The Role of Nutrition in Long-Term Health after Transplant

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The Role of Nutrition in Long-Term Health after Transplant

Wednesday, May 4, 2022

Presenter: Renee Stubbins PhD, RD, LD, CSO, Center for Cell and Gene Therapy Houston Methodist Hospital

Presentation is 39 minutes long with 19 minutes of Q & A.

Summary: Transplant recipients have unique and varied nutritional requirements during the first 100 days after transplant, so a consultation with a registered dietitian is important. Maintaining a healthy diet long-term can help avoid medical problems. This presentation explains which foods need to be included in a healthy diet, how to navigate a grocery store to get truly nutritious foods and addresses various marketing gimmicks and claims about “fad” diets.

Highlights:

• Nutritional needs after transplant can vary from patient to patient so advice from a registered dietician may be helpful. If graft-versus-host-disease is present, nutrition plans must be tailored to each patient’s individual situation.
• Fruits and vegetables are the most effective cancer-fighting foods. They are beneficial in all varieties and can be prepared in many different ways. A balance of grains and plant-based protein is also beneficial.
• There are several common myths about nutrition. Sugar is necessary in our diet but sugar from fruits and whole grains is much better than processed foods. “Organic” food is not necessarily better. Supplements are no substitute for a healthy diet and do not offer cancer protection as effectively as eating whole foods.

Key Points:

(10:42): A variety of fruits and vegetables are a crucial element of a good diet.

(13:36): Grains provide B vitamins, fiber and some provide protein

(14:35): Plant-based proteins, like lentils and legumes, are a good source of fiber and carbohydrates.

(16:47): Nuts are high in unsaturated fats and a good source of protein; seeds are a good source of Omega-3s and fiber.

(18:51): Lean red meat is a good source of protein, B12, iron and zinc. There are differences between beef labeled conventional, organic, grass-fed and grass-finished.

(24:30): Eggs from pasture-raised chickens are higher in Omega-3s and vitamins A, D and E than other eggs.

(25:26): Wild caught fish have a more diverse diet than farm-raised fish and are a healthier choice.

(26:49): Different types of oils have different smoke points. Heating a healthy oil beyond its smoke point turns it into an unhealthy fat.

(29:46): Dairy foods, as well as almond, oat and coconut milk are good sources of protein, calcium and vitamin D.

(34:24): “Organic” food is not necessarily healthier

Transcript of Presentation:

(00:01): [Marsha Seligman] Introduction. Hello, everyone. Welcome to the workshop, The Role of Nutrition in Long-Term Health after Transplant. It is my pleasure to introduce Dr. Renee Stubbins.

(00:12): Dr. Stubbins is a Senior Oncology Dietitian for Houston Methodist Cancer Center and Assistant Clinical Member of the Houston Methodist Research Institute. She is a strong advocate for educating patients and their caregivers on evidence-based nutrition information. She follows patients from pre-transplant through survivorship, acting as a reliable guide during their journey. Please join me in welcoming Dr. Renee Stubbins.

(00:41): [Renee Stubbins] Learning Objective for Presentation. Thank you. It is my pleasure to be here today. All right. These are our learning objectives for today. First, we're going to go over the nutritional needs of recovering hematopoietic recipients in the short term and long term, what constitutes a healthy diet for stem cell transplant recipients, how to determine nutritional value of foods offered in the grocery store, and last but not least, we're going to go over some common myths associated with nutrition and cancer.

(01:14): Nutritional needs of stem cell transplant recipients during first 100 days after transplant. All right, so let's get started. Nutritional needs during short term, during and after transplant. When I'm talking short term here, we're talking the first under a hundred day after the transplant. There are two types of transplants. All right. We have autologous, which is exactly what it sounds like. It's when we use the patient's own stem cells, which are collected before the conditioning regimen. This is very common in multiple myeloma and non-Hodgkin lymphoma and Hodgkin lymphoma. The other type of transplant is an allogeneic transplant. What this means is that this is stem cells from a donor who's either fully or closely matched. This is commonly used in the leukemias, acute and chronic, sometimes in non-Hodgkin's Lymphoma and other marrow diseases, such as aplastic anemia and myelodysplastic syndrome.

(02:16): Patients should connect with a registered dietitian during the first 100 days after transplant to make sure they are on the proper diet. The nutritional care during this process is very personalized. What that means is that it's really important to be connected with a registered dietician because everyone has a little bit of different needs during this process. That first visit is that nutritional assessment. And then we have follow-up visits, during the transplant process and afterwards.

(02:38): Sometimes a neutropenic or a low microbial diet would be recommended during those first hundred days. It also might be recommended to be on a higher calorie, protein and fluid needs. The transplant process is very energy demanding, so we want to make sure we're getting all that nutrition to help with that healing process.

(02:56): A multivitamin without iron, will also be recommended. Now, this is a really important thing to keep in mind because we don't want that extra iron in there. Sometimes during the transplant process, we have to do blood transfusions, and we don't want to be iron overloaded. So, that's why the multivitamin without iron is recommended.

(03:16): For patients with acute graft-versus-host-disease (GVHD), a diet that helps with symptoms of acute GVHD such as nausea, vomiting or diarrhea may be required. The other thing we want to keep in mind during those first hundred days, is graft-versus-host Disease, also known as GVHD. There's acute and chronic. We're going to first talk about acute. This is more common in the allogeneic transplants. It's actually even more common in the unrelated or unmatched donors. Usually, it occurs within the first a hundred days, and it can manifest in a couple of different ways. It can show up sometimes as a skin rash. Sometimes our liver enzymes might be a little bit more elevated, or it might show up in our GI tract. Now the GI tract, believe it or not, starts in the mouth and ends all the way down towards the rectum.

(03:59): The symptoms of GVHD can look very different. So again, remember I said, having that close personal relationship with that dietician is important, because everyone's needs are going to be different during this process. Now the treatment for GVHD in the acute setting is also going to be very personalized. So depending on what's going on, depends on what medications might be prescribed by that care team.

(04:26): Medical nutrition therapy, I know is kind of a broad term, but medical nutrition therapy is just another way of saying a dietician intervention. It's different for if you have nausea versus if you have diarrhea or you're having abdominal pain. We might ask you to keep a food diary, just so we can figure out what's causing the issue. Again, very personalized.

(04:49): In some cases nutrition may need to be given intravenously for a time after transplant. In severe cases now, if we need to give the GI tract some rest, we might do what's called total parenteral nutrition, which is known as TPN. This is when we use nutrition through the bloodstream. That way, we give that gut some time to rest.

(05:08): Symptoms of chronic graft-versus-host disease may lead to malnutrition. Chronic GVHD is after the first hundred days. Now, this is when we become a little bit more concerned for risking of malnutrition. It's when we have chronic issues such as nausea, vomiting, anything that's going to affect the appetite, digestion or absorption of nutrients, where we're going to lose weight unintentionally. That's when we start really getting very proactive and or reactive, in some cases.

(05:38): Oral GVHD can sometimes look like you have dry mouth. You might be very sensitive to certain tastes and smells. The GI tract and the intestinal mucosa can have changes. Sometimes there's bile acid malabsorption. A lot of different things can happen. But the good news is, is that with early nutrition intervention, we can manage a lot of these symptoms.

(06:01): In some cases, we might have pulmonary GVHD, which increases metabolic demand. We're using more energy to breathe, so we're burning more calories than we expected. That's the short term, during your short-term nutritional needs.

(06:19): Now, okay, what happens after that? What about a year, a couple years afterwards? What are the nutritional needs for that long term transplant?

(06:29): Stem cell transplant recipients need adequate calcium and vitamin D long-term to protect bone health.  One thing we want to keep in mind is we want healthy bones. Osteoporosis is very common, especially after the first year, but there's good news. We can do something about it. We want to make sure we're getting adequate calcium and Vitamin D. Calcium and Vitamin D are very common in dairy products.

(06:49): Now, sometimes during the transplant process, we become very sensitive to dairy, maybe become lactose intolerant. That's okay. Now we have a great variety of non-dairy products, like almond milk, coconut milk, oat milk. A lot of these are fortified with calcium and Vitamin D. Fatty fish, like salmon, is also a great source of Vitamin D and Omega-3. So, a lot of benefits there. It's also really important to have that Vitamin D level checked. If we do need a supplement, we need to know how much of a supplement we need.

(07:22): Last but not least, is weight-bearing, muscle-strengthening exercises. Weight-bearing means you're carrying extra weight. So, this is using free weights or using a strength-training machine. What this does is, it puts more weight on your bones. So, it's helping to make those bones stronger.

(07:42): A proper diet can reduce the risk of metabolic syndrome, characterized by high blood pressure and high blood sugar levels and abnormal cholesterol levels, which are common after transplant. The other thing we want to look out for is metabolic syndrome. Remember we talked about that GVHD, earlier. That GVHD, sometimes one of the medications that is used are steroids. Steroids are good and they're bad. They're good because they keep our immune system in check and make sure it doesn't go into overdrive, but they do have consequences. It can affect our metabolism.

(08:07): Metabolic Syndrome has a pretty high incidence after the first year and five years after the transplant. It's characterized by higher blood pressure, higher blood sugar levels. Think about an apple shape. You have that extra weight around your midsection. It can also result in abnormal cholesterol levels. But again, good news. We can be proactive with our nutrition, maintaining a healthy weight, keeping in mind, those portion sizes and meal planning.

(08:40): Portion control, an easy way to think about this is, think about half your plate being vegetables, a quarter of it lean protein and a quarter of it whole grains. Meal planning, yes, it does take time. But studies have shown that planning out your meals will help you make healthier.

(08:56): Of course, exercise, it's not only good for the bones, but it's good for your healthy metabolism.

(09:05): Consuming adequate plant-based foods can help maintain cardiovascular health. The cardiovascular health. Increased risk of cardiovascular-specific mortality is a real thing and specifically, cardiovascular diseases such as hypertension, dyslipidemia and heart failure. If we have extra weight on our body, our heart's working harder.

(09:22): But again, not surprising, I got good news for you guys. You can do something about it. Focusing on plant-based foods, which we'll go into a little bit more later, such as lentils, legumes, cruciferous vegetables and many more, can help add that much needed fiber to your diet. Fiber is great for keeping our heart healthy and our metabolism healthy.

(09:44): Now, this does not mean you need to be a vegetarian or vegan. It just means we need eat more plants than animal foods. And if we do choose to have animal foods, focusing on the leaner animal proteins, such as chicken and fish. Again, watching our portions and planning our healthy meals, is going to be an important part here.

(10:02): Last but not least, is aerobic exercise. Aerobic exercise is different than what we talked about earlier, using the weights. Aerobic exercise works out our heart. You do want to check with your doctor before you start any new exercise regimen.

(10:18): All right. I've given you all this information. Okay, how do I be a healthy survivor?

(10:26): A virtual grocery store tour can help guide healthy food choices. We're going to change directions here. We're going to do what I like to call a virtual grocery store tour. This is something that I started doing for our patients here, and it really has been quite successful. So, we're going to go ahead and get started.

(10:42): A variety of fruits and vegetables are a crucial element of a good diet. This is my favorite section of the grocery store, the produce section. Now you walk in, you see all these colors, everything's bright. Now that we're going into berry season and soon melon season, you can actually smell the produce. This is the most important part of the grocery store. Fruits and vegetables are our cancer-fighting foods. And it's not like one fruit is better than the other fruit. They're all good for us.

(11:06): It's important that we have that variety in our diet. You want something of every color, something red, something yellow, something green, something blue. The reason why is all those different colors are all different antioxidants. They all protect us in different ways. So, when we have all those different colors in our diet, we get this broad spectrum of protection. All right? That's why it's so important to visit this part of the grocery store.

(11:33): Smoothies, dried fruit and using fruit as a snack are excellent ways to add fruit to your diet. All right. So next step is, how do we add more fruit to our diet? There's lots of options here, guys. One of the easiest ways is to start by making smoothies. Fruit is naturally sweet. We don't usually need a lot to add something to it, to sweeten it up, naturally. It's a great snack in summertime because it helps keep you hydrated. It also can be used in the winter times, too.

(12:01): Use dried fruits in your oatmeal, to just give it that extra fiber and natural sweetness. One of my other favorite suggestions is to keep a fruit bowl at your desk versus a candy bowl. This is something I actually do. I usually keep a couple of oranges, apples and bananas. You'd be surprised on how often people stop by, just for a quick snack.

(12:24): Roasting vegetables can bring out their flavor and make them more appealing.  Now what about vegetables? I'll be honest. Whenever I first started adding vegetables to my diet, it took me a while to get used to it, but it's all about trying new things and trial and error and figuring out what's going to work for you.

(12:38): One of the ways I found that I like vegetables is by roasting them with some olive oil or some avocado oil. It brings out the natural flavors. The other tip and trick is, you can see down here, I have these veggie spirals or cauliflower rice. These are nice, convenient ways. So instead of regular pasta with spaghetti, you can use the veggie spirals. Or if you're going to do some stir fry, instead of using white rice, using the cauliflower rice. These are all ways we can add vegetables to our diet and get extra antioxidants and extra fiber added.

(13:25): All right. So if you think about a way a grocery store is set up, you usually have your produce section right when you walk in. And then next to that, we have our bakery. So, we're going to talk a little bit more about grains.

(13:36): Grains provide B vitamins, fiber and some provide protein. Grains kind of have mixed results these days. A lot of people are a little bit anti-carbohydrate, but they're still good for us. They have a lot of B vitamins, a lot of fiber and even protein.

(13:49): When I talk about grains, I'm not just talking about the bread. We're also talking about ancient grains. Ancient grains are kind of the new kid on the block. That's stuff like quinoa or freekeh or bulgur. If you haven't tried these before, I encourage you to be a little bit adventurous. It cooks just like rice. So, it'd be one cup of grain to two cups of liquid. You can use either use a broth or water. These ancient grains not only have protein, but they also have fiber, and they add some fun texture to your diet.

(14:24): If you're looking at breads or cereals, the fewer the ingredients, the better off we are going to be. That's kind of my role of thumb.

(14:35): Plant-based proteins, like lentils and legumes, are a good source of fiber and carbohydrates. After grains, we're going to shift a little bit more to these plant-based foods. So the first thing I'm going to talk about is plant-based proteins, such as lentils and legumes. They're a great source of fiber, carbs and they're economical.

(14:50): Now, lentils, they have brown, green. Those are going to be a little bit sturdier. So, they go well into salads. They're going to hold their texture a little bit more. If you want to make more of a porridge or curry, that's when you would use your red or yellow lentils, because they're a little bit softer.

(15:09): There's all sorts of legumes out there. You have garbanzo or chickpeas. That's used when we make a hummus. Black beans, green peas, lima or kidney beans, all of these are great options for adding plant-based proteins to your diet and fiber.

(15:29): If using canned beans, rinse them to get rid of excess sodium. I wanted to also talk to you guys a little bit more about preparing the beans and lentils. We want to be mindful of our sodium intake. There's nothing wrong with buying canned beans or lentils. I would just recommend that you look for the no-salt-added label, and I would recommend rinsing them once you open it. So I usually open my can of beans, pour it into a colander and run water over it. A lot of times, this is going to get rid of about 50% of that sodium that's in there.

(16:00): Now, if you have a little bit more time or you're feeling a little bit more ambitious, you can always do it kind of the old-fashioned way and do a soak. What this looks like is, if you put your beans in a pot, measure out how much you want to cook, and then you fill the pot up with water. You want about two inches over the bean level. Soaking the beans, it helps a lot, remove the products that give us gas, those phytic acids and the tannins. So, it helps reduce bloating and gas that can sometimes happen when we have beans. It also makes it a little bit easier overall, for our digestion and our body to process it. So, those are the two options for when you are preparing your beans.

(16:47): Nuts are high in unsaturated fats and a good source of protein. Another great plant-based protein is going to be nuts. These are going to be what we will call the healthy fats. It's a plant-based protein, which means they're high in plant fats, which means that these are going to be higher in unsaturated fats, which mean they are healthier for our heart. These make great snacks for on the go. There are all sorts of varieties you have and they're all good. I always give patients a nut mix because they all have different benefits. So kind of like the different fruits and vegetables, all the nuts have different benefits.

(17:22): Actually, now you can find nuts who are sprouted. So kind of like what we were doing with the beans, by soaking them, you can buy sprouted nuts. Again, this helps remove that phytic acid. So, it makes it a little bit easier on our digestion.

(17:38): Now you do want to be mindful when you're purchasing nuts, because you want to check for any added salt or sugar, for flavored nuts. We'll go into label reading a little bit later.

(17:51): Seeds are a good source of Omega-3s and fiber. Seeds. So our last plant-based protein is seeds. Seeds are great because they can be a great source of protein and Omega-3s and fiber. One of my favorite seeds is the Chia seed. If you've never had them before, it can be a little different. I've made some great Chia pudding. Chia seeds, they kind of gel up a little bit. So, the texture can be a little off-putting, the first time you have it. But again, great source of protein, great source of fiber, very nutrient dense. They have a great Omega-3 profile, which is important because Omega-3s are anti-inflammatory. Anti-inflammatory means healthier for our hearts. Chia seeds can be used in a wide variety of things, smoothies, hot cereal or even in overnight oats.

(18:46): All right. We talked about our plant-based proteins. Now we're going to talk about our animal-based proteins.

(18:51): Lean red meat, in moderation, is a good source of protein, B12, iron and zinc. Red meat also kind of gets a bad rep, but there's some good things about red meats. The American Institute of Cancer Research and the American Cancer Society, recommend that we have no more than 18 ounces per week, which I still think is pretty generous. To kind of put that in perspective, you'll see that I have a picture of a piece of meat next to a deck of cards. That's three ounces. So, think about having meat two to three times a week, and you'll be well under your limit of the recommended amount.

(19:21): Red meat is a great source of protein, B12, iron, zinc. There's a lot of potential good things. Again, moderation is key here. Now, red meat isn't just beef. It's also bison, venison, which is deer, pork and lamb. We want to try to, again, focus on those leaner red meats, to protect our heart. So think of round, top sirloin or tenderloin. We do want to try to avoid processed meat, such as ham, bacon, salami and hot dogs and sausage.

(19:57): Conventional beef means the calf lived on a pasture for eight to nine months and was then transferred to a feedlot. The question I get asked quite a bit about beef is, what's the difference between conventional, organic or grass-fed. So, we're going to spend a little bit time talking about that. Conventional beef is just regular beef that you see in the grocery store. It means that the calf has lived on a pasture for seven to nine months and then transferred to a feed lot.

(20:18): Organic beef means the calf was given organic feed and no antibiotics, but is not necessarily grass-fed.  Organic beef does not mean grass-fed. That's a really important thing to remember. Organic beef means that it was given organic feed and forage and wasn't given any antibiotics or hormones. The cattle can get preventative care, and they can be supplemented with vitamins and minerals as needed.

(20:37): Grass-fed beef is the same as conventional beef. Now and then kind of vice versa, grass-fed and finished beef does not mean that it's organic. Grass-fed is basically the same thing as conventional beef. So, it's kind of a marketing trick. So again, you have to be that savvy shopper. Grass-fed beef, and if it just says grass-fed, that just means that the calf was started on grass and then transferred to grain.

(21:02): Grass-fed and grass-finished beef means the calf ate nothing but grass and forage its whole life, and is tougher, but higher in Omega-3s a B vitamins. Now, if it says grass-fed and grass finished, which you can see here... the finished is kind of in small print in that picture I have there to the left, but that means that the cattle ate nothing but grass and forage for their entire life. Now you can visually see the difference between grass-fed beef and regular beef. The grass-fed beef is going to be higher in Omega-3s. It's going to be a little tougher, to be honest with you, and it's going to have higher in B vitamins.

(21:33): Farmer’s markets, community-based agriculture, and community gardens can be economical alternatives to grocery store prices.  Now we all know the price of food is going up. So, it can be very expensive when we're shopping, especially for meat. I wanted to give y'all a couple of economic solutions. One of my favorite things is to go to my local farmer's markets. I do encourage you to check out this website, your local farmers there. Getting to know your local farmers and develop a relationship with them can be very rewarding. Shopping in season, and a lot of times, if you talk to especially your local meat farmers, they may not have that organic label. They might be grass-fed, grass finished, but seeing how they take care of their animals or how they take care of their produce and having those conversations, a lot of times, they're practicing organic practices. They just can't afford the super expensive USDA label. That's why I think the farmer's markets are fun.

(22:23): Another option is joining a community-supported agriculture. Many local farmers' markets, if you aren't able to... there's not one close to you, can have stuff delivered to your door. During the pandemic, me and my neighbor used to split produce boxes and meat boxes. This was just a much more economic choice for us.

(22:42): Last but not least, are community gardens. So this is also very rewarding. Community gardens usually let you rent out a plot, to where you can grow your own produce and participate in that process. Watching something grow from a seed to something you can eat, has many, many rewards. You also get to learn about what goes in season and why we plant things when we plant.

(23:11): All chickens in the US. are cage-free and never given hormones or steroids. All right. So we talked about beef. Now we're going to talk about chickens and eggs. All chickens in the USA are cage-free and never given hormones or steroids. So, when you see that label at the grocery store, hormone-free chicken, again, it's just kind of a market ploy. All chickens are technically hormone-free in the USA.

(23:30): Cage-fee chickens may have a little bit of space to walk around but are very rarely outdoors. Now, organic chickens and cage-free and free range, I find it best to explain this, using the visual. That's why I have this picture here, to the right. If you see our chicken here that's white, this can be a caged or a cage-free. Now caged is exactly what it sounds like. It has a tiny cage that it's in. Cage-free means it might be in a barn, has a little bit more space to walk around, but both of these are very rarely outdoors.

(23:59): Free-range chicken means they can go outside, but there’s no guarantee they ever did so. Now, if you see something that says it's a free-range chicken or free-range eggs, this means that they basically have a door. They can go outside, but they're never guaranteed to go outside. It's kind of up to the chicken's choice, but a lot of times, they don't go outside because they've never been outside, and they're scared.

(24:17):  Pasture raised chickens mean they were raised outdoors. Now we have our brown chicken here. Now the brown chicken is in the pasture. It's just going around, doing its chicken thing and eating what chickens normally eat in the grass.

(24:30): Eggs from pasture-raised chickens are higher in Omega-3s and vitamins A, D and E than eggs from caged chickens. Now this is important because I wanted to show y'all this picture. All right. So if you're looking at this picture, one egg is from a caged chicken. The other one is from a pasture-raised chicken. Now this one on the left is from the caged egg. It's not like it's a bad egg. It is high in protein. But the pasture-raised egg, you see how it's a little more orange? The reason why it's more orange is because it's higher in protein. I'm sorry. It's high in protein as well, but it's higher in Omega-3s. Remember the anti-inflammatory. We want to make sure we have that. It's higher in Vitamin D. We need that for our bone health. It's higher in Vitamin E and Vitamin A. So, that's what gives it that nice orange color. All right. So this is a healthier egg. Both eggs are healthy, but the pasture-raised egg is going to be healthier.

(25:26): Wild caught fish have a more diverse diet than farm-raised fish and are a healthier choice. All right, so now fish. Now I get a lot of questions about wild caught versus farm raised. Wild caught means that they are captured in their natural habitats, such as pond, streams, oceans. They have a much more diverse diet, and they're less likely to be contaminated or diseased. However, sometimes damaging techniques are used, that can be harmful to the environment, such as drift nets.

(25:53): Farm-raised means that the fish consume the same food each day and the diet has less variety, but not all farms are created equal. This picture of the Monterey Bay Aquarium, a website you can go to. Depending on where you are in the country or in the world, it can help guide you in making the choice between if it's best to get wild caught or farm raised.

(26:19): I put this picture here, because this is kind of a difference between the wild caught salmon, which is the one on the left. It's a little bit brighter. You can see that it's leaner, versus the farm-raised salmon is going to be a little fattier. Both are great sources of protein. Both are great sources of Omega-3, but the farm-raised is going to have a little bit more of a fattier profile.

(26:49): Different types of oils have different smoke points. Heating a healthy oil beyond its smoke point turns it into an unhealthy fat. Speaking of fats, we're going to talk about oil. Extra virgin olive oil got a lot of attention a couple of years ago. It's a great oil, but I find that a lot of times, my patients and caregivers and even my loved ones, can sometimes use it not correctly. I put smoke points here. I wanted to explain to you guys what smoke point means. So smoke point, we don't want to heat an oil above its smoke point. The reason why, because it turns a healthy fat into an unhealthy fat.

(27:24): Olive oil has a low smoke point. You don't want to go more than 325. So, you can do it for a low heat sauté, but it's best used as a finishing oil. So, this would be better into salads. Or let's say you roasted your vegetables, and then you wanted to toss them after they came out of the oven, in some olive oil, for flavoring.

(27:44): Peanut oil is used as a high smoke point. So, this is best for frying. And then you have canola oil, which also has a pretty high smoke point. So, that's best for baking.

(27:54): Now, if you still want to have a healthier fatty acid profile, which I will explain in a minute, you can use grapeseed or avocado oil. These have a higher smoke point, and this is often what I use whenever I'm marinating some chicken that I'm going to grill or some vegetables.

(28:12): Coconut oil also has a pretty low smoke point, but it can be used for baking and non-dairy food items.

(28:23): Omega-3 fatty acids are healthier than Omega-6 fatty acids. All right. So let's talk a little bit about the fatty acids. Just a little bit of chemistry here or biochemistry, I should say. We have polyunsaturated fats. These are your Omega-6 fatty acids and Omega-3 fatty acids. Too much Omega-6 fatty acids isn't good for us. It promotes a much more inflammatory state. Inflammation is not good for us.

(28:46): And then you have Omega-3 fatty acids, which I've said a couple of times, these are our anti-inflammatory fatty acids. So, these are kind of the good guys for our hearts.

(28:55): We look over here, we have the linolenic, which is the Omega-6. That's the blue. The alpha-linolenic acid, which is this orange color. So, you can go up.

(29:05): Okay, this one has the most and that's your flaxseed oil. Flaxseed oil comes from flax seeds. They are great for omega-3 fatty acids.

(29:17): And then we have our monounsaturated fatty acids. So, this would be our olive oil. So if we go down here to olive oil, we can see that it's very high in oleic acid. That's why olive oil became so popular because it was known to be heart healthy. The reason why it's said to be heart healthy is because it decreases LDL and increases HDL, which is the good cholesterol.

(29:46): Dairy foods, as well as almond, oat and coconut milk are good sources of protein, calcium and vitamin D. All right. So, now we're moving on to the dairy and non-dairy. As I mentioned earlier, dairy foods are a great source for our protein and our calcium and Vitamin D.

(29:56): Now we have more non-dairy options available, such as the almond, oat and coconut milk. You also have yogurt and kefir, which are great sources for probiotics and they're lower in lactose. So, if you are more sensitive to lactose, some of my patients who are lactose sensitive are able to tolerate yogurt and kefir, to get those good probiotics.

(30:17): All right. I talked about label reading, so I just want to spend a few minutes going over label reading.

(30:26): Ingredients on food labels are listed from the most amount contained in the product to the least. Now this is a label from a strawberry yogurt. We're going to start over here, on the top left. We're going to check the serving size. Okay. So one container has four servings in it. So for one serving it's going to be 130 calories. Okay. That's okay. It's a good amount of protein, 12 grams. Uh-oh but there's some added sugar. We have 18 grams of added sugar. That's a pretty good amount. that's nothing to shy away from.

(30:54): Let's look at the ingredients. First ingredient is non-fat milk. Okay, that makes sense. But the second ingredient is sugar. The way ingredients labels work is that it's kind of listed from the most to the least. That means the first couple ingredients are what makes up most of the food product. All right. So this means that the second most ingredient in this yogurt is sugar.

(31:21): Fewer ingredients usually mean a healthier product. Now what about a plain yogurt? All right? So the plain yogurt serving size, okay, it's a little bit less calories. So, if we're monitoring our weight and we want to be moderate with our sugar intake, this is going to be a healthier choice because this has no sugar added. We can double check, but there's no sugar added, by looking at the ingredients. All right? So, remember I talked about the fewer ingredients, that usually it's a healthier product. So as we can see here, this just has one ingredient, mostly. It's just non-fat yogurt.

(32:00): We're going to shift gears here a little bit. I'm going to go over some common nutrition myths. You've heard me say it a couple of times. I've talked about sugar. I've talked about healthier and healthy food. So I wanted to go over a few questions that I get quite a bit, in my practice.

(32:21): Sugar is a necessary part of a good diet. Fruit is a good source of sugar. Myth number one, does sugar feed cancer? First of all, this is an oversimplified statement. One thing I want to make sure that y'all understand is that sugar feeds your entire body. It feeds your heart. It feeds your brain. It feeds your muscles. And yes, it can feed cancer cells, but we have to have sugar in our diet. That's how our body runs. Our body runs on glucose, AKA sugar. All right?

(32:53):  The bottom line is, that matters where you get your sugar from. Now, if you're getting your sugar from cupcakes all the time or cookies, not so good, versus if we're getting our sugar from fruits and whole grains. So, I always tell people there's sugar that makes us happy, and then there's that sugar that has benefits. It's important to find a balance.

(33:17): Naturally, we want to have more functional sugar. We want to have sugar with benefits. These are your fruits. With those, you have that natural fruit sugar, but you also have the antioxidants and the fiber in there.

(33:29): Excess sugar intake can lead to obesity and the diseases associated with obesity. That means it's okay to have that occasional sweet, such as a cupcake or a cookie. It doesn't mean that if you have that cupcake or cookie, that it goes straight to the cancer cell. It's much more complicated than that. Now, if we have an excess of sugar intake, which leads to empty calories, which leads to weight gain and obesity and all those other chronic diseases, then yeah, we might need to have a conversation and figure out some lifestyle changes. But having that occasional sweet is okay.

(34:00): So, the solution? Focusing on having a balanced diet. Think moderation, not deprivation and be picky with your sweets. If you're going to have a cookie, make sure it's a good cookie. Make sure that it's the best cookie in the world and that you are enjoying it and let yourself enjoy it.

(34:24): “Organic” food is not necessarily healthier. All right. The second myth, organic food, is it healthier? Not necessarily. Studies have not found, I should say, any clinically significant differences between organic foods when it compares to conventional foods. This is a personal decision, but it should be an informed decision. Organic food does not mean that it's healthier.

(34:48): The longer produce is “off the vine”, the lower the nutritional value. Now, one of the things that I talked about earlier was shopping at your local farmer's market. So, one thing I want you to think about is where your produce is coming from. The way produce works is, the longer it stays off the vine, the nutritional value goes down. So, if you're going to your local farmer's market and they just picked the produce yesterday, then that produce has only been off the vine for a day. Versus if you're going to supermarket, it might have come from California. It might have come from Mexico. It might have come from another state. It's been longer off the vine. So, it has less nutritional value. So another kind of bonus to shopping at local farmer's markets.

(35:31): And again, consider joining a community-supported agriculture. There's lots of produce boxes available that you can purchase, that are actually what they would call imperfect. Grocery stores are very picky. They want the prettiest produce. So, sometimes produce that's just as good, but maybe has a couple of bruises or maybe it looks a little weird, so grocery stores don't take them. A couple of companies have started up by taking this produce and making them more economic solutions, for other people to have access to them. One of these would be called Imperfect Foods. Another brand is called Misfit Foods.

(36:17): Alkaline diets don’t increase the body’s PH. Should I follow an alkaline diet? First of all, what is the alkaline diet? The alkaline diet is avoiding foods that increase the acid in your body and increasing foods that your body's... well, that will increase your body's alkalinity or pH. The thing is, we really can't change our body's pH. Our body has a natural buffering system. So the alkaline diet, if you really look at, it's kind of just a healthy diet.

(36:49): It has these foods over here, that are considered more alkaline. But if you look over here, look what's over here. It's fruits, vegetables, water. So overall, okay, yeah, it looks like a healthy diet. The acidic foods are a little bit more processed. So, we already kind of know this. We want to eat more fruits and vegetables because they're just naturally healthy for us. And we need to moderate the foods that are going to be what they're calling "acidic." But the bottom line is that there's not a lot of validity behind the alkaline diet. You can't change your pH.

(37:29): Supplements do not replace a healthy diet or offer cancer protection when compared to eating whole foods. All right, this is our last myth. Can supplements replace a healthy diet? The first thing first, talk to your medical team first. Certain micronutrients can be checked. So, we talked about checking your Vitamin D level, your iron level, B12 and your folate and your zinc.

(37:49): Supplements do not replace a healthy diet. So that's something to keep in mind. Now I know supplements, they might make all sorts of claims. They might say they are the equivalent of five fruits and vegetables in one pill, but if it sounds too good to be true, it usually is. The American Cancer Society put out a statement that I really liked. So, I'm going to share that with you. The dietary ingredients in supplements don't offer the same benefits as eating whole foods. Research has shown that supplements do not offer cancer protection or provide benefits to survivors who are worried about recurrence.

(38:25): Remember in the very beginning, we started in that produce section and talking about those fruits and the vegetables and having something of every color, to get all of those antioxidants naturally from food, because that is the way our body recognizes it. So, that is the best way for our body to get it.

(38:42): I believe that is my last slide. So, I would like to take this time to thank you for letting me come and talk with you guys today. I hope the information was informative and helpful to you. I'd be happy to take any questions.

Question and Answer Session.

(39:00): [Marsha Seligman] Thank you so much, Dr. Stubbins, for your wonderful presentation. That was a lot of great information. We will now take questions. The first question I have is, what are your thoughts on anti-inflammatory diets? I have a lot of itchiness associated with skin GVHD. Would anti-inflammatory diet help with that?

(39:28): [Renee Stubbins] That's a really good question. An anti-inflammatory diet is going to be primarily focused on a lot of the things we were talking about. So, adding more fruits and vegetables to your diet and focusing on incorporating those natural sources of Omega-3s, which have a natural more anti-inflammatory profile. Now, I don't know if this will help with the skin rash, but it is, overall a healthier diet. So, if it doesn't necessarily help with the skin, it's going to potentially help in other ways, that would hopefully lead to helping with the skin issue.

(40:12): [Marsha Seligman] Okay. I know you talked about the multivitamins, but someone wants to know, is it enough to eat fruits and vegetables, or is a multivitamin recommended? They are a two year after an allogeneic transplant and take steroids for GVHD.

(40:32): [Renee Stubbins] In my opinion, if you have a very balanced diet, I don't think a multivitamin is necessary. If you're having issues like fatigue or feeling low on energy, or maybe there's some malabsorption issues or the appetite has been coming and going, then a multivitamin could be beneficial. It's good to just get clarification or approval, from just the medical team, so they know you're taking it. A multivitamin usually isn't going to cause any harm, but it's always good to just keep that team involved and just let them know what's going on too.

(41:17): [Marsha Seligman] Okay. Someone would like to know if you have any recommendations for a vegetarian diet after transplant.

(41:28): [Renee Stubbins] Going back to what we talked about first in that grocery store tour, focusing on a lot of those plant-based proteins and having a variety of them. You want to make sure, as well, that when you're planning your meals, that you're planning for complete proteins. What I mean complete proteins, certain food pairings like rice and beans, have been historically very popular because they give us all the essential amino acids that we need. So, you need to be a little bit savvy and knowledgeable. Do a little bit of research, just to make sure you're getting complete proteins on a vegetarian diet, but it is possible.

(42:06): There are certain natural, high plant-based proteins, such as tofu. It is plant-based and has all the essential amino acids. It's definitely possible to stay on that vegetarian diet and have a healthy survivorship. It's actually going to be beneficial in a lot of ways, because it's going to help with that glucose metabolism and that cardiovascular health and potentially weight management, as well.

(42:37): [Marsha Seligman] Someone is asking, if I am already on cholesterol medication, how would I know if I have metabolic syndrome?

(42:47): [Renee Stubbins] I would follow up with the doctor's office. They would be able to tell you if you have metabolic syndrome. It involves a couple of more tests, such as looking at your hemoglobin A1C and doing a full lipid panel, just to see what it looks like. Just because you have high cholesterol, doesn't mean that we automatically have metabolic syndrome. So, to be officially diagnosed with metabolic syndrome, would require a little bit more testing.

(43:18): [Marsha Seligman] Is there a range of the number of eggs that is generally recommended in a week?

(43:24): [Renee Stubbins] Oh, that's a good question. I think it really depends on the person. Eggs, yes, they are healthy, and it does help to have those pasture-raised eggs. They're going to have a little bit more of a healthier fatty acid profile, but they are still high in cholesterol. So, you have to be mindful of that. So I would probably not exceed more than six to seven eggs in a week.

(43:53): [Marsha Seligman] Someone would like to know if you have any recommendations for books or websites that help with meal planning.

(44:02): [Renee Stubbins] Yes. One of my favorite websites is the American Institute of Cancer Research. The sole purpose of this organization is to do research, regarding nutrition and cancer. They have great recipes for adding fruits and vegetables to your diet. They have great educational materials and great meal planning tips as well.

(44:30): [Marsha Seligman] The next question is, I watched one of the earlier sessions. The infectious disease doctor stated that it is ideal to wait one year after transplant, before eating raw fruits and vegetables. Do you have ideas of how to cook some of these fruits specifically, so I can still get the benefits of them without eating them raw?

(44:50): [Renee Stubbins] Oh, that's a good question. One thing to maybe consider or ask your care team, is if it would be okay for you to have frozen fruits and vegetables. Frozen fruits and vegetables are prepared in a more sterile environment. Sometimes they're even pasteurized during the freezing process. So, they're going to have a lower bacteria risk. So, I would check with your care team, to see if they would be okay with you having frozen fruits and vegetables.

(45:22): But going back to your question of if you could cook them, of course you can cook them. One of the ways I really enjoy apples, is baking them or even making homemade apple sauce. Of course, if you're going to be buying fresh fruit, fresh vegetables and going to be making like a stir fry, I would just make sure you wash the vegetables very thoroughly, with water and vinegar, is what I recommend for my patients. Cooking them will help reduce any bacteria risk, as well.

(45:57): [Marsha Seligman] Would microwaving versus frying allow you to cook without raising the temperature to above the smoke point?

(46:03): [Renee Stubbins] I don't think so. I think microwaving might be a little bit riskier, just because you won't be able to know what temperature it's at. What I do is, for my olive oil, I will either roast it at 325, go nice and slow. Or I'll roast them at a higher temperature and then toss them with olive oil afterwards. I use the oven a lot, just because I know what temperature it's going to be at. If I'm not sure... like I got a new stove, so I'm not sure what temperature it's cooking at really, so I'll go on the safe side and use my avocado oil or grapeseed oil, if I'm going to be sauteing or doing a sear on a chicken breast. I'll use something that has a higher smoke point, just so I know what that temperature is going to be. If you want another option, actually would be to get a thermometer. You can measure the temperature of the oil with a thermometer.

(47:09): [Marsha Seligman] The next question asks, there are so many manifestations of GVHD that include overgrowth of yeast. I have a tendency to try to include sauerkraut, which is pasteurized, and yogurt. Is there any extra preparation or concerns about using these probiotic foods?

(47:27): [Renee Stubbins] In my opinion, no. I think they're perfectly okay to have. Again, I would just make sure that your care team knows that you have those in your diet. Another option, if you haven't tried it, would be kefir. Kefir is also usually pasteurized and can be another good source of the probiotics.

(47:49): [Marsha Seligman] Do you have any specific recommendations for nutrition, when being on small amounts of steroids?

(47:57): [Renee Stubbins] I think the most important thing is to make sure that the meals are balanced. What I mean by that is that, I should say, food pairing. So if you're going to have a snack, it shouldn't just be an apple by itself. You want to have that apple with a piece of cheese or some peanut butter. That protein and fat help buffer the sugar in the apple. So, it's not going to affect the sugar metabolism. I think food pairing is really important on low dose steroids.

 (48:27): The second thing is, I would recommend that we incorporate some sort of type of activity, both weight bearing and light activity, such as walking. One of my patients used to walk with weights. So she'd kind of take care of two things with one stone, so to speak.

(48:47): Walking and exercise help improve your body's insulin sensitivity. Let me explain that just a little bit more briefly. Our pancreas makes insulin. Steroids tend to make us more insulin resistant. So, that means our body doesn't use its own insulin very well. However, if we exercise, our body's insulin sensitivity improves because when we're moving, we're making our muscles hungry. When our muscles are hungry, it helps move the sugar from our bloodstream into the muscles and helps keep it more in control.

(49:26): [Marsha Seligman] Are there any nutrients to help with peripheral neuropathy?

(49:32): [Renee Stubbins] I wish there were. There were some early studies regarding B vitamins, to help with peripheral neuropathy, but there is not strong enough evidence for me to say anything, confidently. I would just encourage a balanced, healthy diet.

(49:56): [Marsha Seligman] Someone would like to know how long to be on a neutropenic diet.

(50:04): [Renee Stubbins] That's a good question and often a controversial one. Every institute is a little bit different. I will tell you here, we recently transitioned from a neutropenic diet to a low microbial diet. What that means is that our patients can have certain fruits and vegetables, as long as they're triple washed, which they are in our cafeteria. Most of everything is on the list, except berries. Berries, we do recommend being frozen. But as far as the timeline, it really comes down to what is recommended by your care team. Studies have shown that there's no consensus on what's a good timeframe. So, it's hard for me to answer that question. Every Institute does a little bit something different. I've seen 30 days. I've seen a hundred days. I've seen a year. So, it really comes down to, what is your care team's preference? If your facility does have a dietician, developing a relationship with her, to see how she can help kind of liberalize that diet a little bit too.

(51:22): [Marsha Seligman] Okay. Someone would like to know how a patient can balance a diet if they have osteoporosis and also prone to kidney stones. Those diets seem to oppose each other.

(51:34): [Renee Stubbins] They are correct. They do seem to oppose each other. It's going to be a balance, to say the least. So, you want to make sure that you have those sources of the Vitamin D. Remember, Vitamin D can come in multiple forms. Calcium can come in multiple forms. I always focus on probably the dairy, the non-dairy products compared to the dark green, leafy vegetables, because those have more oxalates. That can help or could play a role in that kidney stone formation. The other thing to keep in mind is, different things work for different people. So, it might be that we need to avoid altogether, the fortified Vitamin D and calcium, non-dairy products and the dark green, leafy vegetables. Maybe we need to focus on more weight-bearing activities, to help with that bone health and prevent that osteoporosis.

(52:41): [Marsha Seligman] What type of diet would you recommend for the effects of weight gain from the steroids?

(52:48): [Renee Stubbins] I would start by keeping a food diary. It's not fun. I'll be honest, it's quite tedious. But there are free apps, like MyFitnessPal and Calorie Counter, that you can track your calories for free. Seeing where our calories are coming from can be very eye-opening. A lot of times, we have hidden calories and we don't realize it. So, keeping a food diary can help see if we are overconsuming on our calorie intake, or if we need to be more mindful of our distribution of calories. Maybe we have too many carbs in our diet versus too much protein. So I would start by keeping a food diary, just so we can take a closer look, to see where we're overconsuming on certain things, that are leading to the unintentional weight gain or preventing us from losing that weight that we want to lose.

(53:51): And then of course, not to be super repetitive, but incorporating exercise is so important for just overall health. It doesn't have to be a lot. It can be 20 to 30 minutes a day, and it doesn't even have to be all at one time. It can be three 10-minute walks or two 10 walks. But just doing some level of exercise, will help keep your metabolism in a healthy state.

 (54:22): [Marsha Seligman] What are your thoughts on using things like Beyond Meat versus tofu? Since both are processed, is one better than the other?

(54:32): [Renee Stubbins] Oh, good question. I don't mind the Beyond Meat. I've tried it. I've also tried Impossible meat, and I like tofu. They're all good, and they're all not bad. Now, anything can be bad if it's overdone. Tofu and soy kind of get a bad reputation. It really shouldn’t because there's a lot of good benefits around tofu. It is a phytoestrogen, which means that it's a plant estrogen, which can sometimes cause concern, especially with my breast cancer patients. But studies have shown that moderate intakes are perfectly safe. So, I would say both are good. It just depends on what you're going to be cooking it with. I'll be honest to you. I've tried the Beyond Meatballs, where I liked, actually. Those were really good, but when I tried the ground meat products, the texture, I couldn't do it. The texture just didn't agree with me. It wasn't something I enjoyed. Same thing with tofu. I really enjoy tofu in my Pad Thai and when I have a miso soup. So, I think all are good, in the right amount of portions.

(55:45): [Marsha Seligman] Someone would like to know, is it okay to drink wine moderately, daily?

(55:51): [Renee Stubbins] Oh, that's a good question. The American Institute of Cancer Research, the website I mentioned earlier and both the American Cancer Society, do recommend that we minimize our alcohol intake or limit it. Now I say minimize and limit. I did not say avoid. So, I think daily might be a little much. They do recommend zero to one drink per day for women and one to two drinks for men. Which I know that's a little frustrating because what does zero to one mean?

(56:22): I would say a couple of glasses of wine a day... I'm sorry, not a day, a week would be within reason. I don't think daily alcohol intake is necessarily the healthiest choice for us. Now, something to consider is doing a mocktail. There are tons of mocktail recipes out there. A lot of the times, that can help satisfy that behavior of wanting that kind of adult beverage but without that alcohol content.

(57:03): [Marsha Seligman] Okay. We are running out of time. So, this is going to have to be our last question. Someone would like to know what you meant by food pairing while on steroids.

(57:15): [Renee Stubbins] Okay. Sorry. Let me clarify. Food pairing, what I mean by that is, you want to pair a carbohydrate with a protein. This is cheese and crackers, eggs and toast, fruit with cheese or fruits with nuts. The fruit and the crackers and the toast being the carbohydrates, your cheese or your nuts or the egg being the protein.

(57:40): So when you have the protein paired with the carb, it helps control the absorption of the sugar. That way, it doesn't hit your blood system all at one time. It helps slow down the digestion, in a much more controlled manner.

(58:03): [Marsha Seligman]  Closing. Thank you so much, Dr. Stubbins, for all of this wonderful information. On behalf of BMT InfoNet and our partners, we'd like to thank you, Dr. Stubbins, for your helpful remarks. Thank you, the audience, for your excellent questions. Please contact BMT InfoNet, if we can help you in any way. Enjoy the rest of the symposium.