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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.

Interviewer: There's a pretty good chance that either you or one of your family members is affected by diabetes, obesity and other metabolism issues. We're going to talk about a brand new clinic that can help you. Coming up next on The Scope.

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Interviewer: Dr. Tim Graham is the Medical Director of the Diabetes, Obesity and Metabolism Programs for University of Utah Health Care. Let's talk about the brand new clinic for diabetes, obesity and metabolism. It's such a big deal that it's become kind of a thing of its own now.

Dr. Graham: Yeah. We basically have what we call a service line that covers multiple clinics throughout University of Utah Healthcare and we've got a couple of very exciting areas that we've brought new services to the people of Salt Lake and Utah. First off, we've got the Utah Diabetes and Endocrinology Clinic itself, which is now providing team-based diabetes care.

I often joke it really takes a village to take care of a patient with diabetes because individuals with diabetes have problems with eyes, they have problems with feet, they need special nutrition considerations. We like to have them work with exercise physiologists to improve their activity and to do it in a sustainable way where they don't develop sport-related injuries. They often have physical therapy needs, etcetera. And sometimes behavioral health needs. So we like to bring all those services in a team-based fashion to our patients who come into the diabetes center here at University of Utah.

Interviewer: And that's a kind of new way of thinking for diabetes. Am I correct on that?

Dr. Graham: It is. In the past, it used to be a very much a sub special physician-driven care plan where you would go see a doctor that would make some recommendations, send you back to your primary care provider. What we do is when a patient comes in and sees us, we provide all these services and we provide it in a nice, unified way so that you don't feel you've been juggled between providers. And then we send the patient back eventually to their primary care provider with a much more comprehensive care plan that sort of details all these things and doesn't just pay attention to the insulin dosing or other types of diabetes medication dosing.

Interviewer: What else does the clinic do and how is it helping people?

Dr. Graham: So we've also established a really exciting program in conjunction with bariatric surgery. We now have a pretty tremendous way to reverse diabetes using bariatric surgery. So probably better than any medication we can give people, if we can have them undergo gastric bypass surgery or gastric sleeve surgery, it largely reverses diabetes for a lifetime and longer-term studies are just coming now to bear that shows, this is a very sustainable effect and people do extremely well even a decade out past surgery.

And every decade you don't live diabetes is a decade that will save your body from a lot of damage. So we have partnered with bariatric surgery program to develop a unified approach to obesity. So anyone who has a BMI of 35 or more, and BMI is defined as kilograms per meter square, I use that term because I think more people will know what that is. And if you don't know, just Google BMI and you'll find any number of BMI calculators where you pop in your weight and your height and it will tell you what your BMI is.

But if you've got a BMI of 35 or more and you've got any obesity-related condition, that can be diabetes or it can be high cholesterol or it can be high blood pressure, if you have any of these conditions, then you're candidate for bariatric surgery. So we've recognized this is a really important sort of additional therapy we bring patients. And so we've got a medical bariatric program that's now partnered with the surgical bariatric program to provide what we call a comprehensive weight management program. And this also is not just for people who have very high BMI or who have diabetes. It's for people who just want to lose weight and would like get some medically-supervised nutritional attention and exercise physiology attention to help them.

Interviewer: From what you are telling me, this team-based approach, it seems like somebody might be listening and they're thinking, "I should be a little bit healthy, I should be able to eat better why can I not do this on my own?" But it's really a lot more difficult than that in today's world. And that's why you are bringing all these people, all these experts together?

Dr. Graham: Yeah, that's really one of the myths, I think, that our society sets up. It's like somehow, there is something wrong with you if you can't lose weight. That everyone should be able to have the willpower to do it. And we look at things like "The Biggest Loser." And while I love that sort of program for bringing to attention the problem with obesity, these people have all day of training. They have people preparing their meals for them. Who has the time, the money and the willpower to basically do that on a day-to-day basis?

The idea that it's just something we can easily do on our own without having help is really wrong-headed. And furthermore, I think it's even than the attitude of physicians for many years that the patient should just be able to do it on their own. And yet every time I have ever sent a patient out with just generalistic advice like, "Go lose weight and be healthier," they don't seem to come back having lost weight and eating more healthily. So I think that we really have to come up with personalized strategies to help patients, to support them, to even hold them to their goals. And people do better when they are working in a group like that generally.

Interviewer: Yeah. And I would imagine too that over the past many years we've learned a lot more about these things. And really you need to have those experts to have a better understanding of it?

Dr. Graham: Absolutely. The other side of this is that we now know that obesity is at least 50% genetic in origin. And so the idea that it's just because you're lazy and you don't exercise is completely incorrect. And anything that's genetic in origin has a biological basis so we now understand and very cutting edge research done here, both in Utah and elsewhere, that the brain is wired differently when you become obese and it's very hard to undo that wiring. So the fact that people, when they do lose weight, tend to have what we call recidivism where they gain weight back or very quickly.

Interviewer: We've all heard of that, right?

Dr. Graham: Yeah. That yoyo weight thing is absolutely hardwired in the brain. It's biological. It's not because of lack of will.

Interviewer: So a clinic like this really could help somebody that . . . it's not a magic pill, there is probably some work and some time involved, but it sounds like it would offer hope to somebody that has not had hope before or has failed in the past?

Dr. Graham: That's right. And I would say that also includes people who have very significant obesity. We use the term, and I don't like it because it sounds so negative, but morbid obesity, which is a BMI of 40 or more. People who get up that high have a very hard time losing weight and they need additional support, especially physical therapy. Think about many people are starting to get joint problems when you start getting heavier with a BMI of 40-45 range.

And so we need to bring a lot more things to bear to help these people, many of them will be bariatric surgery candidates, some of them won't. But just because they're not doesn't mean that they don't need special health care. And so we really are trying to bring medical bariatrics up to get up to speed with the great advances that have been happening in surgical bariatric. And to give a home for everyone with all these problems so that they don't have to just see the primary care provider who might tell them every time, "You know you need to lose weight. You know you need to . . . "

Interviewer: Every year you hear that, right? And then a year passes and then you come back and you're in the same boat.

Dr. Graham: It takes actually more than that to achieve the results.

Interviewer: Where can I find more information about the Diabetes, Obesity, and Metabolism Program?

Dr. Graham: Well, so we've got on the University of Utah website, we have information about . . . if you go to the Utah Diabetes Center, we've got a web page that will actually branch out all these different programs we've been developing.

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Interviewer: Chewing your food. Is it as important as your mom said it is? We're going to find out next on The Scope.

Man: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: How important is chewing your food well, really, and what does that even mean? We're with Staci McIntosh. She's a registered dietitian and Assistant Professor at the Department of Nutrition at the University of Utah. How important is chewing your food?

Staci McIntosh: Chewing your food is important. It's the first step of mechanical digestion. It's important for not getting choked when you swallow.

Interviewer: That is important.

Staci McIntosh: More importantly, though, is taking your time throughout the meal however you do that. If you want to swallow your food whole and then take five minutes before you eat another bite, or if you want to chew your food 100 times before you take another bite.

Interviewer: Oh, okay. So, take your time. Why would I take my time? What's the purpose behind that?

Staci McIntosh: Because it takes about 20 to 25 minutes for the hormones in your body to reach your brain to tell you that you're full. If I eat an entire Big Mac meal in five minutes, that's not enough time for my brain to register when I'm full, but if I take 30 minutes to eat my dinner, then my brain is going to know that I'm full well before I finished that same amount of food.

Interviewer: So, inhaling your food is bad because you will overeat every time, it sounds like.

Staci McIntosh: Mm-hmm.

Interviewer: Let's talk about chewing as far as digestion is concerned. I've heard 20, 25 times per bite? You kind of rolled your eyes a little bit there.

Staci McIntosh: Our digestive system is really amazing.

Interviewer: Yeah.

Staci McIntosh: Our stomach, our small intestine will continue to go through all the muscular motions of mechanical digestion. The enzymes are going to get in there and will break apart the food [inaudible 1:46] the surface area until it eventually digests it all. Food doesn't just go through the system without being digested, nor does it sit there forever without being digested. It will eventually be digested. The more you chew it up, the less mechanical work your gut has to do.

Interviewer: What about nutritional assimilation in the body? The more that you chew, do you get more nutritional value.

Staci McIntosh: No.

Interviewer: No, really?

Staci McIntosh: No.

Interviewer: That's a myth?

Staci McIntosh: That's a myth. You will liberate some of the B vitamins from fiber a little bit more, early on, but we have a pretty good record in our gut of absorbing 95-99% of all the macronutrients--carbs, fats, and protein--and, much to a lesser degree, for the micronutrients--the vitamins and minerals--but, whether or not you chew five times or 25 times is not going to make that much of a difference.

Interviewer: So, just chew enough to get it down is the minimum, and if you enjoy it do it more?

Staci McIntosh: Sure.

Interviewer: So then I don't need to swish soft foods around in my mouth, like a banana or something, to mix it with the saliva?

Staci McIntosh: No, no.

Interviewer: You didn't like that too much.

Staci McIntosh: No, I can't imagine swishing a banana around in my mouth.

Interviewer: So, at the end of the day, it sounds like the amount of times that I chew my steak doesn't matter too much.

Staci McIntosh: Again, there is a big difference and there is statistical significance in studies that show the longer you take to consume your meal overall will make a difference in your satiety and your overall amount of calories consumed.

Interviewer: Gotcha.

Staci McIntosh: Whether you do that by taking longer to chew your food or if you take longer just in between bites, it's not going to make that much of a difference. I would certainly recommend that people chew their food appropriately, but counting the number of times you chew your food is a little obsessive.

Interviewer: I'm glad to hear that. So, it's more about just caloric intake than anything else?

Staci McIntosh: Caloric intake and the time. Your time will affect your caloric intake overall, but when it comes down to it, it is the caloric intake.

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