The number behind that quiet is not small. Eleven percent of American adults are currently on a GLP-1 drug, up from three percent two years ago; fifteen percent have taken one at some point. Demand outran supply almost as soon as Wegovy was approved in 2022. Novo Nordisk and Eli Lilly make these drugs in a handful of specialised facilities, and both landed on the FDA’s official shortage list within months, driven as much by people who wanted to lose weight as by the diabetics they were built for. The shortage lifted in stages, tirzepatide in December 2024, semaglutide the following February, and demand kept climbing anyway. Awareness caught up with the market too: ninety-one percent of Americans now know what these drugs do, up from eighty percent in 2024. Obesity, which had climbed for three decades without a single meaningful reversal, actually fell this year, down to 36.4 percent from a record 39.9 percent in 2022. All of that happened without a school programme, a public health campaign, or a change to a single nutrition label. It happened because a diabetes drug turned out to have a side effect half the country wanted, faster than the two companies making it could keep up.

And still almost nobody says so directly. Celebrities deny it in the same week photos suggest otherwise. “It doesn’t matter,” one told the Los Angeles Times, “everyone’s going to think I took Ozempic anyway.” Weight has always been the subject Americans discuss least honestly, and a genuinely effective drug for it has not made that easier. It has just given the evasion a more specific shape.

Getting insurance to pay for it runs on its own, less forgiving logic: “Worried about my weight” has never been enough. Novo and Lilly sell the identical molecule under two names depending on the approved use, semaglutide is Ozempic for diabetes and Wegovy for weight, tirzepatide is Mounjaro for diabetes and Zepbound for weight, and insurers check the diagnosis code on the script against that specific brand’s approved indication, not the molecule. A weight-loss code on an Ozempic prescription gets refused; most commercial plans simply exclude the weight-branded versions outright. Medicare goes further. Part D is the prescription drug benefit that covers roughly fifty million Americans over sixty-five, sold through private insurers but shaped entirely by federal rules, and one of those rules has excluded drugs used for weight loss since the programme began. No diagnosis code gets around it.

CMS finally cracked that wall open. Since July 1st, a subset of Medicare Part D enrollees can get Wegovy, pill or injectable, or the Zepbound pen, for a fifty-dollar monthly copay, through an eighteen-month demonstration running into 2027. Eligibility is BMI-based: 35 or higher alone, 27 or higher with a weight-related condition, and CMS estimates 3.8 million beneficiaries could qualify. The fifty dollars doesn’t count toward the Part D deductible or the annual out-of-pocket cap, the fine print that decides whether a benefit is real or mostly theoretical. As far as I can tell, it’s the first time the federal government has paid for a GLP-1 for weight loss on purpose, rather than by diagnostic accident.

Outside insurance, the direct-to-consumer landscape splits into two kinds of business behind the same “get GLP-1s online” interface. NovoCare, LillyDirect, Ro, and Teladoc all sell the real branded drug, $149 to $449 a month depending on the product, no compounding involved. Ro spent its Super Bowl money this year on Serena Williams, who credits Zepbound with her thirty-four pounds loss when, conveniently, her husband is an investor and board member at Ro. Hims & Hers and LifeMD do both: brand-name Wegovy through a distribution deal with Novo, and a cheaper compounded version alongside it, around $49 a month, for anyone the brand price doesn’t work for. That second option survives on a legal distinction worth explaining, because it’s also the reason the shortage story isn’t quite over.

During the actual shortage, from 2022 until the FDA declared it resolved, any pharmacy could legally compound a copy of a drug on the shortage list, no manufacturer approval needed. A large share of what people were injecting in those years did not arrive in a Novo Nordisk pen, branded, boxed, sold with an ad campaign behind it. It arrived in a plain glass vial with their own name on the label, no logo, filled into a syringe by hand. That blanket cover ended with the shortage. What survives it, and what still lets Hims & Hers and a smaller platform called Willow sell compounded GLP-1s today, is a narrower, older rule: a pharmacy can still compound an individualised version of a drug that isn’t a mass copy of the commercial product. Willow’s whole business runs on that distinction. Pills versus injectables (whether a tablet does anything close to what the pen does) positioned closer to vanity than to medicine, weight loss treated as a point-in-time event rather than the chronic condition this was built to manage: it's a genuine ethical and medical grey area, and it's really its own piece.

The pen and the vial are also worth remembering for a second reason: roughly eighty percent of the medications Americans actually take are generic or compounded, unbranded pills and vials indistinguishable from a version sold under a different name for four times the price. Nobody mentions the generic name of their blood pressure medication at dinner. The economics of branded pharma, the ads, the reps, the celebrity campaigns, exist to manufacture a small number of blockbusters precisely because most of what this country actually takes is not brandable at all. GLP-1s are, for now, still inside that blockbuster window. The shortage showed how fast the window can close.

None of this was planned. Two companies built blockbuster drugs faster than they could make them, a two-year shortage handed compounding pharmacies and telehealth platforms an opening, and the government caught up only this July, with a pilot that expires at the end of 2027. I work for Danone, whose high-protein yogurt aisle is one of the few grocery categories growing while the rest of a GLP-1 user’s cart typically shrinks by five to eight percent.

Which leaves the question nobody at the dog run is asking out loud. Once a drug this effective gets this cheap, this normal, and now this federally subsidised, does America keep treating it as a private medical decision, or does someone eventually float putting it in the water. I don't think we're far from someone proposing it in earnest. In the meantime, Europe is still deciding who qualifies: France only started reimbursing Wegovy and Mounjaro for severe obesity this June, the first country in the EU to cover it at all, and most of the continent still won't pay for it under any diagnosis. Europe is still deciding who deserves it. America already decided everyone does.

Further reading: Gallup, GLP-1 usage tracking, July 2026. Forbes Health, GLP-1 statistics 2026. FDA, drug shortage database, semaglutide and tirzepatide, 2022–2025. CMS, GLP-1 weight-loss demonstration, 2026. NPR and AARP, Medicare GLP-1 bridge coverage, 2026.

I wrote about WIC in the last piece: Women, Infants, and Children, the federal nutrition programme available to 40 percent of American households with young children. The standard package covers milk, yogurt, eggs, cheese, canned fish, beans, whole grains, and fresh fruit and vegetables. A family qualifies on income alone. They arrive at an authorised store, choose from the approved list, and the government covers it. No prescription, no clinical step, no diagnosed condition required.

I had never seen anything like it. In France, in the Netherlands, in China, in Hong Kong, there are social support structures for food insecurity and schemes for the very young and the very poor. None of them gives 40 percent of families with young children a monthly allowance for specific food products across the full range of a normal diet. WIC is not a food voucher for the destitute. It is a nutritional infrastructure for the working poor and the lower middle class, built on the assumption that what goes into a child’s first five years of life is a matter of public health, not personal responsibility alone.

That the United States built this in 1974 and has maintained it ever since is the less told half of the story. The more told half is everything the programme still cannot reach, which I covered last time. What I want to think about here is the next step: what happens when the logic behind WIC is extended beyond a pre-approved shopping list into something that more explicitly resembles medicine.

Food is Medicine is the umbrella term the US health policy world has settled on for a loose coalition of programmes, nonprofits, and advocacy organisations sharing the same premise: that food, when clinically targeted and delivered with intent, is a medical intervention and should be funded like one. The phrase is ancient, but the modern movement took institutional shape in the 1980s when nonprofits began delivering meals to AIDS patients, formalised in 2012 with the founding of the Food is Medicine Coalition, and reached the federal policy agenda in 2022 when the White House Conference on Hunger, Nutrition, and Health committed $8 billion to the category.

In practice it takes three forms. Produce prescriptions: a physician issues a voucher redeemable for fruit and vegetables at an authorised retailer. The USDA’s GusNIP programme has funded over 150 of these pilots nationally, typically aimed at patients managing diabetes or hypertension. Medically tailored groceries: a registered dietitian assembles a specific food package for a patient with a diet-sensitive condition, for pickup or delivery. Geisinger Health System’s Fresh Food Farmacy in rural Pennsylvania has been running this for diabetic patients since 2016, tracking HbA1c alongside food delivery as a clinical outcome. Medically tailored meals go furthest: fully prepared food, designed around a patient’s clinical profile, delivered to their door. Community Servings in Boston and God’s Love We Deliver in New York have offered versions of this for decades, and are the programmes with the deepest evidence behind them.

The origin of that evidence is worth knowing, because it tends to get lost in the current conversation about food and wellness. The modern Food is Medicine infrastructure in the United States did not begin with a Goop-adjacent functional medicine practice in Santa Monica. It began with the AIDS crisis. In the 1980s, as the epidemic moved through American cities and the healthcare system had little to offer, organisations like God’s Love We Deliver in New York and Project Open Hand in San Francisco started delivering meals to people dying of AIDS who were too ill to cook. The clinical logic was specific and urgent: severe wasting, immune suppression, bodies that could not eat. The food kept people alive in a period when medicine largely could not. From that foundation, as AIDS mortality receded and antiretroviral therapy transformed the disease, those organisations did not close. They evolved, expanding their remit to cancer, heart disease, kidney failure, diabetes: the full range of conditions where diet and clinical outcome are measurably linked. The evidence base grew with them.

That evidence is, for the most intensive programmes, genuinely striking.

A 2019 study in JAMA Internal Medicine following patients enrolled with Community Servings in Boston found a 16 percent reduction in average monthly medical costs, driven by fewer hospitalisations and emergency department visits. A 2024 modelling study in Health Affairs projected net savings of $23.7 billion nationally in the first year if medically tailored meals were available to all eligible patients, with the programme cost-saving in 49 of 50 states. A JAMA Network Open analysis estimated 1.6 million hospitalisations avoided under full deployment. These are not marginal results. For high-acuity patients with complex diet-sensitive conditions, getting the right food to the right person at the right time reduces the pressure on the rest of the system in ways that show up clearly in the data.

The produce prescription evidence is more modest. The trials are shorter, the outcomes smaller, the effect sizes harder to isolate. The WIC Farmers Market coupon data I cited in the last piece is instructive: vouchers for fresh produce, provided alone, are redeemed at around 40 percent. A coupon is not a meal at the door, and the difference in outcomes reflects that. The more the programme does for the patient, the more it appears to work. Which is worth keeping in mind when assessing the three forms against each other.

Most developed countries have not attempted any of this in any systematic way. They have nutritional guidance, food banks, school meal programmes of varying quality. What they have not built is a clinical and reimbursement infrastructure that treats food as a substitutable medical intervention, fundable on the same basis as a drug or a procedure. The United States is building it, unevenly and without a clear federal mandate, but building it. Sixteen states have approved or proposed Medicaid waivers to cover Food is Medicine interventions. Some Medicare Advantage plans already cover food benefits for high-need members. The evidence has reached the policy agenda, even if the policy has not yet caught up with the evidence: in its 2026 Medicare Physician Fee Schedule, CMS declined to create a billing pathway for medically tailored meals, classifying them as a “beneficiary engagement incentive” instead of a reimbursable service. The prescription can be written. The system has not yet decided to fill it.

What makes this genuinely interesting, from the vantage point of someone who has spent a career in food and nutrition, is the implicit argument the movement is making. In the Candy Bar piece I wrote about nutritionism, the tendency to reduce food to its chemical components and treat a meal as a delivery mechanism for nutrients. It is a logic the processed food industry has long exploited, to put a health claim on anything regardless of its actual composition. The Food is Medicine movement borrows the same framing, food as a clinical input with measurable outcomes, but turns it toward a different purpose: persuading a healthcare system that has spent decades paying for the consequences of poor diet to start paying for good food before those consequences arrive. It is nutritionism in the service of public health rather than profit. Whether that distinction survives the scaling-up process is a question worth watching.

The limitation that the research keeps returning to is the one I raised at the end of the WIC piece. Food is Medicine programmes provide food. They do not provide the time to cook it, the kitchen space that overcrowded housing often cannot accommodate, or the culinary knowledge that was left behind in another country or another generation. One study of a cooking education programme running alongside a WIC food intervention found that cooking confidence improved but shopping skills actually declined. The two things were not the same skill, and treating one did not treat the other.

The medically tailored meal model largely sidesteps this problem: the food arrives prepared, and the patient eats it. That is part of why its outcomes are the strongest in the literature. The produce prescription model does not sidestep it. A bag of vegetables delivered to a household without the knowledge, equipment, or time to prepare them is a gesture toward health rather than an intervention in it. The gap between access and capacity is the same gap I described in the context of WIC, and it runs through every iteration of this movement.

That is not an argument against Food is Medicine programmes. It is an argument for treating them as one component of a larger picture, not the picture itself. The Fresh Food Farmacy works in rural Pennsylvania partly because it sits inside a health system with case managers, dietitians, and follow-up built around the food delivery. The food is not the intervention on its own. The food plus the clinical relationship is the intervention. Isolating the food and expecting it to do the whole job is where the weaker evidence lives.

Food is medicine. The organisations that proved it spent forty years feeding people the healthcare system had given up on, starting with a crisis that most of the country would rather have looked away from. The question the data now raises is not whether food affects health outcomes. That is settled. The question is whether the system built to treat illness can be persuaded to pay for something that, done well, means fewer people need treating at all.

If it can, it will be, among other things, very good for the food industry. I work for a company whose products are already on the benefit card. I want to be clear about that. I also think that the alignment between industry interest and public health interest here is genuine, and that it is more useful to say so than to pretend the conflict does not exist.

The prescription is a piece of paper. Whether it changes anything depends entirely on what happens after it is written.

Further reading: Community Servings study, JAMA Internal Medicine, 2019. Health Affairs, national impact of medically tailored meals, 2024. JAMA Network Open, cost savings modelling, 2022. KFF Medicaid waiver tracker, food-as-medicine provisions. Geisinger Fresh Food Farmacy programme documentation.

WIC stands for Women, Infants and Children. It is a federal nutrition programme that has been running since 1974, offering food benefits, nutritional guidance and healthcare referrals to lower-income pregnant women, new mothers and children under five. It costs the federal government $7.2 billion a year. The programme is available to households at or below 185 percent of the federal poverty line, which is not a narrow slice of the population: 40 percent of American households with young children qualify. Stop and hold that for a moment. Four in ten American families with a baby are eligible for a federal programme that provides free food for mother and child, for up to five years, with nutritional support built in. In a country not typically associated with Euro-style social safety nets, this is a remarkable thing to have built. I use the European comparison as shorthand, but it is not quite accurate, and it undersells what is actually here. The nearest equivalents I have seen in France or the United Kingdom (Healthy Start vouchers in the UK, the PMI network in France) are more modest in scale, more fragmented in delivery, and considerably narrower in what they provide. WIC is not a European model transplanted. In ambition and in reach, it is something Europe has not quite managed to build. It receives a fraction of the attention it deserves.

I left the store with that sense of scale intact. What I wanted to understand was how the programme works in practice, for a family trying to access it from the inside: not the policy design, but the sequence of steps a young mother actually has to take. That is where the structural picture comes into focus, and where you start to see how much the programme’s reach depends not on what it offers, but on what participants’ real lives allow them to do.

First: you have to know you are eligible. More than four in ten people who qualify never enrol. That figure includes the full eligible population: pregnant women, new mothers and children up to age five. The infant enrolment rate is considerably higher, at around 82 percent, because hospitals and paediatricians actively refer families at birth. The programme is easier to reach when a clinician puts it in front of you. The further from that referral moment, the more families fall away.

If you do know you are eligible, you need an in-person appointment at a WIC clinic. Not a phone call, not an online form. An appointment, during clinic hours, which typically run Monday to Friday, nine to five. You bring government-issued identification, proof of address, income documentation (pay stubs, recent tax returns) and your child’s most recent medical records. Pregnant women are also screened with a finger-prick haemoglobin test for iron-deficiency anaemia at their first appointment; children are tested at the 15-month check-in and annually thereafter. For a new mother working two jobs without paid leave, or a family whose documentation is incomplete or complex, assembling all of this and getting to a clinic in business hours is the first real barrier. Almost 40 percent of participants cite clinic hours that conflict with work schedules. Around 30 percent cannot find childcare to attend the appointment.

If you qualify, you are issued an eWIC card, loaded with a specific food package: a defined list of items in defined quantities, approved by the state. The package varies by state and by participant category. The most valuable component for most families is infant formula, which WIC covers almost in full until the child’s first birthday. Mothers who are fully breastfeeding receive a more generous food package for themselves: a higher fruit and vegetable allowance, canned fish, legumes and peanut butter, and food benefits for a full year postpartum, compared to six months for formula-feeding mothers. The incentive structure is deliberate: breastfeeding is the healthier outcome for both mother and infant, and the programme is designed to support it financially.

For families whose infants require specialist formula (for allergies, metabolic conditions or premature birth), the standard eWIC package does not apply. Premature infant formulas are classified as exempt under federal WIC rules and require written medical documentation from a paediatrician or WIC nutritionist, submitted to the WIC office, with a separate benefit loaded onto the card. This adds another appointment, another piece of paper, another step.

The eWIC card looks like any debit card. What it can buy is tightly constrained. Only state-authorized vendors accept it: major supermarket chains and some WIC-specific stores, but not every neighbourhood bodega or small market. For families without a car, this is a routing problem: which authorized store is on the bus route, accessible with a pushchair, reachable on the days you can actually go. Nearly 40 percent of participants report transportation as a barrier.

Inside the authorized store, the card covers specific items, at a level of precision that is easy to underestimate. Not just eggs: eggs of a particular size, from an approved brand list, in a defined quantity. Not just bread: whole grain bread of a specific type. Not just milk: a specific volume and fat content. State WIC offices publish shopping guides, and most now have apps, which help. But a family that nonetheless picks up the wrong size, the wrong brand, or exceeds the approved quantity discovers this at the checkout, when the transaction is declined and the cashier cannot override it. The checkout friction is one of the most consistently documented pain points in WIC participation research. It is a public moment of being caught out, for something that was meant to help you.

Certification periods are more forgiving than the enrollment process implies. Infants enrolled before six months are certified until their first birthday. Children are recertified annually, with a mid-year nutrition check-in. The barrier is not frequency; it is the return appointment, which requires the same logistics as the first.

This is where the age data becomes important. At 82 percent, infant enrollment is high. At 67 percent for one-year-olds, it has already dropped by fifteen points. At 27 percent for four-year-olds, it has collapsed. The reason is not hard to see once you understand the formula benefit. Until the child’s first birthday, formula is covered in full. It is expensive, it is non-substitutable if one doesn’t or stops breastfeeding, and it is only available through WIC or out of pocket. The effort of enrollment, the bus journey, the clinic appointment, the precise shopping list: all of it is worth it because the formula alone justifies the cost. At twelve months, formula coverage ends. The remaining package (milk, fruit and veg, cereals, grains) is available at any supermarket. The transportation friction has not changed; the value of the benefit, for that specific family, has. Each annual recertification is a fresh calculation, and each year, more families decide the effort no longer adds up.

The second complication is redemption. Of the benefits that are issued, a meaningful share go unused. Cheese, eggs and milk are redeemed at 91 to 97 percent: they require little of you, available at any WIC-authorized supermarket. Infant meat vouchers are redeemed at 34 percent. The WIC Farmers Market Nutrition Program is a supplemental benefit, separate from the standard eWIC package and not available in all states, that issues additional seasonal coupons worth $25 to $50 per household, redeemable only at authorized farmers markets and roadside stands. Redemption sits at around 40 percent: not because families do not want fresh produce, but because getting to a farmers market without a car, with young children, on a summer morning, is a specific kind of inconvenience that a coupon alone cannot solve. The pattern is consistent. The benefits that require nothing of you are used. The benefits that require time, planning and transport are not.

The third complication sits underneath both of the others, and it is perhaps the deepest. WIC provides food. It does not provide the time to cook it, the kitchen space that crowded or unstable housing often cannot accommodate, or the culinary knowledge that was never transmitted because the grandmother who had it was left behind in another country, another city, another life. One study of a cooking education programme for WIC participants found that cooking confidence improved after the intervention. Shopping skills, measured alongside it, actually decreased. Access to food and the capacity to use it are not the same thing. They have rarely been treated as the same problem.

The outcomes, to be clear, are real. The 2009 revision of the WIC food packages produced measurable results: it halved juice allowances, switched to lower-fat milk, reduced cheese and eggs, introduced whole grains, and added a cash-value fruit and vegetable voucher for the first time, directly aligning the package with the Dietary Guidelines for Americans. Children who stayed enrolled under the revised packages throughout the study period showed a 10 to 12 percent lower risk of obesity at age four compared to those on the older guidelines. In 2019 alone, an estimated 62,700 cases of childhood obesity were prevented, the gains concentrated entirely among low-income households. Iron deficiency anaemia declined. Breastfeeding rates rose substantially, partly because the programme’s incentive structure had been redesigned to support it. A 2020 analysis found WIC participation associated with a 29 percent reduction in the odds of food insecurity. A 2019 study in Preventive Medicine calculated that every dollar invested in prenatal WIC returns approximately $2.48 in societal savings: reduced NICU costs from fewer preterm births, lower educational costs, and long-term productivity gains. That figure is specific to the prenatal component and calculated from a societal perspective, but it is the health economics argument made precise.

And the increase in fruit and vegetable consumption, across the whole programme, amounts to a quarter of a cup per day.

That is not nothing. It is also a precise measure of what access alone achieves, and what it cannot. The 10 to 12 percent lower obesity risk accrues to children who stayed enrolled, consistently, for long enough to benefit. The 73 percent of eligible four-year-olds who have already dropped off do not appear in that number. They are averaged away.

WIC was a generous founding bet. The proposition that access to better food improves health is correct: fifty years of evidence says so. The question the data now raises is more precise. Access is necessary. It is not sufficient. Between the food voucher and the health outcome sits a sequence of real-life constraints: the bus that does not go to the WIC store, the clinic appointment that falls during a shift, the kitchen too crowded to cook in, the culinary knowledge that was left behind in another country or another generation.

The most direct response to the transportation and scheduling barriers is also the most obvious: move the process online. Several states have begun piloting online WIC grocery ordering through major retailers, and the logic is straightforward. If you can buy your approved items from home, the bus route becomes irrelevant. The USDA is working through the regulatory and fraud infrastructure, but the pilots remain limited and the transition slow. It is a promising direction held back by the precision that makes the programme work in the first place.

These are not programme failures. They are a description of what participants’ lives actually contain, and what any serious food intervention has to reckon with.

Forty percent of American families with young children qualify for this programme. Most people could not tell you it exists. That alone is worth sitting with.

Further reading

WIC Proven Outcomes, National WIC Association, 2025: https://media.nwica.org/proven-outcomes.pdf

National and State-Level Estimates of WIC Eligibility and Program Reach in 2023, USDA Food and Nutrition Service: https://www.fns.usda.gov/research/wic/eer/2023

Barriers and Enablers to WIC Participation: Review of Evidence From Studies Published Between 2019 and 2024, PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC12718199/

Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity, PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC10827651/

Examination of an Online Cooking Education Program among WIC Participants, PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC10574281/

Nianogo et al., Economic evaluation of California prenatal WIC participation, Preventive Medicine, 2019: https://www.sciencedirect.com/science/article/abs/pii/S0091743519301355

WIC Online Ordering and Transactions Proposed Rule, USDA Food and Nutrition Service: https://www.fns.usda.gov/wic/online-ordering-transaction-proposed-rule-qas

WIC Farmers Market Nutrition Program, USDA Food and Nutrition Service: https://www.fns.usda.gov/fmnp/wic-farmers-market-nutrition-program

Trump admin quietly funds some nutrition aid for low-income moms and babies, Politico, 2025: https://www.yahoo.com/news/articles/trump-admin-quietly-funds-nutrition-165819097.html

At the company where I work, whose founding purpose is the idea that food should make people healthier, there is a candy bar in the kitchen, sitting alongside the free yogurt, the mineral water and the fresh fruit. It is perpetually restocked. Everyone reaches for it. I am partial to it too. What struck me was not the candy bar itself. It was the ease of it. Sweet, fatty, instant, requiring nothing of you; no preparation, no occasion, no pause. And the more I sat with that observation, the more I wondered whether it was telling me something I had been slow to articulate about American food culture, and where it comes from.

We tend to forget how young America is. As countries go, it is practically a teenager. The food cultures we think of as deep and settled (Italian, Chinese, Japanese, Mexican and many more) developed over centuries of people staying in one place, learning what grew nearby, cooking what their grandmothers cooked, building rituals around the table that accumulated meaning across generations. That takes time. It takes roots. America has not had that time, and its founders arrived having already left their roots behind.

America’s founders did not arrive with roots. They arrived having left them behind, having had to. The Irish who survived a famine, the Eastern Europeans who fled poverty, the generations of migrants who crossed an ocean and built something entirely new from the materials available. For people who had known genuine scarcity, abundance was not an excess. It was the proof that the journey had been worth it. The full table, the clean plate, the candy bowl on every surface: not a failure of willpower, but the residue of a founding promise. More was safety. More was arrival.

The Puritan inheritance added a different layer. The early settlers brought with them a deep moral suspicion of sensory pleasure, including the pleasure of eating. Food was fuel for God’s work, not an end in itself. That inheritance has faded but not disappeared; it survives as a cultural instinct that eating is primarily a functional act. The writer Michael Pollan called its modern expression “nutritionism”: the ideology that reduces food to its chemical components, that sees a meal as a nutrient delivery system rather than a cultural event. Once you think in nutrients rather than food, you can put a health claim on anything. The vitamin water. The protein bar that is, underneath the packaging, a candy bar. The protein foam topped frapuccino. Nutritionism is Puritanism in a lab coat, and it is extraordinarily useful to the processed food industry, which can add nutrients to anything and call it healthy.

Speed completed the picture. America built itself on productivity, and the cultural pricing of time here is unlike anything I encountered in France or China. The drive-through was not a compromise. It was an innovation, a rational solution for a country that runs on efficiency and treats a two-hour lunch as an indulgence nobody can afford. Fast food is what you get when you optimise for convenience in a country always in a hurry, raising children who learn that food is something you eat quickly, between other things, without ceremony.

There is a French concept that holds all of this together. Hors sol. Literally, it means soilless: the term for hydroponic growing, plants raised without earth. As a metaphor: a country without terroir, without the deep roots in a particular place and its seasons and its history that produce a food culture. Les États-Unis sont un pays hors sol. Not a criticism. A description. A country that never had the chance to develop terroir, because its people were always arriving from somewhere else, always building something new, always leaving the old kitchen behind.

This is, of course, a generalisation. There are extraordinary pockets of food culture in America; the farms of Vermont, the wine country of California, the craft producers who have built something as rooted and particular as anything in the old world. But these remain exceptions, and they tend to cluster where cultural and economic capital is highest. The mainstream food culture, the one that fills the meeting room candy bowl and shapes thirty million school lunches, is a different story. The candy bar, sweet and instant and requiring nothing, is perfectly adapted to that mainstream. It always was.

Take everything above and apply it to thirty million children a day.

The school cafeteria is where a food culture meets the next generation. It is the place where what a society believes about food (consciously or not) is transmitted to the children who will carry it forward. In America, that transmission includes, in the corridors of most middle and high schools, a vending machine. Before recent regulatory intervention, 70 percent of drinks in school vending machines were sugary, and candy, chips and sweet baked goods accounted for 80 percent of snack options. Of nearly 10,000 snack slots surveyed, 26 contained fruit or vegetables.

Sweet. Instant. Convenient. Available without occasion. The meeting room, scaled down to age twelve and installed in a corridor.

The current administration and its MAHA initiative has correctly identified that ultra-processed food in schools is a problem. The childhood chronic disease data is real. The intent is genuine. But every serious attempt to change what children eat has arrived at the same conclusion: you cannot change the tray without changing what surrounds the tray. What children eat at home. What their parents cook, or do not cook. What the culture around them treats as normal. How much time is allocated to eating as an activity worth doing.

Some countries have built school meal cultures that treat the lunch table as a classroom where children learn about taste, seasonality and culinary tradition as a formal part of their education, and where time allocated to eating is considered as important as the food itself. None of that was built quickly, and none of it happened through a menu update alone. (And before anyone points to France as the obvious model: France is also the second largest fast food market in the world after the United States. Food culture is always more complicated than the postcard version.)

The scope of the solution is larger than the budget currently allocated to it, and the cuts to the Local Food for Schools programme are moving in the wrong direction for exactly that reason. What would actually shift the needle over time: cooking in the curriculum, time built into the school day for eating as a ritual rather than a refuelling stop, and the kind of sustained cultural investment that gives a child a different relationship to food before the vending machine gets there first.

That is a generational project, not an administration’s.

The candy bar in the office kitchen is a measure of how deep the work needs to go. The people who reach for it are not hypocrites. They are human beings operating inside a culture shaped by immigrant abundance, Puritan utility, nutritionist rationalisation and the permanent pressure of not enough time. A culture that took a century to build, in a country that is still, in food terms, very young.

Changing that (genuinely, durably, at scale) is the most ambitious public health project imaginable. The fact that anyone is asking the question federally, for thirty million children, is the beginning of something worth taking seriously.

The tray is just where you start.

Further reading

Michael Pollan, In Defense of Food: An Eater’s Manifesto, 2008.

School Meals Case Study: France, School Meals Coalition: https://schoolmealscoalition.org/sites/default/files/2024-05/Avallone_etal_2023_School_Meals_Case_Study_France_.pdf

MAHA Groups Push USDA to Overhaul School Lunches, But Costs Loom Large: https://www.dtnpf.com/agriculture/web/ag/news/article/2026/04/06/maha-groups-push-usda-overhaul-costs

Foods Sold in School Vending Machines are Associated with Overall Student Dietary Intake, PMC: https://pmc.ncbi.nlm.nih.gov/articles/PMC3011970/

Trump Admin. Cuts Program That Brought Local Food to School Cafeterias, Education Week: https://www.edweek.org/policy-politics/trump-admin-cuts-program-that-brought-local-food-to-school-cafeterias/2025/03

I had been in the United States for about six months when I first registered what I was looking at. I had driven past it several times before that without quite seeing it. And then one Saturday morning it clicked. This was an advertisement. A hospital was advertising at me, at speed, on a highway.

I filed it away and drove on.

A few months later, I attended a medical conference in the city. I had expected the usual format: panels, papers, a moderator keeping time. What I found was closer to a trade fair. There were booths. Large, well-funded booths, staffed by people in lanyards, with printed materials and branded tote bags and, in at least one case, a branded coffee station. The booths were not pharmaceutical companies. They were hospitals. Major health systems, presenting themselves to the attending physicians with the unmistakable energy of companies looking for referrals and recruits. Come work here. Send your patients here. We are, as it happens, ranked “Number 1.”

I stood in the middle of it and understood something. The billboard and the booth are the same thing. A commercial system markets itself at every level: outward to patients, inward to the professionals who generate its revenue. This is not a dysfunction. This is the design.

Let me say something that most commentary on American healthcare does not say, because it requires holding two things simultaneously: the American healthcare system is exceptional at the top and unavailable at the bottom. Those are different problems with different solutions, and collapsing them into a single verdict (broken, or fine, depending on your politics) makes both harder to fix.

The system that produced the billboard also produced the most sophisticated medical infrastructure on earth. Drugs arrive here first. Between 2010 and 2019, 95 percent of new oncology therapies were approved in the United States before Europe. The FDA’s median review time is 200 days; the European Medicines Agency takes 426, according to a 2024 review in the British Journal of Pharmacology. In 2024 alone, the FDA approved 50 novel drugs that had never been approved anywhere before. When a Canadian with blood cancer needs stem-cell therapy that the Ontario hospital system cannot provide quickly enough, they are sent (by their own public system) to Buffalo, Cleveland, or Detroit. A 2023 Ipsos poll found that 42 percent of Canadians say they would cross the border and pay out of pocket for care they could not access at home in time. They are not wrong to consider it.

The incentive to compete, to market, to rank “Number 1” in the region for cardiac care, runs all the way through: to investment in equipment, to recruitment of the best surgeons, to the research culture that fills conference halls with fellows presenting posters. The billboard is, in a specific and important sense, honest.

Now look at the cancer survival data. The United States five-year cancer survival rate has risen from 49 percent in the mid-1970s to 68 percent today. That aggregate figure is real. It is also a blended number that flattens the system. Break it down by insurance type and the picture sharpens considerably. For colorectal cancer, the American Cancer Society found that privately insured Americans survive at 63 percent at five years, ahead of the European average of around 57 percent. Uninsured Americans survive at 49 percent, below it. For breast cancer, the US aggregate of 84 percent is comparable to Western Europe — but the gap is not between countries, it is inside this one. The innovation is genuine and the outcomes for those inside the system are exceptional. The aggregate just hides who is and who is not inside the system.

Now the other side of the ledger.

Within the same system, a patient’s insurance status predicts their cancer outcome more reliably than almost any other variable. A 2025 meta-analysis in the International Journal for Equity in Health found that Medicaid patients have a 39 percent higher risk of death from cancer than privately insured patients, and uninsured patients 42 percent higher. A 2022 study in CA: A Cancer Journal for Clinicians found that patients on Medicaid are 76 percent more likely to receive a late-stage breast cancer diagnosis than privately insured patients: a late-stage diagnosis is frequently the difference between treatment and palliation.

The most arresting figure in the research literature: an uninsured patient diagnosed with Stage I cancer has worse survival than a privately insured patient diagnosed with Stage II cancer. The system is so good that being inside it at a lower stage saves you. Being outside it, even at the earliest stage, does not.

The cancer numbers are stark, but they are not the whole picture. The disadvantage runs across the system. Medicaid patients have higher complication rates after surgery, lower rates of specialist referral, and significantly worse access to a primary care physician in the first place: roughly one in three US physicians does not accept new Medicaid patients, compared to fewer than one in twenty who turn away Medicare or privately insured patients. For many Medicaid patients, the emergency room functions as a primary care clinic, because it is the one point in the system legally required to treat them. The inequality is not a cancer story. It is a structural story, visible in every specialty and every stage of care.

A 2018 study in Cancer found that improvements in survival over the past decade have been “almost exclusively limited” to patients with private or Medicare insurance. For those on Medicaid or uninsured, survival has been largely unchanged. Two populations. One system. Diverging trajectories.

The billboard on the highway is for the 54 percent of Americans with employer-sponsored insurance, the ones for whom the commercial system mostly works, expensively but effectively. Expensively is doing a lot of work in that sentence. Medical costs are the leading cause of personal bankruptcy in the United States, and research published in the American Journal of Public Health in 2019 found that in the majority of those cases, the person filing had insurance when they first got sick. A typical employer plan carries a deductible of around $1,600 and an annual out-of-pocket maximum approaching $9,000. A serious diagnosis, even with good coverage, routinely generates five-figure personal costs. The commercial system works. For some of the 54 percent, it works them into bankruptcy.

It is not, in any meaningful sense, for the 37 percent on Medicare and Medicaid (the old and the poor, to be blunt about it, which is not the polite way to say it but is accurate) who access a version of the same system at reimbursement rates that leave most hospitals losing money on every public-payer patient they treat. The infrastructure exists. The access gate does not open equally.

Even within that 37 percent, the trajectories split. Medicare patients (older, with decades of prior insurance behind them and established relationships inside the system) have shared in some of the survival gains. Medicaid patients largely have not. They are nominally in the same category. They are not in the same system.

In France, you go to your local public hospital. The billboard does not exist because the concept it advertises does not exist: a hospital competing for your business is not a thought the system is designed to produce. The care is good. It is not the best in the world for the hardest cases. It is reliably available for everyone.

The question the American system has never fully answered is whether you can have both. Whether the innovation engine that produces the world’s best cancer outcomes for the privately insured can coexist with universal access, or whether the commercial logic that powers one makes the other structurally impossible. There is perhaps a third possibility that the question of access looks different if fewer people need the hospital in the first place. The Centers for Medicare and Medicaid Services has quietly begun testing exactly that idea, funding lifestyle medicine interventions for Medicare beneficiaries on the premise that prevention at scale might do what the billing system cannot. It is an early experiment. It is worth watching.

Further reading

American Cancer Society, Better Cancer Survival Requires Better Health Insurance: https://www.cancer.org/research/acs-research-highlights/cancer-health-disparities-research/better-cancer-survival-requires-better-health-insurance.html

Zhao et al., Health insurance status and cancer stage at diagnosis and survival in the United States, CA: A Cancer Journal for Clinicians, 2022: https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21732

Association of insurance status among cancer patients and survival outcomes: a systematic review and meta-analysis, International Journal for Equity in Health, 2025: https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-025-02629-6

Study finds improvements in cancer survival for privately insured and Medicare patients, but not others, Cancer, 2018: https://acsjournals.onlinelibrary.wiley.com/doi/full/10.1002/cncr.31514

Himmelstein et al., Medical bankruptcy in the United States, American Journal of Public Health, 2019: https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305007

Novel drugs approved by the EMA, the FDA and the MHRA in 2023, British Journal of Pharmacology, 2024: https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bph.16337

Would you cross the border for health care? 42% of Canadians say yes, Global News / Ipsos, 2023: https://globalnews.ca/news/10322678/health-care-canada-us-ipsos-poll/

America, I concluded, had no protein problem.

And then I looked at the shelves.

The average American adult male consumes approximately 95 grams of protein a day.[1] The average adult female, around 70 grams. Both figures comfortably meet, and in many cases exceed, the recommended daily intake. According to the National Health and Nutrition Examination Survey, protein deficiency in the United States is, in clinical terms, next to impossible outside of famine or severe illness.[2] It is not, to be clear, a documented public health problem.

Someone had apparently forgotten to tell the market.

The global protein-fortified food products industry was valued at $66.8 billion in 2023 and is on its way to $101 billion by 2030.[3] Protein snacks alone — bars, balls, chips, clusters of things engineered to look like snacks but branded as supplementation — are projected to reach $42 billion by 2034, up from $21 billion today.[4] Protein has migrated out of the gym and into the coffee aisle, the water aisle, the pasta aisle, the yogurt aisle. There is protein-enriched bread. There is protein water. I have seen, with my own eyes, protein-enhanced hummus. The hummus, I would note, was already,by its very nature, being made of chickpeas, a meaningful source of protein. The label did not seem to consider this relevant.

What is being sold, I have come to understand, is not protein. It is the anxiety that you might not have enough of it.

So where is the alarm coming from? The data tells a more specific story than the marketing suggests, though it does depend, as I discovered, on which guidelines you use, and that turns out to be its own story.

For most of the period during which the protein anxiety industry was built, the recommended daily intake for adults was 0.8 grams of protein per kilogram of body weight; a floor, not a target, designed to prevent deficiency. Against that number, Americans look robustly well-fed. Young men consume around 1.5 grams per kilogram, nearly double the recommendation. Young women, around 1.2 grams. Middle-aged adults of both sexes come in well above. Even older adults, at roughly 1.0 gram, clear the threshold comfortably.[5]

Then, in January 2026, the new dietary guidelines raised the recommendation to between 1.2 and 1.6 grams per kilogram, 50 to 100 percent higher than before. Against this new target, the picture shifts. Young men and women land squarely within the recommended range. Adults over fifty (men and women alike) fall below it. The goalpost moved, and in moving, it did something convenient: it transformed a country of adequate protein consumers into a country with a protein gap.

I want to be careful here. The science is genuinely unsettled. There is real evidence that the old 0.8 gram threshold was always a minimum rather than an optimal, and that muscle preservation in aging adults may require more than the old guidance suggested. These are legitimate debates among serious scientists.[6] But it is also true that regardless of which number you apply, the population most saturated with protein anxiety (active, well-nourished adults in their thirties and forties) falls comfortably within range under either set of guidelines. There is no protein under-consumption problem for the majority of Americans. What changed is the official framing. It arrived, as markets do, fully prepared: among its more recent innovations is a protein cold foam frappuccino. I have no objection to cold foam. I do, gently, note that the cold foam contains more sugar than the protein it delivers is worth worrying about. But this is perhaps not the point.

The protein anxiety, in other words, has found its largest and most lucrative audience in exactly the population that needs it least.

In China, where I lived for years before arriving here, protein was equally present (duck, pork, tofu, fish, egg) but minced, chopped, folded into dishes alongside vegetables and rice, distributed through the meal rather than dominating it. You eat with chopsticks; nothing arrives in a portion that requires a knife. Nobody was anxious. Nobody was tracking grams. The protein was there; it simply did not announce itself [A small footnote: my children, raised across Asia, got to America and did not know how to use a knife and fork properly. They had eaten everything, for years, from bowls with spoons. My French forebears, I am certain, are turning in their graves.]

But the cultural logic is not really about nutrition. It is about competition. Scroll any wellness feed, not just the ones aimed at women, and the message is the same: get stronger or get left behind. The imagery is of performance, not health. Lean bodies lifting things, running things, optimising things. The protein bar is not a supplement. It is a signal, that you are not coasting, not softening, not yielding ground in a society that reads physical effort as moral seriousness. This is not a women’s issue or an aging issue. It is an American issue. The country that turned sport into a last bastion of acceptable competitiveness, as I wrote about a few weeks ago, has also turned eating into a performance category. You do not simply have lunch. You hit your macros.

There is, however, a small inconvenient detail that the protein industry tends not to dwell on: eating more protein is not the same as getting stronger. Muscle is built in response to mechanical load; the actual, un-glamorous, day-in-day-out work of the gym, the field, the track. Protein provides the material; the stimulus has to come from somewhere else entirely, and it cannot be purchased at Starbucks. The bar signals effort. It does not replace it.

I find this genuinely interesting to write about, partly because I think the underlying drive (refuse to disappear, refuse to slow down) is not unreasonable, and partly because I have spent twenty-five years working in clinical nutrition for Danone, a company that manufactures a great deal of protein-enriched yogurt. I should be transparent about that. I have a declared interest in the answer to the question: which protein vehicle actually makes sense?

My honest answer, with that conflict fully on the table: not all protein matrices are equivalent, and the difference matters more than the marketing suggests. Greek yogurt (or any high-protein dairy fermented product) delivers protein alongside calcium, probiotics, and a satiety signal that is hard to replicate in a bar or a supplement. It is a food. A protein-enriched coffee drink, or a bag of chips with added whey, is a product engineered to carry a claim. The protein content may be identical on the label. The nutritional context around it is not.

The anxiety the influencer is selling is real. The solution she is selling is often arbitrary.

There is, I should note, a version of this story with a more sympathetic ending. The groups who do have elevated and often unmet protein needs are real: adults over 65 losing muscle mass, teenage girls systematically under-eating, people recovering from illness or surgery, and, increasingly, the growing number of people on GLP-1 medications, who are eating significantly less overall and risk losing muscle alongside fat if protein intake isn’t actively managed.[5] Still a relatively small share of the population for now, though the numbers are moving fast. The mainstream obsession with protein, for all its manufactured anxiety, has arguably made it culturally acceptable to prioritise nutrient density in a way that was not always true.

But the machine running on that anxiety is not calibrated for elderly women in recovery wards. It is calibrated for the thirty-five-year-old in midtown Manhattan who just ate a chicken caesar the size of a serving bowl, and is now reaching, with a vague sense of virtue, for a protein bar.

Which is how I have come to understand the protein paradox: not a country eating too little, but a country that has learned to feel insufficient regardless of how much it consumes. The Texas BBQ was a religious experience. The anxiety was optional. America chose both.

[1]: Current protein intake in America: analysis of the National Health and Nutrition Examination Survey, 2003–2004. American Journal of Clinical Nutrition, 2008. https://ajcn.nutrition.org/article/S0002-9165(23)23663-1/fulltext

[2]: How Common Is Protein Deficiency? Center for Nutrition Studies. https://nutritionstudies.org/how-common-is-protein-deficiency/

[3]: Protein-Fortified Food Products Market Size Report, 2030. Grand View Research. https://www.grandviewresearch.com/industry-analysis/protein-fortified-food-products-market-report

[4]: 2024 Trends: Protein Fortification Fuels Product Innovation. AB Ingredients. https://abingredients.com/resources/articles/2024_trends_protein_fortification_fuels_product_innovation

[5]: Protein Intake of Adults, What We Eat in America, NHANES 2015–2016. USDA Food Surveys Research Group. https://www.ars.usda.gov/ARSUserFiles/80400530/pdf/DBrief/29_Protein_Intake_of_Adults_1516.pdf; see also Protein Intake of Adults, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK589212/

[6]: For the most balanced current summary of where the science sits, see: How much protein should we really be eating? Five things to know. Stanford Medicine, March 2026. https://med.stanford.edu/news/insights/2026/03/how-much-protein.html. For dissenting views on the new guidelines, see: Americans Don’t Need ‘Dramatically’ More Protein, Despite Officials’ Claims. FactCheck.org, February 2026. https://www.factcheck.org/2026/02/americans-dont-need-dramatically-more-protein-despite-officials-claims/

A brief confession before we begin: when we moved from Hong Kong to New York in the summer of 2024, I secured club transfers for all three of my children’s soccer teams before I had confirmed their school places. I want to be transparent about this. The schools were important. The soccer was non-negotiable. My children play travel soccer — for non-American readers, this means competitive, regionally or nationally organised teams, tournaments across state lines, and a level of parental commitment that Europeans tend to find either admirable or deeply alarming, depending on their temperament.

What I was less prepared for was the cooler.

About three months after arriving, I turned up to my youngest’s game — he was nine at the time — carrying what I considered a reasonable contribution to the sideline: orange slices, a small container of yogurt, a bag of mixed nuts, and water. The cooler that materialised from the other parents contained Gatorade in four flavours, individually wrapped fruit strips listing “fruit puree concentrate” as their primary ingredient, protein bars whose labels required reading glasses and a biochemistry degree to navigate, and a box of Lunchables — which I suspect was more a concession to a picky eater than a considered sports nutrition strategy, and which I mention mainly because it made me laugh. I should add, because it matters to the story: this is a Manhattan team. The sideline demographic runs heavily to finance and tech — parents who read nutritional labels on their own food, who have opinions about seed oils. And yet.

My orange slices were accepted with the polite tolerance extended to a foreign guest who has brought an unfamiliar wine. I stood there on a patch of turf, watching nine-year-olds work through their Gatorades (electric blue, which is not a colour that occurs naturally in any fruit I am aware of), and felt that particular species of confusion that has become, over the past year, quite familiar to me.

A standard 20-ounce bottle of Gatorade contains 34 grams of sugar — roughly equivalent to a can of Coca-Cola¹. The American Academy of Pediatrics states in its official guidance that water is “the appropriate first choice for hydration before, during, and after most exercise regimens” for children, and that sports drinks “offer little to no advantage over plain water for most children and adolescents”². This guidance exists. It is not, from what I can observe, widely consulted at Saturday morning soccer games. It is certainly not what is peddled by social media influencers, who warn of mortal danger lest you fail to replenish your electrolytes, even if your maximum exertion is one hour of yin yoga.

The broader context is worth pausing on. American children aged 6 to 11 currently derive approximately 65% of their daily calories from ultra-processed foods, according to CDC data published in 2025³. In 2020, children consumed an average of 8.2 snacks per day, up from 3 per day in 2004⁴. The sports drinks at the sideline are not an anomaly. They are a faithful cross-section of the American child’s diet, served al fresco on a patch of turf.

Gatorade was invented in 1965 at the University of Florida by scientists responding to a specific and urgent problem: the Gators football team was wilting in Florida heat, losing electrolytes at a rate that was visibly damaging their second-half performance. The first formula was reportedly so unpalatable that some players vomited after consuming it⁵. This detail matters: the drink was not designed to be pleasant. It was designed to work. A medical intervention for elite athletes under extreme physiological stress — not a refreshment for children who have just played forty minutes of recreational football on a mild October morning.

What happened between 1965 and the Manhattan sideline is the story of how American sports culture and the food industry found each other. A product developed for peak athletic performance was marketed, over sixty years and through a $1.6 billion annual advertising industry, as the default hydration for children in any organised sport whatsoever⁶. The logic, once you see it, is coherent within a culture that takes sport seriously: if elite athletes use it to win, and we want our children to compete, then our children should use it too. Performance requires optimisation. Optimisation begins at nine, apparently, with electric-blue sugar water.

The parents on that Manhattan sideline are not making irrational choices. They are making choices that are entirely legible within a culture that has decided sport is where you take things seriously. The Gatorades and the protein bars are, in their way, signals of commitment — we are not here to mess around, we are here to fuel athletes. That several of these athletes are still in primary school is a detail the logic does not pause on. I want to add that I am not opposed to Gatorade — my kids drink it occasionally, in hot weather and when they have a particularly intense sports day. Just not every training, every game.

The orange slice has a different origin, and I will admit I found it rather moving when I looked into it. The halftime orange tradition in junior sport dates to England in the 1950s, with some roots in WWII-era government nutrition initiatives — a public health response to wartime rationing that became, through repetition and habit, simply what you brought to a child’s game⁷. It spread to Australia, New Zealand, the United States. The NFL’s own game operations manual still requires each home team to provide “three dozen sliced oranges” for the visiting team at halftime⁸. Nobody invented the orange slice, nobody sold it, nobody needed a social media strategy to make children accept it. It was a piece of fruit. Children ate it. This was considered sufficient.

The replacement of the orange slice by the sports drink is not primarily a nutritional event. It is a cultural one.

The cultural thread underneath this runs deeper than marketing. In a study published in Appetite in 1999, Paul Rozin and colleagues at the University of Pennsylvania surveyed adults across the United States, France, Flemish Belgium, and Japan on their attitudes toward food⁹. The finding was unambiguous: the group that most associates food with health and least associates it with pleasure is Americans. The group most food-pleasure-oriented and least food-health-oriented is the French. There is an additional detail from the same study that I find almost poignant: Americans, who do the most to alter their diet in the service of health, are the least likely to classify themselves as healthy eaters. The anxiety is, apparently, inexhaustible.

American culture has carried, since its Puritan origins, a discomfort with appetite as pleasure — the stomach as something to be disciplined, food as a moral test rather than one of life’s reliable satisfactions¹⁰. This theology secularised over centuries but its structure remained. What emerged in the twentieth century was what the writer Michael Pollan calls “nutritionism” — the reduction of food to its component nutrients, stripped of culture, pleasure, and context, leaving only the functional question of whether the inputs are optimised. Not food, but a protein delivery system. Not a drink, but an electrolyte vehicle. The Gatorade on the soccer sideline is, in a long line of cultural descent, a Puritan document: we are not here to enjoy a piece of fruit. We are here to fuel a performance.

There is a sideline observation I want to flag here, though it deserves its own piece in the future. Research consistently shows that recent immigrants to the United States arrive eating considerably better than the native-born population — more fruit, more vegetables, less ultra-processed food. Within five to ten years, this advantage erodes. Ultra-processed food consumption rises with acculturation, and the likelihood of eating fruit on a given day falls measurably with time spent in the country¹¹. As a relatively recent arrival, I am, apparently, already mid-race, without having registered to compete.

I want to introduce a comparison that I suspect is unfamiliar to most American readers. Pocari Sweat — the milky white Japanese drink that is ubiquitous across Asia, and that my children drank after hiking and soccer in the oppressive Hong Kong heat — was developed in 1980 by Otsuka Pharmaceutical, a drug company, around the concept of a “drinkable IV”: a beverage that matched the electrolyte and fluid composition of the human body as closely as possible¹². Researchers ran over a thousand test formulas, calibrating sodium, potassium, and citrate ratios until the result approximated what the body naturally loses when it sweats. The lower sugar content — 4.6 grams per 100ml, compared to Gatorade’s 6.8 grams — is a direct consequence: to match body fluid osmolarity, you do not need as much sugar as American drinks have normalised¹³. The goal was not performance optimisation. It was restoration — returning the body to its natural equilibrium.

Two drinks, both developed from science, separated by a decade and a Pacific Ocean. The American one is about winning the second half. The Japanese one is about coming back to balance. I am not arguing that one culture is superior. I am suggesting that what ends up in the cooler is never just a beverage decision.

I want to be careful, at this point, not to sound like someone who arrived in America with conclusions already packed.

One of the genuine surprises of living here has been how quickly I fell in love with the energy of this country — the appetite for competition, the willingness to take risks, the belief that wanting to win is not something to apologise for. Sport is where this shows up most clearly and most honestly. In Europe, junior sport is largely recreational — a word that, I have learned, functions in American English somewhere between a mild insult and a diagnosis. My children have thrived in the American system, and I am genuinely grateful for it.

There are also pockets of extraordinary food culture in this country — farmers’ markets of real abundance, regional cuisines of genuine sophistication, a growing community of people who think carefully about what they eat and where it comes from. Our family exists, and has chosen to exist, firmly outside of mainstream American food culture. I am aware this is a choice, and not a neutral one — it requires time, cultural inheritance, and access that are not equally distributed. That inequality is, in fact, much of what this newsletter is about.

What the cooler at the sideline reveals is not simply that American children drink too much sugar during sport. It reveals something about the broader cultural relationship with food: that nourishment has been subordinated to performance, that pleasure has been replaced by optimisation or convenience, and that the industry which understood this earliest has been shaping children’s relationship with food for sixty years — expensively, deliberately, and with considerable success. The orange slice did not require a $1.6 billion advertising budget. It was just a good thing to eat after running around.

I will keep bringing it. I have made my peace with being that weird parent.

Next issue: The Protein Paradox — America already consumes more protein per capita than almost any country on earth. So why does everything from coffee to water now contain added protein, and who decided nobody was getting enough?

References

¹ Gatorade (20 fl oz): 34g sugar per bottle. Nutritionvalue.org

² American Academy of Pediatrics on sports drinks and children. Via Real Mom Nutrition

³ CDC Data Brief No. 536, August 2025: children aged 6–11 derive 64.8% of daily calories from ultra-processed foods. CDC NCHS

⁴ Children’s snacking: average 8.2 snacks per day in 2020, up from 3 per day in 2004. State of Childhood Obesity

⁵ History of Gatorade, University of Florida, 1965. History.com

⁶ Sports drink advertising increased 745% from 2013 to 2018; food companies spend $1.6 billion annually marketing to youth. Marketing Food and Beverages to Youth Through Sports, PMC

⁷ Halftime orange tradition, England, 1950s, WWII nutrition origins. Spond

⁸ NFL game operations manual: three dozen sliced oranges for visiting team at halftime. The Takeout

⁹ Rozin, P., Fischler, C., Imada, S., Sarubin, A., & Wrzesniewski, A. (1999). Attitudes to food and the role of food in life in the U.S.A., Japan, Flemish Belgium and France: possible implications for the diet-health debate. Appetite, 33(2), 163–180. PubMed

¹⁰ Puritanism and American food culture. The Food Storyteller

¹¹ Immigrant dietary acculturation: new arrivals eat more fruit and vegetables than native-born Americans; ultra-processed food consumption rises with time spent in the US. Frontiers in Public Health, 2025; USDA Economic Research Service

¹² Pocari Sweat development and “drinkable IV” concept. Otsuka Pharmaceutical

¹³ Sugar content comparison: Pocari Sweat 4.6g/100ml vs Gatorade 6.8g/100ml. DrinkBetterNow

I moved to the United States in mid-June 2024, after a decade in Asia and a life spread across three European countries before that. I arrived with what I believed was a reasonable degree of cultural open-mindedness — I had, after all, navigated Shanghai traffic, given birth in the Netherlands without pain relief, acclimated to Australian laid-back culture, lived through Covid in Hong Kong, and managed the particular chaos of international school admissions across four countries. How complicated could America be?

I should mention, at this point, that I work in food and clinical nutrition. Have done for twenty-five years. I have strong opinions about what goes into people’s bodies and why. I arrived in the US genuinely curious about its health system — the world’s most innovative, and also, depending on who you ask, the world’s most baffling. I had Things To Learn. I was Ready.

Three weeks in, a glass shower panel in our rental home fell off the wall and shattered in the bathtub where my son was standing. He did what anyone would do and ran, which is how the undersides of both feet found every shard on the way out. Ambulance, emergency room, a long night of wound cleaning and tests for potential ligament damage -no fun for a soccer player- and a child who was considerably calmer about the whole thing than his parents.

Here is what I was not prepared for: sitting in that ER, my son finally settled, and realising that I had absolutely no idea what this was going to cost. Our health insurance had not yet transferred from China to the US. I did not know if the new policy covered this. I did not know if it covered anything. I found myself doing the mental arithmetic that — I now understand — millions of Americans do routinely, as a matter of course, every time they consider whether to seek care. I had never had to do it before. Not in France. Not in the EU. Not in Australia. Not in China. The care that night was excellent. The uncertainty was a different kind of pain, and a genuinely humbling introduction to a system I thought I understood from the outside.

The second lesson arrived more quietly, and took longer to recognise for what it was.

Within six months of landing, my husband and I had both put on weight. Not a catastrophic amount — enough to feel in the waistband, enough to have the slightly awkward conversation that couples have when they both notice at the same time. We were cooking at home most nights, which is what we have always done. Same habits, roughly the same recipes. We had just changed our ingredient sourcing and embraced a few too many take-aways along the way.

And then we noticed the dog was getting heavy too.

I want to be clear that our dog is not a stress eater. He does not negotiate with himself about dessert or comfort himself with snacks. He eats what he is given (fancy pants premium dog food), he gets walked, and he had been doing both of those things in exactly the same way he had in Hong Kong. He was, objectively, rounder. At that point I stopped attributing everything to the stress of relocation and started reading labels more carefully.

I had, for years, assumed that the European critique of American food was mostly cultural snobbery — the French being the French, suspicious of anything that didn’t involve a two-hour lunch. I had lived in countries with extraordinary food cultures and I assumed I would find the same richness here. What I found instead, on closer inspection, was a food system optimised so thoroughly for shelf life, palatability, and cost efficiency that the gap between what something tasted like and what it actually contained had become, in many product categories, almost impossible to detect without a chemistry degree. The calories were extraordinary (600 kcal choc chip cookies ! 900 kcal milkshakes !). The ingredient lists were long. And the cultural infrastructure that might naturally push back against this — the cooking traditions, the shared mealtimes, the passing down of knowledge about what food is actually for — had, somewhere along the way, been largely replaced by convenience and portion sizes that I still find genuinely startling.

I say this, I should note, as someone whose company makes food for a living. I am not arriving here from a position of innocence.

These two experiences — the ER bill I still didn’t fully understand three months later, and the dog who had somehow caught my husband’s expanding waistline — gave me the frame for what I want to think through in this newsletter.

American healthcare, at its best, is the most sophisticated in the world. The clinical excellence here is real. The innovation infrastructure is genuinely without peer. What the system struggles with is not competence — it is access, and it is the question of what happens before people need that competence at all. Prevention. The upstream. The part of health that lives not in hospitals but in kitchens, in habits, in what a culture collectively believes food is for.

That is what The Health Arbitrage wants to sit with. I am not a clinician, and I am not a policy expert. I am someone who has spent twenty-five years in food and nutrition, who has now lived on four continents, and who arrived in this country genuinely curious — and has been surprised, more than once, by what she found. I have questions I am still working out. I suspect you might recognise a few of them.

Welcome. Mind the shower panels.