Optimizing Nutrition after Transplant

Optimizing Nutrition after Transplant

July 13, 2020 Part of the Virtual Celebrating a Second Chance at Life Survivorship Symposium 2020

Presenter: Paula Charuhas Macris MS, RD, CSO, FAND, Nutrition Education Coordinator, Seattle Cancer Care Alliance

Presentation is 29 minutes with 15 minutes of Q&A.            Download Speaker Slides  

Summary: Learn about proper nutrition for recovering transplant recipients and common myths about popular diets.

Highlights:

• Chronic graft-versus-host disease (GVHD) can disrupt how the body normally processes food after transplant. Patients may need more calories to maintain or gain weight.

• Transplant patients are at a higher risk of developing metabolic syndrome which includes type 2 diabetes and cardiovascular disease.

• It is best to meet nutritional needs and vitamins through food instead of supplements.

Key Points:

04:24     Protein is an important nutrient to help build and repair body mass after transplant.

08:31     A healthy diet can reduce the risk of developing metabolic syndrome after transplant.

10:46     Physical activity, combined with a healthy diet, can lower your risk for numerous chronic diseases.

12:01     A diet rich in plant foods plays a big role in preventing chronic disease and contributes to a healthier life.

13:39     Fast foods and processed food high in fat, starches or sugars can cause obesity and other health problems.

18:06     Limiting or eliminating alcohol can lower your risk of developing certain cancers and other diseases.

22:22     Sugar does not feed cancer

23:26     The alkaline diet is not recommended for recovering transplant patients because it is low in protein, calcium, and vitamin D.

24:34     The ketogenic or keto diet is not recommended for recovering transplant patients because the diet's common side effects of constipation, anemia, cardiac abnormalities, and dehydration are harmful.

27:00     The book  Cancer Fighting Kitchen” andthe webiste  Cook for Your Life are recommended sources of nutrition information and recipes during and after treatment.

Transcript of Presentation

00:00     [Moderator] Welcome to the workshop Optimizing Nutrition after Transplant. My name is Mary Clare Bietila. I will be your moderator today. It is my pleasure to introduce you to Ms. Paula Macris. Ms. Macris has been the Nutrition Education Coordinator at Seattle Cancer Center Alliance for the last 30 years. She has presented at several national and international conferences on nutrition and bone marrow transplantation; and has published multiple review articles, research papers, and book chapters on the topic. Please join me in welcoming Paula Macris.

00:49     [Ms. Macris] Good afternoon everyone and thank you for the opportunity to be here today to talk about optimizing nutrition after transplant. Working with bone marrow transplant long-term survivors is an area that I have a strong passion for. I hope that today I can share some helpful diet and nutrition information with you.

What I'd like to do today is to help you gain a better understanding of some of the long-term nutritional consequences associated with stem cell transplant. I'll go then to discuss some practical skills and tools to maintain a healthy diet post-transplant. Then, finally, describe some common myths associated with nutrition and cancer.

Long-Term Nutritional Consequences After Stem Cell Transplant

01:37     Let's start, first of all, with looking at some of the. As advances in technology and supportive care measures have improved, the number of long-term transplant survivors continues to increase. With this growth, a greater emphasis is now being placed on treating long-term complications. Two common complications with nutritional implications that I'd like to address include chronic graft versus host disease, or GVH, and metabolic syndrome, both of which impact life expectancy and quality of life.

Nutrition and Chronic Graft Versus Host Disease (GVHD) After Transplant

02:20     Chronic GVH is the immune-mediated disorder that occurs after an allogeneic stem cell transplant, or transplant from another donor. Chronic GVH is more common after the first three months post-transplant. It's an issue that may affect many body organs. However, those pertinent to nutrition include the mouth, which may result in painful sores, making it difficult to chew and swallow food; the stomach, which usually manifests as a decrease in appetite, nausea, vomiting, and early fullness; and also the gastrointestinal tract, which typically presents with lower abdominal cramping and diarrhea.

Chronic GVH may change the amount of calories you need. It may cause you to lose weight and muscle mass, so your body may require more calories to repair the damaged tissues. If you have experienced that GVH, your body may digest food less efficiently so you may need to eat more to maintain or gain your weight. A couple of suggestions are listed on this slide.

First of all, instead of eating three meals a day, try to focus on small, frequent meals and snacks with nutrient-dense foods and high protein foods, which I'll be talking about more momentarily. You also want to consider adding healthy fats to foods. Things like extra olive oil, or avocados, or butter to boost the nutrient density.

Conversely, some medications, such as steroids, specifically prednisone, which is a common treatment for GVH, may result in unnecessary weight gain. In this situation, monitoring portions consumed is certainly important, as well as avoiding processed foods high in added sugar, salt, and fat.

Protein is an important nutrient to help build and repair lean body mass, which may be impacted during the transplant course. Protein sources are listed on this slide. Protein comes from both animal and plant products, and it's good to consume a variety of different high protein foods each day from both the animal and the plant groups.

 Fluids are another important component of good nutrition during transplantation, as so many medications impact kidney function. Also, other losses, such as fever or GI symptoms may impact fluid status. Again, variety really is the key and limiting intake of high sugar drinks, such as juices and soda pop, to prevent excessive calorie intake is necessary. You want to focus on non-nutrient dense, non-sugar fluids, such as the ones listed in this slide.

Metabolic Syndrome After Transplant

05:22     Aside from GVHD, the other long-term implication I'd like to address is that of metabolic syndrome. Metabolic syndrome is a cluster of biochemical and physiological abnormalities associated with the development of type 2 diabetes and cardiovascular disease. There's a high incidence of metabolic syndrome in the United States. Having a bone marrow transplant places an individual at an even higher risk of developing this condition.

By definition, someone is diagnosed with metabolic syndrome if they have the presence of at least three of the five characteristics showing on this slide. The first is the apple versus the pear distribution, or the centralized adiposity in the waist area. A large waist circumference, greater than 40 inches for men or greater than 35 inches for women. High blood fats are another component of metabolic syndrome, specifically high serum triglyceride levels, typically greater than 150. Low HDL, or good cholesterol, is another characteristic. Less than 40 for men and less than 50 for women. High blood pressure, or on medications, and a high fasting blood sugar, or also on medications.

 How does diet affect the development of metabolic syndrome after transplant? I just want to also mention that, in addition to the symptoms I previously described, a couple other symptoms are shown on this slide, mainly fatigue and the inability to focus, being very tired of having brain fog, just feeling a little bit off. Again, the blood pressure and the lipid issues, as well as the glucose issues. And the central adiposity where you can see on this slide to the left, the apple versus the pear distribution of fat. Metabolic syndrome may also include symptoms such as the browning of folds of skin and non-alcoholic fatty liver disease, which would be a fat accumulation in the liver when someone's not drinking alcohol.

Looking at some of the studies we've done at our center, as well as other transplant centers, we know that children undergoing transplant are three times more likely to develop diabetes, and two to three times more likely to develop high blood pressure than the general population, if they've gone through transplant. In the adult population, adults are four times more likely to develop diabetes, and two to three times more likely to develop high blood pressure.

Lifestyle changes to prevent metabolic syndrome after transplant

08:31     Given this situation, we want to look at what lifestyle changes we can make to reduce the incidence of developing metabolic syndrome post-transplant. And because of high prevalence of cardiovascular disease and endocrine complications, lifestyle changes can, and really should, be made to decrease the incidence of developing metabolic syndrome.

The American Institute for Cancer Research, or the AICR, has developed some great dietary guidelines to help all of us maintain a healthy diet post-transplant that may actually lessen the risk of developing metabolic syndrome. These guidelines were developed, again, through a cancer research institution, which is an organization associated with the World Cancer Research Fund. All of the diet and lifestyle changes are listed on this next slide. I'm going to talk briefly about each one of these different changes.

Be a healthy weight. Maintaining a healthy weight is probably one of the most important things you can do to protect yourself from cancer and other chronic diseases. When you have excess weight, you increase your risk for a number of health conditions, including heart disease, high blood pressure, and diabetes. You also increase your risk for cancer. Even though awareness is relatively limited on the link between excess weight and cancer risk, the fact is that, aside from not smoking, staying at a healthy weight throughout life is the single most important thing you can do to protect yourself from cancer and other disorders.

Healthy weight is currently defined looking at body mass index, or BMI. You can use that formula there on the slide to determine what your body mass index is. You can also just Google it over the Internet. Formulas are out there that can do the calculation for you. The important thing is that you want to try to be in that normal weight category with a BMI of about 18.5 to 24.9, and if that's really a reasonable goal to maintain.

 Be physically active. That's a recommendation by the AICR. Being physically active and exercising can lower your cancer risk, help you to have a healthy weight, and lessen your risk for numerous chronic diseases. Just 30 minutes of physical activity about five times a week can go a long way towards improving your health. To get the most out of your physical activity, combine it with a healthy diet. When you combine a plant-based eating style with intentional physical activity, you'll more likely balance the calories you take in with what you burn. You'll more naturally have and maintain a healthy weight. Regular exercise or physical activity is endorsed not only by the AICR, but by the American Cancer Society and the American Diabetes Association.

Again, recommendations are shown in this slide. Again, aiming for at least 30 minutes of moderate physical activity on most days of the week, and increasing duration as tolerated. I must add, too, it's important to really pick an exercise or activity that you like, so that you'll be more committed to participate in, and it's something that you'll be able to look forward to doing.

Eat a diet rich in plant foods

12:01 Another recommendation is to eat a diet rich in plant foods, such as whole grains, vegetables, fruits, and legumes. Scientific evidence shows that eating mostly plant-based foods, including the whole grains, fruits, vegetables, and beans, plays a big role in preventing chronic diseases and contributing to healthier lives. That's because plant-based foods are high in the types of fiber, nutrients, phytochemicals, or natural substances, that may help to prevent chronic diseases. Plus, plant-based foods can help you manage your weight and give you the energy you need to enjoy physical activity.

The American Institute for Cancer Research Center emphasizes eating foods that can reduce your risk for cancer and other chronic diseases. Get started by covering at least two-thirds of your plate with plant foods, such as the whole grains, fruits, vegetables, and beans. The remaining one-third of your plate may be filled with animal-based protein rich foods, such as seafood, poultry, and dairy foods, and occasionally with lean, red meat. You want to focus on consuming a rainbow of colors where you're getting in fruits and vegetables that are green, red, orange, and so forth, to provide different vitamins, minerals, and nutrients. Try to consume at least four cups, including both raw and cooked, daily. Legumes in the form of dried beans and peas are becoming more popular and are great sources of plant proteins that provide vitamins, minerals, and fiber.

Limit intake of fast foods and processed foods

13:39     Another recommendation is to limit intake of fast foods or other processed foods high in fat, starches, or sugars, and to choose whole foods. Limiting processed food products helps you control your calorie intake and makes it easier to maintain a healthy weight. Fast food can certainly be tempting and more convenient, but over time eating that way can have negative impacts on your health and lead to weight gain, which can increase your risk for chronic diseases.

You may have heard of the term whole food. What is a whole food? Basically, a whole food contains all or most of the edible, original parts. Whole foods, basically, have not had anything done to them in terms of processing. It's food in its natural state that has not been processed or refined as little as possible. It's free from additives or other artificial substances.

Fast foods and our Western type of food choices often result in an unhealthy diet because we're not eating many whole foods. Just remember to try and skip the junk food. Just one example is that one oversized fast food meal can load your body with more calories than the average person needs in an entire day. This can result in weight gain, leading to the development of becoming overweight or obese. These conditions are linked to the development of at least 12 different kinds of cancers. Consume only fast foods that feature minimally processed, delicious fruits and vegetables, whole grains, and beans. You'll feel better eating nutritious fast foods with more fiber and less calories.

 At the grocery store, be sure to read the nutrition facts labels on any packages you purchase to compare the calories per serving, as well as looking for foods that have minimal processing done. You want more fiber, less sugar, less fat, and less sodium. Eating a nutritious diet comes with many benefits. Again, it's going to help you maintain your weight and reduce your risk of overall developing chronic diseases.

Limit intake of sugary foods

15:54     Another important guideline is to monitor intake of cookies, health bars, candy, commercial condiments, and sweetened yogurt. These foods contain a higher sugar content that may, again, result in an excessive calorie intake. Limit consumption of red and processed meat. You don't have to eat red meat to get the nutrients you need but eating moderate amounts provides a good source of protein, iron, zinc, and vitamin B-12. However, eating more than 18 ounces of red meat weekly can increase your cancer risk. If you do eat red meat, limit the consumption to no more than three portions a week, which is about 12-18 ounces cooked, which really is still a very generous amount.

You also want to eat little, if any, processed meats. Processed meats have been smoked, cured, salted, fermented, or had preservatives added to them. Instead of eating hot dogs, bacon, sausage, and other deli meats, go for fresh roasted poultry, different nut butters like almond nut butter, hummus or other bean spreads for sandwiches and other dining options.

Limit consumption of sugar-sweetened drinks. The sweet flavors that keep us coming back for another soda or another sugary drink are also loading us up with an excess intake of sugar. Again, drinking a lot of sodas or sugar can impact weight and contribute to weight gain and obesity. Instead of reaching for a soda, get into the habit of keeping some water close by and primarily drinking water and unsweetened fluids. Still or sparking water is a refreshing, healthy choice for a beverage. Try to choose plain or flavored waters that do not contain added sugar. You can also enjoy a mug of unsweetened tea or a fresh cup of coffee without sugar. Or even try infusing tea or water with fruits, lemon wedges, or even some cucumber slices. It does make for a refreshing beverage during warm weather.

Limit alcohol consumption after transplant

18:06     Limit alcohol consumption. The less alcohol you drink, the lower your risk for other diseases. Even though most of us understand that drinking alcohol can be harmful, many Americans reach for a beer or glass of wine without giving it too much thought. If you're interested in taking a proactive approach to cancer prevention, it's really best not to drink alcohol.

If you do, however, drink alcohol limit your intake to no more than two drinks a day for men and one drink a day for women. That's because even when men and women drink the same amount of alcohol, higher levels are seen in the bloodstream of women than in men. This means that women's organs are exposed to higher levels of alcohol more so than men. A couple things to be aware of. One is that restaurants and bars often serve larger than standard size alcoholic drink, so order the smaller sizes. Enjoy low or no-alcoholic alternate drinks, such as non-alcoholic beer, or alternate alcohol and non-alcoholic drinks in general.

Do not use nutritional supplements after transplant

19:10     Finally, do not use supplements for cancer prevention. Although supplements are popular for cancer prevention, it's recommended that you meet your nutritional needs through diet alone. There's a lot of marketing out there about dietary nutritional supplements and a lot of bold health claims. While some supplements can offer benefits in specific circumstances, when it comes to cancer prevention, research shows that supplements don't offer the same benefits as eating whole foods.

How to add nutrients to a recovering transplant recipient’s diet

19:41     In addition to the AICR recommendations, I've listed some other diet suggestions on this particular slide. Just easy things you can do at home in your kitchen. Research shows that a diet filled with a variety of fruits and vegetables, whole grains, and beans, and other plant foods will help lower cancer risk, as well as risk for other chronic conditions.

Couple things you might want to consider, adding chopped ground flaxseeds to hot cereal, oatmeal, or in yogurt, adding chopped leafy greens, such as kale or Swiss chard, to soups, salad, or smoothies. This works great for smoothies and is another way to get in some vegetables into your diet. Consider if you're eating hummus to vary the hummus. Hummus is traditionally made of garbanzo beans, or chickpeas. Instead vary it, using white or cannellini beans; edamame, which are immature soybeans; or lentils.

Instead of snacking on high fat or processed snack foods, consider snacking on some roasted pumpkin seeds. Adding chopped walnuts to salads or hot cereal, like cream of wheat, are another thing to consider. You can also make your own salad dressings with olive or flaxseed oils. Avocado and walnut oil also work well.

For meat eaters, choose grass-fed meats rather than grain-fed because they are leaner and higher in nutrients. Choose wild fish. Wild fish have a more diverse diet than farmed raised alternatives, which gives them a better flavor and the meat is also leaner. Finally, loading up on herbs and spices that contain cancer fighting compounds. Things like ginger, curry, cinnamon, great things you can add to different dishes that you're preparing. This not only enhances the flavor, but many studies have shown that these specific herbs and spices contain cancer fighting compounds.

21:42     We've talked about some of the nutritional consequences, specifically GVHD and metabolic syndrome, and some diet and lifestyle changes you can make as a transplant survivor. I want to go on now and talk about some common myths associated with nutrition and cancer. We all know there's a lot of information out there regarding what does and doesn't cause cancer. I wanted to take a few minutes to talk about some of the more common things we as dietitians ask questions about. Specifically, does sugar feed cancer? Do I need to follow an alkaline diet? Is a ketogenic diet safe?

Sugar does not feed cancer

22:22     Many individuals going through or following transplant are concerned about sugar in their diets, often reacting to stories that sugar feeds cancer. For some, this is a very common belief. But the relationship between sugar and cancer is more about obesity and insulin resistance, versus sugar as fuel for cancer cells. All cells, including cancer cells, need glucose, or blood sugar, for energy. Giving more sugar to cancer cells does not make them grow faster. Starving them of sugar does not make them grow more slowly. Cancer risk with regards to sugar intake is more about an individual's own metabolism and response to food over time. The bigger problem is that too much sugar can contribute to weight gain, excess body fat, and obesity, which then increase cancer risk. To date, there really are no randomized controlled trials showing sugar causes cancer.

The alkaline diet is not recommended for recovering transplant recipients

23:26     Another question, do I need to follow an alkaline diet? Claims for this diet is that an acidic environment is toxic to the body and increases cancer risk. Foods that contain more acids, such as red meat, sugar, white rice, refined flours, and dairy products are excluded, while foods that are more alkaline, such as fruits, vegetables, nuts, lentils, are promoted. We know that you can influence your urine pH, but food cannot change your blood pH. Eating alkaline or investing in expensive alkaline water filters does not change your blood pH. There's really no scientific evidence that supports the effectiveness or safety or this diet in humans.

The alkaline diet does include lots of fruits and vegetables and discourages intake of processed foods. However, because it does restrict intake of certain food groups, the diet is low in protein, calcium, and vitamin D. The bottom line is that this diet is just not justified.

The ketogenic or keto diet is not recommended for patients recovering from transplant

24:34     Another common question, is the ketogenic diet safe? I think this is very popular right now. We go to the grocery store, we see lots of keto-friendly processed foods, a lot of information out on the diet. The diet is comprised primarily of protein and fats and contains very low carbohydrates. The theory behind this diet is that sugar feeds cancer, so that by starving a tumor of glucose, it will reduce growth. This is really not the whole picture. The relationship between sugar and cancer is about obesity and insulin resistance, versus sugar as fuel for cancer.

There is some evidence-based therapy that a ketogenic diet may be a treatment for individuals with epilepsy. There are also some current clinical trials evaluating the efficacy of the diet for treatment of select brain tumors. Overall, there's really a lack of consistency and efficacy in the current literature, along with a host of adverse events that do not recommend the ketogenic diet as a therapeutic approach in the cancer setting. Studies evaluating ketogenic diets are really limited by small sample sizes, and they lack consistency with respect to type, location, and cancer stage.

The diets are considered nutritionally inadequate, with a host of reported side effects. Common ones are shown on this slide. Constipation is a huge issue for folks that follow this diet, as is anemia. Following the diet can also lead to cardiac abnormalities and dehydration. Again, in summary, it's not recommended.

Seek out a dietitian to help plan your diet after transplant

26:24     As survivors, we want to eat real whole foods, mostly plant-based; maintain a regular aerobic exercise program, do something you enjoy, whether it's cycling, walking, swimming; and again, try to maintain a healthy weight. If you have additional nutritional concerns or questions, seek out a registered dietitian nutritionist. One specifically that's board certified in oncology. This is a national credential that this individual has passed by taking a national exam. Your healthcare provider or local hospital can likely refer you to the appropriate person.

Reputable resources about diet after transplant

27:00     As you know, the Internet is filled with lots of information about nutrition and diet, cancer, transplantation. It's hard to know which websites are reputable. I've just selected a few here that list good reputable information that I hope will be helpful for you. We've talked a little bit about the American Institute for Cancer Research. The Cancer Fighting Kitchen is another great website with lots of good recipes using whole foods. Cook For Your Life is another website that was developed by a cancer survivor. If you subscribe to their website, you get nice weekly emails with lots of good nutrition information and lots of great recipes. The Oncology Nutrition Diabetic Practice Group is a practice group at the Academy of Nutrition and Dietetics, who's comprised of oncology dietitians. There's a lot of good education materials on there with regards to symptom management, as well as information on some of the common myths that you may hear about.

Our website at the Seattle Cancer Care Alliance also lists diet and nutrition information, food safety information, as well as dietary management of different symptoms. The World's Healthiest Foods also has general nutrition information, talks a little bit about healthy fruits and vegetables, organic foods, and so forth.

 28:37  Thank you for listening today, for joining us for this part of the symposium. I hope this information has been helpful. Feel free to contact me at the email address listed here on this slide, if you desire more information. In the meantime, though, in the remaining time, I'd be happy to try to answer any questions you might have. Thank you again.

Question and Answer Session

29:00     [Moderator] Thank you, Ms. Macris. That was an absolutely wonderful presentation. We're now going to take some questions. As a reminder, if you have a question, please type it into the chat box on the left side of your screen. Okay, our first question is from John. John asks, "Are there any studies that show some foods reduce inflammation with GVHD patients?" Specifically, he asks about blueberries.

29:29     [Ms. Macris] Sure. There have been two studies that I'm familiar with that suggested eicosatetraenoic acid, or EPA, which is an omega-3 fatty acid, may improve chronic GVH of the digestive tract if it was administered prior to and post-transplant. But again, these have been very small studies. They were done in the early 2000's era. It's not really clear if it's effective if administered after the development of GVH. As far as blueberries go, I think if that's something you like, it's certainly a good fruit loaded with lots of vitamins and minerals. I think a lot of different things can impact inflammation, but it certainly doesn't hurt to eat blueberries.

30:14     [Moderator] Great, thank you. Our next question is from Emily. She asks, "Are there recipes or specific cookbooks that you recommend?"

30:25     [Ms. Macris] Sure, I think if you go back to the slide prior to the last one, the Internet resources. The Cancer Fighting Kitchen by Rebecca Katz is a great book. She's written a couple other cookbooks as well. You can certainly go to her website and find out more information about the cookbooks.

Cooking For Your Life has wonderful recipes. They're really geared towards symptom management. If you're having nausea or vomiting, there's some suggestions there. If you're having problems with constipation, other recommendations. I hope that you'll get some information from some of those websites shown in that slide.

31:09     [Moderator] Excellent, thank you. The next question is from Stacy, "As part of my post-transplant treatment regimen, I was put on prednisone to manage GVH. I gained a ton of weight while on the steroid. I think a lot of us know how that goes. I am now completely off prednisone. Do you have any suggestions for how to safely lose that steroid weight?"

31:30     [Ms. Macris] That's a great question, Stacy, and something we encounter a lot with our patients. Not knowing specifically your situation, but some of the suggestions I mentioned on the slide. You may want to think about reaching out and consulting with a local dietitian, again, one that's board certified in oncology nutrition, who's had some experience working directly with oncology patients. They can tailor their recommendations to your specific situation. I think that would probably be the way to go. Again, exercise is great, watching your portions, choosing a whole food, plant-based diet and really eliminating those processed foods. Even just a slow rate of weight loss, whether it's just one pound a week, really can start steering you in the right direction.

32:23     [Moderator] Thank you. This question is from Elle. The high dose chemotherapy that this person had 10 years ago caused them to lose their taste buds, which never returned. On top of that, they have GVHD of the mouth. The lack of taste makes eating extremely unpleasant and distasteful. All the nutritionists and doctors don't seem to understand why the taste buds never came back. Any suggestions?

32:52     [Ms. Macris] Yeah, I think early on in transplant we did some research studies. We found that taste buds started coming back usually around day 30 to 60 post-transplant. However, there's more research now that has come out that says taste buds may come back later. It's a difficult situation. If you would like to email me privately, I'm happy to send you our handout on taste alterations. You can also go to the Seattle Cancer Care Alliance website, and we do have a handout on dysgeusia, which is taste alteration, that may give you some more suggestions. Choosing more strongly flavored foods, that would be listed in the handout, things like marinating, sautéing foods may help. I know that really is a hard issue. Also, practicing good oral hygiene, making sure you're rinsing your mouth before eating to try to get as much taste out of the food as you can.

33:50     [Moderator] All right, Georgeanne has our next question, "I am iron toxic from having had many transfusions, with excess iron in my liver. My ferritin is going down since transplant as I make my own cells. How important is it that I avoid iron in my diet, and by how much?"

34:10     [Ms. Macris] Georgeanne, we do get a lot of patients with high ferritin levels post-transplant, very common. What we practice in Seattle is just maintaining patients on a vitamin without iron. We don't make any diet restrictions, it's more iron in the supplemental form. Some patients also need to even have phlebotomies where they're actually taking blood out, but we at Seattle don't restrict any specific foods. You may check that with your physician and your local hospital or dietitian in an institution to see. They may have different practices.

34:51     [Moderator] Okay, that's great information. Michael asks, "What are reasonable daily limits for coffee and alcoholic drink intake?"

35:00     [Ms. Macris] We talked a little bit about alcohol, that's on one of the slides. As far as coffee goes, I think everything in moderation. I don't know that I want to tell you specific amounts. It depends on your own situation. Drinking too much coffee can actually have a cathartic effect, inducing diarrhea or bowel movements. I think you probably know what your limits are, but, certainly, a cup or two in the morning is probably just fine.

35:31     [Moderator] All right. Kathy asks, "I make fruit smoothies with avocados four to five days a week with no added sugar. Is nutrient absorption and benefits of fiber as good as eating these fruits whole? Does drinking pureed fruit allow you to absorb the nutrients as well?"

35:52     [Ms. Macris] With the avocados and the fruits, certainly fine to blend into smoothies. As far as fruits go in general, you're going to get more benefits, more fiber, more intact nutrients if you're eating fruit more in the whole state versus pureeing or blending. Certainly, avocados are a great fruit and certainly make up a good component of a smoothie.

36:14     [Moderator] All right, okay, Emily asks, "Is Stevia an okay sweetener instead of sugar?"

36:25     [Ms. Macris] Sure, Stevia is fine. It is, I think, about 200 times sweeter than regular sugar. It was banned for some numbers of years, but it's certainly still back on the market. I think anything in moderation is certainly okay to try.

36:41     [Moderator] Okay, we're right on to Brian's question about using monk fruit as a sugar substitute in coffee. What do you think about that?

36:50     [Ms. Macris] I personally don't have any real experience with monk fruit. I think if that's something that you like, again, in moderation it's probably just fine.

37:01     [Moderator] Okay, Jean asks, "Is there an increased risk of metabolic syndrome for auto stem cell transplant survivors?"

37:13     [Ms. Macris] Certainly, metabolic syndrome, anyone who's gone through transplant is more susceptible to it than someone who has not gone through transplant. I think the information and statistics presented in the earlier slides did encompass both allogeneic and autologous transplants. So, yes, I think a person who has had an auto transplant is definitely at high risk. But, hopefully with some lifestyle changes, diet, nutrition, and exercise, that will decrease that risk.

37:46     [Moderator] We talked a little bit earlier about getting off prednisone and dealing with that weight gain. Justin asks about how to maintain a healthy weight while taking prednisone, which, as we all know, stimulates appetite. Are there natural appetite suppressants that he could possibly take or other things that he could do?

38:07     [Ms. Macris] That can definitely be a challenge. We don't really recommend any particular supplements to try to decrease appetite. I think, again, watching your portions, exercising, and maybe, again, working with a local dietitian to try to balance things out and keep your weight intact and try to keep your weight at a maintenance level.

38:38     [Moderator] Kathy asks, "I've switched to a mostly plant-based diet, but I'm reading that as you get older, you need more protein to maintain muscle mass. Is that actually true?" She's afraid she's not getting enough protein. Ways to maybe add that to a plant-based diet.

38:56     [Ms. Macris] Certainly you can get enough protein through a plant-based diet. I think you just have to be real careful choosing foods appropriately and really mixing it up. It's certainly okay to have a little bit of animal protein in there. But, again, that might be a situation where you consult with a local dietitian to make sure that you are getting a well-balanced diet, not missing anything.

39:17     [Moderator] Elliot asks, "What do you think about chicken?"

39:25     [Ms. Macris] What do I think about chicken? I think chicken is just fine. I think it's a good protein source. It's lean, get the boneless skinless chicken and go for more baked to broiled and avoid the deep frying.

39:42     [Moderator] Oh, this is a good question from Katherine, "Do you have any tips for eating healthfully for people with fatigue and have a hard time keeping up with cooking and preparing healthy meals?"

39:52     [Ms. Macris] Yes, certainly we see that a lot. I think if you can enlist your family and friends to help you, that's great. If they're able to cook things in large batches, then pre-portion it out, keep it in the freezer, that way you would have food on hand. I think sometimes, depending on the situation, it might be okay to have prepared foods available just so that, on those days when you are tired, you can do that. But, if you are able to enlist the help of others, that would be a great thing.

40:26     [Moderator] Those are good suggestions. The support we need continues on after transplant, that's for sure. Elliot asks, "Do you believe that Beyond Meat or Impossible Beef, which are vegetable-based, are better than eating animal meats?"

40:43     [Ms. Macris] Again, I think it's a matter of what your preference is. Certainly, plant-based diets are great if you can continue to follow them and get good variety in there. Again, I think the whole concept of making your plate two-thirds plant foods and one-third lean meats, poultry, seafood, is the way to go. I think if that's something that you wanted to do, there is a way to incorporate that into your diet.

41:13     [Moderator] Solas asks, "You only mentioned eating pumpkin seeds and walnuts. Are there other nuts that should be avoided?"

41:22     [Ms. Macris] No, those were just some examples. I think nuts are a great protein source, primarily trying to get nuts that are unsalted. I think they do have a lot of salt added to them commercially when we prepare them. But, again, getting a variety of nuts in there. Focus on the ones you like, it's just fine.

41:38     [Moderator] Okay, great. Jordan asks, "Is there a link between soy and cancer in a broad sense?" This person had a transplant and has had breast cancer in their family. Should they avoid soy?

41:53     [Ms. Macris] That's a great question. Soy, I think, in moderation. Things like tofu or soybeans are certainly fine. The things you want to hold off on, or not eat much of, are the soy protein isolates. These are things that are added to some of the processed, texturized vegetable proteins, or the glorified granola bars that are soy bars. Again, I think in moderation it's fine.

42:23     [Moderator] Rose asks, "What are your thoughts on nitrite-free products, such as nitrite-free bacon, hot dogs, etc.

42:34     [Ms. Macris] There may be some advantages to the nitrite-free. Again, to remember though that bacon, hot dogs are still processed meats and something that's not totally recommended. Again, if you're wanting to have that have it in moderation.

42:53     [Moderator] This is a debated one. Justin asks, "While taking immunosuppressants, is it safe to eat frozen fruit, such as mango, blueberries, or raspberries without washing them?" I mean, I guess I would also add to that, is it safe to eat other fruits that are fresh while being on immunosuppression?

43:15     [Ms. Macris] We've done a lot of food culturing at our center. We may be a little more liberal in Seattle with some of our recommendations that feel comfortable with just because we've done so much food culturing. Fresh fruits and vegetables, as well as frozen ones, are fine to eat. You just need to wash them well. It's fine to eat frozen fruits, but I would definitely wash them.

43:40     [Moderator] Okay, that's great advice. Brian asks, "Is creatinine supplement recommended for building muscle mass?"

43:51     [Ms. Macris] We don't really recommend any specific supplements. I think sometimes they may have untoward side effects. Building muscle is going to come from regular exercise and from eating a high protein diet. Again, that might be a situation where you do consult with a local dietitian.

44:12     [Moderator] Then, back to plant-based, more processed foods, such as Impossible foods and Lightlife. I know they make sandwich slices that are plant-based. What do you think about those foods? Are they a good way to ease yourself into a more vegetarian lifestyle, or would you consider it to be a vegetarian equivalent of processed foods? Is it still eaten with all the salts and things like that?

44:43     [Ms. Macris] Yes, when it comes to those, I think they do tend to be more processed, depending on what level of a vegetarian diet you want to follow. I think there's a lot of other good, healthier options out there. I would stick more with the whole foods approach.

44:58     [Moderator] Thank you so much. That was our final question. On behalf of BMT InfoNet and our partners, I would like to thank Ms. Macris for her helpful remarks, and thank you, the audience for your excellent questions.