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Better Health Through Nutrition and Exercise
Ernest H. Rosenbaum, MD

Lifestyle changes promote better health, QOL, and longevity for cancer and other diseases.
The Benefits of Nutrition

History Of Unproven Methods
Review of Special Supplements

Benefits of Exercise
Benefits of Nutrition and Exercise
Rules - Do Not Exercise
Obesity and Cancer

Breast Cancer
Colon Cancer

GI and Head and Neck Cancers (Esophageal, Gastric, Pancreatic)
Lung Cancer

Prostate Cancer

A change in lifestyle can be life-saving and can help with feeling better, improve quality of life and increase survival.

Lifestyle changes promote better health, QOL, and longevity for cancer and other diseases.
WINS - Women's Intervention and Nutrition Study
WHEL - Women's Healthy Eating and Living Study

Post Treatment - most are free of cancer or stable and are ready for nutrition and exercise programs with weight control.

This links with breast cancer and links with foods and physical activity and under study - use guidelines. There are benefits for C-V, diabetes, osteoporosis and cancer prevention.
1. A healthy diet with five to nine colorful fruits and vegetables.
2. Increase whole grains versus refined grains/sugars.
3. Decrease red meats and fatty foods.
4. Weight control with a healthy diet and try to lose if overweight.
5. Exercise daily greater than 30 minutes, which will help decrease fatigue, especially for breast and colon cancer patients.
6. Limit alcohol intake.

1. Greater than 60% of cancer patients are cured plus many are stable.
2. For those with advanced cancer, nutrition and exercise are vital for quality of life.
3. Try weight control, if losing weight - cachexia.
4. Control symptoms of anorexia, nausea, vomiting, diarrhea, constipation and pain, as well as taste alterations, with special diets as needed with supplements of nutrient-dense drinks, with normal D-V vitamins and minerals, plus calories and protein.
5. Alter diet as needed with supplements and Omega-3 FA plus NSAID's.
6. Physical activity helps appetite and constipation and reduces fatigue and may be individualized.
7. Efforts to avoid weight loss and malnutrition by balancing energy expenditure with food intake.
8. If obese, there is an increased risk of breast cancer, and diet may be helpful, as the increased recurrence rate and death can be reduced with a healthy diet.
9. Breast cancer - adjust treatments and normalize weight for gain or loss with a controlled diet, trying one to two times (+) per week of monitored physical activity.

The Benefits of Nutrition

1. Protein intake of 10% of calories from lean poultry, meats, fish, eggs, non-fat dairy, nuts and legumes.
2. Saturated fats associated with increased risk of illness.
3. Omega-3 fatty acids are good foods from fish and walnuts and are associated with lower heart mortality.
4. Carbohydrate needs - phytochemicals and fiber from whole grains, vegetables, fruits and legumes.
5. Highly refined sugars and carbohydrates exacerbate insulin resistance.
6. Vitamins.
7. Minerals.

Vegetarians eat fish and dairy foods and do well but need supplemental vitamins and minerals, including micronutrients zinc, B1, B12 and iron. Advantage - Vegan Diet Low in Saturated Fats and High Fiber with Vitamins and Phytochemicals but no Proven Anti-cancer Benefit

Higher intakes of colorful fruits and vegetables yield lower incidences of colorectal, lung, oral, esophageal and stomach cancers with a decrease in recurrence and an increased survival.

There is a decrease in cancer risk with increased phytochemicals, vitamins and minerals from whole foods. Note - frozen, canned, and fresh fruits and vegetables are healthy.

Limit alcohol intake, as it increases head and neck, mouth, larynx, esophageal, liver, breast and colon cancers. Note that there is a decreased cardiovascular risk with alcohol, and this needs to be balanced with the increased cancer risk. Five ounces of wine = twelve ounces beer = 1.5 ounces of hard liquor.

Evidence is questionable that supplements equal nutrient-rich diet foods. Dietary supplements - 25-80% of cancer survivors are taking supplements with vitamins, minerals, herbs, biotanicals, amino acids, and hormones. There are some benefits from vitamins and minerals using the recommended daily values. Large doses of A and E can be harmful, NEJM, 1994, "Lung Cancer in Smokers and Colon Adenomas Beta-Carotene Increased Risk If Smoking and Drinking." The supplements are not the same as foods.

Complementary and Alternative Meds
Complementary uses alternative sources to complement standard treatment. Alternative replaces standard medicine. Complementary/integrative help treatment by relieving symptoms and side effects. These include Yoga, massage, acupuncture, meditation and general exercises.

History Of Unproven Methods

Alternative methods use herbs, coffee enemas, unregulated, non-FDA approved supplements.
Gerson uses raw vegetables, fruits, hourly juices, and coffee enemas for detoxification. There is no evidence for prevention of cancer or increased survival.

Gonzales (William Kelly) an intense diet in supplements to remove toxins. Use of up to 150 supplements per day, but there is no evidence of proven improvement in efficacy.

Livingston (Wheeler) stimulates the immune system with antibiotics, vitamins, minerals, supplements, digestive enzymes, a vegan diet, detoxifying enemas and vaccines (vaccines not allowed for use in California).

Macrobiotic Diet Whole grains, cereals, vegetables, fruits, and soy. Attempt to individualize yin and yang diets, but there is no scientific evidence for delay in recurrence, cures or prevention. It is difficult to access, as it may be healthy, but it is not a treatment.

Review of Special Supplements

1. Flaxseed - Omega-3 FA, lignans (fiber), with estrogenic activity. May be helpful for prostate cancer by decreasing cell proliferation and apoptosis. Flaxseed needs grinding or soaking to release Omega-3 FA.
2. Garlic - No evidence for cancer prevention but has side effects of increased gas, stomach pain, vomiting, and inhibits platelet function. (Caution: use of Warfarin or aspirin for clot prevention.)
3. Ginger - helps produce calmness and reduces nausea and motion sickness. Acts on stomach, non CNS, but has anti-platelet activity.
4. Tea - has antioxidant properties. Catechins and polyphenols - affect cell growth and may aid prevention. It is used for nausea, to improve appetite along with ginger, but there is a debate on benefits +/-. Chamomile tea used for GI discomfort. Peppermint tea aids digestion.

Benefits of Exercise

Use a program for physical activity like used for cardiovascular disease.
1. Physical activity decreases with age about 1% per year after age 70 because of increased sedentary state or during and post-therapy.
2. Side effects include cardiopulmonary, neurologic, or muscular weakness from treatment, and exercise helps.
3. Physical activity (PA) counteracts stress and fatigue by improving stamina and strength, which helps promote recovery.
4. Breast cancer - treatment often causes premature menopause and need PA with resistance training, especially for potential osteoporosis prevention.
5. Prostate cancer - premature bone loss due to testosterone reduction, which affects bone strength.
6. Lymphedema is helped with physical therapy - special programs.
7. Physical disabilities - need to be assessed and often a trainer to monitor and encourage.
8. Check for potential problems with: anemia, leucopenia, thrombocytopenia, peripheral neuropathy, a compromised immune system (avoid crowds, swimming pools), severe fatigue and avoid water and pools when undergoing radiation therapy or with skin infections.
9. A study by Edward Gregg in JAMA, 2003, "On Older (Less than 75) Women Who Have Exercised Versus Sedentary Women - Had a 40-50% Lower Mortality Independent of Smoking, BMI, and Other Co-Morbidities."
10. PA slowed decline, enhanced recovery and extended life by prevention of new-onset diseases.
11. Important - America is aging faster; thus, more cancer patients over age 65, who need walking and low-intensity activity to maintain health.

Benefits of Nutrition and Exercise

They are proven to help cardiovascular fitness, muscle strength, decrease fatigue and reduce anxiety, depression and improve self-esteem and quality of life.

Abstracted from the From ACS Guidelines -2005:
1. No adverse affects of exercise therapy.

2. Those who are inactive need a program that may be personalized and individualized.
3. Important to cardiovascular rehabilitation, pre- and post surgery and during cancer therapy - CT or RT.
4. Can be low intensity with stretches, walking, or aerobics, depending on physical condition rated by Karnofsky score and/or co-morbidities (arthritis, neuritis, or physical limitations).

Manson,, NEJM, Sept. 2002, "Women Who Exercise Yield Decreased Cardiovascular Disease." Postmenopausal women who walk and maintain vigorous exercise irrespective of age, ethnic, racial and BMI had prolonged activity yielding a decrease in cardiovascular disease.

Physical Activity (PA) yields increased functional capacity, improved BM transplant recovery, and fewer complications as well as decreased fatigue. Blood, Nov. 1997 - Aerobic exercise yields increased dose of chemotherapy with less decline and better physical function with less neutropenia, thrombocytopenia. Improved physical function for cancer patients with a positive physical effect during chemotherapy. Segal, et. al, JCO, Feb. 2001 - A structured exercise program for stage I, stage II breast cancer with exercise improved physical functioning and less decline, physical functioning if exercising. There is also a positive effect on survival. Improvement in reducing stress, anxiety and depression also shown.

One should start low-intensity exercises and then add time, intensity, interval and number of times done a week in a progressive exercise program.

Also at work, there are over a hundred million people working, and one needs programs to help, whether they are stairwell programs or office programs to exercise at work.

Obesity and Cancer

1. The risk of hypertension, cardiovascular disease, heart disease, diabetes and some cancers are affected.
2. 64.5% of Americans are overweight (JAMA, "National Healthy Examination Survey 2002.")
3. BMI - less than 18.5 underweight
18.5 - 25 healthy
25-30 overweight
> 30 obese
4. Women with a BMI of 24-35 at risk for health problems.
5. Increased obesity in the last 30-40 years from increased use of fatty foods, larger portions, increased soft drinks and fast food outlets - some of the causes.
6. IARC - WHO study on reducing weight may not always reduce cancer risk.
7. A sedentary lifestyle and overweight yields one-third of breast cancer cases: uterus, kidney, esophageal. Thus, try to avoid weight gain to decrease risk but realize that just reducing weight may not always decrease risk.
JCO, February 2002, "Link Between Recurrence and Body Mass After Diagnosis of Breast Cancer if Overweight or Gaining Weight Puts One at a Higher Risk for Recurrence and Death."
Early-stage breast cancer - BMI greater than 30, estrogen positive at greater risk of recurrence and increased risk for Contralateral breast cancer and other forms of cancer.
8.ACS - NEJM, April 2003 - BMI greater than 40, 62% higher risk dying from cancer versus normal weight for females.
9.Estimated BMI less than 25 could avoid early deaths, and there are an estimated 90,000 yearly cancer deaths related to overweight.
a) Hormones and proteins such as insulin and estrogens can stimulate cancer cell growth.
b) BMI greater than 40 - 3x increased mortality versus 18.5-25 BMI.
c) Weight loss is one of many ways to decrease breast cancer mortality.
d) Need active programs - 45% of Americans are aware of the links between obesity and cancer
e) Three to four hours of vigorous exercise per week can reduce breast cancer risk 30-40%
f) To calculate the BMI, your weight (lb) times 705, divide by height (in), and divide again by height (in) = BMI

Rules - Do Not Exercise

1. Day of chemotherapy.
2. If neuropathy or imbalance is present.
3. Severe nausea, vomiting, diarrhea.
4. Low stamina due to muscle weakness.
5. Post-surgery - mastectomy - use relaxation program.
6. Weakness getting up from chair or bed bound - use stage I
7. Good to start with stage I and progress to stages II and III Try walking ten minutes out and ten minutes back as an exercise.
8. Physical Activity (PA) in youth - NEJM, Sept. 2002, by Kim, et. al., "Increased Obesity and Overweight 5% in 1970 and 15% in 2002."
9. Risk of type-II diabetes, especially in Blacks and Hispanics, who are more sedentary, and those using extensive TV time or computer sitting.
10. Decreased Pysical Activity in high schools, especially girls with less PA versus boys.
11. Whites greater PA versus other racial or ethnic groups.
12. Decreased PA in young women 8-9, who need PA during this critical development.

Breast Cancer

Breast cancer patients need a lifestyle change:
1.Control of Excessive weight or obesity
a) 70% increased risk of death from breast cancer
b) Stage II - 40% increased risk from breast cancer, no correlation for stage III and stage IV
Tredy, et. al. - "Effect of Pre-Morbid Height/Weight on Survival of Breast Cancer Patients," BRJCA, 1990.
Goodwin, Boyd - "Body Size and Breast Cancer Prognosis." Cancer Research 49, 3113-3116, June 1, 1989

1. Premenopausal weight gain of 15 pounds equals 1.5 x more likely to relapse and 1.6 x to die versus those who gained less (Camonano and Loprenci, "Weight Change in Women with Adjuvant Therapy or Postmastectomy, Node Positive Breast Cancer," JCO, 1990.)
2. Looking for optimal nutrition by eating well-balanced diets.
3. Treatment: low-calorie restricted diet and exercise, like a cardiovascular or diabetic program, yields longer survival with weight control.
4. Weight loss - should be a part of oncology treatment.
5. WIN Study - postmenopausal breast cancer on a regular diet versus a low-fat (less than 50% fat, calorie, energy).
6. WHEL - usual diet versus low-fat, high-fiber with fruits and vegetables.
7. Alcohol - there is a modest increased risk, and it's important to note that one to two drinks per day are recommended to reduce cardiovascular disease. One has to balance out cardiovascular and cancer risks.
8. Soy - risk uncertain and inconclusive, therefore, a prudent approach. Evidence from the Asian Migration Study of Hanzel - it took 10-20 years of Americanizing the Asians to equal the same breast cancer risk. Soy has isoflavones - with some estrogenic effect. The Asian diet of three servings of soy (soymilk and tofu) a day has some estrogen that may increase breast cancer risk. Studies are in progress.
9. Over thirty studies on exercise and breast cancer but few are randomized, and they show benefits during treatment with improved quality of life, cardiovascular endurance, improved self-esteem, decreased fatigue and increased flexibility.

The Recommended Diet
1. Rich in fruits and vegetables.
2. Low saturated fats - fish rather than meat.
3. Soy in moderation.
4. Minimal alcohol.
5. Exercise to help achieve healthy weight.

Colon Cancer

1. Increased risk with red meats, processed meats, saturated fats, low fruit and vegetable intake, sedentary lifestyle and obesity. A slight increased risk in smokers and drinkers.
2. Many studies showed prevention of polyp recurrence, but not new polyp growth with fiber and antioxidants and increased fruits and vegetables, Byers.
3. "A Randomized Control Trials Tell Us About Nutrition and Cancer," CA Journal Clin, 1999.
4. Exercise yields decreased risk and increased quality of life.
5. Healthy weight with a well-balanced diet.

The Recommended Diet
1. Rich in fruits and vegetables.
2. Low saturated fats - fish rather than meat.
3. Soy in moderation.
4. Minimal alcohol.
5. Exercise to help achieve healthy weight.

GI and Head and Neck Cancers (Esophageal, Gastric, Pancreatic)Colon Cancer

1. Esophageal cancers are associated with reflux, and there is decreased reflux with a high protein, low fat, high carbohydrate diet, which may decrease esophageal sphincter pressure. High fats, chocolate, coffee, peppermint, alcohol and tobacco with onions or garlic can yield increased esophageal sphincter pressure and promote reflux. The goal is to lower esophageal pressure. Thus a low-fat, high-carbohydrate, high-protein diet is helpful.
2. Increase F/V - decrease obesity for pancreatic cancer.
3. H/N - no value in beta-carotene.
4. Acid foods like tomato-based or orange juice may cause esophageal irritation.
5. Pancreas - Omega-3 FA may help short-term survival status.
6. H/N - oral intake during and post-treatment is often problematic with chewing and swallowing problems. Acidic, salty, spicy, hot and cold foods are poorly tolerated.
7. Use liquid, pureed, and juicy foods, which may be better tolerated plus dietary high-density supplements.

Lung Cancer

1. Increased risk with smoking and a diet low in fruits and vegetables.
2. B-carotene in colorful fruits and vegetables, high doses may increase risk.
3. Fruits and vegetables improve stage III and IV lung cancer in some studies.
4. Nutrient-dense foods, Omega-3 FA, six feedings per day, and exercise are essential.

Prostate Cancer (PC)

Diet plays a role:
1. Diet can reduce prostate cancer incidence and growth rate, slow progression of early stage and prolong survival.
2. Increased risk of prostate cancer with high intake of animal sources, especially increased saturated fats.
3. Decrease incidence and mortality with increase of fatty fish.
4. Monosaturated fats improved survival just like a cardiac diet (Kolonel, L., "Dietary Fats and PC", JNCI, 1999).
5. Cohen, J. "Fruit/vegetables(F/V Intake and PC Risk (fruit and vegetable intake on prostate cancer risk), JNCI, 1992.
6. Lycopene (tomato products) and F/V can reduce risk of C-V disease and PC too.
7. Increased soy consumption (tofu, soy milk) with phytoestrogens and decreases prostate cancer risk.
8. Flaxseed (lignan phytoestrogens) and decreased cell growth rate of prostate cancer and also benefit PSA.
9. Vitamin B may reduce PSA; Vitamin E may reduce prostate cancer risk (?).
10. Selenium reduces prostate cancer incidence - use 2 Brazil nuts per day.
11. Avoid obesity and increase physical activity to reduce mortality.
12. Obesity yields increased mortality (Calle, "Overweight, Obesity and Mortality from Cancers," NEJM, 2003.
13. Physical activity benefits have increased muscle strength, weight control and improved survival.
14. Diet rich in F/V, low saturated fats, and an active lifestyle are vital.

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