Enjoying your food again after treatment

1. Enjoying your food again after treatment life with relaxation, food & exercise

2. WCRF / AICR report 2007; 8 main recommendations Depending on the stage of your treatment not all of these may apply at the moment But with any ‘condition’ – the more health promoting activities that one can do, within the constraints of the treatment, the better for our health

3. World Cancer Research Fund report (2007) 8 main recommendations: • Be as lean as possible within normal range of body weight • Be physically active as part of everyday life • Limit consumption of energy dense foods • Eat mostly foods of plant origin • Limit intake of red meat & avoid processed meat • Limit alcohol containing drinks • Limit consumption of salt, avoid mouldy grains, pulses • Aim to meet nutritional needs through diet alone

4. 1. ‘Be as lean as possible within normal range of body weight’avoid weight gain and increases of waist circumference through adulthood Pros of body fat: Provides cushioning for our bones Keeps us warm Provides energy store when we can’t eat (and stops breaking down muscle) Cons of body fat: Convincing evidence  risk cancer in men (colorectal) & in women post menopause (breast) Also  risk diabetes, high blood pressure and heart disease Body Weight includes fat, muscle and water

5. Weight plan What do you feel is a good weight (well weight) for you? Measure weight / BMI (body mass index) at present Are you under or overweight? If under: try to eat more and also increase exercise / activity to promote muscle building If over: (and not due more chemo / radiotherapy) refer to Eatwell plate and increase exercise/ activity

6. 2. Be physically active as part of everyday life: • Pros: • Heart Disease & Diabetes: • - lowers blood pressure • - helps weight-loss (body fat, central fat) • - improve cholesterol & glucose levels – • Mental health • - reduced risk of depression and dementia • - Increased positive emotional well-being • - improves response to stress • Walk at least 30 min/d: (10,000 steps) every day(increasing to 1hr/d of moderate activity) • Limit sedentary activities eg TV watching • Think of ways to include activity in your daily routine: walk to the shops? Use exercise bike / hand weights whilst watching TV?

7. Physical Activity • Convincing evidence that most physically active people have lower risk of developing colo-rectal cancer • Probable evidence that risk of post menopausal breast and endometrial cancer is reduced • Limited evidence that there is risk reduction for lung, pancreas, pre-menopausal breast cancers • Convincing evidence that it prevents weight gain, overweight, obesity CONS

8. AGE UK Nordic walking New age Kurling Tai Chi Exercise on prescription

9. 3. Limit consumption of energy dense foods, • Avoid sugary drinks, • Consume ‘fast food’ sparingly (if at all) • For colorectal cancer there is some suggestion that fatty foods (animal fats) and sugary foods increase risk • What is Energy density ? • 225-275 calories (kcal) per 100g Average energy density of diets to be lowered towards 125kcal per 100g

10. ‘Guess the energy density’ game? 260 25 40 560 305 or 215 416

11. The lower the energy density, the bigger the portion Food ED = 2.3 Food ED = 0.52 Prof B Rolls

12. 4. Eat mostly foods of plant origin: • 600g/d of non-starchy vegetables & fruits • What does this look like… • 25g /d of fibre from cereals & pulses • Eat relatively unprocessed cereals and or pulses with every meal • Limit refined starchy foods

13. Each portion contains 2g of fibre

14. Colorectal cancer • 15 fold range in incidence through out the world • highest risk in US, N Europe, NZ, Australia • lowest rates in rural Africa, India, China • low meat and fat intake , high plant food intake; vegetable and starchy staples (fibre) • Migrants from these areas quickly acquire the same rate of cancer as the host population

15. Any issues having lots of fruit & veg post surgery? Low residue diet (adhesions, narrowing of gut) Wind, diarrhoea, constipation, sore bottom

16. Low residue diet • Doctors often have their patients follow a low-residue diet the first weeks after any abdominal surgery. • This includes only foods that are easily digested and don't leave much waste behind, • When going back to foods you have not eaten since surgery, try one new food a day. Keep a food and symptom log.  • if they seem to cause symptoms, try them again in 2-3 weeks.  Log results.  Eventually you should be able to have a full and varied diet. 

17. Foods and drinks that may cause loose stools: Drinks: • apple juice • prune juice • beer , wine • milk • Hot beverages • Tea & coffee Vegetables & Fruit • baked beans • green beans • spinach • cabbage • broccoli • raw fruit • highly spiced foods, chocolate, liquorice May be helped by; Apple sauce, Peanut butter, Bananas, Rice / pasta / potatoes, Tapioca, marshmallows, pretzels, Boiled milk Drink plenty; bouillon(salty drink), ginger ale, Weak tea

18. Wind Eat regularly; missing meals can use gas build up Avoid swallowing air; relax, take your time and don’t talk with your mouth full Avoid chewing gum or drinking through a straw • fish • melons • Milk • nuts • carbonated beverages • Sweets • Alcohol; beer • asparagus • cabbage family , brussels, broccoli, cauliflower • dried beans and peas , baked beans • onions , radishes, cucumbers These foods may cause more gas to form;

19. FOODS WHICH MAY CONTRIBUTE TO ANAL IRRITATION •  certain raw fruits and vegetables (e.g., oranges, apples, coleslaw, celery and corn) •  popcorn •  Chinese/oriental vegetables •  nuts •  coconut •  dried fruits (e.g. raisins, figs) •  food with seeds •  spicy foods

20. Relieving diarrhoea May be caused by; • Very large meals • Spicy meals • Soup • baked beans / Dried beans • Beer • Hot beverages • chocolate, liquorice, prune juice • Red wine May be helped by: • Apple sauce • Peanut butter • Bananas • Rice / pasta / potatoes • Tapioca • marshmallows, pretzels • Boiled milk • Drink plenty; bouillon, ginger ale, Weak tea

21. Reintroducing foods… ‘It took about 6 months for me to eat fresh fruits and vegetables without them speeding through my system.  It takes time for the body to slow down.  Some foods work better than others, peanut butter made me worse as did applesauce, however others have had great results with them.  Keep a food log.  Try new foods, if they don't work, try them again in 2-3 weeks.  Log results.  Eventually you should be able to have a full and varied diet.  I live on fresh fruits and vegetables now but it took a while to achieve this.  As for weight loss you can try bulking up by using powders or drinking high calorie shake drinks.  They make them dairy-free so you should be able to tolerate them’. ‘I had the reversal ileostomy 10 weeks ago just like Cathy and I eat everything’. ‘Certain foods like salad and chinese do go through a bit quicker, and curry and chilli do cause some bottom burning for a day or so, but I still eat them. I take 10ml of immodium syrup before bed but thats all’.

22. Relieving constipation Increase liquids Eat high fibre foods; fruit (chew well), veg – raw & cooked, Wholemeal breads and cereals (oatmeal, wheat flakes, branflakes) Coffee, chocolate, lemon juice, liquorice, prune juice Exercise Make sure you aren’t taking too many ‘Imodiums’

23. 5. Limit intake of red meat & avoid processed meat: • No more than 18oz (500g) cooked red meat /week (e.g. 150g three times a week) • Eat very little, if any, processed meat • ‘Salting, smoking & curing to make processed meats are a probable cause of some cancers (colorectal, stomach)’ • Use of nitrates as a preservative • Many processed foods are also high in fat, trans fats, refined starch which increase risk of heart disease • ‘Processes’ such as freezing steaming, drying – are not a problem

24. What can I have instead? Sandwiches / snack meals; • Egg • Fish (tinned in water, oil & drained) • Hummus • Fresh chicken, turkey slices • Small portion cheese or lower fat cheeses • Salad Main meal; • Chicken • Turkey • Fish • Pottage! (vegetable and bean / lentil stew); onion / leek / parsnip / carrot – stock, herbs, spices (tumeric, garlic)

25. 6. Limit alcoholic drinks: • No more than 2 drinks /d for man and 1 drink/d for women (10-15g alcohol) • 1 unit = 8g = 10ml of pure alcohol A drink = • ½ pint normal strength beer (3-5%) • One shot, 25ml spirits (40%) • One small glass (125ml wine (12-13%) • Baileys: 100ml • Convincing evidence that alcohol increases risk of cancer of mouth, oesophagus, throat, breast, bowel (in men) • Probably increases risk of liver cancer and bowel (in women) • Other Cons: lots of calories • Pros: reduces heart disease in men over 40 and women (post menopausal)

26. Top tips to keeping alcohol intake within guidelines • Order smallest measure • Alternate with soft drinks • Dilute with low calorie drinks egspritzer • Keep a few nights alcohol free • Don’t drink alcohol if you are thirsty (rehydrate first)

27. 7. Limit consumption of salt, avoid mouldy grains, pulses • Avoid salt preserved, salted or salty foods • Aim for Less than 6g salt/day • Or 2400mg sodium • Sources of sodium: processed food 75-80%, cooking & on food 15-20%, fresh food 10% • Baked beans ½ tin: 2.7g (45% GDA) • Can Soup: 2.4g (40% GDA) • Bacon (2 rashers): 2.4g (40% GDA) • Bread (2 slices): 0.8g (14% GDA) • Egg (60g): 0.2g (4% GDA) • Roast Chicken (50g); 1% GDA

28. Sodium – practical advice • avoid adding salt at the table • reduce salt used in cooking – use other flavourings; herbs, spices, pepper, lemon juice, garlic, stock • choose lower salt/ sodium versions where available, e.g. bread, beans, tinned vegetables • cut down on salty processed foods, e.g. sauces, soups, flavoured noodles • cut down on salty snack foods, e.g. crisps & nuts • limit cured foods (e.g. bacon & ham), foods packed in brine (pickles, olives, fish) and condiments • use fresh, frozen or canned ‘no added salt’ vegetables • choose fresh or frozen plain meat, fish & poultry

29. 8. Aim to meet nutritional needs through diet alone • Dietary supplements are not recommended for cancer prevention • Cons: may promote cancer at certain stages (folate, vitamin A, iron) • Pros: may reduce risk at certain stages, folate, carotene, vitamin D • Selenium, vitamin D, calcium, folate; may be protective • Calcium: low fat dairy, nuts, pulses, edible bones in fish • Selenium: brazil nuts, fish, offal • Vitamin D: oily fish, liver, egg, fortified marg & cereals, sunlight • Folate: green vegetables, pulses, nuts, seeds, fortified cereals

30. Mediterranean diet • Lots of food from plant sources, including fruits, vegetables, potatoes, breads and grains, pulses, beans, nuts, and seeds. • A variety of minimally processed, seasonally fresh, and locally grown foods. • Olive oil , rapeseed? as the principal fat, replacing other fats and oils. • Low saturated fat intake • Red meat consumed a few times per month. • low to moderate amounts of cheese and yogurt daily • fish (oily fish) and poultry • Up to 4 eggs per week. • Fresh fruit as the typical daily dessert; • Moderate consumption of wine, normally with meals,

31. BREAD, RICE, POTATOES, PASTA FRUIT & VEGETABLES MILK & DAIRY FOODS MEAT, FISH, EGGS, BEANS FOODS & DRINKS HIGH IN FAT AND/OR SUGAR

32. Breast Cancer Stress Management and Relaxation Training Programme (B-SMART) • Based on evidence of psychosocial factors that are related to positive adaptation • Optimism • Benefit finding • Social support • Anxiety reduction

33. The programme • Combines Cognitive Behavioural Therapy and relaxation techniques • Techniques to minimise physical tension and anxiety producing thoughts • Provides training in: • anxiety-reduction skills • awareness of sources of stress and indicators of stress • noticing and replacing negative thoughts • cognitive and interpersonal coping skills • Goal to improve ways in which people manage stressors and maintains social support networks • Improved immune functioning • Increased benefit finding and decreased depression • Most effective for women low in optimism

34. Summary • Eat a balanced and varied diet. i.e. food choices from all food groups • Add foods to your diet gradually to see how your body responds. • Keep Active • Relax; Think about how you manage stress and improve response • Speak to a dietitian if you have any specific diet concerns

35. Dietary risk factors in colorectal cancer:  risk  risk

36. Extra slides

37. Probiotics: protective bacteria Definitions; • Live micro-organisms which when administered in adequate amounts confer health benefits on the host (WHO / FAO 2002) • They must remain viable during their passage through the GIT • Usually representative of species present in infants; Lactobacillus, Bifidobacterium, yeast Saccharomyces boulardii • Safe; by virtue of their long use in fermented diary products

38. Protective bacteria • Ferment dietary fibres & complex starches in food in the colon resulting in: • short chain fatty acids; electrolyte uptake in the large intestine (sodium, potassium…) • energy provider for colon cells • (gases H2, CO2, CH4), • also some vitamins B12, K • may alleviate symptoms of lactase intolerance • Reduce inflammation • Improve Bile salt metabolism; • Probiotic associated with decreased reduction in rate of progression of colon cancer

39. Foods that may cause gas and odour: • Alcohol; beer • carbonated beverages • Eggs; meringues • fish • strong flavored cheeses • spiced foods • fatty foods (pastries/deep fried foods) • melons • asparagus • cabbage family , brussels, broccoli • cauliflower • dried beans and peas , baked beans • radishes • pickles • onions • Cucumbers • mustard buttermilk, parsley and yogurt may reduce the odour

40. Other specific nutrients • Phyto-oestrogens: chemicals in plants similar to oestrogens; as they compete with endogenous oestrogens the end result is anti oestrogenic • found in soya, linseed, also in cereals, legumes, veg; insufficient evidence that they are protective against breast cancer • Antioxidants: C,E carotenoids and selenium – prevent oxidation and DNA damage; not enough evidence that increasing intake would decrease risk of breast cancer

42. Breast Cancer WCRF 2007 Pom; post menopause, pre: premenopause  Increases risk  decreases risk

43. Sites for absorption of nutrients • 9 litres of fluid pass through the duodenum each day of which only 1.5L reaches the colon stomach duodenum jejunum ileum Ascending colon minerals Water sol vits sugars Vits A & D Bile salts Water, sodium, potassium, vits Fats Vit B12 Water & sodium Amino acids