since September of last 2025. I weigh myself daily. I thought the weight loss would go on for more, but am still pleased with my weight. I’m down 50 pounds at a 173 lbs. The scale still wanders a few pounds, but after a few months of the scale not moving, I’ve realized something important. Losing weight and maintaining weight are two skills.

You don’t know when the scale will stop moving. A swing of a few pounds is common, but at some point you realize this is the weight you will hopefully maintain. That is okay. I weigh less now than when President Reagan was inaugurated.

Losing weight is chemistry, maintain the weight loss is what you eat.

I had a goal weight, about five pounds less than where I sit, and I was within a pound and a half of it for a day. But mostly in the last year, I am averaging 5-8 pounds above that mark. .

The early phase

Oh, those early days were amazing. Watching the scale drop, making decisions to increase the dose, and finding clothes hidden in the closet for years now fit, and some were even too large. It was a dream.

I didn’t know what food noise was until 12 hours after my first dose of Zepbound. Before the next dose, I notice three things that signal it is time for the dose: I eat faster, I get hungrier, and I am less disciplined about what I ate.

Initially, after starting Zepbound, I would sometimes have 10-14 days between injections.

Physiologic Signals for Injection

I noticed from one of my wearables that my markers of physiologic stress consistently rise as if I am scheduled for my next injection. Those signs measure my autonomic nervous system, and indicate it is working a little harder. Whether that's related to the return of food noise, changing GLP-1 activity, or something else, I don’t know. But the pattern has been consistent for nearly two years.

Now food noise comes back, not with a roar, but quietly. It isn’t the persistent noise that initially quieted. Like many, I get hungrier, eat faster, and if there is ice cream in the freezer, it “calls me”. What is interesting is that when I was my larger self, ice cream was an occasional treat. I could leave it alone.

How do you know it isn’t a long plateau?

Plateaus are frustrating. No weight loss for a few days, then a few weeks, but ultimately the scale drops. Usually dramatically. At some point you realize the scale is just jumping around a bit and not making those dramatic changes.

You have reached maintenance. Some mistakenly increase their dose, hoping to squeeze a few more pounds. Often this comes with increased stomach issues, more constipation, or nausea, and little weight loss. o

Sometimes the increased dose comes with what we call anhedonia. A lack of interest in everything. Not just food, but no pleasure. If that happens, it is time to talk to your doctor about decreasing the dose, and in a few weeks but you will feel better. I will have an entire section about this later.

Building Habits

Starting on a GLP-1 is like having a baby’s stomach. Much like an infant, sometimes things don’t settle well. Often the things that don’t settle well are high fat items, and sometimes this helps you set up some good habits.

For example, pizza laden with greasy meat will sit like the calorie bomb, but if you order a pizza with no meat, half the cheese, and lots of vegetables, you will have more of a flatbread that is tasty and delicious.

Using the GLP-1 to build better eating habits is key to maintaining. I will go over some of my typical dishes later.

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Maintaining - what we don’t get to talk about

Do you remember in the diet world, you thought. If you could get the weight off, would be easy to maintain? GLP-1 makes that possible.

Having reliable foods that are go-to. I have grapes and apples ready almost anytime. Having reliable meals that are easy to make and require little effort.

Here are a few things that I do to maintain (food, recipe to follow):

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Throughout the week, I read medical journals so you don’t have to. Some weeks there is a common thread that immediately jumps out.

And sometimes the stories seem unrelated until you begin to pull on them. This week, headlines ranged from measles to peptides to contaminated lettuce. I kept coming back to the same conclusion: medicine has become increasingly political.

Viruses do not care who you voted for, bacteria don’t read social media, and plaque in your coronary arteries has no political opinion.

Rand Paul and Anthony Fauci

The biggest medical/political story was Anthony Fauci appearing before Senator Rand Paul’s committee. It was sad to see an 85 year old giant in the field take the fifth. Rand Paul telegraphed he wanted Fauci to say something that contradicted what he said in 2021, then refer Fauci for perjury.

The conspiracy types want to believe COVID-19 was made in a lab, then leaked, leading to world wide chaos, all because of Fauci. Oddly, they also state the virus is nothing more than a cold, so I am not sure what their issue is.

I worry about what happens when a future public health physician sees this circus. Easier to stay in university or private practice. We need good people in public service. But who could blame them if they worry they may spend their retirement defending every email, every meeting, every recommendation, and every imperfect decision made in the middle of a rapidly evolving crisis? We absolutely need accountability. We also need good people willing to accept impossible jobs.

Measles Makes a Comeback

While cameras focused on Washington: The United States recorded 2,371 measles cases, making 2026 the worst year for measles since 1991, and we still have four plus months left in the year. I have repeatedly received the same question over the past several weeks: “How many of these cases came from people who entered the United States illegally?”

The answer is none.

That surprises some people, because it does not fit their narrative , or from their echo chamber online. The CDC investigates measles aggressively. Travel history is documented. Contact tracing is performed. Imported cases are identified separately from domestic transmission.

This year, there have been imported cases from citizens who travel internationally. But once they brought measles into susceptible communities, the spread occurred among people with inadequate immunity.

We can talk immigration policy - I won’t. But the issue is that public confidence in vaccines has declined.

Vegetable Confidence

The Cyclospora outbreak causes many Americans to avoid vegetables. I admit, I ordered a burger without lettuce.

A major outbreak of cyclospora was linked to shredded iceberg lettuce. The lettuce came from a farm in Central Mexico, whose lettuce was distributed mostly to the Midwest. And now forty percent of Americans are eating less produce because of the outbreak.

That response illustrates that fear spreads faster than cyclospora. The answer to contaminated lettuce is not to abandon salads forever.

Before we move on to the next headline, I think H. L. Mencken captured something medicine occasionally forgets. Our job is not to decide who deserves illness. It is to understand disease, evaluate evidence, and help people recover.

Peptides and Gym Bros

Another story that generated much excitement involved peptides. Depending on which influencer you follow, you may have heard the FDA “approved” a collection of popular peptides this week. That is not what happened.

An FDA advisory committee recommended that several peptides be eligible for compounding under very specific circumstances. FDA scientists expressed concerns about the lack of human safety data for several of those peptides, and unanswered questions about manufacturing.

An advisory committee recommendation is not the same thing as FDA approval. Nor is a compounded product the same thing as an approved medication. By the time the story reaches social media, “an advisory committee recommended a pathway for compounding” somehow becomes “the FDA proved these peptides work.”

Not every story this week involved controversy. Below are some of my favorites.

Blood Test for Colon Cancer

The FDA approved a blood test for colorectal cancer. This is blood, not stool, not blood in stool, but a sample of blood.

That is good news, because any screening test that persuades people to participate improves our ability to detect cancers early.

The test detected most existing cancers, but it was not effective at identifying precancerous polyps. Colonoscopy remains the gold standard, because it does more than detect disease. It prevents disease by removing those polyps during the examination. Blood tests are not a replacement for colonoscopy.

GLP-1 Data after Treatment

We also saw encouraging data on GLP-1 medications. A study following patients taking semaglutide found participants continued to eat fewer calories, despite increasing hunger.

Hunger, food noise, satiety, and calorie intake are related, but they are not identical. Many patients tell me that while they occasionally feel hungry, they are satisfied with much smaller portions and not compelled to keep eating. This is also what I’ve experienced.

GLP-1 Reduce Fragility in Elderly - the opposite of what some have stated

Another study suggested that GLP-1 medications may reduce fragility fractures in older adults with type 2 diabetes. The group studied had 21% lower risk of fractures over three years in adults aged 50 to 90 with type 2 diabetes. This protective effect is independent of weight loss or blood sugar control.

The fractures occurred in the spine, or vertebral fractures (32% reduction) and hip/femur fractures (30% reduction). I might remind you that there is a significant anti-GLP-1 community who provoked fear in people by stating that GLP-1 will lead to muscle loss in elderly adults. We still recommend bone density scans for GLP-1 users. But know this, with any weight loss, there will be bone remodeling and bone loss. Resistance exercises are still recommended.

A smaller study alternatively reported an 11% increase in fracture risk. This small study was too small to reach statistical significance. Stay tuned.

Calcium Scoring on Routine CT scans

Ever get a chest CAT scan? Researchers found that some chest CAT scans, ordered for coughs or lung checks, had calcium in the arteries going to the heart. There was enough calcium that physicians could identify cardiovascular risk. This means we can save some patients having to order an additional scan. The Researchers showed that risky coronary plaque increases as traditional cardiovascular risk factors accumulate (no surprises here).

Doctors can now use these existing scans to forecast future heart disease risk, just as effectively as a calcium heart scan. Saving patients from extra medical bills and unnecessary radiation exposure. Insurance does not cover most cardiac calcium scans.

If you are over 50, you should ask your doctor to review any recent chest CT scan reports for mentions of “incidental calcium” or “calcification.” That finding can help guide decisions about starting preventative heart medications, like statins or other medications. Although, I would prefer you take the medicine before you get a calcified plaque.

National Blood Supply Crisis - please donate blood

The American Red Cross declared a national blood supply crisis, with less than a one-day supply of O-positive blood available. As a surgeon, I have stood in operating rooms where donated blood meant the difference between life and death. Blood cannot be manufactured. It cannot be synthesized in a laboratory. It still depends on one person rolling up a sleeve to help another person they will never meet. If you are healthy and eligible to donate, this would be an excellent week to do so.

Four Things I’m Telling My Patients This Week

One advantage of spending the week reading journals is that I usually come away with a few practical lessons. Medical news can be fascinating, but my readers rarely ask me to summarize a journal article. They ask a much simpler question: “Doctor, what should I do?”

This week I have four answers.

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Ask me a dozen years ago about olive oil, and I would have told you the molecular structure of this mono-unsaturated oil, and that the data shows it is good for you. Today, it is a more interesting and fun story.

Olive oil isn’t just oil, when you press the juice out of an olive, there are pigments, phytochemicals, anti-oxidants, and tocopherols, just to name a few. Depending on where the olive is grown, determines the characteristic and taste of the oil.

The First Electricity

Before light bulbs, before gas, before candle wax - from bees, there were olive oil lamps. These were the “electricity” of the civilizations of old. How they discovered this is a mystery.

Once someone discovered the olive oil could be a source of fuel, they discovered the light from olive oil was brighter than wood, lasted a long time, and for all biblical history, the night light was from oil lamps. The temple, homes, and markets were given light from the olive oil. The original menorah in the ancient biblical Tabernacle and Holy Temple was fueled exclusively with pure olive oil.

Olive Oil and Wine - the best olive oil is from…

Olives grow in arid climates. Originally grew almost anywhere in the Mediterranean, from Morocco to Lebanon, Italy, Spain, Turkey, Greece. The first human cultivation of olive trees was 8000 years ago in the region of Syria-Palastine. All known for their olive oil, and every region is convinced their oil is the tastiest.

If you want to start a war on the internet, tell someone that the best olive oil comes from your favorite region. If you think politics on the internet are toxic, wait until you argue about olive oil.

Olive oil is like wine, the soil, the sunshine, the climate, are what we call the terroir. Each of those components has a different effect on the flavor of the olive and its juice. Hot dry climates stress the olive trees, which result in olives with more polyphenols, responsible for a bitter taste. Higher altitudes result in cooler nights, and those olives tend to have a more peppery finish. Both of those (hydroxytyrosol and oleocanthal) are the ingredients in olive oil that have a major impact on your health.

In the United States, arid regions can grow olives. When I lived in Phoenix, olive trees were so abundant that they had to be sprayed to not produce pollen, as they were highly allergenic. Still, the olive trees from Queen Creek produced a great, pepper flavored oil.

Moving to California in 2020, I found that many wineries have olive trees, and many their own brands of olive oils. In 1992, California founded The California Olive Oil Council (COOC). This trade association certifies California-grown extra virgin olive oil and has the strictest chemical and tasting standards in the world.

Dip It or Cook It

The components of olive oil determine where the oil is best used. You hear people say some olive oils should only be used for dressing foods, or making salads. Others are okay for cooking.

Occasionally someone will refer to the “smoke point” of olive oils, noting that the smoke point is such that olive oils are not good for frying foods.

But how olive oil is processed determines the quality of the oil, taste of the oil, and how it can be used.

Start with Extra Virgin Olive Oil (EVOO)

Extra Virgin Olive Oil is the oil we talk about with health. And if you have the sense of humor of a teenager, you never forget it. So think about Extra Virgin as a food oil that has not seen anything other than a press to squeeze the olive and extract the olive juices. In the old days, this was done with a large stone press.

Some call this “cold-pressing.” It is far more mechanical than the above press, but it is simply that.

If the juice from the fruit is heated, or further extracted with chemicals, it is not extra virgin.

Moving to Virgin Olive Oil

Virgin olive oil is also mechanically pressed, but it does have some taste flaws, slightly more acidity. To be classified as extra virgin olive oil the acidity must be under 0.8% (or less than 0.5% in California). While Virgin olive oil has good flavor, the acidity comes from the olives, which had some minor damage that caused a change in the juice. For example, if the olive is bruised, over ripe, handled roughly, harvested when they were a bit over rip, or if the olive was attacked by an insect, then the oil is broken down slightly and becomes a bit acidic. You wonder why the EVOO in California costs more, because the olives picked for this were of a high quality, picked a peak ripeness.

Refined, Pure, and Light Olive Oils

Refined olive oil is virgin olive oil extracted using heat and filters to remove some acidity found in virgin olive oil. This olive oil is colorless and tasteless.

Pure Olive Oil is made by mixing 85% refined with 15% EVOO to add some taste and flavor to the olive oil.

Light Olive oil contains even less EVOO, usually 5-10% EVOO.

These are the olive oils used for baking, because of their neutral flavor, and frying or any use for high heat, as they have a high smoke point. They are less expensive than EVOO.

Health Benefits of Olive Oil

The health benefits have been extensively studied over the last seventy years, as one of the components of the Mediterranean Diet.

One of my favorite studies came from Lyon, France, where researchers enrolled people who had already suffered their first heart attack. Half continued eating the French version of their cardiology diet, called the prudent diet. The other half adopted a Mediterranean diet, and they had to convince those French to replace their beloved butter with olive oil. During the first year, the Mediterranean group had about a 75 percent lower risk of another heart attack, and years later the benefit remained remarkably strong. By the second year, the study was so one-sided that they had to drop the study and no longer advocate the prudent diet, but instead the Mediterranean Diet. Over five years, the rate of a second heart attack for those on the Mediterranean diet was 67% less than others.

The PREDIMED (Prevención con DIeta MEDiterránea or Prevention with Mediterranean Diet) trial followed about 7500 Spanish for five years at a high risk of a heart attack. Those who followed a Mediterranean diet supplemented with extra-virgin olive oil had about a 30 percent reduction in major cardiovascular events compared with the control group. The original study was retracted due to statistical methods and later republished. The results remained the same.

Add to that decades of observational studies involving hundreds of thousands of people showing lower rates of heart disease, diabetes, and even mortality, and it’s easy to see why olive oil has earned its reputation.

The Components of Extra Virgin Olive Oil

Let's open the bottle and look inside. Two ingredients, hydroxytyrosol and oleocanthal, I think are the most interesting compounds in extra virgin olive oil. Hydroxytyrosol is highly valued for its cellular antioxidant defense, while oleocanthal is a highly targeted anti-inflammatory agent. They also affect the taste of the oil.

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Yesterday, I watched an 85-year-old physician who devoted fifty-six years to government service sit before a Senate committee and invoke his constitutional right not to incriminate himself.

Dr. Fauci spent more than half a century serving the American people through AIDS, anthrax, Ebola, SARS, Zika, influenza, and finally COVID-19. Whatever you think about his communications during the pandemic, his life has been one of extraordinary public service.

And I found myself asking a question I couldn’t shake:

Who, in their right mind, would choose that life today?

Rand Paul - the Senator and doctor

Senator Rand Paul was clear in his intent. He wanted to prosecute Fauci. To make him say something that would contradict an earlier statement, and then charge him with lying to Congress. Fauci, following his lawyers advice, took the fifth and didn’t take the bait.

Senator Paul had Fauci before the committee many times during the pandemic. Their exchanges became some of the defining moments of the pandemic, with each side believing the other had been exposed. From my perspective, Fauci consistently had the stronger scientific argument. Senator Paul returned to them again and again in the years that followed.

In the anti-vaccination community, believe COVID was made in a lab, leaked by the lab and unleashed on the world by Fauci and Bill Gates.

Many forget, Fauci was praised by both Presidents Trump and Biden for his work. Many of us saw him as the beacon of science and medicine during a dark time. We appreciated his careful and measured tone.

We understood that we were making things up as we went. Those of us on the front line, when the breath of another person could kill you, were reusing N-95 masks. We were upset our personal protective equipment was outsourced to China, who was now using all of it for their pandemic. But we were hopeful, because the gene was sequenced in early January, and mRNA vaccines promised something to come.

Did we make mistakes? Yes. Plenty of them. But we learned. We had never been in a situation where the world was shut down. I remember being told our Hawaiian vacation was to be terminated because visitors were to return to the mainland. Returning to California the day Newsom said to shelter in place was the least cars I’d seen on the 405 in Los Angeles.

Returning to a hospital overrun with patients, many on vents, many who would die. No room for elective patients.

I looked forward to hearing Dr Fauci, calmly explaining things as we knew it with the information we had then. Whether it be flattening the curve - by sheltering in place. He predicted if we did that we could limit deaths in the US to 100,000 by Memorial Day. While many misquote Fauci as saying things with certainty, if you look back, he always couched them in the science as we knew it then - possibilities, probabilities, what percentages the research showed.

Senator Paul became convinced that NIH funding to research in Wuhan ultimately caused the pandemic. That belief drove years of hearings, investigations, and finally yesterday's appearance by Anthony Fauci.

I read the papers so you don’t have to

Paul released thousands of pages of documents in preparation for the hearings. Including emails ending with phrases such as, "Please delete this email after reading." Physicians often send messages like that—not to conceal crimes, but because they don't want patient information or preliminary discussions preserved indefinitely in someone else's inbox.

Or Fauci’s diary, where he, like any good scientist, entertains all possibilities about the virus, its origin, its transmission. Any good scientist, any good physician, would entertain even the remotest possibility with this novel virus.

Paul even mocked Fauci for writing about his newfound fame. I found that criticism curious. Politicians seek fame. Scientists are usually surprised by it. I've gained a measure of fame through social media, and I'm still amazed by it.

The documents did not support the sweeping conclusions that Fauci orchestrated the pandemic or engaged in the broad conspiracy.

Now a brief glimpse into Fauci’s career

Fauci Pre Covid

I first learned of Dr. Fauci when I was a medical student, seeing his name as one of the editors of Harrison's Principles of Internal Medicine—the textbook in medicine. There wasn't another one. Before the internet. Before Google. Every medical student knew the names of the people who wrote Harrison's, and Anthony Fauci was one of them. He was already considered a giant in infectious diseases.

By the time He had published multiple articles about infectious diseases, and was well known in the world with strong academic credentials based on many peer reviewed publications, his leadership at the NIH

Fauci HIV and Community Protests

He was once accused by AIDS activists of perpetuating a system that kept drugs from reaching them. Dr. Fauci sat down and listened to them, and found some of their concerns legitimate. Fauci used his position to advocate for a fast-track system at the FDA for pharmaceuticals. He redirected research and treatment efforts toward community-based health systems where the majority of patients could participate in research and receiving therapies closer to home.

The acceleration in research and drug development transformed HIV infection from a fatal disease to the treatable disease. Science widely recognizes him for his work with HIV. And the communities who once protested against him now consider him one of their great advocates.

Fauci’s actions remind me of Abraham Lincoln, who took those who were his critics, and made them his advisors. The best way to destroy an enemy is to make them a friend.

The Pandemic

Then came the pandemic, and it was horrific. We had all predicted it would come, we assumed it would be influenza, who knew it would come from the coronavirus. Humans were mildly familiar with coronavirus. There are some that infect children, causing symptoms of “a cold.”

When this one landed, we had a preview of what could happen. And within a few weeks of hitting the shores of America, our healthcare system was overwhelmed.

My hospital had to close elective operations, turn away visitors, and quickly I was doing tracheostomies because those who did them normally, the head and neck surgeons, feared people with COVID-19.

Government Service

It is in the public interest to have physicians of the caliber of Anthony Fauci. Not only for what they would quietly contribute over a career, but because there will be another pandemic. Not if, but when.

When that happens, those of us in medicine will need someone who speaks for science, with the humility that uncertainty demands. Medicine and science are not explained in absolutes. We need someone who can explain what we know, what we don’t know, and how those answers may change as the evidence changes. Someone who can advise politicians, if they are willing to listen.

But my question remains - after seeing this, who would want to spend a career devoted to public service only to be 85 years old and have to spend a day pleading the fifth.

Instead he should have spent his day realizing that many of us, who were on the front lines, appreciated this man, for who he was, for how he kept our hopes up in the darkest hour of our medical careers.

Instead, he should have spent that day hearing from those of us who were on the front lines. Because we will continue to thank him for being a steady voice during the darkest months of our professional lives. We didn’t always have the answers. Neither did he. But he never pretended otherwise, and for many of us, that honesty gave us hope when we needed it most.

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Last night, because of several poor decisions, I experienced projectile vomiting, which impressed me.

My job is to keep you from making those same decisions.

I’ve dealt with nausea and vomiting throughout my career as a surgeon, with post operative patients, bowel obstructions, ileus, and when I was in the pediatric wards - well, you can imagine.

Because GLP-1 drugs keep things in the stomach longer than normal (GLP-1 medications “delay gastric emptying”), and that can lead to nausea and vomiting.

What a normal Stomach Does

Normally, your stomach empties liquid quickly. A glass of water leaves the stomach in about 15 minutes. Solid food stays longer. If you eat a steak, the stomach will grind the steak up, attack it with acid and enzymes. After two hours, the steak will have the consistency of a milkshake. The valve at the end of the stomach (the pylorus) will open, and food will go into the first part of the small bowel, called the duodenum. Before that, the pylorus opens only enough to let small amounts of liquids and small particles of food out.

GLP-1 medications Delay That Opening

When you are on a GLP-1, your stomach empties a lot slower. It doesn’t mean you cannot challenge the stomach and add more food, but your stomach will not always appreciate it.

Some see this as one of the reasons we lose weight. We feel full longer. Although I think what happens in the brain is far more important. Still, feeling full with less food is a benefit.

But if your stomach is having an “off” day after you inject (and for some people this could be 1-3 days), it is time to treat it with care. And knowing that high fat foods can cause a problem, it might be time to put pizza, fried foods aside for a bit. Yes, I know the purists out there will say we should never eat such foods, but this isn’t a discussion of perfect nutrition, it’s about what your stomach can handle today.

Foods that Delay the stomach -

Fatty foods delay stomach emptying, fried foods, pizza, cheese, fatty meats. So do high fiber meals. The soluble fibers found in oats and beans form a gel that travels slowly through the stomach. So do large volume meals, high calorie density meals, and smoothies and milkshakes.

If you are feeling a bit full, and the stomach isn’t emptying, the last thing you want is a fried chicken wing and ice cream. Don’t ask me how I know that - OK, I proved that at 2 am.

Comfort Foods

We all want comfort, especially when we don’t feel well. But the comfort foods of our past are often not friendly to a stomach that isn’t emptying well. There is a big difference between how the stomach treats a fried chicken wing, and a bit of chicken breast that is oven roasted. Pizza might be comfort food or even a college diet, but this isn’t the time for that food. Your stomach will rebel. It also isn’t the time for alcohol.

The first priority is hydration.

Not all hydration solutions are created equal. This is not the time to fear a bit of sugar. Pedialyte is found in most grocery stores and pharmacies. It is based on the formula for rehydration solutions that we physicians have used for decades.

Glucose (sugar) helps the intestine absorb the electrolytes more effectively than those products without sugar. I’ve written a post about rehydration solutions on Substack for more information.

I keep Pedialyte popsicles in my freezer. If I get sick, or a member of my family, rehydration can begin sooner. Even diluted apple juice with a bit of salt. There are other high-quality solutions, like Oral Rehydration Salts (ORS), Liquid I.V., or diluted sports drinks.

Instead, think about foods that are easy on the stomach. Toast. Crackers. Applesauce. Rice. Soup. Plain cereal with oat milk. A banana. Plain grilled chicken. They may not sound exciting, but remember, your goal isn’t culinary adventure. Your goal is to let your stomach catch up.

One thing surprised me. Yesterday, my usual protein smoothie didn’t sound good at all. Normally I love it. That’s another lesson. Don’t force food, because it’s on your meal plan. If your stomach says no, listen. There will be another day to get your protein.

Last night taught me something I should have known as a physician. When your stomach talks, listen. Once you have nausea, it is time to pay attention. Most people on a GLP-1 will have a day when their stomach says, "Not today." Knowing how to respond can make the difference between an unpleasant afternoon and a miserable night.

When to Worry, How to take care of yourself

Here is how I took care of myself. Yes, it was a horrible time. But knowing how to recover, what traps to avoid, and when to call for help is important.

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