The Impact of Diet: Understanding Today’s Nutritional and Healthy Living Guidelines

1. The Impact of Diet: Understanding Today’s Nutritional and Healthy Living Guidelines Presented by: Suzanne Dixon, MPH, MS, RD The Health Geek, LLC

2. Overview • Obesity: Why It Happens, Why It Matters • Paradigm Shift: Nutrition vs. Physical Activity • New Paradigm: Great News for Breast Cancer Survivors • New Ideas for an Old Problem: Interoception • Health Guidelines, Survivorship, & Myth

3. Reality for General Public & Cancer Survivors Alike Our (Often Unrealistic) Response & Goals

4. 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.

5. 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.

6. 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

7. 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.

8. 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.

9. 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.

10. Greater Br Ca Survival in Physically Active Women with High FV Intake Regardless of Obesity Mortality (%) Diet and Exercise Categories From data presented in Pierce JP et al. J Clin Oncol.2007;25(17):2345-51.

11. 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.

12. Energy Balance: Nutrition vs. Physical Activity

13. Instead of… New Paradigm Strive to achieve…

14. Greater Br Ca Survival in Physically Active Women with High FV Intake Regardless of Obesity Mortality (%) Diet and Exercise Categories From data presented in Pierce JP et al. J Clin Oncol.2007;25(17):2345-51.

15. Getting from Here to There…

16. 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

17. 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

18. 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.

19. Health Guidelines, Survivorship, & Myth

20. Myth: Dairy Causes Cancer Discovery Education

21. 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

22. Example: Smoking & Risk of Lung Cancer Decreased Risk Increased Risk RR = 1.0 (null value)

23. Example: Exercise & Risk of Heart Disease Decreased Risk Increased Risk RR = 1.0 (null value)

24. Example: Dairy & Risk of Breast Cancer Decreased Risk Increased Risk RR = 1.0 (null value)

25. Myth: Soy Feeds ER+ Breast Tumors SoyBase.org

26. 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.

27. Soy: Safe/Possibly Beneficial to Survivors Represent different groups (2 US, 1 China) varying levels soy intakeAll 3 - no adverse effect of soy food consumptionAll 3 - soy may be protective against recurrence *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.

28. 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.

29. Where to Go for Good Information?

30. 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/

31. Health After Cancer

32. New and Existing Resources Fit What We Know

33. 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.”

34. 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!