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Nutrition in Health
and Wellness
Donald I. Abrams, M.D.
Chief, Hematology-Oncology
San Francisco General Hospital
Integrative Oncology
UCSF Osher Center for Integrative Medicine
Professor of Clinical Medicine, UCSF
14 Components of Dietary Risk
• Diets low in:
– Fruits
– Vegetables
– Whole grains
– Nuts and seeds
– Milk
– Fiber
– Calcium
– Seafood omega 3s
– PUFA’s
• Diets high in:
– Red meat
– Processed meat
– Sugarsweetened
beverages
– Trans fatty acids
– Sodium
Lim et al, Lancet 2012
Proportion of Cancer Deaths Caused
by Different Avoidable Cancers
Causes
Percent
1981(US)*
Percent
1998(UK)**
Tobacco
25-40
29-31
Diet
10-70
20-50
Medicines
0.3-1.5
<1
Infection: parasites,
bacteria, viruses
10
10-20
Ionizing and UV light
2-4
5-7
Occupation
2-8
2-4
Pollution: air, water,
food
<1-5
1-5
Physical inactivity
* Doll and Peto, 1981; ** Doll, 1998
1-2
Diet and Cancer
• Probably involved in 30-35% of all cancers
• Certainty about diet less firm than tobacco
– Contradictory study results i.e. fiber
– Hard to define what the diet actually is
• Diets are very complex
• Diets vary over time
• Is it what we ate in the past? Or perhaps
what our mothers ate? Or theirs?
ACS and WCRF/AICR Guidelines
WEIGHT GUIDELINES
•Maintain a healthy weight throughout life
•Balance caloric intake with physical
activity
•Avoid excessive weight gain throughout
the life cycle
•Achieve & maintain a healthy weight if
currently overweight or obese
Be as lean as possible
without becoming underweight
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
Source: Behavioral Risk Factor Surveillance System, CDC.
25%–29%
≥30%
Obesity-Associated Malignancies
• Breast (postmenopausal)
• Endometrium
• Prostate
• Kidney
• Colon
• Esophagus
• Pancreas
• Gallbladder
AICR report
estimates
that obesity-related
excesses
of these 7 cancers
account for approx
115,000
preventable deaths
a year in the US
Body Fat Increases CA Risk
• Body fat secretes cytokines that promote
inflammation
• Fat increases estrogen production
• Increase in body fat may impair immunity
• Too much body fit triggers insulin
resistance, raising levels of insulin and
growth factors that promote cancer
ENERGY DENSE FOODS GUIDELINES
Choose foods and beverages in
amounts that help achieve & maintain a
healthy weight
•Avoid sugary drinks
•Limit consumption of energy dense
foods
•Particularly processed foods high
in added sugar, low in fiber or high
in fat
How can anyone
consume
that much sugar???
PLANT-BASED GUIDELINES
•Consume a healthy diet, with an emphasis
on plant sources
•Eat 5 or more servings of a variety of fruits
and vegetables each day; every meal and
snacks
•Choose whole grains in preference to
refined
Eat more of a variety of vegetables,
fruits, whole grains and legumes
U.S. Diets Fall Short on F&Vs
• CDC reports only 14% of adults eat
recommended number of servings/day
– 33% eat 2 or more servings of fruit a day
– 27% eat 3 or more servings of vegetables
• DC 20.1%, VT, ME, HI, MA top 5
• WV, SD, AL, OK/SC, MS 8.8% rank last
• Only 9.5% of high school students meet
recommendations (32% fruit, 13% veg)
• Healthy People 2010 objective was to
have 75% meet fruit and 50% vegetable
Centers for Disease Control 2009
Antioxidant Rich Foods
•
•
•
•
•
Fruits
Vegetables
Nuts
Grains
Some meat, fish and poultry
The Benefits of Organic Food
• Produce
– Less exposure to pesticides
– Same macronutrients but increased vitamin C,
minerals and antioxidant phytonutrients
– Often fresher because no preservatives
– Organic farming better for environment
• Animals
– Not given antibiotics, growth hormones, or fed
animal byproducts
Nutritional Prevention Strategies
Eat More:
• Phytoestrogens
– Soy foods
– Flaxseed (Omega 3’s)
•
•
•
•
Cruciferous vegetables
Garlic and onions
Turmeric and ginger
Green tea
Sulforaphane in Prostate Cancer
• Sulforaphane is a constituent of
cruciferous vegetables such as broccoli
• CVs strongly associated with lower CaP
• Preclinical studies suggest sulforaphane
inhibited histone deacetylase (HDAC)
function and suppresses androgen
receptor signalling
• GSTM1 gene contributes to sulforaphane
metabolism
Alumkal et al, ASCO 2013
Sulforaphane in Prostate Cancer
• 20 men with CaP and PSA recurrence
despite surgery or radiation
• Treated with sulforaphane 200 umol/day
• 16 patients completed 20 weeks
– 1 had a PSA decline >50%
– 7 had PSA declines 3-20%
– 3 had final PSA less than baseline
• PSA doubling time ↑’ed from 6 to 9.4 mos
Alumkal et al, ASCO 2013
Sulforaphane in Prostate Cancer
• “The compound we used is limited by not
having several species toxicity, which will
be necessary prior to dose escalation.”
• “Groups are working on developing a
synthetic version with druglike properties.”
• “There are also OTC preparations,but I am
not familiar with their quality control.”
– Joshi J. Alumkal, MD, OHSU, Portland, OR June 2013
www.cancernetwork.com
F&V and Colorectal Cancer
• 85,903 men and 105,108 women 45-75 yo in
Hawaii and California followed 7 years
• Detailed questionnaires on dietary habits
• 2110 participants developed CRC (1138 men)
– For men, high levels of F&V associated with lower risk
across 5 ethnic groups studied (RR- 0.74 [0.59,0.93])
– For women, no risk reduction seen for F&V
– Risk reduction colon CA > rectal CA in men
• Intake of grains had no effect in either sex
Nomura et al Am J Clin Nutr 2008
Green Tea: Human Studies
• Animal studies: Green tea has a protective effect
against tumors of the colon, prostate,
esophagus, liver, stomach, lung, breast,
pancreas and skin
• Iowa Women’s Health Study- catechin intake
from tea was associated with a lower incidence
of digestive tract cancers.
• Chinese tea drinking men have half the risk of
developing stomach or esophageal cancer, and
have significantly lower risk of prostate cancer.
Mushrooms and Green Tea
• Case control study in SE China 2004-2005
• 1009 women with confirmed breast CA and
1009 age-matched controls
– Compared with non-consumers
• OR- 0.36 (95% CI 0.25, 0.51) for daily intake >10g fresh
mushrooms
• OR- 0.53 (95% CI 0.38, 0.73) for daily intake > 4 g dried
mushrooms
• ORs 0.11 and 0.18 for fresh and dried in combo with >1.05 g
dried green tea leaf beverages/day
– Effects seen in pre and post-menopausal women
Zhang et al, Int J CA, 2009
Agaricus species
• Agaricus blazei most
common CAM Rx in
Japanese cancer patients
• Agaricus bisporus may
have aromatase inhibitor
activity
– Significance of agaritine in
raw button mushrooms
unclear
– ALL mushrooms must be
cooked before eating !!!
Turmeric- The Anticancer Spice
• Purported properties
– Antioxidant
– Anti-inflammatory
– Chemopreventive
– Antimutagenic
– Anticarcinogenic
– Antimetastatic
– Antiangiogenic
– Cardioprotective
RED MEAT GUIDELINES
Limit consumption of
processed and red meats
Limit consumption of red
meats (beef, pork and
lamb) and avoid
processed meats
Meat Intake and Colon Cancer
Armstrong and Doll, 1975 in Willett, 1995
Omega 3 vs Omega 6 Fatty
Acids
Transformation of food chain
x20
Omg-6
/Omg-3
x15
x10
x6
Ailhaud et al., Prog. Lip. Res., 2006 – Simopoulos & Salem. NEJM, 1989
Fats, Fatty Acids and Prostate CA
• Preclinical studies had suggested that ↓
dietary fat and ↓ n-6:n-3 lowers risk and slows
progression of prostate cancer
• 48 men undergoing radical prostatectomy
• Randomized to low fat (15%) diet and 5 gm
fish oil (n-6:n3 2:1) or control Western diet
(40% fat, n6:n3 15:1) for 4-6 wks pre-op
• Food prepared by UCLA chefs
• Serum IGF-1 levels selected as primary
Aronson et al, 2011
endpoint
Fats, Fatty Acids and Prostate CA
• No effect on serum IGF-1 levels
• Low fat, high n-3 group had:
– Lower omega-6:omega-3 ratios in blood and
prostate
– Less prostate tissue (benign and malignant)
– Reduced cancer cell proliferation (Ki-67
index)
– Reduced prostate cancer cell proliferation in
vitro with their blood added c/w controls
Aronson et al, 2011
Meat and Colorectal Cancer
• Total iron intake and dietary iron both
inversely associated, although the more
bioavailable heme iron was positively
associated
• Nitrate intake from processed meat
positively associated; nitrite not (p=0.055)
• Heterocyclic amine intake (MeIQx and
DiMeIQx) positively associated but only
associated with colon, not rectal CA
Cross et al, Cancer Res 2010
Dietary Fat and Pancreatic CA
• NIH/AARP study, 6.3 yrs f/u 525K→ 1337 cases
• Pancreatic cancer risk directly related to the intake of:
– Saturated fat 51.5 vs 33.1 cases/100K py
• HR= 1.36 (1.14,1.62; Ptrend<.001)
– Monounsaturated fat 46.2 vs 32.9 cases/100K py
• HR= 1.22 (1.02,1.46; Ptrend=.05)
– Strongest associations for saturated fat from animal
sources 52 vs 32.2 cases/100K py
• HR= 1.43 (1.20,1.70; Ptrend<.001)
• Specifically, intakes from red meat (HR=1.27) and dairy products
(HR=1.19) were both associated with increased risk
Thiebaut et al, JNCI 2009
Chemopreventive Components of Dairy
• Dairy products contain
– Calcium
– Vitamin D
– Butyric acid
– Conjugated linoleic
acid
– Sphingolipids
– Probiotic bacteria in
fermented products
The Problem With Dairy
Lactose and Lactase-Who Is Lactose
Intolerant and Why?
Most animals lose milk-digesting enzymes after
weaning, so lactose intolerance becomes the norm
Montgomery, Robert K; Krasinski,
Stephen D; Hirschhorn, Joel N; Grand,
Richard J
Journal of Pediatric Gastroenterology
and Nutrition. 45():S131-S137,
December 2007.
doi: 10.1097/MPG.0b013e31812e68f6
FIG. 3. Developmental patterns
(transcriptionally regulated) of lactasephlorizin hydrolase expression in
humans and other mammals.
Schematic diagram of developmental
changes in lactase-specific activity
changes from fetal life through birth and
weaning.
Copyright © 2011 Journal of Pediatric Gastroenterology and Nutrition. Published by Lippincott Williams &
Wilkins.
45
Barbara Kingsolver on Dairy
• “A few isolated populations developed
intimate relationships with their domestic
populations” leading to adaptation to keep
lactose-digesting enzymes past childhood
• Genetic mutation (SNP C/T13910) causes
lactase persistence into adulthood (lactasephlorizin hydrolase gene)
• LPH gene rapidly increased in herding
populations
Kingsolver, Animal, Vegetable, Miracle, 2007
Lactose and Lactase-Who Is Lactose Intolerant and Why?
Lactose and Lactase-Who Is Lactose
Intolerant and Why?
Montgomery, Robert K; Krasinski,
Stephen D; Hirschhorn, Joel N; Grand,
Richard J
Journal of Pediatric Gastroenterology
and Nutrition. 45():S131-S137,
December 2007.
doi: 10.1097/MPG.0b013e31812e68f6
LNP- lactase nonpersistent
LP- lactase persistent
TABLE 1. Lactase phenotypes in
selected human populations
Copyright © 2011 Journal of Pediatric Gastroenterology and Nutrition. Published by Lippincott Williams &
Wilkins.
47
Other Dairy Associations
• Positive association prostate, ovarian and
breast; protective in colorectal CA
» Shrier et al, Nutr Cancer 2008
• Borderline positive association between
cheese intake and bladder CA in Belgium
» Brinkman et al, Eur J CA 2010
• Increased HR for death in ovarian CA
observed for prediagnosis milk (all types)
subgroup [HR 2.15, 1.20,3.84, p<0.05]
» Dolecek et al, J Am Dietetic Assn 2010
My Standard Recommendations
• Increase plant based foods
– Whole grains
– Fruits (deep pigment) and vegetables (cruciferous)
• Decrease animal fats
– Eliminate dairy, red and processed meats
– Poultry preferably organic
– Increase marine omega-3’s
• Decrease refined carbohydrates
– Sugar, white flour, white rice
• Season with garlic, ginger, onions, turmeric
• Drink green tea and red wine
The doctor of the future will give
no medicine, but will interest his
patients in the care of the human
body, in diet, and in the cause
and prevention of disease.
Thomas Edison 1847-1931
Let your food be your medicine
And your medicine be your food
Hippocrates