D
N
M AKING H EALTHY C HOICES A FTER B REAST C ANCER
Karen Marr MS, RD, LDN, CSO
Lead Dietitian-Eastern Regional Medical
Center
Cancer Treatment Centers of America
Philadelphia, PA

O VERVIEW

Body Weight


Macronutrient Needs
Physical Activity

Alcohol

Bone Health & Vitamin D

To Soy or Not to Soy

AICR R EPORT

Weight gain, excess body weight, obesity

Physical activity

Alcohol

AICR R ECOMMENDATIONS






Be as lean as possible within the normal range of body weight
Lower end of normal BMI
Avoid weight gain & increases in waist circumference in adulthood
Limit consumption of energy dense foods & avoid sugary drinks
Eat mostly foods of plant origin
Limit intake of red meat & avoid processed meats

H OW MUCH ACTIVITY ?

45 to 60 minutes 5 or more days a week

A LCOHOL & FOLATE

Alcohol increases risk 11%

Risk doubles if inadequate folate intake

M ACRONUTRIENT N EEDS

Calories


25-35 kcal/ kg bw if BMI between 18.5-24.9
20-25 kcal/ kg bw if BMI btween 25-29.9


15-20 kcal/ kg bw if BMI between 30-35
15 kcal/kg bw if BMI >35

Protein


.8-1.0 gm/ kg bw
1.0-1.2 gm/ kg bw during treatment

Carbohydrates

50-65% of daily total calories

Fat

<30% of total calories should come from fat (<10% from saturated fat)

N
D
& A
T



Prevent weight gain & perhaps start weight loss
Address bone health
Other common questions

A
W
G
/E
W
L

Weight gain may increase risk of recurrence

In a study of 300 postmenopausal survivors on adjuvant AI therapy for an average of 23 months
- Weight gain of ≥ 10# since dx. 2x more likely to have hot flashes
- Weight gain & hot flash severity

T RIALS E VALUATING D IET C HANGES

WHEL study
- RCT in 3088 women to increase vegetable
(carotenoid) & decrease fat intake followed for 7 yrs.
- No reduction in recurrence or mortality
- High fiber intake decreases VMS
- Chemotherapy associated with wt gain
- Only 10% returned to pre-diagnosis wt.

T RIALS E VALUATING D IET C HANGES

WINS
- RCT with 2,437 postmenopausal women with early stage breast cancer
- Low-fat arm had a 24%↓ in risk for recurrence
- Greater reduction in ER- cancer

S TRATEGIES FOR W EIGHT L OSS

Raise Awareness
According to a survey by AICR in 2009:
- 94% respondents aware of link w/tobacco
- 87% aware of link with sun
- 51% aware of link with obesity

S TRATEGIES FOR W EIGHT L OSS



WHEL study demonstrated phone counseling effective
NIH endorses incorporating diet, physical activity, & behavior therapy
Knowing and understanding macronutrient needs

S TRATEGIES FOR W EIGHT L OSS

RENEW Trial – RCT 641 survivors received phone counseling on diet, exercise, & wt. loss

- 2.06 kg wt loss vs 0.92 kg over 12 mos.

V ITAMIN D





Prevents excessive cell proliferation & differentiation
Induces apoptosis
Prevents angiogenesis
Initiates immune response through macrophages
Mediates osteoporosis risk for survivors of breast
& prostate cancer through serum calcium/phosphorus balance

C
P
I

Mild to Moderate Deficiency: asymptomatic or nonspecific musculoskeletal pain

Severe Deficiency: deep bone pain, muscle pain, hip pain, weakness, fractures, falls, difficulty getting out of a chair or walking up stairs

R ECOMMENDATIONS FOR “D” I NTAKE

DRI 2010 years
600IU ages 19-50
600IU ages 51-70 years
800IU ages >70 years

Anywhere from 60-80% of the population, including breast cancer survivors have been shown to have inadequate or deficient levels.
Have levels checked.

S OURCES OF V ITAMIN D
Source
Cod Liver Oil
Swordfish, cooked
Salmon, cooked
Serving
1 tbsp
3 oz
3 oz
Tuna fish, canned in water
3 oz
Orange Juice, fortified 8 oz
Amount of IU’s
1,360
566
447
154
137
Milk, vitamin d fortified 8 oz
Sardines, canned in oil 2 sardines
Egg
Fortified cereals
1 large
¾- 1 cup
115-124
46
41
40







C ALCIUM
1 cup milk, yogurt, or calcium fortified beverages = 300 mgs
1 ounce cheese = 200 mgs
½ cup greens = 75-179 mgs
5 dried figs = 200 mgs
1 tbsp flaxseed (10gm) = 25 mgs
3 oz canned salmon w/bones = 200 mgs

Supplement accordingly to meet DRI

C ALCIUM

DRIs for calcium for females:
Age 9 – 18 = 1100 mgs
Age 19 – 50 = 800 mgs
Age 51+ = 1000 mgs

F LAXSEED




Meta-analysis in 2009 found no effect on overall breast cancer risk, but 15% lower risk in postmenopausal women.
5-40 gms may or may not reduce serum estrone and estradiol
5-25 gms shows a shift to weaker form of estrogen.
Interactions with other meds

T O S OY OR N OT TO S OY ?

Factors to consider:
1.
2.
3.
5.
Form & Food Source
Timing of exposure
Equol producer status
Hormone profile

T O S OY OR N OT TO S OY ?

May be okay in amounts similar to typical Asian diet in the form of tofu, soymilk, etc.

Avoid high dose isoflavone supplements

T O S OY OR N OT TO S OY ?

Shanghai Breast Cancer Survival Study of 5042 breast cancer survivors:
- 32% ↓risk for recurrence in highest quartile
- 11 g/d or 40 mg isoflavone/d
- No difference in ER+ or ER- cancers

S UMMARY



Strive to achieve & maintain an ideal body weight with integrative approaches
Move and Move often
Have your Vitamin D level checked & corrected if necessary


Consume adequate calcium with diet/supplements
Flax & Soy with caution

N UTRITION R ESOURCES
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 www.aicr.org
www.cancercenter.com
www.plwc.org
www.CancerRD.com
www.healthy.net/index.html
www.consumerlabs.com
www.eatright.org
www.cancernutrititioninfo.co
m
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
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 www.nutritionu.com
www.cancer.org
www.herbalgram.org
www.ncbi.nlm.nih.gov/pubme d www.onhealth.com
www.usda.gov
www.cancerRD.com

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R EFERENCES
World Cancer Research Fund/American Institute for Cancer Research. Food,
Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective.
Washington DC: AICR, 2007. pp289-295.
Kushi LH, et al. American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Prevention: Reducing the Risk of Cancer With Healthy Food
Choices and Physical Activity. CA Cancer J Clin 2006; 56:254-281.
Doyle C, et al. Nutrition and Physical Activity During and After Cancer
Treatment: An American Cancer Society Guide for Informed Choices. CA Cancer
J Clin 2006; 56:323-353.
Su HI, et al. Weight gain is associated with increased risk of hot flashes in breast cancer survivors on aromatase inhibitors. Breast Cancer Res Treat. 2010 Feb 25
[Epub ahead of print]
Saquib N, et al. Weight Gain and recovery of pre-cancer weight after breast cancer treatments: evidence from the women’s healthy eating and living (WHEL) study. Breast Cancer Res Treat. 2007 Octl105(2):177-86.
Pierce JP, et al. Influence of diet very high in vegetables, fruit, and fiber and low in fat on prognosis following treatment for breast cancer: the Women’s Healthy
Eating and Living (WHEL) randomized trial. JAMA 2007 Jul 18;298(3):289-98.
Gold EB, et al. Dietary factors and vasomotor symptoms in breast cancer survivors: the WHEL study. Menopause 2006 May-Jun;13(3):423-33.
Pierce, JP, et al. A randomized trial of the effect of a plant-based dietary pattern on additional breast cancer events and survival: the Women’s Healthy Eating and Living (WHEL) study. Control Clin Trials 2002 Dec;23(6):728-56.

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12.
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R EFERENCES
Chlebowski RT, Blackburn GL, Elashoff RE, et al. Dietary fat reduction in postmenopausal women with breast cancer: Phase III Women’s Intervention
Nutrition Study (WINS) (Abstract). 2005 ASCO Annual Meeting Proceedings. J
Clin Oncol 2005;23:10. Abstract 10.
Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003; 78( 12):
1463-70
Pfeifer M, Begerow B, MinneH W. Vitamin D and muscle function. Osteoporos Int
2002; 13( 3): 187-94
Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence?
Br J Nutr. 2003;89:552-572.
Whiting SJ, Calvo MS, Dietary recommendations for vitamin D: a critical need for functional end points to establish an estimated average requirement. J Nutr.
2005;2:304-309.
Nagata C. Factors to consider in the association between soy isoflavone intake and breast cancer risk. J Epidemiol 2010(2):83-9.
Messina MJ. Loprinski CL. Soy food for breast cancer survivors: a critical review of the literature. J Nutr 2001 (Suppl):3095S-3108S
Xiao Ou Shu, et al. Soy Food Intake and Breast Cancer Survival. JAMA
2009;302(22):2437-2443.
Pennington JAT. Bowes & Church’s Food Values of Portions Commonly Used –
17th edition. Philadelphia, PA:Lippincott-Raven;1998.

For more information please visit cancercenter.com or
1-800-333-CTCA