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Tag: coming years

  • Older Americans Are About to Lose a Lot of Weight

    Older Americans Are About to Lose a Lot of Weight

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    Imagine an older man goes in to see his doctor. He’s 72 years old and moderately overweight: 5-foot-10, 190 pounds. His blood tests show high levels of triglycerides. Given his BMI—27.3—the man qualifies for taking semaglutide or tirzepatide, two of the wildly popular injectable drugs for diabetes and obesity that have produced dramatic weight loss in clinical trials. So he asks for a prescription, because his 50th college reunion is approaching and he’d like to get back to his freshman-year weight.

    He certainly could use these drugs to lose weight, says Thomas Wadden, a clinical psychologist and obesity researcher at the University of Pennsylvania, who recently laid out this hypothetical in an academic paper. But should he? And what about the tens of millions of Americans 65 and older who aren’t simply trying to slim down for a cocktail party, but live with diagnosable obesity? Should they be on Wegovy or Zepbound?

    Already, seniors make up 26.6 percent of the people who have been prescribed these and other GLP-1 agonists, including Ozempic, since 2018, according to a report from Truveta, which draws data from a large network of health-care systems. In the coming years, that proportion could rise even higher: The bipartisan Treat and Reduce Obesity Act, introduced in Congress last July, would allow Medicare to cover drug treatments for obesity among its roughly 50 million Part D enrollees above the age of 65; in principle, about two-fifths of that number would qualify as patients. Even if this law doesn’t pass (and it’s been introduced half a dozen times since 2012), America’s retirees will continue to be prescribed these drugs for diabetes in enormous numbers, and they’ll be losing weight on them as well. One way or another, the Boomers will be giving shape to our Ozempic Age.

    Economists say the cost to Medicare of giving new drugs for obesity to just a fraction of this aging generation would be staggering—$13.6 billion a year, according to an estimate published in The New England Journal of Medicine last March. But the health effects of such a program might also be unsettling. Until recently, the very notion of prescribing any form of weight loss whatsoever to an elderly patient—i.e., someone 65 or older—was considered suspect, even dangerous. “Advising weight loss in obese older adults is still shunned in the medical community,” the geriatric endocrinologist Dennis Villareal and his co-authors wrote in a 2013 “review of the controversy” for a medical journal. More than a decade later, clinicians are still struggling to reach consensus on safety, Villareal told me.

    Ample research shows that interventions for seniors with obesity can resolve associated complications. Wadden helped run a years-long, randomized trial of dramatic calorie reduction—using liquid meal replacements, in part—and stringent exercise advice for thousands of overweight adults with type 2 diabetes. “Clearly the people who were older did have benefits in terms of improved glycemic control and blood-pressure control,” he told me. Other, smaller studies led by Villareal find that older people who succeed at losing weight through diet and exercise end up feeling more robust.

    Such outcomes are significant on their own terms, says John Batsis, who treats and studies geriatric obesity at the UNC School of Medicine. “When we talk about older adults, we really need to be thinking about what’s important to older adults,” he told me. “It’s for them to be able to get on the floor and play with their grandchildren, or to be able to walk down the hallway without being completely exhausted.” But weight loss can also have adverse effects. When a person addresses their obesity through dieting alone, as much as 25 percent of the weight they lose derives from loss of muscle, bone, and other fat-free tissue. For seniors who, through natural aging, are already near the threshold of developing a functional impairment, a sudden drop like this could be enfeebling. Wadden’s trial found that, among the people who were on the weight-loss program for more than a decade, their risk of fracture to the hip, shoulder, upper arm, or pelvis increased by 39 percent. An analogous increase has turned up in studies of patients who undergo bariatric surgery, Batsis told me.

    Read: Ozempic makes you lose more than fat

    The effect of dieting on muscle and bone can be attenuated, but not prevented, through resistance training. And obesity itself—which is associated with higher bone density, but perhaps also reduced bone quality—may pose its own fracture risks, Batsis said. But even when a weight-loss treatment benefits an older patient, what happens when it ends? People tend to regain fat, but they don’t recover bone and muscle, Debra Waters, the director of gerontology research at the University of Otago, in New Zealand, told me. That makes the long-term effects of these interventions for older adults very murky. “What happens when they’re 80? Are they going to have really poor bone quality, and be at higher risk of fracture? We don’t know,” Waters said. “It’s a pretty big gamble to take, in my opinion.”

    Villareal told me that doctors should apply “the general principle of starting slow and going slow” when their older patients are trying to lose weight. But that approach doesn’t necessarily square with the rapid and remarkable weight loss seen in patients who are taking semaglutide or tirzepatide, which may produce a greater proportional loss of muscle and bone. (For semaglutide, it appears to be about 40 percent.)

    Then again, when given to laboratory animals, GLP-1 drugs seem to tamp down inflammation in the brain; and they’re now in clinical trials to see whether they might slow the progression of Alzheimer’s disease and dementia. Their multiple established benefits could also help seniors address several chronic problems—diabetes, obesity, fatty liver disease, and kidney disease, for instance—all at once. “Such a ‘one-stop shop’ approach can lead to reduction of medication burden, adverse drug events, hypoglycemic episodes, medication costs, and treatment nonadherence,” one team of geriatricians proposed in 2019.

    Overall, Batsis remains optimistic. “As a clinician, I’m very excited about these medications,” he told me. As a scientist, though, he’s inclined to wait and see. It’s surely true that some degree of weight loss is a great idea for some older patients. “But the million-dollar question is: What’s the sweet spot? How much weight is really enough? Is it 5 to 10 percent? Or is it 25 percent? We don’t know.” Waters said that if Medicare is going to pay for people’s Wegovy, then it should also cover scans of their body composition, to help predict how weight loss might affect their muscles and bones. Wadden said he thinks that treatments should be limited to people who have specific, weight-related complications. For everyone else—as for the hypothetical 72-year-old man who is prepping for his college reunion—he counsels prudence.

    To some extent, such advice is beside the point. Older people are already on Ozempic, and they’re already on Trulicity, and some of them are already taking GLP-1 drugs as a treatment for obesity. Truveta reported that the patients in its member health-care systems who are over 65 have received 281,000 prescriptions for GLP-1 drugs across the past five years. Given the network’s size, one can assume that at least 1 million seniors, overall, have already tried these medications. Millions more will try them in the years to come. If we still have questions about their use, mass experience will start providing answers.

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    Daniel Engber

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  • Plenty of People Could Quit Therapy Right Now

    Plenty of People Could Quit Therapy Right Now

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    About four years ago, a new patient came to see me for a psychiatric consultation because he felt stuck. He’d been in therapy for 15 years, despite the fact that the depression and anxiety that first drove him to seek help had long ago faded. Instead of working on problems related to his symptoms, he and his therapist chatted about his vacations, house renovations, and office gripes. His therapist had become, in effect, an expensive and especially supportive friend. And yet, when I asked if he was considering quitting treatment, he grew hesitant, even anxious. “It’s just baked into my life,” he told me.

    Among those who can afford it, regular psychotherapy is often viewed as a lifelong project, like working out or going to the dentist. Studies suggest that most therapy clients can measure their treatments in months instead of years, but a solid chunk of current and former patients expect therapy to last indefinitely. Therapists and clients alike, along with celebrities and media outlets, have endorsed the idea of going to therapy for extended stretches, or when you’re feeling fine. I’ve seen this myself with friends who are basically healthy and think of having a therapist as somewhat like having a physical trainer. The problem is, some of the most commonly sought versions of psychotherapy are simply not designed for long-term use.

    Therapy comes in many varieties, but they all share a common goal: to eventually end treatment because you feel and function well enough to thrive on your own. Stopping doesn’t even need to be permanent. If you’ve been going to therapy for a long time, and you’re no longer in acute distress, and you have few symptoms that bother you, consider taking a break. You might be pleasantly surprised by how much you learn about yourself.

    Therapy, in both the short and long term, can be life-altering. Short-term therapy tends to be focused on a particular problem, such as a depressed mood or social anxiety. In cognitive behavioral therapy, usually used for depressive and anxiety disorders, a clinician helps a client relieve negative feelings by correcting the distorted beliefs that he has about himself. In dialectical behavior therapy, commonly used to treat borderline personality disorder, patients learn skills to manage powerful emotions, which helps improve their mood and relationships. Both treatments typically last less than a year. If you start to get rusty or feel especially challenged by life events that come your way, you simply return for another brief stint. Termination is expected and normal.

    Read: What’s the smallest amount of therapy that’s still effective?

    Some types of therapy, such as psychodynamic therapy and psychoanalysis, are designed to last for several years—but not forever. The main goal of these therapies is much more ambitious than symptom relief; they aim to uncover the unconscious causes of suffering and to change a client’s fundamental character. At least one well-regarded study found that long-term therapy is both highly effective and superior to briefer treatment for people diagnosed with a clinically significant psychiatric illness; other papers have shown less conclusive evidence for long-term therapy. And few studies compare short and extended treatment for clients with milder symptoms.

    In fact, there’s reason to believe that talk therapy in the absence of acute symptoms may sometimes cause harm. Excessive self-focus—easily facilitated in a setting in which you’re literally paying to talk about your feelings—can increase your anxiety, especially when it substitutes for tangible actions. If your neurotic or depressive symptoms are relatively mild (meaning they don’t really interfere with your daily functioning), you might be better served by spending less time in a therapist’s office and more time connecting with friends, pursuing a hobby, or volunteering. Therapists are trained to use the tools they’ve learned for certain types of problems, and many of the stress-inducing minutiae of daily life are not among them. For example, if you mention to your therapist that you’re having trouble being efficient at work, he might decide to teach you a stress-reduction technique, but your colleagues or boss might provide more specific strategies for improving your performance.

    One of my childhood friends, whose parents were both psychoanalysts, went to weekly therapy appointments while we were growing up. He was a happy, energetic kid, but his parents wanted him and his sister to be better acquainted with their inner lives, to help them deal with whatever adversity came their way. My friend and his sister both grew up to be successful adults, but also highly anxious and neurotic ones. I imagine their parents would say the kids would have been worse without the therapy—after all, mental illness ran in their family. But I can find no substantial clinical evidence supporting this kind of “preventive” psychotherapy.

    Read: What it’s like to visit an existential therapist

    Beginning therapy in the first place is, to be clear, a privilege. Therapy is not covered by many insurance plans, and a very large number of people who could benefit from it can’t afford it for any duration. Only 47 percent of Americans with a psychiatric illness received any form of treatment in 2021; in fact, federal estimates suggest that the United States is several thousand mental-health professionals short, a gap that is likely to grow in the coming years. Stopping therapy when you’re ready opens up space for others who might need this scarce service more than you do.

    I do not mean to suggest that a therapy vacation should be considered lightly, or that it’s for everyone. If you have a serious mental-health disorder, such as major depression or bipolar disorder, you should discuss with your mental-health provider whether ending therapy is appropriate for your individual situation. (Keep in mind that your therapist might not be ready to quit when you are. Aside from a financial incentive to continue treatment, parting with a charming, low-maintenance patient is not so easy.) My rule of thumb is that you should have minimal to no symptoms of your illness for six months or so before even considering a pause. Should you and your therapist agree that stopping is reasonable, a temporary break with a clear expiration date is ideal. At any time, if you’re feeling worse, you can always go back.

    Psychiatrists do something similar with psychiatric meds: For example, when I prescribe a depressed patient an antidepressant, and then they remain stable and free of symptoms for several years, I usually consider tapering the medication to determine whether it’s still necessary for the patient’s well-being. I would do this only for patients who are at a low risk of relapse—for example, people who’ve had just one or two episodes, rather than many over a lifetime. Pausing therapy should be even less risky: The beautiful thing about therapy is that, unlike a drug, it equips you with new knowledge and skills, which you carry with you when you leave.

    Read: The quick therapy that actually works

    About a year after my patient and I first talked about ending therapy, I ran into him in a café. He told me that stopping had taken him six months, but now he was thriving. Maybe you, like my patient, are daunted by the idea of quitting cold turkey. If so, consider taking a vacation from treatment instead. It might be the perfect way to see how far you’ve really come.

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    Richard A. Friedman

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  • Red States Are Rolling Back the Rights Revolution

    Red States Are Rolling Back the Rights Revolution

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    The struggle over the sweeping red-state drive to roll back civil rights and liberties has primarily moved to the courts.

    Since 2021, Republican-controlled states have passed a swarm of laws to restrict voting rights, increase penalties for public protest, impose new restrictions on transgender youth, ban books, and limit what teachers, college professors, and employers can say about race, gender, and sexual orientation. Some states are even exploring options to potentially prosecute people who help women travel out of state to obtain an abortion.

    In the early legal skirmishing over this agenda, opponents including the federal Justice Department have won a surprising number of decisions, mostly in federal courts, blocking states from implementing the new laws.

    But eventually most of these issues are likely to be resolved by the U.S. Supreme Court, and the court’s six-member Republican-appointed majority has generally ruled in ways that favor the conservative social-policy priorities reflected in the red-state actions. That inclination was most dramatically demonstrated in last year’s Dobbs decision, when the Court overturned the constitutional right to abortion.

    In the coming years, the Court will face a series of decisions on the new red-state agenda that may determine whether the U.S. maintains a strong baseline of civil rights available in all states or reverts back toward a pre-1960s world where people’s rights varied much more depending on where they lived.

    “The idea of the Bill of Rights was that we would have a floor of civil rights and civil liberties that the states could not go below,” David Cole, the national legal director of the American Civil Liberties Union, told me. “But for that floor to be meaningful, it has to be enforced by the Supreme Court ultimately.

    “In our history, the courts have sometimes done that courageously and bravely, and other times they have fallen down on the job,” Cole continued. “And when they have fallen down on the job, you get a two-tier system in this country.”

    Since President Joe Biden’s election, the 22 states where Republicans hold unified control of the governorship and the state legislature have moved with remarkable speed to create a two-tier system on issues including abortion, classroom censorship, and the treatment of LGBTQ people. “The fact that all of this is happening on so many different fronts simultaneously is unprecedented,” Donald Kettl, a former dean and professor emeritus of the University of Maryland’s School of Public Policy, told me.

    This broad red-state push to retrench rights, as I’ve written, is reversing the general trend since the 1960s of nationalizing more rights, a process often called “the rights revolution.”

    Civil-rights advocates have limited options for reversing this tide of red-state legislation. So long as the Senate filibuster exists, Democrats have virtually no chance of passing national legislation to override the red-state actions on issues such as abortion and voting rights, even if the party regains unified control of the federal government after the 2024 elections.

    Read: Why Biden just can’t shake Trump in the polls

    In some states, opponents can try to rescind these measures directly through ballot initiatives, like the Ohio referendum that, if passed in November, would overturn the state’s six-week abortion ban. But not all states permit such referendums, and even in those that do, ballot measures to reverse many of the key red-state restrictions would face an uncertain fate given the underlying conservative lean of their electorates.

    Opponents are challenging some of the new statutes in state courts. The Center for Reproductive Rights, a group that supports legal abortion, has cases pending in six states, including Ohio, Wyoming, Iowa, and Florida, arguing that abortion restrictions adopted since the Dobbs decision violate provisions in those states’ constitutions. But recent rulings by state supreme courts—in South Carolina, upholding the state’s six-week abortion ban, and in Texas, dismissing an injunction against the state’s ban on gender-affirming care for transgender minors—show the limitations of relying on red-state courts to undo the work of red-state political leaders.

    “Sometimes the state courts provide a sympathetic venue,” Cole said. “But oftentimes in the red states, precisely because the courts have been appointed by red-state governors and legislatures, they are not especially open to challenges to their legislature’s laws.”

    That leaves federal courts as the principal arena for those hoping to overturn the restrictive red-state laws.

    These federal cases raise a range of legal arguments. Mostly they revolve around the claim that the state laws violate the U.S. Constitution’s protection of free speech in the First Amendment and the due process and equal protection provisions of the Fourteenth Amendment. As courts consider these claims, the key early federal rulings have covered cases involving a variety of issues.

    Freedom of speech: In a striking victory for critics, a federal district judge in Florida issued two decisions blocking enforcement of Florida Governor Ron DeSantis’s signature Stop WOKE Act, which restricts how private employers and college and university professors talk about racial inequity. In one ruling, Judge Mark Walker called the law “positively dystopian.” He wrote: “The powers in charge of Florida’s public university system have declared the state has unfettered authority to muzzle its professors in the name of ‘freedom.’”  The Eleventh Circuit Court of Appeals has denied DeSantis’s request to lift Walker’s injunction against the law while the case proceeds.

    Federal courts have also blocked enforcement of the Florida law DeSantis signed increasing the penalties for public protest. But another federal judge has twice dismissed a case attempting to block DeSantis’s “Don’t Say Gay” law restricting discussion of sexual orientation and gender identity in K–12 classrooms. (Opponents of the law are appealing that decision.)

    Litigation against the multiple red-state measures making it easier for critics to ban books in school libraries has not advanced as far. But in May, PEN America, a free-speech group, together with Penguin Random House and several authors filed a suit against Florida’s Escambia County school district over the removal of titles about people of color and LGBTQ people that could become the bellwether case.

    Abortion: Though the Supreme Court’s Dobbs decision preempted any frontal federal legal challenge to the state laws restricting or banning the procedure, abortion-rights supporters continue to fight elements of the new statutes.

    In late July, a federal district judge blocked guidance from Raúl Labrador, the Republican attorney general of Idaho, a state that has banned abortion, warning doctors that they could be prosecuted for helping patients travel out of state to obtain the procedure. A separate federal lawsuit filed in July is challenging Idaho’s law imposing criminal penalties on adults who transport a minor out of state to obtain an abortion. The Justice Department won an injunction last year preventing Idaho from enforcing another portion of its abortion ban on the grounds that it violates federal law requiring treatment of people needing emergency care in hospitals.

    “Dobbs overturned 50 years of precedent and got rid of the fundamental liberty right to abortion, but it definitely didn’t answer every question,” Amy Myrick, a senior staff attorney at the Center for Reproductive Rights, told me. “And federal courts are now being faced with a public-health crisis of enormous magnitude, so at some point they will have to decide whether a ban becomes irrational if it forces patients to get sick or even die based on what a state says.”

    Immigration: Another front in the red-state offensive is an increasing effort to seize control of immigration policy from the federal government. The Biden administration last week won a federal-district-court decision requiring Texas to remove a flotilla of buoys it has placed in the Rio Grande River to repel undocumented migrants (though the conservative Fifth Circuit Court of Appeals put that ruling on hold just one day later). A coalition of civil-rights groups is suing Florida in federal court over a DeSantis law making it a crime to transport an undocumented migrant in the state.

    Voting: As with abortion, critics have found a legal basis to challenge only provisions at the periphery of the voting restrictions approved in most red states since 2021. Last month, the Justice Department won a federal court ruling blocking a measure that Texas had passed making it easier for officials to reject absentee ballots. In July, a federal-district-court judge upheld key components of Georgia’s 2021 law making voting more difficult, but did partially overturn that law’s most controversial element: a ban on providing food and water to people waiting in line to vote.

    LGBTQ rights: Federal litigation has probably progressed most against the intertwined red-state moves to impose new restrictions on transgender people. The Biden Justice Department has joined cases seeking to overturn the red-state actions on each of the major issues.

    Two federal appellate courts have blocked policies requiring transgender students to use the bathroom (or locker room) of their gender assigned at birth, while the Eleventh Circuit late last year upheld such a law in Florida. Two federal circuit courts have also blocked the enforcement of laws in Idaho and West Virginia barring transgender girls from participating on female sports teams in high school, though a lower federal court has subsequently upheld the West Virginia law.

    Of all the issues affecting transgender people, litigation against the statutes passed in 22 Republican-controlled states barring gender-affirming care for minor children, even with their parents’ approval, may reach the Supreme Court first. In a flurry of decisions made mostly this summer, multiple federal district courts have issued injunctions blocking the implementation of such laws in several states. One federal appellate court has upheld such an injunction, but two others recently overturned lower-court rulings and allowed Tennessee and Alabama to put their laws into effect. (After those decisions, a federal district court last week also allowed Georgia to enforce its ban.) Such a split among circuit courts could encourage the Supreme Court to step in, as do the momentous and timely stakes for families facing choices about medical care. “For families who have adolescents who need this care, some of whom have been receiving this care, it’s a matter of family urgency,” Jennifer Pizer, the chief legal officer at Lambda Legal, a group that advocates for LGBTQ rights, told me.

    Although liberal groups and the Biden administration have been heartened by many of these early rulings, they recognize that the most significant legal fights are all rolling toward the same foreboding terminus: the Supreme Court.

    Over recent years, the Court has restricted the ability of blue states to impinge on rights that conservatives prize while mostly allowing red states to constrain rights that liberals prioritize. The Court has displayed the former instinct in its rulings striking down gun-control laws in blue jurisdictions, allowing religious-freedom exemptions to state civil-rights statutes, and barring public universities from using affirmative action. Conversely, the Court has loosened restrictions on red states with the Dobbs decision and the 2013 Shelby County ruling effectively revoking the Justice Department’s authority to preemptively block changes in state voting laws.

    Those who see this past as prologue believe that the current Supreme Court majority may provide the red states great leeway to establish a legal regime that defines rights much more narrowly than in the rest of the country. At various points in American history, the Supreme Court has certainly done that before, most notoriously in the 1896 Plessy v. Ferguson case, when the justices approved the system of “separate but equal” Jim Crow segregation across the South that persisted for nearly the next 70 years.

    But several legal experts I spoke with said it was premature to assume that these recent rulings ensure that the Supreme Court will reflexively uphold the contemporary wave of red-state measures. Erwin Chemerinsky, the dean of UC Berkeley’s law school, told me that the Court’s decisions in recent years have advanced “what’s been the conservative Republican agenda for decades: Overrule Roe v. Wade; eliminate affirmative action; protect gun rights.” It’s less clear, Chemerinsky believes, what the Court will do with this “new conservative agenda” rising from the red states. Although the six Republican-appointed justices are clearly sympathetic to conservative goals, he said, “some of what the [states] are doing is so radical, I don’t know that the Supreme Court will go along.”

    The ACLU’s Cole notes that the Court appeared to move more cautiously in the term that ended in June than it did in the 2021–22 session, which concluded with the cannon shot overruling Roe. With a few prominent exceptions headlined by the decision banning affirmative action in higher education, “civil rights and civil liberties did pretty well in the Supreme Court this term,” Cole maintained. “Much is still to be determined, but I think this term showed us that you can’t just assume that this Court is going to impose right-wing results regardless of precedent.”

    Conservatives remain confident that this Supreme Court majority will not reject many of these new red-state laws. They see an early signal of how some of these fights may play out in the August decision by the Eleventh Circuit Court of Appeals allowing Alabama to enforce its law banning gender-affirming care for minors.

    Written by Barbara Lagoa, who was appointed by Donald Trump, that ruling specifically cited the Supreme Court’s logic in the Dobbs case to argue that Alabama’s ban on gender-affirming care for minors would likely survive legal scrutiny. In Dobbs, the majority opinion written by Justice Samuel Alito said the Fourteenth Amendment did not encompass the right to abortion because there was no evidence that such a right was “deeply rooted” in American history. Likewise, Lagoa wrote of gender-affirming care that “the use of these medications in general—let alone for children—almost certainly is not ‘deeply rooted’ in our nation’s history and tradition.”

    Sarah Parshall Perry, a senior legal fellow at the conservative Heritage Foundation’s Edwin Meese Center for Legal and Judicial Studies, predicted that such logic would ultimately persuade the conservative Supreme Court majority. “What we are seeing now is the use of the Dobbs framework in actual action,” she told me. “I think the Supreme Court quite frankly is going to be very wary of expanding Fourteenth Amendment jurisprudence to rubber-stamp an experimental new treatment, especially when minor children are involved.”

    The one point both sides can agree on is that the Supreme Court’s rulings on the red-state measures will represent a crossroads for the country. One path preserves the broadly consistent floor of civil rights across state lines that Americans have known since the 1960s; the other leads to a widening divergence reminiscent of earlier periods of intense separation among the states.

    Kettl believes that if the Supreme Court doesn’t constrain the red states, they almost certainly will push much further in undoing the rights revolution. “We haven’t seen what the boundary of that effort will be yet,” he told me, pointing to the ordinances some Texas localities have passed attempting to bar women from driving through them to obtain an abortion out of state.

    If the Supreme Court allows the red states a largely free hand to continue devising their own system of civil rights and liberties, Chemerinsky said, it will present Americans with a “profound” question:

    “Will the county accept being two different countries with regard to so many of these important things, as it did with regard to other important things such as slavery and civil rights?” he said. “Or will there be a point that people will say, ‘What divides us as a country is much greater than what unites us.’ And will we start hearing the first serious calls to rethink the United States?”

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    Ronald Brownstein

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  • A Slice of ‘Bacon’ Made Me Believe in Fake Meat

    A Slice of ‘Bacon’ Made Me Believe in Fake Meat

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    Last month, at a dining table in a sunny New York City hotel suite, I found myself thrown completely off guard by a strip of fake bacon. I was there to taste a new kind of plant-based meat, which, like most Americans, I’ve tried before but never truly craved in the way that I’ve craved real meat. But even before I tried the bacon, or even saw it, I could tell it was different. The aroma of salt, smoke, and sizzling fat rising from the nearby kitchen seemed unmistakably real. The crispy bacon strips looked the part too—tiger-striped with golden fat and presented on a miniature BLT. Then crunch gave way to satisfying chew, followed by a burst of hickory and the incomparable juiciness of animal fat.

    I knew it wasn’t real bacon, but for a moment, it fooled me. The bacon was indeed made from plants, just like the burger patties you can buy from companies such as Impossible Foods and Beyond Meat. But it had been mixed with real pork fat. Well, kind of. What marbled the meat had not come from a butchered pig but a living hog whose fat cells had been sampled and grown in a vat.

    This lab-grown fat, or “cultivated fat,” was made by Mission Barns, a San Francisco start-up, with one purpose: to win people over to plant-based meat. And a lot of people need to be won over, it seems. The plant-based-meat industry, which a few years ago seemed destined for mainstream success, is now struggling. Once the novelty of seeing plant protein “bleed” wore off, the high price, middling nutrition, and just-okay flavor of plant-based meat has become harder for consumers to overlook, food analysts told me. In 2021 and 2022, many of the fast-food chains that had once given plant-based meat a national platform—Burger King, Dunkin’, McDonald’s—lost interest in selling it. In the past four months, the two most visible plant-based-meat companies, Beyond Meat and Impossible Foods, have each announced layoffs.

    Meanwhile, the future of meat alternatives—lab-grown meat that is molecularly identical to the real deal—is at least several years away, lodged between science fiction and reality. But we can’t wait until then to eat less meat; it’s one of the single best things that regular people can do for the climate, and also helps address concerns about animal suffering and health. Lab-grown fat might be the bridge. It is created using the same approach as lab-grown meat, but it’s far simpler to make and can be mixed into existing plant-based foods, Elysabeth Alfano, the CEO of the investment firm VegTech Invest, told me. As such, it’s likely to become commercially available far sooner—maybe even within the next few years. Maybe all it will take to save fake meat is a little animal fat.

    Animal fat is culinary magic. It creates the juiciness of a burger, and leaves a buttery coat on the tongue. Its absence is the reason that chicken breasts taste so bland. Fat, the chef Samin Nosrat wrote in Salt, Fat, Acid, Heat, is “a source of both rich flavor and of a particular desired texture.” The fake meat on the market now is definitely lacking in the flavor and texture departments. Most products approximate meatiness using a concoction of plant oils, flavorings, binders, and salt, which is certainly meatier than the bean burgers that came before it, but is far from perfect: The food blog Serious Eats, for instance, has pointed out off-putting flavor notes, at least prior to cooking, including coconut and cat food. On a molecular level, plant fat is ill-equipped to mimic its animal counterpart. Coconut oil, common in plant-based meat, is solid at room temperature but melts under relatively low heat, so it spills out into the pan while cooking. As a result, the mouthfeel of plant-based meat tends to be more greasy than sumptuous.

    Replacing those plant oils with cultivated animal fat, which keeps its structure when heated, would maintain the flavor and juiciness people expect of real meat, Audrey Gyr, the start-up innovation specialist at the Good Food Institute, a nonprofit that advocates for plant-based substitutes, told me. In a sense, the technique of using animal fat to flavor plants is hardly new. Chicken schmaltz has long lent rich nuttiness to potato latkes; rendered guanciale is what gives a classic amatriciana its succulence. Plant-based bacon enhanced with pork fat follows from the same culinary tradition, but it’s very high-tech. Fat cells sampled from a live animal are grown in huge bioreactors and fed with plant-derived sugars, proteins, and other growth components. In time, they multiply to form a mass of fat cells: a soft, pale solid with robust flavor, the same white substance you might see encircling a pork chop or marbling a steak.

    Out of the bioreactor, the fat “looks a little bit like margarine,” Ed Steele, a co-founder of the London-based cultivated-fat company Hoxton Farms, told me. It is a complicated process, but far easier than engineering cultivated meat, which involves many cell types that must be coaxed into rigid muscle fibers. Fat involves one type of cell and is most useful as a formless blob. Just as in the human body, all it takes is time, space, and a steady drip of sugars, oils, and other fats, Eitan Fischer, CEO of Mission Barns, told me. The bacon I’d tried at the tasting had been constructed by layering cultivated fat with plant-based protein, curing and smoking the loaf, then slicing it into bacon-like strips. Mixing just 10 percent cultivated fat with plant-based protein by mass, Steele said, can make a product taste and feel like the real thing.

    Already, cultivated-fat products are within sight. Mission Barns plans to incorporate its cultivated fat into its own plant-based products; Hoxton Farms hopes to sell its fat directly to existing plant-based-meat manufacturers. Other companies, such as the Belgian start-up Peace of Meat, the Berlin-based Cultimate Foods, and Singapore’s fish-focused ImpacFat, are also working on their own versions of cultivated fat. In theory, the fat can be mixed into virtually any type of plant-based meat—nuggets, sausages, paté. In the U.S., a path to market is already being cleared. Last November, cultivated chicken from the California start-up Upside Foods received FDA clearance; now it’s waiting on additional clearance from the Department of Agriculture. Pending its own regulatory approvals, Mission Barns says it is ready to launch its products in a few supermarkets and restaurants, which also include a convincingly porky plant-based meatball I also tried at the tasting. (Due to the pending approval, I had to sign a liability waiver before digging in.)

    I left the tasting with animal fat on my lips and a new conviction in my mind: At the right price, I’d buy this bacon over the regular stuff. Because cultivated fat can be made without harming animals—the fat cells in the bacon I tasted came from a happily free-ranging pig named Dawn, a PR rep for Mission Barns told me—it may appeal to flexitarians like myself who just want to eat less meat.

    Although there’s no guarantee it would taste as good at home as it did when prepared by Mission Barns’s private chef, with its realistic texture and flavor, cultivated fat could solve the main issue plaguing plant-based meat: It just doesn’t taste that good. Cultivated fat is “the next step in making environmentally friendly foods more palatable to the average consumer,” Jennifer Bartashus, a packaged-food analyst at Bloomberg Intelligence, told me.

    But cultivated fat still faces some of the same problems that have turned America off plant-based meat. The current products for sale are not particularly healthy, and cultivated fat would not change that fact. Building consumer trust and familiarity may also be an issue. Some people are leery of plant-based products because they’re confused about what they’re made of. The more complex notion of cultivated fat may be just as unappetizing, if not more so. “We still don’t know exactly how consumers are going to feel about cultivated fat,” Gyr said. Certainly, finding a catchy name for these products would help, but I have struggled to find a term less clunky than “plant-based meat flavored with cultivated animal fat” to describe what I ate. Unless cultivated-fat companies really nail their marketing, they could go the way of “blended meat”—mixtures of plant-based protein and real meat introduced by three meat companies in 2019, which was “a bit of a marketing failure,” Gyr said.

    Above all, though, is the price relative to that of traditional meat. Plant-based meat’s higher cost has partly been blamed for the industry’s slump, and products containing cultivated fat, in all likelihood, will not be cheaper in the near future. Neither founder I spoke with shared specific numbers; Fischer, of Mission Barns, said only that the company’s small production scale makes it “fairly expensive” compared with traditional meat products, while Steele said his hope is that companies using Hoxton Farms’ cultivated fat in their plant-based-meat recipes won’t have to spend more than they do now.

    Despite these obstacles, cultivated fat is promising for the flagging plant-based-meat industry because of the fact that it is absolutely delicious. Cultivated fat could “lead to a new round of innovation that will pull consumers back in,” Bartashus said. After all, plant-based and real meat could reach cost parity around 2026, at which point even more companies might want to get in on meat alternatives. Cultivated fat might warm us up to the future of fully cultivated meat. With enough time, lab-grown chicken breasts could become as boring as regular chicken breasts.

    Enthusiasm about cultivated fat, and fake meat in general, has a distinctly techno-optimist flavor, as if persuading all meat eaters to embrace plants gussied up in bacon grease will be easy. “Eventually our goal is to outcompete current conventional meat prices, whether it’s meatballs or bacon,” Fischer said. But even as the problems with eating meat have only become clearer, meat consumption in the U.S. has continued to rise. Globally, meat consumption in countries such as India and China is expected to skyrocket in the coming years. At the very least, cultivated fat provides consumers with another option at a time when eating a steak for one meal and then opting for plant-based meat the next can count as a win.

    Since the tasting, I’ve often thought about why eating the bacon left me feeling so perplexed. When I gnawed on the crispy golden edge of one of the strips, I knew I was eating real bacon fat, but my brain still wrestled with the idea that it had not come directly from a piece of pork. I’ve only ever known a world where animal fat comes from slaughtered animals. That is changing. If cultivated fat can tide the plant-based-meat industry over until lab-grown meat becomes a reality, these new products will have done their part. In the meantime, we may come to find that they’re already good enough.

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    Yasmin Tayag

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  • The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

    The FDA’s New ‘Don’t Say Gay’ Policy for Blood Donation

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    For decades now, gay men have been barred from giving blood. In 2015, what had been a lifetime ban was loosened, such that gay men could be donors if they’d abstained from sex for at least a year. This was later shortened to three months. Last week, the FDA put out a new and more inclusive plan: Sexually active gay and bisexual people would be permitted to donate so long as they have not recently engaged in anal sex with new or multiple partners. Assistant Secretary for Health Rachel Levine, the first Senate-confirmed transgender official in the U.S., issued a statement commending the proposal for “advancing equity.” It “treats everyone the same,” she said, “regardless of gender and sexual orientation.”

    As a member of the small but honorable league of gay pathologists, I’m affected by these proposed policy changes more than most Americans. I’m subject to restrictions on giving blood, and I’ve also been responsible for monitoring the complications that can arise from transfusions of infected blood. I am quite concerned about HIV, given that men who have sex with men are at much greater risk of contracting the virus than members of other groups. But it’s not the blood-borne illness that I, as a doctor, fear most. Common bacteria lead to far more transfusion-transmitted infections in the U.S. than any virus does, and most of those produce severe or fatal illness. The risk from viruses is extraordinarily low—there hasn’t been a single reported case of transfusion-associated HIV in the U.S. since 2008—because laboratories now use highly accurate tests to screen all donors and ensure the safety of our blood supply. This testing is so accurate that preventing anyone from donating based on their sexual behavior is no longer logical. Meanwhile, new dictates about anal sex, like older ones explicitly targeting men who have sex with men, still discriminate against the queer community—the FDA is simply struggling to find the most socially acceptable way to pursue a policy that it should have abandoned long ago.

    Strict precautions made more sense 30 years ago, when screening didn’t work nearly as well as it does today. Patients with hemophilia, many of whom rely on blood products to live, were prominent, early victims of our inability to keep HIV out of the blood supply. One patient who’d acquired the virus through a transfusion lamented to The New York Times in 1993 that he had already watched an uncle and a cousin die of AIDS. Those days of “shock and denial,” as the Times described it, are thankfully behind us. But for older patients, memories of the crisis in the ’80s and early ’90s linger, and cause significant anxiety. Even people unaware of this historical context may consider the receipt of someone else’s blood disturbing, threatening, or sinful.

    As a doctor, I’ve found that patients tend to be more hesitant about getting a blood transfusion than they are about taking a pill. I’ve had them ask for a detailed medical history of the donor, or say they’re willing to take blood only from a close relative. (Typically, neither of these requests can be fulfilled for reasons of privacy and practicality.) Yet the same patients may accept—without question—drugs that carry a risk of serious complication that is thousands of times higher than the risk of receiving infected blood. Even when it comes to blood-borne infections, patients seem to worry less about the greatest danger—bacterial contamination—than they do about the transfer of viruses such as HIV and hepatitis C. I can’t fault anyone for being sick and scared, but the risk of contracting HIV from a blood transfusion is not just low—it’s essentially nonexistent.

    Read: Blood plasma, sweat, and tears

    Donors’ feelings matter, too, and the FDA’s policies toward gay and bisexual men who wish to give blood have been unfair for many years. While officials speak in the supposedly objective language of risk and safety, their selective deployment of concern suggests a deeper homophobia. As one scholar put it in The American Journal of Bioethics more than a decade ago, “Discrimination resides not in the risk itself but in the FDA response to the risk.” Many demographic groups are at elevated risk of contracting HIV, yet the agency isn’t continually refining its exclusion criteria for young people or urban dwellers or Black and Hispanic people. Federal policy did prohibit Haitians from donating blood from 1983 to 1991, but activists successfully lobbied for the reversal of this ban with the powerful slogan “The H in HIV stands for human, not Haitian.” Nearly everyone today would find the idea of rejecting blood from one racial group to be morally repugnant. Under its new proposal, which purports to target anal sex instead of homosexuality itself, the FDA effectively persists in rejecting blood from sexual minorities.

    The planned update would certainly be an improvement. It comes out of years of advocacy by LGBTQ-rights organizations, and its details are apparently supported by newly conducted government research. Peter Marks, the director of the Center for Biologics Evaluation and Research at the FDA, cited an unpublished study showing that “a significant fraction” of men who have sex with men would now be able to donate. But the plan is still likely to exclude a large portion of them—even those who wear condoms or regularly test for sexually transmitted infections. An FDA spokesperson told me via email that “additional data are needed to determine what proportion of [men who have sex with men] would be able to donate under the proposed change.”

    Research done in France, Canada, and the U.K., where similar policies have since been adopted over the past two years, demonstrates the risk. A French blood-donation study, for instance, estimated that 70 percent of men who have sex with men had more than one recent partner; and when Canadian researchers surveyed queer communities in Montreal, Toronto, and Vancouver, they found that up to 63 percent would not be eligible to donate because they’d recently had anal sex with new or multiple partners. Just 1 percent of previously eligible donors would have been rejected by similar criteria. The U.K. assumed in its calculations that 35 to 50 percent of men who have sex with men would be ineligible under a policy much like the FDA’s, while only 1.4 percent of previous donors would be newly deferred. If the new rule’s net effect is that gay and bisexual men are turned away from blood centers at many times the rate of heterosexual individuals, what else can you call it but discrimination? The U.S. guidance is supposed to ban a lifestyle choice rather than an identity, but the implication is that too many queer men have chosen wrong. The FDA spokesperson told me, “Anal sex with more than one sexual partner has a significantly greater risk of HIV infection when compared to other sexual exposures, including oral sex or penile-vaginal sex.”

    If the FDA wants to pry into my sex life, it should have a good reason for doing so. The increasing granularity and intimacy of these policies—specifying numbers of partners, kinds of sex—gives the impression that the stakes are very high: If we don’t keep out the most dangerous donors, the blood supply could be ruined. But donor-screening questions are a crude tool for picking needles from a haystack. The only HIV infections that are likely to get missed by modern testing are those contracted within the previous week or two. This suggests that, at most, a couple thousand individuals—gay and straight—across the entire country are at risk of slipping past our testing defenses at any given time. Of course, very few of them will happen to donate blood right then. No voluntary questionnaire can ever totally exclude this possibility, but patients and doctors already accept other life-threatening transfusion risks that occur at much greater rates than HIV transmission ever could. When I would be on call for monitoring transfusion reactions at a single hospital, the phone would ring a few times every night. Yet blood has been given out tens of millions of times across the country since the last known instance of a transfusion resulting in a case of HIV.

    Read: How blood-plasma companies target the poorest Americans

    Early data suggest that the overall risk-benefit calculus of receiving blood isn’t likely to change. When eligibility criteria were first relaxed in the U.S. a few years ago, the already tiny rate of HIV-positive donations remained minuscule. Real-world results from other countries that have recently adopted sexual-orientation-neutral policies will become available in the coming years. But modeling studies already support removing any screening question that explicitly or implicitly targets queer men. A 2022 Canadian analysis suggested that removing all questions about men who have sex with men would not result in a significantly higher risk to patients. “Extra behavioral risk questions may not be necessary,” the researchers concluded. If there must be a restriction in place, then one narrowly tailored to the slim risk window of seven to 10 days before donation should be good enough. (The FDA says that its proposed policy “would be expected to reduce the likelihood of donations by individuals with new or recent HIV infection who may be in the window period.”)

    As a gay man, I realize that, brief periods of crisis during the coronavirus pandemic aside, no one needs my blood. Only 6.8 percent of men in the U.S. identify as gay or bisexual, so our potential benefit to the overall supply is inherently modest. If we went back to being banned completely, patients would not be harmed. But reversing that ban, both in letter and in spirit, would send a vital message: Our government and health-care system view sexual minorities as more than a disease vector. A policy that uses anal sex as a stand-in for men who have sex with men only further stigmatizes this population by impugning one of its main sources of sexual pleasure. There is no question that nonmonogamous queer men have a greater chance of contracting HIV. But a policy that truly treats everyone the same would accept a tiny amount of risk as the price of working with human beings.

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    Benjamin Mazer

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  • Outdoor Dining Is Doomed

    Outdoor Dining Is Doomed

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    These days, strolling through downtown New York, where I live, is like picking your way through the aftermath of a party. In many ways, it is exactly that: The limp string lights, trash-strewn puddles, and splintering plywood are all relics of the raucous celebration known as outdoor dining.

    These wooden “streeteries” and the makeshift tables lining sidewalks first popped up during the depths of the pandemic in 2020, when restaurants needed to get diners back in their seats. It was novel, creative, spontaneous—and fun during a time when there wasn’t much fun to be had. For a while, outdoor dining really seemed as though it could outlast the pandemic. Just last October, New York Magazine wrote that it would stick around, “probably permanently.”

    But now someone has switched on the lights and cut the music. Across the country, something about outdoor dining has changed in recent months. With fears about COVID subsiding, people are losing their appetite for eating among the elements. This winter, many streeteries are empty, save for the few COVID-cautious holdouts willing to put up with the cold. Hannah Cutting-Jones, the director of food studies at the University of Oregon, told me that, in Eugene, where she lives,  outdoor dining is “ absolutely not happening” right now. In recent weeks, cities such as New York and Philadelphia have started tearing down unused streeteries. Outdoor dining’s sheen of novelty has faded; what once evoked the grands boulevards of Paris has turned out to be a janky table next to a parked car. Even a pandemic, it turns out, couldn’t overcome the reasons Americans never liked eating outdoors in the first place.

    For a while, the allure of outdoor dining was clear. COVID safety aside, it kept struggling restaurants afloat, boosted some low-income communities, and cultivated joie de vivre in bleak times. At one point, more than 12,700 New York restaurants had taken to the streets, and the city—along with others, including Boston, Los Angeles, Chicago, and Philadelphia—proposed making dining sheds permanent. But so far, few cities have actually adopted any official rules. At this point, whether they ever will is unclear. Without official sanctions, mounting pressure from outdoor-dining opponents will likely lead to the destruction of existing sheds; already, they keep tweeting disapproving photos at sanitation departments. Part of the issue is that as most Americans’ COVID concerns retreat, the potential downsides have gotten harder to overlook: less parking, more trash, tacky aesthetics, and, oh God, the rats. Many top New York restaurants have voluntarily gotten rid of their sheds this winter.

    The economics of outdoor dining may no longer make sense for restaurants, too. Although it was lauded as a boon to struggling restaurants during the height of the pandemic, the practice may make less sense now that indoor dining is back. For one thing, dining sheds tend to take up parking spaces needed to attract customers, Cutting-Jones said. The fact that most restaurants are chains doesn’t help: “If whatever conglomerate owns Longhorn Steakhouse doesn’t want to invest in outdoor dining, it will not become the norm,” Rebecca Spang, a food historian at Indiana University Bloomington, told me. Besides, she added, many restaurants are already short-staffed, even without the extra seats.

    In a sense, outdoor dining was doomed to fail. It always ran counter to the physical makeup of most of the country, as anyone who ate outside during the pandemic inevitably noticed. The most obvious constraint is the weather, which is sometimes pleasant but is more often not. “Who wants to eat on the sidewalk in Phoenix in July?” Spang said.

    The other is the uncomfortable proximity to vehicles. Dining sheds spilled into the streets like patrons after too many drinks. The problem was that U.S. roads were built for cars, not people. This tends not to be true in places renowned for outdoor dining, such as Europe, the Middle East, and Southeast Asia, which urbanized before cars, Megan Elias, a historian and the director of the gastronomy program at Boston University, told me. At best, this means that outdoor meals in America are typically enjoyed with a side of traffic. At worst, they end in dangerous collisions.

    Cars and bad weather were easier to put up with when eating indoors seemed like a more serious health hazard than breathing in fumes and trembling with cold. It had a certain romance—camaraderie born of discomfort. You have to admit, there was a time when cozying up under a heat lamp with a hot drink was downright charming. But now outdoor dining has gone back to what it always was: something that most Americans would like to avoid in all but the most ideal of conditions. This sort of relapse could lead to fewer opportunities to eat outdoors even when the weather does cooperate.

    But outdoor dining is also affected by more existential issues that have surmounted nearly  three years of COVID life. Eating at restaurants is expensive, and Americans like to get their money’s worth. When safety isn’t a concern, shelling out for a streetside meal may simply not seem worthwhile for most diners. “There’s got to be a point to being outdoors, either because the climate is so beautiful or there’s a view,” Paul Freedman, a Yale history professor specializing in cuisine, told me. For some diners, outdoor seating may feel too casual: Historically, Americans associated eating at restaurants with special occasions, like celebrating a milestone at Delmonico’s, the legendary fine-dining establishment that opened in the 1800s, Cutting-Jones said.

    Eating outdoors, in contrast, was linked to more casual experiences, like having a hot dog at Coney Island. “We have high expectations for what dining out should be like,” she said, noting that American diners are especially fussy about comfort. Even the most opulent COVID cabin may be unable to override these associations. “If the restaurant is going to be fancy and charge $200 a person,” said Freedman, most people can’t escape the feeling of having spent that much for “a picnic on the street.”

    Outdoor dining isn’t disappearing entirely. In the coming years there’s a good chance that more Americans will have the opportunity to eat outside in the nicer months than they did before the pandemic—even if it’s not the widespread practice many had anticipated earlier in the pandemic. Where it continues, it will almost certainly be different: more buttoned-up, less lawless—probably less exciting. Santa Barbara, for example, made dining sheds permanent last year but specified that they must be painted an approved “iron color.” It may also be less popular among restaurant owners: If outdoor-dining regulations are too far-reaching or costly, cautioned Hayrettin Günç, an architect with Global Designing Cities Initiative, that will “create barriers for businesses.”

    For now, outdoor dining is yet another COVID-related convention that hasn’t quite stuck—like avoiding handshakes and universal remote work. As the pandemic subsides, the tendency is to default to the ways things used to be. Doing so is easier, certainly, than coming up with policies to accommodate new habits. In the case of outdoor dining, it’s most comfortable, too. If this continues to be the case, then outdoor dining in the U.S. may return to what it was before the pandemic: dining “al fresco” along the streetlamp-lined terraces of the Venetian Las Vegas, and beneath the verdant canopy of the Rainforest Cafe.

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    Yasmin Tayag

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