NUTRITION: FOOD FOR LIFE
Carolyn Katzin, MS, CNS, MNT
Integrative Oncology Specialist
Certified Nutrition Specialist
Living with Aplastic Anemia, MDS or PNH
AA&MDSIF
Los Angeles, CA
Saturday April 5, 2014
WHAT WE WILL COVER IN THIS PRESENTATION
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The building blocks of a diet for healthy bone marrow
functioning
How you may need to modify your diet during
treatment and any barriers preventing this
Habits to optimize your health and well-being
Reliable sources of information on nutrition and
supplements
Questions and Answers
NUTRITION – HOW TO NOURISH YOURSELF
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We all eat but we don’t always eat well
Many chronic illnesses are associated with:
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too much food
too little exercise
too much smoke exposure
too much alcohol
too few fruits and vegetables
too few whole grains, beans and high fiber foods
What are the building blocks of a healthy diet?
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Sufficient energy but not too much
2/3 plant based: beans, nuts, seeds, grains, vegetables, fruit
1/3 fish, poultry, eggs, lean meat
“AS TO DISEASES, MAKE A HABIT OF TWO THINGS
– TO HELP, OR AT LEAST TO DO NO HARM”
HIPPOCRATES, 400 BC
WHAT SHOULD I EAT?
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Make your food choices with a better understanding of what
your body needs – this may be highly personalized based on your
overall health situation
See food as nourishment, pleasure and a way to share with
family and friends
Food also provides Antioxidants, Anti-inflammatories and
Anticarcinogens - the 3 A’s
Other benefits of foods include providing bulk as dietary fiber to
balance blood glucose levels and help manage satiety and
support a healthy microbiome
WHAT YOUR BONE MARROW MAKES
FROM PLURIPOTENT HEMATOPOIETIC STEM CELLS (HSC’S)
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Red cells
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Platelets
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Erythrocytes
Nutrients required
Protein
o Essential Fatty Acids
o Vitamin B Complex
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Thrombocytes
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White cells
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Leukocytes
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B12
Folate
B6
Vitamin E
o Vitamin K
o Iron
o Zinc
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Red marrow, medulla ossium rubra, in heads of long bones is main
site of blood cell and platelet formation
WHAT IS RELEVANT TO YOU IN YOUR CBC

WBC (White Blood Count)
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ANC (Absolute Neutrophil Count) calculated by
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12.6 – 16.1 g/dl
Platelet count
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3.93 – 5.69
Hemoglobin
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White blood cell number multiplied by polys and bands
Typical ANC would be
300 X (0.10 + 0.05) = 300 X 0.15 = 45
RBC (Red Cell Count)


3.3 – 8.7 K/uL
147 – 347 K/uL
Reticulocyte count

0.5 – 1% of RBC
Source: National Institutes of Health
“ONCE YOUR CHOOSE HOPE ANYTHING’S POSSIBLE”
CHRISTOPHER REEVE
CLARK KENT/SUPERMAN
O
symbol
for love
Hydration
HOPE
Exercise
Protein
1954-2004
HEALTHY FOOD CHOICES
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Make your food choices with an understanding of what
your body needs
View food as nourishment, pleasure and a way to share
with family and friends
Food also provides Antioxidants, Anti-inflammatories and
Anticarcinogens (the 3 A’s)
Other benefit of foods include providing bulk as dietary
fiber to balance blood glucose levels
Symptom management with diet
Specific drug-nutrient advice
WHAT DIET CHANGES SHOULD I MAKE?
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A diet rich in nutrients improves your overall health and may also
enhance your therapy
Most people find small, frequent intakes of calories are easier to
tolerate than a few large meals
Protein needs are increased (add an addition serving – usually
about 15 grams or 2 half smoothie portions – one in the
afternoon and one at bed time)
Soft textures are gentler on delicate mouth and upper digestive
system tissues which are more sensitive during treatment
Avoid highly spiced or acidic foods
Stay well hydrated
WHY PROTEIN IS IMPORTANT
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Protein provides peptides and amino acids for new cell
formation
Protein is found in all living things
Protein rich foods include lean meat, poultry, fish, shellfish,
legumes (beans) and tofu, eggs, dairy products, nuts and nut
butters and seeds
During treatment your protein requirements are increased
Sufficient protein is required to avoid anemia
Typically this means including a further 20 grams a day for a
range of 80 – 100 grams each day
TIPS FOR ADDING EXTRA PROTEIN
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Add milk, Greek style non-fat yogurt or whey protein
(unflavored) or dried milk powder to soups and or use as a
base for sauces; or you may select vegan options (rice and
pea or hemp protein)
Include a protein smoothie in addition to your meals
Keep hard boiled eggs in refrigerator and chop on top of
salads or take peeled for quick snack
Use nut butters as spreads (almond, walnut or hazel nut
butters are good, nutrient dense ones)
Snack on low fat cottage cheese or string cheese or hummus
dip
Add cubes of firm tofu or curd cheese to steamed vegetables
COMPARISON OF READY-TO-DRINK BEVERAGES
RTD Beverage
Calories
Protein
Carbs
Fat Fiber
Sugar
Boost
240
10
41
4
0
28
Boost High Protein
240
15
33
6
0
23
Boost Plus
360
14
45
14
3
22
Boost VHC
530
22
46
30
0
14
Ensure
250
9
40
6
0
30
Ensure Complete
350
13
51
11
3
20
Ensure Muscle Health
250
12
32
8
0
23
Ensure High Protein
210
25
23
3
3
5
Ensure Clear
180
9
35
0
0
18
Mix 1
180
15
26
3
4
20
Muscle Milk
160
18
6
7
0
2
Orgain
235
16
32
7
2
12
FOOD SOURCES OF ESSENTIAL FATTY ACIDS
Recommended Fatty Acid Balance Omega 6:3 of ~4:1
(typical American diet is 15 to one)
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1 part Omega-3 (DHA and EPA from oily fish like salmon and
sardines, walnuts and pine nuts)
3 parts mono unsaturated (olive oil, almonds and avocado)
1 part saturated fat (cocoa butter, palm oil or coconut or other
plant source)
Supplement with 100 mg DHA and 500 mg borage or
blackcurrant seed oil (as a source of GLA)
OMEGA-6 AND OMEGA-3 FATTY ACIDS
Vegetable oils
corn oil, nuts,
seeds
Borage, Primrose
or Blackcurrant
seed oil
Red Meat
especially
processed meats
fat in meat from
animals fed corn
EPA (20:5)
Eicosopentanoic Acid
Anti-inflammatory
DHA (22:6)
Docohexanoic Acid
Anti-inflammatory
Table
√
Green leafy
vegetables, flax,
Walnuts, pumpkin,
Grass fed meat fat
√
Fish (cold water)
Algae source
supplements and
fortified milk and
other foods
√
Fish (cold water),
Algae source
supplements and
fortified milk and
other foods
adapted from Simopolous, A (1998)
FOOD SOURCES OF VITAMIN B COMPLEX
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MEATS: Liver, kidney and other organ meats, lean red
meat, dark meat chicken and turkey
EGGS: Egg yolk
FISH: Salmon
BREADS & CEREALS: Wheat germ, Fortified breakfast
cereals such as Product 19, Total and Cream of Wheat,
enriched breads, whole grains, brown rice
NUTS: Walnuts
VEGETABLES: Spinach, broccoli, turnip greens, Romaine
lettuce, asparagus
BEANS: Blackeyes, Pinto, navy, lentils, green peas
VITAMIN E AND FOOD SOURCES
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Vitamin E is important in regulation of thrombosis
Food sources include nuts, seeds, egg yolk, wheat germ
and some vegetable oils
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WARNING! Vitamin E may interact with aspirin and
other anti-clotting agents causing excessive bleeding
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Vitamin E exists as alpha, beta, delta or gamma tocopherols
and tocotrienols.
RDA for alpha-tocopherol is 22.4 IU
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Most supplements provide 400 IU mixed tocopherols
Tolerable Upper Limit is
o 1000 mg α-tocopherol (alpha-tocopherol) or
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1100 IU dl-tocopherol or 1500 IU d-tocopherol
FOOD SOURCES OF VITAMIN K
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BEANS & PEAS: Garbanzo beans, kidney beans,
lima beans, lentils, pinto beans, split peas, soy beans
NUTS & SEEDS: Peanuts, pistachios
VEGETABLES: spinach, leafy greens, mustard greens,
broccoli, Brussels sprouts, turnip greens, watercress, lettuce,
kale, carrots, sweet peppers, leeks, artichoke, celery,
cauliflower
TEAS: Green, black and most herbal teas
FOOD SOURCES OF IRON
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MEATS: liver, lean meat, dark meat poultry, shellfish
EGGS: especially the yolk
DRIED BEANS & PEAS: garbanzo beans, kidney beans,
lima beans, lentils, split peas
BREADS & CEREALS: fortified breakfast cereals such
as Product 19, Total and Cream of Wheat, enriched
breads, oatmeal
FRUITS: prune juice, prunes, raisins, figs
VEGETABLES: spinach, leafy greens, green beans
Vitamin C rich foods enhance iron absorption
FOOD SOURCES OF ZINC
MEATS: Liver, lean meat, dark meat poultry, shellfish
o FISH: Shellfish
o BREADS & CEREALS: Fortified breakfast cereals, bran
cereals, enriched breads, oatmeal
o SEEDS: Sunflower seeds, pumpkin seeds
o DAIRY: Yogurt
 NUTS & SEEDS: Pecans, walnuts, sunflower, sesame
and pumpkin seeds
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VEGETABLES & FRUIT: Avocado
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BEANS: Green peas, black beans
A T YPICAL HEALTHY DAILY MENU
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Breakfast
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Snack
Lunch
Snack
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Dinner
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Beverages
Oatmeal or other whole grain cereal, non fat milk ,
berries or raisins
Apple, tangerine, banana or other fresh fruit
Large salad with dark leafy vegetables (lettuces,
spinach, etc.) topped with colorful vegetables.
Parsley, chives and fresh herbs are good. Sprinkle
slices of avocado, a few pine nuts and sunflower
seeds for added benefit. Tuna, hard boiled eggs or
lean chicken for protein
handful of walnuts, almonds, sunflower seeds (as butters if
your digestive system is sensitive or you are going through
chemotherapy) OR small square of dark chocolate (organic)
Salmon or other fish, lean red meat (not more than
once a week) or chicken or turkey or tofu or
vegetarian protein (Quorn for example), 2 or more
steamed vegetables or stir fry in (small quantity) of
sesame or olive oil, brown rice, baked potato, corn
or whole wheat tortilla, fresh berries for dessert
Iced green tea, water (1.5 – 3 liters a day all fluids)
BARRIERS TO EATING HEALTHILY
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If your mouth is sore
If you have little or no appetite
If you are fatigued
If you are constipated
If you have diarrhea
If you are depressed
If you have insomnia
We need to address each of these important barriers
IF YOUR MOUTH IS SORE OR SWALLOWING IS
PAINFUL
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Soft textured, non-acidic foods are ideal
Temperature is important – room temperature usually
best tolerated
Creamy textures like custard, nut butters and avocado
work well
Avoid citrus fruits, tomato or cranberry juices or
vinegar dressings which may burn
Use (non alcoholic) mouthwash – try Aloe concentrate
Try ice cream at room temperature and full fat Greek
style yogurt
Pasta with cream sauce may be easy to swallow
IDEAS TO IMPROVE APPETITE
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Eat small, easy to digest meals
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Avoid unpleasant odors
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Plan ahead and keep ready to drink products available
Prepare food in well ventilated areas
Ginger may be helpful in reducing nausea
Eat in a relaxed environment
Have food prepared in attractive and colorful way
Garnishes may be helpful like sprig of parsley or lemon
wedge for added color and eye appeal
Try umami flavors
FATIGUE MANAGEMENT
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Maintain a healthy weight Carrying around extra weight is tiring some body fat is pro-inflammatory (not helpful)
Regular physical activity can improve mood and fatigue levels.
Activity is also helpful for insomnia – try T’ai Chi or yoga, going to
the park or a museum
Regular mental stimulation helps brain function and minimizes
fatigue
Protein, iron, zinc, B vitamins and Vitamin C all important for red
cell production to minimize anemia
Eat dark chocolate or drink organic green tea as healthy sources
of stimulants some people are sensitive to caffeine and similar
stimulants – avoid after 3 PM
IF YOU HAVE CONSTIPATION
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Try prunes or prune juice
Try syrup of figs
Try adding rhubarb to your desserts as stewed or pie filling
Try some stewed pitted fruit/compote of peaches, plums,
apricots or cherries
Include wheat germ on top of breakfast cereal for added
insoluble fiber (the type that helps gut motility)
IF YOU HAVE DIARRHEA
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Try the BRAT diet (Bananas, rice, apple sauce and toast)
and include a fortified breakfast cereal like Cheerios
Try a liquid only diet for a day and then reintroduce some
baked potato or white rice
Avoid iceberg lettuce and other foods high in insoluble
fiber such as wheat germ or whole grain breads or crackers
Include soluble fiber such as oatmeal and apple
Make sure you are adequately hydrated – don’t avoid
sodium and have sufficient water
IF YOU ARE DEPRESSED
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Depression can be crippling – ask for help if you find
your mood is consistently preventing you from making
self supportive actions
Dark chocolate is often helpful as a mood lifter – try a
cup of hot cocoa or small square of 70% organic dark
chocolate
Surround yourself with love!
IF YOU HAVE INSOMNIA
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Make sure you have no caffeine or stimulants
(including dark chocolate or peppermint) after 3 pm
Take any green tea supplements before 3 pm unless
decaffeinated
Have light dinner at least three hours before lying
down to sleep – avoid cheese or meat in evening
Try half a banana before bedtime with small glass of
milk
Try a cup of chamomile or passionflower tea
HYDRATION; KEY TO HANDLING YOUR ENERGY LEVEL
During treatment dehydration can happen easily
 Fatigue is an early sign of dehydration. Check for
hydration status:
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color of urine should be light/straw
 press on back of hand – should bounce back quickly
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Make sure you have sufficient water and electrolytes
all through the day and night
 Don’t avoid sodium at this time (use sea salt to season
your food)
 Home made remedy: ½ teaspoon sugar, pinch salt in 1
cup water
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PARTICIPATE IN YOUR NUTRITIONAL HEALTH
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Keep a personal record of your nutrition related health
data with Your Personal Nutrition Health Check
Share your food preferences and supplement choices
with your health care team
Optimize your health by balancing the 3 A’s
o Antioxidants - Anti-inflammatories Anticarcinogens
Select food that is fresh, locally grown and organic
Maintain your resilience and energy with a consistent
intake of nutrient rich foods balanced with an active
lifestyle and regular sleep patterns
WHAT SHOULD I EAT?
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Some foods have more benefit than others - Identify and
select those you like often
Eat a variety of colorful vegetables, fruits and culinary
herbs as these are rich in the 3 A’s
The 3 A’s of good food
Antioxidants
o Anti-inflammatories
o Anticarcinogens
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Eat foods that support your immune system often
including berries, citrus and mushrooms
FOOD SAFETY WHEN WHITE COUNT IS LOW
If your WBC is low food safety is especially important
 Key points: Clean, Separate, Cook, Chill
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Wash your hands with warm water and soap before
handling food. Use paper towels for kitchen clean up
Rinse fresh produce under running water; rub or clean with
a vegetable brush while rinsing with running tap water
Avoid cross contamination of raw and cooked meat,
poultry, eggs or seafood. Always start with a clean scene
and wash all preparing surfaces and utensils with hot,
soapy water. Never place cooked food on a plate that
previously held raw (or marinaded) meat, poultry, fish
Cook to proper internal temperature. Use thermometer
Chill and refrigerate promptly
Keep cold food cold and hot food hot
Source: www.foodsafety.gov
WHAT ARE THE THREE A’S?
YOUR DNA INTEGRITY PROTECTORS
Antioxidants reduce oxidation at the cellular level from
metabolic or external radiation causes
o Anti-inflammatories reduce inflammation (redness,
heat, swelling) often prevent metabolic “mistakes” that
may lead to cancer
o Anticarcinogens reduce the overall risk of developing
cancer
Dysplasia is the result of mutated or altered function of DNA
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1. ANTIOXIDANT NUTRIENTS
Antioxidants prevent free radical formation which, if
unchecked, causes damage to DNA. Also important in
switching genes “on” and “off”
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Many are phytonutrients (plant chemicals) that are colored, often
dark pigmented and aromatic
Important for brain, retina and nervous system health
Coenzyme Q10 in fish, eggs, spinach, broccoli, wheat germ
Vitamin E (a fat soluble antioxidant) in whole grains, nuts and
seeds, wheat germ and avocado
Vitamin C (water soluble) antioxidants in fruits and vegetables;
berries, bell peppers, citrus and kiwi fruit especially good sources
Cocoa, avocado, nuts (walnuts) , tea rich in polyphenols
2. ANTI-INFLAMMATORY FOODS
Anti-inflammatories prevent elevated rates of cell
division which may increase “mistakes”. Cells in the
resting stage have more time to be “corrected” as DNA
repair takes place preventing chronic illnesses
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Omega 3 fatty acids (EPA and DHA)
Flaxseed, borage and blackcurrant seed oils beneficial fatty
acids (GLA and ALA)
Natural salicylate rich foods e.g. turmeric, rosemary, thyme,
apricots, broccoli
Naturally occurring COX-Inhibitors in green tea, cocoa and
red wine
3. ANTICARCINOGENS
Anticarcinogens prevent DNA damage and allow
time for DNA repair or apoptosis
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Curry powder ( a combination of turmeric, cumin and other
spices)
Citrus fruits (naringinin and limonene)
Green tea (EGCG and other natural bioactives)
Pomegranates (especially the oil from the seeds)
Brazil nuts (excellent source of selenium)
Tomatoes (excellent source of lycopene)
Saffron, turmeric and other yellow/brown spices
HEALTH MAINTENANCE
Preventive maintenance is an active state where you
participate with your health care team to:
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Manage fatigue
Eat regular meals including breakfast
Get sufficient protein
Make sure you are adequately hydrated
Manage stress
Have adequate rest – 6-8 hours sleep at night
CARBOHYDRATES: SUGAR AND STARCH
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Sugar (glucose and fructose) also forms starch as long chains. Refined
grains (white flour, corn flour, etc.) are digested similarly to sugar –
whole grains slow down absorption and maintain more even energy
level
High fructose corn syrup, HFCS – sweeter than sugar with slightly
more fructose than table sugar. Used in sodas and many other food
products. HFCS is a recent addition to our diets – not helpful for
healthy insulin levels and contributes to obesity
Smart choice is to restrict sugars to <30 g per day
GLYCEMIC LOAD AND DIETARY FIBER
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Good carbs! These are whole grain sources of starch from plants that
are not fully digested but promote colon health
Dietary fiber improves the Glycemic Load of a meal and helps maintain
healthy and steady blood glucose levels
Dietary fiber promotes health colon environment – supports “friendly
bacteria” such as Bifidus and Lactobacillus
Probiotic supplements or Greek style yogurt provides live culture or
probiotics. Probiotics need dietary fiber (also called prebiotics) to thrive
Acceptable Intake (AI) for dietary fiber is 38 grams for men; 25 grams for
women
DIETARY FIBER RICH FOODS
FOOD TYPE
FIBER (gram)
1 oz whole grain cereals
2 cups dried beans
2 cups prunes, stewed
1/4 cup dried apricots
Corn, 1 ear 5" long
2 cups spinach
1/4 cup wheat germ
1/4 cup almonds
3 cups popcorn, air popped
2 cup berries
4 - 13
8 - 11
8
6
6
6
6
5
5
5
FOODS TO PURCHASE ORGANIC
“THE DIRTY DOZEN”
Apples
Celery
Cherry tomatoes
Cucumbers
Grapes
Hot peppers
Nectarines (imported)
Peaches
Potatoes
Spinach
Strawberries
Sweet bell peppers
Kale/collard greens
Summer squash
Source:
Environmental Working Group
www.ewg.org
PUTTING IT ALL TOGETHER
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Avoid mega-doses or > 100% RDA of any nutritional
supplement (unless specifically prescribed by your
physician or oncologist)
Be cautious with herbals (botanicals or bioactives).
Some may affect liver enzyme pathways (by either
reducing therapeutic dose or increasing toxicity)
Choose nutrient dense foods rather than take
supplements and remember to tell your health team
about EVERYTHING you take
SOME BOTANICALS ARE NOT RECOMMENDED
Some herbs and botanicals may interfere with liver
clearance of some medications commonly used with
MDS. Check with your pharmacist and possibly avoid:

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Ginseng (Panax spp)
St. John’s wort
Garlic
Ginkgo-biloba
Astragalus
Grapefruits and grapefruit juice
Limes and lime juice
Bitter orange (Seville)
Noni
Starflower
WHICH SUPPLEMENTS MAY BE HELPFUL?
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Protein
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Prebiotics
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Mushroom polysaccharides (AHCC, PSK or PSP)
Dietary fiber

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Whey, rice, pea
Citrus pectin, oat, wheat germ
Digestive enzymes

Bromelain, papain, lactase
PERSONALIZED recommendations essential - all of which
should be shared with entire health care team
SUPPLEMENT RESOURCES

Food and Drug Administration (FDA)
www.fda.gov or Tweet @US_FDA
 Report an adverse reaction 1-800-FDA-1088 or file
 FDA 3500 Voluntary Adverse Event Report Form on line


NIH Office of Dietary Supplements


www.ods.nih.gov or Tweet @NIH_ODS
Federal Trade Commission (FTC)
www.consumer.ftc.gov
 Dietary Supplement Consumer Information
 Cancer Treatment Scams information


National Cancer Institute


www.nci.gov or Tweet @theNCI
Consumer Lab (CL)
www.consumerlab.com
 Independent lab testing dietary supplements

WHERE TO LOOK FOR HELP

Seek professional advice from an experienced
nutrition specialist to assist you

Contact www.eatright.org for a Registered Dietitian
or www.cbns.org for a Certified Nutrition Specialist
or www.aanp.org for a Nurse Practitioner
HEALTHY FOOD CHOICES
– NUTRITION TO THRIVE
Choose fish at least 3 times a week
 For omega-3’s and for protein
 Choose fruit for breakfast, dessert and snacks
 For bioactive botanicals
 Choose 2 or more vegetables for lunch and dinner
 Especially from garlic and cabbage families
 Cook often with herbs, curry and spices
 Think of food as sustenance – make healthy food
your friend not a dietary restriction

MIRACLES
There are only two ways to live your life. One is as
though nothing is a miracle. The other is as
though everything is a miracle
Albert Einstein (1879-1955)
THANK YOU
Carolyn Katzin, MS, CNS, MNT
ckatzin@mednet.ucla.edu
Call 310.794.6644 for an appointment to personalize your health
recommendations with Carolyn
at UCLA Simms/Mann Center for Integrative Oncology
www.simmsmanncenter.ucla.edu