1. Enjoying your food again after treatment with relaxation, food & exercise life

2. Depending on the stage of your treatment not all of these may apply at the moment But with any condition – the more health promoting activities that one can do, within the constraints of the treatment, the better for our health WCRF / AICR report 2007; 8 main recommendations

3. 1.Be as lean as possible within normal range of body weight 2.Be physically active as part of everyday life 3.Limit consumption of energy dense foods 4.Eat mostly foods of plant origin 5.Limit intake of red meat & avoid processed meat 6.Limit alcohol containing drinks 7.Limit consumption of salt, avoid mouldy grains, pulses 8.Aim to meet nutritional needs through diet alone World Cancer Research Fund report (2007) 8 main recommendations:

4. Body Weight includes fat, muscle and water 1. Be as lean as possible within normal range of body weight avoid weight gain and increases of waist circumference through adulthood Pros of body fat: 1.Provides cushioning for our bones 2.Keeps us warm 3.Provides energy store when we cant eat (and stops breaking down muscle) Cons of body fat: Convincing evidence risk cancer in men (colorectal) & in women post menopause (breast) Also risk diabetes, high blood pressure and heart disease

5. What do you feel is a good weight (well weight) for you? Measure weight / BMI (body mass index) at present Are you under or overweight? If under: try to eat more and also increase exercise / activity to promote muscle building If over: (and not due more chemo / radiotherapy) refer to Eatwell plate and increase exercise/ activity Weight plan

6. Walk at least 30 min/d: (10,000 steps) every day (increasing to 1hr/d of moderate activity) Limit sedentary activities eg TV watching Think of ways to include activity in your daily routine: walk to the shops? Use exercise bike / hand weights whilst watching TV? 2. Be physically active as part of everyday life: Pros: Heart Disease & Diabetes: - lowers blood pressure - helps weight-loss (body fat, central fat) - improve cholesterol & glucose levels – Mental health - reduced risk of depression and dementia - Increased positive emotional well-being - improves response to stress

7. Physical Activity Convincing evidence that most physically active people have lower risk of developing colo- rectal cancer Probable evidence that risk of post menopausal breast and endometrial cancer is reduced Limited evidence that there is risk reduction for lung, pancreas, pre-menopausal breast cancers Convincing evidence that it prevents weight gain, overweight, obesity CONS

8. Nordic walking New age Kurling Tai Chi Exercise on prescription AGE UK

9. 1.Avoid sugary drinks, 2.Consume fast food sparingly (if at all) 3.For colorectal cancer there is some suggestion that fatty foods (animal fats) and sugary foods increase risk What is Energy density ? 225-275 calories (kcal) per 100g Average energy density of diets to be lowered towards 125kcal per 100g 3. Limit consumption of energy dense foods,

10. Guess the energy density game? 25 260 40 560 305 or 215 416

11. The lower the energy density, the bigger the portion Food ED = 2.3 Food ED = 0.52 Prof B Rolls

12. 600g/d of non-starchy vegetables & fruits What does this look like… 25g /d of fibre from cereals & pulses Eat relatively unprocessed cereals and or pulses with every meal Limit refined starchy foods 4. Eat mostly foods of plant origin:

13. Each portion contains 2g of fibre

14. 15 fold range in incidence through out the world highest risk in US, N Europe, NZ, Australia lowest rates in rural Africa, India, China low meat and fat intake, high plant food intake; vegetable and starchy staples (fibre) Migrants from these areas quickly acquire the same rate of cancer as the host population Colorectal cancer

15. Low residue diet (adhesions, narrowing of gut) Wind, diarrhoea, constipation, sore bottom Any issues having lots of fruit & veg post surgery?

16. Doctors often have their patients follow a low- residue diet the first weeks after any abdominal surgery. This includes only foods that are easily digested and don't leave much waste behind, When going back to foods you have not eaten since surgery, try one new food a day. Keep a food and symptom log. if they seem to cause symptoms, try them again in 2-3 weeks. Log results. Eventually you should be able to have a full and varied diet. Low residue diet

17. Foods and drinks that may cause loose stools: Drinks: apple juice prune juice beer, wine milk Hot beverages Tea & coffee Vegetables & Fruit baked beans green beans spinach cabbage broccoli raw fruit highly spiced foods, chocolate, liquorice May be helped by; Apple sauce, Peanut butter, Bananas, Rice / pasta / potatoes, Tapioca, marshmallows, pretzels, Boiled milk Drink plenty; bouillon(salty drink), ginger ale, Weak tea

18. Wind fish melons Milk nuts carbonated beverages Sweets Alcohol; beer asparagus cabbage family, brussels, broccoli, cauliflower dried beans and peas, baked beans onions, radishes, cucumbers Eat regularly; missing meals can use gas build up Avoid swallowing air; relax, take your time and dont talk with your mouth full Avoid chewing gum or drinking through a straw These foods may cause more gas to form;

19. certain raw fruits and vegetables (e.g., oranges, apples, coleslaw, celery and corn) popcorn Chinese/oriental vegetables nuts coconut dried fruits (e.g. raisins, figs) food with seeds spicy foods FOODS WHICH MAY CONTRIBUTE TO ANAL IRRITATION

20. Relieving diarrhoea May be caused by; Very large meals Spicy meals Soup baked beans / Dried beans Beer Hot beverages chocolate, liquorice, prune juice Red wine May be helped by: Apple sauce Peanut butter Bananas Rice / pasta / potatoes Tapioca marshmallows, pretzels Boiled milk Drink plenty; bouillon, ginger ale, Weak tea

21. It took about 6 months for me to eat fresh fruits and vegetables without them speeding through my system. It takes time for the body to slow down. Some foods work better than others, peanut butter made me worse as did applesauce, however others have had great results with them. Keep a food log. Try new foods, if they don't work, try them again in 2-3 weeks. Log results. Eventually you should be able to have a full and varied diet. I live on fresh fruits and vegetables now but it took a while to achieve this. As for weight loss you can try bulking up by using powders or drinking high calorie shake drinks. They make them dairy-free so you should be able to tolerate them. I had the reversal ileostomy 10 weeks ago just like Cathy and I eat everything. Certain foods like salad and chinese do go through a bit quicker, and curry and chilli do cause some bottom burning for a day or so, but I still eat them. I take 10ml of immodium syrup before bed but thats all. Reintroducing foods…

22. Increase liquids Eat high fibre foods; fruit (chew well), veg – raw & cooked, Wholemeal breads and cereals (oatmeal, wheat flakes, branflakes) Coffee, chocolate, lemon juice, liquorice, prune juice Exercise Make sure you arent taking too many Imodiums Relieving constipation

23. No more than 18oz (500g) cooked red meat /week (e.g. 150g three times a week) Eat very little, if any, processed meat Salting, smoking & curing to make processed meats are a probable cause of some cancers (colorectal, stomach) Use of nitrates as a preservative Many processed foods are also high in fat, trans fats, refined starch which increase risk of heart disease Processes such as freezing steaming, drying – are not a problem 5. Limit intake of red meat & avoid processed meat:

24. What can I have instead? Sandwiches / snack meals; Egg Fish (tinned in water, oil & drained) Hummus Fresh chicken, turkey slices Small portion cheese or lower fat cheeses Salad Main meal; Chicken Turkey Fish Pottage! (vegetable and bean / lentil stew); onion / leek / parsnip / carrot – stock, herbs, spices (tumeric, garlic)

25. 6. Limit alcoholic drinks: No more than 2 drinks /d for man and 1 drink/d for women (10-15g alcohol) 1 unit = 8g = 10ml of pure alcohol A drink = ½ pint normal strength beer (3-5%) One shot, 25ml spirits (40%) One small glass (125ml wine (12-13%) Baileys: 100ml Convincing evidence that alcohol increases risk of cancer of mouth, oesophagus, throat, breast, bowel (in men) Probably increases risk of liver cancer and bowel (in women) Other Cons: lots of calories Pros: reduces heart disease in men over 40 and women (post menopausal)

26. Top tips to keeping alcohol intake within guidelines Order smallest measure Alternate with soft drinks Dilute with low calorie drinks eg spritzer Keep a few nights alcohol free Dont drink alcohol if you are thirsty (rehydrate first)

27. 7. Limit consumption of salt, avoid mouldy grains, pulses Avoid salt preserved, salted or salty foods Aim for Less than 6g salt/day Or 2400mg sodium Sources of sodium: processed food 75-80%, cooking & on food 15-20%, fresh food 10% Baked beans ½ tin: 2.7g (45% GDA) Can Soup: 2.4g (40% GDA) Bacon (2 rashers): 2.4g (40% GDA) Bread (2 slices): 0.8g (14% GDA) Egg (60g): 0.2g (4% GDA) Roast Chicken (50g); 1% GDA

28. Sodium – practical advice avoid adding salt at the table reduce salt used in cooking – use other flavourings; herbs, spices, pepper, lemon juice, garlic, stock choose lower salt/ sodium versions where available, e.g. bread, beans, tinned vegetables cut down on salty processed foods, e.g. sauces, soups, flavoured noodles cut down on salty snack foods, e.g. crisps & nuts limit cured foods (e.g. bacon & ham), foods packed in brine (pickles, olives, fish) and condiments use fresh, frozen or canned no added salt vegetables choose fresh or frozen plain meat, fish & poultry

29. 8. Aim to meet nutritional needs through diet alone Dietary supplements are not recommended for cancer prevention Cons: may promote cancer at certain stages (folate, vitamin A, iron) Pros: may reduce risk at certain stages, folate, carotene, vitamin D Selenium, vitamin D, calcium, folate; may be protective Calcium: low fat dairy, nuts, pulses, edible bones in fish Selenium: brazil nuts, fish, offal Vitamin D: oily fish, liver, egg, fortified marg & cereals, sunlight Folate: green vegetables, pulses, nuts, seeds, fortified cereals

30. Lots of food from plant sources, including fruits, vegetables, potatoes, breads and grains, pulses, beans, nuts, and seeds. A variety of minimally processed, seasonally fresh, and locally grown foods. Olive oil, rapeseed? as the principal fat, replacing other fats and oils. Low saturated fat intake Red meat consumed a few times per month. low to moderate amounts of cheese and yogurt daily fish (oily fish) and poultry Up to 4 eggs per week. Fresh fruit as the typical daily dessert; Moderate consumption of wine, normally with meals, Mediterranean diet

31. FRUIT & VEGETABLES MEAT, FISH, EGGS, BEANS MILK & DAIRY FOODS FOODS & DRINKS HIGH IN FAT AND/OR SUGAR BREAD, RICE, POTATOES, PASTA

32. Breast Cancer Stress Management and Relaxation Training Programme (B-SMART) Based on evidence of psychosocial factors that are related to positive adaptation Optimism Benefit finding Social support Anxiety reduction

33. Combines Cognitive Behavioural Therapy and relaxation techniques Techniques to minimise physical tension and anxiety producing thoughts Provides training in: anxiety-reduction skills awareness of sources of stress and indicators of stress noticing and replacing negative thoughts cognitive and interpersonal coping skills The programme Goal to improve ways in which people manage stressors and maintains social support networks Improved immune functioning Increased benefit finding and decreased depression Most effective for women low in optimism

34. Summary Eat a balanced and varied diet. i.e. food choices from all food groups Add foods to your diet gradually to see how your body responds. Keep Active Relax; Think about how you manage stress and improve response Speak to a dietitian if you have any specific diet concerns

35. ConvincingProbableLimited but suggestive Alcohol (men) High intake red & processed meat Alcohol women Non starchy veg Fruits Fish Physical activity Food containing fibre Garlic Milk Calcium Cheese Fat/Animal fat intake Food containing Fe Sugar intake Cantonese style (fermented) salted fish Body fatness Abdominal fatness Foods containing folate Foods containing Se Foods containing Vit D Dietary risk factors in colorectal cancer: risk risk

36. Extra slides

37. Probiotics: protective bacteria Definitions; 1.Live micro-organisms which when administered in adequate amounts confer health benefits on the host (WHO / FAO 2002) They must remain viable during their passage through the GIT Usually representative of species present in infants; Lactobacillus, Bifidobacterium, yeast Saccharomyces boulardii Safe; by virtue of their long use in fermented diary products

38. Protective bacteria Ferment dietary fibres & complex starches in food in the colon resulting in: short chain fatty acids; electrolyte uptake in the large intestine (sodium, potassium…) energy provider for colon cells (gases H 2, CO 2, CH 4 ), also some vitamins B12, K may alleviate symptoms of lactase intolerance Reduce inflammation Improve Bile salt metabolism; Probiotic associated with decreased reduction in rate of progression of colon cancer

39. Foods that may cause gas and odour: Alcohol; beer carbonated beverages Eggs; meringues fish strong flavored cheeses spiced foods fatty foods (pastries/deep fried foods) melons asparagus cabbage family, brussels, broccoli cauliflower dried beans and peas, baked beans radishes pickles onions Cucumbers mustard buttermilk, parsley and yogurt may reduce the odour

40. Phyto-oestrogens: chemicals in plants similar to oestrogens; as they compete with endogenous oestrogens the end result is anti oestrogenic found in soya, linseed, also in cereals, legumes, veg; insufficient evidence that they are protective against breast cancer Antioxidants: C,E carotenoids and selenium – prevent oxidation and DNA damage; not enough evidence that increasing intake would decrease risk of breast cancer Other specific nutrients

42. Breast Cancer WCRF 2007 ConvincingProbableLimited suggestive Body fatness (pom) Physical Act (pom) Total fat (pom) Alcohol (both) Adult weight gain (pom) Physical Act (pre) Adult attained height (post) Lactation (both) Abdominal fatness (pom) Adult attained height (pre) Pom; post menopause, pre: premenopause Increases risk decreases risk

43. Sites for absorption of nutrients 9 litres of fluid pass through the duodenum each day of which only 1.5L reaches the colon stomachduodenumjejunumileumAscending colon mineralsWater sol vits sugars Vits A & D Bile salts Water, sodium, potassium, vits FatsVit B12 Water & sodium Amino acids