Carl Maronich (Host): Welcome to Live Greater, a University of Maryland Medical System podcast. I'm Carl Maronich. And I'm joined by Dr. Susan Krische, a registered dietician at the Cancer Center at UM Capital Region Health. Today, we're going to be talking about nutrition and cancer care, exploring how diet can play a key role in a patient's cancer treatment and recovery. Doctor, welcome to the podcast.

Susan Krische, PhD: Hi, Carl. Thanks very much for having me today.

Host: When we're talking about cancer patients and treatment and diet, there are a lot of things that factor into it. What side effects might a cancer patient experience when they're going through treatments?

Susan Krische, PhD: So, cancer treatments have progressed so significantly, and the science continues to make progress. But hearing the word cancer can be really scary. I think it's important to realize that what each person experiences with that cancer diagnosis can really depend on the type of cancer, what part of their body is affected, and the type of treatment and how that person, as a unique individual, responds to that treatment.

So while all of that is going on medically from a nutrition perspective, it's useful to remember that people should really continue to follow generally healthful eating guidelines unless or until something gets in the way. Now, much of the time when people think about those side effects to a treatment, they're thinking about a systemic treatment like chemotherapy. So even then, side effects can vary depending on the particular chemotherapy medications, but there are some common ones just as you suggested, like fatigue or general loss of appetite, maybe because of some nausea or dry mouth or changes in taste. Generally speaking, I'd say we're watching out for changes in how much we might appreciate food and in how well we digest our food.

Host: Are there food strategies that might make things easier during treatment?

Susan Krische, PhD: So, I often end up emphasizing the fact that during treatment, our bodies are sometimes giving us mixed signals about how much food we need. Most of our energy and our protein needs come from just maintaining ourselves, our organs, breathing in and out throughout the day. So even though a person may not feel hungry during treatment, we still need to provide our bodies with the energy and protein to maintain our overall strength. So if you're not feeling hungry, you are probably not going to just sit down and eat a regular meal.

One of the most common recommendations that I make is to have small but frequent attempts at eating and drinking. So, that might be a few bites or a few sips at a time, but at least it's something. Since I mentioned particular side effects, so if you're feeling nauseous, again, you're probably not going to sit down to a meal, but you might start with clear liquids like broth or ginger ale, or maybe some juice diluted with water. And of course, if you can't tolerate even those clear liquids, please contact your oncology team, because that's a sign that something more serious is going on. But if you're doing okay with those clear liquids, then some plain, simple starchy foods like crackers or toast or pretzels, white rice or noodles, or a banana applesauce, very easy to digest, very easy to tolerate. From there, plain preparations of foods including protein foods, like some boiled or baked chicken or well-cooked eggs. And yes, that does actually mean that chicken noodle soup does really tend to fit in well.

Host: Yeah, we hear at times that how people taste food when they're going through treatment can change. How do you address those issues with patients?

Susan Krische, PhD: It may sound really simple, but actually rinsing your mouth regularly before and after meals can be really helpful. That's basically trying to get rid of any debris that might be in your mouth and getting in the way of your taste buds. So oftentimes, just a homemade baking soda rinse to rinse, swish, and then spit out before and after meals can be really useful.

For the food itself, focus on tastes that are still coming through. And that will vary from person to person. So from some folks, it might be really sweet tastes are still appealing. Other folks might find that the salty, savory flavors are still coming through. So depending on what it is, you might try a sweet or tart beverage. Something like cranberry juice or a really tart lemonade or eating bites of naturally sweet foods like watermelon or sweet potato as a bit of a palate cleanser in between bites of other foods. Then, of course, you can also add some extras into your food. So, sprinkling a little bit of lemon juice or vinegar. That tartness, that acidity can sometimes be picked up a little bit more easy from our taste buds. And so, we start to appreciate that food a little bit more. Or just adding extra marinades, extra herbs and spices to see if those flavors can start to come through.

Host: As you mentioned earlier, everyone, the way they deal with all that is it can be different from patient to patient. So, probably some experimenting with some of the things you just mentioned would be effective.

Susan Krische, PhD: Absolutely. Everyone does react a little bit differently. And of course, we're coming to this time with all of our own history and our food preferences. So from that perspective, all of these are suggestions for people to try to put into place and see what works for them. What might work for one person really well, another person might just hear that suggestion and go, "No, not going to do that." And that's okay, because we do have our own preferences. And a lot of the time, what I end up doing in conversations with patients or their caregivers is to try to figure out what might work for that individual with their preferences, and what they're currently going through at the moment.

Host: We know food is often a comfort source for folks. We talk about comfort foods. When someone's going through treatment and they're having all these dietary issues, what suggestions can you make about being able to stay with their comfort foods while they're going through treatment?

Susan Krische, PhD: This is something of a mixed question. Because as we just talked about with those taste changes, those taste changes may mean that some of our previous favorite foods just aren't going to taste right. And so, trying them now when you're feeling nauseous or everything is tasting funny, that may actually not be what you want to do, because it just might affect that memory of that favorite food.

So, realizing that our comfort foods will change as we go through this journey is really useful. So, comfort foods are whatever brings comfort in that moment, foods that you feel like you can tolerate well, that you're comfortable with that can still give you comfort. And as I mentioned, that bowl of chicken soup. Although it's the old wive's tale, it's actually really fitting in a number of different situations and can work really well. Or depending on how you are feeling, maybe you want to try something that is a little bit heavier if you can tolerate it, so mashed potatoes and gravy, or macaroni and cheese. And then, trying to add those little extras in where you can, can really be useful. So, that mac and cheese is a really dense source of energy and some protein with the cheese. So, finding those little moments of nutrition as you're going through your day can add up over the course of the day and be really beneficial for trying to make sure that you're getting enough nutrition overall.

Host: So, it sounds like through this process, a lot of it's trial and error, really seeing what works, what still tastes good, and what you enjoy. It sounds like that's kind of the course for patients.

Susan Krische, PhD: It is within a set of guidelines. So for example, we do know that if someone's feeling nauseous, they probably need to stay away from heavy, dense foods, spicy foods, and starting with those clear liquids, like I mentioned. If someone's having diarrhea, there might be another set of recommendations. So for example, again, sticking with very plain, simple foods, staying away from most higher fiber foods including some foods that can help thicken our stools, like the banana, the applesauce, the plain starches or yogurt.

But within each of those recommendations, there absolutely is a range of foods that we would suggest working towards and another range of foods that we would suggest staying away from. But within that range, it is a lot to do with personal preference because of so much of how we deal with food boils down to those personal preferences and those personal experiences that we've had over the years.

Host: Are there certain foods you can say or habits that cancer patients should avoid during treatment?

Susan Krische, PhD: This question comes up a lot. And I will say that the only foods you absolutely need to stay away from are the ones that you are allergic to or you cannot tolerate. So, for example, if you previously we're lactose intolerant, you should obviously stay away from lactose. But beyond that, it really depends on what you're going through at the moment.

So while you're tolerating foods and your treatment well, we do recommend that you follow just generally helpful eating guidelines. But when things start to get in the way, that's when we start to make those recommendations about what you might stay away from, depending on your symptoms, and what you might start to focus more on. And when I'm talking to folks, I really do try to focus a little bit more on things to include in their diet when I can, because otherwise it does seem like it's being restrictive.

Generally speaking, as we're going through cancer treatment, so much is acting potentially against getting enough nutrition that to the extent we can, we try to liberalize and add flexibility rather than try to take it away. Now, occasionally, there'll be other things that come up like, for example, if your medical oncology team has mentioned that your white blood cell count is low and you need to take extra precautions from trying to prevent infections. There, we might also start to include some food safety recommendations.

So, since we're talking about it, I might as well mention, most of us have become a lot better about washing our hands since COVID. But that's a large part of it. But since the question that you just asked was about things to stay away from, this is a good example of where things that we might normally eat, we might want to stay away from in certain circumstances. So for example, if we're trying to be extra cautious about our food safety because of that compromised immune system, staying away from rare or undercooked foods like sushi or a rare steak or personal favorite raw cookie dough. That might not be the best choice because of the possibility of something being introduced through that undercooked foods. So similarly, things that we might typically enjoy, like a buffet we might want to be a little bit more cautious about and choose to order off of the menu rather than going to that more open salad bar, open buffet.

Host: Some great suggestions there. Patients and their caregivers may hear about superfoods. They seem to be kind of in the news a lot. How should they approach some of these claims? And what truly matters most when it comes to nutrition during cancer care?

Susan Krische, PhD: So, the term superfood is actually a marketing term. It is supposed to convince the listener that that particular food has exceptional health benefits, usually because of some component of its makeup. Now, oftentimes, that is based on an actual component of the food, but focusing on any one food or any small group of foods is likely to mean that, on an overall basis, that diet isn't well-balanced. So typically, I will try to encourage people not to focus on particular foods, super foods or otherwise. But if they're able to eat a diverse diet, so that includes a broad range, whole grains, vegetables, fruits, proteins, which can include land, animal-based proteins, but also fish, plant-based proteins like beans and so on. And that diversity is so much more likely to provide the whole mix of nutrients that our bodies need to function well.

Host: Yeah. Maybe we could talk a little about caregivers and caregiver support around food. And I know it may be pressuring the patient, making sure they're eating. But with some of the things you've mentioned, you have to be careful with that.

Susan Krische, PhD: So, many of us grew up in families where food is really an expression of caring and of love. But that is a choice. It may be a generational choice, it may be a cultural choice, but it is a choice. So particularly when someone is struggling with food, recognizing that we can express our care and our love for that person in many other ways. That hand hold, a hug, just smiling at them.

And I would certainly encourage caregivers to continue to offer that support through other expressions, not necessarily stressing the food aspect so much. Because that stress can also lead the individual to feel more stressed and correspondingly to possibly even eat less. So, trying to make mealtimes pleasant, music, flowers, a nice place setting can help to relax and downplay that stress even if the caregiver is still feeling some of that.

Overall, just offering a variety of foods, something that might catch your loved one's attention and interest. And even if that's something that you would normally consider a treat because if they're not eating much, at least they're eating something. As I did mention, oftentimes eating a traditional meal just isn't going to work well for that person because of the various issues that they're going through. So, eating multiple snacks, nutrition breaks, small meals is often much, much easier than eating a traditional larger meal.

One other thing to mention, as I'm thinking about it, sometimes drinking is easier than eating solid food. So if you or your loved one doesn't necessarily feel like they want to face solid food, having a high calorie, high protein nutrition drink as a snack or a meal substitute can actually work pretty well. There certainly are commercial products that you can talk to your medical team about. But you could also try a homemade higher calorie, high protein smoothie for those times too. So, offering different options, again, based on what that person is feeling like they can tolerate at that time. Just making sure that they're getting some nutrition on regular intervals and as consistently as possible, but relaxing a little bit about what specifically that nutrition is coming from can be a really useful way to make sure that they're getting enough calories and hopefully enough protein too.

Host: As a nutritionist, Susan, how would you offer advice if someone wanted to have a relaxing glass of wine when they're going through treatment or something like that?

Susan Krische, PhD: Well, this is a difficult question. Because, honestly, from a cancer prevention, cancer survivor perspective, the research recommendations, for example, from the American Institute of Cancer Research is to avoid or abstain from alcohol. And that includes wine and other spirits. That differs somewhat from our generally healthful eating guidelines. So for example, from the American Heart Institute, where we generally hear recommendations to limit our alcohol intake to one standard serving. So for those who may not be aware, there are standard definitions of what a drink consists of. So, five ounces for a glass of wine, or only an ounce and a half if you're talking about a spirit.

Alcohol has the potential to interact with so many medications. And so, from that perspective, my first go-to is to make the individual aware, that the recommendation really is to abstain. But if they're going to choose to have some, to talk to their medical team first to make sure that it is safe for them to do so from a medical perspective, from the medications that they're taking, the chemotherapy that they might be taking, and then that medical provider can also provide a little bit more clarification about how much or under what circumstances that might be allowed.

Host: Great advice there. And as we wind down, let me ask about beyond treatment, what kind of long-term recovery for cancer survivors do they need to be mindful of with regard to nutrition as they continue on their journey?

Susan Krische, PhD: So, this could be an entire podcast on itself. And in fact, I have an entire one hour class related to this. But generally speaking, we are talking about generally healthful eating guidelines and how to apply those through their lives. From that perspective, as we're recovering, we're really just trying to keep our strength up. And that ends up being my main focus as I talk through those recommendations and those guidelines.

In my case, I base the class on the recommendations that are research-based from the American Institute of Cancer Research. And if anyone is interested in that, I believe that there is a link to our community calendar events provided in the description of this particular podcast. But certainly, they're not going to be limited to my offerings. There are some strong nutrition resources out there supported by oncology dieticians like myself that are publicly available, whether it be through our cancer center and the community events calendar or through other cancer centers. So from that perspective, talk to your oncology team. See what resources are available, where you might be having your own care and whether it's you or a loved one. Again, if you're experiencing any side effects, definitely talk to your oncology team so that we can help to provide the support to help make that journey a little bit easier.

Host: Very good. Registered dietician, Susan Krische, gave us a wealth of information today. We really appreciate a lot of great tips for those going through cancer treatment and how they should view their nutrition.

Susan Krische, PhD: Thank you, Carl.

Host: And find more shows just like this one at umms.org/podcast, on YouTube, and your favorite podcast platforms. This is Live Greater, a Health and Wellness podcast, brought to you by the University of Maryland Medical System. We look forward to you joining us again. And please share this on your social media channels. Thanks for listening.