Nutrition During the Holidays

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Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore.  I am Bruce Barber.  Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists, who are on the forefront of the battle to fight cancer.  This week it is a conversation about nutrition and exercise during cancer with registered dietitians Heidi Larson and Vanessa Solino.  Dr. Gore is a Professor of Internal Medicine in Hematology at Yale School of Medicine and Director of the Hematologic Malignancies at Smilow Cancer Hospital.

Gore My patients who have cancers often assume that they have to stop exercising and they are so worried about nausea, is this a common concern?

Larson It is definitely a myth.  I think historically many years ago doctors used to encourage more rest, but now that dynamic is changing and more and more we are finding out that exercise can be of benefit.  A lot of people think for exercise you need a minimum amount of 30 minutes a day.

Gore Sure, why bother, that is what I say.

Larson Well, that is not the case.

Gore There goes my cover.

Larson Even with a cancer diagnosis, they are showing that you can maintain functional status much better even if you are doing some leisurely walking, volunteer work, even light housekeeping can make a difference in your energy level and of course, we are all trying to maintain our weight or body mass index, so keeping moving maintains muscle and metabolism, so there are many benefits to exercise.

Solino And I think a lot of times during treatment, patients are commonly fatigued, and they think the rationale is I will just rest, but it is actually more helpful to move a little bit to fight fatigue than be sedentary.

Gore It has got to be kind of hard though to get motivated for that.

Solino Oh sure, but even if it is just getting up between commercial breaks or Netflix binge watching and putting the laundry in the drier, things like that.

Gore Gotcha. I also sometimes have patients who come in with baseline obesity and see this as an opportunity to lose weight, is it the time to go on a crash diet?

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Larson I think that can be dangerous because a lot of times we are trying to lose weight in a healthy way and when you are losing weight by not eating, you are actually losing your lean body mass which is more detrimental to overall health than the fat that we are trying to lose, in theory.  What I typically tell patients is if they are just starting treatments like chemotherapy or radiation, I will say let’s wait a few weeks and see how you are feeling from the treatment.  If you are feeling well, start adapting a healthier diet, start increasing vegetables, have more lean meats, healthy fats such as fish oil, olive oils, cut out the butter, those types of little starts can be beneficial and if somebody is losing a small amount of weight because they are eating healthier that never bothers us and has benefits.  What we do not want is for people to be losing weight because they are having nausea or loss of appetite.  So we really try and individualize it to how the patient is feeling and their motivation level at that time.

Gore Gotcha.  And most patients can have expectations of nausea-free treatment, I mean that is not the usual to expect to have nausea?

Larson Yeah, I think the medications they have available now have really come a long way, so I think we definitely see a lot less vomiting and if people have some nausea, it is more like a discomfort in their stomach, queasiness or something, and I think patients can sometimes make it worse themselves by not eating, it is important to keep something in your stomach to try to keep that queasiness at bay.

Gore Do you ever find that the patients may have not mentioned to their doctors or nurse practitioners about ongoing nausea because they feel like well they are getting treated, so they deserve it, but then they bring it up to you and you have to say have you asked your doctor, is that ever the case?

Larson Not as common, I think the teams lately have been really good about continuing to ask questions whether it is a nurse, whether it is the APRN or the PA, but it does come time where they all disclose more information to one provider they feel more comfortable in and that is why it is great to have a multidisciplinary approach where we are kind of communicating with each other and we are always telling them to talk their doctor and helping to optimize any particular medications that they might need.

Gore Do all patients get seen by a nutritionist?

Larson All in the medical oncology infusion area, at least as a consult service, so we are consulted for patients with the most need and an example of that is somebody who presents with a lot of weight loss or in other cases, in the women’s clinic for women who have concerns about gaining weight during treatment.  I also think some people 

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tend to avoid us, those that might not be particularly experiencing symptoms because they feel that we are going to be the food police and tell them that they cannot eat things but we are actually the opposite, we are promoting food and nutrition and whatever that is, we are not going to say never eat this, this is bad.  There are so many different foods that a person has as a choice.

Gore What will you do for the patient who comes in very depleted because of their cancer and lost a lot of weight?

Larson It is important to look and see what their diet consists of, what their restrictions are, what their family support is, who is cooking at the home, are they able to shop for themselves and it might be a matter of making a small tweek, if they are only able to buy packages of frozen dinners or canned soups, but they need more calories, asking them to keep some condiments on hand, like olive oil or extra Parmesan cheese can sneak in more calories if that is what they need without giving them work and effort to eat.

Solino We also try and look at the underlying cause of the weight loss.  Sometimes, that could be loss of appetite, sometimes it can be difficulty swallowing, physically preventing them from eating or the patients can have nausea or if they had surgery, say gastric surgery, that can affect their eating.  So it is very much individualized to the underlying cause of weight loss.

Gore And you sometimes use nutritional supplements I imagine?

Larson Oh yes.  While there are really a lot of supplements on the market, I am finding more and more when people have family support, a lot of times, families want to make something for them.  So some of the things we do is work with them to make sure the nutrients they need are in the shakes they are making at home.

Gore Great and if somebody needs a nutritional supplement, does that get covered by their insurance?

Larson Not typically, the state of Connecticut Medicaid might cover under certain circumstances, but Medicare would not, so a lot of times they are paying out of pocket which is why it is important to think about other options, things that might be a little cheaper like the generic version of Ensure if that is their preference or Carnation instant breakfast packets can be mixed with milk and those are fairly affordable.

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Gore But regular food is going to be cheaper if you can work with it right rather then the packaged formulas, I am guessing, is that true? 

Larson That depends on the circumstances.  In some circumstances, an oral nutrition supplement may be the only thing that the patient can tolerate.

Gore I get that, but I mean all things being equal.  You have a family member who is really interested in learning how to cook and make nutritional shakes and stuffs.

Larson It does typically work out to be a little be cheaper.

Gore But takes more work.

Larson Yeah.  I think it is always good to focus on food first if you can and then resort to a supplement and the other options are exhausted.

Gore Gotcha.  Patients are often asking me about medical marijuana, they seem to think that this is going to be the be all for their appetite, have you got any experience with that, not personally?

Larson Not personally, no, but that is an emerging trend, and for a lot of folks who have loss of appetite it is really hard to correct, because there might not be a medical cause for it, just a general disinterest in food.  So the idea that they can do this recreational, but it is becoming a lot more socially acceptable through the country, they feel that might be the cure all.  However, our challenge is that since it is not very well studied because it is still a controlled substance, we cannot test it.  It is all subjective information as to whether it helps and certainly I think it is individualized benefit if any.

Gore I recently had a patient whose family and he requested a prescription for medical marijuana which we provided and I saw them sometime after and the wife was very upset because he was still fatigued and he still was not eating and I said well it is not well studied, and it does not help everybody, but I have also seen people who have responded.

Larson Sometimes people are dealing with the side effects and I suggest that they do it just before bedtime and sometimes it does help them wake up in the morning with a better appetite, so at least they can eat a larger breakfast.

Gore Right.  There are also other appetite stimulants that are medically approved, right?

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Larson Yes.

Gore And some of them work for some patients and not for others.

Larson Yes. There is the synthetic form, Marinol. 

Gore I have not had a lot of good success with that.

Larson I have not seen that either.

Gore I use a lot of progesterone or Megace suspension which I think works the best in some patients with medical reasons and I know some doctors give some other things, so that is good to know.  So what about the patient who is kind of couch potato lump, and now you give him chemotherapy, is now the time to go to a personal trainer, how does that work if you want them to get exercising?

Larson I think at any point through treatment before or after moving is important. If they are not experiencing residual effects and they want to get moving there are physical therapy programs for people who have limitations in moving, silver sneaker programs and light yoga are really great for someone who might not be ready to hit the treadmill and go through CrossFit and throw tires around.

Gore What about the other patients, the ones who do go to CrossFit and throw tires around, do we encourage them to keep going or take it a little easy, what are your thoughts?

Larson We want to make sure they are getting good hydration, so they are not fatigued and at risk for falling, but it is a matter of their overall performance status and their stamina and it is important to make sure they are eating appropriately because if they are burning more and their energy demands more, they might not be eating well either and they could also get some not directly evidence-based nutrition advice from other providers or folks at the gym who mean well; but might not know the science of nutrition.

Gore So they really need to first of all talk to their practitioners about whether keeping up that very intense exercise program is a good idea. Besides any nutritional concerns that 

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they might have, I am getting that this is not very well studied from our perspective either in terms of patients continuing to exercise and I guess we all assume it is a pretty good idea but what is the evidence of exercise in cancers that is emerging in the US?

Larson The Yale Survivorship Program is currently conducting a lot of research into exercise and that is ongoing, but they recently released a study in ovarian cancer patients that exercise did improve quality of life and maintained functional status and these were patients who were being actively treated, so it is possible to start a program even if you have never exercised before once you have the cancer diagnosis.

Gore That is great.  I am going to want to pick up on that after a break, but right now, we are going to take a short break for medical minute.  Please stay tuned to learn more about nutrition and exercise during cancer with Heidi Larson and Vanessa Solino.

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Gore Welcome back to Yale Cancer Answers.  This is Dr. Steven Gore.  I am joined tonight by my guests, Heidi and Vanessa.  We have been discussing nutrition and exercise during cancer.  Just prior to the break, you were mentioning that the survivorship group here at Yale has been studying the impact of exercise and quality of life in ovarian cancer patients.  I think they have done some work in breast cancer as well, is that true?

Larson Yes, this is now out a few years but they did something called the LEAN study where they looked at nutrition and intervention for breast cancer patients and one of the goals was to prevent weight gain which can be pretty common in breast cancer patients long term and is associated with poorer outcomes when women gain too much weight, so it is a huge challenge that women with those diagnoses have to face because they are often thrown into menopause which changes your metabolism.  Again, we are traditionally focused on preventing weight loss during active treatment, 

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they have discovered that it is more important in this sub group, the breast cancer population, to just focus on maintaining weight, maintaining activity level and adapting a healthier diet.

Gore It seems like you have got enough on your mind, just dealing with your cancer, that it is a lot to worry about what you are eating and getting exercise.

Larson But I think it is a good sense of empowerment.  You do not have much control of your treatment plan or your disease state in so many ways, but nutrition is one place where you can control what you are putting in your mouth and what you are doing and that is a way a person can take back their outcomes and really improve the survivorship, I think.

Gore Are there any special foods that help people deal with certain side effects or anything like that, do you have any special tricks for patients who have difficulty swallowing or appetite problems, any special hints you guys have?

Larson The hints really depend on side effects, actually a lot of my best tips come from patients themselves.  For example, patients dealing with nausea who are very sensitive to smells, a patient once told me they just took peppermint oil and put it on their wrists and whenever they passed the offending smell, they would smell their wrist to kind of cover up that smell that was nauseating to them.  So that is one of the better tips I have gotten and people come back and say that they thought it was effective.  Ginger has been shown to be effective for nausea, so of course you need to use that in conjunction with your anti-nauseants.  Nowadays it is difficult to find ginger ale with real ginger in it.

Gore I was going to say it was like an old remedy when I was a kid, to take some ginger ale if you are nauseated.

Larson Nowadays you can find crystallized ginger candy that you can take.

Gore Right, my wife’s favorite.Larson You can take a ginger tea or you can just pick up ginger root at the grocery store and simmer in it some water and make your own tea.

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Gore And do people like that?

Larson Oh they do.

Gore I mean does it help? I mean I like ginger.Larson There is no harm.

Gore I was recently in southern India and we toured a little place that raises herbs for the south Indian Ayurvedic medicine, and the guy was knowledgeable and he was pointing out all these different things that were used for different things, I do not know how effective that all was, but it was certainly interesting, there was a whole different kind of herbal mindset and certainly ginger was the big one and turmeric was a big one, and cardamom, they do a lot of cardamom.

Larson Yes, fresh herbs are a really good way to enhance cooking, certainly with taste changes, playing around with some fresh mint or basil, even if it is flavoring water with some basil and strawberry, can really help change the taste for some people.  Cranberry extract concentrate juices is another good way, if someone is having taste changes and their water is kind of tasting funky which is common, putting a little splash in is a good way of focusing on getting good hydration as well.

Gore It is so interesting that these changes that happen in the taste sensation and I do not know if it is from the tongue or whether it is in the brain or whatever, but some spices really come through. 

Larson One patient who 2 years after radiation for oral cancer needed to take fresh wasabi before every meal to wake up his palate and that worked for him.

Gore Like he would take the real horseradish root?

Larson Yep, just to give it a little bit of a zest.

Gore And breakfast even?

Larson Exactly.

Gore Oh, I like my sushi with wasabi, but that is so interesting.  So are patients coming up with the stuff every day, do they have support groups, internet groups or chat rooms?

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Larson Well the internet is a funny friend.

Gore Right be careful with what you read there.

Larson Exactly.  As dietitians we get a lot of focus coming to us with Dr. Google’s information that might not always be accurate, so it is important to refocus them to attend support groups and point them to some more credible sources on the internet as well.

Gore Yeah, because there are some right, there are some reasonable sources.

Larson Oh absolutely.

Gore And of course, I would think that if a patient comes up with something and you are not familiar with it, you might refer them back to the practitioner to make sure this is okay.

Larson Exactly.  I think that is an important point.  If anyone is considering taking herbals or supplements, it is important to realize that they can sometimes interact with your treatment and sometimes decrease the effectiveness or cause other side effects.  So whatever you are considering taking make sure you talk to your practitioner about it and make sure that it is safe in your specific situation.

Gore I am impressed at how much money some patients really spend on some of the supplements, if I go to a general nutrition store, the stuff is not cheap, even when I bought stuff from that Ayurvedic shop in India, there was a magic weight loss thing that did not work but I thought it is worth a trial, they are not cheap.

Larson Yeah, it is very common.  It is a major business, and it sells nicely, take this pill, it is a quick solution, but no one food supplement can cause cancer nor can it cure it.  So I think that is important to know when you are thinking about supplements.  The only time we really recommend supplements is if there is a nutrition deficiency and that requires lab work. 

Gore What about the way we prepare our foods, in old days, people did not like vegetables because they were overcooked and then went to the Al-dente thing.  Do you think that cancer patients, is there any general recommendations, and it probably depends, but fresh vegetables, cooked vegetables, fresh fruits, cooked fruits, canned fruits, what seems to work?

Larson There is a food trend lately that a lot of patients have been asking about and it is the raw food restaurants.  So nowadays, you can go to New York City and find dozens of raw food restaurants.

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Gore And I do not understand that appeal at all.

Larson So the thought is you can achieve best nutrient absorption with raw foods, but the reality is that we can absorb some nutrients better from raw foods, but then other nutrients better when they are cooked.  For example, with a tomato, when it is raw you get more vitamin C.

Gore It is delicious, if it is red.Larson Yeah and with tomato sauce, you actually have benefits of lycopene which is better absorbed from cooked tomatoes.  So the best thing to do is use a combination of raw and cooked foods.  If you are cooking foods, the best way to do so is through steaming, it conserves the nutrients the most and not far behind is sautéing in oil and sometimes adding that little bit of fat can help with nutrient absorption.

Gore What about oven roasting, that is my favorite approach to the vegetables lately, is it not good?  It is so delicious.

Larson It is really a time and temperature thing, so you will be losing some nutrients but gaining others.

Solino And I think it is important to focus that anytime you are eating a color diet by way of fruits and vegetables that is always a good choice.  So I think overthinking like always, this is better or worse, I think just eat the vegetable and enjoy it.

Gore I love roasted Brussel sprouts for example and steamed as well.

Larson Have you tried Brussel sprouts and making a salad out of them?

Gore I have eaten it that way, do you like it that way?  It is kind of like coleslaw really, it is cabbage.

Larson We do a little lemon and olive oil and then throw in some nuts and dried cranberries, it is really good.

Gore Oh that sounds great.  Supper yummy.  I was traveling in Eastern Europe this summer and they use a lot of buckwheat and other things that we do not see so much.

Larson I think that is a great point, there is kind of an anti-wheat movement in the United States and I think it is a problem where we do hone in on one food and there are a lot

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of grains out there that you can try, so instead of totally avoiding wheat which can be beneficial, you can just add in other grains, farro is a great one.

Gore I love farro, and quinoa which is really a grain I guess.

Larson Barley is even good, it is very simple.

Gore I like barley.  Barley and farro are kind of similar and do not forget buckwheat, buckwheat is delicious and it is not wheat.  So one of the things that we know is that food is such as an important part of existence right, the whole social thing about food and everything, I imagine when people have a hard time eating, it increases isolation.

Larson Yeah that is a good point, especially around holiday time when friends and family tend to want to push food as a source of love.  So I think it is important to find new family traditions and kind of set your own boundaries if you are not feeling well and you are at a family function and someone loves to push that second portion of pasta on you, make excuses to kind of help serve so that you are in control of your own portions, find a new activity like family game night, something that might not be as food focused.

Gore That is a good idea.  Do you recommend that people try to participate or really just go with what they are feeling?

Larson Well I think Vanessa brings up a good point that food can be a source of conflict for families and I have seen it over and over where the wife might be pushing the husband to eat meals and I think as a caregiver you want to provide support and food is the one of main ways you can do it, but I think it is important for caregivers to realize that they can only do so much, so they can provide the food, but it is probably better not to be pushing it.

Gore I hear this a lot, tell him he needs to eat.  Of course, we all need to eat, but you know if he does not feel like eating, we have got to think of some other ways as well.

Larson I think it is stressor for the caregiver as well, because they are like oh let me go try this and they run to the market and they purchase this and then they have all these ice creams on hand and they ends up eating it and then they come to us and say oh I have gained 20 pounds, he needs it, so it is just sometimes okay to eat routine, this is what I expect to have for breakfast, it might not be that much and then I will try another small frequent meal later, so it is important not have extra stress around eating, because it is so closely tied to our emotions and how we feel as human beings.

Heidi Larson and Vanessa Solino are registered dietitians. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org.  I am Bruce Barber reminding you to tune in each week to learn more about the fight against the cancer on Connecticut Public Radio.