1. Hillary M. Wright, MEd, RD, LDN Dana Farber Cancer Institute Leonard P. Zakim Center for Integrated Therapies Fighting Cancer with Your Fork: Separating Fact From Fiction

2. How Do We Figure Out What May Affect Cancer Risk/Survivorship? The American Institute for Cancer Research Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective The result of an analysis of over 7000 research studies on the link between diet, lifestyle and cancer, and for the first time cancer survivors www.aicr.org comprehensive global report 10 Recommendations, last one specific to survivors.

3. AICR Global Report Recommendations: 1. Be as lean as possible without becoming underweight. 2. Be physically active for at least 30 minutes every day. 3. Avoid sugary drinks. Limit consumption of energy-dense foods.3. Avoid sugary drinks. Limit consumption of energy-dense foods. due to correlation with obesity 4. Eat more of a variety of vegetables, fruits, whole grains and legumes such as beans. 5. Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats.5. Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats. 11 – 18 oz per week max

4. AICR Global Report Recommendations (continued): 6. If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day.6. If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day. 12 oz beer, 5 oz wine, 1.5 oz spirits 7. Limit consumption of salty foods and foods processed with salt (sodium). 7. Limit consumption of salty foods and foods processed with salt (sodium). stomach cancer (also moldy foods due to liver cancer in developing countries) 8. Dont use supplements to protect against cancer. 9. * It is best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods.9. * It is best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods. reduce breast cancer in mom and obesity in child 10. * After treatment, cancer survivors should follow the recommendations for cancer prevention. *Special Population Recommendations

5. Americas Challenging Food Environment

6. Watch Your Weight! 65% of Americans are overweight or obese. Only 6% of Americans identify being overweight or obese as a risk factor for cancer despite a clearly established scientific link. Research shows that fat cells can act as "hormone pumps," secreting hormones and other growth factors into the bloodstream. If the body's cells are exposed to very high levels of these substances over an extended period, they tend to reproduce more quickly ? Increase cancer cell growth. Researchers stress that this potentially dangerous condition is reversible!

7. Physical activity and Cancer: Critical for weight control, growth hormone regulation, stress management, counteract fatigue, support immune system, etc: New Guidelines from the Dept of Health & Human Services Minimum 150 min moderate, or 75 min vigorous to reduce risk of chronic disease Ideally aim for more – and necessary if weight loss and maintenance of loss is the goal – 300 min of moderate or 150 minutes of vigorous. Physical activity linked to lower risk of breast, prostate and colorectal cancer

8. Beyond weight control, fruits and vegetables may exert a protective effect:

9. Phytonutrients Beyond vitamins, minerals and fiber, natural compounds found in plants may exert profound disease preventive effects The immune system of a plant – many also represent the pigment that gives the plant its color.

11. Phytonutrients: Prevention in a Plant How do they work? Stimulate enzymes that help the body detoxify Reduce the genetic damage from cancer causing agents May interfere with growth and multiplication of cancer cells Decrease inflammation

12. If It Stains Your Shirt… If a fruit or vegetable has a strong smell or taste, its probably biomedically active If it stains your shirt, its definitely biomedically active!

13. Antioxidants Vitamin A, C, E, Selenium, phytonutrients from plants Help prevent damage to cells from the attack of free radicals But I take antioxidant supplements in pill form, so Im getting all the antioxidant benefits that way, right?

14. Phytonutrients work together to provide a synergistic benefit Food First!

15. Some studies show high dose nutrient supplementation can be detrimental: Beta carotene supplementation in smokers N Engl J Med. 1994 Apr 14;330(15):1029-35. (ATBC) N Engl J Med. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. N Engl J Med. 1996 May 2;334(18):1150-5. (CARET) N Engl J Med. Effects of a combination of beta carotene and vitamin A on lung cancer and cardiovascular disease.

16. Choose a Predominately Plant Based Diet Eat 5-10 servings fruits & veggies each day 1 serving = 1/2 cup cut, cooked or sliced; 1 piece medium fruit; 1 cup leafy greens Emphasis on variety Richly colored plant foods are most phytonutrient-dense

17. Organic vs. Conventional No scientific evidence to date that organic offers anti-cancer advantage at this point = one study suggested organic blueberries significantly higher sugars (fructose and glucose), malic acid, total phenolics, total anthocyanins, and antioxidant activity (ORAC) * Thousands of studies support the health benefits of diets high in fruits & vegetables and none done exclusively on organics More than ½ of dietary pesticide exposure comes from 12 foods – EWG Dirty Dozen Bottom line: wash things thoroughly and dont let this decrease # of fruits/vegetables you eat! *J Agric Food Chem.*J Agric Food Chem. 2008 Jul 23;56(14):5788-94. Epub 2008 Jul 1

19. Food First 75% of Americans dont eat 5 a day Americans eat 1.5 servings of vegetables & less than 1 serving of fruit daily, despite consistent evidence that these foods decrease the risk of many chronic diseases. We throw away more than 11 billion pounds of fruits and vegetables every year in the US!! Americans spent $26.7 billion per year on dietary supplements in 2009 despite limited and inconclusive scientific evidence of effectiveness in disease prevention and treatment

20. Phytonutrients in Whole Grains Isoprenoids in whole grains suppress tumor growth Tepernoids and Tocotrienols encourage tumor dormancy and decrease tumor cell division Stimulate GST (detoxifying enzyme) **Also, dietary fiber has a probable connection to decrease risk of colorectal CA

22. Does Sugar Feed Cancer? Popular myth Unknown root of myth PET Scan Inject radioactive glucose into veins glow Areas of higher metabolic activity glow

23. Yes, BUT… All cells in the body use sugar for energy This includes cancer cells Cancer cells are more metabolically active than other cells Use more energy (sugar) Body will make sugar from other sources if you do not get enough through diet Break down muscle and fat tissue Tumor can make its own glucose

24. Sugar and Cancer – Its not that simple….. Sugar does not FEED cancer Chronic, excess intake of simple sugar leads to excess production of hormones like insulin, IGF that encourage cellular growth

25. Insulin and Cancer Excess insulin can promote tumor cell growth Behaviors that increase insulin levels Consumption of refined sugar and flour Overeating Weight gain Sedentary lifestyle Behavior that reduces insulin levels Physical activity, weight loss, unrefined carbs Lower fasting insulin level at time of breast cancer diagnosis is associated with improved survival. Mulligan et al. Breast Ca Res Treat. 2007 Jan 13

26. Donut vs.Orange: It is not necessary to avoid fruit! 200 calories 10 grams sugar 0 grams fiber 0 phytonutrients 62 calories 12 grams sugar 3 grams fiber 170 phytonutrients

27. Another reason to mute post-prandial glucose/insulin response! Include fat, protein and fiber with carbohydrates Process sugar more slowly Less insulin released Glycemic Index: number representing insulin response by body to a particular food

28. Summary Sugar does feed cancer cells – but no differently than it feeds the rest of the bodys cells Choose healthier carbohydrate foods Unprocessed/minimally processed Fruits, Vegetables, whole grains Combine foods at meals and snacks Fat and/or protein with carbohydrates

29. Aim to get some protein from plants as well - legumes, nuts, seeds, quinoa

30. What About Soy? Whole soy foods may help prevent: Breast cancer Colon cancer Prostate cancer Bladder caner Heart disease Osteoporosis Issue is phytoestrogens up to 1000 x weaker than estradiol Soy sauce, soy lecithin and soy oil contain no phytoestrogens Caution for people with ER+ breast cancer avoid soy isosflavones in supplements, pills, bars, and powders. Whole soy foods are fine in moderation

31. What about women who have had breast cancer? Two recent studies of Asian women showed reduced risk of recurrence with higher dietary intake of soy foods/isoflavones: Effect of soy isoflavones on breast cancer recurrence and death for patients receiving adjuvant endocrine therapy, Kang X et al, CMAJ. 2010 Oct 18 = 534 women with medium follow up of 5.1 years Soy food intake and breast cancer survival, Shu XO et al, JAMA. 2009 Dec 9: 302(22):2483-4 = 5042 women with median follow up 3.9 years

32. Acid/Alkaline Balance Diet for Cancer Prevention: Proponents Claim - Cancer grows in an acidic environment Chemotherapy is more effective the more alkaline the environment pH of 8.5 kills cancer cells Less acidic MORE ACIDIC Outer area Inner area cell wall pH gradient Tumor Cell

33. pH 1.0 7.35 14.0 _____________________________________________ Acidic NormalAlkaline pH of human body is naturally slightly alkaline ~ 7.35-7.45. Definition of Acidity and Alkalinity

34. To eat or not to eat…. ACID FOODS beef, chicken, duck, eggs, farmed fish, lobster, organ meat, pork, seafood, turkey, veal, venison Cheese, cottage cheese, whey protein mushrooms, potatoes apple, apricot, banana, berries, dried fruit, papaya, peach, pineapple, tangerine ALKALINE FOODS lima beans, soy beans, white beans, pumpkin seeds wheat grass, barley grass, alfalfa spouts, broccoli sprouts, kale, parsley, sea vegetable buckwheat, quinoa, spelt coconut, grapefruit, lemon, lime

35. What patients/families hear from us…. The bodys pH levels may change slightly as a result of eating some foods, but will remain in the tightly held range of 7.35- 7.45. Eating certain foods may change urinary pH levels, however, this does not necessarily mean that your blood pH will change.

36. Bottom Line on Alkaline Diets for Cancer Survivors Studies on the effects of acid/alkaline diets on tumor growth and proliferation are limited only to animal and test tube trials. Scientific research has not proven a beneficial effect of an alkalinizing diet for prevention or treatment of cancer.

37. Dietary Fat and Cancer Issue has been raised in colorectal, breast, pancreatic, prostate cancer, and possibly others AICR Global found no probable or convincing connection between cancer and total fat intake (only limited/suggestive with post-menopausal breast cancer and lung cancer weak) Concern in primarily with saturated fat, but its hard to tease out whats a dietary fat effect, calorie effect, affect on weight influence, tied to the source of fat (i.e. high intakes of red and processed meats). Bottom Line: Encourage Monos and Omega 3s; limit Saturatedand trans fats; portion control

38. Typical American Plate

39. AICR: Limit Red Meat Intake Limit red meat to 18 ounces per week (includes beef pork and lamb), with a long-term goal of no more than 11 oz/week. Avoid processed meats Processed meat refers to meats preserved by smoking, curing or salting, or by the addition of preservatives (ham, bacon, pastrami, salami, hot dogs and sausages. When meat is preserved by smoking, curing or salting, or by the addition of preservatives, cancer-causing substances (carcinogens) can be formed. These substances can damage cells in the body, leading to the development of cancer. Studies show people who eat more meat often eat less plant-based food.

40. Healthy Eating Plate Aim for ½ plate of plants (preferably vegetables) at lunch and dinner ¼ of plate as lean protein ¼ of plate of complex carbohydrate

42. Dietary Supplements That May Help Cancer Survivors Vitamin D Omega-3s Probiotics and calcium (based on individual circumstances) 24,000 Dietary Supplements marketed to Cancer Survivors!

43. Vitamin D and Cancer Inverse relationship between Vitamin D and several types of cancer Possible anti-angiogenesis and helps keep cell replication normal Goal of serum 25(OH) vitamin D level is > 40 ng/ml. Supplementation is likely necessary. 1000 IU/day is safe for most people; many need more.

44. Intake/Exposure Amount of Vitamin D Sun Exposure (arms/legs 10- 15 min) Fortified Multi-vitamin Fortified Milk 3.5oz salmon (fresh, wild) 3.5oz salmon (fresh, farmed) 3000 – 20,000 IU 400 IU 100 IU 600-1000 IU 100-250 IU

45. Vitamin D and Cancer Link first hypothesized in 1980s Rate of colon cancer 3x higher in New York than New Mexico Lower exposure to natural light in large cities and areas at higher latitude Research has been mostly observational, few clinical trials …Vitamin D levels in the blood vary by race, with the season, and possibly with the activity of genes whose products are involved in vitamin D transport and metabolism. These variations complicate the interpretation of studies that measure the concentration of vitamin D in serum at a single point in time. - OCCAM

46. Observational Studies 1. Lower serum vitamin D levels were found more often in oncology patients compared to primary care clinic patients of same region Researchers did adjust results based on age, BMI, and season of blood draw Relationship maintained significance Churilla, T.M., BMJ Open. 2011 Dec 19;1(2). 2. Serum vitamin D levels between 50 and 75nmol were associated with lower risk of colorectal cancer Levels less than 50nmol were associated with increased risk Jenab, M. BMJ. 2010 Jan 21.

47. Clinical Trials 1. Womens Health Initiative: Calcium+D supplement significantly decreased the risk of total, breast, and invasive breast cancers by 14-20% and nonsignificantly reduced the risk of colorectal cancer by 17% Did not decrease risk in women already taking calcium or vitamin D supplement Bolland, M.J. Am J Clin Nutr. 2011 Oct;94(4):1144-9 2. Prostate Cancer Prevention Trial: Dietary or supplemental vitamin D use was not associated with decreased risk of prostate cancer Kristal, A.R. Am J Epidemiol. 2010 Sep 1;172(5):566-77

48. Summary on Vitamin D Inconclusive results between observational studies and clinical trials Many studies only test serum vitamin D levels at one point in time, not the effect of a supplement Recommendation: Dont be Deficient! Take a daily MVI or calcium+D supplement If you are concerned, talk to your doctor. Have him/her measure a baseline level before taking a large supplemental amount

49. Omega 3 Fats Anti-inflammatory Reduce muscle wasting during treatment (cancer cachexia) Great for your cardiovascular system Salmon, herring, sardines, mackerel Aim for 4 oz of oily fish 2-3 times a week Daily goal: 1000 mg of combined EPA/DHA

50. Fish oil supplements during treatment:

51. Alcohol Limit alcohol intake < 1 drink/day for women < 2 drinks/day for men Women who consume 1 drink or more/day have an increased risk of breast cancer (10-40% increased risk) Adequate folate intake (400mcg/d) may reduce the increased risk of breast cancer associated with alcohol use

52. Questions? www.DanaFarber.org/nutrition