Eating Well after Transplant and CAR T-cell Therapy: Why It Matters

Transcript of Presentation

(00:01): Marsha Seligman: Introduction. Welcome to the workshop Eating Well after Transplant and chimeric antigen receptor (CAR) T-cell Therapy: Why It Matters. My name is Marsha, and I will be your moderator for this workshop.

(00:10): It is a pleasure to introduce today's speaker, Ms. Layla Silverman. Layla Silverman is a registered dietitian and board-certified specialist in oncology nutrition. She is the clinical nutrition coordinator and a bone marrow transplant interdisciplinary team member at Memorial Cancer Institute in Pembroke Pines, Florida. In addition to her work at Memorial Cancer Institute, Ms. Silverman is involved in community outreach and has facilitated many cancer prevention programs. Her goal is to translate evidence-based nutrition science into practical advice for patients. Please join me in welcoming Layla Silverman.

(00:52): Layla Silverman: Overview of Talk. Thank you, Marsha. It's a pleasure to be here. Let’s get right in. I'm talking today about why nutrition matters after transplant and CAR T-cell therapy. Thank you for joining me.

(01:09): Our objectives today are for you to learn about your nutritional needs after CAR T-cell therapy or transplant, and how to manage symptoms that impact adequate nutrition afterwards. We're also going to learn about the American Institute for Cancer Research recommendations for eating healthier, and ways to plan healthier meals. We'll also talk a little bit about popular diets and if they're right for you. We hope you learn a lot.

(01:42): Let’s start with your nutritional needs after transplant or CAR T-cell therapy. We normally recommend a diet that's high in protein and high in calories -- those two things are very important after these therapies. Maintaining adequate fluid intake is also very important. We also must make sure that patients remain mindful of food safety to minimize any infection risk after the therapies. And we're also going to talk about how to manage symptoms that impact adequate nutrition. We'll dive into each one of these individually.

(02:23): Frequent, high protein snacks are recommended and there are many options.  How can you get more protein into your diet, especially when you're struggling? One of the main things that we try to get patients to do is to add high protein snacks between meals. The more often you eat, the more chances you have of getting enough protein in your diet. Every meal counts. Every bite counts. Every meal and every snack should include a source of protein.

(02:51): These can be animal proteins or plant proteins. Some examples can be having some yogurt with fruit -- it doesn't have to be regular milk-based yogurt. It can be a non-dairy yogurt. There are a lot of options out there nowadays. Another quick and easy snack can be peanut or almond butter with crackers. It can also be any other nut butter. There are so many out there. There's cashew nut butter as well. Any nut butter combined with crackers can be an easy snack for you to get some extra protein into your diet.

(03:30): It can be cheese and fruit. It can be cottage cheese and fruit. And sometimes a protein shake can be very handy. It can be homemade or store-bought. If you get a store-bought shake, there's a wide variety out there. It’s an easy way to get some extra protein into your diet. There's a lot of high-protein shakes, and it can be plant-based or milk-based protein.

(04:03): Extra calories in every meal and snack can help maintain or regain lost weight. How can you get more calories? Protein is not the only thing that's important. Calories are very important as well, especially if you're losing weight. You need to get some extra calories in every meal and every snack.

(04:18): Eating every two to three hours, eating more often, even if it's just a little bit – a few bites are better than eating nothing or skipping that meal. Make sure that every two to three hours, you're getting a little something to eat. Things that are high in calories can be some of the healthy fats. A snack can be some crackers and avocado like a guacamole, or it can be crackers and peanut butter, like I mentioned earlier. Peanut butter, almond butter, avocado, and olive oil give us healthy fats. Again, you can do a high-calorie or a high-protein shake. And like I mentioned before, it can be dairy or non-dairy-based. Some of the non-dairy-based shakes are easier to tolerate, especially if you're having symptoms like diarrhea.

(05:15): Besides getting enough protein and calories, we need to make sure that you're getting enough fluid in your diet as well. Many symptoms after transplant or CAR T-cell therapy can make you dehydrated very quickly. If you're nauseous and vomiting or if you're having diarrhea, you can get dehydrated quickly. Making sure you're getting enough fluids in your diet is important.

(05:41): One of the main things that I try to get patients to do is to always keep a water bottle with them. Every sip counts. Sometimes patients are very forgetful. You have so many things going on, you can set a reminder. And nowadays, everyone has a smartphone, so setting a reminder on your phone is an easy way to help you get enough fluids.

(06:09): It’s not just water. There are foods that are hydrating as well, like fruit, Jell-O, or broth-based soup popsicles. Those things count as fluid as well. Sometimes, if you're losing fluids from symptoms like vomiting or diarrhea, you need to replace the electrolytes that you're using. You need to make sure you're having some fluids with electrolytes in them, like Gatorade or Pedialyte, or other brands. Find something that works for you. There are many powders that you can add to a water bottle to supplement the electrolytes in your water. That's fine too.

(06:52): Another natural electrolyte drink is coconut water, which is very high in potassium. If you feel like you're not drinking enough water because it doesn't taste good, then add some flavor to it. You can add a splash of juice. You can cut up some fruit and infuse your water with a little bit of flavor that way, because fluids are always going to be important.

(07:16): Make sure you find a way to get enough fluids in your diet. Most people need about eight cups of fluid a day. It really depends on your weight. I always tell patients to look at their weight in pounds and divide that by two, and that's more or less how many ounces you need in a day. So if you weigh 120 pounds, divided by two, you need around 60 ounces a day of fluid.

(07:52): Food safety precautions: you must remain mindful of what you're eating so that you don't get sick from something you ate. Food safety is very important after CAR-T and transplant. One of the most important things you'll do to prevent any foodborne illness is to be to wash your hands and disinfect all the surfaces where you're preparing your food.

(08:19): Make sure you're also checking expiration dates on food. You'd be surprised how many foods you find at the grocery store that are about to expire. Make sure you're checking those expiration dates. Make sure that you're not eating any undercooked meats, and especially no raw meats -- no sushi, no undercooked steaks, or anything like that.

(08:42): Make sure that you're not leaving food out for too long. Food shouldn't be out for more than two hours after cooking. If you're not going to eat it within those two hours, just put it in the refrigerator. For fruits and vegetables, make sure you're washing those thoroughly. Even if it's something that comes in a bag like bagged lettuce or spinach that says it's been washed already or triple washed, you still need to rinse it at home.

(09:09): Make sure you wash all your fruits and vegetables thoroughly. Follow the guidelines that were provided to you by your healthcare provider. Every facility is a little bit different. In my institution, we do allow fresh fruits and vegetables as long as they're washed thoroughly. But in other institutions, I've had patients where they were told they couldn't have any. So just check with your own healthcare provider.  

(09:40): Some of the symptoms that we're going to discuss a little bit more in detail that can impact nutrition after transplant or CAR T-cell therapy are nausea, diarrhea, taste changes, mouth sores, constipation, and the loss of appetite and weight.

(09:58): Patients with nausea should eat more frequently, drink enough fluids, and use natural remedies. Let’s start with nausea. One of the most important things I tell my patients is to make sure that you’re eating more frequently. The longer you go without eating, the more nauseous you can get. Even if you're feeling a little queasy and you don't want to eat, have a couple of crackers, a few salted nuts, or a few pretzels, at least. Have something in your stomach because that's going to help prevent the nausea from getting worse.

(10:29): Do make sure you're drinking enough fluids. Sometimes patients are not drinking enough. You need to take sips throughout the entire day. If you're already nauseous, you still need to get enough fluid. Make sure you're flavoring your water if it doesn't taste good to you, like I mentioned earlier.

(10:49): You can also try some natural remedies for nausea in addition to your medications. For example, ginger is really good for nausea, as is mint. You can do a ginger tea or a mint tea. You can also do ginger candy or mints to help with the nausea. Avoid foods that have a strong odor because that can trigger your nausea. Keep your diet bland and easy to digest. Keep it simple, but make sure you're eating something every couple of hours.

(11:29): For diarrhea, patients should follow a low fiber diet like the BRATT diet. If you're having diarrhea, it’s a little bit trickier. We’d normally recommend a diet that's low in fiber, nothing too greasy, and nothing too spicy or acidic. Dairy can make diarrhea worse if you already have it. It's not going to cause it, but it can make it worse. Try to limit the dairy as much as you can, or choose the lactose free dairy options.

(11:57): A low fiber diet basically means that you're not going to have things like a salad, beans, or nuts and seeds if you're having diarrhea. You're going to keep it very simple, very low fiber. Things that we normally say aren't so healthy like white rice and white bread are the things that are going to help you if you're having diarrhea. We try to educate patients on the BRATT diet, which stands for banana, rice, applesauce, toast, and tea. You have this for breakfast, lunch, and dinner. Now, you can't stay on this diet for too long because it's not a complete diet, but it's something you would do for maybe a day or two, and then you slowly add protein foods to it.

(12:45): But you can add things like broth on a BRATT diet. It’s a modified BRATT diet. You can add a hard-boiled egg. You can add some baked chicken to get some extra nutrients while you're on the BRATT diet. But it really does help to just keep it simple when you have diarrhea. All of this is in addition to taking your medicine.

(13:11): There are several ways to respond to taste changes in food after transplant or CAR T therapy. Now, if you're experiencing taste changes, which are actually very common after transplant and CAR T-cell therapy, these are some suggestions. If you have a metallic taste in your mouth, maybe you need to add a little sweetener to your food, or add a little healthy fat, like drizzling a little bit of olive oil on your food. It can help with the metallic taste.

(13:37): Or you may need to marinate your meats. A lot of times when there's taste changes, what patients tend to stop eating first is the protein -- the chicken, the fish, the meat -- because it just doesn't taste good. So if you marinate those proteins, it will help it taste better to you.

(13:59): Some patients complain of a taste that's too sweet. Everything tastes very sweet. You can add a few drops of lemon to your food if that's the case. If it's too salty, salty is very difficult as well, but you can also add an acid -- maybe a little bit of lemon or lime juice to your food. If it's too bitter, you do the opposite. You make it a little sweeter.

(14:24): Cardboard is when food has no taste. You can add a little salt, or you can add a little drop of lemon juice as well. Try that or you can try different seasonings. Maybe something you are not used to, a different spice. If it's too sour, add a little bit of sweetener and see if that helps. There are different things you can try. Another thing I tell patients to make sure they're drinking enough fluids because a lot of times these taste changes get better if they're better hydrated. Hydration is always important.

(15:07): Mouth sores can be treated with oral rinses or oil pulling. If you develop mouth sores, it can be very difficult, and it really limits patient’s intake after transplant or CAR T-cell therapy. One of the things we try to do for patients is an oral rinse with salt, baking soda, and water. It's very diluted, and you just use that throughout the day. You can also try some oil pulling. Oil pulling is an ancient practice that’s basically swishing oil in your mouth for one or two minutes. You can use coconut oil. It has antibacterial properties, and it's also soothing for a lot of patients. It helps with those sores in the mouth.

(15:52): Obviously, if you have sores in your mouth, you're going to try to avoid things that are too spicy or acidic because that's only going to make it worse. It's going to be irritating. And you're also going to try to choose foods that are soft and moist, things that have a sauce or gravy on them so they're nice and easy to swallow. Another thing that's very important is to make sure that the toothbrush that you're using is soft, so you don't further irritate your gums.

(16:22): For constipation, more fluids and a high fiber diet can be helpful. Now, if you're constipated, it can be related to either not drinking enough fluid or maybe you're just not eating enough, so you're not having a bowel movement every day. Also some pain and nausea medications can cause constipation. It's something that happens as well.

(16:44): If you are constipated, you're going to do a high fiber diet. We want you to get more fiber because that helps regulate you better. But in addition to getting more fiber, we also try to get patients to drink more fluids. Because the more fiber you eat, the more fluids you need. That is very important. They go hand in hand.

(17:05): Increase your fluid intake. Sometimes warm liquids work better than just cold, so we try to get patients to do that. Maybe some teas at night. You can also try prune juice and prunes. Those are very effective. And there's a tea called Smooth Move that tends to be very effective for a lot of patients that are suffering from constipation. And all of this, of course, is in addition to any medications that you're prescribed.

(17:37): If you have a loss of appetite and weight loss, again, eat small frequent meals -- I can't emphasize that enough. Every two to three hours you're going to be eating something because you're eating less. If you don't have an appetite, you're likely eating much less than you were eating before. You need to eat a little more often so that at the end of the day, you get enough calories and enough protein.

(18:02): Try to make the most out of every small bite. Make sure you're eating foods that are higher in calories and higher in protein. Sometimes drinking something is easier than eating, so you can try a protein shake, a nutritional supplement that way. Try different foods. And what I mean by that is foods that are seasoned differently or something that you're not used to eating. Try something new.

(18:28): Make sure you're making mealtime special. If you don't have an appetite, you at least want to have a good time. So set your table nicely. Make sure you're eating with someone. When you eat alone, you tend to not eat as much. Eat with family, with friends, and try to think of something that sounds appetizing to you. When you don't have an appetite, I know you probably can't think of anything, but there's always something like a guilty pleasure that you might want to take advantage of. Honestly, if you're losing weight, we want you to eat. Even if it's something that's not very healthy, we still want you to eat it because we need you to get more calories. We want you to stop the weight loss. So keep that in mind.

(19:14): Once symptoms improve, patients should focus on eating healthier. Besides dealing with symptoms, once the symptoms get better, and you're feeling a little bit better, then we try to get patients to focus a little bit on eating healthier. If your appetite is much better, your weight is more stable, and you don't have any nausea or vomiting or diarrhea, then this is the time when you could start focusing a little bit more on eating healthier.

(19:41): Patients should reduce red meat and limit processed meats in their diet. We follow the recommendations from the American Institute on Cancer Research. They have a really good website. I do invite you to visit that. They have really good information. And some of the recommendations are, number one, to cut back on red meat, and limit processed meats. We're going to talk about each one of these more in detail, including eating more whole grains and beans, increasing your vegetable and fruit intake, limiting alcohol, and getting to a healthier weight and staying active. These are the things that we try to get patients to do once they're feeling better.

(20:25): Let’s start with red meat. Red meat includes beef, veal, pork, venison, and bison. Some people think that pork is the other white meat, but it really isn't. It's still considered a red meat. The recommendation is to have less than 18 ounces per week. And when you do have it, to make sure that it's a lean cut.

(20:51): Another important thing when it comes to meats is that you want to cook it at a low to medium temperature because we don't want you to be eating meats that are charred. These are carcinogenic. You can brown the meat, but don't let it burn. And if it did burn, take that piece out and don’t eat it. Usually the meats that will burn faster are the fatty meats. That's why it's also important to choose lean cuts.

(21:27): Then, there are processed meats. Nitrates are also carcinogenic, and nitrates are found in processed meats. The World Health Organization actually classifies them as carcinogenic, and they're in the same group as smoking, so keep that in mind. There's no recommended amount, but we tell patients to eat as few processed meats as possible. That includes deli meats, bacon, sausage, hot dogs, and things like that.

(22:03): Nowadays, you can find some brands that are nitrate free, and that's okay. If a meat is nitrate free, you can have it, but it will still have quite a bit of sodium, so it's not the healthiest option. If you're looking at making a sandwich, maybe choose something else. You can do a tuna salad or a chicken salad, but try to limit the processed meats as much as you can.

(22:32): Choosing whole grains and beans: This is a very important recommendation. Why? Because whole grains and beans give us a lot of fiber. They give us B vitamins, iron, magnesium, and selenium -- a lot of minerals. And some of the sources of whole grains are going to be ancient grains, but also barley, oats, quinoa, buckwheat, black rice, and beans. It's not a typo. There is black rice. There are black beans too. All of these things give us a lot of fiber. Some of them give us quite a bit of protein too, like beans and quinoa. Some of the benefits are that they have been shown to reduce certain cancers like colon cancer. They also help us regulate digestion.

(23:27): Fiber is also called a prebiotic. I'm sure a lot of you have heard of probiotics, but prebiotics are the food for the probiotics. They help keep your gut healthy because they help keep the probiotics multiplying. If you're eating enough fiber, the probiotics in your colon will keep multiplying, which is good for everything. Fiber also helps regulate blood glucose if you're having trouble controlling that. Whole grains and beans are very important, so they should be a part of your healthy survivorship diet.

(24:07): Another recommendation is to increase fruit and vegetable intake. This sounds very simple or very basic, but it's really one of the hardest things to do on a consistent basis. The recommendation is to eat between three and a half to five cups of fruits and vegetables per day. The most important thing is to make sure you're having different colors. The more colors, the better. They say to eat the rainbow, and you really should be eating the rainbow. Try to choose as many different colors as you can. Try to think of what vegetables you can add to every dish that you're making, whether it's in the sauce that goes with it or in the actual dish. Make sure you're always adding some veggies in there.

(24:56): For example, to get your goal of fruits and vegetables, you can do a cup of fruit in the morning with your breakfast and then have two cups of vegetables with lunch and two with dinner. This means that half your plate for lunch and dinner should be vegetables.

(25:13): And they don't always have to be fresh, although fresh are going to be the best tasting vegetables. They can be frozen. They can even be canned. The only problem with canned veggies is that they're a little higher in sodium. But nowadays, you can find low sodium varieties. So whatever works for you, as long as you're increasing the amount of fruits and vegetables that you're eating every day, that’s always going to help your overall health.

(25:41): Another recommendation for survivors is to limit alcohol. And when you have it, have it in moderation, if at all. Any amount of alcohol can increase your risk for cancer recurrence. Also, if you're on active treatment or if you're still dealing with symptoms, you need to ask your healthcare provider if that's a good time for you to have any alcohol. Often, our recommendation is to avoid it for a very long time after transplant or CAR T-cell therapy because it really just depends on how you're doing at that moment.

(26:18): The serving size for moderate intake is : one serving is about an ounce and a half of liquor, five ounces of wine, or 12 ounces of beer. Drinking in moderation means that if you're a woman, you would have one drink a day. And if you're a man, it would be two drinks in a day. It doesn't mean you would do this every day, but just the least amount possible with the least amount or the least frequency as you can.

(26:50): One of the last recommendations is getting to a healthier weight. So we are always looking at the BMI. We know that excess body fat can increase our risk for cancer, but also for other things like cardiovascular problems. Getting to a healthier weight means you're going to try and have a balanced diet. You're going to try to exercise. It’s really both together. You can't do one without the other or it's going to take forever to get to a healthier weight. Make sure you're doing both -- balancing your diet and also trying to stay as active as you can.

(27:30): The BMI is a good guide, but it's not perfect and it's not the only thing you should be looking at when you're thinking about getting to a healthier weight, because BMI does not take into consideration body composition. If you're someone that has a lot of muscle, muscle weighs more, so you might be in the overweight category here, but it doesn't mean you're overweight because you just have more muscle. It’s one of the things you can look at, but it shouldn't be the only thing you're looking at.

(28:04): And then there’s exercise: To get to a healthier weight, remember you need to stay active. Every little bit counts. So just start slow and increase as you can tolerate it. Always talk to your doctor because maybe this is not a good time for you to be active, but maybe in a couple of weeks it will be. Consult with your healthcare provider.

(28:28): Exercise is important not only for your physical health, but also for your mental health. It helps you feel better. It enhances your quality of life. And even though a lot of patients complain of being tired or feeling fatigued, it really does help with that. It's hard at the beginning because you have to push yourself to get out and go for a walk. But once you do it, it gives you energy, and it makes you feel better. Make sure you're including that. And a lot of cancer centers will have an exercise program for cancer survivors. Make sure you're asking your healthcare provider if that's something that's available to you.

(29:08): Planning healthier meals in advance can help patients regain better health and fitness. Now, besides talking about the recommendations, I also wanted to talk a little bit about planning healthier meals. It's important to make sure that we're planning ahead to be successful. When you're planning meals, make sure to write them down. In this planning process, include your family. Make it enjoyable. Take a look at what you already have at home. Go online. Look at flyers from your local grocery stores. Oftentimes they can give you ideas for healthy meals as well. Make a list when you go shopping and stick to your list. Also, make sure that when you're planning your meals, you are also planning to use those leftovers.  

(30:02): Let's take a look at planning for breakfast. Make sure that you're always thinking about what protein you're going to add to your diet. Proteins for breakfast can include eggs, dairy or non-dairy alternatives, nuts and seeds, or nut butters. It's important to include a carbohydrate. Make sure you have some whole grains available to you or add them to your list, like whole wheat bread. Make sure you have some fruit at home so that you can have some fruit in the morning with your breakfast. And say you only have oranges at home, add a little variety because maybe you don't want to eat oranges every day for the next week.

(30:43): Another important thing when you're planning meals is to make sure that you are including a healthy fat, especially if you're losing weight and trying to get extra calories. Here are some examples for breakfast: It can be something as simple as oatmeal cooked with milk. You add a little bit of peanut butter or nuts and a little bit of fruit. You can keep it simple, or you can get a little fancy and add other things to it as well.

(31:17): Let's take a look at lunch. Again, we're going to look at protein first. What's going to be our protein for our lunches? Do you have chicken at home? The meats are going to be perishable, so you only want to buy what you're going to use, but you can always keep the non-perishable proteins at home as well. Things like beans, lentils, and high-protein grains, make sure you keep them at home.

(31:40): Make sure you have some whole grains, brown rice, whole wheat pasta, and some vegetables, along with a healthy fat. We talked earlier about avocados. Those are a good thing to keep at home too, especially if you need those extra calories.

(31:55): Here are some examples of lunches. You can keep it simple. It can be a salad. It can be a sandwich. If you're doing a salad, I always try to get patients to make sure that they're adding at least five different vegetables to their salad. It sounds like a lot, but it's really not that hard, especially if you're buying a bagged lettuce mix, which already has two or three vegetables in it. Keep that in mind.

(32:27): Now let's take a look at dinner. When planning dinner, again, you want to ensure you're planning for protein. And then for dinner, I do want to mention some recommendations. We said to cut back on red meat. Make sure to have at least one to two meatless meals per week. That will help you cut back on the red meat. You don't want to have red meat more than twice a week in total, not just for dinner, but any meal -- twice a week or less.

(32:58): Try to have more fish. Try to aim to have fish at least twice a week. Again, have some whole grains at home, some vegetables, and some of those healthy fats available to you. Some examples: again, you can keep it as simple or as fancy as you want, but it can just be fish, brown rice, and some steamed veggies. And if you want to keep it plant-based, maybe you want to have some beans with quinoa, a little side salad, and some avocado if you need those extra calories. These are just some examples.

(33:37): Popular diets need to be evaluated carefully in advance. Besides going through some examples of different meals, I also want to talk a little bit about popular diets because there's a lot of fad diets out there, and these are some of the questions we get often from patients. We're going to quickly review the alkaline diet, the ketogenic diet, and the Mediterranean diet.

(34:03): The alkaline diet, in theory, means that an acidic environment causes or promotes cancer. The alkaline diet tries to make your diet more alkaline by eating more fruits, vegetables, limiting red meat, sugar, and white starches. And the thought is that this will create a more alkaline environment, but the fact is that our body already does that.

(34:30): The alkaline diet have no clinical data to support it but it does include high fiber and plant based foods. Our pH is controlled already. Our bodies do that on their own. There's really no clinical data that shows any benefits to this. However, the alkaline diet does include a lot of high fiber and plant-based foods, which are not bad for us. They can be beneficial. You can still follow some aspects of this diet. Just make sure you're getting enough protein and calories. This diet tends to be a little low in calories, and low in protein, vitamin D, and calcium. You can follow some aspects of it, just not to the T.

(35:07): The ketogenic diet may help specialized conditions but it not the standard of care and is hard to follow. The Ketogenic diet is very popular. So the ketogenic diet is basically high in fat, high in protein, and low in carbohydrates. The thought is that you're restricting glucose and you're starving cancer cells and producing ketones, which can be toxic to cancer cells. There is a place for the ketogenic diet, but it's mainly for people that have epilepsy or glioblastoma, but it's really not the standard of care. Plus, it's very hard to follow.

(35:39): At first, it may cause very significant weight loss, which is not ideal for transplant patients. So this diet may not be a good idea for someone who's already losing weight.

(35:53): Another diet is the Mediterranean diet, which is very popular, and actually this one is a good one. It's rich in olive oils, fish, nuts, leafy greens, and vegetables, and it’s based on the traditional diets from people that live in the Mediterranean.

(36:11): It's high in anti-inflammatory foods, which are good for us. The Mediterranean diet is actually a good diet and it has been proven to be beneficial for heart disease, diabetes, dementia, and some types of cancer. The only thing is that if you're new to this diet, just make small changes at a time so that you don't cause drastic weight changes, but overall it is a good diet for cancer survivors.

(36:43): All right, we're nearing the end here. The take-home message today for all of you is that immediately after transplant or CAR T-cell therapy, your needs are basically to maintain your energy and manage symptoms. That should be your focus. Once your symptoms are under control, then you can focus on eating healthier. You can try and plan your meals ahead of time to help you be successful in eating a more balanced diet.

(37:12): And remember, not every meal will be perfect. Be gentle to yourself and celebrate the small wins. Every little change that you make, make sure you celebrate that so that you can keep going. Thank you for this opportunity, and that's all I have. Now we’ll have questions.

Question & Answer Session

(37: 31): Marsha Seligman: Thank you, Ms. Silverman, for all the important information on diet and nutrition. Let's get to the question and answer session. Our first question is, how do you suggest washing fruits and vegetables? Just water, dish soap, or anything else?

(37:56): Layla Silverman: To wash fruits and vegetables, you only need water and friction. But if you need to use something extra, you can use a little bit of vinegar, especially if it's something that's hard to wash, like berries -- raspberries, blueberries, things like that. You can put them in a little bit of water with vinegar. But if it's something that grows underground like carrots or potatoes, you can use a little brush and water. You don't need anything extra.

(38:29) Marsha Seligman : The next person first would like to thank you for your discussion and would like to know your thoughts about using nutritional yeast or tempeh. They ask is there a concern in regards to food safety with having these foods?

(38:44) Layla Silverman: As long as they're pasteurized, they should be fine. They do add some protein to your diet but just check the label. I'm not sure if the nutritional yeast would be pasteurized. I'm pretty sure there are some varieties that are, so just look for that. And then the tempeh, you can find it pasteurized.

(39:06) Marsha Seligman: Is it okay for multiple myeloma patients to use honey?

Layla Silverman: So yes, but it needs to be pasteurized.

Marsha Seligman (39:25): Do you recommend bulgur in place of brown rice?

(39:29) Layla Silverman : Yes, that would be a good option. That would give you probably more protein than the brown rice, and you still get fiber from either of the two. So yes, that would be a good option.

(39:44) Marsha Seligman: When it comes to supplements, I'm always told to buy a good brand. How on earth do I know what is a good brand?

(39:54) Layla Silverman: There is a certification. I can't think of the name right now, but some supplement companies do third-party testing, which means they hire a company to test their supplement and make sure that what they have on the label is what's in the bottle. So as long as they're third-party certified, then it's a better-quality supplement. You can search online. There's a certification for that for third party testing.

(40:26) Marsha Seligman: Coffee is the only way I'm able to take my meds without becoming sleepy. What else could I do?

(40:34) Layla Silverman: You can also try green tea. You not only get the caffeine, but you also get some antioxidants. If you're drinking coffee when you're taking your medications, just make sure that it's not too late in the day so it doesn't affect your sleep at night. Or you can do half-caf. It has half the caffeine as regular coffee.

(41):05 Marsha Seligman): What can you eat to prepare for a PET scan as I am told to not eat any carbohydrates after lunch the day before the exam?

(41:17) Layla Silverman: If they've told you not to have any carbohydrates, you can still have your vegetables. You can have your protein, like chicken or fish. You can do grilled chicken or grilled fish with maybe some steamed or asparagus. It's only probably for a half a day, so it's going to be one or two meals that are going to be low in carbohydrates, so that's fine.

(41:48) Marsha Seligman: My naturopath suggests muscle building diets. Red meats build red blood cells. Do organic broths build red blood cells?

(41:59) Layla Silverman: Do organic broths build red blood cells? Well, the broth doesn't really have iron. It may have some protein, but it doesn't have iron, so I don't think it's going to build red blood cells, the broth alone. I don't know exactly what they mean by the question.  

(42:44) Marsha Seligman: In reference to diet, are chicken and seafood better options than red meat?

Layla Silverman (42:51): Yes, they're better options than red meat. Like I said in the presentation, it doesn't mean you have to stay away completely from red meat, but definitely chicken and fish will be better. Fish would probably be the best because you're getting your omega-3s, which are the anti-inflammatory fats.

(43:12) Marsha Seligman: At the time of my transplant, I was told that I should never eat raw eggs or fish again. It's been 20 years. Are Caesar salads and homemade mayonnaise still off limits?

Layla Silverman (43:26): You can check with your healthcare provider your counts. It's really based on your counts, whether your immune system has completely recovered or not. If it's been that long, I would check with your doctor to see if you still need to be on the low immunity diet. A lot of times, I can tell you in my facility, it's on a case-by-case basis and a lot of times our doctors will make an exception if it's something you really want to have. But Caesar dressing, if it's in the bottle at the grocery store, that's going to be pasteurized so it's going to be okay.

(44:09) Marsha Seligman: Are consuming mushrooms appropriate due to them being a fungus?

Layla Silverman (44:16): Mushrooms are fine to eat. We allow them in our facility as long as they're cooked, but you can ask your healthcare provider to see what's allowed and not allowed at the center you're going to.

(44:33) Marsha Seligman: Is ground turkey a good option?

(44:37) Layla Silverman: Ground turkey is an excellent option if you're trying to cut back on red meat. You can use it in every way where you would use ground beef. You can do turkey burgers or turkey chili. So yes, it's a good option.

(44:55) Marsha Seligman: Someone would like to know how long you can drink kefir. Can you do that all year long?

(45:03) Layla Silverman: You can drink kefir every day. It's a healthy food. It gives you probiotics. If it's right after transplant, just make sure it's pasteurized. Most of the ones that you buy at the grocery store are pasteurized, so there's no issue there.

(45:21) Marsha Seligman: How many grams of protein are needed daily?

(45:25) Layla Silverman: The amount of protein that you need every day depend on your weight. Usually after transplant when you need the most, what we recommend for our patients is about a gram and a half for every kilo of your weight.

(45:44) Marsha Seligman: What is your opinion of prepared meals that come in a box to your home?

(45:51) Layla Silverman: If you're talking about right after transplant when we're worried the most about food safety, you'd have to make sure that those meals are still frozen when you receive them and that you keep them frozen after that. If they're not frozen, if they're fresh meals, we usually don't recommend our patients to eat leftovers that are more than two days old. You wouldn't want to keep those in the fridge for more than two days. It really depends on what kind of meals you're getting delivered.

(46:32) Marsha Seligman: Does coffee contribute to cancer and how much is safe to drink on a daily basis?

(46:39) Layla Silverman: No, coffee does not contribute to cancer. I always tell patients you can drink one cup a day as long as you're drinking enough water.

(46:52) Marsha Seligman: For protein powders, considering whey-based versus plant-based, would you recommend one over the other after transplant?

(47:01) Layla Silverman: It depends on your situation. Diarrhea is the main reason why I would choose one over the other. If you're having diarrhea, I wouldn't get the whey protein, I would get the plant-based. Patients tend to tolerate it a little bit better because it's non-dairy. But if you're not having that issue, you can choose either one.

(47:29) Marsha Seligman: I recall reading that we should limit fish intake due to mercury levels. Is this still true? Is fish twice a week too much for dangerous mercury levels?

(47:39) Layla Silverman: It depends on the type of fish you're eating. There are some fish that are very high in mercury, but most people don't eat those. Chilean sea bass, orange roughy, the larger fish because they eat the smaller fish -- they have more mercury in them. But just look it up and see if you're eating a fish that's high in mercury. Most people are eating salmon, mahi-mahi, or tilapia, and those would be very low in mercury and you can have them every day if you wanted.

(48:19) Marsha Seligman: I know you talked about this in your presentation, but someone would like you to clarify a little bit more about being told that pork is a red meat after years of commercials stating that it's the ‘other white meat.’ They would like a little more clarification on that.

(48:38) Layla Silverman: It was just a marketing thing, calling pork the other white meat, but it's really just considered red meat and it's mainly because of its fat content. Again, it doesn't mean you can't have any. You just have to choose the very lean cuts and have it twice a week or less.

(49:04) Marsha Seligman: And I know you talked about raw eggs as well, but someone would like to know if it's okay in a salad dressing or a pasta dish.

Layla Silverman (49:13): Raw eggs right after transplant? No. Not if they're raw or unpasteurized. No.

(49:23) Marsha Seligman: Are you familiar with mushroom coffee and the benefits of it?

(49:31) Layla Silverman: Yes, I have heard about it. It's become very, very popular. Mushrooms are good for us. They have a lot of nutrients in them, but I am not sure how good those drinks that are being sold are. And I don't know exactly what mushrooms they're using either. You would have to look at that particular product and see what's in it specifically and see if it's something you can have.

(50:05) Marsha Seligman: Good energy food that fights underlying causes of health problems such as inflammation -- no one ever discusses this topic. Please go over healing foods, foods that help prevent weight and muscle loss, and the effects of chemo and other side effects.

(50:29) Layla Silverman: That can be a whole presentation. Healing foods are a lot of the anti-inflammatory foods. It's your fruits, your vegetables, your plant proteins, your whole grains, which are all the things we talked about. Just make sure you're including them in your diet. You don't have to be vegan to eat healthy; it's a combination of things. So you can still include some animal protein, but you should also be including plant foods, which are very healing.

(51:07) Marsha Seligman: This is going to be our last question. Someone would like to know if vitamin D and calcium supplements are good to take on a regular basis.

(51:16) Layla Silverman: If you're deficient in vitamin D, you should be taking vitamin D. It's a simple blood test that your doctor can order. Calcium, it depends on your diet and it depends on your age as well. As we get older, we need more, so it's not a bad thing, but I don't know if it's right for you specifically. Feel free to take advantage of the dietitians that are at your cancer center. We're here to help you. We can look at your medical chart and see your individual needs and see if you need the vitamin D and calcium.

(52:00) Marsha Seligman: Closing: On behalf of BMT InfoNet and our partners, I'd like to thank Ms. Silverman for a very helpful presentation. And thank you, the audience, for your excellent questions. Please contact BMT InfoNet if we can help you in any way.