The Well Being of Breast Cancer PatientCan Nutrition Help? by Nilly Shams

The Well Being of Breast Cancer Patient
Can Nutrition Help?
Nilly Shams
Public Health and Nutrition Specialist
Certified Health Coach, Institute of Integrative Nutrition, USA
President of Egyptian Nutrition and Health Coaching Association, ENHCA
Alexandria Regional Center, 29th of October, 2018

Lets Start with a Quiz!!!
The Alkaline Diet can prevent or help treat cancer.
A. True
B. Myth
C. Unsure –more evidence needed

Does Sugar Feeds Cancer?
A. True
B. Myth

Can we use Ketogenic Diet in Cancer Care?
A. True
B. Myth
C. Unsure –more evidence needed

Do you think nutrition is important for cancer patient?
A. True
B. Myth
 if true, share your experience please???
Why would you care???

Talk Outline
 Good nutrition is important for cancer patients.
 Understanding Malnutrition and Cancer, why should we care?
 Anorexia and cachexia.
 Nutrition and breast cancer management.
 Diet and Lifestyle in Women with Breast Cancer: is their a link?
 Breast cancer and diet/physical activity.
 Dietary intake and breast cancer chemoprevention.

Talk Outline
 Special Diets for Breast Cancer, do they wok?
 Support with nutrition for women receiving chemotherapy for
breast cancer.
 Can Nutrition Lower the Risk of Recurrence in Breast Cancer?
 Nutrition Goals of prevention and treating cancer.
 Side Effects of Cancer and Cancer Treatment, How to Deal with?
 If it is that simple so why it does not work??
 Take Home Messages.

Good nutrition is important for cancer patients
• Nutrition is a process in which food is taken in and used by the body for
growth, to keep the body healthy, and to replace tissue.
• Good nutrition is important for good health.
• Eating the right kinds of foods before, during, and after cancer treatment
can help the patient feel better and stay stronger.

Good nutrition is important for cancer patients
• A healthy diet includes eating and drinking enough of the foods and
liquids that have the important nutrients (vitamins, minerals, protein,
carbohydrates, fat, and water) the body needs.
• When the body does not get or cannot absorb the nutrients needed for
health, it causes a condition called malnutrition or malnourishment.

Eur J Oncol Nurs. 2005
Nutrition and breast cancer management
Not limited only to breast cancer, malnutrition is frequently manifested in cancer
patients, even at the time of diagnosis.
Its incidence varies between 31% and 87%, depending on:
• Stage
• Type
• Treatment

Understanding Malnutrition and Cancer
eating less energy and protein than the amount the body needs
elevated energy requirements
impaired absorption of nutrients
unplanned weight loss, (Wasting Syndrome)
reduction in body fat and muscle
What is malnutrition?
Compared to the rest of the population, people with cancer are at a
higher risk of malnutrition.

malnutrition can affect how body responds to cancer treatment and recovery.

So It is important to prevent malnutrition or identify it early

In cancer patients, undernutrition may be due to:
1- Inflammation and catabolism
result in muscle wasting and weight loss
2- Dysphagia, pain, and vomiting
impair food intake and absorption
J Cachexia Sarcopenia Muscle. 2011

3- The side effects of anticancer treatment
anorexia, nausea, vomiting, oral and intestinal mucositis with dysphagia,
diarrhea, hemorrhoids, anal fissures, and modifications in smell and taste
affect the total energy intake
affect the nutrient absorption
compromising nutritional status

4- the poor psychological state of cancer patients
can affect their energy intake
NJ: pp. 769–789; 2013

Weight loss in cancer is associated with
• Poor prognosis
• Poor quality of life
• Lower activity level
• Increased treatment-related adverse symptoms
• Reduced tumor response to therapy

Weight loss at diagnosis
Shorter failure free and overall survival (OS)
(identified as an independent prognostic factor)
Clin Nutr. 2006
when patients stop losing weight they have better OS

Signs of risk of malnutrition

(2008) Nutritional status of cancer patients in chemotherapy

Screening and assessment
 Screening is used to look for nutrition risks in a patient who has no symptoms.
 Screening and assessment may include questions about the following:
• Weight changes over the past year.
• Changes in the amount and type of food eaten compared to what is usual for the
patient.
• Problems that have affected eating, such as loss of appetite
• Ability to walk and do other activities of daily living (dressing and using the toilet).

Anorexia and Cachexia
 Anorexia and cachexia are common causes of malnutrition in cancer patients.
Anorexia
(the loss of appetite or desire to eat)
• may occur early in the disease or later, if the cancer grows or spreads.
• Anorexia is the most common cause of malnutrition in cancer patients.

Anorexia and Cachexia
 Anorexia and cachexia are common causes of malnutrition in cancer patients.
Cachexia
• It is important to watch for and treat cachexia early in cancer treatment
because it is hard to correct.
• marked by loss of appetite, weight loss, muscle loss, general weakness.
Cancer patients may have anorexia and cachexia at the same time.

Treatment of Anorexia
• Eating in a calm, comfortable place and getting regular exercise may improve
appetite.
• Eat small high-protein and high-calorie meals every 1-2 hours instead of three
large meals.

High-Calorie, High-Protein Food Choices
• Cheese and crackers.
• Muffins.
• Puddings.
• Nutritional supplements.
• Milkshakes.
• Yogurt.
• Ice cream.
• Powdered milk added to foods such as pudding,
milkshakes, or any recipe using milk.
• cream cheese or peanut butter on crackers or celery.
• Chocolate.

• Cheese and crackers.
• Muffins.
• Puddings.
• Nutritional supplements.
• Milkshakes.
• Yogurt.
• Ice cream.
• Powdered milk added to foods such as pudding,
milkshakes, or any recipe using milk.
• cream cheese or peanut butter on crackers or celery.
• Chocolate????

• Add extra calories and protein to food by using
- butter,
- skim milk powder,
- Honey??
- Brown sugar??
• Drink liquid supplements (special drinks that
have nutrients), soups, milk, juices, shakes, and
smoothies, if eating solid food is a problem.
• Eat breakfasts that have one third of the calories
and protein needed for the day.
• Eat foods that smell good.

• Strong odors can be avoided in the following ways:
 Use boiling bags or microwave steaming bags.
 Cook outdoors on the grill.
 Use a kitchen fan when cooking.
 Serve cold food instead of hot (since odors are in the rising
steam).
 Take off any food covers to release the odors before going
into a patient's room.
 Use a small fan to blow food odors away from patients.
Treatment of Anorexia

BioResearch. Volume 7.1, 2018
Nutrition and breast cancer management
Furthermore, scientific observations support the idea that dietary supplement
can prevent breast cancer recurrences.
Diet and nutritional status
Important factors in the etiology of breast cancer
Major determinants of prognosis and treatment outcome in breast cancer patients.

Diet and Lifestyle in Women with Breast Cancer:
is their a link?
The findings from the collaborative analysis of data that were collected from a total of
47 epidemiological studies conducted in 30 countries have contributed tremendously
to shed light on factors that are associated with breast cancer.

Breast cancer is the most common malignancy among Arab women in
Eastern Mediterranean Region (EMR).
is their a link?

It is well documented that the risk factors for breast cancer are mainly related to
hormones through their influence on growth of the mammary glands.
is their a link?

is their a link?

In this review, literature for evidence to link the changes in lifestyle and dietary
choices (including obesity, low fruit and vegetable intake, low level of physical
activity, etc.) and the rise in incidence and mortality of breast cancer among women
in the Middles East was examined.
Conversely, the literature for dietary intake by women in this region of certain nutrients
that will have chemo preventive roles against breast cancer was examined
is their a link?

Considerable experimental evidence supports the potential role of
dietary habits and lifestyle in cancer etiology and cancer prevention.
is their a link?

Evidence was found to suggest that there is an alarming epidemic of
obesity among women in most of the EMR countries, especially Gulf
Cooperation Council (GCC) countries.
is their a link?

The rise in the new breast cancer cases among women could be attributed to
Excess body weight
Dietary pattern
Cancer
is their a link?

Although very few studies were found to support a direct causal relationship
between obesity and breast cancer in the EMR, circumstantial evidence
clearly points to the possible role of the epidemic, obesity, in this population
and the startling rise in cases of breast cancer.
is their a link?

J Carcinog. 2007;6:12.
incidence rate of breast cancer
biologically of a very aggressive type
(overexpression of Her-2 and lack of estrogen receptor expression)
Risk factors of breast cancer??
is their a link?

J Carcinog. 2007;6:12.
 This study also identified some of the risk factors of breast cancer among these
women:
• Early age at menarche
• Late age at first pregnancy
• Hormonal therapy
• High body mass index (BMI)
• Lack of regular exercise
• Frequent consumption of carbohydrate, sugar, animal fat, and hydrogenated
vegetable oil (margarine)
• Low intake of fresh vegetables and olive oil
is their a link?

Features of breast cancer in developing countries, examples from North-Africa. Eur J Cancer. 2014
 In a study comparing breast cancer picture in North African countries, including
Egypt to that in Western countries, the results showed that epidemiological features
of breast cancer were different.
That difference was related to combined factors:
• emerging reproductive behaviors, such as declining in number of children, the
increased age at first pregnancy, and shorter duration of breastfeeding.
the rapid change in the lifestyle & diet
North African countries have higher proportion of young patients
is their a link?

World Health Organization. Cancer fact sheet N 297. 2017.
Agency for Research on Cancer: Lyon, 2014.
J Natl Cancer Inst.1998.
Breast cancer and diet/physical activity
one-third of the breast cancer cases could be prevented by lifestyle intervention
through reducing alcohol intake, increasing the fruit, vegetables, and vegetable
oil intake in the diet, and increasing physical activity level.
 approximately one third of deaths from cancer are
attributed to five leading lifestyle and dietary choices:
• high BMI.
• low fruit and vegetable intake.
• low level of physical activity.
• tobacco, and alcohol consumption.

Int J Gen Med. 2012;5:199–217.
 With the sudden transition and the rapid change in the economy, Eastern
Mediterranean (Middle Eastern) people change their traditional diet to:
• a more westernized diet that has high energy and fat-rich food intake.
• adopted eating out habits.
• an increase in food portion sizes

Asia Pac J Clin Nutr. 2003;12:337–343.
 With the sudden transition and the rapid change in the economy, Eastern
Mediterranean (Middle Eastern) people change their traditional diet to:
• a more westernized diet that has high energy and fat-rich food intake.
• adopted eating out habits.
• an increase in food portion sizes

Lancet Oncol. 2015
 An increase of 4980 (2%) of new cancer cases among adult men and 17,018 (7%)
among adult women in the region were attributed to excess body weight.
Dietary pattern, which correlates with obesity, can be an important
cause of cancer, and lack of physical activity can also contribute to
postmenopausal breast cancer.

J Natl Cancer Inst.1998.
Dietary intake and breast cancer chemoprevention
Dietary B-carotene and vitamin E
In general, dietary intake of certain nutrients can play major roles in modifying
breast cancer risk.
 Diet rich in B-carotene and vitamin E, such as fruits, vegetables, and vegetable oil,
is considered protective against breast cancer risk.
Vitamin E is an antioxidant that was shown to decrease the number of carcinogen
induced mammary tumors in laboratory animals.
B-carotene and vitamin E are considered the strongest protective factors among
numerous micronutrients.

Breast Care 2018
Soy
breast cancer risk.
 A recent review examined the association between soy intake and breast cancer
and concluded that the available data from human studies – concerning risk and
prognosis – are too inconsistent for a clear statement.
There is limited evidence for a negative correlation of soy/soy products with all-
cause mortality in breast cancer patients.

Breast Care 2018
Soy
breast cancer risk.
In total, there is no general recommendation of a soy-rich nutrition for breast cancer
survivors, but occasional intake seems to be acceptable, Supplement intake is clearly
not recommended.

Nutr Cancer. 2013;65:178–187.
J Natl Cancer Inst. 2002;94:1301–1311.
Vitamin D and calcium intake
breast cancer risk.
 However, a case–control study in Saudi women showed that there is an inverse
association between serum 25(OH)D concentrations and breast cancer risk.
Several studies suggested that there was no association between vitamin D and
calcium intake and breast cancer risk

Nutrients. 2016
Dietary fat and protein intake
breast cancer risk.
 A prospective cohort study among women showed that high consumption of
red meat during adolescence was associated with premenopausal breast cancer.
An association was found between protein intake and
breast cancer risk, as the high intake of red meat, fresh and processed,
increases the risk of breast cancer, whereas the high intake of soy food and
skim milk reduces the risk.

Int J Cancer. 2015
breast cancer risk.
 Whereas, replacing red meat with other dietary protein sources in adolescence
could decrease the potential risk of premenopausal breast cancer.
An association was found between protein intake and
breast cancer risk, as the high intake of red meat, fresh and processed,
increases the risk of breast cancer, whereas the high intake of soy food and
skim milk reduces the risk.

Am J Clin Nutr. 2008
breast cancer risk.
On the other hand, some studies pointed out that there is a weak positive
association between saturated fat intake and breast cancer risk, especially
among postmenopausal women who never used hormone therapy.

Epidemiol Rev. 1993
breast cancer risk.
In general, there are rather inconsistent reports on the association between
fat intake and breast cancer.
Saturated fat total &
polyunsaturated fat

An 8-year follow-up. JAMA. 1992
breast cancer risk.
 Results from the nurses study which compared nurses who consumed
low-fat diets with nurses who consumed high-fat diets
No relationship existed between the amount of fat consumed and the
risk of breast cancer

Nature.1989
breast cancer risk.
 The Willett’s review of epidemiological studies of the relationship between diet
and breast and colon cancers suggested that
there was a null or weak association between dietary fat and breast cancer

East Mediterr Health J. 2004
breast cancer risk.
 With regard to Arab women, a case–control study investigating the association
between dietary fat and breast cancer in Saudi women
Significant positive association between the intake of fats,
protein, and calories and risk of breast cancer.

East Mediterr Health J. 2004
breast cancer risk.
 In comparison, dietary patterns and its association to breast cancer have been
investigated in several studies in the west.
Plant based diets, including fruits and vegetables were associated
with a reduction in breast cancer risk as compared with food rich in fat
and meat.

J Prev Med Public Health. 2015
breast cancer risk.
Plant based diets, including fruits and vegetables were associated
with a reduction in breast cancer risk as compared with food rich in fat
and meat.
Fibers + Estrogen Estrogen Excretion

World J Clin Oncol. 2014
Phytoestrogen compounds and breast cancer
breast cancer risk.
 Phytoestrogens, natural compounds that share chemical structure similar to
estrogens are found mainly in plants such as soy beans, red and yellow fruits and
vegetables, flaxseeds, and whole grains.
Several classes of phytoestrogens exist (isoflavones, stilbenes, coumestans, lignans).
Resveratrol, daidzein, quercetin, and genistein represent four of the most commonly
ingested and most widely studied phytoestrogens.

Nutr Clin Pract. 2012
breast cancer risk.
Epidemiological studies provided evidence that phytoestrogens have an effect
in reducing the incidence of breast cancer, especially among Asians who have high
dietary intake of isoflavonoids through their daily diet.
There is a notion that dietary and lifestyle factors may be partially responsible for
the low breast cancer risks detected in Asian women.

breast cancer risk.
Epidemiological studies provided evidence that phytoestrogens have an effect
in reducing the incidence of breast cancer, especially among Asians who have high
dietary intake of isoflavonoids through their daily diet.
Asian women who immigrate to Western countries
The second- and third-generation descendants of women have breast cancer risks
similar to those of women in the host country

breast cancer risk.
A review of 21 case–control and 15 prospective studies concluded that there is no
clear evidence that phytoestrogen intake influences the risk of developing
breast cancer
Suggesting that lifestyle and not genetic factors explains the low breast cancer risk of
women in Asia

Ann N Y Acad Sci. 2004
Mediterranean diet and chemopreventive role of breast cancer
breast cancer risk.
The dietary consumption of fruit, vegetables, grains, legumes, olive oil provide high
levels of different polyphenols and plant bioactive compounds that can serve as
antioxidants, anti-inflammatory, and antitumor

Ann N Y Acad Sci. 2004
breast cancer risk.
Mounting evidence points to the beneficial and preventive role of the
Mediterranean diet (MD) in the onset of cancer and other diseases associated with
increased level of inflammation, oxidative damage, and angiogenesis.

Int J Cancer. 2014
breast cancer risk.
A recent meta-analysis of all the observational studies regarding
the adherence to the MD in relation to cancer risk showed that the MD is
associated with a significant reduction of overall risk of cancer incidence and
mortality by 10%.
meta-analysis by Schwingshackl and Hoffmann did not confirm an effect of the MD on the
risk of breast cancer; however, a subgroup of case control study showed that the risk of
breast cancer could be reduced by 18% in women adhering to the MD.

Eur J Nutr. 2015
breast cancer risk.
Chemoprotective effect of the MD against breast cancer seemed to depend on
individual’s characteristics and potential risk factors:
• Smoking
• Age at menarche,and menopausal status.
• Obesity
• Physical activity

Eur J Nutr. 2015
breast cancer risk.
Notably, the beneficial effect of the MD on breast cancer risk is observed only in normal
weight, nonsmoking women and in women who did not present an early menarche
(<12 years of age).

Special Diets for Breast Cancer, do they work?
cancer-research-update/2018
the American Heart Association issued a scientific statement highlighting that
breast cancer survivors, especially older women, are more likely to die from
cardiovascular diseases such as heart failure rather than breast cancer.
 Breast cancer survivors face a heightened risk for heart disease.
 Research points to chronic inflammation playing a key role in heightening the
risk of many cancers, along with heart disease.
Anti-inflammatory Diet

Some breast cancer therapies can damage the heart, underscoring the
importance of effectively managing heart disease risk factors during and
following cancer treatment

A study suggests that postmenopausal breast cancer survivors who consume an anti-
inflammatory diet after diagnosis, filled with whole grains, fish, and vegetables, have a
lower risk of dying from cardiovascular disease compared to survivors eating a
proinflammatory diet.

JAMA, July 17 2002.
Women's Health Initiative (WHI) randomized clinical trial, showed a preliminary
association between better overall survival and low-fat diet following a breast
cancer diagnosis.
A low-fat diet
The WHI trial then investigated 48,835 postmenopausal women who enrolled in
the study between 1993 and 1998. At the time, however, the trial did not offer
insights as to whether the improved outlook was due to the eating habits that
the women had before developing breast cancer.

there was the possibility that a low-fat diet improved other health outcomes
that are unrelated to breast cancer. Therefore, the longer lifespans could have
been due to these other outcomes.
A low-fat diet
JAMA, July 17 2002.

A low-fat diet
JAMA, July 17 2002.
 The researchers examined 19,541 women diagnosed with breast cancer who
reduced their dietary fat intake by 20 percent and upped the amount of fruits
and vegetables that they consumed.
 The researchers also examined a control group of 29,294 breast cancer patients
who continued their usual diets.
 The dietary interventions lasted for 8.5 years, on average, while the analysis
carried out by the researchers took place 11.5 years after their diagnosis, on
average.

The study revealed that "breast cancer overall survival was significantly greater for
women in the dietary intervention group than in the usual-diet comparison group.
A low-fat diet
JAMA, July 17 2002.
In fact, the 10-year survival rate for the women who consumed less fat was 82
percent, compared with 78 percent in the control group.
Additionally, far fewer deaths were registered in the group that consumed less fat,
compared with the usual-diet group. Specifically, 120 women died in the control
group, compared with only 68 in the intervention group.

A low-fat diet
JAMA, July 17 2002.

Low-Carbohydrate Diet
Cancer Epidemiol Biomarkers Prev 2011
Asia Pac J Clin Nutr 2007
 An inverse correlation between the intake of carbohydrates and mortality from
breast cancer was found, possibly due to a lower fiber intake associated with a
low carbohydrate intake in a prospective study from Japan.
 No significant associations were found for carbohydrate intake, glycemic load or
glycemic index, and overall mortality as well as breast cancer-specific mortality
according to the Health, Eating, Activity, and Lifestyle (HEAL) study.
Although ‘low-carb’ und ‘ketogenic’ diets are popular as well as increasingly
promoted and offered to breast cancer survivors, we found no evidence supporting
this type of diet.

Low-Carbohydrate Diet
Asia Pac J Clin Nutr 2007
 How does this impact our patients?
 Misinformation can produce anxiety, fear and unnecessary weight loss or gain
and fatigue.
 Eliminating all sugars (simple and complex) can impair overall health in the form
of energy for activity, healing and disease-fighting nutrients.
 Avoiding natural sugars such as fructose, lactose can take out many key food
groups from diet, leaving little choice, taste and satisfaction.

Alkaline Diet
 Cancer cells thrive in an acidic environment. Eating an alkaline diet will
change the pH of cancer cells so cancer can’t survive???
Is this true??
 Our bodies are excellent at regulating pH within a very narrow range, any
change would be life threatening.
More research needed to determine the consequences of a foods potential renal acid
load (PRAL) on cancer risk/treatment.

Alkaline Diet
 Cancer cells thrive in an acidic environment. Eating an alkaline diet will
change the pH of your cells so cancer can’t survive???
Is this true??
“Alkaline Diet” excludes many high protein choices, not replaced, significant concern
for cancer patients.
Drinking alkaline water cannot change the pH of the whole body of blood.

Ketogenic Diet
 Pre-clinical and early clinical evidence that ketogenic diets can influence
cancer progression is promising.
 Ketogenic diets are safe and tolerable but require effort to implement and
maintain (medical & nutritional monitoring is highly recommended).
 Risk factors: Weight loss, micronutrient malnutrition, dehydration/electrolyte
imbalance.

Ketogenic Diet
 Pt’s need ++ education & training in order to safely implement.
 Clinician and dietitian’s need help to guide informed decision-making,
assist patients and educate the medical community.
More clinical research is needed (and is underway).

Very high fat diet, low carbohydrate and protein
(75-90%kcal/fat, 10-15%kcal/protein, 5-10%kcal/CHO) ,20-30g CHO/d
Body switches from burning glucose to burning fat for energy
Carbohydrate restriction and fasting promote ketosis or the formation of ketone bodies
Ketone bodies can be used as an alternative energy source for normal cells but not cancer cells.
Ketogenic Diet

Support with nutrition for women receiving chemotherapy
for breast cancer
British Journal of Nursing, 2018 (Oncology Supplement) Vol 27, No 4
This narrative review evaluated the research evidence relating to the nutritional
challenges experienced during chemotherapy and the most effective approaches for
supporting women in dietary choice.

for breast cancer
Influence of chemotherapy on taste, appetite and nutritional status
 Appetite decreases during chemotherapy.
 Diet quality is likely to change over the course of treatment.
e.g. women eating foods with low nutritional content, including diets low
in fruit and vegetables.
 weight loss result from lack of appetite & changes in taste and nausea.

for breast cancer
 A prospective study of 52 Australian women explored the effect of anthracycline
and/or taxane chemotherapy on taste, food likes/dislikes, appetite, nutritional
status and food intake.
Findings showed significant reductions in taste and appetite by cycle three (p=0.043),
although this had reversed 2 months after chemotherapy.
This study also reported a significant association between taste function and kilojoule
intake (p=0.008) and a significant association between reduced appetite and reduced
kilojoule and protein intake (p=0.002 and p=0.001 respectively).

for breast cancer
 A prospective study of 52 Australian women explored the effect of anthracycline
and/or taxane chemotherapy on taste, food likes/dislikes, appetite, nutritional
status and food intake.
Despite this, women are more likely to gain than lose weight during and after
chemotherapy

for breast cancer
Weight gain
was identified as a specific problem for women undergoing chemotherapy
Evidence indicates that, even before chemotherapy, women with breast cancer present
with unhealthy metabolic features in relation to blood lipids, body composition and diet
compared with women without breast cancer.
Chemotherapy, with women receiving cyclophosphamide, methotrexate and
fluorouracil exhibiting a steeper weight increase than in those receiving anthracycline
based chemotherapy.

for breast cancer
Weight gain
 Why???
 Lack of physical activity because of fatigue
 Changes to their usual diet as result of food cravings and comfort eating.
women described themselves as being in transition between their former well-known
body and a current strange and demanding body, caught in a dilemma where
medication that contributed to long-term survival also led to weight gain
and resultant self-blame

for breast cancer
Approaches to providing nutritional support
 Supporting women to manage their body weight.
 Making changes to their diet during and beyond treatment.
 The use of dietary supplements.
 Nutritional education programs.

for breast cancer
Dietary Supplement
 Agaricus sylvaticus (a type of mushroom).
Intervention group was:
• 80% less likely to experience nausea and vomiting
• 92.8% less likely to have problems with bowel function
• 20% less likely to have poor appetite

for breast cancer
Dietary Supplement
 Fish oil supplementation
Significantly improved respiratory function (P<0.05) and
significantly lower blood lactate concentration (P<0.05)
in women in the intervention group compared to
the control group who did not take the supplement.

for breast cancer
Effects of short-term fasting during chemotherapy
At 7 days after chemotherapy, erythrocyte and thrombocyte
counts were significantly higher in the intervention group who
had fasted for 24 before and following chemotherapy
(p=0.007 and p=0.00007 respectively).
Authors suggested that fasting reduced the destruction of healthy circulating cells, and
may reduce haematological toxicity by protecting CD3- and CD45+ cells from
chemotherapy-related damaged by chemotherapy

for breast cancer
The studies have small sample sizes, and often use poorly validated tools.
The evidence in studies of supplement use and fasting during chemotherapy is limited
by small sample groups.
No conclusions can, therefore, be drawn from this particular evidence review, and
further work with larger populations is required.
the studies do not focus on the gastrointestinal effects of chemotherapy nor the impact
of other medications given alongside chemotherapy, such as corticosteroids,
which are likely to contribute to weight gain.

Can Nutrition Lower the Risk of Recurrence in
Breast Cancer?
Breast Care 2018
A positive effect of the Mediterranean Diet was found for all-cause mortality
no beneficial effect from other diets such as low-carbohydrate, ketogenic or
vegetarian/vegan diets was observed.

Breast Cancer?
Breast Care 2018
Alcohol consumption was associated with an increased risk for breast
cancer recurrence.
No general recommendation for soy exists, but occasional
intake seems to be acceptable, whereas the use of other supplements is not justified.

Breast Cancer?
Breast Care 2018
Adherence to high-quality diets and a prudent/healthy dietary
pattern seem to be beneficial for breast cancer prognosis.
No clear evidence for a benefit from special diets, soy products, or
other supplements was found.

Healthcare Team of Nutrition Specialists
• A nutrition support team will check the patient's nutritional health often
during cancer treatment and recovery.
• The team may include the following specialists:
 Physician.
 Nurse.
 Registered dietitian.
 Social worker.
 Psychologist.

Cancer Prevention Dietary Guidelines
• Eat a plant-based diet with a large variety of fruits and vegetables.
• Eat foods low in fat.
• Eat foods low in salt.
• Get to and stay at a healthy weight.
• Be active for 30 minutes on most days of the week.
• Drink few alcoholic drinks or don't drink at all.
• Do not use tobacco in any form.
• Prepare and store food safely.
The American Cancer Society and the American Institute for Cancer Research

Cancer Prevention Recommendations
Breast Care 2018

Goals of Nutrition Therapy for Cancer Patients
in Active Treatment and Recovery

Side Effects of Cancer and Cancer Treatment
• Anorexia (loss of appetite).
• Mouth sores.
• Dry mouth.
• Trouble swallowing.
• Nausea.
• Vomiting.
• Diarrhea.
• Constipation.
• Pain.
• Depression.
• Anxiety.

Caused by
 radiation treatment
 dental problems
 mouth sores
 infections
 some medicines
 cancer patients who receive chemotherapy notice a bitter taste.
 A sudden dislike for certain foods may occur.
Taste Changes
This can cause a loss of appetite, weight loss, a decreased quality of life

 How to help cancer patients who have taste changes:
• Eat small meals and healthy snacks several times a day.
• Eat meals when hungry rather than at set mealtimes.
• Eat favorite foods and try new foods when feeling best.
• Eat poultry, fish, eggs, and cheese instead of red meat.
• Eat citrus fruits (oranges, tangerines, lemons, grapefruit) unless mouth sores
are present.
• Add spices and sauces to foods.
Taste Changes

• How to help cancer patients who have taste changes:
• Eat meat with something sweet, such as cranberry sauce, jelly, or applesauce.
• Find nonmeat, high-protein recipes
• Use sugar-free lemon drops, gum, or mints if there is a metallic or bitter taste in the
mouth.
• Rinse mouth with water before eating.
• Eat with family and friends.
• Have others prepare the meal.
• Use plastic utensils if foods have a metal taste.
Taste Changes

 Dry mouth is often caused by radiation therapy to the head and neck and by certain
medicines.
 Dry mouth may affect speech, taste, and the ability to swallow or to use dentures or
braces.
 There is also an increased risk of cavities and gum disease because less saliva is made
to wash the teeth and gums.
Dry Mouth

Other ways to help relieve dry mouth include the following:
 Keep water handy at all times to moisten the mouth.
 Eat moist foods with extra sauces, gravies, butter, or margarine.
 Eat foods and drinks that are very sweet or tart (to increase saliva).
 Eat ice chips or frozen desserts (such as frozen grapes and ice pops).
 Drink fruit nectar instead of juice.
 Suck on hard candy or chew gum.
 Use a straw to drink liquids.
 Clean teeth (including dentures) and rinse mouth at least four times a day (after
eating and at bedtime).
Dry Mouth
The main treatment for dry mouth is drinking plenty of liquids

 Mouth sores can be caused by chemotherapy and radiation therapy, these treatments
affect fast-growing cells, such as cancer cells.
 Normal cells inside the mouth also grow quickly and may be damaged by these cancer
treatments.
 Mouth sores can be painful and become infected or bleed and make it hard to eat.
 By choosing certain foods and taking good care of their mouths, patients can usually
make eating easier.
Mouth Sores and Infections

Eat soft foods that are easy to chew and swallow, such as the following:
• Soft fruits, including bananas, applesauce, and watermelon.
• Peach, pear, and apricot nectars.
• Cottage cheese.
• Mashed potatoes.
• Macaroni and cheese.
• Custards and puddings.
• Gelatin.
• Milkshakes.
• Scrambled eggs.
• Oatmeal or other cooked cereals.

 Stay away from the following:
• Citrus fruits and juices, (such as oranges, tangerines, lemons, and grapefruit).
• Spicy or salty foods.
• Rough, coarse, or dry foods, including raw vegetables, granola, toast, and crackers.

• Use a blender to make vegetables (such as potatoes, peas, and carrots) and meats
smooth.
• Add gravy, broth, or sauces to food.
• Drink high-calorie, high-protein drinks in addition to meals.
• Cook foods until soft and tender.
• Eat foods cold or at room temperature. Hot and warm foods can irritate a tender
mouth.

• Cut foods into small pieces.
• Use a straw to drink liquids.
• Numb the mouth with ice chips or flavored ice pops before eating.
• Clean teeth (including dentures) and rinse mouth at least four times a day
(after eating and at bedtime).

 Nausea caused by cancer treatment can affect the amount and kinds of food eaten.
How to control nausea
• Eat before cancer treatments.
• Rinse out the mouth before and after eating.
• Eat foods that are bland, soft, and easy-to-digest, rather than heavy meals.
• Eat small meals several times a day.
• Eat dry foods such as crackers, bread sticks, or toast throughout the day.
• Slowly sip fluids throughout the day.
• Suck on hard candies such as peppermints or lemon drops if the mouth has
a bad taste.
Nausea

 Nausea caused by cancer treatment can affect the amount and kinds of food eaten.
How to control nausea
• Stay away from foods that are likely to cause nausea.
(spicy foods, greasy foods, and foods that have strong odors).
• Sit up or lie with the upper body raised for one hour after eating.
• Don't eat in a room that has cooking odors or that is very warm.
• Keep the living space at a comfortable temperature with plenty of fresh air.
Nausea

 Diarrhea may be caused by cancer treatments, surgery on the stomach or intestines,
or by emotional stress.
 Long-term diarrhea may lead to dehydration (lack of water in the body) or
low levels of salt and potassium, which are important minerals needed by the body.
Diarrhea

 The following may help cancer patients control diarrhea:
• Eat broth, soups, bananas, and canned fruits to help replace salt and potassium
lost by diarrhea. Sports drinks can also help.
• Drink plenty of fluids during the day.
• Liquids at room temperature may cause fewer problems than hot or cold liquids.
• Drink at least one cup of liquid after each loose bowel movement.
Diarrhea

 Stay away from the following:
• Greasy foods, hot or cold liquids, or caffeine.
• High-fiber foods—especially dried beans and cruciferous vegetables
(such as broccoli, cauliflower, and cabbage).
• Milk and milk products, until the cause of the diarrhea is known.
• Foods and beverages that cause gas (such as peas, lentils, cruciferous vegetables,
chewing gum, and soda).
• Sugar-free candies or gum made with sorbitol (sugar alcohol).
Diarrhea

 A low white blood cell count may be caused by radiation therapy, chemotherapy,
or the cancer itself.
 Patients who have a low white blood cell count have an increased risk of infection.
Low White Blood Cell Counts and Infections

 Stay away from:
• Raw eggs or raw fish.
• Old, moldy, or damaged fruits and vegetables.
• Food sold in open bins or containers.
• Salad bars and buffets when eating out.

• Wash hands often to prevent the spread of bacteria.
• Thaw foods in the refrigerator or microwave. Never thaw foods at room temperature.
Cook foods immediately after thawing.
• Keep hot foods hot and cold foods cold.
• Cook all meat, poultry, and fish until well done.
• Refrigerate all leftovers within 2 hours of cooking and eat them within 24 hours.
• Buy foods packed as single servings, to avoid leftovers.
• Do not buy or eat food that is out of date.
• Do not buy or eat food in cans that are swollen, dented, or damaged.

 Nausea, vomiting, and pain may keep the patient from drinking and eating enough to
get the amount of water the body needs.
 One of the first signs of dehydration (lack of water in the body) is feeling very tired.
Dehydration (Lack of Fluid)

 The following may help cancer patients prevent dehydration:
• Drink 8 to 12 cups of liquids a day. This can be water, juice, milk, or foods that have a
lot of liquid in them, such as ice pops, flavored ices, and gelatins.
• Stay away from drinks that have caffeine in them, such as sodas, coffee, and tea
(both hot and cold).
• Take a water bottle whenever leaving home.
• It is important to drink even if not thirsty.
• Drink most liquids between meals.
• Use medicines that help prevent and treat nausea and vomiting.
Dehydration (Lack of Fluid)

 It is very common for cancer patients to have constipation (fewer than three bowel
movements a week).
 Constipation may be caused by the following:
• Too little water or fiber in the diet.
• Not being active.
• Cancer treatment, such as chemotherapy.
• Certain medicines used to treat the side effects of chemotherapy, such as nausea
and pain.
Constipation
Preventing and treating constipation is a part of cancer care

 To prevent constipation:
• Eat more fiber-containing foods.
• Twenty-five to 35 grams of fiber a day is best.
• Food labels show the amount of fiber in a serving.
• Add a little more fiber each day and drink plenty of fluids at the same time to keep
the fiber moving through the intestines.
• Drink 8 to 12 cups of fluid each day. Water, prune juice, warm juices, lemonade,
and teas without caffeine can be very helpful.
• Take walks and exercise regularly.
• Wear shoes made for exercise.
Constipation

 To treat constipation:
• Continue to eat high-fiber foods and drink plenty of fluids. Try adding wheat bran
to the diet; begin with 2 heaping tablespoons each day for 3 days, then increase by
1 tablespoon each day until constipation is relieved. Do not take more than 6
tablespoons a day.
• Stay physically active.
• Use over-the-counter constipation treatments, if needed. These include:
• Bulk-forming products (such as Citrucel, Metamucil, Fiberall, and Fiber-Lax).
• Stimulants (such as Dulcolax and Senokot).
Constipation

 To treat constipation:
• Osmotics (such as milk of magnesia).
• Cottonseed and aerosol enemas can also help. Do not use lubricants such as
mineral oil because they may keep the body from using important nutrients the
way it should.
 Good food sources of fiber include the following:
• Legumes (beans and lentils).
• Vegetables.
• Cold cereals (whole grain or bran).
• Hot cereals.
• Fruit.
• Whole-grain breads.
Constipation

If it is that simple so why it does not work??

Health Coaching Plate versus My Plate

Based on the individual, not on a theory

Crowding out
Add foods in . . . rather than take foods out

Dos
 Do give people time to talk about their important relationships.
 Promote participation in social events to meet new people.
 Do recommend that clients explore new hobbies and interests.
 Do advise clients to engage in self-reflection and experience nature.

Time Management
 Prioritize
You cannot be all things to all people
You can do one thing at a time
By doing less, you can do more
Write a ‘not to-do’ list

Meditation tools and Life Style suggestions
Hot Towel Scrub
Life Style Suggestions
Self Care

Eating Habits
• Chew your food well, 30 seconds per mouthful
or more, until it becomes nearly liquid.

Relationships
• View everything and everyone you meet with gratitude.

Hygiene
• to increase your circulation, scrub your entire
body with a hot, damp washcloth morning
and/or night.

Attitude
• Live each day happily without focusing on
your problems

Home practices
• Keep your home in good order,
You are your home

Wish list
• Writing a wish list is a great way for you to let go of societal
ideal of what your life should look like and connect with
your deepest desires for your future.
• write down the elements that are most meaningful to your
future, such as relationships, children, career, health, and
spirituality.
• Write what you want to accomplish or obtain, the places you
want to go, the people you’d like to meet or become closer
with, or anything that your heart, mind, and soul truly
desire.

Wish list
• Start listing your desires.
• Begin with the simple and obvious, and you will notice that
more ideas come to you once you start writing.
• Allow yourself to go crazy – write down all that
• Allow yourself to have fun with it!

Work Group
Make your wish list

Positive Psychology
You have to use positive psychology practice
with your client

Positive Psychology Test
Three Blessings
• Before you go to bed, write down three good
things that happened during the day.
• Then, write down why each of them happened.

Work Group
• Write down 3 blessings and why you consider
them so?

Different Dietary Theories
You have to master all the dietary theories
For Example:
• Eating Raw
• Being Vegetarian, Pros and Cons
• High Carbohydrate Diet
• Macrobiotics
• Anti Inflammatory Diet

1. active listening
• Focus fully on your client.
• Listen carefully to your client’s concerns, beliefs, and goals.
• Pay attention to your client’s body language and tone of voice.
• Repeat what your client expresses to make sure you understand.

2. Coaching Presence
• Be fully present and flexible.
• Ask questions when you’re unsure.
• Trust your intuition.
• Use humor to make clients comfortable.
• Stay confident when clients show strong emotions

3. Establish Trust and Intimacy with the Client
• Show that you’re happy to see your client.
• Ask what’s new and good.
• Ask about significant people in your client’s life.
• Be honest, keep agreements, and promises.
• Show genuine concern for your client’s welfare.

Eat well Guide

Diet, physical activity & breast cancer survival

Take Home Messages
 Globally there is sufficient evidence to strongly support the notion that
overweight, obesity, and reduced physical activities have direct causal
relationship to breast cancer.
 Although very few studies are available to directly document such a
relationship in the Arab world, circumstantial evidence clearly points to the
possible role of the epidemic obesity in this population and the startling rise
in cases of breast cancer.
 Calls to action are urgently needed in many sectors and at all levels of society,
to establish intensive strategies and polices for reducing obesity and
promoting physical activity.

Take Home Messages
 Strong and persistent efforts are also needed to promote an overall healthy
lifestyle with special emphasis on diet that is rich in fruit and vegetables and
whole grains and low in red meat and saturated fats.
 Continued and expanded research on diet, lifestyle and breast cancer risk is
urgently needed to build the foundation for future progress in evidence-based
public health efforts in this region of the world.
 There is a limited-suggestive evidence that consumption of foods containing fiber,
before and after diagnosis, may decrease all-cause mortality risk.

Take Home Messages
 There is a limited-suggestive that intake of foods containing soy, after
diagnosis, decreased all-cause mortality risk.
 Dietary fat has been proposed as one of the etiologic factors for breast
cancer. However, the relationship between fat intake and the risk of breast
cancer has been examined in a number of case–control and cohort studies,
The findings reported in the literature are not conclusive enough to establish
a pattern for the real cause of the disease.
 There is a limited-suggestive that a diet high in fat and saturated fat, before
diagnosis, increased the risk for all-cause mortality.

Take Home Messages
 Despite the lack of convincing data for a significant effect of nutrition on breast
cancer mortality and recurrence, adherence to a healthy diet is also
recommended for other reasons, a prudent/healthy dietary pattern is associated
with prevention of and decreased mortality from cardiovascular disease , the
most common comorbidity of breast cancer survivors.
 women may experience various nutritional difficulties during chemotherapy for
breast cancer, particularly in relation to taste, appetite, nutritional status and
weight gain.
 information and education on food preparation and diet may influence the eating
habits of women having chemotherapy for breast cancer, enabling them to better
manage their weight during treatment.

Take Home Messages
Among all lifestyle factors and beyond physical activity the strongest evidence of an
impact on breast cancer prognosis was found for obesity and overweight.

The Well Being of Breast Cancer PatientCan Nutrition Help? by Nilly Shams

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