Nutrition For the Sarcoma Patient

1. Nutrition For the Sarcoma Patient Gina D’Amato, MD Sylvester Comprehensive Cancer Center University of Miami Health System Sarcoma Alliance September 29, 2019

2. My Disclosures I am NOT a nutritionist But I LOVE food

3. Objectives Review common cancer food myths Tips on eating while on treatment Tips on eating after treatment

4. Debunking the Cancer Food Myths The Myth: Sugar Feeds Cancer The Myth: Cancer Cells Cannot Survive in an Alkaline Environment The Myth: Herbal Supplements Help Fight Cancer The Myth: Artificial Sweeteners Cause Cancer

5. 5 Most Common Nutrition Challenges During Treatment Tips for Nausea/Vomiting Tips for Decreased Appetite/Early Satiety Tips for Coping with Altered Taste Tips for Coping with Diarrhea Tips for Coping with Constipation

6. Tips for Nausea/Vomiting Eat six to eight small meals a day instead of three large meals. Drink clear liquids as often as possible after vomiting to prevent dehydration Freshen your mouth by rinsing it with a solution made of 1 teaspoon of baking soda, 1 teaspoon of salt, in a quart of water. Swish and spit. Eat bland foods, instead of foods that are very sweet, fatty, greasy, or spicy. Eat dry foods (such as crackers, toast, dry cereal, or bread sticks) when you wake up and every few hours during the day when you are taking medications or when you feel nauseated.

7. Tips for Decreased Appetite/Early Satiety Eat 5 or 6 small meals instead of 3 large meals. Eat by the clock. Try to eat something every 2-3 hours. Keep your pantry and freezer well stocked with foods that make quick and easy meals and snacks, such as single-serving entrées and ready-to-eat packaged foods. Eat a bedtime snack. This will give you extra calories without affecting your appetite at your next meal. Make every bite count by choosing protein rich foods. Drink liquids throughout the day even when you do not feel like eating. Choose liquids that add calories and other nutrients. Drink only a small amount of liquids when you are eating meals. Many people feel too full if they eat and drink at the same time

8. Tips For Altered Taste Choose foods with tart flavors, such as lemon wedges, lemonade, citrus fruits, vinegar, and pickled foods. (Caution: avoid these acidic foods if you have a sore mouth or throat.) Marinate foods in a balsamic vinegar salad dressing. Try sugar-free lemon drops, gum or mints. Add lemon juice or other flavorings to water. Season foods with herbs, spices, and other seasonings, such as onion, garlic, chili powder, basil, oregano, rosemary, tarragon, barbecue sauce, mustard, ketchup, or mint. Try Mrs. Dash seasonings. Eat frozen fruits, such as whole grapes and mandarin orange slices, or chopped cantaloupe or watermelon. Before eating, rinse your mouth with a solution of 1 quart water, 1 teaspoon salt, and 1 teaspoon baking soda. This rinse can help keep your mouth clean and improve your sense of taste. If you have a metallic taste, try using plastic flatware and glass cups and plates. Avoid canned vegetables, fruits and soups.

9. Tips for Coping with Diarrhea Avoid high fat and spicy foods Choose low fiber, bland foods Sip on broth and electrolyte replacement drinks to help replenish electrolytes Add foods with soluble fiber to help thicken stool (banana, applesauce, oats) Limit lactose, sugar and sorbitol Limit hot, caffeinated beverages Watch for medications containing magnesium

10. Tips for Coping with Constipation Eat at about the same times each day Drink plenty of liquids (at least 8 cups daily) For variety, drink water, prune juice, warm fruit or vegetable juices, decaffeinated teas, or hot water with added lemon juice and honey. Fluids also include foods that are liquid at room temperature, like frozen ice pops, gelatin, or ice cream. Eat foods high in fiber Work up to 25-38 grams of fiber a day. Be sure to increase fiber slowly. Increase the amount of fiber you eat by no more than 5 grams each day.

11. Loss of Appetite

12. Many different things can cause appetite loss in a person with cancer: Changes in metabolism, which is the body’s process of breaking down food and turning it into energy. Such changes can occur with advanced cancer Cancer inside the abdomen may cause irritation or swelling. An enlarged spleen or liver, which pushes on the stomach and creates a feeling of fullness. Ascites, which is a buildup of fluid in the abdomen that may create a feeling of fullness. Medications, including chemotherapy, immunotherapy, and other drugs. Radiation therapy or surgery to any part of the gastrointestinal organs, such as the stomach or intestines. Causes of appetite loss

13. Nausea and vomiting Mouth sores and mouth pain Infections in the mouth Dry mouth Difficulty swallowing Difficulty chewing Changes in taste and smell Constipation or diarrhea Pain Fatigue Depression Stress or anxiety Other side effects of treatment that can cause appetite loss

14. Relieving side effects is an important part of cancer care and treatment. This is called palliative or supportive care. Talk with your health care team about any symptoms you experience and any change in symptoms. If possible, the first step in treating appetite loss is to address the underlying cause. Treatment for conditions such as nausea, mouth sores, dry mouth, pain, or depression may help improve appetite. Although you may not feel like eating, remember that getting good nutrition and keeping a healthy weight are important parts of your recovery. Eating well can also help you better cope physically and emotionally with the effects of cancer and cancer treatment. Consider the following tips for getting proper nutrition when your appetite is low: Eat 5 to 6 small meals a day, and snack whenever you are hungry. Do not limit how much you eat. Determine which times of day you are hungry and eat at those times. Eat nutritious snacks that are high in calories and protein. This includes dried fruits, nuts and nut butters, yogurt, cheeses, eggs, milkshakes, ice cream, cereal, pudding, and protein bars or granola bars. Keep your favorite foods on hand for snacking. Increase the calories and protein in foods by adding sauces, gravy, butter, cheese, sour cream, half and half, whipped cream, and nuts or nut butters. Drink larger amounts of fluids between meals, rather than with meals, which may make you feel full too quickly. Managing appetite loss

15. Managing appetite loss • Choose nutritious or filling drinks, such as milk or nutritional milkshakes or smoothies. • Ask family members or friends to get groceries and prepare food for you when you are too tired to shop or cook. Also consider buying precooked meals. • Try to eat in pleasant surroundings and with family or friends. • Try placing food on smaller plates rather than larger plates. • If the smell or taste of food makes you nauseous, eat food that is cold or at room temperature. This will decrease its odor and reduce its taste. • If you are having trouble tasting food, try adding spices and condiments to make the foods more appealing. • If you have changes in taste, such as a metallic taste in your mouth, try sucking on hard candy such as mints or lemon drops before eating a meal. • Ask your doctor about ways to relieve gastrointestinal symptoms, such as nausea, vomiting, and constipation. Also tell your doctor if you are having any difficulty with managing pain.

16. Managing appetite loss • Try light exercise, such as a 20-minute walk, about an hour before meals to stimulate your appetite. Consult your health care team before starting an exercise program. Exercise also helps maintain muscle mass. • Meet with a registered dietitian for additional advice on meal planning and symptom management. A dietitian can also be helpful to figure out whether you might benefit from nutritional supplements or digestive enzymes. Ask your health care team if there is a dietitian available at your treatment center. • Your doctor may treat appetite loss and associated weight loss with certain medications, including: • Megestrol acetate (Ovaban, Pallace) or medroxyprogesterone (Amen, Depo-Provera, Provera), which are forms of the progesterone hormone that can improve appetite and weight gain. • Steroid medications, which can increase appetite, improve a person's sense of well-being, and help with nausea, weakness, or pain. • Metoclopramide (Reglan), which helps move food out of the stomach and can prevent feeling full before eating enough food. • Dronabinol (Marinol), a cannabinoid made in the laboratory, which may stimulate appetite. • Sometimes, a feeding tube is placed temporarily through the nose into the stomach. A more permanent tube can also be placed directly into the stomach from the abdominal wall if necessary.

17. Tips for After Treatment

18. Eating Well Plant based eating provides antioxidants and phytonutrients/phytochemicals that help “fight” cancer cells and scavenge free radicals in the body. Plant based eating helps reduce inflammation throughout the body. Try to avoid fast food and “processed foods” Shop at the periphery of the grocery store

19. Phytonutrients/Phytochemicals They provide plants with color, odor and flavor. Not one single food has all the phytonutrients in it. Research has shown that phytonutrients work better together so variety is the message.

20. Eat By Color To Include a Variety of Phytonutrients/Phytochemicals Red: tomatoes, bell peppers, cranberries, cherries, raspberries, onions, apples Orange: carrots, pumpkin, sweet potato, turmeric Yellow: ginger, pineapple, summer squash, pear, apple Green: broccoli, kale, green tea, spinach, Brussel sprouts Purple: blueberries, figs, grapes, blackberries, eggplant Tan/White: coffee, garlic, mushrooms, nuts, onions, seeds, soy, tea, whole grains

21. Plate Method

22. Vegetables Aim for 4 or more servings per day. (1cup raw leafy, ½ cup cooked/raw for all others) When cooking vegetables, they should be slightly cooked. Steam, bake, stir-fry, roast, or lightly sauté. (No deep fried) Drizzle 1tsp. Olive oil on vegetables for greater phytonutrient absorption!

23. Fruits Aim for 2 – 3 servings per day. (1 medium or ½ cup cut up raw or canned, approx. 12 grapes) Choose fresh when in season or canned in their own juice or frozen with no added sugar. Avoid drinking ALL fruit juices!

24. Whole Grains Aim for 3 servings per day. Brown and Wild Rice Oatmeal Quinoa Barley 100% whole wheat bread/English muffin Whole grain cereal Whole wheat pasta Corn Tortillas Corn, sweet potato, pumpkin, winter squash (acorn, butternut) – these are considered grains on your plate not vegetables.

25. Lean Protein Choices Dried Beans, Peas & Lentils: 3 – 4 servings per week Fish: 3 – 4 servings per week (not fried) Chicken and Turkey breast meat no skin Veggie Burgers Eggs – no more than 3 or 4 yolks per week (egg whites unlimited) Tofu Tempeh Soybeans/Edamame

26. Dairy & Dairy Alternatives Aim for 2 – 3 servings per day Skim or 1% milk Non Fat Greek Yogurt Low Fat Cottage Cheese 2% or Low Fat Cheese Skim Soy Milk Skim Lactaid Almond Milk, Oat Milk, Rice Milk needs to be fortified with calcium and does not contain significant amounts of protein.

27. Healthy Fats 1 – 2 servings per day. Nuts and Nut Butters (Peanut Butter, Almond Butter, Cashew Butter) Seeds: Flaxseed, Pumpkin Seed, Sesame Seed, Sunflower Seeds, Chia Seeds Oils: Canola oil, Olive oil, Peanut oil, Flaxseed oil, Grape Seed oil, Safflower oil, Sesame oil, Sunflower oil Avocados Olives

28. Counting calories • Calories are units of energy • Required calories to maintain your weight is a formula based on Kg/cal but an easy way to calculate is • Add 0 to your weight then add that to your weight and that is how many calories per day • Example 180 lbs • 1800 + 80= 1880 • 3500 calories = 1 lb • So if you want to gain 1 lb/week add 500 calories/day • If you want to lose 1lb/week add 500 calories/day

29. Where to Find More Information American Cancer Society: cancer.org 1-800-227-2345 American Institute of Cancer Research (AICR) aicr.org: 1-800-843-8114 Books: American Cancer Society Complete Guide to Nutrition for Cancer Survivors: Eating Well, Staying Well During and After Cancer, 2nd Edition What to Eat During Cancer Treatment American Cancer Society’s Eating Healthy Cookbook, 3rd Edition

30. Thank You