Optimal Nutrition for Individuals Touched by Cancer

M. D. Anderson Cancer Center
Date: 2/1/2008
Duration: 0 / 21:25

Dena Norton, MS, Clinial Nutrition.

Narrator:

At the close of our meeting last year there was a lot of request from you to learn about nutrition and specifically nutrition in oncology so we have recruited Dena Norton who is in our integrative medicine and supportive care clinics and she is going to talk to you about optimal nutrition for the individual touched by cancer, Dena.

Dena Norton:

All right, well thanks for having me. I am glad I got the before lunch spot, and not the after, so I'll see if I can keep you awake. I did note some fresh fruit and yogurt on the way outside, so I just wanted to give my vote that you get approval for the nutritional quality of your snacks outside so. So, I wasn't real sure whether you wanted nutrition for cancer prevention or nutrition during active cancer therapy or nutrition for survivorship, but really it's all the same thing so I'm going to talk from an ideal standpoint what is the optimal diet and this is how I discuss it with patients too. Today, we're going to talk about the ideal and then you leave the table, and you take it home and you make it practical and we know that you're going to marry some of the ideal with some of the not so ideal, but that's life and so we're going to talk from what would be ideal if we could just name what we wanted our patients to eat and how active we wanted them to be during cancer and then I'll address some specific special recommendations as far as side effects of cancer therapies and things like that. All right, so just an overview sort of the why and how to eat so more of the eating attitudes that we need to address with patients and with ourselves quite honestly and then what to eat, which is what every patient wants to know, right. They just want a list of foods or a menu and they just want to do whatever you tell them they should eat so we'll talk about that and then along with that what not to eat because there are certainly a few things on that list and then some additional considerations. Okay so just one slide on why and how to eat; however, this is a soapbox for me so I'll warn you in advance, I might sit here a bit so first thing I would like to address with people because this is something especially in western society that we all need to work on and get a little better at and that is listening for internal signals, internal cues for hunger and satiety so I would like to address with people, you know, how often are you really getting hungry? You know, are you even hearing from your body because ideally you should be having this give and take conversation with your body all day long it should say hunger and you give it enough food to quiet it down for a bit and then it should say hunger and you answer and it should say something and you answer so it should be that sort of give and take; however, unfortunately in our culture there is so much talking on our part that we never hear or we rarely hear back from our body so ideally from a long-term perspective you want to train somebody to listen to their own body and respond to it appropriately. So those cues are important. The caveat is of course during cancer, especially during active therapy, there are multiple things that interfere with those cues and so sometimes they are unreliable and there are definitely patients, particularly in the palliative care or supportive care area where I'm telling them over and over again you don't have cues that are reliable so I want you to eat according to your clock instead of waiting to hear a signal so there are some cases where it doesn't apply, but ideally we get somebody listening to their own body and then healthy choices so obviously you don't want them just to feed food you want them to feed the right food so you want to educate them on what is healthy and this goes for us too, you know, the more you know about something's health properties the more appealing it is the better it tastes, the more you enjoy it because you know that it is doing something good for you so that's the idea it is to learn as much as you can about healthy food so that it becomes more attractive and it becomes actively nourishing yourself rather than just eating whatever is provided and then hugely important, particularly with children, which we're not so much talking about today, but is a special interest of mine and that's eating as a singular activity so probably everyone in this room including myself are guilty of eating while we are doing other things maybe even on a daily basis so the picture here, I was actually appalled, I tried to do Google search something appropriate and I found this, and of course, it is perfect for this slide, but I was horrified someone built this devise where it like holds your fast food meal on your steering wheel so I tried to make a big fat red X so don't do that, so eating while you're driving, eating while you're doing errands around the house, eating while you're dragging your kids to the next event, eating while you're working, all of these things invite all kinds of distractions and data is very clear that the more things you're doing while you're eating the more you eat and the poorer you eat. So we want to move eating back to a singular activity if it takes just shutting everything down, spending even 20 minutes or 15 minutes at a table concentrating on the food so that your mind is engaged in what you're eating and why you're eating it and when to stop instead of going too far like many people do. And then savoring foods and so that's part of the eating as a singular activity is bringing focus back to the foods, but we do want people not just to know about it, but enjoy it and so I try to encourage people to buy new things at the grocery store, I try to do this myself, you know, every few weeks buy something you've never bought before or haven't bought in a long time or don't know how to cook. You know, get over it, just buy it and figure it out and it maybe a flop, but you tried it and you learned something new about that, you know, have fun looking up a recipe for it and give it a shot and have something on back up if the family doesn't like it, you know, but learn about what's out there and I, I tried this with a couple of patients, I have done it in some group classes and it was a profound thing for me and I found that other people enjoy it too, but I didn't exercise during actually while in my college courses, I had this professor that put a piece of chocolate on everybody's desk and so we couldn't touch it till the end of class and we had to as a group go through this exercise of savoring it basically. And so you had to pick it up and look at it in the wrapper and then you had to unwrap it and look at it and then you had to smell it, then you had to put it on your tongue and breathe over it and sort of inhale the aroma and the taste and then you had to suck it till it was gone you couldn't chew it, and she watched you, so it took like five minutes to eat this little tiny piece of dark chocolate and it was the most heavenly thing ever, it was so wonderful and it really is such a good experience and just a reminder to slow down and enjoy what you're eating, you know, visually look at and then enjoy it if it's in your mouth and that's one reason why plant foods are so much fun, you know, fruits and vegetables because there is so much to them and I talk about that a lot when I work with kids, you know, that this banana was created with this little jacket and you kind of take it off, but he is all protected in there for you to eat, you know, and it seems kind of silly as an adult, but it really does help you to focus and enjoy what you're eating and it turns out the healthier foods are a lot more fun to do that way, so that's on the why and how. Now we'll get to the 'what,' which is what everybody wants to know. So we will start with the 7 to 11 which no one likes to hear, right, it is a full-time job every time you turn around there upping the anti on how much you have to eat of these things, but what we are saying now is as a minimum for women 7 servings, for men 9 servings a day up to a 11 servings a day of fruits and vegetables any combination of the two, although in general most people are kind of watching the weight management issue and as far as nutritional density, the vegetables do win out there on both of those accounts, so I generally tell people, you know, double the vegetables as the fruits, but in total 7 to 11 a day. Focus a little more on the vegetables if you can so one serving. I just have examples there the cut measures, but if you don't carry them around with you the visual image is about a tennis ball for something raw, so raw vegetable or a raw piece of fruit about a tennis ball size. If it's cooked or canned, kind of lost some of its body, it's a half cup or so and then a half cup for juices also. So really, if you order a large salad at lunch that's just once a day your making a change, but if you order a salad as a meal even if it has some seafood on it or whatever, you can get four servings of vegetables right there. If you grab an apple to add as a mid afternoon and a mid morning snack, then you've got two right there, so now you're at six, you only have one more to go so it's not that hard if you just make three or so efforts at it a day and then choose whole forms over juices so this is a few reasons. One is that the whole obviously has the fiber, the skin, which does have nutrients, not just fiber but phytochemicals that are really healthy for fighting disease specifically cancer and so we want the whole form as much as you're able to and then kind of supplement with juices to make up the difference or if you're on the run and you can't get the whole form that day or whatever or maybe a cancer patient who has difficulty swallowing different textures, juices are a great alternative, but from the weight management perspective not only do you miss out on some of the nutrients and the fiber, but it doesn't feel like a whole lot of food, if you down a 16-ounce glass of orange juice, but how many servings is it of fruit according to the servings? 16 divided by 4 is 4 yeah it's four fruits, you know, so most people drink juice not as a meal instead of other food, but in addition to the bagel or in addition to whatever as a beverage, but you've just consumed four pieces of fruit. Would you really have sat down and peeled four oranges in succession? No, so visually this looks like food when you eat the whole forms and that's just a good reminder to us that this is nourishment it is not just a beverage, am I mostly drinking it, I want to be, you know, conscientious about everything that I'm eating. So juices as nice, but I encourage them as supplements rather than as a mainstay and then consider organic, which in the world of cancer, in the world in general, I guess, but in the world of cancer, this is certainly moving to the forefront as an issue with patients and they are concerned for these pesticides and hormones and genetic engineering of fruits and vegetables and all these concerns and we are saying as an integrative medicine department - Yes, definitely consider it. Is it necessary? We really don't know yet, we don't have enough long-term literature to know for certain that it's necessary. Will it hurt you? No chance in the world it's going to hurt you except for your pocketbook. So, you know, if you can afford it, if it would buy you some peace of mind, go for it all the way. I think particularly if you have a hormone sensitive cancer like breast or prostate, ovarian, then you need to be extra careful about organic versions of possible hormone containing foods like animal derivatives, which we'll talk about a little bit. As far as organic goes also, I didn't go into it in this presentation, but the Environmental Working Group is a great resource for practical information, you know, the USDA.gov is a good information source for definitions of organic, but EWG.org has some good practical lists, which ones are the dirtiest, so I should buy those, which ones are the cleanest so it's all right if I skip that and just buy the regular version so those are some good resources there USDA and EWG for some more information on organic, but it is definitely something to consider. And then as far as what to eat, the brighter the better, so the more intense the color of the plant food, the more concentrated the vitamins and minerals, and phytochemicals there, so an easy comparison that everybody is familiar with is like iceberg lettuce versus fresh baby spinach. So iceberg, you know, really has very little of anything in it, it has a lot of water and it is fine for a filler, but if you're looking for vitamins and minerals and nutrition go with the darker color and that's true for all plant foods. And then use a variety of cooking methods so there are definitely advocates out there, particularly for cancer for raw food diets, which is fine and I know a lot of people who have done well on them, but there are some nutrients that are actually enhanced with heat treatment and then there are others that are destroyed and so we would recommend just getting a variety having some raw, having some cooked, if you are going to cook vegetables, particularly steaming is preferred because that's where you're going to maintain the most nutrients within that food and not lose them in the water or whatever so having some cooked, some raw, avoiding grilling and charbroiling so we know that the high heat methods are not so good and actually create carcinogens so we'd rather the lower heat cooked over a longer period of time and then if someone is going to use the microwave we'd encourage you not to use plastic containers in the microwave, but rather use Pyrex or glass so that the plastic materials don't leach into your foods those are still areas of evolving understanding and research and really knowing what that does, but it's clearly unnatural, so for now, we'd like to use caution until we do know definitively what to do about that. And then the rainbow principle, so get a variety of color groups within a day if possible but certainly within a week, choose from different color groups within the plant families so these phytochemicals which you probably at least heard the term comes from the Greek root meaning plant so these are chemicals that are unique to plant foods at this point, we have vitamins and minerals and fiber that are added back in to non-plant foods, but at this point phytochemicals have not really been fortified into the other foods and they are only in the plants, but these are the chemicals that are still becoming well understood. We have identified lots of them, but we feel like there are lots more yet to be identified, but there are the cancer fighters, the disease fighters, the health promoters that are really at the forefront of research. So we want to get as many of those as possible. I do have a chart I think just as a very brief glance at some of the different color groups that are associated to certain phytochemicals. So you can look through that on your own probably the most notable here that we all recognize are lycopene as in tomatoes that's the one that's actually enhanced with heat treatment maybe three to five fold more available to your body if you cook it or pasteurize it so canned tomatoes products are good. Beta-carotene is in the oranges, we're all familiar with that so those are just some examples there. So beyond the fruits and vegetables, we don't want to forget about the other good plants that are out there so nuts and nut butters can be an excellent source of healthy fat they do have some protein and a little bit of fiber, so that's nice, particularly if someone is trying to cut back on their meats or poultries and then beans, peas, and lentils, often overlooked, but really a fun family group because they have protein and a little bit of fat and carbohydrate with fiber and then they have vitamins and minerals. They are just a really nice one shot deal they are a really balanced food and they can be a great protein source for people who are cutting back on animal foods and then fatty fish and so we are all familiar in the past few years with the media attention for salmon and other fatty fish because of their Omega-3 content. Literature is still evolving in multiple areas of cancer, but at this point, we are pushing Omega-3's for anti-inflammation and possible anticancer properties plus fish don't carry saturated fats or trans fat like some of your animal meats do, so they are an easy swap out for that with the benefit of Omega-3's added in if they're a fatty fish. I probably should mention the concern about mercury toxicities since that often comes up as a question, and yes, there are... Oh, I don't know how to go back, so we'll just, I'll just freeze there and quit clicking. So mercury toxicity is a concern as well as other sorts of contamination of fish sources and I think that trying to buy wild from... I generally tell people geographically as north of us or as south of us and wild is the rule of thumb, so like Alaskan salmon, as an example, so go far north or further south and those waters tend to be lower in contaminants certainly avoid Asia and then parts of Europe like England, Scotland, those coast lands you want to avoid those, but if you can get wild that is certainly better and the other thing to remember is that if you'll buy from different sources within a given a week you're really going to dilute your risk of getting any one source that was highly contaminated and eating at multiple times in a small amount in a small period of time. So if you'll chose like they even sell wild Alaskan salmon in cans now, and I eat it regularly and it's pretty good so, you know, you can choose that as one night a week and then maybe two days later you have a salmon steak at a restaurant and those are two entirely different sources even though they are both salmons. So you really cut down your risk and we are still saying three to four times a week on the fatty fish for sure so. I'm trying to remember what slide I skipped. I think it was the New American Plate so you have that in your handouts for reference. I hesitate to click again once I go forward but the AICR American Institute for Cancer Research, you're probably familiar with them, and their website, but they put out several years back this New American Plate mentality trying to get people to think this way where it's two thirds of your plate is some sort of plant including whole grains, fruit, vegetable, bean, whole grain and then there is only a third of the plate reserved for your lean protein portion and you only get one plate by the way so the whole idea is just fill up on the plants and whatever room is left is all you have to work with for the meat or the animal so it's basically just portion, you know, controlling, but it gets people in that mindset of fill up on plants and then all you have left for the protein or the lean animal is this much here so it's just a mindset that for a lot of people it is easy to remember when they sit down at a restaurant rather than referring to your specific menu and trying to decide what they are allowed to eat and what they are not so I use that some with patients. And then finally, just one quick slide on not just what to eat, but what to drink so in our culture drinking has become very problematic as far as just excess calories go, as far as the amount of alcohol goes, as far concentration and portions, which we've already talked about even fruit juice can turn into a really problematic thing for weight management if someone misuses it. So what to drink? We want to make the beverages count, so green, black, white, Oolong, Rooibos, any kind of tea generally is encouraged and those have various different health properties, green is widely noted for anticancer properties, although the others have them too. So teas we like in general the benefits of caffeine as far as we know thus far is caffeine is good than the tea we'd rather you drink the caffeine, the caffeinated version to get all of the antioxidant and other benefits. So if that's a problem for someone, you know, I talk with them about starting earlier in the morning and getting it all done before noon to give it, to give it at least six hours to start diluting out of their body, although it won't all be gone by then probably caffeine for you is better than nothing, but still studies show at this point that the caffeine is important there and then fresh vegetable juices like we talked about earlier just the concentration. For some people, if they are opposed to vegetables or their lifestyle makes it difficult to do fresh juicing or to cook up large quantities of vegetables everyday, this can be a good alternative to get several servings in, in one shot. So a lot of people like that. It's also a good way for say someone, you know, had a particular cancer like prostate, that's an easy one to pull out, and they were trying to get in a lot of lycopene because they heard that this was good for their prostate cancer. Well, it's pretty tough for most prostate cancer patients to cook up a whole lot of Marinara sauce every single day and eat it or you know eat a bushel of raw tomatoes to get the lycopene that we'd encourage so for them you know a pasteurized tomato juice like V8, something like that is a simple way and 10 ounces to get the amount we've seen in some studies to be very helpful for prevention and maybe reducing aggressiveness so the juices can be a simple way for a lot of people to get a single nutrient that's in that juice in a high concentration without having to take a supplement. So the fresh vegetable juices are good. Notice I didn't include fresh fruit juices, not because they are overtly harmful, but again just I hesitate to really encourage them unless someone physically cannot consume two or three pieces of whole fruit a day. I'd rather yet proportions sake stick to the whole fruit and then plenty of water of course. Alright so a little bit on what not to eat so I have a list for things to avoid entirely if possible and then we have a slide, but that has limitations so the things to avoid probably number one on my list and number one really in all areas of health that I'm aware of at this point are the trans fats and interesterified fats, which are similar but a bit different. So the trans are the partially hydrogenated and the interesterified are the hydrogenated fats and there is no positive role for these in the body there is no reason why you need any amount of them a day and in fact they are quite harmful based on our knowledge at this point so they act in the body similarly to saturated fats; however, the preliminary research we have at this point shows that the degree to which they are harmful is much, much, much worse than saturated fats. So at this point, because you don't need them, and because they're probably one of the most harmful things we've come across as a single nutrient, we're telling people none if possible. I think the American Heart Association is saying, I think they are saying up to 1% of your calories from trans fat, which probably comes out to a couple of grams a day but the 2 gram a day level has been shown kind of harmful some studies involving reproduction and some other chronic diseases so I generally try to tell people to steer clear so you have a food label there and most of us are familiar now in the last few years since it has been legislated we can see trans fats up on the label so this product in fact is quite high, you'd really just want to leave this one on the shelf and run the other direction, but for the sake of an example it does have the trans fat at 2 grams there; however, you need to be aware as the consumer that trans fat needs to say zero for one thing, but by law it can't stay zero if it's up to half a gram so it does not sound like that bit a deal unless you're eating two or three different packaged products a day that all have half a gram and are called zero and then you're getting a gram and a half, not zero. So we really try to educate consumers on the two-fold process of checking one is find a zero up top and the other is go down below and make sure that there are no hydrogenated or partially hydrogenated ingredients, so that's your kind of two-fold check to make sure its clear of trans fats; otherwise, leave it there find a replacement product and never look back. Artificial sweeteners, although there is not really long term, clinical trial, really definitive data on this, I tend to lean toward you know A it's artificial, B there is data, C you know I think the data is coming along enough at this point to just say get it out, is it necessary, I really don't know, but I suspect that it is so we are trying to encourage people to cut down at least, but get it out if possible and this is pretty difficult to do, I mean if you eat sugar-free gum, anyone? Anyone? I mean it's in there if you eat a couple of sticks of that a day you're getting some. If you eat the light yogurts, the light this, the light that, the reduced sugar, the reduced calorie, it's really in a lot of things, and of course, the number one thing that we all think of when we think of artificial sweeteners is ... Yeah someone can say it even though we all drink it. It's Diet Coke, yeah so we should probably start getting that out, I mean this is something personally I'm working on just for full disclosure I'm, you know, I'm a dietitian, but I double as a human being so yeah we should all quit it. So probably wise is to get it out, easier said than done. Red meats and processed meats so come in two different concerns here, but definitely quite a few cancers as I'm sure you're well aware related to red meat intake so the more red meat you eat throughout your life the more likely you are to get a diagnosis of these cancers. That data has been collected over decades and decades so it's a little muddy. What about the red meat was a problem? And I'd say that we still don't know yet, but in general cut down on the red meat, there is no reason to have the amount that the average American consumes, no reason at all so cut down, consider cutting it out. And then processed meat so luncheon meats, hot dogs, things like that, that have been preserved using nitrites particularly, but probably preserved in anyway with any sort of sodium, these are linked to cancer as well and so I think the most recent ACS Guidelines are definitely now saying cut the processed meats and that's definitely what we are saying as well. And then hormones, which I mentioned earlier, so this is primarily related to animal products, animal meats and their derivatives, so dairy, eggs, and then meats from animals and poultry so it's not just the endogenous hormones, but the exogenous hormones and they've become a really big part of industry now to grow the animals quickly so they can be slaughtered so they can produce more and it makes sense from a business perspective, but we are just not real sure what all that exogenous hormone is really doing, how much is it filtering down into our food supply? How does that affect, particularly hormone sensitive cancers? Things like that. so we're saying for the most part choose hormone-free meats and poultry if you're going to do meats and poultry, try to avoid them and then other additives, dyes, artificial things, sure. In an ideal world, we would have none of that stuff because it's artificial and it probably doesn't belong in our body, is it benign? I don't know. Is it harmful? I don't know, but if you want to be as safe as you can be, which lots of the patients that we see, particularly in integrative medicine do, they want to do everything they can to reduce risk as much as possible, so we're trying to give them the things that might hurt even though they might not be harmful, we're just not sure, but if you want to be wise about it, cut it out, so. Oh! I skipped one again, ah! Got it, okay. Also, on what not to eat, this is the limit list so it's not so staunch as to say that you should never eat it again, but limit it so saturated fats we do need a small amount of saturated fat in our body to create healthy cholesterol and do some other things so yeah most Americans could probably benefit from trying to cut it out because they are still going to get some of it anyway, but the truth is you really will need to limit it 7% of your calories or so. So what does that mean? It means that for an average male you should chew for 10 to 15 grams of saturated fat a day it's not very much and then processed foods and this is where a lot of people think white, they want to cut out the white flours, and the white sugars, and the white this, and the white that and that's a fairly good rule of thumb, although there are some exceptions, there are so white potatoes unfortunately get lumped into that list, but potatoes are a vegetable, they are in a green leafy vegetable, but they are the plant so they come with beneficial stuff and I'm not keen on dumping them, but if you want to think of it as white that's fine, so most of us do need to cut back on that. And then sweets and sodas so I got you on the diet soda so if you are a regular drinker, you thought you got out of it, but you should still probably at least cut back on that safety wise, it's probably safer than the diet stuff because it's a little more natural, but there is not any real nutrition there it's just enjoyment so enjoy yourself a little, but you can see there are nine teaspoons of sugar just in the can. Well nobody even buys cans anymore we are offering them here, but now we have bottles so now we are drinking, you know, time and a half the portion size, but a can has 9 teaspoons of sugar and really no vitamins or minerals or anything beneficial so limit that, spin those calories on something else more beneficial. And then additional considerations, I wanted to at least address even though I was talking more as a global what should people eat for cancer we know that there are exceptions where people can't always adhere to all of those things so there are disease specific recommendations as one topic, which I address with patients a lot in the integrative medicine setting because a person will come in with a certain disease and they want to know basically what's my nutrition prescription? What should I be eating everyday because I have this type of cancer? So that's what I try to provide to them, so an easy example is again prostate and breast, you know, we all know that they have the most study with regard to nutrition and lifestyle. So if a man, you know, were to have prostate cancer I would probably at least mention to him pomegranate and the studies that we have for managing PSA post surgery, with just a cup a day of pomegranate juice and things like that so I try to equip them with studies, again many of them are in vitro, oh pomegranate is actually in human so many of them are in vitro, but I at least tell them what we know and what we don't know because in the food setting as opposed to maybe a supplement setting, but in the food setting they are not going to harm themselves you know they leave equipped with what they can do to interact with their own cancer and feel empowered that they can make a difference. I have to tell them that I don't know how much difference it will make, but it's at least a way to direct your efforts at something that has more study than other efforts. So disease specific recommendations for nutrition as well as treatment related side effects, which of course can be hugely problematic with fatigue and nausea, and on and on and on so that can you know fatigue I think is experienced by generally everyone who gets a therapy for cancer right so that definitely comes into play with preparing all these lovely wonderful foods and shopping and fresh everything and cooking all the time. Nuts are not at the top of the list for some people so we do have to make concessions and I'm a big proponent of hearing where someone is and going there with them and helping them move just one or two steps further toward ideal so we don't just throw all this ideals at someone and, you know, throw them out in the rain and expect them to come back totally changed for life so we do have to find the practical what's practical to them and bring them a little further toward ideal. And then oral nutrition supplements as well a nutrition support of course are a necessary option for many patients depending on the stage of disease or how severe their treatment related side effects are so those are a necessary place to go with some people; however, we'd like to never get there, but the key here is staying one step ahead of the need for it, which I think unfortunately really sets us back a lot of times with nutrition support sometimes it comes in as the final option or everybody has thrown their hands up and they are just asking for something that I can do to at least throw something at this problem and then a tube gets placed, for example. So we want to stay one or two steps ahead with regard to nutrition support and I think the clinic area I am in right now is very good about that, I can't speak for other clinics, but we want to be attentive to the root causes of problems so we can offer suggestions along the way and foresee what's coming because we've seen the trend in other patients and maybe a place the tube one or two steps ahead of when they would need it to prevent that need from ever arising basically. So nutrition support I think in some cases needs to be more aggressive maybe in others it needs to be less aggressive, in fact, and encourage the patient to take more autonomy of their own diet and lifestyle. All right, I think that's all that I prepared, but I'd be glad to answer some questions, I think we have some time left.