Cancer: Nutrition During Treatment

New Research: Breast Cancer Low-Fat Diet

Friday, September 14, 2007 - 2:13pm

By Dena McDowell, MS, RD

According to the United States Mortality statistics in 2004, cancer-related deaths came in number two of all deaths in the U.S. In 2007, 26% of all newly diagnosed cancer cases were breast (176,436 new cases). And in 2007, 40,515 women died of breast cancer in the United States. With statistics as startling as these, researchers are searching for answers. There is a known link between certain forms of cancer and diet .

Diet and Breast Cancer

A new study called the Women's Interventional Nutrition Study (WINS) was published in the December 2006 issue of the Journal of the National Cancer Institute by Rowan Chlebowski, M.D., Ph. D and colleagues. These scientists recently revealed that a diet low in fat may reduce a women's chance of breast cancer recurrence. Over 2,400 post-menopausal women who were diagnosed with stage I breast cancer and treated by conventional methods participated in this study. The main goal of the study was to reduce dietary fat intake to 15 percent of total daily calories. Forty percent of the participants were part of a low-fat group and received intense dietary counseling, whereas the other 60 percent of participants were part of the control group and received nutrition information on low-fat eating without intensive counseling. Both groups started out eating 30 percent of their daily calories from fat (56.5 grams on average between the two groups). However, by the end of the five-year research period the counseling group reduced their fat intake to a mere 33 grams a day, whereas the control group only reduced their intake to 51 grams a day. After the five-year study period, the counseling group had a 24 percent reduction in breast cancer recurrence.

Low-fat diet reduces cancerous tumor formation

Previous research shows that low-fat diets reduce the risk of estrogen receptor (ER)-positive breast cancer; however, this study showed of the 24 percent reduction, there was only a slight decrease in estrogen-fueled tumors. However this study noted a 42 percent decrease in non-estrogen fueled tumors. Researchers are now interested in learning more about the connection of low-fat eating and other factors such as weight loss (the counseling group lost an average of 4.6 pounds) and reduction of risk.

The Low-Fat Diet/Breast Cancer Take-Home Message

More research needs to be done to determine the exact mechanism of diet and breast cancer risk reduction; however, we do know that losing weight by cutting calories can reduce the risk of many health conditions such as cancer, diabetes, heart disease, and stroke. According to the American Cancer Society, every state in the U.S. except for one has at least 55 percent of its population falling into the overweight category. This is based on having a body mass index (BMI) of 25 or greater. As our nation continues to grow, so do the related health problems. Losing weight will help reduce the risk of developing certain forms of cancer including breast, heart disease, stroke, and diabetes.

Plan to Lose Weight

As this study shows, even a small reduction in body weight may reduce your risk of breast cancer recurrence. To reduce your risk of developing weight-related health problems, it is best to seek the advice of a Registered Dietitian to help with meal planning and calorie assessment . Other things to help promote a healthy life are to eat foods low in fats, eat more whole grains, fruits, and vegetables more often. Keeping a food log may help prevent over-eating and hold you accountable for unhealthy food choices. Adding exercise is also a great way to shed extra unwanted pounds and convert body fat into muscle. Losing even a small amount of weight will help promote a healthier body and reduce your risk of weight-related diseases.

Nutritional Needs of the Bone Marrow Transplant Patient

Thursday, June 14, 2007 - 5:52pm

By Dena McDowell, MS, RD

Bone marrow transplantation is a relatively new medical technique used in the treatment of certain blood cancers. People who suffer from aplastic anemia, certain forms of leukemia, and lymphoma or multiple myeloma may be candidates for transplantation. Patients undergoing transplantation have specific nutritional needs during their hospital stay and after as they continue to recover and regenerate their immune system. This article outlines the nutrition plan recommended for these patients.

Types of bone marrow transplantation

Patients may receive stem cells from either themselves or from a donor. Receiving your own cells is known as an autologus stem cell transplant. Receiving cells from a donor is known as an allogenic stem cell transplant. Each type of transplant carries its own risks; however, the autologus transplant usually has a quicker recovery time and less stringent dietary rules as compared to the allogenic transplant. In either case, it is important to follow safe food handling practices as well as practice prudence in food selection and preparation.

Nutrition while in the hospital

In either case of transplantation the patient's immune system is altered for a period of time. During this time the patient follows a neutropenic diet. As the cells engraft, the white blood cells return to normal and the neutropenic diet restriction is lifted. Patients often will have nausea and vomiting, taste alterations, and a heightened sense of smell during their hospital stay. The dietitian working with this patient will adjust the menu patterns accordingly to make foods palatable while trying to provide a high-protein balanced diet. Some patients will suffer from sores in the mouth and throat, making eating painful. In this case, following a liquid diet supplemented by nutritional shakes will help the patient meet his/her dietary needs. If the patient is unable to eat due to nausea, vomiting, diarrhea, or mouth sores, nutrition support either through a feeding tube or through a vein may be used temporarily to meet dietary needs. The patient's weight and labs, including protein status and electrolytes, will be analyzed by the dietitian and recommendations will be made to correct nutritional imbalances and well as prevent excessive weight loss.

Nutritional needs at home

Patients receiving transplants must follow strict dietary restrictions while at home to prevent food-borne illness.

Autogenic transplant guidelines

Patients need to avoid the following foods for 30 days post-transplant (or until the physician lifts the diet restrictions):

  • Raw or undercooked meat
  • Poultry
  • Fish
  • Game meats
  • Eggs
  • Hot dogs
  • Sausage
  • Tofu
  • Cold smoked fish
  • Lox
  • Unpasteurized dairy products
  • Deli items including meats and prepared foods
  • Soft cheeses
  • Unpasteurized honey
  • Unrefrigerated cream-filled donuts
  • Unpasteurized fruit and vegetable juices
  • Raw nuts
  • Popcorn
  • Unwashed herbs
  • Fruits and vegetables
  • Alfalfa sprouts
  • Unpasteurized beer.

It is also recommended that patients follow proper food safety including washing hands before food preparation, washing countertops, using separate cuts boards for meat and vegetables, cleaning the tops of cans before using, washing towels daily, defrosting all meat and poultry in the refrigerator before using, and freezing all leftovers for later use.

Allogenic transplant guidelines

Patients receiving donor cells need to follow the same precautions for 100 days post transplant (or until the physician lifts the diet restrictions). These patients also need to avoid well water (unless tested and free of coli forms) and food from street vendors or coffee carts.

Restaurant eating after a bone marrow transplant

Patients receiving either type of transplant need to exercise caution when eating in restaurants. If choosing to dine out, follow these simple rules:

  • Pick restaurants with good reputations (check with your local health department for details).
  • Avoid peak dining hours or ask to be seated away from high-traffic areas.
  • Avoid salad bars and buffets.
  • Ask how foods are prepared and make sure meats are cooked well before eating.
  • Order items without condiments to ensure freshness.
  • Avoid the condiment bar and ask for individually-wrapped packets instead.
  • If taking carry-out, reheat before eating to ensure proper temperature.

Other things to consider after your transplant

Although the patient must follow strict dietary restrictions, it is also extremely important to eat well after transplant. Eating enough calories and protein will help promote a quicker healing time. Including whole grains, fruits, vegetables, meats or meat alternatives, cheese, and dairy every day will help meet daily needs. Log onto for more specific needs based on age, gender, and activity level. It is also recommended that patients take an iron-free daily complete multivitamin after transplant. Taking this supplement will help ensure the patient is meeting their dietary needs. If the patient is taking corticosteroids (often prescribed to prevent or treat graft-versus-host disease) then it is important to increase consumption of calcium because this type of medication can weaken the bones. If being treated for multiple myeloma, speak to the physician for calcium recommendations. If on corticosteroids, blood sugar levels may also be temporarily altered. Insulin or a diabetic diet may be warranted to help control blood sugar levels.

Conclusion: the right diet is key to success of the transplant

Stem cell transplantation carries specific dietary requirements in order to successfully regenerate the immune system. Following the dietary restrictions and working closely with a dietitian will help the patient meet his/her daily needs.

Fat and Fiction

Thursday, May 31, 2007 - 12:10pm

The following excerpt is adapted from Women and Cancer Magazine

What to Eat If You Have Cancer: Healing Foods That Boost Your Immune System by Maureen Keane, MS, and Daniella Chace, MS (McGraw-Hill, 2006).

Our diets comprise three macro-nutrients: carbohydrates, proteins, and dietary fats. Most dietary fats come from animal sources such as meats, dairy, and eggs, but they may also be found in plant sources, including nuts, seeds, avocados, and flaxseed. Each of these foods contains different types of oils that are associated with a variety of activities in the body, including the suppression or encouragement of cancer.

A global effort to define "healthy fats" for cancer patients

Conflicting results from research on diet are everywhere in the news, and the research on dietary fats is no exception. Although there appears to be many conflicting studies, a closer look reveals that those conducted on humans produce fairly consistent results. This is because many studies on diet are conducted on animals, and humans differ enough from animals that findings from these may generate misleading results. Once the animal studies were eliminated from this evaluation, the findings on dietary fat were fairly clear.

Over the past 18 months, numerous studies have been conducted throughout the world that address specific types of cancer and how each of the animal and plant oils affects them.

1.   Omega-3 fats and hormone-sensitive cancers

Research recommends against omega-3 fats for patients with hormone-sensitive cancers such as breast and prostate.1

2.   Fish oils and breast cancer

The benefits of fish oils for people with breast cancer have long been debated. The most recent large-scale studies that looked for a connection between fish oils and breast cancer have failed to find preventive effects.2

3.   Fish oils and hormone-sensitive cancers

Although fish oils are a healthful part of the diet for most of us, they should be minimized in the diets of patients with hormone-related cancers.3 At this point we know that eicosapentaenoic acid(EPA) is good for patients with cancer but not for those with hormone-sensitive cancers such as breast and prostate.

4.   Cancer patients and beneficial fats

A 2005 study reported in the European Journal of Oncology Nursing suggests that many cancer patients may be deficient in EPA due to an increase in nutritional needs when cancer is present. Studies suggest that increasing EPA-containing foods in the diet or supplementing with EPA capsules can reverse EPA deficiency and improve immune function. Studies also found that EPA has been shown to have specific anti-tumor effects.4 EPA also plays an important role in preventing inflammation, and polyunsaturated fatty acids improve immune response. This study also recommends against omega-3 fats for patients with hormone-sensitive cancers such as breast and prostate.5

5.   Extravirgin olive oil and the spread of cancer

Recent research combined human study reviews and animal studies and found that extravirgin olive oil contains concentrations of polyphenols, which appear to suppress the development and the spread of cancers across the board. This is a very exciting study because it helps answer some questions surrounding conflicting studies on olive oil and cancer. It appears that olive oil that has been extracted with chemical use-meaning oils that are not extravirgin-do not have these anticancer properties because they do not contain the beneficial polyphenols. Extravirgin olive oil retains its polyphenols, however, thus differentiating it from the more highly processed varieties.6 Olive oil also contains monounsaturated fatty acids and specific compounds (squalene, tocopherols, and phenolic) that are associated with its anticancer properties, particularly for colon cancer.7

6.   A compound found in fats that protects

A very recent study in the journal Anticancer Research reports that conjugated linoleic acid (CLA), a compound found in animal fats and sold as a supplement, has a protective effect against breast cancer.8 Because CLA itself is beneficial for breast cancer but animal fats should be minimized, supplementing with just this compound may be more beneficial than trying to derive it from foods.


Defining fats

1.   Saturated Fatty Acids

Fats from meats, such as sausage and bacon; dairy products, such as butter, cheese, cream, and ice cream; and some plant oils, such as coconut and palm oils.

2. Polyunsaturated fatty acids

Omega-3 Fatty Acids

  • Alpha-linolenic acid (ALA) from soybeans, walnuts, flaxseed, and their oils
  • Eicosapentaenoic acid (EPA) from fish and fish oils
  • Docosahexaenoic acid (DHA) from fish and fish oils

Omega-6 Fatty Acids

  • Gamma-linolenic acid (GLA) from evening primrose oil (EPO), black currant seed oil, and borage oil
  • Linoleic acid (LA) from cottonseed, sunflower oil, safflower oil, EPO, soybeans, wheat germ, and pumpkin seeds
  • Conjugated linoleic acid (CLA) is created in our bodies from ingesting linoleic acid; also found in meats such as beef, lamb, and poultry; dairy products such as eggs, cheese, and yogurt; and plant foods, including safflower oil and sunflower oil
  • Archadonic acid (ARA) from meats, eggs, and poultry


Shopping for high-quality, healthy fats

Finding high-quality, healthy fats is fairly simple if you know what to look for. Generally, avoid the low-quality fats such as hydrogenated oils (found in many crackers, chips, and packaged baked goods) and excessive intake of saturated fats from animal products. The following are shopping suggestions based on a healthy, whole-foods diet.

  • Beef. Look for organic, grass-fed, lean beef.
  • Fish. Choose wild, small fish (under 4 feet long) to avoid mercury contamination.
  • Eggs. Buy hormone-free, organic eggs (to avoid pesticide or herbicide residue) from cage-free or free-range hens.
  • Milk. Choose hormone-free or organic (inherently hormone-free) milk that states it is free of bovine growth hormone or bovine somatotropin.
  • Nuts and seeds and their oils. Choose organic if possible; be sure they are fresh and smell nutty, not fishy.
  • Avocados. Eat them when they are ripe (soft); because avocados are not generally sprayed with agricultural chemicals, it's not necessary to buy organic.
  • Flax oil. Choose fresh, organic oil and keep it refrigerated.
  • Olive oil. Buy an extravirgin variety (extravirgin indicates that the oil is from the first press of the olives and that no chemicals were used in the extraction process.

Proper Storage and Use of Oils

Store oils in a dark, cool place because heat, oxygen, and light will chemically change their composition. It is also important that you not heat oils to the point that they start smoking. Excessive heating causes a chemical change in oils that makes them unhealthy to ingest. A recent Japanese study confirmed what many previous studies have also found: oils heated past the smoking point lose their nutritional value, and carcinogens are produced in the process.9 If you are cooking with oil and it starts to smoke, throw it away and start over.

Many labels indicate whether that particular oil is for cooking with low, medium, or high temperatures. For example, you should never heat flaxseed oil because it has a very low smoking point. Instead of cooking with it, use it as a salad dressing base or in smoothies. Olive oil, however, can be used for baking and sautéing.


1.   Summer spinach salad with edamame and citrus dressing

This recipe is supportive for all forms of cancer-and especially for prostate cancer-because it is rich in ALA from the soybeans (edamame), walnuts, and flaxseed oil.

juice of 1 lemon
4 tablespoons flaxseed oil
sea salt to taste
4 cups spinach, cleaned and chopped
1 cup edamame, shelled
½ cup walnuts, chopped

Whisk together the lemon juice, flaxseed oil, and salt. Combine the remaining ingredients in a large salad bowl and toss with the dressing.

2.   Garlic curry tuna salad sandwich

This recipe contains skipjack tuna, which is one of the safest canned fishes in regard to mercury. It's also a rich source of EPA and DHA. The walnuts are not only complementary in flavor and texture but also offer the recommended ALA.

6-ounce can of skipjack tuna
¼ cup minced walnuts
½ cup minced cilantro (optional)
2 cloves garlic, minced
1 tablespoon fresh lemon juice
1 tablespoon curry powder
1 tablespoon Nayonnaise (egg-free mayonnaise)
4 slices whole-grain bread, toasted

In a large bowl, combine tuna, walnuts, cilantro, garlic, lemon juice, curry powder, and Nayonnaise. Spread the tuna salad on toast and enjoy. Makes 2 servings.

[1]. La Guardia M, Giammanco S, Di Majo D, Tabacchi G, Tripoli E, Giammanco M. Omega 3 fatty acids: biological activity and effects on human health. Panminerva Medica.2005;47(4):245-257.

[2]. Engeset D, Alsaker E, Lund E, et al. Fish consumption and breast cancer risk. The European Prospective Investigation into Cancer and Nutrition (EPIC). International Journal of Cancer. 2006;119(1):175-182.

[3]. Christensen JH, Fabrin K, Borup K, Barber N, Poulsen J. Prostate tissue and leukocyte levels of n-3 polyunsaturated fatty acids in men with benign prostate hyperplasia or prostate cancer. BJU International. 2006;97(2):270-273.

[4]. Van Bokhorst-de van der Schueren MA. Nutritional support strategies for malnourished cancer patients. European Journal of Oncology Nursing. 2005;9(suppl 2):74-83.

[5]. La Guardia M, Giammanco S, Di Majo D, Tabacchi G, Tripoli E, Giammanco M. Omega 3 fatty acids: biological activity and effects on human health. Panminerva Medica. 2005;47(4):245-257.

[6]. Fabiani R, De Bartolomeo A, Rosignoli P, et al. Virgin olive oil phenols inhibit proliferation of human promyelocytic leukemia cells (HL60) by inducing apoptosis and differentiation. Journal of Nutrition. 2006;136(3):614-619.

[7]. Hashim YZ, Eng M, Gill CI, McGlynn H, Rowland IR. Components of olive oil and chemoprevention of colorectal cancer. Nutrition Reviews. 2005;63(11):374-386.

[8]. Wang LS, Huang YW, Sugimoto Y, et al. Conjugated linoleic acid (CLA) up-regulates the estrogen-regulated cancer suppressor gene, protein tyrosine phosphatase gamma (PTPgama), in human breast cells. Anticancer Research. 2006;26(1A):27-34.

[9]. Kawai K, Matsuno K, Kasai H. Detection of 4-oxo-2-hexenal, a novel mutagenic product of lipid peroxidation, in human diet and cooking vapor. Mutation Research.2006;603(2):186-192.

Review of “The Survivor Handbook: Eating Right for Cancer Survival”

Thursday, May 24, 2007 - 5:24pm

By Dena McDowell, MS, RD

Many people have heard the adage "You are what you eat." When it comes to surviving a cancer diagnosis, this phrase could not be more true. After receiving medical treatment to help manage or hopefully rid the body of the disease, many people wonder what else they can do to prevent a recurrence. Eating a healthy diet is one thing people can do to help themselves in their fight to survive. In The Cancer Project's free online book "The Survivor Handbook: Eating Right for Cancer Survival" Dr. Neal Barnard and Jennifer Reilly, RD discuss some dietary principles of cancer survival.

The principles of the Book

Section 1: Low-fat foods

This section explains why eating low-fat foods are important in preventing cancer recurrence. Homework for analyzing your dietary fat intake and looking for low-fat options are given at the end of this chapter. Low-fat recipes are also provided to give the reader ideas of how low-fat foods can be appetizing and incorporated into a healthy diet.

Section 2: Fiber Basics

Fiber is important to maintain a healthy gut. This section explains why you need fiber in the diet and the different types of dietary fiber. There is an excellent quiz at the end of this section which helps the reader analyze how much fiber they are currently taking in each day. However it should be noted that the recommended amount of dietary fiber of 40 grams a day is higher than what the United States Department of Agriculture recommends in its dietary guidelines (20-35 grams/day). Recipes are also given at the end of this chapter.

Section 3: Reducing dairy consumption

In this section Dr. Barnard and Ms. Reilly recommend reducing dairy consumption as some studies show an increased risk of prostate cancer that they believe is linked to dairy consumption. Although the authors list alternative sources of calcium-rich food sources, they lack enough research to make the claim that cancer cells are fueled by cow's milk. Furthermore, the authors recommend soy milk as a good alternative to cow's milk; however, they fail to cite research relating to soy and the potential for an increase of cancer cell growth in women who have had estrogen receptor positive breast cancer. More research is needed to understand how the components of cow's milk affect cancer cell growth. At this time the American Cancer Society still recommends consuming low-fat dairy products to help meet calcium needs. There is also a well-known link to calcium and a reduced risk of developing colon cancer, which is not discussed in this book (American Cancer Society and American Institute for Cancer Research ). Osteoporosis, as it is related to calcium consumption, is also reviewed. According to the authors, "(Osteoporosis) is a condition of overly rapid calcium loss." Yet the authors say that calcium is not as important to bone mass development and retention as avoiding salt, sulfur containing amino acids, and smoking. According to the National Osteoporosis Foundation, getting enough calcium throughout life through dairy sources or supplements is a key to preventing the development of this crippling disease ( ).

Section 4: Alternatives to meat

Dr. Barnard and Ms. Reilly recommend that cancer survivors avoid all meats and fish. In this section the discussion of vegan eating is discussed (avoiding all meat, fish, eggs, and dairy). Alternatives to meat are given as well as meatless recipes. It is true that a diet high in meat can increase risk of cancer as well as other health conditions due to carcinogen content (cancer causing compounds) of cooked meat and fat content. However to avoid all meat and fish is an over generalization. Lean meats and fish can be part of a healthy varied diet according to the American Cancer Society. Fish, although potentially high in mercury can be eaten safely in small amounts and provides healthy fats that are cancer protective. The authors' recommendation of plant protein sources including soy, legumes (beans), and nuts are warranted; however, a healthy anticancer diet can also incorporate lean meats and fish.

Section 5: Phytochemicals and antioxidants

This section explains what phytochemicals and antioxidants are and how they relate to disease prevention. The authors recommend food first which is important since research shows that eating foods rich in antioxidants and phytochemicals is more beneficial then taking supplements. Charts of common foods rich in these disease-fighting compounds are given; however, this book does not give the reader recommended daily intakes of each antioxidant.

Section 6: Immune-enhancing foods

Vitamins and minerals, including beta carotene, vitamin C, vitamin E, and zinc and the relatedness to providing protection to the body are discussed in this section. The authors also briefly discuss how fat and cholesterol decreases ones' immune system, yet they fail to discuss the role of sugar and decreased immunity. Refined sugar consumption and immunity need to be addressed to make this a complete chapter.

Section 7: Weight loss

Losing weight if overweight is an important part of cancer survival. This section provides a good overview of how to take the pounds off sensibly. Avoiding fad diets and losing the weight slowly are the keys to success. There are good meal planning tips in this section and good basic dietary information to help the reader start a weight loss plan.

Section 8: Appendix and recipes

In this section the authors address basic nutrition questions. These concise answers are helpful for novice readers to decipher nutrition information given in the book. Recipes are also given at the end of the book which are seemingly easy and helpful in allowing the reader to apply the principles of vegan eating.

Bottom line: There is more to cancer prevention than what is in this book

Although some the principles that Dr. Barnard and Ms. Reilly discuss are warranted in the fight against cancer recurrence, other important information is left out. First of all in the note to the reader, the authors reference the "four food groups" as the basis for an American diet. The "four food group" concept is completely outdated and has since been revised twice with the latest being the Food Guide Pyramid which came out in 2005 from the United States Department of Agriculture (log onto for more information). Although this handbook was first published in 2003, no revision or new edition has been made to update this information. Secondly, the authors fail to include the American Cancer Society's guidelines in their recommendations. These guidelines have been created by scientists who review all current nutrition and cancer research. The principles outlined by Dr. Barnard and Ms. Reilly are a little too extreme when it comes to the validity of the current research that is available. As a clinical dietitian who works directly with cancer patients, I would not recommend this book as it lacks enough scientific evidence in its recommendations. I would refer a patient to read it with caution, keeping the American Cancer Society's principles at the forefront of their minds. However that being said, the recipes listed at the end of this book are worth reviewing and may be incorporated into a healthy anticancer diet.

Note from the Author, Jennifer Reilly, RD

Thank you for reviewing The Survivor's Handbook by The Cancer Project. Our organization is dedicated to advancing cancer prevention and survival through nutrition education and research and we appreciate your interest in our publication. 

As one of the authors of the Handbook, I'd like to clear up a few misunderstandings about our work. The dietary recommendations included in the Handbook--like all of our publications, public service announcements, and reports--are based solidly on the scientific literature. In fact, Handbook readers will note 88 citations of peer-reviewed nutrition studies.

Although it's true that The Cancer Project and the American Cancer Society differ in some of their recommendations--we recommend a low-fat vegan diet and the ACS advises limited consumption of processed and red meats--we agree on several important issues. Both organizations advise choosing whole grains over refined grains and eating five or more servings a day of fruits and vegetables.

Unfortunately, the book reviewer misunderstood our use of the term "Four Food Groups." Our Handbook doesn't reference those outdated guidelines issued by the U.S. Department of Agriculture in 1956. Instead, we refer to the "New Four Food Groups" put forth by our affiliate organization, the Physicians Committee for Responsible Medicine in 1991. Created as an alternative to the USDA's dietary guidelines, this guide to basic nutrition recommends building one's diet from vegetables, legumes, fruits, and whole grains.

Finally, I wanted to let everyone know that we are working on a revised edition of the Survivor's Handbook which will be published this fall. Check our Web site for updates on its release, information on free cooking classes around the country, and the latest in nutrition science.

Thank you for bringing attention to the all-important topic of good nutrition for cancer prevention and survival.

In good health,

Jennifer Reilly, R.D.

Senior Nutritionist

Guidelines for Effective Weight Loss and Weight Gain during Cancer Treatment

Thursday, May 17, 2007 - 4:34pm

The following excerpt is adapted from; What to Eat If You Have Cancer: Healing Foods That Boost Your Immune System by Maureen Keane, MS, and Daniella Chace, MS (McGraw-Hill, 2006).

Maintaining a healthy body weight and making good food choices that give your body the right nutrients can sometimes be a challenge. But if you are preparing for cancer treatment, now more than ever is the time to focus on your body's nutritional needs. The fact is that maintaining a healthy body weight may contribute to your recovery and the success of your treatment plan.

Keep in mind that a thin, underweight body may not be able to tolerate the stress of cancer treatment. At the other end of the spectrum, there is evidence that being overweight may increase the chance of cancer recurrence. So whether your goal is weight loss or weight gain during treatment, you'll want to be sure that you are getting the nutrients your body needs to heal while carefully eliminating foods that no longer serve you.

Weight-gain guidelines

If you have a low body weight, it is likely that you also have low levels of lean muscle tissue, low stores of fat, and low stores of essential vitamins and minerals such as vitamin A, iron, and calcium. Some patients with a low body weight have difficulty tolerating cancer treatment. This is because those necessary stores that a healthy body builds up are depleted; and problems occur when, for example, a person with a low body weight does not have the necessary energy reserves for that needed boost on days when it may be difficult to eat.

A low body weight may be the result of a naturally high metabolism or of careful management of food intake and energy expenditures. Other times it is a sign of malabsorption or malnutrition. If you have trouble gaining or maintaining weight, it is important to inform your doctor to be sure that there are no medical factors that need to be addressed. For example, if you have a thyroid problem or a disease that causes malabsorption-such as celiac disease-you will want to address these issues before cancer treatment begins.

Preparation for cancer treatment is not the right time to be on a calorie-restricted diet (fewer than 1,200 calories per day) with the intention of losing weight. It is impossible to get all of the nutrients you need to prepare your body for treatment when you are consuming this limited amount of calories. At this point you need to be storing nutrients to help fuel your immune system as you undergo treatment.

On the other hand, do not eat indiscriminately in a quest for calories. Fried foods and sweets will indeed result in weight gain-but not the type you need. Junk food will do nothing to build nutrient stores or lean muscle tissue. Be mindful of the nutritional value of the foods you choose.

Weight-gain tips and food choices

When your goal is to build a healthy body for treatment, certain foods pack an especially powerful nutritional punch. Choose those that provide you with more than just empty calories.

Nuts and seeds are an excellent choice when you are looking for a nutrient-rich snack that will help you build a healthy body. They are rich in cancer-fighting and heart-healthy oils and are high in protein. But again, be mindful: Don't just grab any snack that includes nuts or seeds. Avoid nuts and seeds that are flavored, oiled, fried, or salted. Eat yogurt- or chocolate-coated nuts only in small quantities.

Tips for adding nuts and seeds to your diet

1.   Whole nuts and seeds

One serving equals one medium handful. Sprinkle seeds and crushed nuts on cereals, vegetables, and salads. Mix them with a small amount of dried fruit and eat as a snack or small meal. Use them as a crunchy topping on casseroles.

2.   Nut and seed butters

One serving equals 3 tablespoons. Examples of nut butters include sesame seed butter (tahini), hazelnut butter, and peanut butter. To make your own nut butter, add fresh unsalted nuts to a blender, food processor, or food grinder. Add sweeteners such as molasses or honey and seasonings such as cinnamon or nutmeg. Process until smooth.

3.   Savory nut butters

One serving equals 3 tablespoons. These can be made by adding garlic, onions, peppers, or other seasonings to the unsweetened nuts. Dilute nut butters with canola, flaxseed, or olive oil and use as a salad dressing; or mix them with a little soymilk and use as a sauce or a vegetable dip.

4.   Nut milks

Commercially available nut milks, which can be purchased at health-food stores and some grocery stores, include coconut milk, almond milk, and hazelnut milk. Nut milks can easily be made at home. Just add a handful of nuts to a blender with 1 cup of filtered water. Process until the water is milky in color. Strain to remove the fiber and store in the refrigerator. Nut milks can be sweetened with honey or molasses and then blended with fruit juice, dried fruit, soft whole fruit, yogurt, or soymilk to produce a calorie-rich shake. Store in the refrigerator, where it will keep for four or five days.

Incorporating smoothies into your diet is another option for promoting healthy weight gain. There are a multitude of ingredients that can enhance the nutritional value of a simple fruit smoothie, including flaxseed oil, protein powder (soy, rice, or whey), ground flaxseed for increased fiber, and nut butters.

In addition to choosing foods like nuts, seeds, and smoothies that pack a nutritious punch, you might try changing some of your mealtime habits to ensure that eating continues to be an enjoyable part of your day. For instance, try eating five or six small meals per day instead of two or three large ones. If you cannot manage to eat all of the recommended vegetable servings, try juicing some of them. Choose foods that are as appealing to the eye as they are to the palate. And try to make mealtimes a pleasant experience by relaxing beforehand, eating with friends or family, and creating a positive atmosphere at the table. All of these small changes to your routine may help you enjoy the food you eat and will make your mealtime experience more pleasurable, enabling you to get the nutrition you need.

A few more tips

  • Foods that taste sweet should be eaten only on a full stomach.
  • Drink eight to 10 glasses of (preferably filtered) water per day.
  • Drink half a glass of water with a teaspoon of lemon juice to stimulate digestive juices a half hour before mealtime.
  • Exercise for about a half hour before meals to stimulate your appetite.
  • Don't drink fluids or soups with meals; they will fill you up and leave no room for foods that are dense in nutrients.
  • If you do not gain weight, increase serving sizes.

For more information on gaining weight during your cancer treatment see the following article from TheDietChannel: Increase Your Calories & Protein during Cancer Treatment.

When you have lost weight before or during treatment

A 5 percent weight loss from your normal weight is considered significant. Losing 10 percent of your normal weight is a red flag. A 15 percent weight loss may lead to fatigue, depression, and loss of appetite and can reduce your body's ability to heal.

If you have lost a lot of weight as a result of your cancer treatment, your physician may want you to increase the amount of fats in your diet. This is because fats and other lipids are a concentrated source of energy. Carbohydrates and proteins each contribute 4 calories for every gram consumed. Fats contribute 9 calories per gram, more than double the other energy sources. Fats are also easily stored in the body, providing you with a backup energy source for times when you cannot eat.

If your doctor recommends that you increase the fat in your diet, look for foods that are high in omega-3 or monounsaturated fatty acids, such as canola or olive oil. The fatty acids in coconut milk are also a good choice because they are high in medium-chain triglycerides, which are easily absorbed with minimal digestion. The foods rich in monounsaturated fats will not only increase your caloric intake but also aid in preventing metastasis and enhance your immune system.1,2

Sometimes radiation and chemotherapy can cause temporary intestinal damage, which decreases your ability to digest fats. If this happens, your stools will be frequent, bulky, and light in color. Treatment may also affect the liver's ability to produce bile, which also results in fat malabsorption. Pancreatic enzymes may be reduced by treatment, as well. If you suffer from malabsorption, you may want to speak with your doctor about adding a digestive enzyme supplement to your diet.

Weight loss and cancer treatment

Weight loss can be beneficial for cancer patients both as a preventive measure and to aid recovery. There is evidence that being overweight may increase the chances of cancer recurrence, especially with hormone-related cancers.3 In breast cancer patients who are overweight, weight loss can aid the healing process.4,5

Set reasonable weight-loss goals

Needless to say, losing weight is easier said than done. To help the process along, set realistic goals. Start with a moderate goal of 10 percent. This means if you weigh 200 pounds, your first 10 percent will be 20 pounds; your second 10 percent will be 18 pounds. After that first 10 percent, your risk of developing many diseases decreases substantially. You do not have to aim for an "ideal" weight, which is often unrealistically low. Moderate reductions are easier to sustain and are accompanied by many of the same benefits you would gain with more ambitious-and more difficult-weight-loss goals.

What to eat for weight loss

If you do not already eat a whole-foods diet, this is a good time to start. The term whole foods refers to foods that are minimally processed and do not contain additives or preservatives. For example, if you were making a food choice based on a whole-foods diet, you would choose grains and beans over refined white bread and pasta.

When people first begin a whole-foods diet, they often lose weight because the higher fiber content of the food causes satiety and increases metabolism. In addition to eating whole foods, practice portion control and concentrate on the quality of the foods you choose. If you set your sights on becoming healthier, rather than thinner, you might be surprised at how quickly you start seeing results.

Portion control for weight control

Portion size is the key to weight control. Supersized portions are a major cause of obesity in the United States, and monitoring portion sizes can help you regain control of your weight. Here are some tips to help you with portion control:

  • Buy yourself a set of measuring cups and spoons. For one month measure everything you eat. This will teach you how to estimate portion sizes.
  • Most restaurants serve at least double serving sizes. Eat half your entrée and take the rest home for lunch or dinner the next day.
  • Stop serving meals family-style. Rather than bring all the food to the table and have everyone fill their own plates, measure food out in the kitchen for the adults and allow no seconds.
  • Let young children determine how much they want to eat. Adults often overestimate a child's energy needs and offer too much food. Insisting that your children finish all the food on their plates is the same as encouraging them to overeat.
  • Divide your plate into quarters. One quarter should be filled with a protein food, one with a whole-grain starch or starchy vegetable, and two quarters with vegetables. In at least one meal each day, half of the vegetables should be raw, such as a salad or raw vegetable appetizer.
  • Choose a serving of fruit for dessert.
  • You should be able to see your plate under the food. If you like the sight of your plate piled high, switch to a small salad plate.
  • Start dinner with a low-calorie soup course. This can curb your hunger, so you eat less for the rest of the meal.

Managing your weight during cancer treatment does not need to be a daunting task. Learn to listen to your body's needs. Making methodical lifestyle changes will help you achieve your goal-whether it's maintenance, weight loss, or weight gain-and will support your overall health as well as assist you in your recovery.


Weight-gain Smoothies

The following recipes are from More Smoothies for Life by Daniella Chace (Random House, 2007). For best results, combine all ingredients in a blender or food processor and purée until smooth. Served chilled.

Peanut Butter Cup

1 cup organic milk
1 cup ice
¼ cup nonfat dry milk or protein powder
1 tablespoon organic flaxseed oil
2 tablespoons cocoa powder
2 tablespoons peanut butter or almond butter
1 tablespoon toasted wheat germ

Use organic milk or a milk substitute such as rice milk, almond milk, oat milk, or soymilk; whey also works well in smoothies because it dissolves easily, making creamy drinks. It also contains detoxifying agents such as glutathione that help remove metals and environmental chemicals from our bodies. If you are allergic or sensitive to dairy products, however, try one of the alternatives such as soy, rice, or pea protein.

Chai Crème Frappe

1 cup chai tea
1 cup milk
½ cup ice
¼ cup nonfat dried milk
1 tablespoon honey

Nonfat dry milk adds creaminess to recipes and a substantial dose of protein. Each tablespoon adds more than a gram of easily metabolized protein.

Weight-loss Recipes

Quinoa Tabouli Salad

Fresh parsley, mint, and lemon juice are the bright flavors that make this Lebanese dish so popular. Quinoa cooks quickly; it is easy to digest, high in fiber, and fairly high in protein. It's also delicious!

1 cup cooked quinoa
1 green onion, minced
1¼ cup minced parsley
½ cup fresh mint, minced
1 tablespoon lemon juice
1 tablespoon extravirgin olive oil
1 teaspoon cumin
white pepper to taste

Precook quinoa, following the instructions on the package. It's very simple and takes only minutes to prepare. Combine all ingredients and chill. Serves 4.

White Bean Salad

1 can white beans, drained and rinsed
1 cup chopped fresh Italian parsley
2 fresh tomatoes, chopped
½ red onion, minced
juice of ½ a lemon
2 tablespoons balsamic vinegar
¼ teaspoon sea salt
1 tablespoon extravirgin olive oil

Mix all ingredients and serve or chill. Serves 4.

[1]. Kimoto Y, Tanji Y, Taguchi T, et el. Antitumor effect of medium-chain triglyceride and its influence on the self-defense system of the body. Cancer Detection and Prevention. 1998;22(3):219-224.

[2]. Tisdale MJ, Brennan RA. A comparison of long-chain triglycerides and medium-chain triglycerides on weight loss and tumour size in cachexia model. British Journal of Cancer. 1988;58(5):580-583.

[3]. Samanic C, Chow WH, Gridley G, Jarvholm B, Fraumeni JF Jr. Relation of body mass index to cancer risk in 362,552 Swedish men. Cancer Causes and Control. 2006;17(7):901-909.

[4]. Eliassen AH, Colditz GA, Rosner B, Willett WC, Hankinson SE. Adult weight change and risk of postmenopausal breast cancer. Journal of the American Medical Association. 2006;296(2):193-201.

[5]. Kuhl H, Stevenson J. The effect of medroxyprogesterone acetate on estrogen-dependent risks and benefits-an attempt to interpret the Women's Health Initiative results. Gynecological endocrinology. 2006;22(6):303-317.

Macrobiotic Diet for Cancer Treatment

Monday, May 7, 2007 - 12:08pm

By Erin Dummert RD, CD

The macrobiotic diet was invented in the 1930s by a Japanese philosopher who sought to integrate Zen Buddhism, Asian medicine, Christian teachings, and some aspects of Western medicine. Proponents claim that it is the key to preventing and even curing many diseases, including cancer. Following a diagnosis of cancer, many patients initiate a macrobiotic diet with the hope of curing their cancer. Many who recover believe that their renewed health was a result of the macrobiotic diet they followed. Can this diet really cure cancer? Let's look at what it means to follow the macrobiotic diet, and if it is safe during cancer treatment.

The macrobiotic diet

According to the macrobiotic diet principles, cancer and other diseases are classified into categories of yin or yang, which dictate specific dietary restrictions and cooking styles. While the diet is modified for an individual based on age, sex, activity, and location, the standard macrobiotic diet is:

  • Low in fat
  • High in fiber
  • Predominantly vegetarian.

It emphasizes organic whole grains, fruits and vegetables, soups made with vegetables, seaweed, grains, beans, and miso. Occasional servings of fresh whitefish, nuts, seeds, pickles, and Asian condiments are allowed. Some vegetables including potatoes, tomatoes, eggplant, peppers, asparagus, spinach, beets, zucchini, and avocados are prohibited. The diet also discourages eating fruits that are not grown locally, such as bananas, pineapples, and other tropical fruits. In addition, dairy, eggs, coffee, sugar, stimulant and aromatic herbs, red meat, poultry, and processed foods are not recommended.

Macrobiotic principles also dictate cooking techniques and equipment. Pots, pans, and utensils must be made only from wood, glass, ceramic, stainless steel, or enamel. Microwaving or cooking with electricity is also discouraged.

The macrobiotic diet and cancer treatment

The founders of the macrobiotic diet movement traditionally did not encourage conventional cancer treatment, and advised patients to gradually reduce their reliance on mainstream medicine as their health improved. Currently, many macrobiotic practitioners do encourage patients to use the diet in combination with their conventional cancer treatment.

Current studies are underway to determine if the macrobiotic diet may play a role in cancer prevention. However, preventing cancer is very different from curing cancer. Despite proponents' claims that the macrobiotic diet can cure cancer, there is no scientific evidence to support this.

While there are no known side-effects of combining the macrobiotic diet with cancer treatment, many oncology nutrition professionals believe that the diet is too restrictive when followed diligently. Because the diet limits so many foods, including entire food groups, it lacks key nutrients essential to health including calories, protein, vitamin B12, iron, magnesium, and calcium.

Conclusion: a macrobiotic diet maybe too much change during cancer treatment

While the macrobiotic diet does include many cancer preventive foods and eliminates known cancer promoters such as alcohol and red meat, it is not recommended for treatment of existing cancer. Not only can changing the way you eat, shop, and cook be stressful during an already traumatic time, the diet is extremely restrictive and makes getting adequate calories and nutrients difficult, if not impossible. The foods used on the macrobiotic diet are healthy foods that can be added to your diet as you feel ready. However, restricting entire groups of food is not recommended during this time of increased nutritional demand.

*This article is intended for general information purposes only, is not individual-specific, nor is it intended to replace the advice of your healthcare team.

Breast Cancer Treatment & Weight Gain

Tuesday, January 9, 2007 - 4:06pm

By Donna Feldman, MS, RD

It’s hard enough for a woman to deal with breast cancer. Unfortunately, the treatment may add insult to injury for some women: certain regimens for certain women can lead to weight gain. As if the physical and emotional toll of surgery, radiation, chemotherapy and losing one’s hair wasn’t enough, many patients have to deal with unwelcome extra pounds. Fortunately, recent research indicates this weight gain may not be inevitable. Certainly the possibility of weight gain shouldn’t deter anyone from getting appropriate treatment.

Not all patients are affected
Not all breast cancer patients gain weight. Studies indicate that, in general, the patients who are most affected are premenopausal women who receive chemotherapy as part of their treatment. Postmenopausal women, and those who receive only radiation treatment are less likely to gain. Of course, some women lose weight, or have no weight change. The big question is: does chemotherapy treatment somehow set women up for weight gain, or is some other factor causing it? Research hints at some answers.

Is chemo to blame?
Does chemotherapy somehow alter metabolism, causing weight gain? Many studies have looked at this possibility. In one from Duke University, premenopausal breast cancer patients on chemotherapy were compared to a similar group not on chemo. Over a year, the chemo patients gained twice as much weight. And, unlike typical weight gain, this was mostly just fat. Another study followed breast cancer patients for 10 years after diagnosis, and found that women under age 55 tended to gain weight compared to older women, and gained at a faster rate than non-cancer patients.

Lifestyle factors
All these studies looked not just at chemotherapy, but also at lifestyle factors that impact weight, including diet and exercise. One universal finding is that breast cancer patients who gain weight report much less physical activity than those who do not gain. In other words, exercise has a profound impact on this type of weight gain. It’s easy to imagine how this would happen. The exhaustion and anxiety of treatment regimens is so disruptive that regular exercise routines are thrown off. You may just be too tired to think about jogging or biking or even walking. Even if you didn’t have a regular exercise routine before diagnosis, you might spend more time resting during cancer treatment. The result: fewer calories burned. If you don’t reduce your food intake accordingly, you are likely to gain weight.

An unfortunate cause for some patients might be overeating due to depression. Some anti-depressants can themselves lead to overeating, and breast cancer patients may be given these medications to help them deal with their situation. Or untreated depression could lead some breast cancer patients to overeat, and gain weight.

Why premenopausal women?
There is no good answer to why premenopausal breast cancer patients are more likely to gain weight, but there is speculation. One theory is that the treatment actually creates premature menopause. And as any woman of a certain age knows, menopause slows metabolism. Many women gain weight gradually throughout normal menopause, which may take several years. Breast cancer treatment speeds up the effect, and you might end up with the metabolism of a person 10 or more years older. If you continue eating as usual, you set yourself up for weight gain.

Conclusion--Have a plan
If you are facing breast cancer treatment that includes chemotherapy, discuss your weight concerns with your health care team. This discussion is especially important if you are taking anti-depressants, or suspect your diagnosis is leading to serious depression.

To combat weight gain, you will need to keep up physical activity as much as reasonably possible. You might find that certain rigorous activities, like running, are more difficult. If that’s the case, don’t simply give up. Walking or other activities that are easier to do, or fit your schedule better, should be considered at least temporarily. Make your diet as healthy as possible, emphasizing low fat/high fiber foods. But leave room for foods you enjoy. Cancer treatment is bad enough without missing foods you enjoy.

Expert Q&A

Calcium: Special Requirements During Cancer Treatment

What is my calcium requirement during cancer treatment?

Calcium is an essential mineral for bone health and blood regulation. In general, requirements for calcium are not different for cancer patients. The United States Department of Agriculture (USDA) has established Recommended Daily Intakes for calcium as well as other minerals and vitamins.

The Adequate Intake (AI) for calcium is:

  • 1300 milligrams a day for adolescents
  • 1000 milligrams a day for people between the ages of 19-50
  • 1200 milligrams a day for people over 51 years of age.

The Upper Limit (UL) for calcium is 2500 milligrams a day. The average American intake of calcium is 650 milligrams a day. 1 cup of milk has 300 milligrams of calcium. It is recommended to consume 3 to 4 servings of dairy rich foods everyday or to take a calcium supplement.

A few groups of people have special calcium needs:

  • Men with prostate cancer may want to limit their calcium intake and stay within the recommended parameters of 1000 to 1200 milligrams a day. Research is unclear at this time, but some studies show high calcium intake is associated with increased prostate cancer risk.

  • Cancer patients taking the steroid Prednisone should increase their calcium intake due to the bone leaching effects of this medication. People taking Prednisone need at least 1500 milligrams of calcium a day.
  • Women who have breast cancer and have undergone menopause should take at least 1200 milligrams of calcium daily to prevent early bone loss due to the lack of estrogen circulating in their bodies.

Regardless of a cancer diagnosis, calcium should be a regular part of your diet. Studies have suggested that eating a dairy-rich diet or taking calcium supplements, specifically calcium carbonate, may reduce the risk of colon cancer. While further investigation into the matter is necessary, the national Nurses' Health Study and Physicians' Health Study found that those who took 700 to 800 milligrams of calcium each day had a 40 to 50 percent decreased risk of developing colon cancer.

Dena McDowell, MS, RD
Contributing Expert

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Expert Q&A

Before Chemo: Which Foods to Eat on the Day of Chemo?

What are good foods to eat on the day of chemotherapy?

It is important to eat a well balanced diet while undergoing cancer treatment to help maintain body weight, prevent fatigue, and fuel the immune system. People are often nervous when starting chemotherapy and are afraid to eat on their first drug infusion day because they worry about nausea or vomiting. This fear is unwarranted as most cancer centers add anti-nausea medications into the chemotherapy infusion bag to minimize nausea during treatment.

On your first day of chemo, you should eat a low fat meal based on complex carbohydrates and protein. Eating a breakfast of toast with eggs and fruit juice will get you started in the right direction. Drinking extra fluids is also helpful. If you have an all day infusion, remember to pack a lunch and some snacks. Granola bars, crackers, yogurt, pudding, and fruit are all good snack options. Many patients forget to do this and may end up feeling nauseous because they lack food in their stomach. A turkey sandwich and bowl of broth-based soup with a side of fruit is a great light option.

When you get home, it is important to eat dinner even if you are tired. Eating comfort foods such as mashed potatoes and gravy, chicken noodle soup, gelatin, and sandwiches are light and healthy options. If you are feeling nauseous, take the prescribed nausea medication to lessen the side effects and try to eat small amounts of food every two to three hours. Avoid your favorite foods during this time so that you do not associate them with nausea later on.

Dena McDowell, MS, RD
Contributing Expert

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Expert Q&A

Appetite Loss and Chemo: How to Make Foods More Appealing

My appetite has changed due to chemotherapy. How can I make foods more appealing?

-Kyle from Idaho

Having a decreased appetite during chemotherapy is common, and there are many different causes of this problem. Some chemotherapy drugs cause taste alterations or a change in a patient’s sense of smell. They can also cause dry mouth, mouth sores, nausea, and vomiting. In other instances, a patient’s appetite is affected by an early sense of satiety or a persistent sense of always being full. Depression may also alter a patient’s desire to eat.

Here are some quick and easy ways you and your caregivers can make the most of meal times:

  • Try eating small meals frequently. Snacking every 2 to 3 hours throughout the day can be easier to digest; the smaller portions will also be less overwhelming.

  • Start out the day strong with a well balanced breakfast. Oftentimes, your appetite will wane by the end of the day. Eating a healthy breakfast such as peanut butter or eggs on toast, or toast with fruit, can help get the needed calories in your system.
  • Eat foods at room temperature to increase their palatability.
  • If tastes or smell is off, add extra seasonings to meats.
  • Using plastic utensils to decrease the metallic taste in the mouth.
  • Using a salt water rinse or brushing teeth with a mint-based paste may also help food taste better.
  • If feeling full is a problem, try eating small frequent meals that are low in fat but high in carbohydrates and protein.
  • Drinking fluids between meals may also help prevent feeling overly full at meal times. Use friends and family to help in the meal preparation and shopping. Go through recipe books to look for new concoctions that may be appealing to you.
  • Make meal time an enjoyable event. Eat with friends and family members or listen to your favorite music or television show.

Speak to your physician if your appetite is affected by nausea, vomiting, constipation, diarrhea, or pain. There are many medications as well as appetite stimulants that may help maximize your appetite. Eating well during cancer therapy will help you maintain weight and quicken the recovery time when your treatment has finished.

Nutrition is an integral part of the cancer treatment process. Without proper nutrition you may alter your immune system and potentially delay the recovery process.

For more information on tips for improving your appetite during cancer treatment see the following article from TheDietChannel: Increase Your Calories and Protein during Cancer Treatment.

Dena McDowell, MS, RD
Contributing Expert

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