Nutrition: What You Eat Does Matter

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Nutrition: What You Eat Does Matter

May 4, 2023

Presenter: Michelle Myers, MS, RDN, CSO, CDN, Memorial Sloan Kettering Cancer Center

Presentation is 38 minutes long followed by 20 minutes of Q&A

Summary: This presentation explains how to manage some common eating difficulties experienced by stem cell transplant recipients. It also discusses the impact of transplant and diet on long-term health problems such as metabolic syndrome and osteoporosis, and common myths about the relationship between cancer and certain foods and diets.

Many thanks to Astellas whose support, in part, made this presentation possible.

Highlights:

• Graft-versus-host disease (GVHD), experienced by many patients after a transplant using donor cells, can increase the number of calories a patient needs. It can also cause mouth sores and GI tract irritation, making it difficult to eat.
• Metabolic syndrome is a frequent, long-term problem after transplant. A healthy diet can reduce the risk of developing metabolic syndrome.
• Getting science-based information on the internet about nutrition and diets can be difficult. People should be wary of food products and diets described with words such as breakthrough, discovery, or miracle, and supported only by anecdotal evidence, rather than scientific studies.

Key Points:

(02:18): Chronic graft-versus-host disease (GVHD) can make it difficult to chew or swallow food, and cause nausea, vomiting, diarrhea and/decreased appetite. Eating foods that are high in calories and protein can help reduce weight loss caused by GVHD and malnutrition.

(08:14): If you have nausea, try eating several small meals each day, instead of three large meals; choosing bland foods, rather than fatty, greasy foods; and eating foods cold or at room temperature.  Avoid foods and drinks that are high in fiber or contain caffeine, and sugar-free foods sweetened with sorbitol or xylitol.

(14:53): Persistently high levels of cholesterol, as well as another blood fat called triglycerides, are associated with metabolic syndrome, and place a person at risk for cardiovascular or heart disease.

(17:10): Unsaturated fats found in plant-based food can help lower bad cholesterol. Omega-3 fats, found in plant-based foods and fish, can help lower your triglycerides.

(18:48): Saturated fats, such as those found in processed meats and red meats, increase blood cholesterol. Trans-fats are artificial fats, primarily found in processed foods, that increase bad cholesterol.

(20:38): Osteoporosis is common after transplant, affecting 50-60% of patients. Weight bearing exercises and vitamin D can help prevent osteoporosis and bone fractures.

(28:02): The notion that sugar feeds cancer is a myth.

(30:34): A ketogenic diet severely restricts intake of carbohydrates and can cause side effect such as constipation, anemia, some cardiac abnormalities, as well as dehydration.

(35:44): Dietary supplements are not a good substitute for the nutrients found in food.

(36:49): Studies have not found a clinically significant difference on health between eating organic foods, compared to conventional foods.

Transcript of Presentation

(00:01): Hello, everyone. Welcome to the workshop, Nutrition: What You Eat Does Matter. My name is Marsha Seligman; I will be your moderator for this workshop.

(00:09): Before we begin, I'd like to thank Astellas, whose support helped make this workshop possible.

(00:15): Introduction of Speaker.  It is now my pleasure to introduce today's speaker, Michelle Myers. Ms. Myers is a certified dietician with a specialty in oncology at Memorial Sloan Kettering Cancer Center in New York City. She serves as the primary bone marrow transplant dietician in the outpatient clinic, where she assesses the nutritional needs of oncology patients before, during, and after treatment. She also collaborates with the graft-versus-host disease clinic on nutritional issues.

(00:44): In addition to her work at Memorial Sloan Kettering, Ms. Myers is a nutrition consultant for Savor Health Worldwide, where she provides cancer patients with personalized, clinically appropriate nutritional support on demand. Please join me in welcoming Michelle Myers.

(01:05): [Michelle Myers]: Learning Objectives. Thank you all for having me today. I'm going to start by going over some learning objectives for this talk. I will talk about the long-term nutritional consequences associated with stem cell transplantation, including graft-versus-host disease, which I'm going to refer to as GVHD, metabolic syndrome, and osteoporosis.

(01:28):  I will also describe tips and tricks to manage some common side effects that can impact your nutritional status. And finally, I will address some common myths about cancer and nutrition, and hopefully help you evaluate any new nutrition information you may find on the internet.

(01:50): The survival rates for transplant patients have increased. Therefore, the long-term and late nutritional effects are of growing importance for things such as graft-versus-host disease, metabolic syndrome, which can lead to cardiovascular issues, and osteoporosis.

(02:18): Chronic graft-versus-host disease (GVHD) can make it difficult to chew or swallow food, and cause nausea, vomiting, diarrhea and/decreased appetite. Chronic graft-versus-host disease may occur after the first 100 days post-transplant. It's a problem that occurs when the donor's immune system attacks the patient's organs and tissues following an allogeneic transplant or transplant using cells from a donor.

(02:39): Chronic GVHD is more common after three months post-transplant. It can affect many body organs, but those most pertinent to nutrition include the mouth, where a patient may develop pain or sores, making it difficult to chew or swallow food. It can also affect the stomach, resulting in decreased appetite, nausea or vomiting, and a feeling of early fullness. And lastly, it can affect the gastrointestinal tract where a patient may experience some lower abdominal cramping and/or diarrhea.

(03:21): Chronic GVHD  can actually change your caloric needs, either increasing or decreasing them. You may notice you have increased needs of calories. After a transplant, you may have damaged body tissue and need more calories to help regain that weight and strength. But your body may also digest food less efficiently, requiring increased nutrient intake to maintain your weight.

(03:54): Eating foods that are high in calories and protein can help deal with weight loss cause by GVHD. The bottom line is that chronic GVHD can cause involuntary weight changes. There are ways to manage involuntary weight loss. The first thing we want to focus on is higher calorie, higher protein foods… so eating on a schedule instead of waiting until you feel hungry. I like to tell patients to schedule eating events almost like you schedule appointments, so you don't have to wait for your stomach to tell your brain, "Hey, I'm hungry." It can also be very helpful to eat five or six small mini meals or eating events, instead of trying to force yourself to eat three large meals.

(04:50): You can also get the most ‘bang for your buck’, or nutrition for your dietary needs, every time you choose foods that are high in calories and protein ... such as sauces, gravies, cheese, butter, any nut butter such as peanut butter or almond butter, cream, olive oil, avocado, honey, and jam. These are good ways to get extra calories.

(05:12): It's a good idea to try to incorporate a source of protein at each eating event. Some examples would be chicken, fish, turkey, eggs, nuts, beef, pork, yogurt, cottage cheese, milk, beans, or tofu.

(05:29): Often, if you're losing weight and don't have a great appetite, it may be easier to drink your calories in the form of a high calorie smoothie or shake, or an oral nutrition supplement. You may have heard of Boost® or Ensure®, but there are other products out there, as well.

(05:46): Another way to make a high calorie smoothie or shake that we call MSK, Memorial Sloan Kettering, double milk, is made with fortified milk; you may have heard of it. You can double the calories and protein in milk by mixing about one quart of whole milk - or if you really prefer low fat milk, which is also fine, with one cup of nonfat dry milk powder. That will double the calories and protein in your milk; you can use that milk for the entire week.

(06:20): Eating lots of fruits and vegetables, lean proteins and whole grain products, and increasing physical activity can prevent involuntary weight gain. Next, I'm going to talk about involuntary weight gain. There are many things we could do for that. Mainly, eat a lot of fruits and vegetables, since they are high in dietary fiber, but low in calories. Dietary fiber helps keep you full longer.

(06:39): Other sources of fiber include whole grain cereals and whole wheat pastas. Incorporate such lean proteins as fish and chicken without the skin. Choose low fat or nonfat dairy products versus a full fat or whole full fat, which would be helpful if you are experiencing involuntary weight loss.

(07:03): It can also be helpful to keep a food journal. This can help you track what you eat, when you eat, and monitor your portion sizes. It also can help you just be a mindful eater in general. It may make you stop and think, "Do I want that second cookie" if you have to write it down.

(07:20): And last, increase your daily physical activity. That can be helpful for involuntary weight loss, as well, because physical activity can improve your energy and your appetite, and also burn some calories.

(07:36): Eating difficulties and weight loss, caused by chronic GVHD can lead to malnutrition. Next, I'm going to go through the common nutritional side effects of chronic GVHD and how to manage them. This is when we become a little bit more concerned about the risk of developing malnutrition. It's when we have chronic issues such as nausea, vomiting, diarrhea, or anything that's going to affect the appetite, digestion, or absorption of nutrients, and cause us to lose weight unintentionally. That's when I like to be proactive, or even reactive in some cases.

(08:14): Eating several small meals each day, instead of three large meals, choosing bland foods, rather than fatty, greasy foods, and eating foods cold or at room temperature can help reduce nausea. In my next slides, I'm going to go through some of these common symptoms and give you some tips and tricks on how to manage them.  First, I'm going to talk about managing nausea. It can be helpful to eat six to eight small meals per day instead of three large meals. Try not to skip meals, because an empty stomach can exacerbate nausea, making it worse.

(08:37): You may notice some blander foods may be tolerated better, versus really fatty, greasy, or spicy foods. Sucking on any ginger candies or incorporating ginger tea can also decrease nausea. Additionally, eating dry foods like crackers, toast, dry cereal, breadsticks, or pretzels can be a good option. Put them by your bedside, so when you wake up, you can have them. Or have them every few hours to settle your stomach.

(09:10): If smells bother you, try eating foods that are cold or at room temperature, or avoid the kitchen during meal prep if you have someone preparing food for you, so you don't get an aversion to that smell. It can also be helpful to eat in a cool, well-ventilated room that doesn't have any strong smells. Cover an open cup with a lid and drink through a straw. Remember, meals on an empty stomach can make nausea worse.

(09:47): If nausea prevents you from eating, try avoiding foods and drinks that are high in fiber or contain caffeine, and sugar-free foods sweetened with sorbitol or xylitol. Following is an overview of how you can manage chronic diarrhea. You will want to avoid foods or beverages that can make diarrhea worse. Some of these foods include foods high in fiber, such as whole wheat breads and whole wheat pasta; drinks that have a lot of sugar, such as regular soda or fruit punch; very hot or very cold drinks; greasy, fatty, or fried foods, like French fries or hamburgers; or food and drinks that can cause gas, such as dried beans, raw fruit, and vegetables. Sometimes people have an intolerance to milk products unless those products are low lactose or lactose-free.

(10:31): Some foods with caffeine may make diarrhea worse, like regular coffee or tea, soda or chocolate. Lastly, sugar-free products, so anything sweetened with sorbitol or xylitol, may exacerbate diarrhea. It's very important to drink plenty of fluids to replace those you lose from diarrhea and prevent dehydration. A nice rule of thumb is that for each loose stool you have, try repleting it with one cup of fluid. That could be water, but you could also choose foods and liquids with sodium and potassium, because those are the electrolytes we lose when we have diarrhea.

(11:13): For example, we could do a sports drink or broth to replace sodium, or bananas and potatoes for potassium. We could eat several small meals throughout the day which, I think you see, is a common theme in a lot of these side effects. Lying down for 30 minutes after a meal may help slow your digestion. But to really personalize this further for you, I recommend working with a dietitian. because it's not a one-size-fits-all approach.

(11:43): If you have difficulty eating due to a dry mouth, try bland foods served cold or at room temperature, moisten food with broths or gravy, and eat tart foods to increase saliva production. Next is managing dry mouth. If you notice your mouth is dry, you're probably going to tolerate soft blander foods that are cold or at room temperature. You can moisten foods in broths, soups, sauces, gravies, oils, and butter. You can also use these foods as dips.

(12:03): To increase saliva production, try tart foods and drinks such as lemonade, lemon sorbet, or cranberry juice. It may be helpful to suck on sugar-free candies or even chew some sugar-free gum, to stimulate saliva production. I've noticed that citrus-flavored candies may work best.

(12:24): Practicing proper oral hygiene is very important. Make a mouth rinse with one quart of water mixed with about three quarters of a teaspoon of salt, and one teaspoon of baking soda, and just swish and spit. You can do this frequently throughout the day.

(12:45): If you just have an overall lack of appetite, try eating six to eight small meals a day, eating on the clock. Get the most nutrition eating high calorie, high protein foods. Always bring something with you to eat, as well.

(13:05): You could drink high calorie beverages in between meals, and also drink more of your fluid  between meals. If you notice you're getting full quickly, it could be helpful to separate eating and drinking. Finally, taking part in physical activity can help improve your appetite.

(13:21): There is a high incidence of metabolic syndrome among stem cell transplant survivors. Now we're going to switch gears a bit and talk about the long-term metabolic consequences following transplant. First, would be managing metabolic syndrome. There is a fairly high incidence of metabolic syndrome after the first-year post-transplant, and five years after transplant. It's characterized by at least three of the five characteristics listed below.

(13:49): First, you could see an ‘apple versus pear distribution’ for centralized obesity. We ideally want to see that pear body shape. Second, high levels of fat in the blood, LDL or bad cholesterol or triglycerides and/or low levels of HDL or good cholesterol. Third, high blood pressure, and high fasting blood sugar.

(14:21): Healthy eating habits can help reduce the risk of developing metabolic syndrome. The good news: We can be proactive with our nutrition by maintaining a healthy weight, keeping in mind appropriate portion sizes and meal planning. Portion control is an easy way to think about this. Make half your plate vegetables, a quarter lean protein, and a quarter full grain. Meal planning also works. It does take time, but studies show that planning your meals will help keep you healthier.

(14:53): Persistently high levels of cholesterol, as well as another blood fat called triglycerides, are associated with metabolic syndrome and place a person at risk for cardiovascular or heart disease. Let's switch gears again and return to discussing cholesterol. What is it? We've heard a lot about this in recent years. It's a type of lipid, or we could call it blood fat, in our bodies that forms cells, makes hormones, and produces vitamin D. Our bodies make both good cholesterol, HDL, and bad cholesterol, LDL. Persistently high levels of cholesterol, as well as another blood fat called triglycerides, are associated with metabolic syndrome, and place a person at risk for cardiovascular or heart disease. If you look at the diagram on the right, you'll see that normally, without any kind of cardiovascular disease, our blood flows through our body very easily. But with time, and buildup of cholesterol and other fats, the vessels become narrowed. During a prolonged period of time, one could see that the actual vessels become occluded (blocked), so blood cannot flow through them. This may set a person up for a cardiac event, which we want to prevent that.

(16:14): This slide lists what our normal blood fat or cholesterol and triglyceride levels are. This is data from the American Heart Association. Cholesterol levels ideally should be below 200. And then you have the values there for both the good and the bad cholesterol. And the triglyceride levels, again, another blood fat, should be below 150.

(16:39): If you're not sure what your cholesterol or your blood fat lipids are, you may want to ask your healthcare provider to check these levels. We recommend that you get fasting levels. In other words, going for an eight-hour period, without eating or drinking, prior to getting your blood drawn. Because this will give a more accurate result. You can then track it, to determine if there is any intervention that can be done, since this is usually a treatable problem.

(17:10): Unsaturated fats found in plant-based food can help lower bad cholesterol. What can a patient do if you have high cholesterol and/or high triglyceride levels? What kind of dietary measures can you take to help lower these levels? I'm going to talk about dietary fats. There are different types of fats found in our common food supply. There's a group called unsaturated fats, which are plant-based foods. We know that these types of foods can lower LDL, or bad cholesterol.

(17:40): Common foods include avocado, canola oil, olive oil, both the fruit and the oils. Sesame or sunflower, whole grain bread, nuts, and whole grain cereals. All of these are plant-based foods that can help lower bad cholesterol.

(18:02): Omega-3 fats, found in plant-based foods and fish, can help lower your triglycerides. Omega-3 is another type of good fat, or healthy fat that's found in plant-based foods and fish. These help to lower the triglyceride levels. Things like salmon, sardines, tuna, dark green, leafy veggies such as kale or spinach, legumes such as lentils or other dried beans, walnuts, or flaxseed oils, or even Omega-3 rich eggs. Omega-3 eggs are actually developed when hens are given flaxseed or sunflower oil or as part of their diet. So again, more plant-based foods help lower the triglyceride levels. These are all the good things we can incorporate into our diet to help lower our cholesterol.

(18:48): Saturated fats, such as those found in processed meats and red meats, increase bad blood cholesterol. Saturated fats are the ones you will want to avoid; these are the saturated fats and trans-fats. Saturated fats come primarily from animal sources. Saturated fat will increase your blood cholesterol. Things like processed meats, bacon, sausage, red meat, beef, lamb and pork, and full-fat dairy. But if you are experiencing involuntary weight loss, I recommend incorporating the full- fat dairy into your food regimen. That includes cream, butter, cheese, palm oil, lard, and chocolate, as well as any processed food, in general.

(19:42): Trans-fats are artificial fats, primarily found in processed foods, that increase bad cholesterol. The last type of fat I'm going to talk about is trans-fats. These are artificial fats. Basically, you take a liquid fat, and pump it full of hydrogen molecules to make it more solid. These types of fats can actually increase the bad cholesterol, while decreasing the good cholesterol. They are primarily found in such processed foods as margarine and shortening, many fried foods, and some crackers and chips. Chips may, recently, contain trans-fat less and less, as food manufacturers are changing how they prepare these snacks. These are the fats that we want to limit in our diet, while focusing more on plant-based fats, such as Omega-3 fatty acids, and unsaturated fats like the polyunsaturated and monounsaturated fats.

(20:38): Osteoporosis is common after transplant, affecting 50-60% of patients. Having just examined metabolic syndrome and cardiovascular disease, I am now going to discuss another complication that we often witness post-transplant, osteoporosis. By definition, osteo means bones, and -porosis means full of holes. So, osteoporosis is a condition where the bones are full of holes; the density or the thickness having decreased. You can see in this picture there, if you look at the vertebrae and the femur (thigh) bones, the normal on the left, and someone with osteoporotic bones on the right. You can see the vertebrae are starting to tilt a bit. They become soft, more of the hunched over appearance.

(21:26): Why are transplant patients at higher risk of developing osteoporosis? It's a common side effect that affects about 50 to 60% of transplant patients. Some of the primary causes and risk factors include any kind of preexisting disease going into transplant. Hormonal changes may also play a role. We know that patients who are on long-term steroid therapy, specifically one called prednisone, may be at a higher risk of developing osteoporosis. Patients who lead a sedentary lifestyle are also more at risk.

(22:06): Osteoporosis can cause long-term issues such as fractures, disability, or loss of independence. This can be a major complication post-transplant. Luckily, there are things you can do to help prevent or help reverse osteoporosis.

(22:26): Transplant recipients need calcium and vitamin D to protect their bones against fractures caused osteoporosis. The best thing one can do is to maintain good bone health after transplant, since osteoporosis can be reversible. You will want to get adequate calcium and vitamin D to protect your bone health. Specific food sources can be noted on the next slide. Remember that 1500 milligrams of calcium is the recommended dose. If we look at this a bit further, how do you know how much calcium is in a particular food? On a food label, it lists calcium at the bottom, and that's for a specific serving size.

(22:47): You should also check with your healthcare provider to see if you need a calcium or vitamin D supplement, as osteoporosis is very common, especially after the first year.

(22:59): Sometimes during the transplant process we become very sensitive to dairy, and may become lactose intolerant. There are other food sources where you can get calcium, which can be seen on the next slide. Here are some sources of calcium and how much calcium is in each of these foods.

(23:12): Weight-bearing exercise helps make bones stronger. You should also consider incorporating weight-bearing exercise to help with your bone health if you are able. Weight-bearing exercise means you're carrying extra weight, such as free weights or using a strength training machine. What this does is increase weight on your bones, helping to make bones stronger.

(24:28): We see a lot of foods fortified with calcium or vitamin D. So, if you're lactose intolerant, don't worry. Many breakfast foods are calcium fortified. That could be a great source, and they'll say it right on the food label. For example, one cup of low-fat milk has about 305 milligrams of calcium per serving, which is one cup. There are other sources such as almonds, sardines, figs, and soy milk.

(24:47): Reliable, science-based information about nutrition and diet can be difficult to find on the internet. I am now going to tell you how you can evaluate some nutrition myths. I will demonstrate how you can evaluate nutritional information. Since there is so much incorrect information on social media, the Internet, Dr. Google, friends, and family, we will want to evaluate it critically. I find that cancer survivors, as a group, are highly motivated to learn about health issues and make positive lifestyle changes.

(25:20): However, survivorship research is in its early stages, and dependable science-based recommendations can be difficult to determine. Too often, uninformed, or unscrupulous people often rush to fill the information gap with inaccurate or misleading advice. Media reports can overstate the results of research. Makers of products may tout unproven health claims. And the Internet to often enables baseless rumors about diet and cancer to reach people around the world.

(25:55): Be wary of food products and diets described with words such as breakthrough, miracle or discovery, or whose claims are supported only by anecdotal information. There are some tips to evaluate what's reliable when it comes to health claims. First, read information closely. Science progresses slowly and carefully. So, be wary of products described with words such as breakthrough, miracle, or discovery. Another red flag is a product whose claims rely on anecdotal evidence. What I mean by that is testimonials or case histories, which are often falsified, rather than published data based on research with many patients.

(26:26): Next, make sure to get the whole story. Television, radio reports, and podcasts about science can be short and lacking in detail. Look for more complete information in reputable magazines and newspapers. You should always think, "Who conducted and paid for the study? Was it published by a trusted source? Is there a consensus from research in the field to round out information from a single study?" Maintain that healthy skepticism and particular wariness of easy answers.

(27:02): Human nature has us looking for quick fixes to solve health problems; but cancer is a complex disease; the human body, an intricate machine. The foods we eat contain a vast number of health promoting components. The most helpful strategy will address the overall diet, not single foods, or supplements.

(27:23): Always talk to your healthcare provider before trying any new product or diet. Lastly, turn to your healthcare provider or dietitian for advice you can rely on. Always talk to your healthcare professional before trying any new strategy. You can rely on their extensive training, experience, and knowledge of meaningful developments in the cancer field. Inform them about all the medications and supplements you're taking. There are certain herbal supplements, for example, that may interact with cancer medication, making treatment less effective. So, always talk to your doctor before starting a new drug or supplement.

(28:02): The notion that sugar feeds cancer is a myth. The following are some common myths versus facts which I will explain in some detail. Has anyone read that sugar feeds cancer? I'd assume yes, but, hopefully, I can bust this myth for you. Because the belief that sugar in the diet somehow preferentially feeds cancer is a very common belief among patients. But the truth is a lot more complicated.

(28:29): All cells, including cancer cells in our body, use sugar in the form of glucose from our bloodstream for fuel. We get that blood sugar from foods we eat that contain carbohydrates, including healthful vegetables, fruits, whole grains, and low-fat dairy sources. Some glucose is even produced within our bodies from protein.

(28:55): The connection between sugar and cancer is very indirect. People who eat a lot of high sugar foods or added sugar foods like cookies, candies, and cakes, may be getting more calories than they need in their diet. Overeating in general can lead to excess weight and body fat. It is really that excess body fat that has been convincingly linked to a greater risk of certain cancers. Being overweight, or obese, can put your body in that state of inflammation, which can lead to DNA damage, and thus, certain cancers.

(29:32): Bottom line, sugar doesn't necessarily feed cancer;  it's a very indirect relationship. Eating a lot of high sugar foods leads to excess calories in your diet, which leads to excess weight and body fat, which is all linked to chronic disease.

(29:58): Focus on having a balanced, healthy diet. Choose those healthy carbohydrates like whole grains and natural fruit. If you want to indulge in cookies, candies, cakes, indulge mindfully, and have a small portion.  Choose foods that provide nutritional benefits, like whole grains that are high in fiber, and fruits that have high antioxidant and anti-inflammatory benefits. The list is endless.

(30:34): A ketogenic diet severely restricts intake of carbohydrates and is associated with side effect such as constipation, anemia, some cardiac abnormalities, as well as dehydration. Now I'm going to talk about a ketogenic diet. It is a very high fat, moderate protein, low carbohydrate diet. Don't mistake this for a high protein diet. Keto means ketone, -genic means producing. So, ketogenic means producing ketones in the body.

(30:58): What does this mean exactly? The theory behind this, in general, for cancer patients, is that if we think sugar feeds cancer, we can starve the tumor of glucose by not eating any carbohydrates. But this isn't really the whole picture. The relationship between sugar and cancer is more about obesity than sugar as a fuel for cancer.

(31:27): For a ketogenic diet, if you're having very small amounts of carbohydrate, ketones are formed when the body uses fat for its source of energy. Normally, the body uses carbohydrates like sugar, bread, pasta, et cetera, for fuel. But because the ketogenic diet is very, very low in carbohydrates, fat becomes the primary fuel instead.

(31:54): To put this in perspective, truly following that ketogenic diet, carbohydrates would be about 5% of your total intake, based on the 2,000 calorie a day diet. That means you would get 25 grams of carbohydrate per day maximum, to stay in ketosis. But one medium apple contains about 25 grams of carbohydrate. Anything more than that, and you're out of ketosis. It's a very hard, restrictive diet to follow.

(32:29): The ketogenic diet has been an acceptable medical option for treating epilepsy, and is currently being studied for people with brain cancer. The use of the ketogenic diet during any treatment for different types of cancer is also being studied. But there's certainly no recommendation for cancer patients or survivors to follow this very restrictive diet.

(32:55): A lot of side effects have been reported, like constipation, anemia, some cardiac abnormalities, as well as dehydration. It also produces bad breath. Currently there is no recommendation or research to promote it.

(33:12): A gluten-free diet is required for people who have celiac disease. If you don’t have celiac disease, a gluten-free diet could cause you to miss out on a lot of nutritious foods. A current hot topic is gluten, and do you need to follow a gluten-free diet. What is a gluten-free diet? It excludes any foods that have gluten in it, so you can eat only whole foods that don't contain gluten such as fruits, vegetables, meat, and eggs, as well as processed gluten-free foods, such as gluten-free breads or pasta.

(33:43): Gluten is a protein naturally occurring in certain foods, but can also be added to foods for texture during processing. Gluten can be used as a binding agent and flavoring, so you can sometimes find it in foods you wouldn't necessarily expect.

(33:59): In addition to foods like pizza, pasta, cereals, and baked goods, it can be found in things like beauty products and dietary supplements. Some people think going gluten-free means not eating any carbohydrates. That's not the case. Lots of foods contain carbs, such as rice, potatoes, beans, but don't contain gluten.

(34:28): A gluten-free diet is necessary for people with celiac disease, which is an autoimmune response to gluten that causes the body to attack the small intestine, causing belly pain, nausea, bloating, or diarrhea. Sometimes, less commonly, celiac disease sufferers may be symptom-free, but it will still cause damage to the lining of the small intestine. People with celiac disease can't tolerate gluten in any form and may need to follow a strict gluten-free diet for the rest of their lives.

(34:59): If you cut out all gluten from your diet and you don't have celiac disease, there's a risk that you will miss out on a lot of nutritious foods, like whole grains, fiber and micronutrients. The bottom line, unless you have celiac disease or experience discomfort when you eat gluten, there's no need to avoid it.

(35:18): Some people are gluten sensitive, but don't have celiac disease. If you notice that any of those gluten products cause you discomfort, perhaps try keeping a food symptom journal to see if it's something you do need to avoid. But overall, no need to follow it. No health benefits unless you have celiac disease.

(35:44): Dietary supplements are not a good substitute for the nutrients found in food. The next myth: are supplements a substitute for nutrients in food? The short answer is ‘no’. There's a quote that came out from the American Cancer Society that I want to repeat to you. I thought it was really good. "Dietary ingredients in supplements don't offer the same benefits as eating whole foods."

(36:11): Research has shown that supplements do not offer cancer protection or provide benefits to survivors worried about re-occurrence. Supplements also may not be well absorbed by the body, and in high doses may be potentially harmful.

(36:28): Some supplements have been shown to interfere with medication. Be wary of all the claims about supplements. I know some may say you can get all your fruits and/or vegetables in this one pill. Be careful of these since these statements are not regulated by the Food and Drug Administration (FDA).

(36:49): Studies have not found a clinically significant difference on health between eating organic foods, compared to conventional foods. Do you need to eat all organic foods? Is organic food healthier? Well, what is organic food to begin with? They're plant foods grown without pesticides or weed killers. But is it healthier? Not necessarily. Studies have not found clinically significant differences between organic foods, compared to conventional foods.

(37:18): This is a personal decision, but it should be an informed decision. Organic food does not mean healthier. Remember, you could still buy organic cookies, chips, and other snacks, and they can contain the same number of calories, fats, including the bad fats like that saturated fat, and sugar, as conventional brands. So, bottom line, you could still get a very nutrient rich diet from a non-organic diet. This comes down to real personal preference.

(37:53): There is no clear evidence that a vegetarian diet is more protective against cancer than a mostly plant-based diet that contains small amounts of meat and dairy foods. I'm going to end with one last myth. Do you need to follow a vegetarian diet?

(37:59): A vegetarian diet may be a healthier alternative to that typical Western diet with all the fried food and red meat. But there is no clear evidence that a vegetarian diet is more protective against cancer than a mostly plant-based diet, meaning a diet that contains small amounts of meat and dairy foods. If you do follow a vegetarian diet, you should make sure you include many different vegetables and fruits, but also protein alternatives to meat such as beans, eggs, tofu, fish, or small amounts of low-fat cheeses.

(38:36): I believe we are now going to open it up to questions.

Question and Answer Session

(38:54): [Marsha Seligman]: Thank you, Ms. Myers, for this wonderful presentation. We will now begin the question-and-answer session. The first person would like to know if yeast and honey are okay to eat when you are on immunosuppression meds?

 (39:10): [Michelle Myers]:  I would be careful of eating raw, unpasteurized honey. But I think any honey found in the grocery store should be just fine. In terms of nutritional yeast, I would look at the food label. But you should be okay with it. We really cut back on having a very restrictive diet. We like to just focus on basic food safety guidelines.

(39:40): [Marsha Seligman]:  I make chicken broth or bone broth every week. Should I worry about my kidney function? And can bone broth help bone function?

 (39:54): [Michelle Myers]:  It would all depend on your personal situation, but broth is great. Bone broth doesn't necessarily mean it can promote healthy bones, but it does have more protein than regular broth. It could be a good option, but I love the idea of making it yourself; however, the true benefits are unclear.

(40:23): [Marsha Seligman]:  Do you find black or green teas benefit blood pressure or other health parameters? If so, what quantity?

 (40:34): [Michelle Myers]:  If you want to incorporate tea, that's great. I think green tea might have a little bit more health benefits in general. But go with your personal preference. I wouldn't force yourself to drink any certain amount since the research is unclear.

(41:02): [Marsha Seligman]:  The next question, is it okay to take a small dose of vitamin K2? I have read that it helps direct calcium to the bones where it should go.

 (41:14): [Michelle Myers]:  I would definitely talk to your medical team about any supplements, as I had mentioned earlier.

 (41:23): [Marsha Seligman]:  Is GVHD an inflammatory response? If so, is eating a gluten-free diet beneficial to reduce inflammation? Or are these two types of inflammation unrelated? I ask because I have been gluten-free since my transplant two years ago. Can I stop my gluten-free diet, or is being gluten-free beneficial for transplant recipients? You can assume I am not gluten intolerant.

 (41:49): [Michelle Myers]:  If you do not have intolerance to gluten, there is no need for you to avoid it. While chronic GVHD does put your body in a state of inflammation, gluten does not put your body in an increased state of inflammation. You can start liberalizing your diet and incorporating gluten.

(42:13): [Marsha Seligman]:  I am 71. How do I reconcile increased calcium intake for my bones with the risk of heart disease?

 (42:23): [Michelle Myers]:  You can increase your calcium without increasing your risk of heart disease by incorporating a lot of great food sources of calcium that are heart healthy, like any calcium fortified cereal. You could also ingest low-fat or nonfat dairy products. Your medical team may advise you to take a calcium and vitamin D supplement.

(42:52): [Marsha Seligman]:  Any tips on how to get Vitamin C if I am avoiding citrus due to significant acid reflux?

 (43:00): [Michelle Myers]:  Yes; Vitamin C is found in a lot of green, leafy vegetables.

(43:11): [Marsha Seligman]:  Should I be juicing instead of a meal? Can I eat greens and green tea in treatment?

 (43:19): [Michelle Myers]:  I would prefer eating the food instead of juicing it. Greens, definitely. During treatment, make sure you're just washing all your produce really well. Green tea should not be a problem unless you are told otherwise.

(43:45): [Marsha Seligman]:  Someone would like some suggestions on what to eat while they have GVHD in the mouth.

 (43:52): [Michelle Myers]:  I suggest softer, more moist foods. Or some good smoothies or shakes that are high calorie or high protein. For example, they could blend some yogurt, avocado, peanut butter, banana; even add some protein powder. That may be a lot easier to tolerate and not exacerbate any pain in your mouth.

 (44:23): [Marsha Seligman]:  How much protein can an athlete consume after an allogeneic transplant; trying to build back strength and muscle, 22 years post-transplant?

 (44:36): [Michelle Myers]:  First of all, if you have only a lot of protein, but not enough calories, that protein won't be spared for your muscle. So first, you want to make sure you're getting enough calories from your diet. Instead of counting grams, which you definitely can do, I would try to focus on having a source of protein in all meals and snacks, and then doing physical exercise. The rule of thumb is, if you don't have any kidney issues, if you want to take your weight in kilograms, which is pounds divided by 2.2, and then multiply that by 1.5, that could be your target grams of protein.

(45:22): [Marsha Seligman]:  How can I regain a good gut microbiome without eating yogurt every day?

 (45:30):[ Michelle Myers]:  Gut microbiome's a very hot topic now days. You can have a healthy gut microbiome by eating a wide variety of high fiber foods. I like to say eat the rainbow, so a wide variety of fruits and vegetables, because each fruit and vegetable, or each color, has different health benefits. But also eat high fiber foods; the way they're digested, they promote good gut bacteria; they're food for the bacteria in your gut. You don't have to focus only on yogurt.

(46:08): [Marsha Seligman]:  I usually feel tired after lunch and dinner. So, lying down right after meals, is it good or bad for the health?

 (46:18): [Michelle Myers]:  If you have anything like reflux, lying down after eating is probably not a good idea; you want to be staying upright. But if you feel a need to lie down, definitely do so. I don't think it's going to be detrimental to your health unless you're experiencing reflux. You may want to try just eating smaller and more frequent meals throughout the day if you're feeling really tired. That may make eating a lot easier.

(46:46): [Marsha Seligman]:   Is it true that cancer patients should follow a Mediterranean diet?

 (46:55): [Michelle Myers]:  There's some interesting research about the benefits of the Mediterranean diet. It’s really just a general balanced, healthy diet. It focuses on healthy fats, like I spoke about previously. It doesn't have a lot of red meat in the diet; I recommend limiting red meat, which is beef, lamb, and pork, to less than about 12 ounces a week. That's about three portions a week if each portion is about the size of your palm or a deck of cards. The Mediterranean diet incorporates a lot of good healthy fats, and fruits and vegetables, which I love.

(47:34): [Marsha Seligman]:  I wonder why someone would suddenly change from having minimal appetite to having a huge appetite with no change in meds or exercise?

 (47:49): [Michelle Myers]:  I don't necessarily know the exact reason. But oftentimes, I just see, all of a sudden, patients turn a corner completely, and their appetite returns. They no longer have any difficulty if they're having any taste changes. But when things happen all of a sudden, I would always ask your doctor.

(48:16): [Marsha Seligman]:  Someone would like to know what are the best antioxidants for them to eat?

 (48:23): [Michelle Myers]:  Remember when I talked about evaluating nutrition information? No single, specific food is the best. Having a wide variety of these plant-based foods is preferred. A great resource is American Institute of Cancer Research. On their website they have a whole list of foods that fight cancer, and it explains their health benefits. For example, blueberries are very high in antioxidants. But again, eating that rainbow gives you all the antioxidants.

(48:58): [Marsha Seligman]:  Do you recommend probiotics?

 (49:02): [Michelle Myers]:  I would talk to your medical team before taking any probiotic.

(49:09): [Marsha Seligman]:  Do you have any data on post-metabolic syndrome issues with CAR T therapy, compared to stem cell transplant?

 (49:18): [Michelle Myers]: I know CAR T-cell therapy is very new. So, off of the top of my head, I do not.

(49:29): [Marsha Seligman]:  What is your opinion about nutrients of supplementation with high vitamin C infusions that some places sell, as a way to deal with cancer?

 (49:41): [Michelle Myers]:  That really upsets me. I work at an institution that's all evidence-based, so I am very against that.

(49:55): [Marsha Seligman]:  Do you know why some people develop coatings in their mouth?

 (50:04): [Michelle Myers]:  I don't know why. But if you notice you have that white coating on your tongue, something that I found that could be really helpful is if you just put a little fresh pineapple on your tongue, that could really help. It's the enzyme in that pineapple.

(50:19): [Marsha Seligman]:  Why do some people become lactose intolerant after transplant?

 (50:26): [Michelle Myers]:  There are many reasons for this. But if you notice you become lactose intolerant, it's a good time in the world to be lactose intolerant since there are so many products on the market now that are dairy-free. I think the flavors of Ben and Jerry ice cream in the dairy-free options are better than the regular.

(50:53): [Marsha Seligman]:  I know it is not safe for us to eat hamburger rare. But if you are several years post-transplant, is it safe to eat rare steak or roast beef?

 (51:05): [Michelle Myers]:   I would say most likely. Not fully rare, maybe just because it's never really great to eat fully rare meat. But if your counts are fine, you should be fine. But for most people, I want you to stick to cooking food to that safe minimum internal temperature.

 (51:27): [Marsha Seligman]:  A few years ago I was advised to avoid pre- and probiotics, as research was still being done on whether these were helpful or harmful post-transplant. Do you know if they are recommended these days, or not?

 (51:42): [Michelle Myers]:  During the actual transplant process, they are not routinely recommended.

(51:52): [Marsha Seligman]:  I have a great deal of nausea, and cannot tolerate most foods. I have tried taking Zofran and other meds, but they don't seem to help. I also find that I cannot tolerate eating foods when they are hot or warm. They must be room temperature or cold. I'm also finding I cannot tolerate most proteins except seafood or a very limited amount of chicken. What do you recommend?

 (52:18): [Michelle Myers]:  I'm sorry you are dealing with that. There are other anti-nausea medications out there, such as Reglan, so talk to your team.  I really like the website CookforYourLife.org. You could filter recipes by symptom. You can research anti- nausea recipes. They may have a lot of good smoothies or shakes. If you're having trouble with protein, consider some unconventional sources of protein that aren’t meat, chicken, or fish. For example, beans, lentils, and some nuts or seeds, can be a good source of protein.

(52:59): [Marsha Seligman]:   Someone would like to know about prednisone for chronic GVHD. They said their A1C has increased into pre-diabetic range. "How can I find a dietitian to help me create a plan to help address weight gain? And are there any meal planning books or resources that you would recommend?"

 (53:27): [Michelle Myers]:  Prednisone does, unfortunately, increase blood sugar. To find a dietitian, you can ask your healthcare provider. The Academy of Nutrition and Dietetics has a website where you can search Find a Provider. You can search for one that may take your insurance. If you're working with an endocrinologist, s/he may have a dietitian on staff, as well.

(54:03): [Marsha Seligman]:  On behalf of BMT InfoNet and our partners, I'd like to thank Ms. Myers 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.