Providence Integrative Medicine Our approach : focus on evidence - PDF document

Integrative Cancer Care Ken Weizer, ND Kenneth.Weizer@Providence.org 1 Providence Integrative Medicine Our approach : focus on evidence based interventions, use reasonable interventions if evidence is not available Services : Naturopathy, Chinese Medicine, Acupuncture, Massage Therapy and Nutrition Consultation Westside: Zidell Center for Integrative Medicine at St. Vincent Hospital (503-216-0246) Eastside: Stuvland Center for Integrative Medicine at Providence Portland Medical Center (503-215-3219) 2 Lifestyle, Diet and Cancer: Your Choices Matter  Studies suggest that dietary and exercise choices affect:  Risk of getting cancer  Risk of cancer coming back or dying from it  How well patients tolerate cancer treatment  Studies suggest that the greater the involvement in positive lifestyle and diet choices, the greater the benefit is to your health 3 1

Few cancer survivors do lifestyle modification  Only 5% of cancer survivors implement dietary changes and physical activity and non-smoking  Dietary Changes – 5 a Day fruits and veggies  Physical Activity – 150 minutes of moderate to strenuous or 60 minutes of strenuous physical activity per week. ACS SCS-II , J Clin Oncol 2008;13:2198-2204 J Clin Oncol, 2007 Jun 10;25(17):2345-51. 4 What You Eat Matters When You Have Cancer Prospective Observational Study: Looked at food habits of 1009 people with Stage III colon cancer, undergoing chemotherapy, followed 5+ years “Western Diet” – More meat, fat, desserts, sweets, refined grains “Prudent Diet” – Similar to Mediterranean diet: more fruit, vegetables, fish, poultry Outcome: Greater intake of “Western” foods associated with 3x the risk of recurrence and death from colon cancer p = <0.001 Meyerhardt JAMA 2007;298(7):757-764 5 Diet and Breast Cancer PREDIMED Study Randomized 4282 women to either an olive oil enhanced Mediterranean diet or a low fat diet, Med diet group 68% less likely to develop breast cancer over 4.8 years. JAMA Intern Med, 2015 Nov;175(11):1752-60 6 2

Diet and Breast Cancer WINS Study - Women’s Intervention Nutrition Study Looked at adding lower-fat diet (20% of calories as fat) to usual breast cancer treatment Findings with addition of low-fat diet:  Significant (6 lb) weight loss  Lower breast cancer recurrence rate: after 3 years, 24% less recurrence overall, 40% less ER- tumor recurrence rate Chlebowski JNCI 2006;98:1767-76 7 Fat Other studies haven’t shown a link between breast cancer and total fat intake. Other aspects of diet change (less processed foods, less bad fats, weight loss) in this study may contributed to the positive outcome seen in this low-fat study. Chlebowski JNCI 2006;98:1767-76 8 The Mediterranean-Style Diet  Vegetables, legumes, fruit, nuts, unrefined (whole) grains, extra-virgin olive oil, fish  Traditional dairy - cheese and yogurt The benefits:  Studies on this eating pattern show many benefits: less obesity, heart disease and a reduced risk of cancer. 9 3

Mediterranean Diet Studies Lyon Heart Study  4 year study comparing Mediterranean Diet to standard diet  60% reduction of all cancers , 70% less cardiac events, 45% less deaths  50% less deaths from all causes! 4 year follow up. deLorgeril Arch Int Med 1998;158:1181-87 Knoops JAMA 2004;292:1433 DIANA 1 & 2  Lowers weight, cholesterol and insulin resistance, improves hormones linked to breast cancer risk Berrino Cancer Epid Bio Prev 2001;10:25-33 Berrino Int J Ca 2005;113:499-502 10 Foods and Breast Cancer Probably Influence Breast Cancer  Refined grains & sugar (increases risk)  Beans, whole grains (decrease risk)  Flax seed, but probably not flax oil (decreases) Probably Do Not Influence Breast Cancer  Soy  Dairy products  Meat  Total fat intake Probably Influence Breast Cancer  Fruit & Vegetables 11 Vegetables and Fruit  Data conflicting van Gils JAMA 2005;293:183-93, AICR 2007  Probably need to eat at least 600g/day – a little over a pound - for benefit  Type consumed may be important (e.g. more cruciferous vegetables – cabbage, broccoli etc)  Higher blood levels of carotenoids (indicating greater fruit and vegetable intake) associated with better recurrence-free survival WHEL Rock J Clin Oncol 2005;23:6631-38 12 4

Eat 9 servings every day - about 1 pound Serving sizes: • 1 medium piece of fruit • 1/2 cup chopped fruit • 1 cup raw leafy vegetables • 1/2 cup chopped vegetables  Choose raw, cooked and frozen over dried or canned. Check ingredient labels for salt and sugar  Juices are less beneficial: more calories, less fiber, less total nutritional content, lead to weight gain 13 Whole Grains  100% whole wheat, brown rice, corn, oats, rye, brown (unpearled) barley, millet, quinoia  Contain more minerals, vitamins, antioxidants, and fiber than refined grains  Associated with lower risk of constipation, breast and colon cancer, heart disease and type 2 diabetes 14 Refined Flours and Sugars  Includes enriched flour, most breads, pastries, pasta, bagels, cold cereals, white rice  Refined sugars include: white and brown sugars, dextrose, glucose, high fructose corn syrup, juice, agave, cane juice, fruit juice concentrates  Little nutrition, LOTS of calories  Worsens insulin resistance, obesity  May increase breast cancer risk Int J Cancer 2005;114:653-58  May increase breast cancer mortality Borugian Cancer Epid Biomarkers Prev 2004;13:1163-72 15 5

The Hard News About Soft Drinks Soft drinks (regular and diet, one or more daily) worsen:  Insulin resistance (which raises risk of breast cancer)  Increases obesity (which raises risk of breast cancer)  Cholesterol and triglycerides; raises blood pressure and blood sugar Framingham, 4 yrs, n=6039, Dhingra Circulation 2007;116:480-88  Artificial sweeteners seem to increase total calorie intake through increased appetite Swithers, S. Behavioral Neuroscience 2008;122:161-73 16 Flax Seed  Women who ate 25 gm (4 tablespoons or ¼ cup) ground flaxseed in a muffin research study had reduced tumor growth at 39 days. Significant reduction in Ki67 and Cerb-B2 labeling index, increased apoptosis N=47 thompson, Goss, Clin Cancer Res 2005;11:3828-3835  Flaxseed lignans reduce breast cancer cell adhesion, invasion and migration in in vitro and animal studies. ER- cell lines Chen & Thompson Br Ca Res Treatment 2003;80:163-170 17 Using Flax Seed  Buy whole flaxseed, store in fridge or freezer  Time saver: grind a week’s worth; store in a flip-top jar in the fridge  Ground flax has a mild nutty flavor, put in hot cereal, salad, yogurt, cottage cheese, smoothies. Can also take mixed in 4-6 oz water.  Use in baking only if you can track the amount in each serving  Sesame seeds may have similar benefit Nutrition and Cancer 2005:52:156-65 18 6

Beans and Legumes  Rich in healthful plant chemicals, antioxidants, fiber and minerals   Examples: split peas, lentils, dried peas (black- eyed, chickpeas) and beans of all kinds (black, pinto, navy, white, red, kidney, etc).  Eat 5 or more servings per week Manios, Mediterranean Diet as Nutrition Education and Dietary Guide, Forum Nutr 2006 19 Soy  Soy foods appear most protective against breast cancer if eaten in childhood and the early teen years.  Avoid soy protein powders, isoflavones and large quantities of soy milk until more is known about their safety.  Acceptable choices (3-5 servings a week): whole soybeans, tofu, miso, tempeh and green soybeans (edamame). Boyapati. Breast Ca Res Treatment 2005;92:11-17; J Nutr 2001;131:3095S-3108S 20 Meat  Red meat appears to be safe up to about 18oz (raw weight) weekly. Fish may have some protective properties. AICR 2007  Of all the types of meat, processed and preserved meats are more strongly associated with increased breast cancer risk than other forms of animal proteins. (23-64% increased risk) Egeberg, R. Eur J Cancer Prevention 2008;17:39-47 Taylor E.F. British J Cancer 2007;96:1139-46 21 7

Alcohol  Alcohol consumption >7 servings/week seems to significantly increase the risk of breast cancer  Risk most increased at 2 drinks a day, but probably begins increasing around one drink daily  The choice to drink alcohol should be based on individualized medical history - talk to your physician. CA Cancer J Clin 2006;56:323-353 22 Dietary Fat  Total energy (calorie) intake more important for risk than total fat intake  Total fat intake not related to risk or prognosis in most (not all) studies  (for discussion, see Mc Eligot 2006)  Certain fats may be more beneficial:  Olive oil associated with less breast cancer Sieri Ca Epid Bio Prev 2004;13:567-572 Lancet Oncology 2005;6:69 Conflicting: McEligot Nutr Cancer 2006; 55:132-40  Omega 3 fats may be protective Menedez, J. et al Clin Transl Oncol 2006; 8:812-20 23 High Fat or Low Fat Diets?  Randomized trials consistently show better results for health outcomes with higher fat diets (typically Mediterranean or Atkins) compared to low fat diets.  However, low fat whole food low-processed-carb diet probably work for some people, but there is very little good data.  Mediterranean and Atkins superior to low fat diet for weight loss, glucose and insulin levels, and cholesterol levels. Shai, I. NEJM 2008;359:229-41 24 8