Nutrition and Wellness in Cancer Survivorship. Kathy Hunt RD,CD,CSO Pediatric Oncology Dietitian Seattle Children s Hospital October 27, 2012

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1 Nutrition and Wellness in Cancer Survivorship Kathy Hunt RD,CD,CSO Pediatric Oncology Dietitian Seattle Children s Hospital October 27, 2012

2 Survivorship, quite simply, begins when you are told you have cancer and continues for the rest of your life. (Mullan, NCCS)

3 Childhood Cancer Survivorship 5 year survival rates approaching 80% 270,000 childhood cancer survivors live in the US today 20,000 children in US diagnosed with cancer each year; 15,000 will be cured 1 in every 570 individuals ages 20-30yrs is a survivor of childhood cancer

4 Why So Much Progress In Curing Childhood Cancer? Clinical Research is organized COG Most children with cancer participate in clinical trials (~70%) New anti-cancer medications are being developed and tested in children Understanding the biology of childhood cancer allows for new and less toxic treatments for cancer Strong interdisciplinary care available for patients and families nutrition, social work

5 Common Late Effects of Childhood Cancer Treatment Nutrition Related Effects: Weight Gain: overweight obesity Underweight Altered bone metabolism bone mineral loss osteoporosis Growth hormone deficiency short stature Need for vitamin and mineral supplementation

6 Nutrition and Survivorship Topics for Today Bone loss Cause Intervention Calcium and Vitamin D Weight control Inflammation Diet and exercise

7 Effect of Cancer Treatment on Bone Metabolism Commonly seen in childhood leukemia survivors who receive steroids ( bone mineral accretion) Radiation induced growth hormone deficiency: (cranial radiation) peak bone mass Bone marrow transplant GVHD steroids loss of bone mineral density

8 Why Worry About Bone Loss? Increased risk for fractures (hip, vertebrae, long bones) Painful Decreased activity, altered lifestyle More rapid bone loss than normal age-associated bone loss

9 Treatments For Bone Loss Lifestyle Increase weight-bearing exercises: running, jumping Diet Adequate calcium and vitamin D intake (slows rate of bone loss) mg/day calcium units per day vitamin D Obtain from diet and supplementation

10 Calcium and Vitamin D Requirements Age Calcium (mgs/day) *Elemental Vitamin D (IU/day) *cholecalciferol IOM DRI On Steroids IOM DRI On Steroids Birth 6 mos mos yrs yrs yrs yrs 1, Institute of Medicine, Food and Nutrition Board, 2010 Wasilewski-Masker, K et al. Pediatrics. March 2008

11 Calcium Sources in Food Examples: Calcium content (mg) Sardines, including bones, 3 oz 325 Milk (2%, whole), yogurt, soy milk 300 Calcium fortified orange juice 300 Cheeses, 1 oz 200 Canned salmon with bones 3 oz 185 Ice Cream, 1 cup 175 Tofu, firm, ¼ block 163 Cottage cheese, 1 cup 156 Almonds, 1/3 cup 126 Baked beans, black, kidney, ½ cup Broccoli, ½ cup cooked ~50

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13 Calcium Supplementation If calcium supplementation is necessary: Calcium citrate (Citracal ) best absorbed Take a calcium supplement that contains vitamin D Take no more than 500 mgs at one time Avoid taking calcium with iron for best absorption Limit calcium intake from supplements to 2 gms per day (can lead to kidney stones and constipation)

14 Vitamin D Essential for absorption of calcium from the intestine Difficult to get adequate vitamin D from sunshine at this latitude and from dietary sources Important in prevention of bone disease and fractures New research showing relationship between vitamin D deficiency and cancer of the breast, prostate and colon blood levels < 30 ng/ml (ref: Grant WB, Cancer 2002)

15 Vitamin D: Diet and Supplementation Milk Fortified Food Sources 100 IU per 8 oz Supplementation Soy Milk Yogurt Fatty fish (salmon) Eggs 120 IU per 8 oz 40 IU per ½ cup Natural Food Sources 300-1,300 IU/4 oz 25 IU/yolk 400 IU/day is suggested for maintenance of blood levels of vitamin D > than 20 ng/ml 1000 IU/day suggestion for repletion of vitamin D Vitamin D supplementation not to exceed 2,000 IU/day unless directed by MD Cod liver oil 450 IU/tsp *recommend 800 IU/ day during winter months

16 Recommendations for Vitamin D Repletion: Children Deficiency: < 20 ng/ml Recommendations based on age < 1 month: 1000 IU/day 1-12 months: IU/day > 12 months: > 5000 IU/day Provide for 2-3 months, recheck 25-OH vitamin D level. Vitamin D3 preferred form Misra M, et al Pediatrics 2008; 122:

17 Weight Gain Overweight Associated with recurrence of cancer No magic bullets to achieve weight loss Seek individual counseling from a Registered Dietitian Practice mindful eating Portion control

18 Vary colors and textures of food for greater intake and satisfaction 5 servings per day of fruits and vegetables: ~2 cups fruit and ~ 2.5 cups vegetables Mindful Eating

19 Portion Control 20 Years Ago Today 210 calories 1.5 ounces How many calories are in today s muffin?

20 Portion Control 20 Years Ago Today 210 calories 1.5 ounces 500 calories 4 ounces Calorie Difference: 290 calories

21 Inflammatory Response in Chronic Disease and Cancer Prevention We have markers in our body that show there is inflammation. Examples are: C-Reative Protein (CRP) Interleukin-6 (IL-6) Tumor Necrosis Factor- alpha (TNF-α)

22 Inflammation There is research that shows, the foods we eat and lifestyle choices we make can lower inflammatory markers in our body, and reduce the risk of chronic diseases, such as diabetes, cardiovascular disease, and some types of cancer

23 Anti-Inflammatory Foods and Lifestyle Whole foods fruits, vegetables, whole grains Eat minimally processed foods Choose foods high in omega-3 fatty acids: (fatty fish, broccoli, kale, walnuts, flax & soybean oil) Limit foods containing trans-fats (hydrogenated vegetable oils found in certain crackers, chips, foods with long shelf-lives) Increase anti-oxidants: selenium, vitamin E, Vitamin C (also found in deeply pigmented fruits and vegetables) Minimize overcooking: broiling, grilling, frying (limit eating of charred foods-glycotoxins)

24 Sources of Omega- 3 Fatty Acids Per 3 oz serving cooked Omega-3 (mg) Herring 2300 Salmon 2300 Mackerel 1571 Halibut 800 Trout 2000 Tuna 900 Cod 200 Best choices: wild salmon, cod, sardines

25 Foods That May Fight Cancer No single food or food substance can protect you against cancer. Beans Berries Cruciferous vegetables (broccoli, cauliflower) Dark Green Leafy Vegetables Flaxseed Garlic Grapes and Grape Juice Green Tea Soy Tomatoes Whole Grains Ref: American Institute for Cancer Research (AICR) Omega-3 s ( fish oil)

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27 Recommendations For Cancer Prevention (AICR) Maintain a healthy body weight Be physically active for at least 30 minutes/day Avoid sugary drinks. Limit consumption of energy- dense foods (high fat, high in sugar) Eat a variety of vegetables, fruits, whole grains and legumes Limit consumption of red meats, processed meats If consumed at all, limit alcoholic drinks to 2 for men, 1 for women Limit salty foods and foods processed with salt Don t rely on vitamins and supplements to protect against cancer Adequate sleep

28 References Madhusmita, Misra MD et.al. Vitamin D Deficiency in Children and Its Management. Review of Current Knowledge and Recommendations. Pediatrics. Aug 2008; Vol 122, Number 2. p Wasilewski-Masker, Karen MD et.al. Bone Mineral Density Deficits in Survivors of Childhood Cancer: Long-term Follow-up Guidelines and Review of the Literature. Pediatrics. March 2008; Vol 121, Number 3. e705-e713. Miles EA, Zoubouli P, Calder PC. Differential anti-inflammatory effects of phenolic compounds from extra virgin olive oil indentified in human whole blood cultures. Nutrition. 2005;21(3):389. American Institute for Cancer Research COG Long Term Follow up Environmental Working Group

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