Hillary M. Wright, MEd, RD, LDN

Dana Farber Cancer Institute

Leonard P. Zakim Center for Integrated Therapies

Fighting Cancer with Your Fork: Separating Fact

From Fiction

How Do We Figure Out What May Affect Cancer Risk/Survivorship?

The American Institute for Cancer Research

“Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective”

The result of an analysis of over 7000 research studies on the link between diet, lifestyle and cancer, and for the first time cancer survivors

www.aicr.org “comprehensive global report” 10 Recommendations, last one specific to survivors.

AICR Global Report Recommendations:

1. Be as lean as possible without becoming underweight.

2. Be physically active for at least 30 minutes every day.

3. Avoid sugary drinks. Limit consumption of energy-dense foods. due to correlation with obesity

4. Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans.

5. Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats. 11 – 18 oz per week max

AICR Global Report Recommendations (continued):

6. If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day. 12 oz beer, 5 oz wine, 1.5 oz spirits

7. Limit consumption of salty foods and foods processed with salt (sodium). stomach cancer (also moldy foods due to liver cancer in developing countries)

8. Don’t use supplements to protect against cancer.

9. * It is best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods. reduce breast cancer in mom and obesity in child

10. * After treatment, cancer survivors should follow the recommendations for cancer prevention. *Special Population Recommendations

America’s Challenging Food Environment

Watch Your Weight! 65% of Americans are overweight or obese.

Only 6% of Americans identify being overweight or obese as a risk factor for cancer despite a clearly established scientific link.

Research shows that fat cells can act as "hormone pumps," secreting hormones and other growth factors into the bloodstream.

If the body's cells are exposed to very high levels of these substances over an extended period, they tend to reproduce more quickly ? Increase cancer cell growth.

Researchers stress that this potentially dangerous condition is reversible!

Physical activity and Cancer: Critical for weight control, growth hormone regulation,

stress management, counteract fatigue, support immune system , etc:

New Guidelines from the Dept of Health & Human Services Minimum 150 min moderate, or 75 min vigorous to reduce risk of chronic diseaseIdeally aim for more – and necessary if weight

loss and maintenance of loss is the goal – 300 min of moderate or 150 minutes of vigorous.

Physical activity linked to lower risk of breast, prostate and colorectal cancer

Beyond weight control, fruits and vegetables may exert a protective effect:

Phytonutrients

Beyond vitamins, minerals and fiber, natural compounds found in plants may exert profound disease preventive effects

The “immune system” of a plant – many also represent the pigment that gives the plant it’s color.

Phytonutrients: Prevention in a Plant

How do they work? Stimulate enzymes that help the body

detoxify

Reduce the genetic damage from cancer causing agents

May interfere with growth and multiplication of cancer cells

Decrease inflammation

If It Stains Your Shirt…

If a fruit or vegetable has a strong smell or taste, it’s probably biomedically active

If it stains your shirt, it’s definitely biomedically active!

AntioxidantsVitamin A, C, E, Selenium, phytonutrients

from plants

Help prevent damage to cells from the attack of free radicals

“But I take antioxidant supplements in pill form, so I’m getting all the antioxidant benefits that way, right?”

Phytonutrients work together to provide a synergistic benefit

Food First!

Some studies show high dose nutrient supplementation can be detrimental:Beta carotene supplementation in smokersN Engl J Med. 1994 Apr 14;330(15):1029-35. (ATBC) The effect of vitamin E and beta carotene on

the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group.

N Engl J Med. 1996 May 2;334(18):1150-5. (CARET) Effects of a combination of beta

carotene and vitamin A on lung cancer and cardiovascular disease.

Choose a Predominately Plant Based Diet

Eat 5-10 servings fruits & veggies each day1 serving = 1/2 cup cut, cooked or sliced; 1 piece medium fruit; 1 cup leafy greens

Emphasis on variety

Richly colored plant foods are most phytonutrient-dense

Organic vs. ConventionalNo scientific evidence to date that organic offers anti-cancer

advantage at this point

= one study suggested organic blueberries significantly higher sugars (fructose and glucose), malic acid, total phenolics, total anthocyanins, and antioxidant activity (ORAC) *

Thousands of studies support the health benefits of diets high in fruits & vegetables and none done exclusively on organics

More than ½ of dietary pesticide exposure comes from 12 foods – EWG “Dirty Dozen”

Bottom line: wash things thoroughly and don’t let this decrease # of fruits/vegetables you eat!

*J Agric Food Chem. 2008 Jul 23;56(14):5788-94. Epub 2008 Jul 1

Food First 75% of Americans don’t eat “5 a day”

Americans eat 1.5 servings of vegetables & less than 1 serving of fruit daily, despite consistent evidence that these foods decrease the risk of many chronic diseases.

We throw away more than 11 billion pounds of fruits and vegetables every year in the US!!

Americans spent $26.7 billion per year on dietary supplements in 2009 despite limited and inconclusive scientific evidence of effectiveness in disease prevention and treatment

Phytonutrients in Whole Grains

Isoprenoids in whole grains suppress tumor growth

Tepernoids and Tocotrienols encourage tumor dormancy and decrease tumor cell division

Stimulate GST (detoxifying enzyme)

**Also, dietary fiber has a “probable” connection to decrease risk of colorectal CA

Does Sugar Feed Cancer?Popular myth

Unknown root of myth

PET ScanInject radioactive glucose into veinsAreas of higher metabolic activity

“glowglow”

Yes, BUT…All cells in the body use sugar for energy

This includes cancer cellsCancer cells are more metabolically active

than other cellsUse more energy (sugar)

Body will make sugar from other sources if you do not get enough through dietBreak down muscle and fat tissueTumor can make its own glucose

Sugar and Cancer – It’s not that simple…..Sugar does not

FEED cancer

Chronic, excess intake of simple sugar leads to excess production of hormones like insulin, IGF that encourage cellular growth

Insulin and Cancer

Excess insulin can promote tumor cell growth

Behaviors that increase insulin levelsConsumption of refined sugar and flourOvereating Weight gainSedentary lifestyle

Behavior that reduces insulin levelsPhysical activity, weight loss, unrefined carbs

Lower fasting insulin level at time of breast cancer diagnosis is associated with improved survival.

Mulligan et al. Breast Ca Res Treat. 2007 Jan 13

Donut vs.Orange: It is not necessary to avoid fruit!

200 calories10 grams sugar0 grams fiber0 phytonutrients

62 calories12 grams sugar3 grams fiber170 phytonutrients

Another reason to mute post-prandial glucose/insulin

response!Include fat, protein and fiber with

carbohydrates Process sugar more slowlyLess insulin released

Glycemic Index: number representing insulin response by body to a particular food

SummarySugar does “feed” cancer cells – but no

differently than it “feeds” the rest of the body’s cells

Choose healthier carbohydrate foodsUnprocessed/minimally processedFruits, Vegetables, whole grains

Combine foods at meals and snacks

Fat and/or protein with carbohydrates

Aim to get some protein from plants as well - legumes, nuts, seeds, quinoa

What About Soy?

Whole soy foods may help prevent:Breast cancerColon cancerProstate cancerBladder canerHeart diseaseOsteoporosis

Issue is phytoestrogens up to 1000 x weaker than estradiol

Soy sauce, soy lecithin and soy oil contain no phytoestrogens

Caution for people with ER+ breast cancer avoid soy isosflavones in supplements, pills, bars, and powders.

Whole soy foods are fine in moderation

What about women who have had breast cancer?

Two recent studies of Asian women showed reduced risk of recurrence with higher dietary intake of soy foods/isoflavones:

Effect of soy isoflavones on breast cancer recurrence and death for patients receiving adjuvant endocrine therapy, Kang X et al, CMAJ. 2010 Oct 18

= 534 women with medium follow up of 5.1 yearsSoy food intake and breast cancer survival, Shu

XO et al, JAMA. 2009 Dec 9: 302(22):2483-4= 5042 women with median follow up 3.9 years

Acid/Alkaline Balance Diet for Cancer Prevention:

Proponents Claim - Cancer grows in an acidic environmentChemotherapy is more effective the more

alkaline the environmentpH of 8.5 “kills” cancer cells

Less acidic MORE ACIDIC

Outer area Inner areacell wall

pH gradient

Tumor Cell

pH 1.0 7.35 14.0

_____________________________________________

Acidic Normal Alkaline

pH of human body is naturally slightly alkaline ~ 7.35-7.45.

Definition of Acidity and Alkalinity

To eat or not to eat….ACID FOODS

beef, chicken, duck, eggs, farmed fish, lobster, organ meat, pork, seafood, turkey, veal, venison

Cheese, cottage cheese, whey protein

mushrooms, potatoes apple, apricot, banana,

berries, dried fruit, papaya, peach, pineapple, tangerine

ALKALINE FOODS lima beans, soy beans,

white beans, pumpkin seeds

wheat grass, barley grass, alfalfa spouts, broccoli sprouts, kale, parsley, sea vegetable

buckwheat, quinoa, spelt

coconut, grapefruit, lemon, lime

What patients/families hear from us….

The body’s pH levels may change slightly as a result of eating some foods, but will remain in the tightly held range of 7.35-7.45.

Eating certain foods may change urinary pH levels, however, this does not necessarily mean that your blood pH will change.

Bottom Line on Alkaline Diets for Cancer Survivors

Studies on the effects of acid/alkaline diets on tumor growth and proliferation are limited only to animal and test tube trials.

Scientific research has not proven a beneficial effect of an alkalinizing diet for prevention or treatment of cancer.

Dietary Fat and CancerIssue has been raised in colorectal, breast, pancreatic,

prostate cancer, and possibly others

AICR Global found no “probable or convincing” connection between cancer and total fat intake (only “limited/suggestive” with post-menopausal breast cancer and lung cancer weak)

Concern in primarily with saturated fat, but it’s hard to tease out what’s a dietary fat effect, calorie effect, affect on weight influence, tied to the source of fat (i.e. high intakes of red and processed meats).

Bottom Line: Encourage Mono’s and Omega 3’s; limit

Saturatedand trans fats; portion control

Typical American Plate

AICR: Limit Red Meat IntakeLimit red meat to 18 ounces per week (includes beef

pork and lamb), with a long-term goal of no more than 11 oz/week.

Avoid processed meats

“Processed meat” refers to meats preserved by smoking, curing or salting, or by the addition of preservatives (ham, bacon, pastrami, salami, hot dogs and sausages.

When meat is preserved by smoking, curing or salting, or by the addition of preservatives, cancer-causing substances (carcinogens) can be formed. These substances can damage cells in the body, leading to the development of cancer.

Studies show people who eat more meat often eat less plant-based food.

Healthy Eating PlateAim for ½ plate of

plants (preferably vegetables) at lunch and dinner

¼ of plate as lean protein

¼ of plate of complex carbohydrate

Dietary Supplements That May Dietary Supplements That May Help Cancer SurvivorsHelp Cancer Survivors

Vitamin D Omega-3’sProbiotics and

calcium (based on individual circumstances)

24,000 Dietary Supplements marketed to Cancer Survivors!

Vitamin D and CancerInverse relationship

between Vitamin D and several types of cancer Possible anti-angiogenesis

and helps keep cell replication normal

Goal of serum 25(OH) vitamin D level is > 40 ng/ml.

Supplementation is likely necessary.1000 IU/day is safe for

most people; many need more.

Intake/Exposure Amount of Vitamin D

Sun Exposure (arms/legs 10-15 min)

Fortified Multi-vitaminFortified Milk3.5oz salmon (fresh,

wild)3.5oz salmon (fresh,

farmed)

3000 – 20,000 IU

400 IU 100 IU 600-1000 IU

100-250 IU

Vitamin D and Cancer

Link first hypothesized in 1980sRate of colon cancer 3x higher in New York than New

MexicoLower exposure to natural light in large cities and

areas at higher latitude

Research has been mostly observational, few clinical trials“…Vitamin D levels in the blood vary by race, with the

season, and possibly with the activity of genes whose products are involved in vitamin D transport and metabolism. These variations complicate the interpretation of studies that measure the concentration of vitamin D in serum at a single point in time.” - OCCAM

Observational Studies

1. Lower serum vitamin D levels were found more often in oncology patients compared to primary care clinic patients of same region

Researchers did adjust results based on age, BMI, and season of blood draw

Relationship maintained significanceChurilla, T.M., BMJ Open. 2011 Dec 19;1(2).

2. Serum vitamin D levels between 50 and 75nmol were associated with lower risk of colorectal cancer

Levels less than 50nmol were associated with increased risk

Jenab, M. BMJ. 2010 Jan 21.

Clinical Trials

1. Women’s Health Initiative: Calcium+D supplement significantly decreased the risk of total, breast, and invasive breast cancers by 14-20% and nonsignificantly reduced the risk of colorectal cancer by 17%

Did not decrease risk in women already taking calcium or vitamin D supplement

Bolland, M.J. Am J Clin Nutr. 2011 Oct;94(4):1144-9

2. Prostate Cancer Prevention Trial: Dietary or supplemental vitamin D use was not associated with decreased risk of prostate cancer

Kristal, A.R. Am J Epidemiol. 2010 Sep 1;172(5):566-77

Summary on Vitamin D

Inconclusive results between observational studies and clinical trials

Many studies only test serum vitamin D levels at one point in time, not the effect of a supplement

Recommendation: Don’t be Deficient! Take a daily MVI or calcium+D supplementIf you are concerned, talk to your doctor.

Have him/her measure a baseline level before taking a large supplemental amount

Omega 3 FatsAnti-inflammatoryReduce muscle wasting during treatment (cancer cachexia)

Great for your cardiovascular system

Salmon, herring, sardines, mackerel

Aim for 4 oz of oily fish 2-3 times a week

Daily goal: 1000 mg of combined EPA/DHA

Fish oil supplements during treatment:

Alcohol

Limit alcohol intake< 1 drink/day for women< 2 drinks/day for men

Women who consume 1 drink or more/day have an increased risk of breast cancer (10-40% increased risk)

Adequate folate intake (400mcg/d) may reduce the increased risk of breast cancer associated with alcohol use

Questions?

www.DanaFarber.org/nutrition