When we are well, most of us do not usually spend too much time thinking about the connection between eating and taking in the many food nutrients our body needs daily to keep it all ticking along and functioning well, never mind managing the many extra tasks that take a fair bit of effort and energy, including thinking, breathing, moving, warding off bugs and infections, breaking down the food, converting it into a form the body can use like petrol, rebuilding and repairing cells, getting rid of waste products and so much more!
Most of us also do not really think about how amazing our body is. We may not realize how much work it does each day even before we get out of bed, and we probably won’t think about how our food can affect the body’s ability to do all it needs to do.
That is, we won’t normally think about it until we have to deal with the shock of a diagnosis like cancer, which then quite understandably sends people into a state where they agonize over what they might have eaten or been exposed to in their life. And unless this is quite obvious, they often make nutrition into a kind of quest, exploring diet as a way of trying to explain why they have been struck with cancer. This is especially so when they have lived normal healthy lives or the cancer has presented at an early age.
So while it is true that a poor diet, inactivity and an excessive alcohol intake are key risk factors in around 30 per cent of cancers, it is important to recognize that they are not the only reasons for cancer. Instead of specific dietary causes per se, it is more about how good your genetic hardware is, and then your body’s ability to deal with both the good and bad environmental exposures in your life experiences.
This is so important, as once you are diagnosed the immediate priority is to work with your medical team to decide which treatments are going to give you the best outcome. This also means looking at which approach to diet will give you the most nourishment and the additional support you need to cope.
If you do not have any food problems, it is certainly reasonable to keep eating a normal healthy protective diet. However, in case of difficulties – if weight loss is a problem, say – then alternative dietary strategies will need to be employed. However, now is not the time to embark on some prudish anti-cancer meal plan which restricts your intake of the foods that give you the most support and nourishment to help boost blood counts, give you energy and help you to cope.
It never ceases to amaze me that someone who is about to start treatment for cancer should think that taking on some sort of extreme or greatly restricted dietary approach will help his or her body to do well. I sometimes explain that in many ways a cancer journey and the treatments should be approached as if you were about to take on a long-distance trek through the mountains or, in some cases, an extreme endurance event like the Tour de France.
There is nothing wrong with wanting to use nutrition to support and protect yourself, but before you write out the shopping list or proclaim the merits of the latest diet book you need to be sure that the approach you have researched is in fact the right one for you.
This can be quite confusing, as unlike many other chronic illnesses such as heart disease or diabetes, where diet approaches are reasonably standard, diet for cancer is quite specific to the type and stage of the cancer.
Cancer is quite a heterogeneous disease, and as its causes centre around the complicated processes the billions of cells in our body go through to divide and replicate every second of the day, it is hard to pin down the causes. There are more than 200 different types of cancer, there are different stages of the disease, and there are many options for and combinations of treatment, which can include surgery, chemotherapy, radiotherapy and biological treatments. In addition to the various effects cancer itself has on the body, the treatments themselves often contribute their own set of challenges and side effects.
It is also important to recognize that everyone with cancer has a different starting point, and simply adopting broad-brush recommendations or a radical internet diet is often not what is needed by your body at this time.
Doing your best to eat to meet your energy (calorie) and protein requirements during the treatment is so important. When the body is not receiving the nutrition it needs, it is rather like trying to run the car when the petrol tank is empty.
Today I was called in to see a lovely gentleman who informed me that all he had been eating was fruit and ‘a few extra bits’ over the past few weeks. During this time his weight had dropped a further 10 kg (22 lb) to 59 kg (130 lb). He was having trouble getting up and taking a shower, and he just didn’t feel like going out or catching up with friends. He was very weak, and when I left him he immediately fell asleep.
While some of the reasons he was having trouble with his food had to be unravelled with the medical team, the key issue was that, as his food intake was well below ideal, he had become malnourished. His body was so run down that the actions of getting out of bed, sitting in a chair and taking a shower were all a challenge. Little wonder he felt so low in himself, with limited interest in getting out with friends, not to mention his frustration at having his treatments cancelled because his bloods showed that his body had not recovered from his last dose of chemotherapy. Chemotherapy is normally worked out according to a person’s weight, and if there is significant weight loss the dose usually has to be reduced, which can affect the potency of the treatment.
Most of us think of malnutrition as only being a problem in countries of the Global South exposed to famine situations. However, it is one of the biggest problems in the NHS. My gripe is that, all too often, people are referred to me when they have already become extremely malnourished and when their treatment is already significantly under way, instead of earlier on, when intervention would have had a better effect and would have helped prevent the associated complications. We hear so much about the problems of obesity in our society, but in actual fact it is the problems of disease-related malnutrition that cost our health system more. While awareness of disease-related malnutrition is being actively promoted in the community and healthcare institutions, a much greater collaborative effort to intervene earlier is still needed. Like this gentleman, people live with low energy and experience more problems with infection, with the result that their treatments are affected – and often because their nutritional health was left to dwindle.
The more you can do to eat well and embrace the type of diet that can best support you, the better your treatment outcomes are likely to be. This also means being proactive if you are having difficulties, and asking for extra help sooner rather than later.
Your diet can influence the appearance of your skin, eyes, stamina, shape, strength, bowel function, immune system and even mood; doing your best to eat the right sort of foods in the proportions you need at that particular time can really make a difference. This means different things for different people depending on the type and stage of cancer you have, but whatever you can do to ensure your diet supports you in the right way is beneficial.
Ways nutrition helps support your treatment for cancer
Good nutrition helps you to
•cope with optimal treatment options and doses;
•recover and heal;
•maintain a healthy body size and shape;
•better manage treatment side effects;
•reduce some risks of recurrence;
•boost immune system function and fight off infection, preventing unnecessary setbacks and hospital stays;
•feel more energized and cope with common problems associated with fatigue;
•ensure your body is equipped with a good store of the key nutrients such as iron, calcium and zinc, along with other vitamins and minerals;
•improve your ability to concentrate and manage daily tasks;
•improve mood;
•possibly reduce recurrence risks, according to emerging evidence.
One of the most difficult concepts for many people with cancer to grasp is that they may need to adopt very different dietary approaches from those they may have been used to, and from those widely promoted as healthy dietary guidelines. These are the well-known guidelines which recommend eating more fruit and vegetables, grains, lean meats, fish and low-fat dairy foods, and limiting fat, sugar and salt in the diet. They have been represented pictorially over the years as pyramids, healthy plates and the like, and I’m sure you’re very familiar with them.
However, it is important to realize that you may need to make some changes to what you know as healthy eating. Usually when people are well they have no trouble eating enough food and can manage the extra bulk and fibre provided by a healthy diet. Owing to treatment side effects and the burden of the cancer on the body, though, you may actually need to reverse accepted ideas about healthy eating and to eat in an opposite way to how you may have eaten in the past. You may need to focus on eating more snacks and higher-calorie foods, using extra butter, salt and at times sugar. Quite often I tell people that they may need to start eating like a stereotypical teenager! This can be quite difficult as most of us have our eating habits fairly ingrained. So I often encourage people who are having difficulties to think back to their teenage years and eat as they may have when it was cool to hang out with their friends at McDonald’s and the like. While my views and food preferences are now quite different, I well remember begging my parents to take us out for a burger and my old favourite of a caramel sundae!
If you have a cancer which is not associated with any nutritional problems, remember that guarding against muscle loss and nutrition depletion is the biggest priority during treatments, and it may be appropriate for you to start with a dietary approach recommended for people who are well into their cancer treatments.
The fundamental role of a specialist cancer dietitian or nutritionist (as some practitioners prefer to be called) is to help mitigate the impact cancer and its treatment can have on your nutritional health. This is important as it relates to how well your body copes with the treatment and to your overall ability to cope. It affects your recovery, your energy levels and your ability to resist infections, and it can also impact on other longer-term health outcomes.
To ensure that we are best placed to give sound advice on diet and cancer, cancer dietitians work hard at keeping up with the scientific literature, including constant reviews of the evidence around diet and the many types of cancer. We also participate in continuing education, which includes attending regular updates with other specialist oncology dietitians. We have meetings with the nutritional supplement companies, we work with colleagues to review best practices, and as most of us work in the NHS or have worked in hospitals we have the advantage of being able to continually learn from our other healthcare colleagues, including doctors, nurses and other cancer specialist practitioners.
In our first meetings with people with cancer, we take time to review their individual situations. This includes not just looking at their medical history and blood results, but also understanding their current situation, their social supports and how they are coping. We find it useful to know what type of cancer they have and at what stage, where they are in terms of their treatment, whether there are any struggles or side effects affecting their dietary intake or tolerance, what they are managing to eat and how this measures up to their current requirements.
I personally also like to know what people hope to gain from their treatment and what they feel are the best and most manageable options for them to engage with so that nutrition will make a difference. People work in different ways, but I have found that many of my patients head home from their day at the clinic quite overloaded with information, not to mention ‘chemo brain’. Hence I always put together a personalized food plan that they can put on the fridge door. In addition to outlining the key recommendations, I aim to cram in lots of new and refreshing food suggestions for them to try, or at least to refer to at a later stage. Prescribable nutrition supplement drinks or special feeds may also need to be considered.
There are of course many doctors, specialist nurses and health professionals who advise on nutrition, and this is usually a good starting point for advice in a cancer clinic. However, the benefit of seeing the dietitian is that you can seek out the best options for you, tapping into the expertise and practical nutritional know-how we have acquired from working specifically in this area.
There are many people who claim expertise in nutrition, those I like to describe as the fringe-dwellers. While they make big claims, quite often they do not have any real clinical training or experience. These people can often do more damage than good and can be recognized as the ones who claim that nutrition can cure just about anything. I really hate it when I see someone who walks in after meeting an alternative-type quasi-nutritionist, and who has been promised big outcomes if he or she signs up to a particular nutritional therapy approach. In addition to weird diet recommendations, there is the sheer cost of such programmes, and often people will have spent a fortune on large amounts of supplements. One of the doctors who ran the Living Well programme at our clinic told of a lady she once met who was somehow managing to take 126 nutrition type supplements a day! The internet can also be lethal as far as these kinds of nutritional traps are concerned. I always warn people to be very wary about handing over credit card details or buying supplements on the internet without first talking to their doctor, nurse specialist or a dietitian like me about whether the purchase will in fact provide any real benefit.
The final piece of information you should know is that dietitians are the only legally recognized nutrition health professionals in the UK. They are registered by an independent body called the Health and Care Professions Council (HCPC), which regulates health professions in order to protect the public. The HCPC maintains a register of nearly 8,000 dietitians, and if you go to its website, <www.hpc-uk.org/>, you can check whether or not a practitioner is registered.
As I mentioned, when an individual first consults me I spend time reviewing the medical history, the stage and type of the cancer, the prognosis, treatments completed or planned, any nutritional problems or difficulties with eating normally, blood test results, any changes in bowel function, problems swallowing, taste changes, digestive difficulties, difficulties with nausea or vomiting, and activity and general energy levels.
I will be especially interested in whether a person has had any recent shape or body weight changes and, if so, in considering what might be the main contributory factors. It is important to learn what people normally like to do with their diet and what they are managing at this time. I will want to understand how someone approaches the shopping and cooking and whether any help or support is available, especially when the individual may not be feeling well.
When I meet people I am always very pleased to hear that they are interested in nutrition and have looked at ways to improve their eating habits. However, because of the complex nature of cancer, I always recommend that they take the time to discuss their planned dietary approaches with their medical team, and if possible with a specialist dietitian. The right approach helps make the whole cancer experience more manageable, and I would also hope that people enjoy the extra goodness that can be gained from eating well during their treatment.