1. D IET AND N UTRITION M AKING H EALTHY C HOICES A FTER B REAST C ANCER Karen Marr MS, RD, LDN, CSO Lead Dietitian-Eastern Regional Medical Center Cancer Treatment Centers of America Philadelphia, PA

3. O VERVIEW Body Weight Macronutrient Needs Physical Activity Alcohol Bone Health & Vitamin D To Soy or Not to Soy

4. AICR R EPORT Weight gain, excess body weight, obesity Physical activity Alcohol

5. AICR R ECOMMENDATIONS 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

6. H OW MUCH ACTIVITY ? 45 to 60 minutes 5 or more days a week

7. A LCOHOL & FOLATE Alcohol increases risk 11% Risk doubles if inadequate folate intake

8. M ACRONUTRIENT N EEDS 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.8-1.0 gm/ kg bw 1.0-1.2 gm/ kg bw during treatment Carbohydrates 50-65% of daily total calories Fat <30% of total calories should come from fat (<10% from saturated fat)

9. N UTRITION D URING & A FTER T REATMENT Prevent weight gain & perhaps start weight loss Address bone health Other common questions

10. A VOID W EIGHT G AIN /E NCOURAGE W EIGHT L OSS 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

11. T RIALS E VALUATING D IET C HANGES 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.

12. T RIALS E VALUATING D IET C HANGES 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

13. S TRATEGIES FOR W EIGHT L OSS 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

15. S TRATEGIES FOR W EIGHT L OSS WHEL study demonstrated phone counseling effective NIH endorses incorporating diet, physical activity, & behavior therapy Knowing and understanding macronutrient needs

16. S TRATEGIES FOR W EIGHT L OSS 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.

17. V ITAMIN 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

18. C LINICAL P RESENTATION OF I NSUFFICIENCY 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

19. R ECOMMENDATIONS FOR “D” I NTAKE DRI 2010600IU ages 19-50 years 600IU ages 51-70 years 800IU ages >70 years Anywhere from 60-80% of the population, including breast cancer survivors have been shown to have inadequate or deficient levels. Have levels checked.

20. S OURCES OF V ITAMIN D SourceServingAmount of IU’s Cod Liver Oil1 tbsp1,360 Swordfish, cooked3 oz566 Salmon, cooked3 oz447 Tuna fish, canned in water 3 oz154 Orange Juice, fortified8 oz137 Milk, vitamin d fortified8 oz115-124 Sardines, canned in oil2 sardines46 Egg1 large41 Fortified cereals¾- 1 cup40

21. C ALCIUM 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

22. C ALCIUM DRIs for calcium for females: Age 9 – 18 = 1100 mgs Age 19 – 50 = 800 mgs Age 51+ = 1000 mgs

23. F LAXSEED 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

24. T O S OY OR N OT TO S OY ? Factors to consider: 1. Form & Food Source 2. Timing of exposure 3. Equol producer status 5. Hormone profile

25. T O S OY OR N OT TO S OY ? May be okay in amounts similar to typical Asian diet in the form of tofu, soymilk, etc. Avoid high dose isoflavone supplements

26. T O S OY OR N OT TO S OY ? 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

27. S UMMARY 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

28. N UTRITION R ESOURCES 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

29. R EFERENCES 1. 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. 2. 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. 3. 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. 4. 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] 5. 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. 6. 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. 7. Gold EB, et al. Dietary factors and vasomotor symptoms in breast cancer survivors: the WHEL study. Menopause 2006 May-Jun;13(3):423-33. 8. 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.

30. R EFERENCES 11. 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. 12. Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78( 12): 1463-70 13. Pfeifer M, Begerow B, MinneH W. Vitamin D and muscle function. Osteoporos Int 2002; 13( 3): 187-94 14. Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003;89:552-572. 15. 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. 19. Pennington JAT. Bowes & Church’s Food Values of Portions Commonly Used – 17th edition. Philadelphia, PA:Lippincott-Raven;1998.

31. For more information please visit cancercenter.com or 1-800-333-CTCA