ADDRESSING ONCOLOGY NUTRITION MYTHS AND CONTROVERSIES

Prepared by Colleen Gill, MS RD CSO

University of Colorado Hospital colleen.gill@uchealth.org

Vermont Academy of Nutrition and Dietetics

4/10/2015

presented by AUDREY CASPAR-CLARK, MA RD CSO LDN, HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA

Statement of Disclosure

I have no relevant financial relationships with commercial

interest pertaining to the content presented in this program

EFFECTIVELY BALANCING COMPETING GOALS IN ONCOLOGY Symptom Management for QOL/independence  Strategies to maintain nutrition during treatment

Integration of CAM and Traditional therapies   Optimize recovery, limit recurrence   Handling Myths/CAM practices

 Does Sugar Feed the Tumor; Ketogenic diets  Overstated themes: Immune support, detoxification  Valid themes: Weight management, exercise, plate model  Miscellaneous: anemia/iron, soy/estrogen concerns

Overviews are TMI! Highlights with references

“DON’T GO NUTS” NUTRITION WITHOUT STRESS

STRESS = Novel Unexpected Threat to self or ego Sense of lack of control

Stress can eliminate any benefit of change  Keep diet empowering; Not a new stress  Limit focus to 2 changes: 1 diet, 1 exercise

Fight or Flight hormones Increasing blood sugars Decreasing immune function

GIVE PATIENTS CONTROL THEY HAVE IT ANYWAY!

Never get into battles over eating,

sleeping, or peeing,

Because you’ll lose Help patients make informed choices

Must appeal to, acknowledge their goals

CONSEQUENCES OF EXCESS WEIGHT LOSS

 Loss of weight and muscle   Impacting QOL, ADLs; independence, fatigue

 Malnutrition; higher risk if pending surgery   Compromises immune function, slows healing

  Micronutrient deficiencies  Delayed therapy, holds for FTT

 Data on worse outcomes with weight loss

 Rapid release of toxins; overloading detox processes

WEIGHT LOSS LIMITED SURVIVAL GI Cancer Patients  Lower doses  More side effects and treatment breaks

 Shorter overall survival, DFS; p = 0.0002  Decreased QOL, performance status; p< 0.0001 Halting weight loss improved survival; p<0.0004

Andreyev HJN, et al. European Journal of Cancer 1998, 34:503

Terminal cancer patients  Weight status was an independent determinant

of survival Reuben et al. Arch Internal Med 1988; 148:1586

3 WAYS TO LIMIT LOSS OF MUSCLE/WEIGHT

1. Set up a schedule! Eat often   Set cell phone timers

2. Post a list: “Things I Tolerate”   Include the “extras” for calories, prevent burn out

  Start “healthy”, but with calories! 3. Fluids with Calories make it easy

  Divert with TV, friends; walk for 5” between programs   Pick easier things on “bad” days; keep them near chair

Fix anything getting in the way!  Dehydration, constipation, diarrhea   Severe anorexia: Remeron (Marinol, Megace ES) The Elephant in the room= Desired weight loss

STABILIZING BLOOD SUGAR LEVELS FOR FATIGUE MANAGEMENT

Low blood sugars = Less energy available for cells

= Fatigue

 Eat 4+ times/day to stabilize blood sugar

 Include protein in every meal/snack   1/3 will convert to carbohydrate over two hours,

stabilizing blood sugars and improving energy   Sources: meats, dairy, eggs, nuts, beans, soy

 Sleep well to limit insulin resistance Donga et al. J Clin Endocrinol Metab 2010, 95(6):2963

FLUIDS SUPPORT LIFE 2% weight loss dysfunction

Headache, anorexia, nausea, dark/low urine

Dehydration: Cells can’t work well as “raisins”  Exacerbates fatigue, pain, nausea (constipation)

Advice for “non-drinkers”  Mix it up! Variety limits burn out  Flavor for taste change issues  Eat “solid” fluids: jello, popsicles  Pace it: 2 oz with each TV commercial, x pages…

Fluids with calories count twice!   Smoothies, including a protein source (yogurt, PB, powders, etc)   Plus versions, milk + Carnation/Scandishakes, Breeze/Ensure

Active, Odwalla/Naked Juice/Bolthouse Farm drinks with protein

MAKING INFORMED CHOICES IN COMPLEMENTARY THERAPIES

CAM “those therapies which I have to pay for out-of –pocket and never feel comfortable discussing with my physicians”

 Most cancer patients include CAM   42% overall, 64% in cancer

 8% delay cancer therapy   83% use both, <1/3 tell their MDs

 Drug interactions, malnutrition  Financial toxicity

Integrative Medicine

COMMUNICATING WITH PATIENTS ABOUT DIET/CAM

What gets in your way? If you don’t, who will?   The competition is less informed, but very specific & certain   Be OK with vulnerability (Brene Brown); don’t reject ideas

 Understand enough to be “in the ballpark”, and offer to look up answers to their questions/concerns

 Oncology Nutrition in Clinical Practice; 2013  ONDPG list serve! www.oncologynutrition.org

What gets in their way?  Hope, fear of missing something

  Help them evaluate, prioritize  KISS; in their language

 Read Chip/Dan Heath: Made to Stick, Switch

ATTRACTION TO EXTREMES, & ANECTODAL STORIES

 Traditional medicine/research offers statistics   75% cure still leaves the patient concerned

 Complementary and Alternative (CAM) extremes offer less data, but “positive” appealing anecdotes   Many imply that Western Medicine conspires for financial

gains; though their products are $$$

 Difficult/strict regimens make us feel that it must be doing something!

Leave the brain engaged! Guarantee of cure = red flag

TMI, and confusing research!  We are all eating “Shades of gray”

 We are all unique! Genetics matters

 Human studies   Long timelines, expensive, human subjects

Advice from friends and family  Good intentions, but adds stress  Thank them, then talk with the team

  Concrete ideas keep friends off the internet Walks, laundry, meals (with recipes)

  mealtrain.com; lotsofhelpinghands.com

WHAT MUDDIES DIRECTION?

EVALUATING CAM

Predicted Benefit   How will this interfere with cancer?

Does it make sense?

  How strong is the research? in vitro/cell culture < in vivo/animal < human

Risk, Cost, Effort (Time)

“Be open-minded, but not so open-minded that your brains fall out” Groucho Marx

“A state of doubt is unpleasant, but a state of certainty is ridiculous” Voltaire

www.aicr.org

www.oncologynutrition.org

www.nutrition-foundations.com

www.karencollinsnutrition.com/smartbytes/ http://onlinelibrary.wiley.com/doi/10.3322/caac.21142/full

Cancer Diets

Sugar/Tumor

Fatigue

Detoxification

Vitamins

Herbs

Breast Cancer

Immune Function

Late Effects

Provides a framework to “hang” information

Cancer cells like sugar as “fuel”   Basis of PET scans to detect tumor activity   Tumors can and will make their own glucose for fuel

 Stimulates growth directly and through IGF1   Increases inflammatory hormones  Suppresses immune function   Limits normal cell death

BUT, DOESN’T SUGAR FEED THE TUMOR?

Real Concern “Quick Carbs” or large volumes Higher blood sugars

More Insulin (if IR)

THE PLATE MODEL = OPTIMAL BLOOD SUGARS

 The Right Amounts   ¼ carbohydrate sources

bread, pasta, potatoes, rice, cereals   ¼ protein (and fat) sources   ~ ½ fruit (fist size), vegetables, beans

 The Right Mix No Naked Carbs   Eat sweets as part of a mixed meal   With protein, fat, fiber to slow stomach emptying

 With The Right Type   Limit processed, “white” foods, high glycemic index options

With adequate sleep, exercise! www.oncologynutrition.org/erfc/healthy-nutrition-now/sugar-and-cancer/

KETOGENIC DIET VERY-LOW-CARBOHYDRATE

Originated 1920s for epilepsy therapy Diet: >70% of calories as fat; 20 g carbohydrate

 Case reports show benefit in brain tumors   Brain is glucose dependent; converts to ketone bodies if

deprived. Theoretically may have toxic impact on tumor

 Clinical trials: lung and pancreatic cancer; U. Iowa   Still recruiting, with 10 – 20 subjects per trial

 Pilot studies have focused on safety and feasibility   5/16 pt were able to complete a 3 month intervention

 As yet, no RCT to evaluate impact on tumor growth and patient survival; anecdotal as yet

KETOGENIC DIET VERY-LOW-CARBOHYDRATE

Risks: malnutrition/excess weight loss “Contraindicated in anyone unable to maintain adequate nutrition”. It relies on sufficient fat reserves to have ketones to burn for fuel.

 Hypoglycemia, BG levels of 40 – 50 fasting initially  Appetite & thirst suppression, added to that of opiate use  Delayed gastric emptying; increased reflux/GERD  Constipation (low fiber), increased fluid/medication needs  Kidney stones (1 in 20); include polycitrate/ more fluids  Low calcium, trace minerals, D, zinc, selenium: supplement  Acidosis, with low levels of bicarbonate with ketosis Long Term: Elevated lipids, triglycerides > 400, bone changes

Acknowledge the element of truth Intact immune system aids early surveillance,

control  May limit ability of cancer cells to metastasize  Patients who are immune suppressed after organ

transplant have significantly increased risk of cancer

Only supportive, unlikely to eliminate larger, established cancers

OVERSTATED THEME: IMMUNE SYSTEM SUPPORT

Nutritional changes that can improve resistance to infections, maintain WBC

  Adequate protein, calorie intake   Avoid rapid weight loss to “spare” protein

  Limit Inflammation   Improve Omega 6 : Omega 3 ratio   Control blood sugar and insulin levels   Include F/V for phytochemicals

  Consume a plant based diet   Providing a range of antioxidants, vitamins, minerals

  Increase fluid intake; for moist membranes

  Maintain a healthy GI tract   Probiotics, glutamine, whey, food safety

MAXIMIZING IMMUNE FUNCTION

OVERSTATED THEME DETOX DIET RESTRICTIONS/CLEANSE

GSTs, UGTs P450s

+

Cancer

Phase 1 creates the “intermediate” Phase 2 makes it soluble

Phase 3 moves it out of the cell Courtesy of: Sabrina Peterson Trudo, PhD, RD; U. Minnesota

DETOX, THEN AND NOW Historical: Physical, emotional, spiritual purification   Lent, Ramadan, Yom Kippur, Vision Quest

Modern Times: Commercial, selling promises   Improved energy, clarity, “glow”   Simplistic appeal (versus boring 24/7) “Spring clean” “Oil change”

Common Detox Elements/risks  Colonic enemas; risk perforation, infection  Dandelion, diuretics; risk dehydration  Cascara/laxative; risk: GI pain/diarrhea  Milk Thistle/Silymarin; liver health

Little evidence that anything but weight loss removes toxins stored in fat

DETOXIFICATION BASICS

Detox scare tactics: Overstate toxins, genetic variance, diet inadequacy. Claim inevitable poor liver function and “Toxic reservoir”

Where?  GI Tract: Stomach acid, enzyme breakdown, mucosa

barrier, immune defense system

  Liver: changes toxins into soluble forms for excretion   Urine or stool

 Toxin storage in fat reserves, if not detoxified

Detoxification is a 24/7 process! Absent excess exposure the body rids itself of toxins

SUPPORTING DETOXIFICATION 24/7

 Protein; Inadequate limits phase 1, quality affects Phase 2  Enough carbohydrate

  Excess impacts Phase 1, too little limits Phase 2  Weight control: Limits fat and toxin storage   Fiber/probiotics, support GI function  B Vitamins/Minerals (zinc, mag, selenium; enzymes)  Plant based foods/antioxidants   Fluids for good renal clearance

 Phase 2 support:   Cruciferous vegetables; glutathione support

  Sulfur containing foods: garlic, legumes, onions, eggs

  Limit stress to liver: excess alcohol and caffeine

VALID THEMES  Weight Management  Exercise

Plate Model/Healthy Diet  Plant-based  Limited/healthy fats  Limited/healthy carbohydrates

Lifestyle  Avoidance of smoking  Limited alcohol  Sleep  Stress management

WEIGHT’S IMPACT ON CANCER SOURCE OF 14% (M) 20% (F)

  Calorie restriction limits growth signals   Under duress/wars; rarely voluntary

  Obesity increased cancer risk   Breast (2x), ovarian, endometrial, cervical   Colon, liver, pancreatic, GI, esophageal; Kidney, bladder   (AML, CLL, Multiple myeloma, melanoma), prostate

  Physical Damage: Reflux Esophagus   Aromatase in fat higher estrogen levels   Fat is metabolically active

  Associated with IR; insulin stimulated growth   Release messages that promote growth

  Inflammation, angiogenesis, cell division

VALID THEMES EXERCISE

Roles:  Increased blood flow, releasing hormones that improve sleep/mood  Decreases inflammation  Improves immune function  Improves blood sugar control  Weight management  Stress management

Exercise limits loss of muscle and strength

  30 minutes/day 20–50% ↓ heart disease, osteoporosis, stroke, cancer, diabetes, kidney disease, depression

  Eliminated weight gain during BrCa therapy   2 kg wt loss, 1.3% decrease in body fat   Controls with 2.2 kg gain and 1.8% increase in fat

  Just Walk! 1 mile/2000 steps/100 calories   < 2.5 hours/week walking ↓ Br Ca diagnosis 18%

JAMA, 290: 1331 – 36; 2003

  3 – 5 hours/week reduced recurrence by 30% JAMA 293:2479; 2005

VITAMIN EX: LIMITS WT DISEASE, RECURRENCE

  Is fresh best? Try 50/50   Different absorption from fresh and cooked; i.e. lycopene

 Organic? Risk: cost buy less; fear eat less   Claims of 10 –40% more vitamins, minerals not verified; but   Stressed plants make more phytochemicals   Limits impact on wildlife, farm workers, soil/water   Need not avoid non-organic produce or fear pesticides

www.ewg.org

 Range of colors; herbs count too!  An Alkaline Diet = Plant Based/Plate Model

  The wrong rationale, but the right result? http://www.denvernaturopathic.com/alkalineash.htm

VALID THEME: F/V MINUS ANXIETY

WHEL-GREATER BREAST CANCER SURVIVAL IN PHYSICALLY ACTIVE WOMEN WITH HIGH VF INTAKE – REGARDLESS OF OBESITY

Mor

talit

y (%

)

Diet and Exercise Categories Pierce JP et al. JCO 2007

  2/3 of your plate should be plant based   50% vegetables, legumes; daily cruciferous

  Eat small, frequent, mixed meals   Less refined, processed foods   More fish, olive oil and healthy fats

  Limit the “bad stuff”   Avoid trans fats, deep fried foods   Limit excess saturated fat, sugar and alcohol

  Drink!   Water, green tea, vegetable juices, hormone free dairy

Get regular exercise   Make it a scheduled priority

Sleep well! Limits insulin resistance, weight

FOOD "TALKS" TO CELLS WHAT WE ADD = WHAT WE LIMIT

WHY JOURNALING WORKS AKA “PLAYING

DETECTIVE”

"People are generally better persuaded by the reasons they have themselves discovered than by those that enter the minds of others...” Blaise Pascal

Mathematician & Theologian (1623-1662)

“Bumps” identify barriers •  Or skills yet to be mastered

We also learn from what goes right •  Meal pattern, exercise

ANEMIA IN CANCER TREATMENT During chemotherapy, low blood counts are

inevitably due to its impact on bone marrow function, not a lack of nutrients

 Support RBCs with adequate protein, folate, B12   Iron therapy only with documented deficiency!

 Avoid borderline deficiencies   400 mcg folate, 2 mg B6, 6 mcg B12, 250 mg

magnesium

 Practice food safety, especially during WBC nadirs   www.oncologynutrition.org/erfc/eating-well-when-unwell/white-

blood-count-diet/

SOY AS A WEAK ESTROGEN

  May decrease risk in pre-menopausal woman by competing with estrogen at sites   30% decrease early Br Ca; 60% less Stage 2

Weaver, AACR 2010

  Q: Is it a source of “estrogen-like” stimulation in post-menopausal with less natural estrogen   But sends much weaker signal (1/100 – 1/1000th)   Genestein stimulated growth in animal models

SOY BENEFITS IN CANCER  Stimulates the immune system  Inhibits growth signals, promotes cell death  Limits angiogenesis  Antioxidant less free radicals  ↑ Cell differentiation; less cells at risk

  Especially during periods of growth (10 -15yo)   11 g soy protein in teens 50% ↓ Br Ca   GUTS (Growing Up Today Study); NHS kids;pending

 Inhibits aromatase; synergistic with AI  Encourages less carcinogenic estrogens” (2-OH)  Increases gut excretion of estrogen

PHYTOESTROGENS: FLAX (AND LIKELY SESAME)

Lignans in gut Phytoestrogens  May help block estrogen effect on receptors

  With Tamoxifen, increased tumor regression

 ↑ Sex Hormone Binding Globulin  25 g flax meal/day (2T)

  ↓ markers of growth = Tamoxifen   ↓ cell division 34%, ↑ cell death 30%, ↓ production of HER 2 neu protein 71%

Clin Cancer Res 11(10):3828-35, 2005

RISKY, SAFE, OR BENEFICIAL? HTTP://ONLINELIBRARY.WILEY.COM/DOI/10.3322/CAAC.21142/FULL   WHI: Estrogen/progestin (HRT) ↑ risk 26%

  But estrogen alone lowered risk 23%   Soy is estrogen-like; no increased breast density seen

  35% ↓ with lifetime soy use in Asian studies   Other differences: weight, lifestyle, genetics, timing?

  Shanghai Study Q: Can we extrapolate to US?   ↓ recurrence 30% with 11 g/day JAMA 302: 2437; 2009

  3 oz tofu; Starbucks grande soy latte

 Synergistic with Tamoxifen, less recurrence Br Can Res Treat 118(2)395; 2009

  In vivo, positive (whole food); negative (processed)   In vitro, genestein stimulated growth

12 – 25% lower risk (highest versus lowest quartiles) Pooled: Overall mortality 0.87; BC mortality 0.83

RECOMMENDATIONS?  Regardless of ER status soy foods are safe

  Evidence not yet strong enough to promote for all   Medically without concerns a personal choice

 Recommend average Asian isoflavone levels, ~ 35 - 40 mg (max 100), as soy food   0.2 – 0.4 mg/g of soy food, 3 mg/g soy protein   40 – 50 mg = ½ cup beans/tofu/tempeh; ½ - 1 c soy drinks; www.soyfoods.org

 Avoid soy isoflavone supplements   Fortified foods with high levels

Messina, Women’s Health 2010; 6 (3) 335

HOW IT ALL FITS: ESTROGEN BALANCE

Moving metabolism to the 2-OH path  Indole-3-Carbinol (I3C)

  Important factor in detoxification pathways   <120#@ 2-400; >120#@ 4-600; > 180#@ 6-800mg

 Diindolylmethane (DIM)   Bio-available form of I3C; 60 – 120 mg bid with meals

Diet/Lifestyle Recommendations:  Cruciferous, exercise, (soy), green tea

Fowke C Epid Biomarkers Prev (8) 773: 2009 Morrison Altern Ther Health Med 15(2) 52 ; 2009

Women with more 2-OH had 30% less Br Ca

HOW IT ALL FITS: ESTROGEN BALANCE

Limit GI reabsorption of Estrogen due to Beta Glucuronidase Enzyme

Glucuronidation (liver) conjugated estrogen excreted in bile unless B-G recycles it in gut  Probiotics to ↓ gut pH, limit enzyme activity  Low animal fat (High fat increases BG enzyme)  High fiber 30– 35 g/day (= plate model)  Calcium D-glucarate

  Found in cruciferous vegetables (or 400–1200 mg/d)

HOW IT ALL FITS: ESTROGEN BALANCE

Increase Sex Hormone Binding Globulin (SHBG) to limit “free” estrogen

 Moderate carbohydrate   Lower insulin levels support production

of SHBG

 Low fat diet, high fiber, (soy/?)

 Exercise Forman J Nutr 2007; 137(1s) 170S

 Weight Management   SHBG levels drop with higher BMI

HOW IT ALL FITS: ESTROGEN BALANCE

Reduce Endogenous Estrogen  Limit alcohol intake  Exercise lowered estrogen levels 9%  Weight management

  Estrogen levels double with BMI > 27

Remove Outside Estrogens  Avoid synthetic estrogens (HRT) which are

metabolized to 4, 16-OH forms  Xenoestrogens: Bisphenol A (in growth periods);

parabens (cosmetics), rBST, phthalates (plastics)

RD AS DETECTIVE AND EDUCATOR

Helping a patient resolve their concerns is rarely simple, but always rewarding

 Listen; integrate their concerns and goals  Adherence improves when patients feel heard  Leave it alone if it isn’t harmful

 Our recommendations and education matter  We obtain information critical to the team/patient  RD counseling = oral supplements to limit malnutrition

Singh et al, Clin Gastroenterol Hepatol 2008;6:353

 Follow up helps the patient, RD & team   Monitor; reinforce and adjust strategies

Eat Food

Not too much

Mostly plants

Michael Pollan

Questions? Other Strategies?