Vera Prokopieva is a nutrition scientist from Bulgaria who has studied food from three angles: as an anthropologist, as a cook in Copenhagen kitchens, and as a researcher at Stanford, working on clinical trials of food as medicine and on how fermented foods shape the gut microbiome. Albania is living through many of the changes Bulgaria did, as diets shift, obesity rises, and new weight-loss drugs arrive. We asked her about nutrition science, applying it in the Balkans, and why it matters.
A lot of what we know about diet and disease comes from population studies in the West. You’ve worked on dietary tracking and clinical trials in the US. Why does that matter for people in the Balkans?
I don’t believe we fully understand the extent and danger of the obesity epidemic in the Balkans, and since it’s so related to diet, the regional differences matter a lot. In 2019, self-reported adult obesity in Bulgaria was around 12 to 15%, while modeled estimates put it closer to 25%. When researchers actually measure people, the picture gets worse. A 2026 study that weighed and measured about 3,500 adults in Stara Zagora, Bulgaria, found around 30% were obese. It covered one city and wasn’t a random sample, but it suggests self-reports undercount by a lot.
Most of the big nutrition studies come from the US, the UK, and the Nordic countries, and their tools assume a certain kind of eating. For example, one difference is that in the Balkans, informally procured food is a big part of the diet, and this makes it difficult to estimate its contents. A 2013 survey found that 84% of Bulgarians ate at least some home-produced food, and home production supplied 60% of the pickled vegetables people ate (and almost 40% of their rakia). Bulgaria’s national household budget survey collects information on food received in kind and on household production, but the published consumption data don’t give us a clear breakdown by source. Solid dietary data are an essential starting point for obesity policy going forward.
Albania was once known for an “Albanian paradox“: people in Europe’s poorest country lived surprisingly long, partly thanks to a simple diet. Today almost a third of Albanian 8- and 9-year-olds are overweight. You’ve studied how Bulgaria’s diet changed after socialism. What happened?
Nutrition scientists use the term “nutrition transition” for the way diets change as countries urbanize and get richer: they move from grains, beans, and vegetables toward more meat, sugar, fat, and processed food, and obesity follows. The original study of Albania found a diet at the early end of that path, with little meat, milk, or total energy and plenty of fruit, vegetables, and carbohydrates.
My historical research suggests that Bulgaria’s nutrition transition began before 1989. State policies expanded collective catering and industrial food provision. I argued that these changes may have helped shape how households responded to the food market after socialism. Albania was far more rural, about a third urban in 1989 compared with two-thirds in Bulgaria, so I suspect its transition came later and much faster.
In both countries, once prices were freed after socialism, what people ate came to depend much more on what they could afford. Today, cost seems to be one of the biggest things standing between people and a healthy diet. The FAO estimated that about one in nine Albanians couldn’t afford a healthy diet in 2024. In Bulgaria similarly, the poorest households there still eat less fresh produce than the richest (NSI, 2024).
The patent on semaglutide, the drug in Ozempic, expired this year in several large markets including India, China and Brazil. When cheap weight-loss injections reach the Balkans, is there still a case for promoting healthy eating?
Yes, and if anything the case gets stronger. It’s important to remember that the drug turns down appetite, so every meal has to count. People need enough protein to protect muscle, enough fiber, and enough vitamins and minerals. When you eat less, quality matters more.
In my clinical trial work at Stanford, where we delivered healthy meals to heart failure patients, the hardest part is keeping the habits once the deliveries stop. That’s where food education comes in, and one of the best intervention points is in schools. For children, an injection shouldn’t be the first answer. The habits they learn now are the ones they will take forward, and in the past learning to eat and cook was mainly done by mothers and grandmothers. I am really supportive of a school curriculum that takes on this task, so that every child gets a chance to learn.
Albania’s UNICEF-backed pilot on nutrition education and junk-food marketing in schools seemed promising, with more than 300 teachers trained, and Tirana is now trying out school meals. But scaling these programs is hard. Across the Balkans, governance is often fragile, and other political issues can feel far more pressing than public health pilots.
The new US dietary guidelines recommend fermented foods for the first time. In the Balkans this is already a staple of the diet. How important is the difference between supermarket and homemade versions?
The evidence on fermented foods and the microbiome is young but promising. For example, in a small trial from the Stanford lab where I worked, adults who ate about six servings of fermented foods a day for ten weeks had more diverse gut microbes and lower levels of 19 inflammatory proteins.
Plain yogurt with live cultures is a perfectly good food. Supermarket yogurt usually runs on two bacterial strains, though, and non-industrial versions have a better chance of having more diverse cultures. Curiously, food microbes mostly pass through rather than populate the gut, but they seem to help shape the environment where a more diverse community can grow.
One of my favorite stories is that a Copenhagen University team recently revived ant yogurt from a Rhodope mountain village in Bulgaria, where a few live forest ants dropped into warm milk started the ferment, and it sort of worked.
Turshi is where people sometimes get confused. A jar made with vinegar isn’t fermented but rather pickled. It’s delicious, but the sourness comes from the vinegar, and the low pH actually holds bacteria back. On the other hand, lacto-fermentation needs only salt and water to support the growth of lactobacilli and preserve vegetables that way. When shopping for fermented foods, make sure they’re actually fermented and try to pick refrigerated ones, which most often means they have not been pasteurized.
You grew up around Bulgarian kitchens and now work with patients in California. What do the Balkans get right about food?
I’ve been lucky to grow up in a family that loves cooking deeply, and I was exposed to regional variations within Bulgaria. From a young age I saw how to make home-cured meats, pickles, yogurt, rakia and lutenitsa, and was also fortunate to have an uncle and a godfather who are both winemakers. My paternal grandparents lived in the hunting regions of the central Bulgarian mountains, where my grandmother learned regional mountain recipes and how to cook game. She also swapped recipes with the private chefs of the socialist political elite when they came on hunting trips. That was a very unusual culinary background in a country that otherwise tried to standardize and centralize cooking. Unlike Yugoslavia, where most farmland stayed private, Bulgaria collectivized almost all of it, which affected how food production knowledge was transmitted between generations.
When I started working in the labs at Stanford, I found that this background made it much easier to talk to patients and explain practical ways to improve their diets. A lot of people in America think “healthy” tastes bad. In the Balkans, diets can be high in fat and salt on average, but we still have a cohesive culinary culture. That isn’t a given in fragmented, industrialized food systems like those in the US and UK.
The question of how to eat is not a simple one, and most countries get it wrong as they grow richer. They just get it wrong in different ways. We are starting from a strong foundation: our foods are regional and tasty, most people know how to cook them, and we agree on what it means to eat real food. That consensus is really valuable.
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