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, end-

therapy, 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.

0

2

4

6

8

10

12

14

16

18

20

Low VF,

Low PA

Low VF,

High PA

High VF,

Low PA

High VF,

High PA

Nonobese (n = 1100)

Obese (n = 380)

Mo

rtali

ty (

%)

Diet and Exercise CategoriesFrom data presented in Pierce JP et al. J Clin Oncol. 2007;25(17):2345-51.

Greater Br Ca Survival in Physically Active Women

with High FV Intake Regardless of Obesity

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…

0

2

4

6

8

10

12

14

16

18

20

Low VF,

Low PA

Low VF,

High PA

High VF,

Low PA

High VF,

High PA

Nonobese (n = 1100)

Obese (n = 380)

Mo

rtali

ty (

%)

Diet and Exercise CategoriesFrom data presented in Pierce JP et al. J Clin Oncol. 2007;25(17):2345-51.

Greater Br Ca Survival in Physically Active Women

with High FV Intake Regardless of Obesity

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 Soy intake associated

with reduced risk of

recurrence

Magnitude of risk

reduction, lowest vs.

highest intake

WHEL 3,088 7 years >16.3 mg isoflavones

per day*

54%

LACE 1,954 6.3 years > 1.4 mg daidzein per

day**

60%

Kang, X, et al. 524 5 years > 43.2 mg total

isoflavones per day

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!