DIET AND NUTRITION

MAKING HEALTHY CHOICES AFTER BREAST CANCER

Karen Marr MS, RD, LDN, CSO

Lead Dietitian-Eastern Regional Medical
Center
Cancer Treatment Centers of America
Philadelphia, PA
 OVERVIEW
 Body Weight

 Macronutrient Needs
 Physical Activity

 Alcohol

 Bone Health & Vitamin D

 To Soy or Not to Soy

 AICR REPORT

 Weight gain, excess body weight, obesity

 Physical activity

 Alcohol
 AICR RECOMMENDATIONS
 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
 HOW MUCH ACTIVITY?

 45 to 60 minutes 5 or more days a week

 ALCOHOL & FOLATE

 Alcohol increases risk 11%

 Risk doubles if inadequate folate intake

MACRONUTRIENT NEEDS
 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)
 NUTRITION DURING & AFTER
TREATMENT

 Prevent weight gain & perhaps start weight loss

 Address bone health

 Other common questions

 AVOID WEIGHT GAIN/ENCOURAGE
WEIGHT LOSS
 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

 TRIALS EVALUATING DIET CHANGES
 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.
 TRIALS EVALUATING DIET CHANGES
 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
 STRATEGIES FOR WEIGHT LOSS
 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
 STRATEGIES FOR WEIGHT LOSS

 WHEL study demonstrated phone counseling

effective
 NIH endorses incorporating diet, physical
activity, & behavior therapy
 Knowing and understanding macronutrient
needs
 STRATEGIES FOR WEIGHT LOSS

 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.
 VITAMIN 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
 CLINICAL PRESENTATION OF
INSUFFICIENCY

 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
 RECOMMENDATIONS FOR “D” INTAKE

 DRI 2010 600IU 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.
 SOURCES OF VITAMIN D
Source Serving Amount of IU’s
Cod Liver Oil 1 tbsp 1,360
Swordfish, cooked 3 oz 566
Salmon, cooked 3 oz 447
Tuna fish, canned in 3 oz 154
water
Orange Juice, fortified 8 oz 137

Milk, vitamin d fortified 8 oz 115-124

Sardines, canned in oil 2 sardines 46

Egg 1 large 41
Fortified cereals ¾- 1 cup 40
 CALCIUM
 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

 CALCIUM

 DRIs for calcium for females:

Age 9 – 18 = 1100 mgs

Age 19 – 50 = 800 mgs

Age 51+ = 1000 mgs

 FLAXSEED

 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
 TO SOY OR NOT TO SOY?
 Factors to consider:

1. Form & Food Source

2. Timing of exposure
3. Equol producer status
5. Hormone profile
 TO SOY OR NOT TO SOY?

 May be okay in amounts similar to typical Asian

diet in the form of tofu, soymilk, etc.

 Avoid high dose isoflavone supplements

 TO SOY OR NOT TO SOY?

 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
 SUMMARY

 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
NUTRITION RESOURCES
 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
 REFERENCES
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.
 REFERENCES
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.
For more information please visit cancercenter.com
or
1-800-333-CTCA