Transcription:
Nutrition Advice Along the Cancer Care Journey

Dr. John Leonard (Host): Welcome to Weill Cornell Medicine Cancer Cast, conversations about new developments in medicine, cancer care, and research. I'm your host, Dr. John Leonard. And today on the podcast, we will be talking about nutrition for patients before, during, and after cancer treatment.

This episode, we have two special guests, both registered dietitians with a certified specialty in oncology nutrition here at Weill Cornell Medicine and NewYork-Presbyterian Hospital. I'm particularly excited for this because this is our first time having two guests together along with me.

So first, Emily Buchholtz focuses on using holistic techniques to improve patient's quality of life through nutrition and exercise along the cancer prevention, treatment and survivorship continuum. And our second guest, Stephanie Roit, provides nutrition counseling for patients during their medical, radiation and surgical cancer treatment to help optimize nutrition and maximize quality of life.

So, I know both of you individually counsel patients. And as always, this isn't a substitute for a one-on-one consultation with a dietitian. But what we've done is put together some common questions that we can answer generally, remembering that people should always speak to their local either physician or dietitian for their own individualized advice. We've also had a number of questions that our audience has sent in ahead of time. And so, hopefully, you're out there awaiting these answers. I know I am because these are really important questions that come up a lot and are of great interest to patients and families and our listeners.

I'll start with you, Emily, and then I'll ask Stephanie the same question. How long have you been practicing and what is your specialty area within this field?

Emily Buchholtz: I've been practicing nutrition since 2015. I did work inpatient for several years. I then moved over to the Weill Cornell Health System in 2017. When I started my role, I covered all of outpatient oncology for chemo and radiation. And over the last two or three years, my focus has been on women's health. So, I work mostly now with breast cancer patients, GYN-ONC patients, and the survivorship practice. And I work with patients throughout surgery, chemo and radiation therapy.

Dr. John Leonard: Great. And Stephanie?

Stephanie Roit: I've been a registered dietitian now for about six years. I started off my dietitian career here in the hospital at Weill Cornell. So when I started, I was an inpatient dietitian, mostly covering the bone marrow transplant service. But I also saw some patients that were admitted for chemo for leukemia, lymphoma, things like that as well.

After a couple of years, I transitioned to my current role, which is outpatient here at Cornell. I mostly see a lot of gastrointestinal cancers such as colorectal, pancreatic, liver. But I do also in the radiation clinic see a lot of head and neck cancer, prostate cancer, and some lung cancer. So, a pretty wide range of patients.

Dr. John Leonard: What's the training that a registered dietitian has? People get nutrition advice from lots of different sources, the internet. I know it's really important to see somebody who's professionally trained and has experience. It's one of the great parts of seeing somebody at a center that has a multidisciplinary team.

Stephanie Roit: It's often a common question, what is the difference between a nutritionist and a dietitian? And a registered dietitian or an alternative credential, the registered dietitian nutritionist, are both anyone who has gone through a pretty rigorous academic program. So, it requires both an undergraduate degree in nutrition or another field. And then if you do your degree in another field, you have to do what's called a DPD for short, which is basically a lot of science courses like biochemistry and chemistry, and you really do a lot of science-based education and research-based education before you do the next step, which is called a dietetic internship. So, that is where you're doing your supervised practice, often in multiple settings. You might be in a clinical setting, you might be in a food service setting, probably a community setting, so you learn under supervision from a registered dietitian who already has all this education. They actually are changing the requirement and also will require a master's degree in the future.

Nutritionists may just do a certificate program online and then they can call themselves a nutritionist and technically give nutrition advice. So, without having as much of the medical background, especially in the oncology field, we have years of learning how to read research, interpret research. So really, it's not always a great substitute for somebody who's going through an intensive treatment like chemotherapy or radiation.

So, when you're looking for nutrition advice, it's often good to look at someone's credentials, make sure that they do have the registered dietitian credential because you have a pretty rigorous academic education behind you. And that can be really helpful when you're going through these medical treatments.

Dr. John Leonard: That's good advice and very helpful to know given all of the sources of information out there. So now, let's jump into our discussion and our questions.

From the standpoint of diet and cancer risk, I think we all know that certain diets are associated with risks of different medical conditions to varying degrees. At a high level, what are some of the big cancers that are associated with certain types of diets?

Emily Buchholtz:The first thing I always want to mention and make sure people realize is cancer is very multifactorial. So it is not one particular item or one particular thing we do that will increase the risk. The average cancer takes about 10 years to develop in someone's body. There is obviously variation there based on disease states. But generally speaking, when we're talking about diet and cancer risk, it's 10 years of poor habits, poor choices, things like that.

Many foods we eat contribute to inflammation, which increases risk of cancer. But then, there's also many foods that we eat that decrease inflammation and help reduce risk of cancer. So, some of the foods that help to reduce risk of someone developing cancer are all of these really healthy, unprocessed plant-based foods. So, those foods are things like fruits and vegetables, whole grain carbohydrates, varying nuts and seeds, and beans and lentils, choosing lean proteins, like poultry and fish and eggs. These are all these anti-inflammatory foods that provide a lot of vitamins, minerals, fiber that can really help promote a healthy diet, a healthy weight, and reduce risk of cancer.

On the other hand, there's many foods that have less nutritional value. So, things like white flour, for example, from bagels and pizza crust and regular pasta, high sugary things, so sodas and juices and ice cream and cookies. So, these things are okay to consume in moderation. But when we're eating them too often, what can occur is this inflammatory response in our body. And over time, if we're doing this frequently and regularly, that inflammatory response can also create weight gain or someone to become overweight. And the more inflammation we accumulate over the years, the more DNA damage our body can accrue. And that DNA damage ultimately increases risk of cancer cell development.

Dr. John Leonard: So, another big topic that often comes up, lots of people think that either they can treat cancer with supplements or maybe improve their chances of a good outcome with supplements. How do you advise patients around the potential use of supplements as part of their care or just globally in their cancer journey?

Stephanie Roit: The supplement industry is a really big industry in the United States and, unfortunately, it's not well regulated. So, you'll see a lot of claims on supplement bottles and from supplement companies that aren't well supported. And you'll notice on those same bottles, it'll say that these claims have not been substantiated by research or approved by the FDA. So, definitely, we get a lot of questions about supplements, and we approach this on a very individual basis because there is a time where supplements may be appropriate for someone. Maybe somebody is experiencing malabsorption due to their cancer. Maybe we've checked some lab work, and someone might have some deficiencies in vitamins or nutrients that are important for blood cell formation. But on the other side of things, high doses of supplements can also be harmful. So, we want to be careful about how many supplements people are taking and what doses.

There might be times where we sort of globally recommend not taking certain supplements during treatments on more of a theoretical basis. So, for example, during radiation treatment, we might recommend not taking high doses of antioxidant vitamins like vitamin C. There might be other times where a treatment actually is processed in the body, similarly to an herbal supplement. Even some chemos are coming from natural sources, and so they're going to be processed similarly. And if you take a supplement at the same time, you might actually be impacting how that chemo is working in your body. So, we do have to be very careful, and we always recommend reviewing your supplement list with your oncologist or if you have a registered dietitian who is specialized in oncology, just to make sure you're not doing anything that might be counteracting your treatment.

We're seeing in some newer studies that sometimes when we look at the foods versus the supplements, we actually see more of a benefit when people are including the food sources of nutrients. One that we commonly get asked about as probiotics and I think that's something that we still need a lot more research on before we can really recommend supplements. But we can recommend foods that are sources of probiotics or foods that naturally encourage the probiotics in our gut to grow and be healthy. So, I think it's certainly a big topic and something that's best approached on an individual basis. But I can say there are a time and a place for supplements certainly. But just across the board, we can't say, "Take this and it's going to help your treatment outcome."

Dr. John Leonard: Again, just to emphasize that it could potentially interfere with treatment, have you seen examples of that, of supplements affecting treatment or at least making things more complicated?

Stephanie Roit: We have a couple of really well-known interactions. So if somebody is receiving a certain chemotherapy or treatment like Velcade, for example, it's very important to avoid green tea, green tea supplements. In those cases, that's where it's helpful to discuss your list with either your oncologist or your dietitian prior to taking it, so we don't end up with that problem. Also sometimes supplements don't sit so well in the body, so supplements can have their side effects too. We've certainly seen in our practice where people are taking a long list of supplements. And when we reduce that down, it can actually help reduce some of the digestive issues that people are experiencing, which in turn can help them to better tolerate their treatments.

Dr. John Leonard: I'd like to move into kind of the different phases of treatments. Let's start with when a patient is starting treatment and this could include different forms of therapy, chemotherapy, immunotherapy, radiation. But generally speaking, when you see a new patient who's starting cancer therapy, what advice do you give them to plan and to make things go more smoothly from the perspective of their diet?

Emily Buchholtz: Most of the time, as you said, each patient can be getting a completely different regimen, but most patients we're working with are getting some form of chemo or radiation. And a lot of times each patient has different GI symptoms and reacts differently. So right off the bat, before treatment starts, we always like to meet with each person and really just make sure they have food stocked in the house that they like, that is easy to make and reliable to see what happens in that first week because most people feel a little queasy, more fatigued than usual. Sometimes they have no appetite. Sometimes they're feeling weak. And so, the big thing we push that first week before we can really understand how they're going to feel is really just getting easy to prep simple foods in the house. So, things like whole grain bread, oatmeal, peanut butter, Greek yogurt, fresh or frozen fruits, prepared soups, canned beans, canned lentils, rotisserie chicken, eggs, just really simple protein-rich, well-balanced options that they can grab. They can lay down and eat them on the couch if they're not feeling up for it. That's definitely one of the things we want people to have accessible starting day one.

The other thing that we really want to emphasize is it's very important to remain hydrated during this time. And so, we often encourage people to get extra water bottles stocked, electrolyte-rich fluids available. That way, they always have something on hand that they can be sipping throughout the day to help them get through that first week or so.

Dr. John Leonard: Let's move into the treatment period and questions that come up. I'm sure patients ask you these all the time. The first one is around foods that can help you avoid infection while your immune system may be suppressed, and also foods to avoid eating to avoid infections while your immune system may be suppressed.

Stephanie Roit: It is a common side effect with many treatments. I would say one of the most important things is nutrient adequacy overall. So by that, I mean there are a lot of different nutrients from foods that are important to keep our immune system strong. So especially protein, it's something that we emphasize a lot in our counseling. Not losing muscle mass, not losing weight and making sure that you're eating enough calories and protein can actually really help to support your immune system and reduce your risk for infection overall. So, really getting a variety of nutrients as best you can during those weeks can really help your body stay stronger.

Now, the second thing that can come up is we know that blood counts can be lower as a result of these treatments, and that's something that even if you're eating a well-balanced diet can still happen. So, when you are going through something like chemotherapy that might be lowering your immune response, then we want to also make sure we're following the USDA Food Safety Guidelines pretty closely. We're all washing our hands these days still hopefully. So, that's an important point before preparing food, before eating meals. Make sure you're being good about hand hygiene. Washing your produce before you eat it, so you don't have to avoid raw fruits or vegetables. That was sort of a common old advice that was given that hasn't been well supported in newer studies. If you're going to have a salad, just make sure everything in it has been washed very thoroughly. Meat and fish and eggs, which are high-protein foods, you want to make sure that those are cooked through all the way. We'll often recommend avoiding things like sushi or undercooked eggs, which present a high risk for a food-borne illness. And then, just using separate cutting boards when you're cooking things that have a higher risk for contamination with food-borne bacteria. So, maybe you keep a separate cutting board for fish and meat than you do for the vegetables when you're making your salad. Keeping a clean kitchen and washing your hands can really go a long way so you don't have to restrict foods too much.

You also just want to be cautious for anything that's not made with pasteurized dairy. So, raw milk cheeses or cheeses that have been cured with mold, you want to generally avoid those. And being good about not keeping leftovers for too long, keeping things in proper temperatures are probably the best guidelines you can follow to reduce your risk for infection from food.

Dr. John Leonard: How about nausea, a big issue for many people. We have good drugs for nausea, but still, it's an issue for many people. What do you tell people as far as minimizing their nausea symptoms? What kind of diet?

Emily Buchholtz: So with nausea, a lot of times simple plain foods go a very long way. When you have a queasy stomach, you really want to try to choose cold, plain, bland foods until the nausea subsides. Greek yogurt with fruit, a smoothie, whole wheat bread with avocado or peanut butter. Really, things that don't have a strong smell will also be helpful. Ginger is also another superpower that we can use. So if you like ginger tea or they make ginger seltzers now or ginger sucking candy, something like that might help combat queasy, nausea sensation if it just happens out of nowhere.

Also, don't drink liquids too quickly. We have a job of always encouraging patients to drink lots of fluids, drink more fluids. We're constantly pushing them. But if you ever have a very nauseous stomach, you want to actually drink super slowly. You don't want to chug any liquids. And you also don't want to consume liquids on an empty stomach. You definitely want to eat something simple first, even if it's one piece of dry toast, wait a few minutes for that to digest and then start drinking some fluids.

Another thing I notice a lot is many of my patients tend to have coffee on an empty stomach in the morning, and that can also really interfere with nausea. So, if you are a morning coffee drinker, try again to have something simple and plain first. Let that coat your stomach and then wait about 20 minutes and then go for the coffee.

Dr. John Leonard: Another question I get all the time is about, "Can I have a glass of wine? Can I have a drink?" What about alcohol? And what do you tell patients? Is it okay for patients to have a drink or two here and there?

Stephanie Roit: When you're going through treatment, if you're having side effects, it's usually best to avoid alcohol. If you're having side effects such as nausea, diarrhea, even fatigue or for example, prostate cancer patients may have changes to urination and alcohol can often exacerbate these symptoms. So if you're already not feeling so great, adding alcohol on top of that is not always the best option. We know that a lot of people are getting chemotherapy or treatments for very long periods of time, and often are going to want to enjoy a ritual of a glass of wine or on a special occasion have alcohol. And so, we say moderation when possible, and also making sure you're not currently taking any medications where alcohol might be a contraindication for that.

But otherwise, you know, occasional glass of wine should be okay if someone is otherwise eating well, hydrating well, feeling well, and it's not going to worsen any of those side effects. Some people don't have the taste for alcohol the same because of some of the side effects of chemo, too. So, we just work with people on limiting it when they can because we know that there is a lot of extra processing that the body has to do with alcohol when it's already processing some of these other medications.

Dr. John Leonard: And what do you advise people on the other end of the spectrum who are having nausea and getting fluid depleted? What are your kind of go-to liquids?

Stephanie Roit: People can have electrolyte losses for a varying reason. So, maybe they're losing extra electrolytes because of diarrhea or an acute day of vomiting. Maybe their chemo is causing them to lose extra electrolytes. Maybe it's due to even malabsorption from a surgery they had on their gastrointestinal tract. So, in those cases, we do recommend increasing fluids that have electrolytes. That would normally be things like salt and potassium in fluids. You can get them from natural fluids like broths and coconut water and some vegetable juices. But if you're having a lot of fluid loss, we usually recommend using more of an oral rehydration solution, which you can either find recipes for or you can get Pedialyte or a similar equivalent at the store. And those are specially formulated with the right amount of glucose and salt and sometimes other added electrolytes to better rehydrate you when you've had a lot of fluid and electrolyte loss from something like diarrhea or vomiting.

Otherwise, some people just like a little bit of extra electrolytes to help them have more energy. Gatorade does have a lot of sugar. It's meant as more of a sports drink. So, we do just have to make sure somebody's not having high blood sugar levels. Otherwise, a little bit of Gatorade is okay or lower sugar versions of these can be helpful. And a lot of people do just like to use some of the more basic liquids like broth and coconut water to help if they're a little bit low or need a little bit extra energy from their hydration.

Dr. John Leonard: Now, let's get into weight changes during therapy. And you know, it's interesting, one patient can be losing weight, another patient can be gaining weight. It seems like people also tend to focus a lot on their weight during therapy because it's either going up or down or they just notice the other changes of their body as they're having some side effects of treatment. So, what do you tell patients?

Emily Buchholtz: The patient population I work with now is mostly women, and so a lot of them are going through a lot of hormonal changes during treatment. Most of this is medication-induced. And so, for a lot of people, this alters their metabolism. In addition to that, these patients are going through an extremely stressful situation, and a lot of people tend to cope with stress by snacking or bingeing or craving comfort foods such as sweets.

And then in addition to that, before each chemo regimen, we often give patients steroids to help prevent reactions, which the steroids do a great job with that, but that also can increase hunger spikes in these women. So, when you're doing that for six months to a year, it is very common that the weight keeps creeping up, if we don't take medical intervention. What I do in working with those patients is I try to touch base with them monthly at least, and just really try to make sure that they are still eating well-balanced despite these things that are happening in their bodies. For example, I'll coach people on really making sure they have protein at every meal, which is going to be lower in calories, but help with satiety and help keep people full. I also promote choosing a lot of non-starchy vegetables that are packed with fiber that are also going to help keep people full. And carbohydrates and healthy fats and all of that stuff is not off limits for any of these people. But what I really want people to do is be accountable of the portion size. So, measure the portion of some of these more nutrient-dense foods. And if someone still feels hungry, go back for seconds of the lean protein or the non-starchy vegetables or the fresh fruits.

The other thing that can be very beneficial is exercise. I think a lot of people don't talk about exercise during treatment, but it is so important not only for weight maintenance, but it helps build muscle mass. It helps keep us strong through treatment. It helps with fatigue. It helps with our mental sanity. So, I always try to push all of my patients to do whatever exercise they can. Some of them are recovering from surgery and have certain limitations, but I want everyone out there walking and moving to the best of their ability because I think that also makes a big difference for them.

Dr. John Leonard: And what about the patient who's having weight loss?

Stephanie Roit: Weight loss is something that I think oftentimes is a reason we get referrals because someone might be having weight loss during their chemotherapy treatment, and we have a lot of research showing that people who lose a significant amount of weight can actually experience more side effects or even not tolerate their treatment regimen as well. So, when we talk about weight loss, I always emphasize with people that really the weight is easy to measure, so that's why we follow it. But what we want to do is really support your muscle tone, because when you lose weight quickly, a lot of that tends to be muscle. And cancer is already an inflammatory disease, which can cause breakdown of muscle on its own. When you're not eating well, it can just accelerate that muscle loss, which in turn can increase side effects like fatigue.

There's a lot of different things we can try when somebody doesn't have a great appetite and is losing weight during treatment. Some people feel full easily. So, we'll often recommend having small meals and snacks more often and just snacking and eating throughout the day, which might look a little bit different than their usual eating plan of breakfast, lunch, and dinner. I emphasize getting protein with each meal. And then if you're eating something, even if it's small, is there some kind of topping you can add on that you can maximize the calories and the protein of that meal? So, if you have a sandwich, can you add an extra slice of cheese or can you add some mashed avocado on the bread? If you're having yogurt, can you put some fruit or some peanut butter in there? Always thinking of how can I maximize the nutrition of this meal, so you don't have to really eat that much larger of a portion, but you're going to help support your body and help support your muscle strength.

Also, some people just feel full very easily and liquids are often easier to tolerate. So, we often will encourage those in between meals instead of having more solids that maybe are high in fiber and require a lot of energy for chewing. Can you instead make a smoothie that has some high calorie ingredients in it like peanut butter or avocado or coconut milk? And that way, you're going to be able to drink that slowly, tolerate more and, oftentimes, it can be absorbed more easily for people as well. If you're not having energy to make your own smoothies and soups, there are also some commercially prepared protein shakes that we might have somebody have if they don't have an appetite for some of your more common high-protein foods. I'd say really the key is eating often and then just maximizing both the calories and the protein in what you're eating.

Dr. John Leonard: What about the issue that goes along with weight loss often, is that metallic taste or bitter taste that patients have in their mouth sometimes with certain treatments? What do you tell patients experiencing that?

Stephanie Roit: Taste changes can be really distressing for people. Their normal foods suddenly don't taste good. Or like you mentioned, the bitter taste can be really common. The first thing I always say is make sure you're doing good regular mouth care. And if you're having dry mouth, which can be a common side effect of medications, make sure that you're treating that because keeping your mouth clean and having saliva flow is really going to help enhance your taste of food. So, that can go a long way. We'll often recommend starting with just a rinse that you can make with water, baking soda and salt at home and you just rinse your mouth with that a couple times a day. I'll recommend it sometimes before meals or after meals, depending on what taste changes somebody is experiencing. And that's going to help reduce any buildup in the mouth and help the flavor stand out better of food.

Dry mouth, you can treat a lot with over-the-counter products. Lozenges, sprays, rinses can really help. Having a lozenge in between meals that's going to stimulate more saliva may help your next meal taste a lot better. And then, the bitter taste sometimes can be countered well with some sweet flavors like maple or honey. So, I'll often recommend maybe having a little bit of that in a marinade for your dish or in a dressing for your dish, adding it to your smoothie for that flavor, which can help counter the bitter taste. We also will recommend not having metallic silverware that actually can enhance the taste of it as well.

And then for other taste changes, either a lack of taste or some people say, "Everything I eat tastes like cardboard," We'll say, "Let's play around with a lot of different flavors in your food." As long as someone's not having mouth sores or mucositis, you can really play with different things like tart flavors, lemon juice, vinegar, tart fruits. You can do a lot with those to help stand out flavor. And those often work really well for people. You can also add healthy fats, which can also help the flavor stand out better. So, olive oil is a great option to use alongside those tart flavors to help it stand out. And then, I often recommend using lots of fresh herbs or even fresh fruits and vegetables, which are going to have a stronger flavor. And combining sometimes two of these things together is going to be more effective than just one.

Since sometimes you can't have all these foods on hand at once, I also recommend using a lot of dry herb blends that are sodium-free, so you can really use a lot more of them without worrying about overdoing the salt content. You can also have dressings and they make pre-bottled lemon juice and things like that that you can keep in your fridge and add to your meal as you're eating it. And oftentimes if you add a couple of those components, it can make that dish a lot more appealing and taste a lot better for someone.

Dr. John Leonard: I want to briefly touch on the issue of raw vegetables and patients who have bone marrow transplants or leukemia situations where they may be more immunosuppressed.

Emily Buchholtz: The average person getting chemotherapy, so not a BMT patient, it is safe for them to consume all raw fruits and vegetables. The reason we say this is what studies have really shown is that patients getting chemotherapy in an outpatient setting, although their immune system is weaker than normal, it's usually still strong enough to eat raw fruits and vegetables. We're not really hearing about people getting E. coli or salmonella or any of these other food-borne illness because they ate an apple, or they ate a strawberry or a banana. So, we just encourage everyone to wash them. You don't need any of those fancy washes. You don't need to wash them with soap. Just rinse them normally and you should be totally fine.

Stephanie Roit: And for the bone marrow transplant population, obviously they are dealing with a lot of immunosuppression. And when they're getting their actual transplant, they're going to be mostly having foods that are provided in the hospital. But we still aren't super strict with the diet because it can be so hard to eat after receiving that particular treatment. And they've actually done studies on what is called the low microbial diet. You may hear the term the neutropenic diet. And years and years ago, they used to restrict raw fruits and vegetables. They were pretty restrictive with it.

But what they saw was in studies that as long as people were following the USDA Food Safety Guidelines, there actually wasn't a difference in infection rates in those patients and even in immunosuppressed patients, there was higher infection rates in the neutropenic diet group. So, it's thought that actually eating these fiber-rich foods might be supporting the immune system. What we want to do is just make sure that you're eating them in a safe way. I would always tell people, when you're choosing produce that you're going to eat raw, make sure that you're washing the outside well, even for something that you're cutting open and only eating the inside. So a melon, you still want to make sure you're rinsing and scrubbing the outside well. Things like other produce where they have skin that you'll be eating, make sure it's good quality. There's not like a nick or a cut where there might be more risk of bacteria or mold growing. Make sure you're not eating anything that has visible mold. Especially things like berries and grapes, you have to be very careful about looking at them and washing them really well. Same thing with leafy greens. Make sure you're really rinsing them in a big container of water to get any bacteria out. But we don't want to restrict these healthy foods when they've been shown to be safe in studies. So, the most important thing is really washing them thoroughly, so that they're safe to eat and low risk.

Dr. John Leonard: So, I want to ask you both about the issue of sugar. And the question about does eating sugar affect cancer growth or treatment? And should patients avoid sugar?

Emily Buchholtz: The $1-million question, we get asked about this at least once a day, if not more. So, what we know about sugar and feeding cancer is similar to what I was describing in the beginning. A lot of patients have this fear that if they have a cookie or a piece of chocolate while going through treatment, cancer cells just start rapidly growing in their body, and that is completely false. What we know is that cancer is an inflammatory illness. And so, the more inflammatory foods, such as sugar, we eat creates this chronic cycle of inflammation in our body. And again, when we expose our body over years and years to this chronic inflammatory response, which is created from sugar, high-fat foods, stress, inactivity, all of these things create that inflammation. And that inflammation over time leads to DNA damage. And then, that DNA damage increases risk of cancer cell development. So, whether you are someone sitting in to reduce risk of cancer or you are actively going through cancer treatment, we don't want people spending their whole day eating sugar. We want to focus on nourishing healthy foods. But if you want a serving of a sweet treat every few days, or you add a little bit of sugar in your coffee, that you spend the rest of the day eating clean and well-nourished foods, that is not going to impact your cancer cell development or the impact of the drugs treating the disease.

Dr. John Leonard: And how about going on the keto diet?

Stephanie Roit: Keto is also another diet that we get asked about a lot. And keto is short for the ketogenic diet, which the classic keto diet was originally developed and used as part of epilepsy treatment and still is being used. And really, the classic ketogenic diet that's used in studies is often very different than the keto diet that your coworker or your neighbor might be following.

The classic keto diet is really a strict ratio of a high-fat diet that can be up to 80% of your calories from fat. More commonly, what people will sometimes in the community refer to as the keto diet is just a high-fat, high-protein diet that's often focused on a lot red meats, processed meats, processed fats and oils that we know aren't always great to have in the highest amounts.

So, across the board, we can't say that the keto diet is beneficial for everyone. But what's interesting about the keto diet is that it's actually being studied to potentially help other specific targeted treatments work better. We don't have studies at this point in humans that we can really support it as part of routine cancer care. There are a couple of trials. We even have a couple of trials being done here at Cornell with brain cancer patients and with a specific type of targeted treatment to see if results that we see in animal studies where keto may help enhance the effective treatment will also show in human studies. But it can be hard for people to tolerate such a high-fat diet, especially if people with digestive cancers had a surgical resection or they have pancreatic cancer and they're having trouble digesting a lot of fat, that's probably not going to be appropriate for somebody to try a keto diet.

So, there's, I think, a lot of cases where it might actually cause harm. So again, anytime you're looking to restrict food, you just want to check with somebody like a dietitian who can help better advise if that could be appropriate for you. I think, hopefully, in the coming years, we'll have a little bit more information on specific tumor types and treatments where keto might be able to be used for a short amount of time to help, but we just don't have the research yet to support that.

Dr. John Leonard: So before we wrap up, I want to ask you both for a takeaway for patients who have finished their therapy, who are in remission, hopefully doing well. What do you tell patients as far as their diet after treatment? Do you change your diet at all?

Stephanie Roit: I think it depends a little bit on what point you're at after treatment. So, people, when they initially finish treatment, I think a lot of people want to make a big change, something that's going to help reduce recurrence, but there's often a recovery period that someone might have to go through. Maybe they lost a lot of weight and muscle from a surgery and a chemo. Maybe they have lasting mucositis, it's going to be there for another month or two, and we have to still be careful about what types of foods you're eating.

So, I always say first and foremost, these side effects don't go away overnight. So, you want to still support your body by getting enough nutrition before switching to something new or adding in any new foods. In general, after cancer treatment, we do recommend incorporating a lot of the cancer prevention guidelines and there have been some studies that do show that following these may help reduce risk for recurrence in certain cancers. And typically, studies that are showing a benefit from foods that you're incorporating is these plant-based foods that have antioxidants and cancer-fighting properties, like nuts and seeds and fruits and vegetables.

So, we do, when somebody is ready, recommend including lots of these. We generally will recommend about two-thirds of your foods coming from a plant-based diet. But of course, this is also going to be individualized if somebody might not tolerate that many high-fiber foods.

Dr. John Leonard: And as far as your weight post-treatment?

Emily Buchholtz: There are some that are able to maintain their weight. Some people have a harder time and are gaining weight. So really, once chemotherapy is done, I really try to work with everyone individually and really reinforce that there's no one size that fits all. And I really want people to start focusing on very small changes that they can implement. So, for example, if someone's not exercising, start with an exercise goal. If during chemo you were grossed out by all fruits and vegetables, let's start replacing some of those carbohydrates with fruits and vegetables. Getting back into cooking, getting back into planning meals ahead of time so we have a good game plan. Just different things like that that don't feel so overwhelming, but to start with that. And then, patients are able to work with me as much or as little as they need to just set different goals, come back and report what's working, what's not working, and we can always improvise and go back to the drawing board.

Dr. John Leonard: Well, I want to thank you both. This has been a great discussion. And it's really wonderful to hear your insights and guidance. I think it's been packed with useful information for patients. I think it also highlights the importance and the value of speaking with a dietitian and particularly somebody with expertise in cancer therapy if you are a patient dealing with cancer and cancer treatment.

And just a reminder, if you happen to be a patient at Weill Cornell, we make these services, these consultations available for all of our patients. All you have to do is ask your primary oncology care team for a referral and a consultation to really tailor things to your own situation. Thank you Emily Buchholtz and Stephanie Roit, for your comments today.

And before we wrap up, I just want to invite our audience to download, subscribe, rate and review CancerCast on Apple Podcasts, Google Podcasts, Spotify or online at weillcornell.org. We also encourage you to write to us at cancercast@med.cornell.edu with questions, comments, and topics you'd like to see us cover more in depth in the future. 📍

That's it for CancerCast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard. Thanks for tuning in.

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