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Life After Cancer A Roadmap for Cancer Survivors

Nutrition for Healthy Survivorship
Natalie Ledesma, MS, RD, and Ernest H. Rosenbaum, MD

A Cancer Prevention Nutrition Program
A Plan for Risk Reduction
Multivitamins and Supplements

A Global Approach to the Obesity Epidemic
The Good Fats
Colorectal Cancer
Prostate Cancer

Eye Disease
Memory and Cognition

A Cancer Prevention Nutrition Program
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The healthy prudent diet is an optimal diet for both cancer and heart disease. By increasing the food intake of fruits, vegetables and whole grains you can promote better health. There is a correlation between the risk of cancer and heart disease when the LDL cholesterol is elevated (due to having too much cholesterol, saturated fat and trans fats in the diet). A recent study found that stage III colon cancer survivors had a greater risk of relapse after surgery if their diet was heavy in red meat, fat and refined grains. By controlling what you eat and how much you exercise, you can reduce your risk and live both healthier and longer. Dieting and maintaining a healthy weight can be made easier by following the healthy prudent diet.

The Healthy Prudent Diet
Eat a well-balanced diet. Eat a variety of 8-10 servings of fruits and vegetables daily:
    Opt for vibrantly colored fruits and vegetables.
    Increase cruciferous vegetables, members of the cabbage family.
    Increase vegetables high in carotenoids, orange and dark green vegetables.
Consume a high fiber diet (30-35 g/day). Increase beans and whole grains (brown rice, oatmeal, quinoa, corn tortillas, whole grain breads and pastas).
Avoid processed and refined grains/flours/sugars.
Aim for a low fat diet (~20% fat calories). Limit saturated fats to 8% of calories.
    Decrease animal fats, trans fats, and processed meats.
    Increase cold-water fish (salmon, herring, tuna and sardines).
Include healthy fats in the diet, such as flaxseed, avocado, olive oil, and soybeans.
Limit salt-cured, smoked and nitrate cured foods.
Limit fried and barbecued foods.
Limit alcohol consumption.
Drink 1-4 cups of green tea daily.

The body mass index (BMI) is one of the ways of estimating a healthy weight, which should vary somewhere between 18.5 and 24.9. Higher and lower values are proportional to increased risk.

BMI = Weight (kilograms)/Height (Meters)2
BMI = weight (lbs) / height (in)2 x 703

Another way to assess to measure a health risk factor is the waist/hip ratio. The waist/hip ratio is determined by taking the waist measurement and dividing it by the hip measurement. In a study, those with a waist-to-hip ratio of ~ 1 or higher were shown to be 40% more likely to die of cardiovascular disease than those with a ratio of 0.8 or lower.

Waist/Hip Ratio = Waist Size (inches) / Hip (inches)

People with elevated BMIs have a higher risk of pancreatic, gallbladder, kidney, cervical, ovarian and non-Hodgkin's lymphoma cancers. There is an increased risk for colon cancer in those with enlarged waists and a BMI greater than 27 and for breast cancer in postmenopausal women, especially in those who have never used postmenopausal hormone therapy. Studies by universities and the American Cancer Society have found that weight loss reduces the risk of aggressive prostate cancer.

In large studies, it has been shown that gaining over 50 pounds during adulthood doubles the risk for breast cancer. This risk can be reduced through weight loss. Reducing weight by 22-25 pounds appears to reduce breast cancer risk by half.

Endometrial cancer is another problem related to obesity, as the risk increases three to five times for women with a BMI greater than 23.5. One estimate is that 40% of endometrial cancers relate to obesity.

A Plan for Risk Reduction
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Try to maintain a normal weight and not gain weight.
Instill healthy lifestyle habits in your children early in life; adolescent children who gain weight will often maintain this weight later in life, putting them at increased risk.
Even a 10% loss in body weight will reduce cancer risk.
Increased physical activity can complement a healthy diet. An estimated 30 minutes a day of moderately intense physical exercise five days a week is recommended. Of note is that even a reduction of 50-100 calories with exercise can promote effective weight loss.
A sensible approach is eating smaller portions, reducing saturated fats, trans fats, starches, alcohol and sugars, replacing them with fruits, vegetables and whole grains.
By reducing red meats, lowering fat dairy products, avoiding hydrogenated fats, and use of more fruits, vegetables and fish in your diet, you will promote healthy nutrition.

Multivitamins and Supplements
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There is an ongoing debate on the use of multivitamins and supplements. A National Institutes of Health study recently reviewed many conflicting studies. In their summary, they found that:
Supplements of beta-carotene, and vitamins C, E, and zinc did help prevent age-related eye macular degeneration.
Folic acid should be taken by child-bearing women to prevent birth defects.
Use of calcium and vitamin D supplements help reduce osteoporosis and bone fractures in postmenopausal women.
Beta-carotene was not recommended in general, and there has been a link to increased lung cancer in smokers.
A healthy diet was recommended rather than consuming high-potency vitamins and single-nutrient supplements.
Exercise promotes a healthy approach. The suggested thirty minutes daily can be an accumulation of various activities from house cleaning to walking to polishing the car.

The potency and formulas of multivitamins and vitamin supplements are unfortunately not regulated by the FDA. Many of the claims made for these products are only partially valid, and many are untruthful. The antioxidant vitamins C and E and selenium should not be used during chemotherapy or radiotherapy as they can reduce the effectiveness of the therapy.

A Global Approach to the Obesity Epidemic
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Fad diets need to be replaced by a healthy prudent diet, in which you make a gradual change to low- and non-fat dairy products, use brown rice instead of white rice, and take smaller portion sizes of meats, by trying to cut back on nutrient-poor foods and by reducing or avoiding soft drinks, fruit juices, coffee concoctions and alcoholic beverages (these calories are not satisfying to the body).

The new American Heart Association guidelines can be used for prevention of all diseases:
Limit saturated fat intake to less than 7% of calories.
Limit dangerous trans fats to less than 1% of calories.
Limit cholesterol to less than 300 mg per day.
Sodium intake should be less than 2300 mg per day.
Limit alcohol to two drinks per day for men, one for women.
Eat cold-water fatty fish (salmon, sardines, tuna, and herring) high in Omega-3 fatty acids at least twice a week.
Eat a diet rich in fruits, vegetables, and whole grains with a goal of 25 gm of fiber daily and choose leaner meat.
Limit the amount of food eaten.

The Good Fats
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Olive Oil
The Mediterranean diet, which emphasizes olive oil, can have health benefits. There appears to be a decrease in breast, colon and possibly prostate cancers for those eating the Mediterranean diet versus the diet of the northern European population. In a recent study, men taking 2.5 tablespoons of olive oil daily - a monosaturated fat - in combination with calorie control and regular exercise had reduced cardiac disease.

Fish and Omega-3 Fatty Acid
Many studies have shown that long-chain Omega-3 fatty acids (DHA {docosahexaenoic acid} plus EPA {eicosapentaenoic acid}) can help prevent sudden death from heart attacks. Government experts in Australia and Britain recommend taking 400-600 mg daily. The October 2007 Nutrition Action Health Letter reports that the American Heart Association advises 1,000 mg (1 gm) of DHA plus EPA from fish oil, preferably by eating a fatty cold-water fish like salmon twice a week for heart protection. One meta-analysis of 13 studies of 220,000 persons over twelve years found those who ate fish five times a week had a 40% lower risk of death from heart disease.

In addition to the benefits for heart health, it has been established that eating cold-water fish containing omega-3 fatty acids (see table below) may be protective against colorectal cancer. It has also been used for many other illnesses, such as asthma, cancer, aging of the brain, diabetes, inflammatory bowel disease, rheumatoid arthritis, osteoporosis, eye health, and others. Thus far, there is limited proven value of omega-3 fatty acids for cancer, in general, dementia, memory loss and macular degeneration. More studies are needed.

Fish (6-ounce serving)Estimated Average Grams of Omega 3 fatty acids (DHA+ EPA)
Blue fin tuna3.2
Sable fish (black cod)2.8
Bumblebee® salmon (canned)1.2
Starkist® white Albacore tuna0.33

Vegetarians can supplement DHA from algal oil. Those who have burping side effects from supplemental fish oil may try taking them at bedtime or using a doctor's prescription for pure fish oil. Taking excessive DHA plus EPA (greater than 3000 mg a day) can cause bleeding.

Colorectal Cancer
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Although fatty fish with omega-3 fatty acids was not specifically investigated, the European Prospective Investigation into Cancer and Nutrition (EPIC) study, following 478,000 persons in ten countries over five years, found that people consuming three ounces of fish a day had a 30% lower risk of colorectal cancer than those who consumed only a third of an ounce a day. Other studies could not confirm a lower risk.

Omega-3 fatty acids and aspirin may help reduce colorectal cancer risk. Omega-3 fats appear to inhibit an enzyme, COX-2, associated with inflammation and cancer development.

Prostate Cancer
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In one study on prostate cancer, following 47,000 U.S. health professionals over twelve years, those who ate fish more than three times a week had a 45% lower risk of metastatic prostate cancer than those who ate fish less than twice a month. Fried fish and fishburgers have an increased heart disease risk.

An Italian study (GISSI) followed 11,000 recent heart attack survivors, of which a randomized group took fish oil (850 mg of DHA plus EPA) daily. After 3.5 years, those taking fish oil were half as likely to die of a sudden heart attack.

The study also noted that men taking 1500 mg of ALA (alpha-linolenic acid), a shorter-chain Omega-3 fat found in flaxseed oil, had twice the risk of advanced prostate cancer than those taking 700 mg a day. There is also less evidence that ALA reduces heart disease risks.

Eye Disease
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The study of 47,000 U.S. health professionals showed potential benefit for eye disease. The retina is made of DHA, and Omega-3 fats may slow the rate of macular degeneration. Antioxidants, such as vitamin E, vitamin C, beta-carotene and zinc, can also help slow the progression of macular degeneration. Also, those who ate fish at least twice a week had a 50% chance of reducing macular degeneration. A randomized trial is needed.

Memory and Cognition
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There is a high concentration of DHA in the brain and brain cell membranes, and some research suggests that DHA can be effective against Alzheimer's, although it has not worked in people who already have the disease. One study of 32 patients with mild Alzheimer's did show that those using DHA and EPA had some improvement in their test scores for dementia and Alzheimer's disease. This is also being tried in healthy older people without Alzheimer's disease with some positive results in those who consume more fish over those who eat less. Of note is that people who eat more fish may also exercise more and take better care of their health, which could also make a difference.

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