You Are What You Eat: How Food Choices affect Recovery

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You Are What You Eat: How Food Choices affect Recovery

May 1, 2024

Presenter: Stephanie Wiese RD, CNSC,  Colorado Blood Cancer Institute, part of Sarah Cannon Cancer Institute at Presbyterian St. Luke's Medical Center

The presentation is 40 minutes long followed by 20 minutes of Q & A.

Summary:    What you eat can significantly impact recovery after transplant and CAR T-cell therapy. This presentation discusses the nutritional needs of stem cell transplant and CAR T-cell recipients in the short- and long-term; how food choices affect organ function and help prevent complications; how to manage eating difficulties; the role of prebiotics and probiotic in nutrition; and common myths about the relationship between cancer and nutrition.

Highlights: 

• Calorie and protein needs are much higher than normal up to 90 days after a stem cell transplant or CAR T-cell therapy, and longer for patients who are transplanted with donor cells (allogeneic transplant).
• The most important things to do after transplant or CAR T-cell therapy are to eat the daily recommended amount of fruit, vegetables and protein, and keep moving.  
• There are many myths circulating about the relationship between certain diets and cancer. Stem cell transplant and CAR T-cell recipients should consult with a registered dietitian to ensure they are getting the right foods, in the right amounts and at the right time to speed recovery.

Key Points:

(02:25):  Macronutrients (protein carbohydrates and fat) and micronutrients (vitamins, minerals and water) are not only important for recovery after transplant or CAR T-cell therapy but are also important before and during treatment.

(03:09):  Chemotherapy damages both cancer cells and healthy cells. Protein is necessary to repair the damage, build muscles and promote a healthy immune system. Carbohydrates provide a source of energy for the rebuilding process.

(07:31):  Typically, after transplant the GI tract is inflamed. Frequent, small meals are better than trying to consume a large volume of food all at once to meet your calorie goals.

(10:51):  After CAR T-cell therapy, a side effects called cytokine release syndrome (CRS) reduces appetite, increase the body's demand for nutrition and accelerates the rate at which muscles break down.

(13:40):  Physical activity is important for maintaining muscle mass and strength. 

(14:21):  Aim to meet your nutritional needs through diet alone, rather than with supplements.

(16:52):  Several strategies can help address a poor appetite, change in taste or smell, a dry mouth, mouth sores, nausea and vomiting, reflux, burping and diarrhea.

(26:37):  People with GI graft-versus-host disease (GVHD) have higher need for protein, due to damage to the gut.  Fatty. starchy and acidic foods, well as caffeine and dairy products should be avoided.

(33:27):  A common myth is that sugar feeds cancer.

(37:33):  Prebiotics and probiotics can help improve gut health and are better derived from food, than from supplements. 

Transcript of Presentation:

(00:02): [Michala O’Brien]:  Introduction of Speaker.  Welcome to the Workshop. You Are What You Eat, How Food Choices Affect Recovery. My name is Michala O’Brien and I will be your moderator for this workshop.

(00:11):  It's my pleasure to introduce today's speaker, Ms. Stephanie Wiese. Ms. Wiese is a registered dietitian and certified nutrition support clinician at the Colorado Blood Cancer Institute in Denver, Colorado. She supervises a team of dietitians in the inpatient and outpatient setting. She oversees the care of hematology, oncology, stem cell transplant, critical care and steroid-induced diabetic patients. Please join me today in welcoming Stephanie Wiese.

(00:46): [Stephanie Wiese]:  Overview of Talk.  Thank you Michala and thank you everybody for your time and for being here today. I'm really excited to talk about nutrition and its’ importance. 

So, let's just jump right in. Here are a few of our objectives that we're going to cover today. I am not going to go into a lot of detail about side effects management, but we are going to talk about nutritional needs of stem cell transplant and CAR-T cell recipients in the short and long term.

We're going to talk through how to manage eating difficulties due to chemotherapy, radiation, GVHD, and other medications.

We are going to talk about how food choices impact organ function and help prevent complications after a stem cell transplant or CAR-T.

You'll notice in my slide deck I use HCT for hematopoietic stem cell transplant. We use that interchangeably with bone marrow transplant and stem cell transplant. So you'll hear me use all of those terms and they all mean the same thing in the context of this talk.

We'll talk through some common myths associated with nutrition and cancer, which is one of my passions. And I love working with patients when they have questions or they've heard something or they've seen something and they have questions for me regarding that.

And then, the role of prebiotics and probiotics in nutrition, which is also super interesting.

(02:25):  Macronutrients (protein carbohydrates and fat) and micronutrients (vitamins, minerals and water) are not only important for recovery after transplant or CAR T, but are also important before and during treatment. There are a lot of organs, there are a lot of cells, there are a lot of parts of your body that are going to need recovery, and they're going to need a lot of nutrition to do that.

(02:47):  When we think about nutrition, I break it down into macronutrients and micronutrients. Protein, carbohydrates and fats are going to be our macronutrients. They're really, really important for post-transplant recovery, but also they're important before, during and after transplant.

(03:09):  Chemotherapy damages both cancer cells and healthy cells. Protein is necessary to repair the damage, build muscles and promote a healthy immune system. Protein is necessary for tissue formation and cell repair, which is huge. When you think about what chemotherapy and what some of these therapies do, they're damaging all of a person’s cells, the cancer cells and their healthy cells. Protein is super important for that cell repair, because they bolster and repair those healthy cells. Then hormone and enzyme production and building strong muscles in a healthy immune system - those are the other two really, really important details to remember when we're emphasizing the importance of protein intake. I want to keep you strong, want to get your immune system back healthy and want to repair those damaged cells.

(03:56):  Carbohydrates are really important for a steady source of energy. And they help provide structural components for the formation of cells. When we're talking about anything to do with cell repair, and when we think about what treatment does, we're going to want to focus on these three macronutrients, protein, carbohydrates and fat.

(04:17):  Fat will provide stored energy for our bodies. It functions as a structural component for ourselves. It helps signal and support proper cellular communication. And then, it provides insulation to our vital organs and helps us maintain body temperature.

(04:38):  As for micronutrients, there's subgroups to all of these, but we want to look at vitamins, minerals, and water. Those are the micronutrients that we focus on.

(04:54):  Vitamins and minerals help the body use the energy and nutrients provided by macronutrients. Vitamins and minerals really are important. They're involved in a lot of metabolic processes, so they help us use the energy and nutrients we get from the macronutrients as well as help our body and our organs create a state of homeostasis. Vitamins and minerals are a very, very important part of our diet.

(05:20):  And then, water, of course, helps transport things in our bodies. It helps remove waste products. Staying hydrated is also really critical before, during, and after treatment, transplant, and CAR-T cell therapy.

(05:39):  Calorie and protein needs are much higher during and after transplant and CAR T-cell therapy. The need for increased protein and calories can persist for 90 days or more. Now we'll move on to short term and long-term nutritional needs of both stem cell transplant patients and CAR-T transplant patients and CAR-T cell therapy patients.

Short term, we want to make sure that we're meeting calorie and protein needs. Calorie and protein needs are much higher during treatment and transplant. We call this being in a metabolic state, meaning internally your body is in a state of stress, whether it's dealing with an acute illness, a disease state, or the treatment that we're giving you.

(06:28):  Your body is inflamed and trying to initiate lots of functions and lots of repair that require extra nutrition. These energy needs can be higher for up to 90 days after transplant, and usually longer for allogeneic transplant patients.

(06:59):  There's nutrition before transplant or treatment, during, and then after. And they all look a little bit different.

(07:16):  I always want to be very clear that some of the things that we recommend during treatment or during transplant and post-transplant is a little bit different than what we would recommend long-term or what we recommend before transplant or treatment.

(07:31):  Typically after transplant the GI tract is inflamed. Frequent, small meals are better than trying to consume a large volume of food all at once to meet your calorie goals. These are short-term nutrition goals for one to three months after transplant treatment, small frequent meals to meet calorie and protein goals. Typically, when you've been through treatment or transplant, your GI tract is inflamed and it's not working at its full capacity. Eating or consuming large volumes of food and large meals is usually not realistic. Breaking those down into small frequent meals, eating every two or three hours will meet your protein goals.

(08:05):  The other thing that this does is it maintains gut integrity. So, if someone goes days and days without anything in their gut or stomach, their gut can start to atrophy and it can create all kinds of complications. We don't want that to happen. We want to maintain that gut integrity and gut function by having it do its job, which is digesting and absorbing food.

(08:33):  We want to maintain lean body mass. We want to participate in physical activity daily. The other piece of maintaining that muscle mass is going to be meeting estimated calorie and protein goals.

(08:49):  This chart shows the estimated calorie and protein needs during a transplant.  These are little tricky because they are in kilograms of body weight instead of pounds. That conversion is to take your weight in pounds and divide that by 2.2 and that would be your kilograms of body weight. Your estimated calorie needs during transplant, during treatment are typically 25 to 30 calories per kilogram of body weight.

(09:22):  Now, there are some nuances. If somebody is morbidly obese, we must use an adjusted weight, which is a totally different calculation, but these are pretty standard. They would be increased from there to 30 to 35 calories per kilogram of body weight if a person is malnourished.

(09:41):  If somebody comes in and is very malnourished or seems to have some cachexia going on, then we're going to want to bump up and increase the amount of calories that they're needing. Typically, it's 1.3 to two grams of protein per kilogram of body weight. To do those calculations, you would just take your weight and kilograms and multiply it by 1.3 to two, and that would give you a range of protein goals.

(10:16):  We're also going to want to manage GI side effects with medications and food choices when able. We'll talk a little bit more about that in some other slides, but make sure we're taking the medications that help with nausea or diarrhea.  If I'm having any of those GI symptoms and side effects, what are some food choices that I can make that will kind of help with those?

(10:51):  After CAR T-cell therapy, a side effects called cytokine release syndrome (CRS) reduces appetite, increase the body's demand for nutrition and accelerates the rate at which muscles break down. The most common side effects of CAR-T cell therapy that can impact nutrition are cytokine release syndromes (CRS) and neurotoxicity.  Usually, those side effects resolve within the first 30 days, but not always. The release of those pro-inflammatory cytokines are known to reduce appetite, increase the body's demand for nutrition and accelerate catabolism.

(11:30):  What we mean by accelerate catabolism is this type of therapy is going to accelerate the rate at which the body breaks down muscle, typically muscle. Sometimes it'll break down fat, but protein is in our muscle, and that's the preferred fuel.  If we're not eating and drinking enough, it accelerates that rate that your body is breaking down muscle.

(12:02):  Eating small frequent meals and physical activity can help preserve lean body mass after CAR T-cell therapy. Some of the short-term goals we work with our CAR-T patients on is small frequent meals. Since we know that neurotoxicity, confusion and CRS are the most common side effects, we're going to make sure mentation is appropriate and our patients are swallowing safely. We don't want any aspiration and we don't want choking.  We don't want any of those risks at play. We want to maintain lean body mass by consuming adequate calories and protein, then continue physical activity to preserve lean body mass.

(12:43):  I'm always saying that the two things that you really can control and add the most value to your treatment is eating and moving, because those are the two things that have the most impact, besides the overall treatment, that you can control.

(13:09):  Long-term, maintaining a healthy body weight is very important.  Those are the couple of things that are really important. So long-term nutrition goals are super important. So now we've moved on from that acute phase. So, this is like three plus months out from your transplant. The long-term nutrition goal we want to focus on is maintaining a healthy body weight. I'll go into this a little bit more when I'm talking through some of the myths, but maintaining a healthy body weight is important.

(13:40):  Physical activity is important for maintaining muscle mass and strength.  Participate in physical activity for at least 30 minutes per day; household chores count, vacuuming, laundry, dishes. All of those things count. Walking, biking, resistance training, those are all going to be really important for maintaining that muscle mass and maintaining that strength, which is very, very important.

(14:03):  Limit alcohol consumption, avoid sugary sweetened beverages and limit consumption of salt-preserved or highly processed foods. These are all recommendations that prevent cancer and prevent reoccurrence. I'll run through some more of them.

(14:21):  We want to aim to meet nutritional needs through diet alone. What that means is I'm not relying on a bunch of different supplements to meet my nutritional needs. We can use them to supplement if we're lacking, but eating a variety of fruits and vegetables, which is two to three servings of fruit and three to five servings of vegetables per day is really key.

(14:50):  The most important things to do after transplant or CAR-T are to eat the daily recommended amount of fruit, vegetables and protein, and keep moving.  There are three things that I really think are the key to overall good nutrition status. Meet your daily recommendations of fruits and vegetables, meet your daily protein needs, and move your body. So, if there are three things you take away, those ones are very important.

(15:25):  Fruits and Vegetables.  Fruits and vegetables are so important, because of phytonutrients. Phytonutrients are beneficial chemical compounds that are found in fruits and veggies. Think about antioxidants, flavonoids. There are hundreds of these chemical compounds that are so beneficial to many different parts of our bodies. Try to eat and cook with a wide variety of vegetables.

(15:54):  Eat the rainbow, try new recipes and try new ingredients. The fiber in fruits and vegetables are super important long-term. Meet your protein goals with lean meat, poultry, fish, beans, legumes, tofu, tempeh. Then, limit consumption of red meat and avoid processed meat. Red meat one to two times a week is what we consider limiting it. Avoid processed meat. If you're having it once a week or something like that, it's not going to have the same impact as if you're relying on it as your sole source of protein.

(16:38):  I'm going to run through some of these GI side effects. I'm not going to spend a ton of time on each one of these because I want to get to some information about GVHD and the nutrition and cancer myths.

(16:52):  A poor appetite is common after transplant or CAR-T therapy. Setting timers to remind you to eat, drinking high-calorie, high-protein fluids, eating in a calm, pleasant place and appetite stimulants can help you get the nutrients you need. Most every patient that I've worked with has some type of GI problem.  Cancer treatment, chemotherapy, radiation, and some medications all cause inflammation and damage to the GI tract. Some of the most common ones that I hear about and work with patients on are poor appetite or feeling full early; we call it early satiety.

(17:23):  One of the recommendations is to eat by the clock, making sure you're setting either the timer on your phone or a loved one reminding you to eat. Loss of appetite is one of the biggest reasons that patients will lose weight, muscle mass and functionality ...their appetite is gone.

(17:49):  Drinking high calorie, high protein fluids like protein supplements or smoothies are a great way to pack in your servings of fruits and vegetables. In some smoothies, you can get three or four servings of fruits, and if you add in spinach or kale, you're getting one of your vegetables too. There are so many recipes out there. We have a lot of different ones that we like, but if you look anywhere on the internet, there are a ton of smoothie recipes and add some protein in there as well.

(18:26):  Maximize intake when you're the most hungry. Eat in pleasant surroundings, avoiding stress and conflicts. This is a really, really important one, and I feel like this one is underutilized just because it's not talked about a lot, but make sure when you're getting ready to eat,  that you are in an environment that is peaceful to you.  How are you feeling when you're eating?  Change up the setting, put on some music or enjoy the aroma around you, pay attention to all of your senses to set yourself up for success.. If you're struggling eating, changing the environment can help. Eat outside if you can, eat in another part of the house. Switching things up can be beneficial if you’re struggling.

(19:18):  Treatment for contributing conditions like constipation or depression. Look at medications that will stimulate a depressed appetite.  Possibly talk to your doctor or healthcare provider about using an appetite stimulant. Those can have great benefits. Sometimes they don't work, but sometimes they do.

(19:37):  Nutrition Interventions for Changes in Taste and Smell.  I want to make sure everybody has all the tools and resources to try. Nutrition interventions abound for taste and smell changes. I’m not going to run through all of these, but there are lots of different ways to add or take out, if you're having an off taste. Sweeter foods are usually the things that taste the best.

(20:01):  If it's a loss of taste, marinating meats, using stronger, heavily spiced food is really beneficial. If it's a metallic taste, using plastic utensils instead of metal silverware helps.

(20:23):  The other thing that I always like to talk through is when we're having taste changes, it can be due to dry mouth.  We want to assess that and address that, if dry mouth and oral hygiene is causing the taste change.

(20:40):  Chewing on sugar-free gum, sucking on lemon drops, mints or ginger candies can be helpful too. That's all going to help with dry mouth and creating saliva. Avoid strong smells and avoid cooking areas if you're dealing with any nausea. Choosing cold or room temperature foods that don't have a strong smell may help.

(21:03):  Zinc supplements can be beneficial if you have a true zinc deficiency, and that can happen if you have prolonged poor nutrition intake. Sometimes the zinc supplement will help your taste return. If the taste changes and alterations are caused by the treatment, the zinc supplement is not going to help.

(21:32):  Dry mouth is a very, very common side effect of most treatments. Eat foods with sauces or gravy, use dips or dip dry foods in liquid, alternate bites of foods and sips of liquid at meals. Sucking on hard candies can also stimulate saliva production.

(21:54):  Frozen grapes are also really good for dry mouth. They can really help your mouth produce some saliva. Thin oral secretions with carbonated beverages. This can be really helpful when you have a thick oral secretion or secretions in your esophagus that water just won't cut through. Carbonated beverages can help with that as well as papaya nectar.  Use Biotene® or Lubricity® as artificial saliva. We've heard a lot of really good feedback about Lubricity® for dry mouth. It's newer on the market, but I think it's really promising.

(22:34):  Interventions for Mouth Sores (mucositis).  Soft foods are easy to swallow. Avoid dry, chewy, or crunchy foods. Obviously, that is going to be painful. Dunk or soak foods in liquid to make them softer. Avoid acidic and citrus flavored foods and juices. Those can be really painful. Utilize bicarb mouthwash. That can even be preventative from developing those sores. Utilize Lidocaine or Dexamethasone, swish and spit for oral pain relief.

(23:12):  Nutrition interventions for nausea, vomiting, reflux, burping.  For nausea, vomiting, reflux and burping, make sure you have the proper antiemetic, like Zofran®, oral Compazine®, Ativan®, whatever works for you, and make sure you're taking them on time. I usually tell the patients that I get to work with, timing the meds 30 to 45 minutes before meals; you're “pre-medding” your meals to keep on top of those things.

(23:37):  Smaller, more frequent meals are going to be helpful. Avoid high fat or greasy foods. I will get into this a little bit more when we're talking about GVHD, but high-fat foods and high-fiber foods are harder for our bellies to digest. Long term, we don't want to avoid fat and fiber.  But when our GI tract is inflamed or in distress, not feeling good and not working properly, we want to limit those foods that are harder for it to digest and increase the foods that are easy for it to digest and absorb.

(24:14):  Avoid taking medications on an empty stomach. This is a big one, unless it’s required. I do know there are some medications that do need to be taken on an empty stomach.

(24:25):  Natural Antiemetics.  Try ginger containing foods, ginger candy, ginger teas. Those are a natural antiemetics as well as acupuncture bracelets, massage, and distraction techniques. I have patients try any and all of these because everybody's body is a little bit different as to what will give them relief.

(24:50):  Nutrition Interventions for diarrhea.  Nutrition interventions for diarrhea, this is a very common one too, and it's a bit tricky because we can't manage your GI side effects and diarrhea that are being caused by chemotherapy. We can't manage those with food because they're not being caused directly by the food. It's not the same as an intolerance or an allergy where you just cut that food out and go on. We're just trying to manage the side effects. So I always like to discuss food history and symptom history with the patients I get to work with.

(25:22):  Try to correlate data.  Are you having bouts of diarrhea after every meal, after a certain meal? What's in that meal? Is it after a certain medication? Is it a certain time of day? We really want to try to pinpoint the timing, because it helps when we're trying to manage some of these side effects. Try a low-fat, low-fiber, low-lactose diet. Dairy and lactose are inherently disruptive or bad, but they can be harder to digest for our stomachs. We want to limit those foods, while avoiding gas-producing foods or caffeine. You can consider bulking agents or soluble fiber foods. I find bananas or banana flakes, rice, stuff like that can really help bulk the stools.

(26:17):  Avoid sorbitol or other sugar alcohol-containing products that can actually cause osmotic diarrhea. We definitely don't want that. Drink plenty of fluids and consider electrolytes or multivitamins. We just don't want you to get dehydrated.

(26:37):  People with GI graft-versus-host disease (GVHD) should avoid fatty. starchy and acidic foods, well as caffeine and dairy products.   It can be really scary and dangerous. It is a very common complication of allogeneic stem cell transplants. It's a complication of the donor cells attacking the host's organs and in this case the GI tract. The symptoms can be mild, moderate, or severe, including nausea, vomiting, diarrhea, blood in the stool, abdominal cramping, poor appetite and severe weight loss.

(27:24):  We're managing and making recommendations pending all of these GI side effects. Typically, our recommendations are based on the grade of GVHD and what is being impacted and symptoms that are being reported.

(27:46):  Standard GVHD treatment always involves high-dose corticosteroids or steroids, prednisone, Solu-Medrol, dexamethasone, all of those. There are a lot of other really new exciting drugs out there to treat GVHD. I'm not going to go into those. I'm not a pharmacist, so I'm just going to speak to the nutrition piece of it.  Just know that as providers, as clinicians, we're working closely with providers, the physicians, the pharmacists, because we know all of this impacts the care of our patients.

(28:23):  Diet modifications vary depending on the severity of symptoms, but we really want to avoid high-fat foods. We know those are harder to digest. Avoid high-fiber foods or limit those, avoid acidic foods, caffeine and dairy. Those are all foods that are either harder to digest or can cause a little bit of irritation to our GI tract.

(28:53):  We want to focus on easy-to-digest carbohydrates and lean protein. I run through some of those on the right-hand side.  Fruit without the skin, bananas, applesauce, canned pears, peaches, even smoothies with berries are easy to digest.

(29:24):  White rice, white bread, pasta, low-fiber, cereal, potatoes, sweet potatoes, mostly simple carbohydrates that our bodies and our bellies can digest easily.  Lean protein, eggs, egg whites, chicken, turkey, tofu, fish, usually white fish, tilapia, cod or flounder. They're all a little bit lower in fat and a little easier to digest.

(29:52):  Calorie and protein needs of patients dealing with GVHD are higher than during treatment. Your body is going through a lot, so it typically needs 30 to 40 calories per kilogram of body weight and 1.5 to two grams of protein per kilogram of body weight. In cases of malnutrition or severe complications, even more protein than that is required; same calories, but 1.8 to 2.5 grams of protein. You can see when we're trying to combat and heal a gut impacted or damaged by GVHD, your protein needs are a lot higher.  That’s the importance of protein during treatment, transplant and dealing with any of the complications, when we're talking about recovery and repair.

(30:55):  Standard treatment is steroids for GVHD and muscle wasting, muscle atrophy. Myopathy is a common and unfortunate side effect of using steroids, but the steroids are necessary because they treat the symptoms of GVHD.  Muscle wasting typically happens in the first month or two, after starting high dose steroids, and can cause weakness, atrophy, usually in the hands, legs, arms and feet. The prevention and treatment is really interesting because it's what I've been talking about for all the other recommendations of meeting your calorie and protein needs, making sure you're getting enough calories and getting enough protein, not forgetting about vitamins, minerals and healthy fats.

(32:03):  Physical activity and resistance training can be super beneficial. Whether it's getting a physical therapist on board to teach you some activities or teach you some resistance training exercises, physical activity is critical.

(32:28):  Taper steroids if you’re able. Sometimes it's a very fast steroid taper. Sometimes you're going to be on a certain dose of steroids for a prolonged amount of time. There are a few things that you can do to help with that. Prevent or slow down muscle wasting or atrophy by meeting calorie and protein goals and then moving. I'm going to run through some of the most common cancer myths that I hear from my lovely patients that trust me with their questions.

(33:06):  We all see stuff online. I think it's wonderful that people are interested in their care and their health and they're trying to figure out things online. With the good information can also be some confusing information. I really like vetting some of these things out and getting these questions from my patients.

(33:27):  A common, often-repeated myth is that sugar feeds cancer. The most common one that I hear is sugar feeds cancer. A direct link between sugar intake and cancer has not been found. However, excess sugar intake can lead to obesity and the chronic inflammation with obesity can increase your risk of certain types of cancer.

(34:02):  Glucose or sugar feeds all of our cells, our healthy cells and our cancer cells. If we just stopped eating sugar, I've heard people say that it'll starve the cancer. Unfortunately that is not totally how it works.  Cancer cells are so smart, they will find other metabolic pathways to leach energy ... they will find a way.

(34:27):  I don't recommend eating a diet full of excess sugar, especially refined sugar. The recommendation is eating less than 25 grams of added sugar per day, and that's not a lot. So you can see, we're not saying there's a direct link, but we're also not promoting a diet full of processed sugar.

(34:54):  Transplant and CAR T-cell therapy should not be viewed as weight loss program. Losing weight in a healthy way can be done after, not during recovery. I get this a lot. I've been trying to lose weight. Now, I finally am, and I'm going to just go with it. Unfortunately, during times of treatment and during times of acute illness, especially when dealing with cancer, the weight loss that happens is primarily from your muscles. And that is the opposite of what we want. There are lots of studies that show a loss of as little as 6% of body weight can predict reductions in treatment response, survival and quality of life. So 6% is not a ton, but as it goes up from there, we see quality of life, response to treatment and outcomes decrease. I always like to say weight loss can be done post-treatment in a very healthy way by preserving lean body mass, moving and making sure you're nourishing your body.

(35:57):  Typically, during times of treatment, you're under-nourishing your body, you're losing muscle mass, you're losing strength, and that's not what we want to do. We want to wait until things settle down when you're not actively getting treatment anymore and your metabolism slows back down before we start talking weight loss.

(36:24):  Juicing fruits and vegetables instead of eating them whole is not recommended. Juice cleanses and detox are beneficial during cancer treatment. There are lots of different ways to add in vitamins and minerals. I don't recommend only juicing as a full source nutrition, because you're missing out on fiber and protein and calories in those cases.

(36:49):  There is no “superfood” that can fight cancer alone.   There are superfoods that alone can fight cancer. I love all of these foods in general, but there's not one of them that you're going to add to your diet to fight cancer or totally revamp your nutritional status. It's the food industry tricking you with their marketing.

(37:16):  High doses of vitamins and minerals can be beneficial during cancer treatment, but we don't want to do mega doses of anything. It can interfere with medications. It can put extra strain on your liver and kidneys. We want to get those through eating fruits and vegetables. Now I want to run through probiotics and prebiotics.

(37:33):  Prebiotics and probiotics can help improve gut health and are better derived from food, than from supplements.  Probiotics and prebiotics are so good for your gut health. Usually, you want to get them in food form. There are some instances where a supplement is recommended, but we always have to remember that the supplement industry is unregulated, so we don't totally know what bacteria are in those. And we don't want to introduce live bacteria, especially to somebody who has a compromised immune system, but the probiotics or bacteria in foods are regulated by the FDA.  There's a list of foods from vegetables, fruits, yogurt. Yogurt is the preferred, it's just easily accessible. Kefir, kombucha, miso, tempeh, those are all really good ones as well.

(38:20):  Prebiotics are going to be the fiber-rich foods which help probiotics flourish. There are a lot of protective properties that are produced as a byproduct when our gut bacteria eat prebiotics.  It actually produces butyric acid that can help heal and protect our digestive tract. That is also an added benefit.

(38:49):  I have some food sources here of prebiotics that I'll just quickly run through.  You can see the CFUs or the colony forming units of probiotics in foods. Kefir, yogurt, kimchi, all are going to have a lot more CFUs in them naturally. Supplements typically contain one to 10 billion per dose, and we don't know where those capsules are dropping them in the GI tract; there are a lot of technicalities with probiotic supplements.  Probiotics are more bioavailable, meaning your body will absorb and use them properly, in food form rather than in supplement form. That was my last slide and I made it with only one minute to spare, so that was good.

Questions and Answers

(39:54): [Michala O’Brien]:  Thank you Ms. Wiese for this excellent presentation. We'll now begin the question and answer session. Our first question is, I have developed multiple new autoimmune diseases since transplant. Are there any diet changes to reduce autoimmunity?

(40:24): [Stephanie Wiese]:  That's a really good question. Most autoimmune diets, I won't even call it a diet, but there's usually gluten sensitivity. Minimizing or cutting out gluten would be the first place that I would start with that.

(40:50): [Michala O’Brien]:  Great. What are some helpful resources for treating steroid-induced pre-diabetes? Any guidance in the number of carbs per meals?

(41:00): [Stephanie Wiese]:  That's a good one too. For a number of carbs per meal, we usually want to stick around 60 to 75 grams of carbs per meal. That's what our body’s metabolism and pancreas can handle. So that's the goal of carbs per meal. And as far as resources, there are a lot of diabetic resources. The American Association for Diabetes is probably the most reputable one; that's the one that I would recommend.

(42:01): [Michala O’Brien]:  Thank you. This patient has graft-versus-host disease, and they're taking steroids and antibiotics. Is Biotin® safe to use if you have graft-versus-host disease?

(42:16): [Stephanie Wiese]:  There are a few questions that I would ask. It wouldn't be a totally straight answer, but I would say, why are you wanting to use Biotin? And I'm guessing maybe hair, nails, stuff like that, because we get that one a lot too. That one can interact with immunosuppressants. Most of us dietitians or healthcare providers that work at cancer care clinics have access to a natural medicine database, and we can type in the supplement that you're interested in. And then, we can compare it to interactions with a bunch of different medications just to make sure there are no severe interactions.   I would ask your provider if they can compare those two because it might be totally fine.  If I had it in front of me, I would do it for you, but I don't. 

(43:20): [Michala O’Brien]:  This is a question on protein as far as protein intake, post-transplant. Any suggestions?

(43:30): [Stephanie Wiese]:  Yes. If you are looking for your protein goals, that's where I would start. Say you're 150 pounds, that's 68 kilograms. You would want to figure out, "Okay, well how much protein am I aiming for?" Probably right around 100 grams of protein. And how are you going to get that?

Make a plan. I want to do how many eggs for breakfast and how much protein is that?" What am I going to do for lunch that's going to have protein? Am I going to do a tuna fish sandwich? Am I going to do rotisserie chicken on my salad? How am I going to incorporate it in each meal?  Think through lean protein options. Snacks can help too. High protein snacks are beneficial, and that can be anything from an apple with peanut butter, beef jerky (even though it is processed), protein supplements.  String cheese has a little bit of protein, yogurt, cottage cheese. When you're talking about meeting a protein goal that's a little bit higher, you want to plan out your day, but know what your goal is.

(44:58): [Michala O’Brien]:  Okay. Here's another egg question. Would you recommend limiting eggs because of cholesterol if a patient is on a statin?

(45:07): [Stephanie Wiese]:  That is a great question, and I love this question so much because I get it all the time, even from doctors. Before I ever go after somebody's egg consumption, I would want to look at the rest of their diet and where they're getting cholesterol or saturated fat. If they're not getting it anywhere else and it's only the eggs that contain it, then yes, we could talk about doing egg whites. But if they're eating fried foods, pastries, a lot of other high cholesterol-containing foods; that's the stuff that I would want to cut down on, rather than the eggs, because eggs contain so much good nutrition. I know that's just the thing that everybody thinks about when they're thinking about cholesterol, but that would be the last thing I would cut back on.  I would want to look at a few days’ worth of “what else are you eating?”

(46:12): [Michala O’Brien]:  This person is post-BMT for seven years, and they have non-smelling gas every day. Does this mean anything? I rarely drink soda.

(46:26): [Stephanie Wiese]:  Interesting, that's a good question. I would keep a food diary and then, alongside the food diary, is there a time of day that it happens? Is there something that triggers it or at a certain point of the day, are there certain foods? That's the only way to pinpoint it. It doesn't sound like a cause for concern, especially if it's not causing you any uncomfortable symptoms, not any bloating or anything like that. I would try to pinpoint what's causing it by way of food diary/looking at when you're developing the gas during the day.

(47:22): [Michala O’Brien]:  Okay. You mentioned honey as a prebiotic, but for this patient, honey was not allowed after transplant. How long before can it be consumed safely?

(47:34): [Stephanie Wiese]:  That's a good question. We get this one a lot too. That's a hard one because typically we're looking at overall clinical picture and blood counts, but usually, three to six months after transplant; depending on lots of other factors, it's considered safe.

(48:04): [Michala O’Brien]:  What resources would you suggest to make the best dietary decisions? Is there an app you could recommend or an internet site reference materials?

(48:15): [Stephanie Wiese]:  That's a really good question too. It depends on what your nutrition goals are, but there are so many great resources out there. If you're wanting to diversify your diet, add in more fruits and veggies, and get some more recipes, a website that I absolutely love is called cookforyourlife.com. It has so many recipes, it has a plethora of information.

If you're wanting to look at total calorie or protein intake versus what your goals might be, there are a lot of apps that I think are helpful, especially if you're first starting out saying, "Okay, I want to make some diet changes."  It might be you want to increase protein or eat within your calorie goals. Sometimes, you don't know how much you're eating or if you're meeting those goals until you track it.  

The tracking app I think is the easiest is MyFitnessPal, and it has all the different types of foods and all of their nutrition values. It can give you a better idea of, "Okay, what am I doing in a day? What does this look like and where are there areas for opportunities and improvement." Those are two resources that I like to point my patients to.

(49:59): [Michala O’Brien]:  Here's a question on soy and whey protein. Is soy or whey protein recommended? Does it contribute to inflammation?

(50:12): [Stephanie Wiese]:  That's a good question too;  I get that one a lot. With any protein supplement including soy, whey protein or pea protein, everybody has a different preference and a different tolerance. Some people don't really digest whey as well as a soy-based protein. By that I mean when they eat it or drink it in a smoothie or supplement, they experienced gas, bloating, burping or heartburn. Then I would say, let's move on and try a different one, because for some reason, your body or your GI tract is not digesting, and absorbing that well. Neither of them is known to cause inflammation across the board.  I will say everybody's belly, especially post-treatment or transplant, tolerates things a little bit differently. Some people tolerate whey really well. And they don't tolerate a pea or vegan-based protein powder. So it varies, and it's a preference thing too on taste and all of that.  Hopefully that answered your question.

(51:34): [Michala O’Brien]:  Okay. This male patient is seven years, post BMT. He's 43 years old. His weight before BMT was 182 pounds. Now, he weighs 205. He's tried everything to regain the previous weight, including exercise, cutting out desserts, processed foods. I just can't get my weight down. Do you have any ideas or suggestions?

(52:05): [Stephanie Wiese]:  That's a good one, and I know it's interesting because during all of this, I think it doesn't get talked about enough that body composition changes because of treatment in a lot of cases. And so, just be kind to yourself. Don't be overly frustrated but looking at a couple of days of your intake and physical activity and saying, "Okay, well, maybe I'm not meeting my protein needs." Maybe with building a little bit more muscle and having a little bit more strength training, weightlifting plus increasing my protein needs, I'll build a little bit more muscle, which automatically increases your metabolism. Look at things more on what to add in instead of what to take out, because that can be super defeating.  I think when you add things in and try them, if they don't work, you're like, "Oh, okay, well, maybe I'll add something else in," but if you are constantly restricting and it's not working, I think that can be so defeating and frustrating. So try to add a couple of things in.

(53:20): [Michala O’Brien]:  Okay, this is a female patient who's five years post-transplant and she's physically active. Initially, she had a hard time keeping on weight, but now, her metabolism seems to have slowed down, and unless she watches what she eats, she's fearing that she's going to gain unwanted weight. Does your metabolism change long-term after transplant?

(53:47): [Stephanie Wiese]:  It can, yes. The simple answer is it absolutely can. We see that happen. Like I said, some of the body composition and hormonal changes happen; there are just a lot of things that are impacted by treatment and transplant. Your goals sound like weight maintenance or even strength maintenance. Your weight might fluctuate, all of our weights will fluctuate in life.  How can I maintain the functionality of my body that I've worked so hard at having ... how can I maintain that with things that I'm adding in and nourishing it with?  You're going to have your own set of goals.  Maintain strength rather than fear losing weight.  Tweaking those things can be really helpful.

(55:06): [Michala O’Brien]:  Okay, this person is dealing with ocular GVHD, specifically dry and burning eyes. Do you have any dietary or nutritional recommendations or possibly supplements for dealing with ocular GVHD?

(55:23): [Stephanie Wiese]:  I wish I did, but I do not. I am sorry that you're dealing with that. I don't have anything that I've seen on diet in connection with ocular GVHD. I'm sorry.

(55:44): [Michala O’Brien]:  Okay. This person is a caregiver of a spouse who had a stem cell transplant two years ago. Is the DASH diet appropriate after a stem cell transplant?

(55:59): [Stephanie Wiese]:  Yes. I love the DASH diet. I love the Mediterranean diet, even more, because it's adding in a bunch of healthy fats and healthy calories, but there's a combination of those two diets that is ... I can't remember the name of it off the top of my head, but it blends those two diets together.  Yes, I do like the DASH diet and I love the Mediterranean diet, and that one has been researched shows increasing benefits in health over and over again.

(56:42): [Michala O’Brien]:  Can you tell our audience what the DASH diet is?

(56:47): [Stephanie Wiese]:  Yeah, so it's typically low sodium, low processed foods. DASH stands for Dietary Approaches to Stop Hypertension. It’s mostly low sodium, low processed foods. It's kind of like the Mediterranean diet in that you're eating a lot of fresh fruits and vegetables. That's the bulk of your diet. You're incorporating lean proteins and you're limiting foods high in saturated fat and processed meats, high salt processed foods, limiting sugar sweetened beverages. In a lot of ways, it's the recommendations that I was talking about earlier. It's used for heart health, but it will help you with overall health.

(57:49): [Michala O’Brien]:  Okay, this is post-transplant patient, but was told not to eat lettuce, some vegetables and fruits because of the bacteria that you can't wash it off. Is a vinegar cold water wash appropriate, or should I just stay away from some of these fruits and vegetables?

(58:10): [Stephanie Wiese]:  That's another really, really good question. We stopped having our patients follow the neutropenic diet maybe seven or eight years ago, because there was a bunch of new research and literature published that it was almost causing more harm than it was preventing risk of infection. Yes, the one part vinegar, three parts water, even warm tap water.  It is important to continue to eat fresh fruits and vegetables. The one thing I will say is wash pre-packaged spinach again.  I would definitely make sure there's no funky slimy pieces of spinach on the bottom or anything like that.  We have not seen an increase in foodborne illness or bacterial infections from letting the patients we work with eat fresh fruits and vegetables.  We educate our patients on hand hygiene and then washing those fruits and vegetables before eating.

(59:23): [Michala O’Brien]:  Well, thank you. We are running out of time and on behalf of BMT InfoNet and our partners, I want to thank Ms. Wiese for a very helpful presentation. And thank you, the audience for your excellent questions. Please contact BMT InfoNet if we can help you in any way.