Weight Maintenance during Treatment Challenges and Solutions

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Weight Maintenance during TreatmentChallenges
and Solutions

• Carolyn Katzin, MS, CNS
• Nutritionist

Thursday September 25, 2008
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Overview

• What food choices should I make to improve my
  outcome?
• How do I maintain a healthy weight?
• Are some supplements harmful or of benefit?
• Nutrition as protection the 3 As
• Antioxidants
• Anticarcinogens
• Anti-inflammatories
• Specific issues related to treatment
• Fatigue
• Anemia
• Drug-nutrient interactions

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Health Risks and Weight as BMI
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Weight Assessment

• Body Mass Index (BMI)
• (ratio of weight to height as wt in kilograms
  ht2 in meters2)
• 19 24 healthy
• 25 29 overweight
• 30 34 obesity (level I)
• 35 39 obesity (level II)
• 40 extreme obesity (level III)
• Waist Circumference

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Hydration Assessment

• Body weight is made up of lean mass and fat mass
• Lean mass is associated with more water
• Bio-impedance analysis (BIA) is a test that can
  determine your hydration status
• Intracellular and Extracellular fluids are
  balanced but the intracellular are the hardest to
  replenish only about 10 mls per day from diet
• Hydration is very important
• Electrolyte replacement drinks help rehydrate

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The Three As key components of good health in
your diet

• Antioxidants (prevent free radical formation
  which if unchecked causes damage to DNA)
• Anti-inflammatories (prevent elevated rates of
  cell turn over which may increase mistakes)
• Anticarcinogens (prevent permanent damage to DNA)
  
• Good News! Many delicious foods are rich in all
  three As

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1. Antioxidants(protect DNA from free radical
damage)

• Spinach and other dark green leafy vegetables
  rich in Lutein and zeaxanthin
• Oranges, Lemons, Lime and other citrus fruits
  rich in limonene, tangeretin, nobelitin and other
  flavonoids use oils from zest of rind
• Blueberries rich in pterostilbene
• Pomegranates and pomegranate juice rich in
  punicalates
• Red grapes (raisins and red wine too) rich in
  resveratrol
• Xanthones from mangosteen
• Black raspberries rich in EGCG

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2. Anti-inflammatory Nutrients (prevent elevated
rates of cell turn over which may increase
molecular mistakes)

• Omega 3 fatty acids (EPA and DHA)
• Flaxseed, borage and blackcurrant seed oils
  beneficial fatty acids (GLA and ALA)
• Natural salicylates, e.g. turmeric, rosemary,
  thyme, apricots, broccoli
• Naturally occurring bioflavonoids with apoptosis
  and anti-angiogenesis inhibitor activity, e.g.
  tangeretin and nobeletin from citrus fruit
• Naturally occurring NSAIDs or COX-2 Inhibitors,
  e.g. green tea and cocoa

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3. Anticarcinogens (Anti-cancer) (prevent
permanent damage to DNA)

• Curry powder ( a combination of turmeric, cumin
  and other spices)
• Grapefruit and other citrus fruits (naringinin
  and limonene)
• Green tea (EGCG and other natural ingredients)
• Pomegranates (especially the oil from the seeds)
• Brazil nuts (excellent source of selenium)
• Tomatoes (excellent source of lycopene)
• Saffron

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Vitamin D as an Anti-carcinogen

• Vitamin D is a vitamin (found in the diet) and
  also acts as a hormone when activated in the skin
  (and kidney).
• Functions
• Calcium uptake and bone breakdown regulation
• Carbohydrate and insulin regulation
• Brain and nervous system function
• Prostate, breast and colorectal cancer
  relationship thought to be associated with
  Vitamin D receptor polymorphisms and UV light
  exposure
• Most people need 15 minutes in daylight (darker
  skinned people need 3 times longer) choose
  early morning or late afternoon to avoid burning
  rays
• RDA (Acceptable Intake) is 400 IU - many need
  more
• Serum levels of 25 hydroxy Vitamin D may be a
  better way to assess adequacy (should be 50-100
  ng/dl)

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Food Sources of Vitamin D
Daily Recommended Intake (DRI) 10 micrograms or
400 IU for adults aged 51 70 years. Tolerable
Upper Limit 2000 IU. Source NIH Office of
Dietary Supplements
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Tips for Eating Well

• Eat more vegetables and fruits especially
  colorful ones
• Use culinary herbs often especially oregano,
  thyme, marjoram, cilantro and mint
• Use yellow and brown spices often especially
  cinnamon, turmeric, cardamom and saffron
• Choose whole grains often in place of refined
  (whole wheat in place of wheat flour on label for
  example brown rice instead of white)
• Watch your simple sugar intake
• Maintain a healthy waist size (Waist to Height
  should be 0.5 or less) maintain core strength

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More Nutrition Tips

• Ensure your Vitamin D status is adequate by
  including oily fish often sardines and salmon
  are good sources
• Include blueberries, red and black raspberries,
  blackberries and other darkly pigmented fruit as
  toppings for breakfast cereals and in protein
  smoothies for cancer phyters
• Include watercress in salads as excellent source
  of carotenes and as a member of Brassica family
  to support liver health
• Eat beans often for Vitamin B complex and dietary
  fiber
• Eat Greek style yogurt for healthy probiotics

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Nutrition During TreatmentProtein (from Latin
for life)

• Choose protein regularly during treatment.
• You will need an extra serving each day (15
  grams of protein in about 4 ounces)
• - eggs, fish, chicken, turkey, lean meat
• - tofu and beans
• - pre-digested or hydrolyzed protein (milk
  protein as whey or casein, soy, etc.)
• - rice and beans
• For most people 6-7 servings a day or a protein
  serving at each meal with an extra serving
  between

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Foods Rich in Protein

• Almond or peanut butter (unsweetened, not
  hydrogenated)
• Almonds, peanuts, walnuts, pignolas (pine),
  pistachios, pecans and other Nuts
• Non-fat dairy products (cottage cheese, Greek
  style yogurt, whey protein)
• Eggs (egg whites have no cholesterol and can be
  freely eaten)
• Lean meat and poultry, especially when cooked
  slowly in liquids
• Fish and shellfish
• Beans, tofu and other fermented bean products

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Tips for Adding Extra Protein

• Add milk, yogurt or dried milk powder to soups
  and use as a base for sauces
• Keep hard boiled eggs in refrigerator and chop on
  top of salads
• Use nut butters as spreads
• Snack on cottage cheese
• Add cubes of firm tofu to steamed vegetables
• Make fruit smoothies with 2 tablespoons whey
  protein powder

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Nutrition During Treatment Oils and Fats
Recommended Fatty Acid Balance (Omega 63 of
approx 4 to 1 typical American diet is 15 to
one)

• 1 part Omega-3 (DHA and EPA from oily fish like
  salmon and sardines, walnuts and pine nuts)
• 3 parts mono unsaturated (olive oil, almonds and
  avocado)
• 1 part saturated fat (cocoa butter, palm oil or
  coconut)
• Supplement with 100 mg DHA and 500 mg borage or
  blackcurrant seed oil (as a source of GLA)

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Omega-6 and Omega-3 Fatty Acids
Vegetable oils, seeds, nuts
Green leafy vegetables, flax, walnuts
Borage or Evening Primrose oil
Fish oil
Meat
Fish oil
Table adapted from Simopolous, A (1998)
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An Omega-3 Fatty Acid from plant sources
Linolenic Acid or GLA is found in Blackcurrant
seed Borage and Evening primrose oil
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Nutrition During Treatment Healthy Carbs

• Carbohydrates are the bodys preferred source of
  energy
• Good carbs are starches including dietary fiber
• Oats, whole wheat, dark rye, brown rice are all
  good carbs
• Beans are also good carbs
• Be moderate with sugar, sweet fruits and fruit
  juices
• Most of us should restrict table sugar (sucrose)
  to 10 total calories or less or about 30 grams
  per day
• Have sweet foods at same time as dietary fiber
  rich ones to lower the glycemic load of the meal
  (provide more sustainable energy)

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Healthy Weight and Detox

• Detox is how your liver protects you from
  potentially harmful chemicals in the environment
• Garlic, onions, chives (Allium family) are rich
  in sulfur amino acids and phytonutrients and
  support detox
• Cruciferous or cabbage family (Brassica family)
  also rich in sulfur amino acids, indoles and
  other phytonutrients which also support liver
  health
• Green and black tea (Camellia sinensis) are rich
  in phytonutrients and may enhance some
  chemotherapy treatments
• Avoid fad detox diets these may be harmful
  and usually contain strong laxatives

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Nutrition During Treatment Expedient Diet

• This is YOUR time
• Focus on staying as healthy as you can by eating
  frequent, small, tasty meals
• Dont make huge changes to your usual routine
  routines are comforting
• Make sure you get good quality sleep
• Avoid going long periods with no calories about
  300 calories every 4-6 hours is ideal
• if you wake in the night have something to drink
  or nibble on (about 100 calories)
• Keep a written record of all important events and
  test results. Share with your health care team
  as needed

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Taste and Smell Changes

• Each of us has different taste perceptions
  treatment affects us each differently so no
  advice is universal
• - super tasters are especially sensitive to
  bitter
• Choose foods that smell and taste good, even if
  the food is unfamiliar be creative with colors,
  garnishes and presentation
• Eliminate cooking smells by using an exhaust fan,
  cooking on an outdoor grill, or buying precooked
  foods. Cold or room-temperature foods also have
  less of an aroma and may taste better than hot
  foods.
• Try marinating meats in fruit juices, sweet
  wines, salad dressings, or other sauces.Flavor
  foods with herbs, spices, sugar, lemon, or
  sauces.

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More on Taste and Smell

• Try using plastic utensils and glass cookware to
  lessen a metallic taste.
• Try sugar-free, mint gum or hard candies (such as
  mint, lemon, or orange) to mask a bitter or
  metallic taste in the mouth.
• If red meats don't taste good, try other protein
  sources such as poultry, eggs, fish, peanut
  butter, beans, or dairy products
• Rinsing with a salt and baking soda solution
  before meals may help neutralize bad tastes in
  the mouth (½ teaspoon of salt and ½ teaspoon of
  baking soda in 1 cup of warm water)
• Keep a clean and healthy mouth by brushing
  frequently and flossing daily.

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Nutrition Advice for Typical Symptom Management
- 1

• Fatigue and general malaise - drink green or
  black tea, dark chocolate
• Nausea - choose whole grain crackers,
  melba toast
• Constipation
• - choose prune juice, dried or stewed pitted
  fruits, e.g. prunes, figs, apricots wheat
  bran Benefiber , Metamucil . Avoid apple
  sauce (binding)
• Headache - avoid caffeine, chocolate,
  cheese and tyramine containing foods
  (anchovies, processed meats and gravies)

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Nutrition Advice for Typical Symptom Management -
2

• Weight loss - choose avocado, high calorie
  smoothies
• Tendency to bleed easily - choose oranges,
  lemons, limes
• Vision loss - choose dark green leafy vegetables,
  blueberries and bilberries, apricots
• Cold sensitivity - avoid spicy foods
• Depression - try foods rich in dopamine
  precursors and B vitamins such as salmon,
  walnuts and dark rye crackers

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Nutritional Treatment for Diarrhea

• Traditional remedy Arrowroot Maranta
  arundinacea
• A gluten free root from a tropical plant that is
  highly digestible and can be made into a pudding
• Two teaspoons of Arrowroot can be substituted
  for one tablespoon of cornstarch. One teaspoon
  of Arrowroot can be substituted for one
  tablespoon of flour. Arrowroot makes clear,
  shimmering fruit gels and prevents ice crystals
  from forming in homemade ice cream
• Arrowroot is native to the West Indies and
  imported to the UK where it is widely used to
  treat diarrhea and considered safe for use in
  pediatric care
•   

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Bowel Health and Friendly Bacteria

• Probiotics (Bios is Greek for Life) - opposite
  of antibiotics - Greek style yogurt is a
  source of probiotics
• Prebiotics are non-digestible food ingredients
  that beneficially affect the host by selectively
  stimulating the growth and/or activity of one or
  a limited number of bacteria in the colon, and
  thus improve host health 1
• - FOS is an example of a prebiotic

1 Gibson, GR, Roberfroid, MB , 1995
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Nutrition to Regulate Bowels

• Probiotics including Bifidus infantis may be
  helpful, e.g. Align or Natrens Lifestart or
• New Chapters Probiotics with a Purpose
• Yogurt. Some yogurts are constipating but others
  may be helpful, e.g. Yo-Plus from Yoplait or
  Activia from Dannon which contain Bifidus
  regularis
• Calcium supplements and hard cheeses may be
  constipating
• Coconut and coconut oil
• Macaroon cookies (almond paste)

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Diet and Fatigue

• Regular physical activity can improve mood and
  fatigue levels. May help with insomnia try
  Tai Chi or visit an art museum. Good quality
  sleep is important for healing
• Protein, iron, zinc, B vitamins and Vitamin C all
  important for red cell production to minimize
  anemia related fatigue.
• Avoid caffeine and stimulants
• Share a cup of tea with a friend
• Eat a small piece of dark chocolate
  (best not after 4 PM to avoid disturbing sleep as
  cocoa is a stimulant)

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Supplements Risk or Benefit?

• Avoid mega-doses (more than twice RDI or
  Acceptable Intake) of any supplemental nutrient
  (unless specifically prescribed by your physician
  or oncologist)
• Be cautious with herbal products. Many affect
  drug detoxification pathway activity (could cause
  toxicity or reduce effectiveness)
• Pharmacogenomics is a new field of personalized
  medicine based on individual genetic variations
  of liver detoxification enzymes example
  grapefruit and Seville oranges may cause adverse
  drug reactions by inhibiting liver
  detoxification enzyme Cyp 3A4
• Choose nutrient dense foods rather than take
  supplements and tell your health team about
  EVERYTHING you take

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Supplements of Possible Benefit(Look for USP on
label FDA requires companies to provide Good
Manufacturing Practices cGMP should be
identified by reputable companies)

• Multivitamin
• Alpha lipoic acid
• N-acetyl cysteine (NAC)
• Coenzyme Q10
• Green tea extract (decaffeinated)
• Vitamin D (if plasma levels are tested low)
• Vitamin B6, B12 and folic acid

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Choose Food that is Delicious AND Nutritious

• Choose foods that are
• - tasty and appealing
• - easily digested
• - nutrient dense (more nutrients per gram of
  food)
• Eat in a relaxed environment
• Use garnishes and attractive place settings
• Structure your meal time and size to optimize
  your appetite and energy levels
• For many of us it means adding small snacks
  rather than trying to eat more at meal time

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• "There are only two ways to live your life. One
  is as though nothing is a miracle. The other is
  as though everything is a miracle.
• Albert Einstein (1879-1955)
• Thank you for listening Be well!
• Carolyn Katzin
• Nutritionist, Premiere Oncology Foundation