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, April 21, 2021

Presenter: Paula Macris, MS, RD, CSO, FAND, Seattle Cancer Care Alliance

Presentation is 37 minutes long plus 21 minutes of Q & A

Summary:  It can be hard for stem transplant recipients to get sufficient calories, protein and nutrients needed after transplant to repair tissue damage and promote health. This presentation describes which types of food and beverage help recovery after transplant, and whether some popular diets are safe for transplant survivors.

Highlights:

• Transplant recipients have an elevated risk of developing several medical conditions after transplant, including metabolic syndrome, diabetes, high blood pressure, cardiovascular disease, and osteoporosis.
• Chronic graft-versus-host disease can increase a transplant recipient’s need for calories, protein, and fluids. If patients remain on immunosuppressive medications, the need for adequate hydration becomes especially important.
• Some popular diets often don’t meet the nutritional requirements of recovering transplant recipients.

Key Points:

(05:39) Recovering transplant recipients need additional calories and protein to repair organ damage during transplant, or damage caused by graft-versus-host disease (GVHD).

(07:09)  Keeping well hydrated is important for recovering transplant recipients.

(08:05) Following food safety guidelines in the preparation and storage of foods is very important for transplant recipients in order to avoid infection. This is particularly true for patients on immunosuppressive drugs.

(11:31) A patient whose had a transplant can have a three-to-four times higher risk of developing diabetes, and three times higher risk higher of developing  high blood pressure than the general population.

(14:04) Dietary changes to control cholesterol can reduce the risk of cardiovascular disease.

(16:54) Osteoporosis is a problem for many patients after transplant, especially if steroid therapy is being used. However, vitamin D and high calcium foods can help promote good bone health.

(21:10) Lifestyle and dietary changes can reduce the incidence of nutrition-related issues. These include maintaining a healthy weight and regular exercise.

(24:28) Eating a diet rich in plant based foods or whole foods and limiting processed food intake is important.  

(30:48) Sugar does not increase the risk of getting cancer.

(32:11) An alkaline diet and a ketogenic do not prevent cancer, and may provide insufficient nutrients for a recovering transplant recipient.

Transcript of Presentation:

(00:00) [Mary C. Bietila]      Introduction. Hello. My name is Mary Clare Bietila and I will be your moderator today. I'd like to welcome you to the workshop, The Role of Nutrition in Long-Term Health after Transplant.

(00:11) It is my pleasure to introduce you to Ms. Paula Macris. Ms. Macris has been the nutrition education coordinator at the Seattle Cancer Alliance in Seattle for over 30 years. She is a nationally recognized expert in the nutritional needs of transplant patients.

(00:28) Ms. Macris has presented at national and international conferences on nutrition and bone marrow transplantation, and has published multiple review articles, research papers and book chapters on the topic.

(00:42) Her goal is to help patients stay strong and nourished as they deal with the side effects of treatment and after, and to assist with their long-term health and nutrition goals. Please join me in welcoming, Paula Macris.

(01:01) [Paula Macris]     Overview of Talk. Hello, everyone and greetings from Seattle. Thank you for the opportunity to be here today to talk about the role of nutrition in long-term health after transplant. Working with 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.

(01:25) What I'd like to do today is talk about how nutrition after transplant affects long-term health, and how to manage some eating difficulties that can arise after transplant. I'll then go on to discuss optimal diets to maintain good health, and then end the presentation with reviewing some common myths associated with nutrition and cancer.

(01:50) Well, let's, first of all, look at how does nutrition effect stem cell transplantation after... after stem cell transplantation effect long-term health?

(02:04) Treating long-term complications in transplant survivors. As advances in technology and supportive care measures have improved, the number of long-term transplant survivors continues to increase. And with this growth, the greater emphasis is now being placed on treating long-term complications.

(02:19) Some of the common complications with nutritional implication that I'd like to address today include chronic graft-versus-host disease, or GVHD, metabolic syndrome, cardiovascular issues and osteoporosis, all of which impact life expectancy and the quality of life.

(02:45) Chronic GVHD can affect the mouth, stomach and GI tract. Let's look, first of all, at chronic GVHD. Chronic GVH is a problem that occurs when the donor's system attacks the patient's organs and tissue following an allogeneic transplant, or transplant from another donor. Chronic GVHD is more common typically after the first three months post-transplant.

(03:06) This condition can affect many body organs, but those pertinent to nutrition include the mouth, where a patient may develop pain or sores, making it difficult to chew or swallow food.

(03:19) GVHD can affect the stomach, resulting in decreased appetite, nausea or vomiting and early fullness. It can also affect the gastrointestinal tract, where a patient may experience lower abdominal cramping and diarrhea.

(03:39) Chronic oral or gastrointestinal GVHD can result in changes in this body organ. The mouth may become more sensitive. It might become more dry, or swallowing ability may be impacted. On this slide, I've just listed some suggestions that you can do should you be experiencing any of these problems.

(04:00)  Some practical tips for mouth sores and staying hydrated. For example, if your mouth is sore, you may need to modify the texture of the foods that you eat. Instead of coarse dry foods, going with softer foods, or even a liquid diet, if swallowing is impaired. Things like smoothies, shakes, soups, all work really well.

(04:17) If your mouth does become more sensitive to toothpaste, carbonated beverages, tomato products and so forth, choose a blander diet, choose less spicy foods.

(04:28) For those of you who like to drink any kind of carbonated beverages, waters and so forth, one little trick is to take the carbonated beverage, pour it into your blender, and then just blend it. This will help the carbonation to dissipate and you can still enjoy the beverage without having the difficulty perhaps of the carbonation sensation.

(04:51) We're really advocates too in terms of making sure our patients drink adequate fluids with meals, and especially if the weather is getting warmer in some parts of the country, just making sure that you're drinking enough at mealtime and throughout the day.

(05:04) Chronic GVHD means we may need more calories, protein and fluids. Chronic GVHD can also affect appetite, resulting in weight gain or weight loss. So if we look specifically at nutrient and fluid needs, we know that for the most part calorie, protein and fluid needs all increase with graft-versus-host disease. We'll talk a little bit about each of these different components.

(05:26) As calorie needs increase, consider eating more but smaller meals per day. Calorie needs may also increase if you've lost weight or muscle mass. Protein is important. Some medication, specifically, may increase your protein or your fluid needs.

(05:39) Well, let's look first at calories. We know that calories are important post-transplant as different body organs, damaged tissues may occur as a result of the transplant process or graft-versus-host disease. You may have lost weight, so you need to regain weight and body strength.

(06:01) Food may also be digested less efficiently, so nutrient intake is important to help maintain your weight. A couple suggestions: if you're used to eating three meals a day, think about maybe changing your meal plan to focus on maybe five or six smaller nutrient dense meals and snacks.

(06:21) Meeting needs for additional protein and healthy fats. We want to make sure you're consuming adequate protein, and I'll go into this a little bit more in the next slide, and also, including healthy fats in your diet, which can help to boost caloric intake if you've had weight loss. Adding things like olive oil or avocados, other healthy fats, butters and so forth can be beneficial.

(06:43) Well, protein is a very important nutrient after transplant. It's used 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 food. It's important to get a good amount of protein in your diet with a variety of animal and plant sources.

(07:09) Keeping hydrated is especially important for multiple reasons. Fluids are also very important during transplantation. Many of the immunosuppressive medications that are often used for patients, specifically cyclosporine and tacrolimus, are a bit hard on the kidneys, so making sure you're drinking enough is very important.

(07:25) We also lose a lot of fluids if we're perspiring, have a fever, breathing rapidly, having issues with vomiting or diarrhea. So it's important, again, to keep yourself well hydrated with a variety of different fluid sources, whether it's water, broth, smoothies, milk alternatives and so forth, and really drinking throughout the day. Don't wait until you're thirsty.

(07:48) Again, drinking more on hot days or if you're exercising. And just as a little reminder, keeping a bottle or a cup with you of water or other fluids, if you're watching TV, using the computer, just relaxing in the evening, that's often a good reminder to drink and keep up your fluid intake.

(08:05) Tips for food safety. At Seattle Cancer Care Alliance, we also practice food safety, and this is especially important is you're maintained on any kind of immunosuppressants. Our food safety guidelines are listed there at the website on this slide, and that will have more detailed information for you.

(08:27) But, it's important to practice good food safety when you're preparing food, making sure your kitchen is clean, that you're disinfecting countertops, you're separating raw foods, or raw meats from cooked foods, cooking foods to proper temperatures and making sure you're chilling foods properly.

(08:47) We also encourage our patients to avoid high risk foods. We want to prevent any kind of food-related infection, which could potentially flare the GVHD. Some suggestions include, avoiding unpasteurized milk and milk products, so again, making sure everything is pasteurized.

(09:06) You also want to avoid undercooked meat, seafood and eggs, unwashed fresh fruits and vegetables, and uncooked bulk foods. So you want to make sure that you are cooking any food that you purchase in bulk. Again, the website is there with more detailed information.

(09:26) Metabolic syndrome is another risk in transplant recipients. Well, aside from GVHD, another chronic condition that our patients often face with nutritional implications is that of metabolic syndrome.

(09:37) In metabolic syndrome, you may have heard about it, we're doing more and more research as the years go on after transplant. It's a cluster of biochemical and physiological abnormalities. It's associated potentially with the development of diabetes and cardiovascular disease. There is a high incidence of metabolic syndrome in the United States, and having a transplant actually places you at an even higher risk.

(10:03) Characteristics of metabolic syndrome include body fat distribution, high blood pressure or blood sugar, and treatment for the latter. So by definition, a person has metabolic syndrome if they have at least three of the five characteristics shown on this slide.

(10:12) We look at body fat distribution and centralized obesity. So think about an apple versus a pear. Our fat distribution should be like a pear throughout, not like an apple, which is more centrally located. High blood fats, high cholesterol and triglyceride levels. Low HDL, which is the good cholesterol.

(10:36) Any problems with high blood pressure or on medications for hypertension or high blood pressure. And a high fasting blood sugar or on medication for blood sugar. So again, any three of these characteristics would define a person as having metabolic syndrome

(10:52) Additional symptoms of metabolic syndrome. If we look at it a little bit step further in this diagram there, you can, again, see the centralized obesity in the stomach there. In addition to the cardiovascular and blood sugar issues, some other symptoms may include just fatigue or inability to focus, this term brain fog that you may have heard of. Non-alcoholic fatty liver disease, browning in the folds of the skin of the neck and so forth. And maybe reproductive issues. So again, these are some of the symptoms associated with metabolic syndrome.

(11:31) Elevated risk of diabetes and high blood pressure in transplant recipients. Studies have shown that, again, pediatric and adult transplant patients are more likely to have these symptoms of metabolic syndrome. And with regards to diabetes, a patient whose had a transplant may have a three to four times higher risk of developing diabetes down the road, or a two, a three time risk higher to develop high blood pressure than the general population.

(12:01) Preventing cardiovascular disease by managing cholesterol. Well, looking specifically at cardiovascular disease and what we can do to try to circumvent this as a symptom of metabolic syndrome.

(12:13) Looking first at cholesterol and really, what is cholesterol? We've heard a lot about this in recent years. It's a type of lipid or blood fat in our bodies that forms cells, makes hormones and produces vitamin D. Our bodies make both good and bad cholesterol, but persistently high levels of cholesterol as well as another blood fat called triglycerides are associated with metabolic syndrome and do place a person at increased risk for cardiovascular disease.

(12:45) And if you look at the diagram there on the right, you'll see that normally without any kind of cardiovascular disease, our blood flows throughout our body very easily. But with time, and build up of cholesterol and other fats, the vessels there become narrowed. And with many years or a prolonged period of time, you can see that the actual vessels become occluded, so that blood flow cannot flow through and may set a person up for a cardiac event.

(13:17) This next slide lists what our normal blood fat or cholesterol and triglyceride levels are. This is all data from the American Heart Association. So cholesterol levels ideally should be below 200. And then you have the values there for both the good and the bad cholesterol. And then the triglyceride levels, again another blood fat, should be below 150.

(13:41) So if you're not sure what your cholesterol or your blood fat lipids are, you may want to think about asking your healthcare provider to check levels. We recommend that you get fasting levels. In other words, going an eight hour periods without having had anything to eat or drink, for this will bring a more accurate result back and you can then track it and see if there is any kind of intervention that needs to be done.

(14:04) Dietary changes can help lower cholesterol. Well, what can we do if you have high cholesterol or triglyceride levels? What kinds of dietary measures can you take to help lower these levels?

(14:18) There are different types of fats found in our common food supply. There is a group called polyunsaturated and monounsaturated fats. These are all plant-based foods. We know that these types of foods help to lower the LDL or bad cholesterol. Common foods include, avocados, canola, olives, both the fruit and the oils, sesame or sunflower seeds, butters and oils, a variety of different kinds of nuts and nut butters, the whole grains, whole grain bread, whole grain cereals and vegetables. Again, all of these are more plant-based foods that can help to lower the bad cholesterol.

(15:03) Omega-3 fatty acids, another type of good fat or healthy fat that's found in plant-based foods and fish. These help to lower the triglyceride level. Things like a wild cold-water fish, salmon, sardines and tuna, dark green leafy vegetables, kale, spinach, legumes made up of lentils or other dried beans, walnuts or flaxseed oils, omega-3 eggs. Omega-3 eggs are actually developed when hens are given flaxseeds. Oil is part of their diet. So again, more plant-based foods to help lower the triglyceride levels.

(15:43) The fats, however, that we want to watch out for are listed on this slide. These are the saturated fats and the trans fats. Saturated fats come primarily from animal sources. These actually can increase the LDL or the bad cholesterol levels. Things like processed meats, bacon, sausage, red meats, beef, lamb and pork, whole milk products, cream, butters, cheese, palm oil, lard and chocolate.

(16:15) Trans fats are really artificial fats. Basically, you take a liquid fat, you pump it up with hydrogen molecules to make it more solid. These type of fats can actually increase the bad cholesterol and decrease the good cholesterol. They're primarily found in processed foods, things like margarine and shortening, many fried foods and some crackers and chips also contain trans fats. So again, these are the fats that we want to try to limit in our diet and focus more on the plant-based fats, the omega-3 fatty acids, polyunsaturated and monounsaturated fats.

(16:54) Osteoporosis as a post-transplant complication. Well, moving along now with another complication that we frequently see post-transplant is that of osteoporosis. By definition, osteo means bone and porosis means full of holes. So osteoporosis essentially is a condition where bones are full of holes. The density or the thickness has decrease.

(17:18) You can see in this picture there, if you look at the vertebra and the femur bones, the normal on the left and someone with osteoporotic bones on the right. You can see the vertebra are starting to tilt. They become soft, more of the hunched over appearance and again, changes in our bone density. This really is a very common complication post-transplant, about 50 or 60% incidence.

(17:47) Steroid therapy increases the risk of osteoporosis. Some of the primary causes and risk factors include, if a patient has had any kind of preexisting bone disease going into transplant. Hormonal changes certainly play a role. And we know that patients maintained on long-term steroid therapy, specifically prednisone, may be more at risk for developing osteoporosis. We also know patients with a sedentary lifestyle are more at risk.

 Finally, with osteoporosis, this can cause long-term issues such as fractures, disability or loss of independence. Again, so this can be a major complication post-transplant.

(18:36) This next slide has a lot of information here, but basically, I want to focus on the bottom there where it lists receiving steroid therapy and adults with osteopenia osteoporosis.

(18:47) Vitamin D and high calcium foods can maintain good bone health. These are the recommended amounts of vitamin D and calcium, which are known treatments for osteoporosis, recommended calcium and vitamin D milligrams and micrograms that you should have per day.

(19:01) If we look at this a little bit further, how do you know how much calcium is in a particular food? You can look at the food labels. There again, if we look at this example at the bottom, this lists the calcium and vitamin D amount in a particular serving of food. So again, for calcium, if a patient has osteoporosis 1500 milligrams is the recommended calcium dose.

(19:34) Well, to maintain good bone health, again, looking at these nutrients, high calcium foods includes, low fat or fat-free milk, yogurt and cheese. Many of the dairy alternatives such as soy milk and almond milk also have calcium enrichment, so these are good sources. Some breakfast foods are calcium-fortified. Sardines with bones are another good source.

(20:01) And then as far as vitamin D, some good food sources include, some seafood such as herring, halibut, canned salmon, again, low fat or fat-free milk, soy milk. Some juices now do have fortification with calcium and vitamin D, and that would be listed on the label.

(20:21) So if you're feeling like you're just not getting enough calcium or vitamin D in your diet, check with your healthcare provide about taking a supplement.

(20:30) Exercise, dietary measures, and medications can protect bone health. Exercise is something else you can do to help build your bones back up, walking, dancing, gardening, stair climb, all good examples. And then in some situations, your provider may recommend medications, which can help to slow bone loss.

(20:49) So again, osteoporosis, we want calcium, we want vitamin D and we want exercise. Again, this condition is reversible, so that is good news with regards to osteoporosis. But again, taking dietary measures, exercise and sometimes medications are necessary.

(21:10) Lifestyle and dietary changes to reduce the incidence of nutrition-related issues. Well, we've talked a little bit about some of the different complications associated with transplants from a nutrition standpoint. Now, I want to focus on specific dietary and lifestyle changes that can be made to reduce the incidence of developing some of these nutrition-related issues.

(21:36) The American Institute for Cancer Research is an organization that looked at evidence-based research, and they developed guidelines for the general population to help maintain a healthy diet.

(21:53) These are the lifestyle and diet changes that they've reviewed and recommended. I'm going to talk a little bit about each one of these. At the end of the presentation, the website is also listed for you. So if you would like more information, you can easily go to the website and read up a little bit more about each of these different guidelines.

(22:15) Maintain a healthy weight and body mass index. The first guideline is be a healthy weight. Really, aside from smoking, maintaining a healthy weight is probably the most important thing you can do to prevent cancer and other chronic diseases.

(22:30) You'd probably heard the term body mass index. This is basically looking at the ratio of weight to height. The recommendation for the body mass index is to maintain your weight in the BMI of about 18.5 to 24.9. There are lots of ways you can calculate this. Just this simple formula listed there on the slide where you look at your weight in kilograms and divide that by your height in meters squared.

(22:59) However, an easy way to actually calculate your BMI is just to go to the internet, google BMI calculation. You can put in your weight and height, and they will do that for you there. And it will tell you where your BMI is and in what category your weight for height ratio is.

(23:17) Exercise goals and benefits. Aside from being a healthy weight, American Institute for Cancer Research really encourages us to exercise and be physically active. 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.

Try and build exercise into your daily routine, and aim for about 30 minutes five days a week, or 150 minutes of moderate exercise per week, which can really go a long way towards improving your health. Weight-bearing activity is especially important also in preserving bone health.

 Finally, work to achieve an exercise routine of up to 45 to 60 minutes of moderate intensity daily physical activity. Again, I think it's important to pick an activity that you like, so that you're more likely to stick with it, or recruit a family member or friend to help you go on walks, other physical activities, again, so that you'll be more likely to stay with the exercise plan.

(24:28) Eat a diet rich in plant based foods. The next recommendation by the American Institute for Cancer Research is to eat a diet rich in plant foods such as whole grain, vegetables, fruits and legumes. I mentioned this a little bit earlier when we talked about polyunsaturated and monounsaturated fats, but basically, the recommendation is to base your diet around plant foods, which contain fiber and other nutrients to reduce cancer risk. Consuming plant foods, which are naturally lower in calories, helps us to maintain a healthy weight.

 It's recommended that about two thirds of our plate should include plant-based foods, again, fruits and vegetables, legumes and whole grains. Enjoying around four cups of raw, uncooked vegetables a day is recommended, and really to build your plate using a rainbow of colors. What I mean by this is choosing red, orange, green and all different kinds of colors of fruits and vegetables, because each of them give us so many different nutrients. Looking at green leafy vegetables, Swiss chard, spinach and kale, cabbage family, brussel sprouts, broccoli, different kinds of berries, different kinds of citrus fruits such as oranges and tangerines.

As we're approaching spring and summertime now, there is just a huge amount of wonderful, delicious fruits and vegetables available. I really encourage you to consider that.

 Legumes are becoming more and more popular now, lots of websites, lots of recipes out there looking at how to cook garbanzo beans, kidney beans and so forth. These foods are rich in antioxidants, fiber and give us lots of good vitamins and minerals.

(26:13) Eat whole foods and limit processed foods. We also want to limit our consumption of fast foods and other processed foods high in fats, starches or sugars, and consume what we call whole foods. You may have heard this term, but really, what is a whole food?

 Well, a whole food contains all or most of the original edible parts. So again, you've got whole grain bread versus white bread, brown rice versus white rice. The whole food really has had very little done to it. It hasn't been fortified or enriched, bleached, dehydrated. Basically, it's food in its natural form versus the processed foods, which essentially are fast foods and the Western type of diet that so many of us follow that can result in weight gain, overweight and obesity. These conditions really are linked to the development of several different kinds of cancers.

Also, limiting processed foods helps us control our calorie intake and help us maintain a healthy weight. Again, the processed or the more refined foods do contain many artificial ingredients, which may not be healthy.

(27:20) Another guideline from the AICR includes to monitor intake of cookies, health bars, candy, commercial condiments and sweetened yogurt. Again, lots of sugar added to these different foods, which can result in unnecessary weight gain.

(27:33) Limit consumption of red and processed meats. We want to limit consumption of red and processed meat. The AICR recommends that we consume no more than 12 to 18 ounces of cooked red meat per week. Red meat is considered beef, lamb and pork. And if you think about the size of a deck of cards, that's about three ounces, so this recommendation still is pretty generous in the amount of cooked meat that's recommended.

 Also, want to watch intake, however, of processed meats. These are things like ham and bacon, hot dogs and sausage. Again, a lot of additives, preservatives have been added to these different foods. There is evidence that increased consumption of these foods is associated with a higher incidence of colorectal cancer.

(28:24) Limit sugary drinks and alcohol consumption. Limit consumption of sugar-sweetened drinks. Again, the sugar there causing weight gain, overweight, obesity. I think there are so many different sodas and sweet teas and coffees and electrolyte containing sugar-contained drinks that are out there, that really be mindful of how much you're drinking, and choose mostly water and unsweetened fluids.

Alcohol: AICR recommends that we limit alcohol consumption. It's really best not to drink any, which, because we know alcohol really is a known carcinogen. If, however, you do choose to drink alcohol, limit your consumption. For women, one drink a day. And for men, two drinks a day. Some examples of what one drink would consist of is shown in this slide. For example, 12 ounces of beer, a five ounce glass of wine.

(29:24) Other healthy food choices. Well, some additional suggestions to supplement the AICR recommendations are listed in this slide. Flaxseeds are becoming more popular. You can add chopped ground flaxseeds to things like oatmeal or yogurt. Again, the green leafy vegetables mix in really well to soups and salads or smoothies. Hummus is certainly becoming a more popular food item, traditionally made with garbanzo beans or chickpeas. We can vary that using other different kinds of beans or lentils. Snacking on roasted pumpkin seeds, perhaps, instead of higher fat chips. Chopped walnuts added to salads or hot cereals is a nice combination. Making your own salad dressing using olive oil or flaxseed oils.

(30:12) Grass fed meat and wild fish are preferable. And if you are eating red meat, choose grass-fed meat or choose wild fish. These seem to have a different fat profile that's much more healthy.

(30:23) Healthy herbs and spices. Finally, a lot of research has been done on different herbs and spices that contain cancer fighting compounds, things like ginger, turmeric and curry. Adding these to your different recipes and different family recipes is certainly something to consider, because they can help to enhance the flavor as well as providing cancer fighting compounds.

(30:48) Sugar does not increase the risk of getting cancer. So we talked a lot about some of the different nutrition complications associated with transplants as well as some of the diet guidelines. In the remainder of the time, I just want to focus a little bit on some of the nutrition myths associated with cancer. These are some common questions we as dieticians often receive: Does sugar feed cancer? Do I need to follow an alkaline diet? Is a ketogenic diet safe?

So let's look first at sugar and cancer. Many individuals going through transplant are concerned about sugar in their diets, often reacting to stories that quote, "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 rather than sugar as fuel for cancer cells.

) All cells including cancer cells need glucose or blood sugar for energy. But, giving more sugar to cancer cells does not make them grow faster, and starving them of sugar does not make them grow more slowly. The cancer risk with regard 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 does increase cancer risk.

(32:11) An alkaline diet and alkaline water do not prevent cancer, and may provide insufficient nutrients for a recovering transplant recipient. Another common myth we hear about is that of the alkaline diet. Does one need to follow an alkaline diet? Well, claims for this diet is that an acidic environment is toxic to the body and increases cancer risk and thus, tumors cannot grow in an alkaline environment. Foods contain more acids such as red meat, sugars and dairy products are excluded, while foods that are more alkaline such as fruits and vegetables are promoted.

 Well, you can influence your urine pH, but you cannot influence your blood pH. Eating alkaline cannot influence your blood pH. There is a lot of promotion out there these days for alkaline water filters. They're very expensive. But again, this won't change your blood pH, and there is really no scientific evidence that supports that the effectiveness or safety of this diet in humans.

 The alkaline diet does support consuming lots of fruits and vegetables, which is a good thing. However, it limits, may over restrict things, foods that are high in protein, calcium and vitamin D. So again, in summary, promotion of the alkaline diet or alkaline water for cancer prevention or treatment really is not justified.

(33:43) Evaluating a ketogenic diet. Then we have a ketogenic diet. A ketogenic diet is compromised primarily of protein and fats and contains very little carbohydrate. The theory behind this diet is that sugar feeds cancer, so that by starving a tumor of glucose, it will reduce growth. But, this really isn't the whole picture. Again, the relationship between sugar and cancer is about obesity and insulin resistance versus sugar as fuel for cancer.

 Well, there is some evidence-based therapy that a ketogenic diet may be appropriate for individuals with epilepsy. There are also some current clinical trials going on now evaluating the efficacy of this diet for select brain tumors. But overall, there is 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.

 Again, it's a diet that promotes very little carbohydrate intake. Lots of side effects have been reported, constipation, anemia, some cardiac abnormalities as well as dehydration. So again, lack of consistency, and this diet really is not recommended as an approach in the cancer setting.

(35:13) Summary: how to have a healthy diet and lifestyle. So in summary, I encourage you to eat real whole food, less processed foods, and mostly foods that are plant-based, participate in regular aerobic exercise, which can help build muscle and keep bones nice and strong, and maintain a healthy weight.

(35:33) When to consult a nutritionist. And if you have additional nutrition-related questions, or want to develop more of a meal plan, seek out a registered dietician, nutritionist who is board certified in oncology nutrition. This is something your healthcare provider can hopefully help you identify this individual.

(35:50) Foods are preferable to supplements.  also wanted to mention, that it's important to get nutrition from foods and not rely on supplements. No one supplement is going to be effective in preventing cancer, but rather eating a good variety of foods.

(36:07) Useful websites. As we all know, there is a lot of information out on the internet regarding what's appropriate, what kinds of diets we should follow and so forth. I've just listed a couple of different websites here that we know are reputable. Again, the American Institute for Cancer Research is the one I referred to during the presentation. The other websites as well have lots of good nutrition, evidence-based information, recipes, suggestions if you're having any kind of treatment-related side effects. Again, feel free to go to our website there at the Seattle Cancer Care Alliance for more information.

(36:45) Thank you very much for your time today. I hope you enjoyed the presentation. We'll open it up now for questions, but if down the road or after the presentation you think of a question, feel free to email me at the address listed there on the slide. Thank you very much.

Mary C. Bietila (37:03):

Thank you, Ms. Macris for this wonderful presentation. We are going to now take questions. We have quite a few lined up, that you guys have been asking great questions. As a reminder, you can still ask a question. You can type that into the chat box in the lower left-hand corner of your screen.

(37:20) [Mary C. Bietila]     Q & A. All right. Our first question is, "When, if ever, can someone eat fast food after transplants?"

(37:29) [Paula Macris]     At the Seattle Cancer Care Alliance, we actually allow our patients to eat fast foods, if that's something they want to do. However, somethings to consider, you want to make sure when you're eating any kind of fast food that everything is made fresh. So basically, if you decide to order a cheeseburger, it should be a cheeseburger, the meat, the cheese and the bun. Avoid any kind of vegetables, lettuce or tomatoes. You don't know if they're washing these. I would avoid any kind of special sauces.

(37:59) And if you need condiments, ketchup, mustards, ask for those little packets or a new unopened bottle of ketchup or mustard. Basically, what happens sometimes is that ketchup bottle has been sitting there, if many different customers may use it, and people may stick dirty knives, other utensils, into the ketchup bottle and then it's there. So if you were to eat fast food, again, make sure everything is cooked fresh.

(38:27) [Mary C. Bietila]      All right, that's great. All right, our next question comes from someone who is five months after transplant. "We are curious, is it safe to eat cooked mushrooms, lettuce or other greens?" I'm assuming lettuce not cooked.

(38:42) [Paula Macris]      Okay. So again, what we practice at Seattle Cancer Care Alliance that may be different at your other centers, but we've done a lot of food culturing over the years. We do allow our patients to eat fresh fruits and vegetables at any point of the transplant course.

(38:57): The main thing is, you want to make sure that you're washing them really well. So washing the mushrooms really well if you're planning to eat them raw, or lettuce. Cooked mushrooms, we have never restricted those. That's what we're currently practicing.

(39:12): [Mary C. Bietila]      Okay, great. Well, the next question has to do with how do you wash those fruits and vegetables? This person usually adds white vinegar to the water. Is that sufficient to disinfect fruits and vegetables?

(39:25) [Paula Macris]      So what we recommend to our patients, let's use lettuce as an example, instead of putting that whole head of lettuce under the kitchen faucet, take the lettuce, wash it leaf by leaf just with your hand, making sure there is no dirt or any residue. Again, wash it separately in clear running water.

If you buy any of the packaged vegetable, or packaged salad mixes, even though the label says pre-washed, I would still wash them to play it safe.

Things that maybe are harder to clean like a cantaloupe or avocado or potato, you may want to use just a scrub brush and gently scrub that potato, again, under running water.

We don't recommend any kind of vegetable washes or other types of washes be added, but we know just cold, clear running water, and friction is safe.

(40:16) [Mary C. Bietila]      Wonderful. All right. This person asks, "Is it safe to eat steamed shellfish?"

(40:24) [Paula Macris]      Steamed shellfish, yes. With the shellfish, you want to make sure that it's, of course, cooked really well. But, we have not had any problem at our center with shellfish. So again, cooking things like shrimp or any of the other variety is just fine.

(40:39) [Mary C. Bietila]     Okay. The next question is, "I like to use grapeseed oil for cooking instead of olive oil? Is this okay?"

(40:47): [Paula Macris]     Grapeseed oil is a great oil to use. And yes, that's fine to be using.

(40:54) [Mary C. Bietila]      Okay. I actually have a question. For high heat cooking, you can't really use olive oil in a 450 oven. What's the next oil? Is peanut oil good or is canola oil better?

(41:08) [Paula Macris]      Canola oil would be a good one. I think you just have to look at the high heat and what the smoke... excuse me, what the smoke point is. So yeah, that would be fine to use.

(41:19) [Mary C. Bietila]      Okay. All right. "How important are organic food choices in recovery?"

(41:24) [Paula Macris]      I think organic food choices are certainly a matter of preference. If you go to your computer and google, what, just say, is the dirty dozen, it will take you to a website that basically lists what foods are maybe more appropriate to get in an organic state. And a lot of research has gone into this, again, the top dozen.

(41:48) So just from memory, things like apples, strawberries, peaches, those might be better if your budget allows to get organic versus the non-organic. But again, google dirty dozen and that will give more information in terms of which foods are appropriate to buy in the organic form.

(42:08) [Mary C. Bietila]      Okay. The next question is, "Are bagged vegetables better for transplant recipients versus fresh, just sitting on the shelf vegetables in the grocery store?"

(42:20) [Paula Macris]      The bagged vegetables, again, I think they're fine to use. Again, even though that package may say pre-washed, I would still wash any kind of bagged vegetable, especially if you're going to be eating it raw.

(42:35) [Mary C. Bietila]      Okay. "How much fish can we safely eat without incurring mercury poisoning?"

(42:45) [Paula Macris]      Well, as fish goes, again, fish is a very healthy good protein. I think you want to have a variety in your diet. I don't know that I can tell you specifically how much is too much for you, but certainly mixing it up, choosing fish, and again, the cold-water fish that I mentioned earlier, salmon, halibut. These are certainly good choices to have in your diet. They have relatively healthy fats and good sources of protein.

(43:14) [Mary C. Bietila]      Excellent. When I was at Whole Foods recently, there was a little card they had that showed how much mercury was in different types of fish. They also were comparing farmed to fresh. I think there is a lot of information out there, if people want to look at specific fish and how they're raised. It might be helpful.

(43:35) [Paula Macris]      Yeah. Yeah, Whole Foods is someone who has a little more information on some of the products than some of the other supermarkets, so that's a great suggestion. You can certainly judge it that way.

(43:45) [Mary C. Bietila]      You can probably find it on their website as well, if you want to shop somewhere else, or don't have a Whole Foods.

(43:51) "How often is too often to eat red meat?"

(43:54) [Paula Macris]      This I mentioned during the presentation, the recommendation is 12 to 18 ounces of cook red meat per week. So again, if you think about the size of a deck of cards, that's three ounces. The recommendation is 12 to 18 ounces a week. So you can use that as a guide and use your portion there, the deck of cards, as a guide.

(44:20) [Mary C. Bietila]      Okay. "How safe is it to reheat cooked food, for example, food ordered from a restaurant?"

(44:30) [Paula Macris]      So I think if you're at a restaurant and have leftovers and want a doggie bag, have the server bring you the doggie bag and you dish up your leftovers. Just, you really want to have control of that food, so that it doesn't go back into the kitchen and something happen to it. If you bring it home, refrigerate it right away and it should be good to go ahead and eat. Reheat it really well, make sure the center is hot.

(44:56) Make sure if you're reheating in the microwave that you're rotating the tray, so that again, the center and the outside is all hot at a good temperature.

(45:05) [Mary C. Bietila]     Okay. "What about whole milk instead of low fat milk or fat-free?"

(45:14) [Paula Macris]      I think that's a matter of preference. Certainly, milk is a great calcium and protein source. If you're watching your fat intake, calorie intake, probably think about going with the 2% or the fat-free instead of the whole milk. If you're trying to gain weight, whole milk might be something else to consider.

(45:34) [Mary C. Bietila]     Excellent. This next question is about chocolate and cocoa. "Isn't it true that chocolate like cocoa and dairy fats..." Oh, wait. I'm going to paraphrase this one. So they're talking about trying to mitigate osteoporosis, and they're thinking is, is chocolate or cocoa and the fat within there helpful, harmful?

(46:06) [Paula Macris]      Okay. If I'm understanding the question, so chocolate was one of the food items I had on the slide, if you go back after the presentation, in terms of a saturated fat. Essentially, over time, a larger consumption of dietary cholesterol saturated fat can actually help to, can actually narrow the blood vessels, if you remember that slide that showed the diagrams of the different vessels. So again, I think it would be a food to consume in moderation.

(46:35) [Mary C. Bietila]      Okay. All right. Right in that same frame of mind, we're talking about calcium. "So how many milligrams of calcium is it... has research shown that the body can absorb at one time when you take a supplement?"

(46:52) [Paula Macris]      What we recommend is that the body can absorb about 500 milligrams at a time. So for example, if you're taking a 500 milligram calcium supplement, have it at a time when you're not having a high calcium snack or meal. Different forms of calcium, some calcium such as calcium carbonate, you need gastric acid or food to absorb it, so that's appropriate to take with food. Other types of calcium, like calcium citrate, you can take it any time. But typically, 500 milligrams is the dose that your body will absorb at one time.

(47:30) [Mary C. Bietila]      Oh, that's really good to know. Okay. The next one is about weight vests. "Are they good for sustaining or building bone strength?" I'm not really sure what a weight vest is, maybe you're familiar.

(47:45) Paula Macris]      I'm sorry, I don't know what weight vests are either, but I'm happy to look into it for you, if you wanted to email me after the presentation. Again, my email address is there in the slides. I'm happy to look into it for you, but I don't have any information at this time.

(48:03) [Mary C. Bietila]      Okay. All right. "How much should we be aiming to drink a day? Is it possible to drink too much water?" This person drinks two to three liters of fluid per day, mostly water, but they still find they suffer from cramps in their hands and feet when they drink towards the lower end of that range. So if they drink just two liters or less, they're getting that cramping. What do you suggest?

(48:36) [Paula Macris]       I think it depends on if you're taking any kind of nephrotoxic, or potential kidney harming... I don't want to really say kidney harming, but medications that are hard on your kidneys. You certainly are going to need more fluid. But typically, I think there is an old adage out there, drinking eight cups a day, but people need different amounts depending on what medications they're taking, if they have kidney issues, other conditions. So I think, I probably would check with your healthcare provider more on that, and checking electrolytes to make sure that there isn't some kind of electrolyte issue, perhaps contributing to the cramping.

(49:19) [Mary C. Bietila]      Oh, that's a good thing. So electrolytes and salt is my number one priority in my drinks most of the time.

(49:27) Okay. "Can anti-inflammatory foods, especially blueberries and black raspberries help produce GVHD inflammation?"

(49:38) [Paula Macris]      So there is really no specific food that decreases GVHD inflammation. You want to get, again, a good variety in your diet. Blueberries and black raspberries are certainly great fruits to consume, but there is no real evidence that I'm aware of that they can actually help to reduce GVHD inflammation.

(49:58) [Mary C. Bietila]      What about turmeric supplements or fish oil supplements? Do they help with GVHD inflammation. I know they help with... can help with other inflammation.

(50:10) [Paula Macris]      Yeah. I think with the fish oil, we've certainly prescribed higher dose fish oil for patients that have had high triglyceride levels, for example. Turmeric supplements, I'm just really not aware of that for decreasing inflammation in a setting of GVHD.

(50:31) [Mary C. Bietila]      Gotcha. All right. "Do diet sodas make you gain weight?"

(50:39) [Paula Macris]        Diet sodas certainly don't contain the amount of sugar that regular sodas would. If you're going to drink them, I think drink them in moderation. I think it's more an overall caloric intake versus a specific food.

(50:55) [Mary C. Bietila]     Okay. The next question, I think, is going to have a similar answer. You touched on it in your presentation as far as alcohol. "Is it ever safe to drink alcohol after transplant?" They were referencing beer or cocktails, wine. Is there a better choice within there, or should people just refrain?

(51:20) [Paula Macris]      Again, I would follow the recommendations of the American Institute for Cancer Research, which for women, it's one drink a day, for men, it's two drinks a day. And follow those guidelines with regards to the portion.

(51:33) [Mary C. Bietila]      Excellent. "What is your take on whole food vitamins as opposed to synthetic vitamins, wild fish as opposed to farmed fish?"

(51:46) [Paula Macris]      Whole foods vitamins, I'm not sure that I've really heard that term, specifically. I think you want to check labels. You want to get a vitamin from a good, reputable company. You don't want a vitamin that has large and large, hundreds of percentages of amounts above the dietary reference intake. I'm sorry, what was the second question, wild fish?

(52:13) [Mary C. Bietila]      Oh, sure. The second one was wild fish opposed to farmed fish, is there a nutritional difference?

(52:21) [Paula Macris]      Sure. With the wild fish, the fat profile tends to be healthier, so if you have that option and your budgets allows, I would recommend the wild fish versus the farm raised.

(52:33) [Mary C. Bietila]    Okay. I often hear that with environmental impact too, so that's important.

(52:40) "How do you suggest that patients get their doctor to recognize that they're having GVHD side effects? It's not just a bad tummy month."

 (52:53) [Paula Macris]      What you could think about doing is keeping a diary of the different symptoms that you're having. That way, you have some documented information to show your healthcare provider when you're feeling that something just isn't right.

(53:08) [Mary C. Bietila]      Yeah. Any evidence, I think is always helpful to bring into your doctor's appointment.

(53:13)   "Do you have a preference for canned vegetables versus frozen vegetables?"

(53:20) [Paula Macris]      No real preference. I think either one is fine. I think it's just a matter of preference. They're all still going to give you good nutritional value.

(53:28) [Mary C. Bietila]      Okay. This individual takes B-complex vitamins that includes thiamine, and noticed that their urine has changed color. Are vitamins helpful, or does the body discharge those entirely?

(53:42) [Paula Macris]      The body will absorb what it needs for vitamins, but yes, if you are taking a supplement that has larger doses of these vitamins, it will just be excluded in the urine. So that's probably what you're seeing.

(53:55) [Mary C. Bietila]     The body will still take some of those nutrients?

(53:58) [Paula Macris]     The body will take what it needs, and then excrete what it doesn't need.

(54:01) [Mary C. Bietila]     Okay, thank you. "Can food allergies show up after a stem cell transplant?" This particular person had seemed to develop a shellfish allergy, which they're not very happy about. Can that be passed on from your donor, or picked-up since you have a new, totally new immune system?

(54:23) [Paula Macris]      There is certainly some theories out there that yes, you can pick-up, potentially a food allergy, if your donor was allergic. There is that possibility. Interesting. I'm sorry that that's not working out for you. But yes, there is certainly that possibility.

(54:41) [Mary C. Bietila]      Okay. This is a really interesting question. "How can you keep a healthy weight when you're on prednisone, unless you are walking constantly? It makes you hungry and of course, angry." How do you keep that weight going? I don't think you can do much for the moon face, but otherwise, how do you keep your weight in check?

(55:06) [Paula Macris]      Understandable, we see a lot of patients on prednisone that have gained weight. Choosing a plant-based diet, I think is a good suggestion. Really watching your portions, exercising what you can, watching salt intake with prednisone, because sometime the salt can make your body hold onto more fluids. Yeah, really watching your portions and again, limiting really the high sugar, the higher fats snack foods.

(55:35) [Mary C. Bietila]      Anything as far as the hunger, because I know that hunger can be really significant?

(55:42) [Paula Macris]      Hunger can be significant. You may want to think about consulting with a dietician that can help work with you more directly. Perhaps, your oncologist can refer you to somebody, or there is somebody at your hospital that, again, they can really look specifically at what you are eating and then maybe offer you some suggests on some modifications you can make.

(56:03) [Mary C. Bietila]      Great. This person would like to know, "Is it safe to eat kimchi, sauerkraut, kefir, all those good sources of probiotics?"

(56:15) [Paula Macris]      Kefir is a pasteurized drink. It's a yogurt-like drink. That's certainly fine. Kimchi and sauerkraut, we would recommend that you go with reputable companies. Again, it depends on your situation. If you're still being treated for chronic graft versus host disease, then the kimchi, I would get it from more store bought types and more reputable, larger manufacturing companies. Again, if you're not on immunosuppressants, then it's probably not an issue.

(56:49) [Mary C. Bietila ]     Okay. This particular person, this is going to be actually our last question, has been soaking potatoes in water for 15 to 30 minutes before baking. I think for cleanliness. Their concern is that it might reduce the potassium and the nutritional aspect of those potatoes.

(57:07) [Paula Macris]      Soaking for that period of time can reduce some of the potassium. I know that's a recommendation that sometimes is made for renal, for kidney patients that have to watch their potassium intake. You'll still get some nutrition from them. So another alternative would be to just take each potato, use a scrub brush, and wash it individually, and just under cold, clear, running water.

(57:31) [Mary C. Bietila]  Closing. Wonderful. We still have tons of questions, but we are out of time. We have over 60 questions today, amazing. You guys have her email address, and she so graciously, Dr. Macris, or is it Macris, will answer your questions if you send her an email at the... She put the slide back up there.

(58:07) So on behalf of the BMT InfoNet and our partners, I would love to thank you, Ms. Macris, for your very helpful remarks. And thank you, the audience, for your very excellent questions. We hope everyone has a wonderful day.