Colleen Gill, MS RD CSO University of Colorado Cancer Center

[email protected] 720-848-0300

11/2/13

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

Keep diet empowering, Not a new stress  The Big Picture = Plate

Demystify controversies  www.aicr.org

 Two Goals at a time  1 diet, 1 exercise

Advice from friends and family  Out of concern, but stressful  Thank them, then talk with your team

 Concrete ideas keep friends off the internet

Walks, laundry, meals (with recipes)

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mealtrain.com; lotsofhelpinghands.com

Interpreting Research  We are all eating “Shades of gray”  We are all unique! Genetics matters

 Human studies  Long timelines, expensive

 No licensure in Colorado  RD/RDN = BS/MS + internship  Check training/experience with the disease/condition  Internet and Magazines?

Free appointments at UCCC 720-848-0300  Symptom management  Survivorship, supplements  Overviews: Brain, Breast, Prostate, Pancreatic,

Lung, Colon, Ovarian, Kidney

 Classes: 720-848-0316

Watch Your Weight, Exercise Regularly, Eat a Healthy Diet  Rates higher in Westernized countries; and

climb in those that adopt our dietary patterns  Migrants moving from low to high risk areas assume the host country rates within one to two generations

Increased Risk/Limit  Diets high in calcium  Processed meats  Milk and dairy products Decreased Risk/Include  Foods containing lycopene or selenium (Selenium*)  Legumes, including soy  Foods containing vitamin E (E*) *no longer supported by SELECT research; www.aicr.org

Increased Risk/Limit  Foods with iron, animal fat, sugar  Red meat, processed meats, alcohol, cheese  Abdominal fat, body fat Decreased Risk/Include  Fiber, garlic, fruits/vegetables, fish, milk  Foods with folate, selenium, vitamin D  Calcium, selenium  Physical Activity www.aicr.org

Breast, CRC, endometrial, esophagus, kidney, liver, pancreas, GB, ovarian, NHL, MM, aggressive PC  2 – 3.6 times at BMI > 40  1.5 times at BMI’s of 27 - 30

 More advanced disease, recurrence, death

Obesity  14% cancer deaths M; 20% of F

Waist Circumference = Abdominal fat  Increased inflammatory messages

  Insulin resistance   Estrogen levels increase with number of fat cells

 Slow down! After ~ 4 - 5 bites, taste declines  Study: 646 calories/9 minutes; 579 in 29 minutes  Listen to your body (and journal)  Keep hunger on a scale between 3 – 7  Small meals/snacks with protein controls appetite  Avoid fluids with calories! Starbucks?  Adults don’t compensate  Eat out less often  2+ times a week  10# gain www.tcme.org

 Exercise 30 minutes/day

 20–50% ↓ heart disease, osteoporosis, stroke, cancer,

diabetes, kidney disease, depression

 In Treatment: Eliminated weight gain

 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 

18% ↓ Br Ca with < 2.5 hours/week walking JAMA, 290: 1331 – 36; 2003

 3 – 5 hours/week reduced recurrence by over 1/3  WHEL: 3 hr exercise + f/v ↓ recurrence 50%  Required both; worked in obese/normal weight!

Controls weight ↓ blood pressure, stress, Insulin resistance, fatigue, cancer Increases HDL, ↓ LDL

Break it up! •Start slow 5” •10 – 20 ” bouts •F.I.T.T.

Pedometers offer great feedback! (When used)

Fitbit www.digiwalker.com © 2010 Sports Cardiovascular and Wellness Nutrition (SCAN)

Filling your 9” plate  ¼ Carbohydrates  Whole-grain breads, cereals, rice, potatoes, pasta  ¼ Lean Protein  Low fat milk, lean fish/poultry/red meat  Eggs; Nuts  ½ vegetables, 1 fist size fruit, beans

Light on  (Saturated/trans) fat  Sugar, salt and alcohol

Fluids Dairy

Organic?

Fruits/vegetables Meats…

Carbs Sugar

Fats

Omega 6 Flax Oil

Proteins

Red Meat Processed Meat Soy

Probable/suggestive benefits Primarily those in the GI tract Head/neck, esophageal, lung, stomach, pancreatic, colorectal, liver, prostate Benefits of adding plant based foods was not equal to that gained from cutting the amount of meat

 Is fresh best? Try 50/50

 Different absorption from fresh and cooked

 Organic? Risk: increased cost  buying less  Stressed plants make more phytochemicals  Limits impact to wildlife, farm workers, soil/water  Wash well to limit pesticides, needn’t avoid non-organic www.ewg.org

 Include a range of colors, herbs count too!

 Alkaline Diet = Plant Based/Plate Model  The wrong rationale, but the right result? http://www.denvernaturopathic.com/alkalineash.htm

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• The fastest growing sector in the food marketplace, but…organic junk food is still junk food • Beware of the “health halo” effect • Do pesticides cause cancer? Yes and no • Definitely with large exposures: farm workers • Other reasons to go organic? • Antibiotic resistance from use in meat industry • Farming practices that are environmentally friendly

No matter how you eat your plant foods, more is better, and conventional provides benefit Wan-Chen Lee J. Experimental Biology April 2011, Washington, D.C. Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective Bhat AR, et al. Indian J Occup Environ Med. 2010;14:78-86 Cockburn M, et al. Am J Epidemiol. Mar 2011; Published online before print.

Lower fat diet was associated with lower blood levels of inflammatory markers linked to cancer progression  ? Due to low fat or associated weight loss Limit Saturated Fat  Fat itself, or red meat/ high-fat dairy?  Tripled PC mortality: >13% of cal vs < 10.8%  Saturated fat = link to PC progression  Cholesterol levels associated with PC risk  Increases bile acids toxic to colon  Substitute Monounsaturated Fats

Cardiac benefits clear, and important 3x as many men died of CVD than PC While enrolled in PC studies

Finding: 9% fewer breast cancers

Borderline significant Compliance differed, generally poor  WHI: 37% fat  29% ( 22%)  WINS: 34%  22% ( 36% )

Compliant WHI participants = WINS  22% lower risk ( = WINS at 24% less) JAMA 295 (6): 629, 2006 Hay, JADA 109 (4): 688; 2009

Meat  Bake, broil, or poach, limit frying/ charbroiling  Choose fish, poultry, or beans more often than

beef, pork, and lamb (lean cuts).  Limit red meat to < 18 oz/week; NO processed  Grill safely; avoid well-done meat

Eggs, limit to 7 yolks/week  Add 1 egg white, per egg yolk

Dairy and cancer risk • • • •

Breast cancer: No clear effect on risk Colon cancer: Probably decreases risk Prostate cancer: Possibly increases risk (calcium related) Ovarian Cancer: Possibly increases risk, but only if you are a “slow galactose metabolizer” Dong JY, et al. Breast Cancer Res Treat. 2011;127:23-31.

Benefits • • • •

Huncharek M, et al. Nutr Cancer. 2009;61:47-69. Newmark HL et al. Nutr Cancer. 2010;62:297-99. Larsson SC, et al. Int J Cancer. 2006;118:431-41.

Yogurt, source of probiotics Low glycemic index carb, good protein source Provides the bulk of calcium in Americans’ diet CLA, conjugated linoleic acid may protect Select low fat cheese, yogurt, BHT free milk

Example: Dairy & Risk of Breast Cancer

Decreased Risk

Increased Risk RR = 1.0 (null value)

Tumors with 0-6 hormones support growth and metastases  Replace vegetable oils with olive and canola oil

 Olive oil also decreases production of bile acids (toxic

to colon)

 Limit processed and convenience food  Consider balsalmic oil/vinegar for salad dressings  Include more vegetarian meals

Food supply has shifted Omega 6:3 ratio  Goal: Move from ~20x Omega 6 to < 4x  Include more Omega 3  O-3 Eggs, fatty fish, supplements

Avoid alpha-linolenic acid in PC

 Studies showed increased PC risk ***

 Flax spoils easily Grind, refrigerate/freeze  Ground seeds can be used in baking  Oil is unstable at the high temperatures for frying

 Flax seed maximum: 3 – 4 T/day  Compounds in

uncooked flax are toxic in large amts

 Include 4 – 8 ounces of water/T (fiber)

 Flax can bind meds; separate thyroid, bisphosphonates Lowered PSA levels, testosterone, cholesterol, proliferation rates Increased Sex Hormone Binding Globulin, limited cell division and Her2/neu protein in breast cancer

Structure, enzymes, stabilizing blood sugars Immune function/healing Whey (Dairy protein)  Antiviral, antifungal, antibacterial  Damages pathogenic bacteria  Limits “sticking” to GI wall  Glutamine source  glutathione, intracellular antioxidant that protects normal cells  Increases immunoglobulin levels

 Stimulates the immune system

 Inhibits growth signals, promotes cell death  Limits angiogenesis   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

 Inhibits aromatase (synergistic with AI)  Antioxidant  Blocks activity of enzymes converting androstenedione

to testosterone

Han H, et al. Nutr Cancer. 2010;62:641-47. Yu X, et al. Med Oncol. Dec 2010; published online before print. Barnes S. Lymphat Res Biol. 2010;8:89-98.

3 recent large-scale, population studies  Different ethnic groups (two US, one Chinese) and

varying levels/type of soy food consumption  All 3 - no adverse effect, potentially protective Average Asian isoflavone levels, ~ 35 - 40 mg (max 100), with 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

Soy is food and should be treated like food Enjoy soy if you like it, avoid if you don’t Caan BJ, et al. Cancer Epidemiol Biomarkers Prev. Feb 2011

Cancer cells like sugar as “fuel”

 Basis of PET scans to detect tumor activity  Tumors can and will make their own glucose for fuel

Real Concern

“Quick Carbs” or large volumes  Higher blood sugars

 More Insulin ( if IR)   

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

The Right Amounts

 ¼ carbohydrate sources

bread, pasta, potatoes, rice, cereals  ¼ protein (and fat) sources  ~ ½ F/V fruit, vegetables, beans

The Right Mix

No Naked Carbs

 Eat sweets as part of a mixed meal  With protein/fat, fiber to slow stomach emptying; rescue

With The Right Type

 Limit processed foods, high glycemic index options

With Sleep, Exercise, Healthy Weight!

1355 vs. 475 16 oz rib eye steak 12 oz baked potato with: 2 T of butter 4 T of sour cream ½ c squash with butter © 2010 Sports Cardiovascular and Wellness Nutrition (SCAN)

6 oz grilled chicken 1½ c greens ½ c carrots & green beans ½ c brown rice 29

Omega 3/fish oil for inflammation/cardiac Multivitamin, Maybe? Adequacy vs. Excess Pick lowest dose, business side is making up the difference  Folic acid at 400 mcg/100%  Government fortification  adequacy  Concern that excess may promote cancer/recurrence

 Beta carotene: Studies in smokers stopped early; limit to 100%  Selenium: SELECT trial showed no benefit  Average intakes now keep levels sufficient

 Iron: only if menstruating, or documented iron deficiency

 D (1000+ IU); levels ~ 40 ng/ml, Fillers Blocks Bone Density

Supports Density

Alcohol; limit to 1/day

Calcium; 1,500 mg/total!

Caffeine; limit to 2 c/day

Vit D; 1000+ IU/day*

Smoking; stop

Protein, Vitamins C, K

Sodium; processed foods

Potassium, Magnesium

Excess Vitamin A

Sunlight Weight bearing exercise*

Eat Food Not too much Mostly plants Michael Pollan Questions? Are you leaving less stressed?