prepared by colleen gill, ms rd cso meeting/annual... · eat 4+ times/day to stabilize blood sugar...
TRANSCRIPT
ADDRESSING ONCOLOGY NUTRITION MYTHS AND CONTROVERSIES
Prepared by Colleen Gill, MS RD CSO
University of Colorado Hospital [email protected]
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?