When considering dietary approaches, it is important to be aware that cancer and its treatments can be broadly divided into certain key stages. It is important to then understand what effects the cancer and treatments are likely to have on the body at each of these stages, and how the diet should be framed around them. The stages of the treatment are often described as being part of the cancer journey. While some journeys can be relatively straightforward, others are filled with twists and turns which may not take you quite where you had hoped to be. It is important to be as prepared as you can for the entire journey, but also to understand that detours are often part of the course and may require different approaches to the diet.
While stages are not clear-cut and tend to cross over, key stages may be summarized as follows. This book focuses on Stage 2, the treatment stage.
This is the stage before a first cancer develops, and the dietary focus is on how to balance overall intake so as to reduce the risks associated with cancer development.
The World Cancer Research Fund (WCRF) is a wonderful charity dedicated to research and resource development on diet and exercise for cancer prevention. In 2007 this organization, in conjunction with the American Institute for Cancer Research (AICR), produced a landmark report, known as the Expert Report, which presented seven years of research evaluating the data around diet as a contributing factor to cancer and is the most comprehensive report ever produced on the links between lifestyle and cancer risk. The research was undertaken by leading scientists across the globe and is being used to develop strategies and action plans to help people eat better and be more active, with a view to reducing the risks of cancer. The Report looked at the half-million studies of the relationship between cancer and diet and physical activity, screening them down to 22,000, of which a final 7,000 were deemed relevant. Information from these then formed the basis of the recommendations for cancer prevention, drawn up by a panel of world-renowned experts. This was a rigorous and thorough process, and really constitutes the best advice we have to date globally on how to reduce your risk of cancer. While detailed dietary advice on this stage is outside the scope of this book, the main findings are summarized below.
•Maintain a healthy weight. Be as lean as possible without becoming underweight.
•Be physically active for at least 30 minutes every day.
•Avoid energy-dense foods, particularly processed foods that are high in added sugar, low in fibre or high in fat, and sugary drinks.
•Eat more fruit, vegetables and plant foods, including wholegrains (cereals) such as rice, oats, pasta and bread, and pulses such as lentils, chickpeas and beans.
•Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats.
•Limit salt intake, salty foods and foods processed with salt (sodium).
•Limit alcohol – if consumed at all, alcoholic drinks should be limited to two a day for men and one a day for women.
•Don’t use supplements to protect against cancer – get your supplements from foods, not pills. Research suggests that it’s better to choose a balanced diet with a variety of foods rather than high-dose nutrient supplements, in order to reduce your risk of cancer.
Meanwhile I would recommend any family members who want more details to go to the UK World Cancer Research Fund website at <http://www.wcrf-uk.org/>.
This is the key stage around which this book centres. It should be viewed as a window of opportunity in which your diet priorities can be geared to support and boost you. There is quite a spectrum of dietary approaches, depending on how well you are tolerating your diet. The basic starting point for people who are fortunate in being otherwise well and who are not having any trouble eating or maintaining a healthy weight is a good varied and healthy diet – do visit WCRF’s website. There is more on this in Chapter 10.
However, if you are having even a little trouble, have a more advanced cancer or have simply lost your way with food, it is important to experiment with alternative dietary approaches to help meet your biggest nutritional priority at this time, which is to ensure you are as strong as you can be for your treatment. This may at times require you to eat differently, take supplement drinks or in some cases accept other ways of feeding, called enteral or parenteral nutrition support. This is not the time to start redlining key food groups out of your diet.
Energy intakes
Energy intakes need to match up to the energy your body is using for all the tasks required to function well during your treatments. If you do not meet these requirements, your body will need to take stock and start cutting back on these functions. It is rather like a company which has had to make some of its staff redundant and cancel some contracts because it can no longer afford to pay the wages.
A struggling company may be able to go on as normal for a short while, but sooner or later it will need to make some tough decisions to cut costs so that it can continue to survive. The body often has to make these tough decisions if nutritional supplies continue to fall short of its requirements. Cutbacks will normally be in the areas of functions that are not absolutely essential, such as energy for extra activity, energy for a better mood, energy to think straight and energy for the immune system.
The objective of eating at this stage is to encourage individuals to make the effort to eat as well as possible even if they don’t feel like it. Being better nourished helps them have more energy and feel like doing more; it also helps prevent problems due to infection or dehydration.
However, this stage can be difficult, and it is important for family and loved ones to respect the fact that eating is not always easy and can at times cause pain. It can be hard for the family to accept that you may not want to eat, and this can cause a great deal of unnecessary stress and friction. Food is something with which many of us express our love, but it is equally important that family know and respect the ground rules, which include acknowledging that you may not always feel like eating or finishing what’s on your plate. It is also important that mealtimes should be celebrated as time spent together and need not be about what or how much you eat. This is also important if you are being fed with a feeding tube. While it can be difficult and feel odd, I still encourage people to make the effort to sit down with the family at mealtimes if this has been the normal ritual. There is much more to the family mealtime than just eating – the focus at this time should be on enjoying each other’s company, catching up on news, laughing and having an enjoyable mealtime experience.
Moving on can vary, as some people will be lucky enough to have stayed quite well during their treatment while others will feel very drained and need more time to recover from the side effects. However, although daunting for many people, it can be the best time to undertake an audit of those not-so-perfect habits around diet, activity levels and other key areas of your life, and work out how to move forward. You may wish to refer to my booklet, Eating Well and Being Active Following Cancer Treatment. It can be ordered or downloaded free of charge from the WCRF website (<http://www.wcrf-uk.org/PDFs/EatingWellBeingActive.pdf>.)
We are fortunate these days to have an ever-increasing range of incredibly potent cancer treatments such as chemotherapy, radiotherapy, biological therapies and surgery. However, in the process of destroying cancer cells, many of the body’s healthy fast-growing cells can be damaged. These include bone marrow, which is responsible for blood cell production (this one is the key driver behind the blood counts), the hair follicles, the immune system and the core lining of the digestive tract right through from the mouth (taste buds) to the other end of the bowel. It is the damage done to a good number of these high-turnover healthy cells that often has the most impact. This is the reason for many of the physical symptoms people have during treatment, and at times it will also interfere with your ability to eat well.
At the same time, these are the organs or body parts which are more likely to be drained by poor nutrition. This is because they are working overtime to try to repair the damage, and constant nutritional supplies are required to enable them to be replenished.
The lining of the digestive tract has two major roles. First, it enables the body to absorb nutrients from the food we eat: the process called digestion. You may not know that the digestive tract or the bowel is considered to be an outer part of the body, rather like an arm or a leg. It is like a brick wall that helps keep unwanted visitors out. The gut also acts as a big security guard or barrier that prevents unwanted bacteria or viruses from getting into the bloodstream where they can cause more serious infections.
When the cells lining the gut are damaged by the effects of some treatments, it can be more difficult to taste and properly digest higher-fibre foods, too much lactose (dairy foods) or too many rich foods. This can also impact on how well the gut is able to prevent what is called the translocation of bugs into the bloodstream, especially if food intake is poor over an extended period of time, when the gut wall becomes thinner and more porous.
Red and white blood cells have many important roles in cancer treatment; if your nutritional health suffers, this can reduce the ability of the body to produce enough blood cells to cope with certain treatments.
Specifically, lack of red blood cells (anaemia) reduces the body’s capacity to carry oxygen from the lungs around the body, contributing to fatigue and shortness of breath. This also means there is a reduced amount of oxygen circulating in the body, which affects the function of all body cells and tissues.
The white blood cells are the body’s soldiers or defence forces against infections and other internal insults. If you have a low count of white blood cells such as neutrophils you will be at a high risk of infection, and this is why you will be started on antibiotics and told to keep out of public places and to eat a low microbial diet. For more about this, see Chapter 8.
Around a third of our nutritional intake is used to keep our immune system functioning. One of the main ways in which poor nutrition can affect this is thinning of key barriers such as the skin and the lining of the digestive tract, as mentioned above. Furthermore, it can cause a significant reduction in body proteins and the specific bacteria-fighting cells such as the white blood cells, with the result that we are less able to fight the cancer.
During cancer treatment, the body is working overtime to try to heal and to rebuild the damage done to healthy tissues and cells. If the body is not well nourished, this healing process can be slow as the extra nutrients needed are in short supply. If you are having chemotherapy and your blood counts do not recover between treatments, then treatment doses may need to be reduced or delayed. This may affect your treatment response.
Evidence shows that people who are well nourished are able to heal and recover faster than those who are nutritionally compromised. Hospital stays are also normally shorter and associated with fewer complications in people who are stronger and well nourished.
If you are not eating enough to maintain your weight and meet your increased protein requirements, the body takes on a rationing approach to the fuel supplies it is able to access. It is rather like a petrol strike: when limits are placed on the days you can buy fuel and the amounts available, you will not be able to drive as far as you normally would.
Our bodies use up quite a lot of fuel. In particular, the brain uses a staggering amount – around a quarter of the food energy we consume. Fuel is also need for the pumping efforts involved in keeping the heart and lungs functioning, as well as the liver, the kidneys and other major organs. If a fuel shortage threatens, though, the body’s management systems start to make tough rationing decisions. Cutbacks will normally take away the energy needed for activities and functions that are not essential for survival. This may include energy for extra activity, energy for a better mood, energy to think straight and energy for the immune system.
The body also needs a constant supply of glucose to enable the brain and other vital organs to keep functioning. If you are not taking in enough food, it must break down muscle and fat stores to top up supplies. As the majority of the body’s protein stores are in the form of muscles, this breaking-down process incurs definite losses which affect tone and strength. And as the arms and legs are not the only stores of muscle, muscle stores are also drained from within the heart, lungs, digestive tract and immune system.
Think, for example, of the main role of the heart and lungs: to enable us to breathe in oxygen and then pump it around the body. When muscle is lost from the heart and lungs, these essential processes can also be affected. This means it takes the body much more effort to breathe in and move sufficient oxygen. Getting rid of waste products, including carbon dioxide, is also done more slowly. This can have a big effect on stamina and energy levels.
The psychological impact of cancer can be enormous. One of the most difficult areas can be the way loss of appetite or a change in shape can affect people’s social life and how they feel about themselves. A change in appearance – either losing or gaining a lot of weight – tends to make people feel very self-conscious, and it is a common reaction to want to hide away or to disguise yourself in unflattering clothes. The way you appear to yourself and others can also be a constant reminder of illness. Many people find it very hard to deal with this.
At times, given the nature of the illness, changes of this kind are almost unavoidable. However, I do hope that such reminders help you realize again the importance of keeping track of your nutritional health, and of finding practical ways in which you may limit the impact of cancer and its treatment. As I’ve said before, this doesn’t always have to involve huge changes or a superhuman quest. Investing in the effort to nibble when you are not feeling hungry and adjusting some of the usual ways you eat are small things that you can do for yourself. Such changes may make a big difference in your treatment outcome, and also will give you more confidence, help you maintain energy, boost your concentration and enable you to keep enjoying the life you want. So if you do look in the mirror and feel discouraged, sad or distraught, bear in mind that while this is a natural reaction, there are also ways you can take action to change things.
Cachexia is a wasting syndrome with loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite in someone who is not actively trying to lose weight. It is also known as anorexia cachexia syndrome.
There are certain cancers which affect the way the body metabolizes the food that is ingested. Up to six out of ten people (60 per cent) with advanced cancer develop some degree of cachexia. It is also why some people find they keep losing weight despite their best efforts to eat as well as they can.
Cachexia (kak-ex-ee-a) comes from the Greek words kakos, meaning ‘bad’, and hexis, meaning ‘condition’. ‘Anorexia’ simply means ‘loss of appetite’ – though, as mentioned, cachexia is more than a simple loss of appetite. It is a very complex problem involving changes in the way your body normally uses protein, carbohydrate and fat.
It isn’t usual to develop cachexia in the early stages of cancer. Cachexia in advanced cancer can be very upsetting and can make you feel very weak. It isn’t just associated with cancer, though. It is common in the advanced stages of other illnesses such as heart disease, HIV and kidney disease.
Cachexia is more common in people with lung cancer or with cancers anywhere in the digestive system. The main symptoms are:
•severe loss of weight, including loss of fat and muscle mass
•loss of appetite
•feeling sick (nausea)
•feeling full after eating small amounts
•anaemia (low red blood cell count)
•weakness and fatigue.
The processes of cachexia are not fully understood, but it is thought that the cancer releases chemicals into the blood that contribute to the loss of fat and muscle. These chemicals may make your metabolism speed up so that you use up calories faster – a bit like the body putting its foot on the fat and muscle burn accelerator. Because your body is using up energy faster than it is getting it, severe weight loss may result even if you are eating normally. This may also be exacerbated by the side effects of cancer treatment.
Changes that may occur include the following:
•Fat stores are broken down to top up the body’s energy needs. They become difficult to re-stock as the fat is broken down more quickly and the rate at which the body stores fat is reduced.
•Protein requirements are met through a process that eats away at vital organs, muscles and the immune system. This has an effect on the weight lost, and on grip strength and functional abilities. There may also be an increased risk of infection.
•Carbohydrate is burnt for energy at a greater rate and some of this is wasted through inefficiencies, which may account for an additional 300 kcal.
It is also because of cachexia, and the changes in the way the body uses the nutrition that you can ingest, that it becomes very difficult to reverse the weight loss associated with cancer. This is why, if you have cancer, the best insurance policy you can take out is a commitment to early and continued nutritional therapy, particularly if you are having difficulties with your food intake. Protecting your muscle and energy stores and the reserves needed to deal with the treatments is one of the prime goals of your treatment that you personally can attend to.
Having waved red flags around the need to nourish your body well and to guard against weight loss, I must stress that it is also important to understand that some types of cancers, mostly the hormonal types, are associated with weight and body fat gains.
Although it is important to nourish your body and to eat in the best way you can during treatment, many people are surprised to discover that they are ravenous a lot of the time and crave more sugary foods. The associated weight gain can vary from around 1–2 kg (2–4 lb) up to 10–20 kg (22–44 lb) in extreme cases.
There are many reasons why certain individuals are prone to weight gain, apart from the types of cancer they have. Certain treatments including hormone therapy, at times the earlier onset of menopause, some types of chemotherapy, and medicines such as steroids can cause weight gain. Some treatments can also cause your body to retain water, which makes you feel puffy and gain weight.
Although there are many factors that contribute to the potential for weight gain, there are two basic prongs in the equation:
1Because of an increase in appetite and, sometimes, changes in food preferences towards more sugary, high-fat foods, people tend to feel hungry and eat more of these higher-calorie foods. The general rule still holds good: you gain weight when you eat more calories than your body needs.
2Because of fatigue and feelings of lethargy, there are often changes in activity levels. This means you may not be burning as many calories as before, and the lower levels of exercise mean that you tend to put on more fat weight and to lose muscle. This explains some of the changes in body shape and composition that may also occur.
Weight gain, changes in body shape, feeling fatigued and, for some, hair loss can be difficult pills to swallow. The good news is that the treatments will improve your chances of survival, and the odds are now so much better than in years gone by. At the last count, in 2009, there were around two million cancer survivors in the UK. This is around 13 per cent of the population. Doing what you can to eat well, managing the excessive sugar cravings and being as active as you can are not only helpful strategies to keep you well, but can distract you and pull you through the difficult times. A walk in the park, on the beach or even around an interesting farmer-type market will get you out of the house, and more often than not you will feel so much better for making the effort.
At our clinic we now have an exercise specialist who advises individuals on suitable activities and programmes. Exercise has many benefits during treatment. It can:
•make you feel better;
•help you maintain a healthy weight;
•boost fitness and stamina;
•build muscle;
•reduce the risk of cancer recurrence.
Of course, at times it is not possible to do as much activity as you may like. It is important to listen to your body to be sure you do not overdo things. It is also best to talk to your doctor and specialist team about an appropriate level of activity for you. For some it may seem difficult to walk as far as the front door or further than the front of the house, while others may feel they can manage to continue much as normal. It is an individual equation; however, unless you are feeling very unwell, try not to hibernate on the couch for too long.
Although this is still an emerging area of research, excessive weight gain during treatment may increase risks of other associated longer-term health conditions such as heart disease and diabetes. Evidence also suggests that it is associated with increased recurrence and so with survival rates.
Sometimes weight gain may be associated with endocrine issues such as insulin resistance, contributing to treatment-associated weight gain. If you find you are gaining weight despite your best efforts to eat well and be active, you should talk to your doctor about your concerns, sooner rather than later.
The need for good nutrition does not end the minute you walk out of the clinic door for the last time. On the contrary, now is the time to be building up your future health with a vengeance. In addition, the effects of some cancer treatments make themselves felt for several weeks afterwards, so you may need to continue implementing the suggestions given for coping with specific treatments in Chapters 6 and 7. I also look at this subject in Chapter 10.
You also need to bear in mind that, after treatment ends, cancer survivors may be at increased risk of recurrence of the cancer, or of the development of a second cancer or other health conditions such as heart disease, type 2 diabetes and osteoporosis. Your follow-up care will monitor this closely, of course, but, to reduce the risk of further disease, doctors generally recommend that people follow common nutritional recommendations, including eating fruits, vegetables and wholegrains. The effect of specific dietary factors on cancer survival rates is not well understood and is actively being studied. According to WCRF, there is growing evidence that physical activity, a healthy weight and a balanced diet may help to prevent cancer recurrence, particularly for breast cancer. Until this is fully proven, WCRF advises following its recommendations for cancer prevention (visit: www.wcrf-uk.org/cancer_prevention/recommendations.php>). My booklet, Eating Well and Being Active Following Cancer Treatment, provides some recommendations and practical suggestions to assist you to take all this forward. It can be obtained for free – see page 18.