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Interviewer: Eating well is a crucial component for good health, but for a lot of us, it's a skill that we never really were taught or learned much about. The Utah Wellness Bus visits communities and offers free health screenings in addition to education to anybody who wants it. And if you visit the Wellness Bus, one of the people you might talk to is our guest today, clinical dietician Alex Marie Hernandez.

In today's interview, we're going to talk to Alex about tips that could help you eat healthier, some common barriers and misconceptions about eating well, and how a free nutrition counseling session from Utah Wellness Bus can help you understand about nutrition and help you improve your health.

Alex, let's go ahead and start with what could somebody expect during a nutrition counseling session if they visit you on the Wellness Bus?

Alex: Part of the sessions when somebody comes to see me for a nutrition or lifestyle coaching is that we take some time to get to know the client. So part of that includes a dietary assessment. So I ask them, "What do you normally eat? What does a normal day of eating look like for you?" And from there, I can then see what are some of the common foods that they eat? What are some of those that maybe we can improve?

Based off of that, then we go into different nutrition, education topics, right? So one thing that's very helpful is learning how to read a nutrition label, which is something that a lot of people aren't too familiar with. So just checking that nutrition label for things like added sugars.

And then a lot of times, if they are drinking something, for example, that has a lot of added sugars . . . Just yesterday, I had a client who mentioned that she was drinking a lot of vitamin water. She was like, "This is great. I'm getting lots of vitamins."

Interviewer: It sounds healthy.

Alex: Yeah. And then I'm like, "What brand is it? Let's take a look at this." So we look it up online, we look at the nutrition label, and it turns out it has like 26 grams of added sugars in one bottle. And she was having multiple every day.

So then we go through and we look at . . . we'll compare that to what the maximum amount that you should be having in a day is, and then they come to that realization, "Wow, I'm having a lot of added sugars and I didn't even know."

So things like that. The nutrition label is a very great tool in figuring out how to make healthier choices.

Interviewer: Do you find that a lot of not such great stuff is hiding in our food and we really need to do some research . . .

Alex: Oh, yeah.

Interviewer: . . . looking at that label to figure out what that is?

Alex: Mm-hmm. Because some things can be marketed as healthy. The label will make it seem like it's a healthy choice, but you look at that nutrition label and it turns out that's not the case.

One example that I talk to a lot about with clients is when it comes to breads, like whole wheat bread. It may say that, but you look at the nutrition label, look at the fiber content, and it actually doesn't have a lot of fiber. You look at the ingredients, whole grains is not one of the first ingredients. So that nutrition label is going to tell you the truth versus what's just marketed or advertised on that label in the front of the product.

Interviewer: And this is kind of a new phenomenon, isn't it? That you have to be aware of what's in your food. I would think many years ago, we made a lot of our meals from scratch, so we kind of knew what was in our food, but now you just really don't know. You do have to do that due diligence.

Alex: Yeah.

Interviewer: Give me a tip on how I can start that process, because it sounds a little overwhelming, right? I've got to know what I'm looking for, and then I've got to know how much of that thing that I can have and still be healthy. I've got to do all that math. So how do you make it simple for people? Or is there not a way to make it simple?

Alex: There is a way to make it simple. But I guess my tip here . . . I don't know if it's appropriate, but come to the Wellness Bus.

Interviewer: That's right. Take advantage of you.

Alex: Yeah. We can talk about it some more, because one of the things we offer as well in these sessions is this health coaching book. And it has a lot of great information, visuals, things are colorful, which makes it easier to understand.

So we go over those things. We point things out. We do some teach-back as well, like, "Well, now that we've learned this, can you tell me this?" So I really think taking the time to talk to someone who can walk you through that is going to be helpful. So come to the Wellness Bus.

Interviewer: And realize that it is complicated.

Alex: It is complicated, yeah.

Interviewer: I think some people might feel a little ashamed, like, "Well, I should understand this stuff," but it's not necessarily super easy to understand all the time.

Alex: Right. And I'm trying to think . . . I don't know if it's always taught in schools. I took a nutrition class in high school, which is where I became interested in nutrition, and that's where we went over the nutrition label. But even then, not too much in depth. It was later on when I studied more nutrition that I better understood how to use that nutrition label.

Interviewer: Right. You've this for how many years of schooling?

Alex: Oh, I took longer to get my Bachelor's, but . . .

Interviewer: But it's a Bachelor's degree, so . . .

Alex: Bachelor's plus Master's. In a few years, Master's will be required for all dieticians.

Interviewer: Okay. So I think that really illustrates how much there is out there to know that somebody could dedicate two degrees to it, right? So come to the bus and capitalize on that knowledge that you have.

Alex: Yes.

Interviewer: What do people think their nutritional challenges are generally, and do they align with what you know?

Alex: We work with a lot of diverse communities, right? So I think with that, a lot of people come to the bus thinking that their cultural foods are not healthy foods. And we want to highlight that you can still eat healthy within your cultural foods.

When they come to the United States, maybe they're presented with one way of eating, and that that's the only way of healthy eating. But that's not true. There are so many healthy foods across the world.

For example, the Mediterranean diet, right? That's one of the healthiest diets in the world. So it's just highlighting their staple foods and why those are healthy.

A lot of times, it just comes down to portion sizes, right? Maybe people are eating too much of one thing and not really balancing it out with the other nutrients that they need.

Interviewer: What are some of the barriers to good nutrition that you encounter? So we talked about just knowledge. Are there other barriers?

Alex: There are other barriers. For example, access to healthy foods. That's a big challenge. Sometimes, we'll talk about some . . . For an example, healthy fats like salmon, great source of healthy fats. But when I mention that, they'll say, "Oh, that's too expensive." So then we can talk about other sources of healthy fats as well, right?

Or even thinking about frozen or canned foods, it's okay to eat those foods. Again, just reading that nutrition label is going to help you make better choices there.

But we can also talk about food pantry, local resources, where they can go get more food if they're not able to afford that at the grocery store. And also just talking about how you can still eat healthy on a budget is important. So I think that access to foods is another big barrier that we encounter.

Interviewer: How about time to make meals at home? Is that a barrier?

Alex: That is another one as well, yeah. That's a good point. And there, we talk about ideas. Based on what they like, their food preferences, what are some quick, easy meals or even snacks that you can eat to incorporate more healthy eating?

One thing, for example, that I mention a lot is baby carrots are super easy to take with you as a way to add some more vegetable in your day. However, people don't think that. Maybe it's not as glamorous, but there are ways to do it. There are.

Interviewer: When somebody comes to the Wellness Bus, if they see it in their neighborhood and they want to come in and talk to a nutritionist there, you, is there something they should prepare? Should they come in with a list of what they've eaten for the past couple days? Is there anything else that they should come in with that could make the job a little bit easier, more productive?

Alex: I want to say that they don't have to prepare at all if it's going to make it easier for them to come in. No worries. Just come in. I'll ask you the questions to learn what I need to know to help you.

Interviewer: One of the programs on the bus is called Journey to Health. Tell me a little bit about that.

Alex: It's a nutrition education program. We're collaborating with the Nutrition Department at the University of Utah. It's six months long. There are four nutrition classes that a participant would go to. And then part of it is also to come see me, dietician on the bus, for two sessions. And then at the end, the participants gather together for a community meal to celebrate their successes and what they've accomplished throughout the program.

The program has been very well received by the community. People are loving it. Some of the classes include cooking demos. You get free gifts like kitchen items, which is wonderful. Learn how to shop around a grocery store and find healthy foods on a budget.

It's been something that people have really enjoyed. And when they come see me, they rave about the classes, like, "They were great. I love them. When are there more?" I was like, "Sorry, there were only four classes."

But it's great because they get a good foundation of healthy eating from the classes. And then when they come see me, we can talk more individualized about their specific situation, what's going on, and how we can set some goals specific to them. It's open to the community, so come check it out.

Salt, sugar, and fat, what's not to like? Well, there is such a thing as too much of a good thing, and salt may be one of them.

We evolved as humans in a low-sodium environment, the inlands of Africa. We have taste buds specifically for salt, sodium chloride, and most of us like salty things. We may be the sweatiest animal on the planet, and we lose salt when we sweat from heat and vigorous exercise. So we do have dietary needs for a little bit of sodium chloride, the chemical we usually mean when we use the word "salt" in terms of food. But is there such a thing as too much salt?

We know that drinking seawater is remarkably unpleasant because it's too salty, and you can't survive by getting your water needs from seawater. You'll die.

And when we eat a lot of salt in our food, potato chips followed by boxed macaroni and cheese for lunch and a store-bought pizza with cheese and pepperoni for dinner, we get thirsty. We drink a lot of water, and we wake up all puffy. And who wants to wake up puffy? And all that puff shows up on the bathroom scales. Well, being puffy means that your body has held on to water to help dilute all the salt in your blood that you ate yesterday, and holding on to extra water means that your blood pressure can go up. And when your blood pressure goes up, it puts you at risk for heart disease and strokes and kidney failure.

America's high-salt diet, on average 3,000 to 6,000 milligrams a day, has been linked to high blood pressure, a leading risk of heart attacks, strokes, and kidney failure. More than 4 in 10 American adults have high blood pressure, and among black adults the number is 6 in 10.

The issue of salt in food is a complicated one. Of course, some people are sensitive to increased amounts of salt in their diet. Research studies have defined this salt sensitivity as people for whom an increase of 1,000 milligrams of sodium, about half a teaspoon of table salt, increases their blood pressure by 5%. Now, that doesn't sound like very much, but it's a significant difference when it comes to health outcomes. Some people are genetically salt sensitive, and some people are salt sensitive because they already have a chronic medical condition that gets worse on a high-salt diet.

Of course, there are studies that suggest that people who eat sodium at the 3,000 to 6,000 milligrams per day and say they don't necessarily have bad health outcomes. An international study of more than 100,000 people suggests that while there's a relationship between salt intake and high blood pressure, if you don't already have high blood pressure and you're not over 60 or eating way too much salt, salt won't have much impact on your blood pressure. However, most research suggests that a lower sodium diet is good for people who are older, over 50, who are African American descent, who have high blood pressure or diabetes, or whose blood pressure is gradually creeping up.

The Institute of Medicine, the Dietary Guidelines for Americans, and the American Heart Association recommend limiting your sodium intake to no more than 2,300 milligrams a day. That's about a teaspoon. People with heart failure and kidney disease are advised to keep their sodium at about 1,200 milligrams a day or about half a teaspoon. And for the very significant percent of Americans who have kidney stones, including yours truly, excess salt in the diet contributes to the formation of the most common kinds of kidney stones. Ouch. I had to have that explained to me by my urologist.

Now, low-sodium diet, that's easy, you say. You wouldn't put half a teaspoon from your saltshaker on your food each day. It turns out that the major source of sodium in our diet comes from prepared foods from the store, that boxed macaroni and cheese, prepared soup, bread, prepared salad dressings. About 70% of the sodium people consume comes from premade or packaged foods according to the FDA.

With that in mind, the FDA recently issued voluntary guidelines for the food industry to lower the amount of sodium in prepared foods, manufacturers, restaurants, and food service operators. These guidelines are voluntary and temporary to seek to decrease average sodium intake from approximately 3,400 milligrams to 3,000 milligrams per day, about a 12% reduction over the next 2.5 years. Now, that isn't very much, but it can make a difference in a population of people.

A recent study published in "The New England Journal of Medicine," done in China in 600 rural villages, randomized households to using regular salt in their cooking to a salt substitute, which switched out about 25% of the sodium chloride in their saltshaker with potassium chloride. This isn't enough for most people to taste the difference. They were encouraged to use a little less salt in their cooking, but could use other sources of sodium, like soy sauce, in the usual way. This is a very small dietary change. The control villages did their regular cooking. There were about 21,000 people in the study, with an average follow-up of about 5 years. The average age of the participants was 65 years. Half of them were women. About 72% had a history of stroke, and 88% had hypertension. That's a pretty high risk group. There was about a 15% decrease in strokes and major cardiovascular events and deaths in the salt substitute group over this 5 years, which would be quite significant if you're talking about a billion people or talking about 10 years. So it was kind of a big deal.

Other studies have shown similar effects in the U.S. in people who adhere to the DASH diet, which stands for dietary approaches to stop hypertension, sort of a Mediterranean diet with lower sodium. They have lower blood pressures.

So how much sodium in your diet if you're mostly healthy? About 2,300 milligrams or one teaspoon of table salt. If you have genetic or medical conditions that predispose you to greater risks with salt, even less. If you're like the average American and get 70% of your sodium intake from prepared and packaged foods, read the label.

Americans consume a lot more salt in their diet today than they did 50 years ago. Largely this is a change in how we cook or rather how we don't cook. Many more meals are pre-prepared from the store, and many more meals are eaten out with a lot of salt. Women are often in charge of the food shopping and food prep in the house. Clearly this isn't always the case, and there are many days many people just don't cook. They eat out and they eat foods in restaurants that are often very high in sodium and few actually will give you the amount, but sometimes you can look it up online. Or they eat in prepared or prepackaged foods.

Sodium is important enough for your health that the FDA food labels on the back of the package let you know how much sodium there is per serving. Your local pizza place with high sodium crust, high sodium cheese, and high sodium pepperoni, yum, won't have the sodium content. You can make choices in the food you buy. Many prepared food companies, like Campbell Soup, have offered lower sodium soup options in their canned soups. Even the chip aisle in the grocery store has chips with lower sodium.

So what do the labels on the front of the box mean? Sodium free or salt free, each serving in this product contains less than five milligrams of sodium, very low sodium. Each serving contains 35 milligrams of sodium or less, low sodium. Each serving contains 140 milligrams of sodium or less, reduced or less sodium. The product contains at least 25% less sodium than the regular version, but in the case of some soups that may mean going from 700 milligrams of sodium per serving to 500 per serving, and that is still a lot. Unsalted or no salt added, no salt added during processing of food that normally contains salt. So this could still be salty.

So make a commitment to cook more food at home from scratch and more whole foods, whole grains, veggies and beans, and don't add salt when you cook. Let people add the salt at the table if they need. Adding spices, pepper, or lemon can increase the flavor in your home foods without adding extra sodium. Do you like sea salt on your chocolate chip cookies? Forget adding salt to the dough and sparingly grind a few flakes, a very few flakes on the top of the cookies.

Even though you and your family might not be salt sensitive or have risk factors that would make a low-sodium diet important, some of you will someday. Getting out of the salt habit, eating more food cooked at home by somebody is good for you and the people you love. Have everyone become involve in food shopping choices and cooking at least some of the time and guide these choices, and that will help everyone be more independent in their sodium, sugar, and calorie choices and maybe your face won't be so puffy after pizza night.

Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.

Being confined in a space close to the refrigerator isn't good for me. Is it good for you?

So you're at home, with kids, with partners, or by yourself. You're cozy and in your most stretchy yoga pants and a big turtleneck fleece. Well, that describes me. Now, I can put on some nice earrings and a cover of scarf and call it dressed up for a Zoom meeting, and no one can see below my waist. But sooner or later, I'm going to have to put on my jeans.

This is how many Americans are making food choices this pandemic, during physical isolation. They are eating junk food. According to Bloomberg News, sales of Oreos, Cheetos, and boxed macaroni and cheese are up. Cans of Spam are up 37%. Of course, those in charge of the shopping may be looking for food with a long shelf life, a very long shelf life. Whether you're buying comfort food because you are stressed and want the foods that you had when someone was taking care of you or you're buying foods that you can use to bargain with your kids into doing some schoolwork, these choices aren't very good ones, not for you or your family.

One of the problems is, when these foods are in the cupboard or the fridge, you and your family are close to the fridge all day long. For the kids, it's a shuffle between the sweet caffeinated drinks, the chips, and the computer. For you, it is snack, snack, snack all day. The fridge and the goodies are always there, and you are always there.

We probably evolved to crave sweet, salt, and fat. We evolved in a low salt environment, so salty is craved. The easiest foods that were low energy to hunt and gather and chew were an advantage when they were high energy in our bodies, meaning easy calories, not high energy like coffee. That meant sugar and fat. Salt, sugar, and fat. And the comfort food industry knows this and adds a lot of fat and salt to their chips, bagels, cookies, and boxed macaroni and cheese.

We are not hunter-gatherers anymore, except in the time of quarantine when we hunt for chips and gather them up to eat in front of the TV. Hunter-gatherers walked all day long and were always on the verge of starvation. We are not. We evolved to pack away these calories into fat to use during times of stress. But this was caloric stress, not this pandemic stress when we may be flooded with calories.

Now, refined carbs, such as cookies, donuts, and granola bars, are the largest source of calories in the American diet, followed by breads, chips, sugary drinks, pizza, and pasta dishes, and other processed foods. They're also high in sodium, except for the sugary drinks. These foods are awful for our blood pressure, our cholesterol, and our insulin. These carbs are low fiber carbs, so they increase the insulin response and push us closer to diabetes.

In this COVID-19 epidemic, people who are hypertensive, obese, and diabetic, and they often all go together, are at the highest risk of becoming seriously ill and dying from this virus. Eating well may help our immune system. Eating poorly may suppress our immune system. Eating poorly makes you feel out of control in your life, and you're already in a global pandemic that is out of your control. However, eating well is in your control, so here are some suggestions.

Eat a healthy meal. Then, make your shopping list. Buy only what is on your list. Plan your shop and shop your plan. Don't buy that awful stuff. It's a rare treat, not a daily treat. The stores are well stocked with fresh produce. Buy crunchy veggies and hummus, or better yet, make your own hummus and you can make it with less fat. Dip veggies into plain Greek yogurt spiced up with whatever works for you and your family. It's really easy if you have a blender or a food processor. And it's cheaper. Lock down the fridge for 22 hours a day, the fridge and the cupboards. If possible, set a time for meals, and everyone helps. This pandemic time is not the time when kids are all over the place with friends and activities. This is not the time, unless you're an essential worker, a health care provider, first responders, grocery store workers, car fixers, electricians, plumbers, and farmers, that you are spread out all over the city at mealtimes. You're all home. Set a schedule and stick to it.

Phones, laptops, iPad, etc. are left behind. Make the food at these meals count, count for you and your family if you have your family with you. Make the food count nutritionally. Whole foods and grains and colors and spices. Limit salt. No easy carbs. Everyone helps chop, cook, and clean. Those who don't cook have to clean.

If you cannot get by on three meals a day, schedule snacks. Keep them prepared so that they're right there in the fridge. Alcohol can short-circuit your resolve. Make it once a week treat, not a daily necessity.

Kids say, "I'm hungry," and that whine goes right to your mommy brain. If they're really hungry, they'll eat fruit and veggies. If they don't want that, then they're not really hungry. No foods squirreled away in the bedrooms. It's okay to go to bed a little hungry. Don't eat a lot of easy calories before you go to bed or your kids go to bed. It's especially bad for your heart, your gut, your immune system, and your sugar control.

If you get this virus, you need a strong heart and strong lungs. There are many ways to exercise during this time. Physically distanced walks, jumping jacks in the living room. There are jillions of exercise classes online that you can do in front of your computer or your smart TV. You can do them in your yoga stretchy pants, and you already have them on.

So, just some ideas, and thanks for joining us on The Scope.

Interviewer: Sharee Thompson is a registered dietician nutritionist at University of Utah. And today, we want to talk to her and find out how an RDN can help you. And it's more than just I think what a lot of us think about when we think of an RDN, which is losing weight. I was shocked at all the different things that a registered dietician can help with, conditions that are actually very much influenced by the food you eat -- diabetes, kidney disease, heart disease, cancer.

There's a whole bunch of mental health conditions, including ADHD, depression, schizophrenia, eating issues like food allergies, which makes sense, but poor appetite or eating disorders. And then, even things like your mood, or sleep, or digestion issues, or fertility issues. I mean, so many things that we're like, "What's the answer?" And maybe we search for answers, and the answer is no further than the plate in front of our face. So how is it that food impacts these things so significantly?

Sharee: So I think one of the things that we need to understand is that our physical health, our mental health, and our nutrition are all highly intertwined. And, well, oftentimes, if one of these things is compromised, one of the others is likely as well. And so what we eat and how we eat has a major impact on our mood, mind, and overall well-being.

Interviewer: Is it something going on chemically there, the way the food is interacting with our body? Or, I mean, like, what . . .

Sharee: Yeah. So a very simplified way of looking at this is the food that we eat provides our bodies with the information or instructions and materials on how our bodies will function. And so if we're not getting these materials, being the nutrients in the food that we eat, our bodies will have issues carrying out the metabolic processes that they need to. Some examples of these functions that nutrients play a big role in are building neurotransmitters, brain chemicals that influence our mood and our health. Some examples of these are serotonin, sleep and relaxation, dopamine, endorphins. In addition to those, we also have immune function, nerve impulses, tissue repair, and also metabolism.

Interviewer: I loved what you said, but I didn't quite remember it. The food provides the instructions?

Sharee: The food provides the nutrients or the instructions that our body needs to carry out these functions.

Interviewer: To do what it needs to do. Thinking of it that way kind of totally changes the way I think about the food I put in my body.

Sharee: Yeah. And so if it's not getting those nutrients or the materials that it needs, it can't carry out the functions.

Interviewer: Yeah, If I'm eating a lot of fast food, then now, all of a sudden, my body's not getting the proper instructions to carry out the metabolic processes it needs to, so things start malfunctioning. So a registered dietician nutritionist, what do you do when a client comes in then with one of these conditions to help them feel better?

Sharee: So, through assessment, I mean, we're getting a better picture of the person as a whole. We take a look at their history, their dietary patterns, what their symptoms are, their issues. And each condition or disease has a medical nutrition therapy component to it. So it'll be different depending on the various condition. But we are educated in all of those areas where we can kind of tailor the plan to meet those needs.

Interviewer: Sure. So the right food for the right condition. That's really the value a registered dietician nutritionist brings to the table. But I also have a feeling other than helping with those food choices and evaluating somebody's diet, there's a certain amount of motivation that you have to offer, behavior modification.

Sharee: Yes. A lot of what we tend to focus on are just lifestyle behavioral changes, making these dietary changes, but also incorporating physical activity into our daily lives. And, you know, registered dieticians can also provide that ongoing support and feedback and advice. You know, if you have a bad week and you come back to see a registered dietician, they can continue to motivate you and be there to talk through these things and keep providing that information to you.

Interviewer: I know that's helpful, because after you have a bad weekend sometimes, then you really get down on yourself, like, "I'm such a loser. Why am I even bothering with this?" But the reality is you can pick it back up again.

Sharee: Yeah. And there's that accountability piece too. So if you know you have an appointment with your registered dietician the next week, you're just more accountable for those behaviors.

Interviewer: Help me understand the difference here because I want to make sure that I'm going to the right person, right? So there's a lot of kind of monikers I see out there. I see dieticians, I see nutritionists, I see registered dietician nutritionists. Is there somebody that's a little bit more . . . I mean, like, what are the education behind that?

Sharee: You can become a nutritionist. It's a certification. But a registered dietician, that requires a four-year degree with an accredited nutrition curriculum, extensive internships, hands-on internships, registration exam, and so you're credentialed with the Academy of Nutrition and Dietetics, and it also requires continuing education. And so we're continuing to be able to offer that science-based information.

Interviewer: Yeah, the latest information based on science and not speculation or, "This works for a lot of my clients. You should try it too."

Sharee: And we're not only nutrition experts, but we also are very educated and knowledgeable with the human body and how food affects it biologically and physiologically.

Interviewer: From my point of view, you'd want to look for an RDN because you know they've got a lot of education and schooling and the practical experience behind them. That's what those letters indicate.

Sharee: Yes, definitely.

Interviewer: That's what you just told us, yeah. If you are referred by a physician for an RDN visit, does insurance generally cover that?

Sharee: For certain conditions, insurance will cover. Some common ones are for diabetes and kidney disease. But you will want to definitely reach out to your insurance carrier, because they all vary, to find out if visits are covered and also what the specific benefits are.

Interviewer: So if you're experiencing any of the symptoms we talked about at the top of the podcast, by all means, go ahead and talk to your primary care physician and see if perhaps a registered dietician nutritionist might be able to help you get some relief or get a cure.

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Four in 10 women are obese, and over 2 in 10 are overweight. That adds up to 6 in 10 women who are overweight or obese. And many of these women would like to lose some weight. And many of those women have medical problems, such as diabetes, or pre-diabetes, or high blood pressure that would be improved or resolved with weight loss.

Okay, diet and exercise can help with weight loss, and exercise alone doesn't really lead to much weight loss. So the focus of interventions for weight loss is diet. There've been medications approved to decrease appetite. These medications change brain chemistry to decrease interest in eating, but these medications have side effects and some of them are very significant, and the FDA has been very careful about approving new weight loss medications.

Many women who take these medications gain their weight back when they stop them. The alternative is weight loss surgeries that decrease the room in your stomach or decrease the absorption of food in your intestines. This approach has been the most successful for sustained weight loss, but it's expensive and with all surgeries it can be risky.

So what if you feel full before you ate, sort of like weight loss surgery without the surgery? The FDA just unanimously approved a new device for weight loss. The device is a pill with a special compound called Gelesis 100 that absorbs water. If you take these pills 20 to 30 minutes before you eat and drink half a liter of water, which is about two eight-ounce glasses, the compound, which is cellulose, swells up and fills up your stomach so that you aren't too hungry and you can't eat so much. The compound is like those over-the-counter bulk laxatives, a cellulose compound.

Now how well did it work? The GLOW study, that's the name of the study with Gelesis as the G, published in the "Journal of Obesity," was conducted in the U.S. and was sponsored by the manufacturer. About 400 men and women took the active pills or placebo with two eight-ounce glasses of water 20 to 30 minutes before lunch or dinner for six months. The average weight loss for those who took the active pills was about 6% of their body weight, and those who took the placebo pills was the average about 4% of their body weight.

So in a 200 pound person . . . Now of this is for people who are math averse, so I'm doing the numbers for you. The average weight loss was 12 pounds over 6 months in the active group and 8 pounds in the placebo. Now looking more carefully at these results, it appears early on that you could predict who is going to lose weight with the pills and who wasn't. Of course, eating patterns are different person to person. If you get lots of your calories in snacking between meals, and that's such an American thing, taking these pills before meals won't make a difference, because you will have already snacked up your calories in there too late. If you're someone who doesn't really pay attention to how full you are before you eat that second serving of pizza or that dessert, that won't make a difference.

But for those who were losing weight on the active pills in the first several weeks, they were very likely to lose over 10% of their body weight in 6 months, about 20 pounds for a 200 pound person, and that's significant.

And among the participants with pre-diabetes or lifestyle treated type two diabetes, people taking the active pills were 6 times more likely to lose 10% of their baseline weight by the end of the study. And people who are pre-diabetic, or had diabetes that was treated with diet, were more likely to have a significant drop in their fasting glucose and insulin. So these pills helped people with diabetes or pre-diabetes get better control over their sugars.

Now unfortunately, the study didn't differentiate between men and women, and that's outrageous. There's the . . . I got the numbers. They should have done that. Women probably eat differently than men, have different eating and fullness cues, and we're going to need to find out more about that.

Now, one quarter of the participants dropped out in both the active pill group and the placebo group. Now that may be related to how hard it is to eat moderately, one, on a schedule, two, exercise 30 minutes a day, and three, drink water and take pills. All were required of the study, and, of course, there were side effects that were bloating, that only women use and I've never heard a man use, was more common in the active pill than in the placebo. Of course, they didn't call it bloating. They called it fullness or distension. It was noted 11% of the time in active pills and 6% in the placebo group. There you go, take nothing and you get bloated. I don't figure that one out.

Now, tummy side effects were common, 43% in the active pill group and 34% in the placebo, but that's how the pills work. The cellulose, which expands to fill up the stomach breaks down as it passes through the intestines and the large bowel, and it's excreted with bowel movements and so you have more bowel movements.

The product which will be called Plentity, that's kind of a cool name, is termed a device because cellulose is a commonly available chemical in food and in laxatives, but the way it's delivered in these pills makes it unique. It will be marketed in the fall of 2019 and available probably in early 2020.

So how does this help the overweight or obese woman who wants to lose weight? Well, firstly, you have to know your pattern of eating and whether you can change it to eating most of your foods at lunch and dinner and not snacking or drinking those mocha frappuccinos. Keep a log of what you eat and when you eat it so you can figure this out. If you don't want to wait until this new weight loss device is available, you can drink two large glasses of water before lunch or dinner.

In the GLOW study, those drinking water and the placebo also lost weight and water's free. Or you can do what some dietitians have suggested, and that is to eat a large bowl of low-calorie vegetable soup before your regular lunch or dinner. This soup thing is common all over the world and particularly in Asian cultures. This has also been shown to facilitate weight loss in American women.

Or you can buy a bulk laxative like psyllium. Take two doses with two large glasses of water before lunch and dinner. This is much like the strategy of this new weight loss device. It's also been shown to facilitate weight loss. Taking this much new soluble fiber in your diet all at once may have the same side effects as this new device, fullness, and that's the goal, nausea, bloating, more frequent bowel movements, that's also the goal of bulk laxatives, and possibly diarrhea.

We'll be watching to see how this new weight loss product works in American eaters and adolescents as it's introduced into the U.S. In the meantime, eat more fiber, drink your water, and thanks for joining us on The Scope.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.