Transcript Cancer Survivorship & Energy Balance: Going Beyond Obesity

The Impact of Diet: Understanding Today’s
Nutritional and Healthy Living Guidelines
Presented by: Suzanne Dixon, MPH, MS, RD
The Health Geek, LLC
Overview
G Obesity: Why It Happens, Why It Matters
G Paradigm Shift: Nutrition vs. Physical Activity
G New Paradigm: Great News for Breast Cancer
Survivors
G New Ideas for an Old Problem: Interoception
G Health Guidelines, Survivorship, & Myth
Reality for General Public & Cancer Survivors Alike
Our (Often Unrealistic) Response & Goals
Energy Imbalance: The Myth We Perpetuate
An energy deficit of approximately 500 kcal per day
leads to steady rate of weight loss of 1 pound per
week, however…
This static weight-loss rule of thumb does not account
for physiological adaptation to decreased bodyweight
Widespread use of this estimate leads to drastically
overestimated expectations for weight loss
Hall KD, et al. Lancet. 2011;378(9793):826-37.
Energy Imbalance: By the Numbers
What is driving obesity epidemic? Population-averaged
model, energy-balance dynamics demonstrate:
+30 kJ per day average daily energy imbalance gap
underlies the observed average weight gain, however…
The larger we become, the more calories we burn
Average energy intake increase to sustain increased
weight, called the maintenance energy gap, is
approximately 0.9 MJ per day
Hall KD, et al. Lancet. 2011;378(9793):826-37.
Energy Imbalance: By the Numbers
What does +30 kJ per day look like?
Hint: 7.16 kcal
What does 0.9 MJ per day look like?
Hint: 214 kcal
Weight Mgmt: Nutrition vs. Physical Activity
Large behavior changes are required to produce and
maintain reductions in body weight
Small behavior changes may be sufficient to prevent
excessive weight gain
“Dieting” effective for weight loss, but very ineffective
(alone) for weight maintenance
Physical activity to match intake is likely the most
effective way to achieve weight maintenance
Hill, JO, et al. Circulation. 2012;126(1):126-32.
Cannot Afford to Ignore (+) Energy Balance
Breast cancer: > 50% gain weight during/after treatment
>10% weight gain post-dx = 2.7 HR (all-cause mortality)
>5% gain (2 years post-dx) = 5.9 HR (all-cause mortality)
Survivors of other tumor types experience gain as well:
Adult lymphoma: 9% experience gain > 20%
Childhood ALL: Overweight: 21%, 45%, 35% at diagnosis, endtherapy, and 7 yrs post-treatment, respectively
Prostate cancer: 2001-2007 survey suggests 42% gain wt
Vance V, et al. Obes Rev. 2011;12(4):282-94.
Bradshaw PT, et al. Epidemiology. 2012;23(2):320-7.
Lynce F, et al. Leuk Lymphoma. 2012;53(4):569-74.
Love E, et al. Pediatr Blood Cancer. 2011;57(7):1204-09.
Whitley BM, et el. Prostate Cancer Prostatic Dis. 2011;14(4):361-6.
For Cancer Survivors, Be Kind to Yourself
Normalize your experience but don’t create
expectation of gain
Needs are unique: fear and anxiety can drive
behavior
Nutrition and food go far beyond meeting basic
needs for most people – who eats for fuel?
Cannot ignore physical activity
Benedetti F, et al. Neuroscience. 2007;147(2):260-71.
Mortality (%)
Greater Br Ca Survival in Physically Active Women
with High FV Intake Regardless of Obesity
20
18
16
14
12
10
8
6
4
2
0
Nonobese (n = 1100)
Obese (n = 380)
Low VF, Low VF, High VF, High VF,
Low PA High PA Low PA High PA
Diet and Exercise Categories
From data presented in Pierce JP et al. J Clin Oncol. 2007;25(17):2345-51.
Survivorship: More Promising Research
Low Fat Diet for Breast Cancer Survivors (WINS)
2,437 women with early stage breast cancer
Assigned low-fat or regular diet
Followed 5 years
Low fat diet group significantly lower risk of
recurrence
24% non-significant lower risk of recurrence in group
overall
42% lower risk of recurrence in ER- breast cancer group
Chlebowski RT, et al. J Natl Cancer Inst. 2006 98:1767-76.
Energy Balance: Nutrition vs. Physical Activity
New Paradigm
Instead of…
Strive to achieve…
Mortality (%)
Greater Br Ca Survival in Physically Active Women
with High FV Intake Regardless of Obesity
20
18
16
14
12
10
8
6
4
2
0
Nonobese (n = 1100)
Obese (n = 380)
Low VF, Low VF, High VF, High VF,
Low PA High PA Low PA High PA
Diet and Exercise Categories
From data presented in Pierce JP et al. J Clin Oncol. 2007;25(17):2345-51.
Getting from Here to There…
A Quick Exercise For You
For one minute, count your heartbeats just by
feeling your heart’s rhythm (estimated heartbeat)
Write down this number
Now take your pulse the usual way - wrist or neck
Take pulse again; average these two numbers
Calculate difference between estimate and average:
1- [(estimated - average)/average]
Adapted from Sci Am Mind; http://www.scientificamerican.com/article.cfm?id=inside-the-wrong-body
How is Your Interoception?
Interpretation of interoception test:
1- [(estimated - average)/average] = ?
Score:
> 0.80 very good interoceptive ability
0.60 to 0.79 moderately good interoception
< 0.59 poor interoception
Good interoceptive awareness, as measured by
heartbeat perception test, correlates strongly with
sensitivity for gastric functions
Herbert BM, et al. PLoS ONE. 2012;7(5): e36646.
Adapted from Sci Am Mind; http://www.scientificamerican.com/article.cfm?id=inside-the-wrong-body
Improving Interoception
What Improves Interoception?
Yoga, Meditation
Looking at your face in the mirror
Cognitive Behavior Therapy
Regular, enjoyable physical activity
Journaling; Keeping Food/Mood Records
What Hinders Interoception?
Anxiety/Mislabeling emotional/mental cues
Ignoring body function/sensory cues
Eating in front of TV, in the car, when distracted, off
your kids’ plates, etc
Ainley V, et al. Poster Presentation at ASSC 16. 2012; (179).
Pollatos O, et al. Hum Brain Map. 2007;28(1):9-18.
McDonald K. J Fam Pract. 2007;6(11):www.jfponline.com/Pages.asp?AID=5462.
Health Guidelines, Survivorship, & Myth
Myth: Dairy Causes Cancer
Discovery Education
Things to Consider About Dairy
Dairy is highly politicized in North America
Pro-Dairy states you must have dairy for good health
Anti-Dairy states you can’t have dairy for good health
The truth? Somewhere in the middle
Example: Smoking & Risk of Lung Cancer
Decreased Risk
Increased Risk
RR = 1.0 (null value)
Example: Exercise & Risk of Heart Disease
Decreased Risk
Increased Risk
RR = 1.0 (null value)
Example: Dairy & Risk of Breast Cancer
Decreased Risk
Increased Risk
RR = 1.0 (null value)
Myth: Soy Feeds ER+ Breast Tumors
SoyBase.org
Soy: Beyond Hormones
Soy nutrients have dozens of anti-cancer properties
completely unrelated to so-called “estrogenic” effects
Anti-angiogenesis through actions on VEGF & EGF pathways
Induce G2/M cell cycle phase arrest (expression of P21)
Inhibit tyrosine kinases
Antioxidant activity
Inhibit enzymes in our own estrogen-producing pathways
Upregulate natural killer cell function
Turn up production of sex hormone binding globulin
Inhibit metastasis through multiple pathways
Han H, et al. Nutr Cancer. 2010;62:641-47.
Yu X, et al. Med Oncol. Dec 2010; published online before print.
Barnes S. Lymphat Res Biol. 2010;8:89-98.
Soy: Safe/Possibly Beneficial to Survivors
Represent different groups (2 US, 1 China) varying levels soy intake
All 3 - no adverse effect of soy food consumption
All 3 - soy may be protective against recurrence
Study
n
Follow up
WHEL
3,088
7 years
LACE
1,954
6.3 years
524
5 years
Kang, X, et al.
Soy intake associated
with reduced risk of
recurrence
>16.3 mg isoflavones
per day*
> 1.4 mg daidzein per
day**
> 43.2 mg total
isoflavones per day
Magnitude of risk
reduction, lowest vs.
highest intake
54%
60%
33%***
*16.3 mg of isoflavones = 3+ servings soy food per day
**Daidzein = one of two main soy isoflavones
***Reduced risk postmenopausal women; no association with recurrence risk in premenopausal women
Cancer Epidemiol Biomarkers Prev. 2011;20:854-58.
Breast Cancer Res Treat. 2009;118:395-405.
CMAJ. 2010;182:1857-62.
Soy - More Reassurance
96 women in randomized, cross-over diet study; soy
intervention provided 50 mg isoflavones per day
Did not affect nipple aspirate volume
Did not affect nipple aspirate estrogen levels
Meta-analysis (14 studies on incidence; 4 on recurrence)
24% reduced risk of breast cancer in women consuming the
most soy; significant among Asian populations, non-significant
in western populations
16% reduced risk of recurrence among all populations combined
for breast cancer survivors consuming the most soy
Soy is food and should be treated like food
Enjoy soy if you like it, avoid if you don’t: The choice is yours!
Maskarinec G, et al. Cancer Epidemiol Biomarkers Prev. 2011;20:1815-21.
Maskarinec G, et al. J Nutr. 2011;141:626-30.
Dong JY & Qin LQ. Breast Cancer Res Treat. 2011;125:315-23.
Magee PJ & Rowland I. Curr Opin Clin Nutr Metab Care. 2012;15(6):586-91.
Where to Go for Good Information?
Other Useful Resources/Communities
American Institute for Cancer Research (AICR)
The only large cancer organization focused principally
on connection between nutrition & cancer
http://www.aicr.org
Health at Every Size (HAES)
Developed by Dr. Linda Bacon, Nutrition Professor,
City College of San Francisco
“We’ve lost the war on obesity. Fighting fat hasn’t
made the fat go away.”
http://www.haescommunity.org/
Health After Cancer
New and Existing Resources Fit What We Know
The Big Picture: What Should I Eat?
Plants, plants, and more plants
2/3 to 3/4 of plate should be covered by vegetables,
legumes, fruit – in that order of volume/amount –
heavy emphasis on cruciferous and dark purple/red
fruit
Remaining 1/4 to 1/3 of plate should be split between
whole grains and small amount of lean protein
Michael Pollan said it best: “Eat Food. Not too much.
Mostly Plants.”
In Summary
• We must:
– Place focus on health, not weight
– Become educated and take care of ourselves
– Foster neutral energy balance and total health
• Stop dwelling on nutritional “minutia” and
instead focus on whole foods
• Stop reading labels; we know what healthy
eating looks like and it doesn’t involve a
label!