NUTRITION: FOOD FOR LIFE

Carolyn Katzin, MS, CNS, MNT

Integrative Oncology Specialist Certified Nutrition Specialist

Living with Aplastic Anemia, MDS or PNHAA&MDSIFLos Angeles, CA Saturday April 5,

2014

WHAT WE WILL COVER IN THIS PRESENTATION

o The building blocks of a diet for healthy bone marrow functioning

o How you may need to modify your diet during treatment and any barriers preventing this

o Habits to optimize your health and well-beingo Reliable sources of information on nutrition

and supplementso Questions and Answers

NUTRITION – HOW TO NOURISH YOURSELFo We all eat but we don’t always eat well o Many chronic illnesses are associated with:

o too much foodo too little exerciseo too much smoke exposureo too much alcoholo too few fruits and vegetableso too few whole grains, beans and high fiber

foodso What are the building blocks of a healthy diet?

o Sufficient energy but not too mucho 2/3 plant based: beans, nuts, seeds, grains,

vegetables, fruito 1/3 fish, poultry, eggs, lean meat

“AS TO DISEASES, MAKE A HABIT OF TWO THINGS – TO HELP, OR AT LEAST TO DO NO HARM”

HIPPOCRATES, 400 BC

WHAT SHOULD I EAT?o Make your food choices with a better understanding of

what your body needs – this may be highly personalized based on your overall health situation

o See food as nourishment, pleasure and a way to share with family and friends

o Food also provides Antioxidants, Anti-inflammatories and Anticarcinogens - the 3 A’s

o Other benefits of foods include providing bulk as dietary fiber to balance blood glucose levels and help manage satiety and support a healthy microbiome

WHAT YOUR BONE MARROW MAKES FROM PLURIPOTENT HEMATOPOIETIC STEM CELLS (HSC’S)

o Red cells o Erythrocytes

o Platelets o Thrombocytes

o White cells o Leukocytes

Nutrients required o Proteino Essential Fatty Acidso Vitamin B Complex

o B12o Folateo B6

o Vitamin Eo Vitamin Ko Irono Zinc

Red marrow, medulla ossium rubra, in heads of long bones is main site of blood cell and platelet formation

WHAT IS RELEVANT TO YOU IN YOUR CBC WBC (White Blood Count)

3.3 – 8.7 K/uL

ANC (Absolute Neutrophil Count) calculated by White blood cell number multiplied by polys and bands Typical ANC would be 300 X (0.10 + 0.05) = 300 X 0.15 = 45

RBC (Red Cell Count) 3.93 – 5.69

Hemoglobin 12.6 – 16.1 g/dl

Platelet count 147 – 347 K/uL

Reticulocyte count 0.5 – 1% of RBC

Source: National Institutes of Health

“ONCE YOUR CHOOSE HOPE ANYTHING’S POSSIBLE” CHRISTOPHER REEVE CLARK KENT/SUPERMAN

1954-2004

HOPE

O symbol for love

Protein

Exercise

Hydration

HEALTHY FOOD CHOICES

Make your food choices with an understanding of what your body needs

View food as nourishment, pleasure and a way to share with family and friends

Food also provides Antioxidants, Anti-inflammatories and Anticarcinogens (the 3 A’s)

Other benefit of foods include providing bulk as dietary fiber to balance blood glucose levels

Symptom management with diet Specific drug-nutrient advice

WHAT DIET CHANGES SHOULD I MAKE?

A diet rich in nutrients improves your overall health and may also enhance your therapy

Most people find small, frequent intakes of calories are easier to tolerate than a few large meals

Protein needs are increased (add an addition serving – usually about 15 grams or 2 half smoothie portions – one in the afternoon and one at bed time)

Soft textures are gentler on delicate mouth and upper digestive system tissues which are more sensitive during treatment

Avoid highly spiced or acidic foods Stay well hydrated

WHY PROTEIN IS IMPORTANT

Protein provides peptides and amino acids for new cell formation

Protein is found in all living things Protein rich foods include lean meat, poultry, fish,

shellfish, legumes (beans) and tofu, eggs, dairy products, nuts and nut butters and seeds

During treatment your protein requirements are increased

Sufficient protein is required to avoid anemia Typically this means including a further 20 grams a

day for a range of 80 – 100 grams each day

TIPS FOR ADDING EXTRA PROTEINo Add milk, Greek style non-fat yogurt or whey protein

(unflavored) or dried milk powder to soups and or use as a base for sauces; or you may select vegan options (rice and pea or hemp protein)

o Include a protein smoothie in addition to your mealso Keep hard boiled eggs in refrigerator and chop on top of

salads or take peeled for quick snacko Use nut butters as spreads (almond, walnut or hazel nut

butters are good, nutrient dense ones)o Snack on low fat cottage cheese or string cheese or

hummus dipo Add cubes of firm tofu or curd cheese to steamed

vegetables

COMPARISON OF READY-TO-DRINK BEVERAGES

RTD Beverage Calories Protein Carbs Fat Fiber Sugar

Boost 240 10 41 4 0 28

Boost High Protein 240 15 33 6 0 23

Boost Plus 360 14 45 14 3 22

Boost VHC 530 22 46 30 0 14

Ensure 250 9 40 6 0 30

Ensure Complete 350 13 51 11 3 20

Ensure Muscle Health 250 12 32 8 0 23

Ensure High Protein 210 25 23 3 3 5

Ensure Clear 180 9 35 0 0 18

Mix 1 180 15 26 3 4 20

Muscle Milk 160 18 6 7 0 2

Orgain 235 16 32 7 2 12

FOOD SOURCES OF ESSENTIAL FATTY ACIDS

o 1 part Omega-3 (DHA and EPA from oily fish like salmon and sardines, walnuts and pine nuts)

o 3 parts mono unsaturated (olive oil, almonds and avocado)

o 1 part saturated fat (cocoa butter, palm oil or coconut or other plant source)

o Supplement with 100 mg DHA and 500 mg borage or blackcurrant seed oil (as a source of GLA)

Recommended Fatty Acid Balance Omega 6:3 of ~4:1

(typical American diet is 15 to one)

OMEGA-6 AND OMEGA-3 FATTY ACIDS

Vegetable oils corn oil, nuts, seeds

Borage, Primrose or Blackcurrant seed oil

Red Meat especially processed meats fat in meat from animals fed corn

Green leafy vegetables, flax, Walnuts, pumpkin, Grass fed meat fat

EPA (20:5) Eicosopentanoic

Acid Anti-inflammatory

DHA (22:6) Docohexanoic

Acid Anti-

inflammatory

Fish (cold water) Algae source supplements and fortified milk and other foods

Fish (cold water),Algae source supplements and fortified milk and other foods

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Table adapted from Simopolous, A (1998)

FOOD SOURCES OF VITAMIN B COMPLEX

o MEATS: Liver, kidney and other organ meats, lean red meat, dark meat chicken and turkey

o EGGS: Egg yolko FISH: Salmono BREADS & CEREALS: Wheat germ, Fortified

breakfast cereals such as Product 19, Total and Cream of Wheat, enriched breads, whole grains, brown rice

o NUTS: Walnutso VEGETABLES: Spinach, broccoli, turnip greens,

Romaine lettuce, asparaguso BEANS: Blackeyes, Pinto, navy, lentils, green peas

VITAMIN E AND FOOD SOURCES

o Vitamin E is important in regulation of thrombosiso Food sources include nuts, seeds, egg yolk,

wheat germ and some vegetable oilso WARNING! Vitamin E may interact with

aspirin and other anti-clotting agents causing excessive bleeding

o Vitamin E exists as alpha, beta, delta or gamma tocopherols and tocotrienols.

o RDA for alpha-tocopherol is 22.4 IU o Most supplements provide 400 IU mixed tocopherols

o Tolerable Upper Limit iso 1000 mg α-tocopherol (alpha-tocopherol) oro 1100 IU dl-tocopherol or 1500 IU d-tocopherol

FOOD SOURCES OF VITAMIN K 

o BEANS & PEAS: Garbanzo beans, kidney beans,

lima beans, lentils, pinto beans, split peas, soy beanso NUTS & SEEDS: Peanuts, pistachioso VEGETABLES: spinach, leafy greens, mustard

greens, broccoli, Brussels sprouts, turnip greens, watercress, lettuce, kale, carrots, sweet peppers, leeks, artichoke, celery, cauliflower

o TEAS: Green, black and most herbal teas

FOOD SOURCES OF IRON

o MEATS: liver, lean meat, dark meat poultry, shellfish

o EGGS: especially the yolk o DRIED BEANS & PEAS: garbanzo beans, kidney

beans, lima beans, lentils, split peaso  BREADS & CEREALS: fortified breakfast cereals

such as Product 19, Total and Cream of Wheat, enriched breads, oatmeal

o  FRUITS: prune juice, prunes, raisins, figso  VEGETABLES: spinach, leafy greens, green beans

Vitamin C rich foods enhance iron absorption

FOOD SOURCES OF ZINC

o MEATS: Liver, lean meat, dark meat poultry, shellfish

o FISH: Shellfisho BREADS & CEREALS: Fortified breakfast

cereals, bran cereals, enriched breads, oatmeal

o SEEDS: Sunflower seeds, pumpkin seedso DAIRY: Yogurt NUTS & SEEDS: Pecans, walnuts, sunflower,

sesame and pumpkin seeds VEGETABLES & FRUIT: Avocado BEANS: Green peas, black beans

A TYPICAL HEALTHY DAILY MENU Breakfast Oatmeal or other whole grain cereal, non fat milk ,

berries or raisins

Snack Apple, tangerine, banana or other fresh fruit Lunch Large salad with dark leafy vegetables (lettuces,

spinach, etc.) topped with colorful vegetables. Parsley, chives and fresh herbs are good. Sprinkle slices of avocado, a few pine nuts and sunflower

seeds for added benefit. Tuna, hard boiled eggs or lean chicken for protein

Snack handful of walnuts, almonds, sunflower seeds (as butters if your digestive system is sensitive or you are going through chemotherapy) OR small square of dark chocolate (organic)

Dinner Salmon or other fish, lean red meat (not more than once a week) or chicken or turkey or tofu or vegetarian protein (Quorn for example), 2 or more steamed vegetables or stir fry in (small quantity) of sesame or olive oil, brown rice, baked potato, corn or whole wheat tortilla, fresh berries for dessert

Beverages Iced green tea, water (1.5 – 3 liters a day all fluids)

BARRIERS TO EATING HEALTHILYo If your mouth is soreo If you have little or no appetiteo If you are fatiguedo If you are constipatedo If you have diarrheao If you are depressedo If you have insomnia

We need to address each of these important barriers

IF YOUR MOUTH IS SORE OR SWALLOWING IS PAINFUL

o Soft textured, non-acidic foods are idealo Temperature is important – room

temperature usually best toleratedo Creamy textures like custard, nut butters and

avocado work wello Avoid citrus fruits, tomato or cranberry juices

or vinegar dressings which may burno Use (non alcoholic) mouthwash – try Aloe

concentrateo Try ice cream at room temperature and full

fat Greek style yogurto Pasta with cream sauce may be easy to

swallow

IDEAS TO IMPROVE APPETITE Eat small, easy to digest meals

Plan ahead and keep ready to drink products available

Avoid unpleasant odors Prepare food in well ventilated areas

Ginger may be helpful in reducing nausea Eat in a relaxed environment Have food prepared in attractive and colorful

way Garnishes may be helpful like sprig of parsley

or lemon wedge for added color and eye appeal

Try umami flavors

FATIGUE MANAGEMENT

Maintain a healthy weight Carrying around extra weight is tiring - some body fat is pro-inflammatory (not helpful)

Regular physical activity can improve mood and fatigue levels. Activity is also helpful for insomnia – try T’ai Chi or yoga, going to the park or a museum

Regular mental stimulation helps brain function and minimizes fatigue

Protein, iron, zinc, B vitamins and Vitamin C all important for red cell production to minimize anemia

Eat dark chocolate or drink organic green tea as healthy sources of stimulants some people are sensitive to caffeine and similar stimulants – avoid after 3 PM

IF YOU HAVE CONSTIPATION

Try prunes or prune juice Try syrup of figs Try adding rhubarb to your desserts as stewed or

pie filling Try some stewed pitted fruit/compote of peaches,

plums, apricots or cherries Include wheat germ on top of breakfast cereal for

added insoluble fiber (the type that helps gut motility)

IF YOU HAVE DIARRHEA Try the BRAT diet (Bananas, rice, apple sauce and

toast) and include a fortified breakfast cereal like Cheerios

Try a liquid only diet for a day and then reintroduce some baked potato or white rice

Avoid iceberg lettuce and other foods high in insoluble fiber such as wheat germ or whole grain breads or crackers

Include soluble fiber such as oatmeal and apple Make sure you are adequately hydrated – don’t

avoid sodium and have sufficient water

IF YOU ARE DEPRESSED

o Depression can be crippling – ask for help if you find your mood is consistently preventing you from making self supportive actions

o Dark chocolate is often helpful as a mood lifter – try a cup of hot cocoa or small square of 70% organic dark chocolate

o Surround yourself with love!

IF YOU HAVE INSOMNIA

o Make sure you have no caffeine or stimulants (including dark chocolate or peppermint) after 3 pm

o Take any green tea supplements before 3 pm unless decaffeinated

o Have light dinner at least three hours before lying down to sleep – avoid cheese or meat in evening

o Try half a banana before bedtime with small glass of milk

o Try a cup of chamomile or passionflower tea

HYDRATION; KEY TO HANDLING YOUR ENERGY LEVEL During treatment dehydration can happen

easily Fatigue is an early sign of dehydration. Check

for hydration status: color of urine should be light/straw press on back of hand – should bounce back

quickly Make sure you have sufficient water and

electrolytes all through the day and night Don’t avoid sodium at this time (use sea salt

to season your food) Home made remedy: ½ teaspoon sugar,

pinch salt in 1 cup water

PARTICIPATE IN YOUR NUTRITIONAL HEALTH

o Keep a personal record of your nutrition related health data with Your Personal Nutrition Health Check

o Share your food preferences and supplement choices with your health care team

o Optimize your health by balancing the 3 A’so Antioxidants - Anti-inflammatories -

Anticarcinogenso Select food that is fresh, locally grown and organico Maintain your resilience and energy with a

consistent intake of nutrient rich foods balanced with an active lifestyle and regular sleep patterns

WHAT SHOULD I EAT?

o Some foods have more benefit than others - Identify and select those you like often

o Eat a variety of colorful vegetables, fruits and culinary herbs as these are rich in the 3 A’s

o The 3 A’s of good foodo Antioxidants o Anti-inflammatorieso Anticarcinogens

o Eat foods that support your immune system often including berries, citrus and mushrooms

FOOD SAFETY WHEN WHITE COUNT IS LOW If your WBC is low food safety is especially

important Key points: Clean, Separate, Cook, Chill

Wash your hands with warm water and soap before handling food. Use paper towels for kitchen clean up

Rinse fresh produce under running water; rub or clean with a vegetable brush while rinsing with running tap water

Avoid cross contamination of raw and cooked meat, poultry, eggs or seafood. Always start with a clean scene and wash all preparing surfaces and utensils with hot, soapy water. Never place cooked food on a plate that previously held raw (or marinaded) meat, poultry, fish

Cook to proper internal temperature. Use thermometer

Chill and refrigerate promptly Keep cold food cold and hot food hot

Source: www.foodsafety.gov

WHAT ARE THE THREE A’S?YOUR DNA INTEGRITY PROTECTORS

o Antioxidants reduce oxidation at the cellular level from metabolic or external radiation causes

o Anti-inflammatories reduce inflammation (redness, heat, swelling) often prevent metabolic “mistakes” that may lead to cancer

o Anticarcinogens reduce the overall risk of developing cancer

Dysplasia is the result of mutated or altered function of DNA

1. ANTIOXIDANT NUTRIENTSAntioxidants prevent free radical formation which, if unchecked, causes damage to DNA. Also important in switching genes “on” and “off”

o Many are phytonutrients (plant chemicals) that are colored, often dark pigmented and aromatic

o Important for brain, retina and nervous system healtho Coenzyme Q10 in fish, eggs, spinach, broccoli, wheat

germo Vitamin E (a fat soluble antioxidant) in whole grains,

nuts and seeds, wheat germ and avocadoo Vitamin C (water soluble) antioxidants in fruits and

vegetables; berries, bell peppers, citrus and kiwi fruit especially good sources

o Cocoa, avocado, nuts (walnuts) , tea rich in polyphenols

2. ANTI-INFLAMMATORY FOODS

Anti-inflammatories prevent elevated rates of cell division which may increase “mistakes”. Cells in the resting stage have more time to be “corrected” as DNA repair takes place preventing chronic illnesses

o Omega 3 fatty acids (EPA and DHA)o Flaxseed, borage and blackcurrant seed oils

beneficial fatty acids (GLA and ALA)o Natural salicylate rich foods e.g. turmeric,

rosemary, thyme, apricots, broccolio Naturally occurring COX-Inhibitors in green tea,

cocoa and red wine

3. ANTICARCINOGENS

Anticarcinogens prevent DNA damage and allow time for DNA repair or apoptosis

o Curry powder ( a combination of turmeric, cumin and other spices)

o Citrus fruits (naringinin and limonene) o Green tea (EGCG and other natural bioactives)o Pomegranates (especially the oil from the seeds)o Brazil nuts (excellent source of selenium)o Tomatoes (excellent source of lycopene)o Saffron, turmeric and other yellow/brown spices

HEALTH MAINTENANCE

Preventive maintenance is an active state where you participate with your health care team to:o Manage fatigueo Eat regular meals including breakfasto Get sufficient proteino Make sure you are adequately hydratedo Manage stresso Have adequate rest – 6-8 hours sleep at night

CARBOHYDRATES: SUGAR AND STARCH Sugar (glucose and fructose) also forms starch as long

chains. Refined grains (white flour, corn flour, etc.) are digested similarly to sugar – whole grains slow down absorption and maintain more even energy level

High fructose corn syrup, HFCS – sweeter than sugar with slightly more fructose than table sugar. Used in sodas and many other food products. HFCS is a recent addition to our diets – not helpful for healthy insulin levels and contributes to obesity

Smart choice is to restrict sugars to <30 g per day

GLYCEMIC LOAD AND DIETARY FIBER

Good carbs! These are whole grain sources of starch from plants that are not fully digested but promote colon health

Dietary fiber improves the Glycemic Load of a meal and helps maintain healthy and steady blood glucose levels

Dietary fiber promotes health colon environment – supports “friendly bacteria” such as Bifidus and Lactobacillus

Probiotic supplements or Greek style yogurt provides live culture or probiotics. Probiotics need dietary fiber (also called prebiotics) to thrive

Acceptable Intake (AI) for dietary fiber is 38 grams for men; 25 grams for women

FOOD TYPE FIBER (gram)

1 oz whole grain cereals 4 - 13

2 cups dried beans 8 - 11

2 cups prunes, stewed 8

1/4 cup dried apricots 6

Corn, 1 ear 5" long 6

2 cups spinach 6

1/4 cup wheat germ 6

1/4 cup almonds 5

3 cups popcorn, air popped 5

2 cup berries 5

DIETARY FIBER RICH FOODS

FOODS TO PURCHASE ORGANIC “THE DIRTY DOZEN”

ApplesCeleryCherry tomatoesCucumbersGrapesHot peppersNectarines (imported)

PeachesPotatoesSpinachStrawberriesSweet bell peppersKale/collard greensSummer squash

Source: Environmental Working Group

www.ewg.org

PUTTING IT ALL TOGETHER o Avoid mega-doses or > 100% RDA of any

nutritional supplement (unless specifically prescribed by your physician or oncologist)

o Be cautious with herbals (botanicals or bioactives). Some may affect liver enzyme pathways (by either reducing therapeutic dose or increasing toxicity)

o Choose nutrient dense foods rather than take supplements and remember to tell your health team about EVERYTHING you take

SOME BOTANICALS ARE NOT RECOMMENDED Some herbs and botanicals may interfere with liver clearance of some medications commonly used with MDS. Check with your pharmacist and possibly avoid:

Ginseng (Panax spp) o St. John’s wort o Garlico Ginkgo-bilobao Astragaluso Grapefruits and grapefruit juiceo Limes and lime juiceo Bitter orange (Seville) o Nonio Starflower

WHICH SUPPLEMENTS MAY BE HELPFUL?

Protein Whey, rice, pea

Prebiotics Mushroom polysaccharides (AHCC, PSK or PSP)

Dietary fiber Citrus pectin, oat, wheat germ

Digestive enzymes Bromelain, papain, lactase

PERSONALIZED recommendations essential - all of which should be shared with entire health care team

SUPPLEMENT RESOURCES Food and Drug Administration (FDA)

www.fda.gov or Tweet @US_FDA Report an adverse reaction 1-800-FDA-1088 or file FDA 3500 Voluntary Adverse Event Report Form on line

NIH Office of Dietary Supplements www.ods.nih.gov or Tweet @NIH_ODS

Federal Trade Commission (FTC) www.consumer.ftc.gov Dietary Supplement Consumer Information Cancer Treatment Scams information

National Cancer Institute www.nci.gov or Tweet @theNCI

Consumer Lab (CL) www.consumerlab.com Independent lab testing dietary supplements

WHERE TO LOOK FOR HELP Seek professional advice from an

experienced nutrition specialist to assist you

Contact www.eatright.org for a Registered Dietitian or www.cbns.org for a Certified Nutrition Specialist or www.aanp.org for a Nurse Practitioner

HEALTHY FOOD CHOICES – NUTRITION TO THRIVE

Choose fish at least 3 times a weekFor omega-3’s and for protein

Choose fruit for breakfast, dessert and snacksFor bioactive botanicals

Choose 2 or more vegetables for lunch and dinner Especially from garlic and cabbage

families Cook often with herbs, curry and spices Think of food as sustenance – make healthy

food your friend not a dietary restriction

MIRACLES

There are only two ways to live your life. One is as though nothing is a miracle. The other is as though everything is a miracle

Albert Einstein (1879-1955)

THANK YOU

Carolyn Katzin, MS, CNS, MNTckatzin@mednet.ucla.edu

Call 310.794.6644 for an appointment to personalize your health recommendations with Carolyn

at UCLA Simms/Mann Center for Integrative Oncologywww.simmsmanncenter.ucla.edu