Nutrition During and After Treatment

WMFC Toronto Support Group

September 26, 2018

Megan Morrison, BScH, RD

Malignant Hematology/Allogeneic Blood and Marrow Transplant Program

Princess Margaret Cancer Centre

Outline

! Eating well while on treatment

! Nutrition goals while on treatment

! Side effect management

! Food safety guidelines

! Cancer and Diet- General Recommendations

! Blood building nutrients

! AICR Guidelines for prevention and survivorship

! FAQs and key messages

! Resources/Questions

Eating well while on treatment

! Eating well during treatment can help:

! Tissues heal and prevent tissue breakdown

! Rebuild immune system

! Reduce risk for infections

! Provide energy and strength to withstand treatment

! Promote healing and recovery

! Contribute to quality of life, wellbeing

Nutrition goals while on treatment

! Rebuild nutritional status

! Optimize calories

! Good quality protein

! Hydration

! Vitamins and minerals

! Help manage treatment related side effects

! Help get back on track

Individualized nutrition care plan

Fluids

“Drinking fluids is crucial to staying healthy and maintaining the function of every system in your body, including your heart, brain, and muscles. Fluids carry nutrients to your cells, flush bacteria from your bladder, and prevent constipation”, Harvard Health, 2015

! If you don’t drink enough fluids you may become dehydrated which can lead to fatigue, light-headedness & nausea

How much liquid should I drink?

! Aim for 8 cups or 2 litres of fluid each day

(1 cup = 8 ounces = 250ml)

! You may need extra fluids if you have diarrhea, vomiting or fever

! Sip fluids throughout the day. Try to carry something to drink with you wherever you go

Fluids

! Low calorie options: water, soup broth, soda water, tea

! High calorie options: full fat milk/non dairy beverage, fruit juices, Gatorade

! Protein rich options: milk, milkshakes, nondairy beverages (rice, soy), oral nutritional supplements (i.e. Ensure®, Boost®)

! Caffeinated drinks: limit to 3-4cups daily

*Remember some individuals require more or less fluid ! always check with your medical team*

Protein

! What’s the hype?

! Helps build your immune system to fight infections

! Help your body heal during & after treatment

! Maintain and strengthens your muscles

What are some protein rich options?

! Animal sources: poultry, tuna or salmon, eggs, meat, dairy products

! Plant sources: legumes (i.e. lentils, chick peas), tofu, nut butters, roasted nuts/seeds, non dairy beverages (i.e. rice, cashew)

! Protein powders – i.e. whey, skim milk powder, pea protein, hemp protein

! Oral nutritional supplements- i.e. Ensure®, Boost®, Resource 2.0®

Protein

Food Item Approximate amount of protein/serving

Meat/poultry (i.e. chicken, turkey) 3 oz. = 25g

Fish 3 oz. (1/2 can tuna or salmon)

Beans and legumes ½ cup= 8 g

Milk and non dairy beverages 1 cup milk= 9g1 cup soy milk= 8g

Eggs 1 large egg= 6g

Nuts and nut butters ¼ cup= 8g2 tbsp. peanut butter= 8g

Calories

Calories from the foods you eat give your body energy.

Food is your fuel.

Energy is important to help keep up your strength and weight stable.

Tips to add more calories to your diet:

! Make every mouthful count

! Focus on smaller more frequent meals

! Carry a snack with you when your out of the house

A few practical strategies to adding more calories to your meals:

Food or Beverage Add..

Cooked vegetables Stir in olive or avocado oil,Top with nuts and seedsUse cream/cheese (or alternative) sauce

Cereal with 1% milk 2% or homogenized milk

Plain omelet Shredded cheese, make with whole milk or cream

Homemade fruit smoothie Homogenized milk, full fat Greek/Icelandic yogurt

Hot cereals, muffins, yogurt parfait Add a little sweetness- add jam, honey or maple syrup

Soups and stews Add extra lentils or beans, seafood or turkey, mix in an egg into hot soup, use pesto or cream sauce

Food-borne illness (Food Poisoning)

! Health Canada defines it as diseases “caused by consuming contaminated food or beverages”

! Contaminants can be bacteria, parasites or viruses, commonly known as germs

! Approx. 4 million(1 in 8) Canadians per year suffer food-borne illness according to Health Canada

! 11,600 hospitalizations

Health Canada, December 2015, WHO, FDA

Recent food-borne illness outbreaks

! Randsland brand Super Salad Kit – August 2018 listeriosis ! Smoked salmon-Nov.2017 listeriosis

! Packaged frozen chicken burgers-Oct. 2017 salmonellosis

! Smoked fish-2017 botulism

! Packaged salads-2016 listeriosis

! Undercooked poultry-2015 salmonellosis

! Raw shellfish-2015 vibrio

! Peanut butter-2009 salmonellosis

! Jalapeno peppers-2008 salmonellosis

! Cold cuts-2007 listeriosis

Sources: Health Canada, CFIA, WHO

Highest risk groups for food-borne illness

! The Immunocompromised

! i.e. cancer (especially on treatment), Bone Marrow Transplant, organ transplant , HIV/AIDS, diabetes and alcoholism

! Pregnant women/newborn children

! Ages 60+

! People on immune suppressing drugs and high dose steroids

Health Canada 2015; FDA,CDC,WHO

Food Safety

! Follow the 4 Basic Safety Tips

! Clean

! Separate

! Cook

! Chill

www.fightbac.org/

Foods Safety Procedures! Hand washing

! Avoid damaged cans/containers

! Check expiry dates

! Proper thawing techniques

! Describe “danger zone” temperatures

! Throw out foods in danger zone > 2 hrs

! Proper internal cooking temps

! Throw away leftovers after 3 days

Health Canada, WHO, CFIA, FDA, CDC

Government Regulations

Food Safety Foods allowed

! Well-done cooked meat, poultry, fish, eggs (not runny)

! Canned tuna and salmon

! Washed fresh fruits, vegetables and salads (including bag/box lettuce)

! Hard cheeses such as cheddar, parmesan

! Pasteurized dairy products, juices and honey

! Non dried deli meats- cooked until completely steaming hot

*this is not the extended list, please visit https://www.canada.ca/en/health-canada.html

Food Safety Foods to avoid:

! Undercooked meat, poultry, fish or eggs

! Raw tofu

! Raw nuts

! Non-dried deli meats, such as turkey breast and smoked meat

! Raw shellfish, sushi, smoked salmon

! Unpasteurized dairy products, juices, honey

! Soft cheeses such as Brie, Camembert and blue-veined

! Raw sprouts

*this is not the extended list, please visit https://www.canada.ca/en/health-canada.html

Side Effect Management

Poor Appetite

! A loss of appetite and the desire to eat is common side effect during treatment

! Poor appetite can be caused by:

! Medications

! Illness and medical conditions

! Cancer treatment

! Psychosocial well- being

Poor appetite decreased food intake weakness, fatigue, weight loss

Poor Appetite - strategies

! Eat smaller more frequent meals throughout the day

! Eat every 2-3 hours

! Choose calorie dense meals and beverages – try not to fill up on empty calories

! Walk around when possible- light activity may help encourage appetite

! Keep your fridge/freezer and food pantry filled with ready to eat snacks and easy to prepare meals

! Set reminders for yourself – keep a note on the fridge or set an alarm on your phone

! Engage in social activities i.e. have meals with friends/family

Nausea and Vomiting

! Inform your healthcare team if you are experiencing nausea/vomiting

! Especially if severe for more than 24hours and unable to keep down pills/liquid/food

Four helpful tips to fighting nausea

1. Focus on fluids- sip on water and other clear fluids

! Aim for at least 1.5-2L

! Drink between meals

2. Eat smaller frequent meals and snacks

! Hunger and skipping meals can increase nausea

! Nibble on bland, dry foods

Nausea and vomiting

3. Avoid foods that worsen nausea

! Avoid greasy or fried foods

! Avoid fatty desserts

4. Talk to your team about anti nausea medication

! Do not take anything without talking to your doctor

Pear Ginger Sorbet Recipe taken from “Goes Down Easy”, Cookbook

Recipe

1 can (14oz/398ml) pears in light syrup 1

1 tsp fresh peeled ginger, minced 5ml

Place pears, syrup, and ginger in blender and blend until smooth. Pour into small bowl and freeze until firm, about 2 hours. To serve, scoop into serving dishes. Use within 3 days

Makes 3 servings

Fun fact: Ginger has been shown to help ease nausea. It is available in most supermarket s and can be peeled and kept in the freezer for future use.

Gastrointestinal Distress- Diarrhea

! Diarrhea is loose watery bowel movements

! Medications and treatment can cause changes to your bowel movements, stool frequency, cramping and/or gas

! Some helpful tips to help manage diarrhea

! Choose lower fiber breads, cereals and crackers

! Eat smaller meals at once

! Avoid fried, spicy and greasy foods

! Switch to lactose free or non dairy beverages

! Drink decaffeinated beverages such as decaf tea/cola and coffee

Talk to your medical team about medications that may help with diarrhea management

Gastrointestinal Distress- Constipation

! Are you straining with each bowel movement? Having fewer bowel movements than usual?

! Do you feel bloated and full? Or feel gassy?

! These can all be signs of constipation

! Contact your healthcare team if you think you are constipated and have not had a bowel movement with 2-3 days and this is different from your usual

! You may need medication to relieve the constipation and diet alone may not help. Discuss this with your healthcare team

! Constipation can be caused by medications, change in diet and activity, some chemotherapies, stress/anxiety etc.

Gastrointestinal Distress- Constipation

Some things you can do to help your gut

! Drink at least 1.5-2L water/fluid every day

Fun fact: warm liquids can help with bowel activity

! Add physical activity – as tolerated

! Once fluid intake is at least 1.5L/day start to slowly add more fiber to your diet

Fun fact: high fibre foods hold fluids in the stool. This makes it softer and easier for stool to pass.

! Make sure to drink a lot of fluids to prevent bloating, gas or cramps

! Foods rich in fiber include fruits, whole grains, vegetables, legumes

*if you have been told you are at risk for bowel obstruction, talk to your healthcare professional before adding more fiber

Cancer and Diet General Information

Blood Building Nutrients “What can I eat to help build up my immune system”?

! There is not one single diet, food or supplement that will build your immune system however it is important to give your body the nutrients it needs to speed your recovery

AICR, 2018

American Institute for Cancer Research

1. Be a healthy body weight

2. Be physically active- aim for 150minutes of moderate activity/week

3. Choose foods rich in whole grains, fruits/vegetables, legumes – fill at least 2/3 of your plate with these foods

4. Limit intake of fast foods and processed foods high fat, starches and sugar

5. Limit consumption of red meat (12-18ounces cooked/week) and avoid processed meat

American Institute for Cancer Research

6. Limit consumption of sugar- sweetened drinks

7. Limit alcohol:

! Limit alcoholic drinks (2 for men & 1 for women)

! One drink= 12 oz. beer, or 5 oz. wine, or 1 ½ oz. liquor

8. Do not use supplements for cancer prevention

! Aim to meet nutritional needs through diet alone not pills

“After a cancer diagnosis: follow our Recommendations, if you can”- AICR 2018

Does sugar cause cancer cells to grow faster and should be avoided?

Facts: ! All of our cells use glucose (sugar) for energy

! Glucose is found in most carbohydrate foods – main source of energy for cells

! There is currently lack of evidence to support that added dietary sugars directly feed cancer cells.

! There is also lack of evidence to support that removing sugars can starve cancer cells and change outcomes.

! Miss out on healthy nutrients by avoiding all sugar containing foods

Does sugar cause cancer cells to grow faster and should be avoided?

Bottom Line: ! Our cells need energy, especially healthy ones during tx

! Sugar is a natural part of our diets

! Not all sugar works the same way

Dairy Candies

Fruit Chocolate

Legumes (beans, peas) Fruit Drinks

Do I need to take vitamin and mineral supplements? General recommendation: no in fact you may need to stop during treatment

Why?

! May interact with your medications

! Antioxidants protect all cells in the body, including cancer cells

! Antioxidants include vitamin A, C, E, beta-carotene, selenium and others

! Some supplements have antioxidant properties and should be stopped (for example- CoQ10)

! Food sources are okay!!

Do I need to take vitamin and mineral supplements?

! Choose food first to get your vitamins and minerals

! A multi-vitamin may be safe for you to take

! Check with your doctor first

! Fun Facts: Found in sunflower seeds, peanut butter and fortified cereals Vitamin E works as an antioxidant and may improve immune function.

! Found in seafood, whole grains, and beans, Zinc helps the immune system function and may helps wounds heal.

Is it safe to take an herbal supplement?

! There is limited evidence on the safety of herbal supplements during cancer treatment

! Avoid taking during treatment

! Use food herbs in your cooking!

Memorial Sloan Kettering has a database of herbal supplements.

https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine/herbs/search

Do I need to eat all organic food?

! No proven health benefit over non-organic food

! Grown conventionally or organically, fruits and vegetables are important part of diet which helps to lower overall cancer risk

! If you choose to buy organic, look for the certification seal

Should I be juicing to help with cancer/cancer treatment? The good:

! Juicing is a good option for people with small appetites or those who feel full easily.

! Juicing is a good option for people who need to follow a lower fiber diet.

The not-so good:

! Juices should not be used as the only source of nutrition - do not provide all the nutrients our bodies need They are low in protein, fat, fibre, calcium, vitamin D and iron.

! Juices may lead to weight loss and muscle loss if used as a meal replacement

! Without fiber, the natural sugars in juice can enter your bloodstream too quickly leading to a spike in your blood glucose (sugar).

! Good blood glucose control is recommended for people with diabetes and those trying to maintain a healthy weight

The bottom line:

! If you are able to, choose to eat whole vegetables and fruits whenever you can. Research shows that consuming whole fruits and vegetables may protect against different cancers.

Credible information Where can I go for “good” information?

! It can be often be challenging for cancer patients and caregivers to navigate the flood of “cancer-specific” nutrition information found online through websites or blogs, in books and in the media. Misconceptions can easily spread through social media and can leave you with many unanswered questions.

! Here are 5 tips to help you spot misinformation:

! 1. Is the person or product promising a quick fix? TIP: if it sounds too good to be true, it probably is.

! 2. Is the website trying to sell you a product? Special foods or supplements? TIP: do not take any new

product without discussing with your healthcare team

! 3. Does the website or blog provide more information on personal stories than facts? TIP: nutrition

advice should be based on the best available scientific research.

! 4. Is the claim based on a single study? Is it based on few research studies? Were the studies done in animals or humans? If studied in humans, are you similar to those that were studied? (I.e. sex, age, diagnosis etc.). TIP: the stronger the study design and more studies available that have the same

conclusions, the stronger the evidence that there is truth.

! 5. What are the qualifications of the person writing the information? TIP: look for the word RD to

identify a registered dietitian.

Key Messages

It’s a balancing act

If you are eating well

! Continue to eat your usual diet

! Focus on healthy and wholesome sources of calories, protein, carbohydrates and fat

! Choose a variety of foods

! Changes to your diet may be needed if you experience side effects

! Look for credible information

!Ask a member of your healthcare team for referral to a dietitian

Helpful Websites/Resources

! aicr.org

! bccancer.bc.ca

! cancer.ca

! cancer.org

! theprincessmargaret.ca

! mayoclinic.org

! Nourish

! ELLICSR/ELLICSR Kitchen

Questions???