Nutrition for Cancer Survivors

Maura Harrigan, RD, Nutrition for Cancer
Survivors December 27, 2009Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Foss is a Professor of Medical Oncology and Dermatology
specializing in the treatment of lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening, Francine
welcomes Maura Harrigan.  Maura is a nutritionist for the
Connecticut Challenge Survivorship Clinic at Yale Cancer
Center.Foss
How can nutrition help to ease the burden for cancer patients?Harrigan
Well, food is sustenance, food is comfort, and as we know, food is
love.  So, emotionally and physically, food eases the
burden.  Nutrition plays a vital role across the spectrum of
cancer survivorship beginning with active treatment, recovery, and
through the transition to health maintenance and wellness
care.  Each of these phases has a different nutrition need and
challenge.Foss
What role does nutrition play in planning cancer treatment?Harrigan
Actually, a very important one; it is all about having a good
offense entering treatment.  As you know, addressing a
person's nutritional needs before treatment starts will help that
person better tolerate this acute phase of their care.  The
goal is to prevent deficiencies and preserve lean body mass. 
First, there must be an assessment of the person's current
nutritional status.  Are they well nourished or are they
entering treatment already undernourished?  Their energy and
nutrient requirements need to be determined.  Now, the
question is, can the person meet these needs through eating their
usual foods?  There are many common symptoms such as fatigue,
anorexia, and pain that may interfere with eating.  Then there
are nutritional problems related to the treatment itself that must
be anticipated.  Surgery, radiation, and chemotherapy
can cause side effects such as nausea, vomiting, changes in taste,
or smell, or in bowel habits.  Again, these symptoms may
interfere with a person's ability to eat.  So, temporary
adjustments to the choice and preparation of foods, small frequent
feedings, and adding supplemental nutrient dense drinks may be
helpful, but sometimes even that may not be enough and there may be
a need for temporary use of tube feedings to prevent weight loss
and ensure adequate nutrient intake.Foss
When a patient is diagnosed with cancer and they start thinking
about all their treatment and maybe have anxiety about all of that,
they oftentimes are not focusing on their nutrition, should all
patients see a nutritionist at the very beginning when they get a
diagnosis of cancer?Harrigan
That would be ideal to have a registered dietitian come and speak
with the patient and their3:00 into mp3 file 
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 family members and also consult with the oncologist to determine
the best pro-active actions to take before entering treatment.Foss
And oftentimes patients have symptoms that you mentioned like
fatigue, anorexia, etc., and many of those symptoms are related to
cancer itself.  How does a patient know whether their diet is
playing a role in that?  Again, is this something that is
going to require a careful nutritional assessment?Harrigan
Yes, what we do as dietitians is take a careful diet history from
the patient and we could ferret out with the issues for the patient
and discuss it with their family.Foss
So, even patients who think they are on a so called 'good diet' may
potentially have issues with their diet and their intake?Harrigan
Yes, because how you define a good diet varies with each
person.Foss
What about the issues with respect to the specific kinds of cancer
that a patient has, say breast versus colon for instance?  Are
there different dietary recommendations?  I know we have heard
things in the lay press about the role of potentially fats in some
of these cancers and soy as well with respect to treatment. 
Are there specific diets that you recommend for specific kinds of
cancer?Harrigan
Well, I know that research is trying to determine how best to
target nutrition therapy to specific cancers and some examples are
a low-fat diet, and limiting trans fat and saturated fat, is
thought to be protective in breast and prostate cancer, also a diet
high in fruits and vegetables is considered protective for lung,
oral, esophageal, stomach, and colon cancers, but what I would like
to add here is that eating well in our culture is very difficult to
do even without the challenge of the cancer diagnosis, and what is
convenient and accessible is high fat, high salt, high sugar, and
high calorie foods.  So assessing a person's customary diet
prior to diagnosis is helpful in determining the diet changes to
target and also to assess the person's readiness and ability to
change.  So, I guess what I am trying to say is where research
is going is ideal, but you have to really look at where the person
is starting from.Foss
Many of us then really do not have enough fruits and vegetables in
our diet as it is.Harrigan
That is so true.  The FDA 5-a-Day Program, which I'll ask
people to do, is eat two servings of fruit a day and three servings
of vegetables to be the cornerstone of our diet.  Only 25% of
us actually make that goal in a day, and the number one vegetable
is potato, which is diced, fried, and salted so it becomes French
fries.6:11 into mp3 file 
http://www.yalecancercenter.org/podcast/dec2709-nutrition-cancer-survivors.mp3Foss             
 I have heard ketchup, at least in school systems, ketchup appears
to be a vegetable.Harrigan
I have to say, one of my daughters counted that as a vegetable
growing up.Foss
One interesting thing after just having come back from the far east
and seeing how folks there eat, is it's really, really clear that
they do eat more natural foods and more vegetables, and certainly
in those parts of the world, the risk of cancer is a lot less than
in the United States.Harrigan
Yes, and that's really the diet that we are promoting, a
plant-based diet where the majority of your plate, if you look at
it, should be filled with plant foods, fruits, vegetables, whole
grains, and then you are actually using meat as a condiment. 
I try to get people to visualize what a healthy meal looks
like.  It is predominantly filled with fruits and vegetables
and grains, and meat is just a condiment, not the centerpiece of
the meal. That mimics more the diet that you were seeing in the
other cultures.Foss
You talk a lot about trans fat and certainly this is a
buzzword.  Nowadays, a lot of our products are labeled as 'no
trans fat'.  Can you talk about the role of trans fat and
saturated fat?  Is this mostly coming from meat or is this in
other foods that we are eating as well?Harrigan
The saturated fat does come mostly from animal sources, so that
would be red meat, processed meats, and also full fat dairy
products.  Now the trans fats, I find are more in processed
foods is where they do partially hydrogenated oils as an
additive.  So, something like a Pop-Tart would be a food item
that would have a trans fat in it.Foss
What about the fats in nuts?  A lot of people say, well I know
nuts are healthy, but they have a lot of calories and a lot of
fat.Harrigan
Nuts can be a hard sell for people for just that reason.  Nuts
do contain a lot of fat, which happens to be concentrated in
calories, but it is a type of fat called a mono-saturated fat,
which is actually quite heart healthy and I find nuts to be a very
useful food for cancer survivors throughout their day to snack on
because it is nutrient dense, meaning it packs in a lot of calories
and nutrients in a very small package.  So, for someone who is
having a hard time keeping up their food intake, nuts are a very
useful food.Foss
You talked about the role of supplements, these nutritional drinks
that we give to patients.  Can you talk about those, the ones
that are medically prescribed, and then some of the other ones that
are available in the drug store?9:14 into mp3 file 
http://www.yalecancercenter.org/podcast/dec2709-nutrition-cancer-survivors.mp3Harrigan       
 Well, the ones that are medically prescribed are ideal in terms of
their composition of carbohydrate, protein, and the types of fat in
it.  Preparations that are found over the counter in the
store, particularly high protein powders, can be detrimental to
people and misused, though there is one product that I find that
you can get in the grocery store that works beautifully, which is
an old standby that we have grown up with, which is Carnation
Instant Breakfast mixed with organic skim milk. That is a wonderful
supplement and it is inexpensive.Foss
And we tell a lot of patients that and they do not actually believe
us, so I am glad that we are hearing it from a nutritionist. 
What about the whole issue of control over your diet?  Once
you have a diagnosis of cancer, you already have lost a lot of
control in your life.  How important is it for people to start
really controlling their nutrition at this point in their care?Harrigan
It is very important because the person can feel empowered and it
gives them an active role in their care, and it is also a wonderful
way for family and friends to be supportive and help by assisting
with food shopping and preparing meals.  Food can be a
wonderful focal point for healing and nurturing in this
process.Foss
In terms of family and support folks, knowing what the right foods
are, are there specific guidelines or are there any handouts that
you recommend?Harrigan
That is a good question because there is a lot of nutrition
misinformation out there.  Where you get your nutrition
information from is very important.  There are some wonderful
resources that are out there available to patients and
families.  There are a few websites that are actually quite
terrific, and one is the American Institute for Cancer Research,
that is www.aicr.org, and it has
wonderful nutrition information and you can actually sign up for an
E-mail recipe service so they E-mail you nutritious recipes every
week, and I look forward to that E-mail every week.Foss
That sounds great.  Actually, I know that organization because
I used to review grants for them and they really are studying
specifically the effects of natural substances in foods with
anti-cancer properties, as well as the benefit of things like
omega-3 and omega-6, which were studied for a number of years and
shown to have specific benefits for a lot of diseases.  I
think that is an excellent website.  Talking about omega-3 and
omega-6, can you mention something about fish oil, this is
something that we have all heard about and it seems to be good for
a lot of different things, is it good for cancer?Harrigan
Yes, that happens to be one of the supplements that is actually
panning out to have a benefit.  Omega-3 has been processed out
of our food supply, so there is a real deficiency of omega-3,12:34 into mp3 file 
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 and it is the balance of omega-3 with omega-6 that seems to be out
of whack.  So, supplementing with omega-3 I feel is a very
good idea and I usually recommend 1000 mg a day. There are food
sources of omega-3, which are salmon and also certain eggs are
fortified with omega-3, and the way they do that is they feed
flaxseed to the chickens.  You can also add flaxseed to your
food, grind it up and mix it into soups, stews, or sprinkle it on
your cereal, and also taking a fish oil supplement.Foss
Is there any difference with respect to the omega-3 and omega-6
balance in the fish supplements that are out there?  I know
that there are a lot of different ones out there and I know people
have said that some are better than others.Harrigan
You would have to read labels, and that is something I do recommend
for people.  You do have to look at the brand and put your
glasses on and read the fine print and look for the amount of
omega-3 that is in the product.Foss
Of course, it is also useful if people eat the fish.Harrigan
Well, I will make this point over and over again, find it in
food.  It is much better to find the nutrients in the whole
food source than in the supplement.  Though we are always
looking for a magic bullet, the research just is not panning out in
identifying a particular supplement that will prevent cancer, or be
the cure we are looking for.  The real power is in the power
of whole foods and the nutrients in the food are packaged by nature
to actually act in synergy and provide a potency that is not found
in any supplement.Foss
Thank you for that information and I think we should all heed
that.  We are going to come back after a short break for a
medical minute.  Please stay tuned to learn more about
nutrition and cancer with Maura Harrigan.15:24 into mp3 file 
http://www.yalecancercenter.org/podcast/dec2709-nutrition-cancer-survivors.mp3information at www.yalecancercenter.org. 
You are listening to the WNPR Health Forum from Connecticut Public
Radio. Foss
Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and I am joined by Maura Harrigan to discuss issues
of nutrition and cancer.  Maura, can you start out by telling
us whether there are differences in nutritional recommendations for
cancer patients and survivors?Harrigan
The short answer is yes.  We have already talked about the
nutrition needs in the active treatment phase, but since I define
survivorship from the moment of diagnosis, I would rephrase this
question to ask, what are the nutritional concerns of persons
transitioning out of active care and into health maintenance and
wellness? These are issues that I find working in the Survivorship
Clinic.  A predominant concern of people in this phase is fear
of recurrence of cancer, and many people fear that eating a wrong
food would actually cause the cancer to recur, and a person may
also feel guilty that having eaten a wrong food actually brought on
the cancer.  These are very powerful emotions that people
bring to the Survivorship Clinic and discuss.  I try to allay
their concerns by explaining that there is no one food that will
trigger a recurrence, or protect you from recurrence. 
However, following an overall healthy diet may help prevent
recurrence and certainly help one feel more energized, improve
mood, and all that is through good blood glucose control.Foss
What is the ideal diet?Harrigan
The ideal diet consists of eating predominately what we call a
plant-based diet, that is one rich in vegetables, fruits, and whole
grains, and also limiting the consumption of processed and red
meats.  Now, just adopting these two steps creates a
high-fiber diet that is naturally low in total fat, trans fat, and
saturated fat.  This is also ideal for managing weight and
also the late effects of treatment, which include a higher risk for
cardiovascular disease, diabetes, and osteoporosis.  I have a
few more things to add on to that.  I do recommend limiting
sugar intake including what I call the 'stealth sugars'. 
These are the corn syrup solids and high fructose corn syrups that
are often added unnecessarily to foods. Also another important
aspect not to overlook is to evaluate a person's consumption of
alcohol.  The benefits of alcohol are really related to
cardiovascular disease protection and are not specific to any
cancers.  So, alcohol consumption in cancer survivors should
be looked at and many people do self-medicate in terms of their
anxiety and depression with alcohol.  It is worth evaluating
and asking them about their alcohol intake.  Foss
So, alcohol can actually have a deleterious effect if you are a
cancer survivor?18:32 into mp3 file 
http://www.yalecancercenter.org/podcast/dec2709-nutrition-cancer-survivors.mp3Harrigan  
     
 Yes, and outside of just the cancer process itself, it is an extra
source of calories and people can put on weight through excess
alcohol calories. The excess body fat is metabolically active, it
is not an inert substance.  So, we are finding that the excess
body fat is hormonally active and that is where the concern about
weight gain comes in with cancer survivors. Our goal is one, to
prevent further weight gain, and also to promote weight loss.Foss
Can you give us some helpful hints on how to actually implement
this and how would you actually go about implementing these
recommendations in your diet?Harrigan
Well, it is a challenge as I said to eat this way in our culture
and that is the real hard work at the Survivorship Clinic, turning
this into real nitty-gritty how to do. Each person that comes in
walks out with a different plan because we try to tailor to the
individual, but generally I tell people we have to start with a
good food shop. I give them a very extensive shopping list, teach
them how to go through the supermarket so that they bring healthy
foods into their home environment. That is the first big step,
surround yourself with healthy foods and also carry these foods
with you outside your home, into your work environment, and into
your day so that you are armed and ready to eat well.Foss
Should people be eating more than three meals a day?Harrigan
Yes, ideally six small feedings a day seems to help people on many
levels.  One, it helps stabilize blood sugar levels, so that
helps across the board with managing hunger and also stabilizing
mood, and also someone who is having difficulty keeping up their
calorie intake or their nutrient intake, eating smaller more
frequent meals is an easier way to reach their goals.Foss
What about specific foods, we have heard a lot about the benefits
of say green tea, is that something that we should be doing?Harrigan
Yes, green tea is actually categorized as a supplement, but green
tea is a wonderful food and I recommend that to patients and often
a warm beverage like green tea in the evening before bedtime can
actually be quite soothing to the digestive system and help promote
a restful sleep.Foss
Great, what about other supplements?  Could you make some
recommendations about the use of these supplements and also talk
about how, when you are actively undergoing cancer treatment,
sometimes supplements can be deleterious?Harrigan
Supplements are controversial.  Up to 70% of cancer survivors
actually use supplements, but21:56 into mp3 file 
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 they have to be used with caution and concern, and I always
encourage survivors to discuss their use of supplements with their
physician first because there are certain supplements that can
interfere with treatment.  For example, folic acid supplements
may interfere with methotrexate, a chemo drug that works by
interfering with folic acid metabolism, also antioxidant vitamins
such as vitamin C and E could interfere with the cellular oxidative
damage to cancer cells that is intended by radiotherapy and
chemotherapy. Another supplement, soy isoflavones, is supplemental
soy in a pill form and this is not recommended for women with
estrogen receptive positive breast cancer because the supplemental
soy does mimic the action of estrogen in the body.  Now this
soy supplement is considered to be different from soy in whole
foods, where in fact soy is considered to be a protective factor of
breast cancer.  So, you can understand why there is so much
confusion out there.Foss
Should all cancer patients be talking about these supplements with
their physicians?Harrigan
Absolutely, because while we know vitamins and minerals are
important, more is not necessarily better, and people often take
multiple formulas, many different bottles of supplements, not
realizing that there may be nutrients that are repeated in each of
those bottles.  So, they actually multiply their dosages and
there is actually what is called an upper tolerated limit. 
There is a ceiling on these nutrients that we need to honor. 
For example, vitamin A is often a nutrient I see repeated in
multiple formulations and I will ask people to bring in their
bottles.  They may come with a shopping bag of 8 to 10 bottles
of supplements and I take them out look at the labels and I start
with vitamin A and I start adding up all the dosages of vitamin A
and find out that they are well above what we call the upper
tolerated limit of vitamin A, which is 3000 mcg a day. Other
vitamins would be vitamin C, there is a ceiling on that of 2000 mg
a day, and vitamin E, which is 1000 mg a day.  So, I am
looking for overdosing, which can do harm.Foss
Rather than coming in with a shopping bag of pill bottles, can we
trust the One-A-Day or the Centrum, the kind of all inclusive
multivitamin, multi-mineral supplement, is that adequate for most
people?Harrigan
Yes, and that is what I recommend.  I recommend just your good
old solid multivitamin as a way to fill in the gaps of any possible
nutrient deficiency.Foss
Maura, there are lot of people out there who are talking other
things like herbal supplements or naturopathic type treatments, and
oftentimes it is difficult for them to talk to the physician about
this.  Can you talk about your role in advising patients about
those kinds of supplements?25:26 into mp3 file 
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 Harrigan        That is a
challenge even for me because there are times when people come in
with supplements that frankly I never heard of.  There is a
wonderful web-based referral, which is called www.naturaldatabase.com,
which is a complete listing of all herbal and botanical supplements
that frankly I have to use to look up to evaluate these
products.Foss
And we have had the same experience and it has been very helpful
going to that website trying to figure out what is in some of these
herbal remedies.  Do you recommend that patient use these or
are you keeping kind of a neutral stance on it?Harrigan
I try to stay neutral and I try to steer people back towards a
healthful whole food approach.  So, when people are telling me
that they are going the supplement route, I take a detailed diet
history to assess what the real foods that you are eating are and
look for gaps in that and try to round out their normal eating of
whole foods as a way to kind of counter the supplements.Foss
We keep coming back to the same message here, which is, you are
what you eat.Harrigan
Our grandmothers told us that and it still holds true.Foss
In addition to healthy eating, what other lifestyle factors are
thought to be helpful in terms of cancer prevention?Harrigan
Well, the obvious one about smoking, that has been very clear, and
avoidance of excessive sun exposure.  Again, I do want to
mention the importance of achieving a healthy weight, which we
define ideally as a body mass index of 25, but even a weight loss
of just 10% from your starting weight can actually confer
tremendous benefits of health, and at the very least, if you cannot
achieve weight loss, at least preventing further weight gain.
Dovetailing with that is the value of exercise and again we address
that in the Survivorship Clinic.  The ideal recommendation is
30 minutes a day, five days a week, but again you need to assess
where the person is starting from.  For some people that may
be very daunting, so we start small and look at just working
activity into their day, parking farther away, taking a flight of
stairs instead of the elevator, all those things are beneficial to
managing your weight and your overall sense of well being. What is
interesting is that regardless of your activity level prior to your
diagnosis, any increase in your movement or activity after
diagnosis has been shown to have very profound effects on your
health and on cancer prevention.Foss
Can we just talk for the last minute about stress, everybody
obviously is concerned about the role of stress in both cancer and
in healing.  Can you make some recommendations?Harrigan
Yes, and again in the Survivorship Clinic our social worker, Lina
Chase, offers many28:49 into mp3 file 
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 different methods to manage stress. One is just deep breathing
exercises, taking 10 deep breaths.  If you take the time and
do that and feel the difference before you started and after, it is
just remarkable in terms of the calming affect that it has. 
Also, we strongly recommend yoga; it is a wonderful stress
management and also helps with flexibility. Tai Chi is another
wonderful exercise; that mind-body connection is very powerful and
very much a part of our holistic approach to managing cancer.Foss
Maura, this has been a terrific discussion and certainly a lot of
us have gotten some helpful hints that we can implement immediately
in our lifestyles.  I would like to thank you for joining me
on Yale Cancer Center Answers.  Until next week, this is Dr.
Francine Foss from Yale Cancer Center wishing you a safe and
healthy week.If you have any questions or would like to share your
comments, go to www.yalecancercenter.org
where you can also subscribe to our podcast and find written
transcripts of past programs.  I am Bruce Barber and you are
listening to the WNPR Health Forum from Connecticut Public
Radio.