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DIET AND NUTRITION MAKING HEALTHY CHOICES AFTER BREAST CANCER Karen Marr MS, RD, LDN, CSO Lead Dietitian-Eastern Regional Medical Center Cancer Treatment Centers of America Philadelphia, PA OVERVIEW Body Weight Macronutrient Needs Physical Activity Alcohol Bone Health & Vitamin D To Soy or Not to Soy AICR REPORT Weight gain, excess body weight, obesity Physical activity Alcohol AICR RECOMMENDATIONS Be as lean as possible within the normal range of body weight Lower end of normal BMI Avoid weight gain & increases in waist circumference in adulthood Limit consumption of energy dense foods & avoid sugary drinks Eat mostly foods of plant origin Limit intake of red meat & avoid processed meats HOW MUCH ACTIVITY? 45 to 60 minutes 5 or more days a week ALCOHOL & FOLATE Alcohol increases risk 11% Risk doubles if inadequate folate intake MACRONUTRIENT NEEDS Calories 25-35 kcal/ kg bw if BMI between 18.5-24.9 20-25 kcal/ kg bw if BMI btween 25-29.9 15-20 kcal/ kg bw if BMI between 30-35 15 kcal/kg bw if BMI >35 Protein Carbohydrates .8-1.0 gm/ kg bw 1.0-1.2 gm/ kg bw during treatment 50-65% of daily total calories Fat <30% of total calories should come from fat (<10% from saturated fat) NUTRITION DURING & AFTER TREATMENT Prevent weight gain & perhaps start weight loss Address bone health Other common questions AVOID WEIGHT GAIN/ENCOURAGE WEIGHT LOSS Weight gain may increase risk of recurrence In a study of 300 postmenopausal survivors on adjuvant AI therapy for an average of 23 months - Weight gain of ≥ 10# since dx. 2x more likely to have hot flashes - Weight gain & hot flash severity TRIALS EVALUATING DIET CHANGES WHEL study - RCT in 3088 women to increase vegetable (carotenoid) & decrease fat intake followed for 7 yrs. - No reduction in recurrence or mortality - High fiber intake decreases VMS - Chemotherapy associated with wt gain - Only 10% returned to pre-diagnosis wt. TRIALS EVALUATING DIET CHANGES WINS - RCT with 2,437 postmenopausal women with early stage breast cancer - Low-fat arm had a 24%↓ in risk for recurrence - Greater reduction in ER- cancer STRATEGIES FOR WEIGHT LOSS Raise Awareness According to a survey by AICR in 2009: - 94% respondents aware of link w/tobacco - 87% aware of link with sun - 51% aware of link with obesity STRATEGIES FOR WEIGHT LOSS WHEL study demonstrated phone counseling effective NIH endorses incorporating diet, physical activity, & behavior therapy Knowing and understanding macronutrient needs STRATEGIES FOR WEIGHT LOSS RENEW Trial – RCT 641 survivors received phone counseling on diet, exercise, & wt. loss - QOL - 2.06 kg wt loss vs 0.92 kg over 12 mos. VITAMIN D Prevents excessive cell proliferation & differentiation Induces apoptosis Prevents angiogenesis Initiates immune response through macrophages Mediates osteoporosis risk for survivors of breast & prostate cancer through serum calcium/phosphorus balance CLINICAL PRESENTATION OF INSUFFICIENCY Mild to Moderate Deficiency: asymptomatic or nonspecific musculoskeletal pain Severe Deficiency: deep bone pain, muscle pain, hip pain, weakness, fractures, falls, difficulty getting out of a chair or walking up stairs RECOMMENDATIONS FOR “D” INTAKE DRI 2010 years years years 600IU ages 19-50 600IU ages 51-70 800IU ages >70 Anywhere from 60-80% of the population, including breast cancer survivors have been shown to have inadequate or deficient levels. Have levels checked. SOURCES OF VITAMIN D Source Serving Amount of IU’s Cod Liver Oil 1 tbsp 1,360 Swordfish, cooked 3 oz 566 Salmon, cooked 3 oz 447 Tuna fish, canned in water 3 oz 154 Orange Juice, fortified 8 oz 137 Milk, vitamin d fortified 8 oz 115-124 Sardines, canned in oil 2 sardines 46 Egg 1 large 41 Fortified cereals ¾- 1 cup 40 CALCIUM 1 cup milk, yogurt, or calcium fortified beverages = 300 mgs 1 ounce cheese = 200 mgs ½ cup greens = 75-179 mgs 5 dried figs = 200 mgs 1 tbsp flaxseed (10gm) = 25 mgs 3 oz canned salmon w/bones = 200 mgs Supplement accordingly to meet DRI CALCIUM DRIs for calcium for females: Age 9 – 18 = 1100 mgs Age 19 – 50 = 800 mgs Age 51+ = 1000 mgs FLAXSEED Meta-analysis in 2009 found no effect on overall breast cancer risk, but 15% lower risk in postmenopausal women. 5-40 gms may or may not reduce serum estrone and estradiol 5-25 gms shows a shift to weaker form of estrogen. Interactions with other meds TO SOY OR NOT TO SOY? 1. 2. 3. 5. Factors to consider: Form & Food Source Timing of exposure Equol producer status Hormone profile TO SOY OR NOT TO SOY? May be okay in amounts similar to typical Asian diet in the form of tofu, soymilk, etc. Avoid high dose isoflavone supplements TO SOY OR NOT TO SOY? Shanghai Breast Cancer Survival Study of 5042 breast cancer survivors: - 32% ↓risk for recurrence in highest quartile - 11 g/d or 40 mg isoflavone/d - No difference in ER+ or ER- cancers SUMMARY Strive to achieve & maintain an ideal body weight with integrative approaches Move and Move often Have your Vitamin D level checked & corrected if necessary Consume adequate calcium with diet/supplements Flax & Soy with caution NUTRITION RESOURCES www.aicr.org www.cancercenter.com www.plwc.org www.CancerRD.com www.healthy.net/index.html www.consumerlabs.com www.eatright.org www.cancernutrititioninfo.co m www.nutritionu.com www.cancer.org www.herbalgram.org www.ncbi.nlm.nih.gov/pubme d www.onhealth.com www.usda.gov www.cancerRD.com REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007. pp289-295. Kushi LH, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer With Healthy Food Choices and Physical Activity. CA Cancer J Clin 2006; 56:254-281. Doyle C, et al. Nutrition and Physical Activity During and After Cancer Treatment: An American Cancer Society Guide for Informed Choices. CA Cancer J Clin 2006; 56:323-353. Su HI, et al. Weight gain is associated with increased risk of hot flashes in breast cancer survivors on aromatase inhibitors. Breast Cancer Res Treat. 2010 Feb 25 [Epub ahead of print] Saquib N, et al. Weight Gain and recovery of pre-cancer weight after breast cancer treatments: evidence from the women’s healthy eating and living (WHEL) study. Breast Cancer Res Treat. 2007 Octl105(2):177-86. Pierce JP, et al. Influence of diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women’s Healthy Eating and Living (WHEL) randomized trial. JAMA 2007 Jul 18;298(3):289-98. Gold EB, et al. Dietary factors and vasomotor symptoms in breast cancer survivors: the WHEL study. Menopause 2006 May-Jun;13(3):423-33. Pierce, JP, et al. A randomized trial of the effect of a plant-based dietary pattern on additional breast cancer events and survival: the Women’s Healthy Eating and Living (WHEL) study. Control Clin Trials 2002 Dec;23(6):728-56. REFERENCES 11. 12. 13. 14. 15. Chlebowski RT, Blackburn GL, Elashoff RE, et al. Dietary fat reduction in postmenopausal women with breast cancer: Phase III Women’s Intervention Nutrition Study (WINS) (Abstract). 2005 ASCO Annual Meeting Proceedings. J Clin Oncol 2005;23:10. Abstract 10. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78( 12): 1463-70 Pfeifer M, Begerow B, MinneH W. Vitamin D and muscle function. Osteoporos Int 2002; 13( 3): 187-94 Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003;89:552-572. Whiting SJ, Calvo MS, Dietary recommendations for vitamin D: a critical need for functional end points to establish an estimated average requirement. J Nutr. 2005;2:304-309. 16. Nagata C. Factors to consider in the association between soy isoflavone intake and breast cancer risk. J Epidemiol 2010(2):83-9. 17. Messina MJ. Loprinski CL. Soy food for breast cancer survivors: a critical review of the literature. J Nutr 2001 (Suppl):3095S-3108S 18. Xiao Ou Shu, et al. Soy Food Intake and Breast Cancer Survival. JAMA 2009;302(22):2437-2443. Pennington JAT. Bowes & Church’s Food Values of Portions Commonly Used – 17th edition. Philadelphia, PA:Lippincott-Raven;1998. 19. For more information please visit cancercenter.com or 1-800-333-CTCA