Eating and Walking Your Way to Wellness as a Cancer Survivor
William J. McCarthy, PhD, Associate Professor, UCLA School of Public Health, Division of Cancer Prevention and Control Research, UCLA’s Jonsson Comprehensive Cancer Center and researcher
This is summary of a lecture presented on May 13, 2008.
Recent research has indicated that what is good for cancer prevention is also good for cancer survivors. In 2007, the World Cancer Research Fund issued a report that summarized all of the research to date from around the world on how food, nutrition and physical activity protect against cancer, and provided both a global perspective and recommendations for cancer prevention and cancer survivors. This is generalized advice and readers should note that information provided by your medical practitioner, who knows your personal medical situation, should always take precedence over these suggestions.
Special Recommendations for Cancer Survivors: Follow the recommendations for cancer prevention unless countermanded by your oncologist. All cancer survivors should receive nutritional counseling from an appropriately trained professional. If able to do so, and unless otherwise advised, aim to follow the recommendations for healthy food choices, healthy weight, and daily physical activity.
To date, the research conducted on cancer survivors has been conducted primarily using people who had breast cancer, prostate cancer or colon cancer, with the largest majority of studies being done with breast cancer survivors. The lifestyle choices tested in healthy adults generally reflect the 2005 Dietary Guidelines for Americans, the 2006 American Cancer Society lifestyle recommendations, and the 2007 recommendations of the World Cancer Research Fund. The research in breast cancer survivors suggests that there are quality of life benefits from engaging in regular physical activity following a diagnosis of cancer. Healthy physical activity is defined as at least 30 minutes of walking per day. Exercise reduces the negative consequences of breast cancer such as psychological distress, fatigue, weight gain, premature menopause and undesirable changes in body image. It also contributes to patient rehabilitation after treatment. In 2004, a review of exercise studies done during treatment for breast cancer found 12 intervention studies that showed statistically significant beneficial effects of exercise during treatment, including increased exercise capacity, body weight improvement, enhanced psychological well-being, decreased fatigue, less nausea, increased physical well-being and overall improvement of quality of life. Studies looking at exercise after treatment for breast cancer showed similar findings, including increased exercise capacity, enhanced immune function, decreased depression, improved physical well-being and improvements in overall quality of life.
There are also weight control benefits and prevention of disease recurrence benefits from eating more fruits and vegetables and less processed food. The Women’s Intervention Nutrition Study (WINS), published in 2006, had a dietary intervention that reduced the percentage of fat to 15% while maintaining nutritional adequacy. The average American diet contains about 30-35% of calories from fat. While the goal was 15%, early feasibility studies suggested that this goal would result in a sustained approximately 20% reduction of fat intake. After seven years of follow-up there was a significant increase in relapse-free survival in women who ate this diet especially in the patients who had estrogen receptor negative breast cancer. It is believed that the diet helped reduce recurrence of breast cancer by reducing insulin levels, insulin resistance, insulin-like growth factor (IGF) and inflammation. Additional research is needed, but these studies support the importance of following cancer prevention recommendations after a cancer diagnosis.
A diagnosis of cancer in the family should be a warning to other family members who may have a diet and lifestyle similar to those of the person diagnosed. Having the whole family adopt these recommendations may be helpful for cancer prevention and cancer recurrence. It also increases the likelihood of individuals sustaining these changes when the whole family is involved in changing their eating and exercise practices.
Recommendation #1: Median adult body mass index (BMI) should be between 21 and 23 depending on the normal range for different populations.
It is important to avoid excess weight gain and increases in waist circumference throughout adulthood. The Body Mass Index (BMI) is an easy-to-calculate ratio of height to weight that can be used to gauge whether one has too much body fat. A more accurate measurement is through bioelectrical impedance (Note: This is included in the Wellness Assessments and Nutrition Classes offered at the Simms/Mann Center by our Integrative Medicine Physician). Your BMI can be calculated by multiplying your weight in pounds by 704 and dividing it by (height in inches) X (height in inches) or your height squared. There are calculators on the web that can do this for you and one can be found on the American Cancer Society web site.
Recommendation #2: Be physically active as part of everyday life.
Moderate physical activity, equivalent to brisk walking, is recommended for at least 30 minutes every day. As your fitness improves, your goal should be to increase to 60 minutes or more of moderate physical activity or 30 minutes of more vigorous physical activity every day. In addition to these activities, it is important to do some resistance training, e.g., lifting light weights or using tension bands. These activities help preserve healthy bone density. Studies show that people who lose excess weight and keep excess weight off regularly use resistance training exercise. Like other physical activities, resistance training helps to increase the body’s core temperature. It is also important to limit sedentary activities such as watching television. A research study conducted with kids allowed them to watch as much television as they desired. However, the one provision was that the television could only be operated by peddle power resulting in the kids losing excess weight.
Recommendation #3: Limit foods and drinks that promote weight gain.
It is important to limit your intake of foods that are energy dense, essentially highly processed foods and those that are high in sugar. Avoid sugary drinks and consume ‘fast foods’ sparingly if at all. Sugar has an energy density of 4 calories per gram. The lower the number of calories per gram that a food has, the better it is for you. As an example, a nectarine has .6 calories per gram. A slice of pizza has about 3 calories per gram. Did you know that Teddy Grahams snacks, which are offered to school children, have a 4.5 energy density which is more than straight sugar! Because they are so highly processed, they also have a shelf-life of about two years. I know many people like to have some foods on hand for emergencies, but you really should question whether food that can sit on a shelf for 2 or more years is really good for your body!
Recommendation #4: Eat mostly foods of plant origin.
It is essential to eat about 10 serving of fruits and vegetables per day. Californians, who are thought to eat healthier than most Americans, only eat on average 4 fruits and vegetables per day, well below the recommended healthy standards. It is also important to eat relatively unprocessed cereal (grains) and/or beans, legumes and nuts with every meal. Everyone should limit refined starchy foods. I have to warn you, however, that if you are not already eating foods of plant origin, it may take time for your gut to get used to consuming more fruits, vegetables and grains daily. In some cases it can cause a temporary increase in flatulence (gas). With persistence, time for your body to adjust and daily exercise, your body will adjust and you will enjoy eating more daily servings of fruits and vegetables.
Recommendation #5: Limit the intake of red meat and avoid processed meat.
Red meat refers to beef, pork, lamb and goat from domesticated animals including meats contained in processed foods. Processed meat refers to meat preserved by smoking, curing or salting or the addition of chemical preservatives. The average consumption of red meat should not be more than 11 oz per WEEK and very little, if any, of this should be processed. The body does need red meat to produce vitamin B12; however, your body can store enough B12 to last several years if necessary; thus, red meat does not need to be consumed daily or even weekly to maintain good vitamin B12 health.
Recommendation #6: Limit alcoholic drinks.
Alcoholic drinks should be limited to no more than one per day for women and 1-2 per day for men. There is growing evidence linking alcoholic beverage consumption with cancer. Only three non-alcoholic beverages are approved for optimal health in adults and they include water, tea and limited coffee without sugar or cream.
Recommendation #7: Limit sodium (salt) intake.
Sodium is used as a preservative in foods. While many people may watch how much salt they put on their foods from the shaker, the reality is that most people’s intake of sodium comes from the processed foods that they eat. Processed foods are very high in sodium and should be avoided.
Recommendation #8: Aim to meet nutritional need through diet.
Eating your dietary requirements for vitamins is an important goal. The more balanced your diet and the wider the range of foods (including an array of fruits and vegetables), the greater the likelihood that you will obtain most of the recommended vitamins, minerals and nutrients from your diet. While supplementation is not globally recommended for cancer prevention, some supplementation may be appropriate under the care of a knowledgeable clinician.
Special Recommendation: Breastfeeding
Breast feeding reduces a woman’s likelihood of breast cancer. More recently it has been discovered that it also confers benefit to babies, too. Breast-fed daughters have a reduced incidence of breast cancer as well. The recommendation is to breastfeed infants exclusively up to six months and then to continue with complementary feeding thereafter.
Nutrition and Exercise
Eating a healthy diet is very important. The US dietary gold standard is the DASH (Dietary Approaches to Stop Hypertension) eating plan. It is rich in fruits, vegetables (8-10 servings per day), has low fat or nonfat dairy, and also includes grains, especially whole grains; lean meats, fish and poultry; nuts and beans. It has less that 25% of calories from fat, and less than 1500 mg of sodium per day. The DASH eating plan lowers cholesterol and makes it easy to lose weight. One strategy when trying to make your meals more in line with this method of eating is to think of dividing your plate into 4 quadrants; half the plate should be filled with fruits and vegetables, ¼ whole grains and ¼ protein-rich foods such as lean meat (fish, white skinless chicken), beans or nuts. In addition, there is an inverse relationship between the amount of excess weight lost and the weight of the food eaten; the heavier the food consumed the more excess weight that was lost. A greater weight of food was consumed on the DASH diet than in the control group; however, the extra weight came from the fruits and vegetables, which are 75%-90% water. The DASH diet has similarities to the Ancestral (prudent) diet in which leaves (e.g., lettuce, cabbage, Swiss chard) fresh fruit, root veggies (e.g., carrots, potatoes, yams), broccoli like vegetables, seeds, nuts, fish and wild game were eaten in that order of frequency and quantity. It also has similarities to the traditional healthy Mediterranean diet and the traditional healthy Asian diet.
It is important to combine dietary strategies with exercise. If exercise is fun, people are more likely to do it. Walking can be good exercise and some people benefit from wearing a step counter to measure overall physical activity. A minimum of 10,000 steps per day are needed to meet minimum federal exercise recommendations. After exercise, the body typically craves foods that are rich in water, such as most fruits. This is because the body uses sweat during exercise to keep the core body temperature to a healthy level, but then needs to re-hydrate. An interesting study was conducted in support of this in which students were allowed to eat whatever they wanted from a buffet after participating in a study that had three 2-hour events as the experimental conditions. The three events included resting, two hours of cycling and sitting in a sauna. After the 2-hour event the group that consumed the fewest calories turned out, ironically, to be the ones who cycled for two hours while the individuals who rested or sat in the sauna for two hours consumed considerably more. The reason for this was that the cyclers were more interested in consuming foods rich in water than in consuming calories and so they filled up on foods such as fruits and vegetables that have a lot of water and few calories.
As an example, strawberries are an excellent food rich in water, they are 92% water. One cup has 3.4 grams of fiber and only 45 calories. The calorie density is 0.3 calories per gram. For the record, fruit roll-ups do not count as fruits. Fruit roll-ups are, metabolically speaking, no better than sugar. They are only 9% water, 0 g of fiber, 110 calories and have a calorie density of 3.9 calories per gram. Strawberry fruit roll-ups have 13 times more calories than fresh strawberries gram for gram. It should also be noted that sensory-specific satiety will prevent people from eating 13 ounces of strawberries if they are trying to consume the same number of strawberry calories as in 1 ounce of fruit roll-up. This means that the body will tire of eating them and want something different. This is part of the body’s natural mechanism to help it diversify the selection of foods to create a more balanced diet. While on the topic of strawberries, metabolically speaking a strawberry drink is no different from soda. They are 91% water, 0 grams of fiber and 85 calories. The bottom line: eat the fresh strawberries and not the processed strawberries.
The digestive tract works harder and better when given foods high in fiber rather than highly processed foods. Refined carbohydrates are quickly and entirely absorbed in the small intestine while hard-to-digest foods such as fiber-rich foods are partly digested in the colon via fermentation. Colonic fermentation is the breakdown of dietary fiber, resistant starch and some other undigested foods by bacteria in the large intestine. The end products of fermentation include volatile fatty acids that help fuel a healthy colonic epithelium. One volatile fatty acid, propionic acid, is thought to lower blood cholesterol levels. Another volatile fatty acid, butyric acid, may have an anti-cancer effect by stimulating the growth of normal cells in the bowel wall rather than cancer cells.
One of the most difficult issues for many people is figuring out what constitutes a serving of fruits and vegetables. Here are some guidelines that represent ½ cup servings which would count as one of the 9-10 servings of fruits and vegetables per day.
1 snack container of applesauce (4 oz)
1 medium cantaloupe wedge
½ medium grapefruit
4 large strawberries
5 Broccoli florets
6 baby carrots
1 large plum
1 small box (1/4 cup) raisins.
Foods that count as a cup which is the equivalent of 2 servings include:
1 small apple
1 large banana
1 medium grapefruit
1 large orange
1 medium pear
1 small wedge watermelon
2 large or 3 medium plums
8 large strawberries
1 large bell pepper
1 medium plain baked potato
2 large stalks of celery
1 cup cooked greens or 2 cups raw (spinach, collard, mustard greens, turnip greens)
12 baby carrots or 2 medium carrots
1 large sweet potato
1 large ear of fresh corn
American Cancer Society (ACS) Lifestyle Recommendations
The American Cancer Society has its own recommendations for individuals and communities which are consistent with the recommendations listed above. For individuals they include:
Avoid all tobacco use and inhalation of all tobacco smoke.
Eat a variety of healthful foods
5 or more servings of fruits and veggies
Choose whole grains in preference to refined
Limit consumption of red meat, especially processed & high fat
Maintain a physically active lifestyle with at least 30 minutes (60 for children) of exercise 5 times per week.
Maintain a healthy weight and lose weight if overweight
Limit the intake of alcohol if you drink at all.
The ACS recommends the following community actions:
Public, private and community organizations should work to create social and physical environments that support the adoption and maintenance of healthful nutrition and physical activity.
Increase access to healthful foods in schools, worksites, and communities
Provide safe, enjoyable and accessible environments for physical activity in schools and for transportation and recreation in communities.
Editors Note: The Simms/Mann – UCLA Center for Integrative Oncology offers many programs for people diagnosed with cancer and for those concerned about preventing cancer. Our integrative medicine physicians offer small group classes and individual educational sessions that help people create nutrition, dietary supplementation and exercise plans to meet individual wellness and symptom management goals. Lean body mass is assessed using bioelectrical impedance, protein needs are assessed, and a review of current supplements are included in these evaluation and wellness plans. Call the Center at 310 794-6644 to schedule a 1.25-1.5 hour appointment. These services are fee-for-service and are not reimbursed by insurance.