Ask-the-Expert Online ConferenceOn Wednesday, January 19, 2005, our Ask-the-Expert Online Conference was called Nutrition and Weight. Cyndi Thomson, Ph.D., R.D. and Marisa Weiss M.D. answered your questions about nutrition and weight.
"Is weight gain something you just have to deal with while on tamoxifen?" Answer
"Is it true that after having breast cancer you should not try to lose weight as it can increase your risk of getting a recurrence?" Answer
"Is there a safe amount of alcohol that one can drink without increasing one's risk of breast cancer?" Answer
"What are your feelings about macrobiotic diets and their usefulness in improving a cancer patient's diagnosis?" Answer
"I have Stage IV metastasized breast cancer of the bone that appears to be in check. What is the nutritional diet you would recommend for someone like me?" Answer
- Question from BaldyBean3: How long does it take for the weight to come off from all the steroids that you take from chemo? When do you get back to a normal weight?
Cyndi Thomson, Ph.D., R.D.
In terms of weight gain during treatment, it's important to understand that steroids are not the only source of weight gain. It's clear that other factors play a role. For example, many women become less physically active during treatment. There may be emotional issues that lead women to eat comfort food. Also, small frequent meals may decrease nausea, which may lead to weight gain.
Resting energy expenditures (the calories your body uses to breathe and function) is lowered in some women during treatment. And all of these factors can contribute to weight gain. As steroid therapy dwindles down, there will be a loss of body weight related to fluid shift, but it's also important to begin to develop healthy eating and activity habits to control body weight.
- Marisa Weiss, M.D. For sure, losing the extra weight is hard work that takes time. Give yourself credit for any progress you make—even a few ounces is great, and particularly if you manage to get rid of a few extra pounds. Losing weight with a friend or a group like Weight Watchers can help a lot.
- Question from Ms.Fitness6: Is weight gain something you just have to deal with while on tamoxifen? I have gained almost 8 pounds since being on it. I started treatment with it in October. The gain is mostly in my stomach. I feel bloated. What can I do to combat this?
- Answers - Cyndi Thomson, Ph.D., R.D. The realization that tamoxifen can contribute is important but realize that are other factors contributing to weight gain similar to what we said about the steroids. It's important to continue your tamoxifen and look for other ways to control your body weight.
- Marisa Weiss, M.D. Also, in addition to increased body weight, you might be noticing a difference in the way your weight is distributed. As you grow older and the hormones in our body shift around, we do tend to gain more weight in our middles, in the belly area.
- Cyndi Thomson, Ph.D., R.D. This what we call central body fat.
- Marisa Weiss, M.D. As you grow older, even without the tamoxifen, you would notice that change in fat distribution. But many women say that tamoxifen may bring it on in a faster or in a more noticeable way. Plenty of my patients do manage to get some control over their weight and lose some weight and then try to keep their weight as stable as possible. This of course takes a lot of effort and continued encouragement.
- Cyndi Thomson, Ph.D., R.D. In terms of central body weight gain, some women are more responsive to a lower carbohydrate/more simple sugar intake than to a low-fat diet. But there are wide individual variations and you should work with a health care provider to design the best weight loss diet for you.
- Question from Rima: I am sugar-sensitive, eat some sugars and have read that cancer cells thrive on sugar. I'm concerned about cutting out sugar completely during chemo treatment, because it might stress my body too much. Is it more important to maintain my weight than improve my eating habits?
- Answers - Cyndi Thomson, Ph.D., R.D. I think the important thing to keep in mind is that sugar does not promote tumor growth. It does not feed the cancer cells per se. However, women who have elevated glucose, or more importantly elevated insulin levels, should work hard to reduce total energy intake, including sugars.
- Marisa Weiss, M.D. Nutritionists do get concerned about binge eating or eating several big meals rather than more frequent, smaller meals. When you bring in a lot of calories into your body at one time, it can put your digestive system under more stress. Growth factors in your bloodstream can increase. There is some concern that a higher level of these growth factors might stimulate growth of some type of cancer cells. This is being studied carefully.
- Question from BridgetS46: How do you get well between chemo treatments and how do you detox after chemo finishes?
- Answers - Cyndi Thomson, Ph.D., R.D. Research has shown that women who remain physically active during treatment have less fatigue and improved quality of life. Thus at this point in time we would recommend that women try to work a daily walk into their schedule to help promote physical activity during treatment—realizing of course that when you're not feeling well it can be difficult to stay physically active.
- Marisa Weiss, M.D. Be sure to tell your doctor or nurse if you are having certain symptoms, like nausea or pain because it's likely they can give you something to relieve those symptoms. Helping you with trouble sleeping is important. Rest is important.
- Cyndi Thomson, Ph.D., R.D. It's important to get plenty of fluids and eat a balanced diet as much as possible. Avoid high intakes of caffeine prior to bed time. Sugars may cause a short term increase in energy, but within an hour or two a drop of energy. Avoid alcohol, particularly close to bed time. Avoidance of alcohol is generally a good idea during treatment.
- Marisa Weiss, M.D. Give up the housework and go buy some shoes and jewelry!
- Question from U and Me: Is it true that after having breast cancer you should not try to lose weight as it can increase your risk of getting a recurrence?
Cyndi Thomson, Ph.D., R.D.
There's about a threefold increased risk of recurrence in women who are overweight (20 pounds above the recommended body weight). For women, a quick rule of thumb is 100 pounds for the first 5 feet and 5 to 6 pounds per inch for the height above 5 feet. So if you were 5'5", it would be 100 pounds plus 25-30 pounds for a total weight of about 125-130 pounds.
These weight-for-height recommendations do not change with age other than we lose height with age. However, few breast cancer patients, or women overall, are able to sustain the same body weight throughout adulthood, although ideally this would be the goal. After treatment, if you are overweight or if you have gained weight during treatment, it is important to try and achieve a healthier body weight. It's just as important to try and optimize your body composition—in other words, drop the fat and keep the muscle. This can be done by increasing physical activity while eating your healthy diet.
- Question from NMPaxton: Please discuss the latest findings on the effects of coffee/caffeine in relation to breast cancer.
- Answers - Cyndi Thomson, Ph.D., R.D. I don't know of any indications that caffeine is unadvisable in women who are diagnosed with breast cancer with the exception that high caffeine intake may disturb sleep patterns and women who have high blood pressure or irregular heartbeat should avoid or restrict caffeine. The bigger problem is the addition of cream and sugar to the coffee that may contribute calories in someone who is trying to control their weight. Coffee enemas are not advised due to the health risks and lack of proven benefits.
- Question from R Silverman: Is there a safe amount of alcohol that one can drink without increasing one's risk of breast cancer? Has alcohol been proven to increase one's risk of breast cancer?
- Answers - Cyndi Thomson, Ph.D., R.D. It's not as straightforward as we thought. About five years ago, evidence suggested that even one alcoholic drink per week might be problematic. However, it's now more clear that the effects of alcohol on breast cancer risk are dependent on a woman's folate (a B vitamin) status. If a woman has normal to high folate levels in her blood, the negative effects of alcohol drop significantly. But if a woman's folate levels are low, even low levels of alcohol intake can increase risk.
- Marisa Weiss, M.D. If you enjoy drinking alcohol and want to find out whether moderate amounts are okay for you, please ask your doctor to measure the folate levels in your blood.
- Cyndi Thomson, Ph.D., R.D. Folate levels can be increased through diet or B vitamin supplements. Dietary sources of folate include green leafy vegetables, citrus, and fortified breakfast cereals, all of which should be part of a healthy diet.
- Marisa Weiss, M.D. How does folate protect your body against alcohol?
- Cyndi Thomson, Ph.D., R.D. I think the bigger issue is that alcohol intake can lower folate levels, and lower folate levels can increase your risk of cancer.
- Question from NellyG: What impact do antidepressant medications—Celexa, Prozac, Effexor, etc.—have on a woman's weight?
Marisa Weiss, M.D.
Some of the antidepressants are associated with weight gain. It depends on the drug and also on the person. For some patients, Effexor tends to put on the pounds more than another brand. Talk to your doctor about the best choice for you. There may be some trial and error along the way to finding the one that's least likely to cause weight gain. You want the one that is associated with the least amount of weight gain and the lowest effect on your libido as well.
Editor's Note: If you are taking tamoxifen, talk to your doctor about which antidepressants are safe for you to take. Some antidepressants -- including Paxil (chemical name: paroxetine), Wellbutrin (chemical name: bupropion), Prozac (chemical name: fluoxetine), Cymbalta (chemical name: duloxetine), and Zoloft (chemical name: sertraline) -- interfere with the body's ability to convert tamoxifen into its active form, preventing you from getting the full benefit of tamoxifen. For more information, please visit the Tamoxifen page.
- Cyndi Thomson, Ph.D., R.D. It's important to work with your doctor on this issue, as weight gain can further contribute to depression. If your doctor doesn't have the answer, have him/her work carefully with a registered dietician.
- Question from Al: What's the latest news on supplements/antioxidants and dosage during treatments with Herceptin and Navelbine?
- Answers - Cyndi Thomson, Ph.D., R.D. This is an area of significant controversy and given the theoretical risks, it's very difficult to conduct clinical research in this area. Based on the mechanisms of action, most oncologists, oncology dieticians and oncology nurses recommend avoiding antioxidant supplements during treatments.
- Question from Sue: What are your feelings about macrobiotic diets and their usefulness in improving a cancer patient's diagnosis?
Cyndi Thomson, Ph.D., R.D.
There are 2 great papers on this subject. (van Gils CH et al. "Consumption of Vegetables and Fruits and Risk of Breast Cancer." JAMA, Jan. 12, 2005. 293(2):183-193 and also Kushi LH et al. "The Macrobiotic Diet in Cancer." 11th Annual Research Conference on Diet, Nutrition, and Cancer. Washington, D.C. July 16-17, 2001.) The biggest concern with this diet is that it's highly restrictive and the potential for vitamin and mineral deficiencies is great. Before embarking on a macrobiotic diet, seek counseling from a registered dietician and discuss your plans with your physician. A modified macrobiotic diet may be reasonable. The macrobiotic diet is a step-wise progression in restricting food components. It's primarily raw vegetables and brown rice.
Because a diet is something that you do every day and every night, day after day, week after week, month after month, the diet you follow is one that you have to be able to enjoy and sustain over time. This is very hard to do if you ask yourself to take on an extreme diet or one that's highly restrictive. It can feel like punishment. It's not fun to eat one way and have all your friends and family eat all the good stuff around you. It's important to think in terms not of diet, but of healthy eating habits, not losing sight of the enjoyment of food.
- Question from Katherine: Are there any foods that are wise to avoid if you have lymphedema?
- Answers - Cyndi Thomson, Ph.D., R.D. A lower salt diet may be helpful, but the research has not been done. To lower your salt intake or your sodium intake, avoid salty foods: canned vegetables, soups, etc., processed foods such as hot dogs, lunch meats, and unfortunately even olives and pickled beets are high in salt.
- Marisa Weiss, M.D. It's also probably a good idea to avoid a high protein diet because this can make the situation worse. A balanced diet is best.
- Cyndi Thomson, Ph.D., R.D. Be sure you're engaged in physical therapy or some kind of medically supervised exercises that will help reduce this problem.
- Marisa Weiss, M.D. Avoid regular use of diuretics (water pills) to manage lymphedema. This leads to loss of salt and minerals to your body and can make things out of balance. There are better ways to deal with this condition. Be sure to check out other pages in our site on managing lymphedema.
- Question from Sassy: Should I be eating only organic foods to keep pesticides and other toxins out of my diet?
Cyndi Thomson, Ph.D., R.D.
The issue of organic foods is another area of controversy. What is important is to eat fruits and vegetables, and whether you select organic or not, it's important to wash your fruits and vegetables not simply with tap water but with either a commercial vegetable wash or even a drop of Palmolive. Washing non-organic vegetables will reduce pesticides by over 95 percent.
Many people are under the false assumption that organic vegetables are much higher in vitamins. Although some organic vegetables may have slightly more vitamin C for example, it is not enough to be of any relevance in terms of your overall intake of vitamin C or your overall health. Besides, organic vegetables can be very expensive and do spoil more rapidly. The key issue is to eat your vegetables.
Vegetable washes are available in most produce markets. They're spray bottles.
- Question from Christin: Can you control your estrogen levels by dramatically lowering your body fat and then what percentage would you want to be at? I currently am 47 and have 23% body fat, but have been told my estrogen levels are still too high.
- Answers - Marisa Weiss, M.D. The amount of estrogen in your body depends on a number of factors. If you are premenopausal, the estrogen levels depend mostly on how much estrogen is being made in your ovaries. After menopause, most of the estrogen in your blood comes from a chemical process in your fat and muscle cells. The more fat you have, in general, the higher the estrogen levels in your blood stream. Controlling the amount of fat in your body, therefore, has only a partial effect on how much estrogen is in your blood.
- Cyndi Thomson, Ph.D., R.D. It's important to eat healthy and remain physically active in an effort to reduce body fat. Compared to most women in America your age, you're well on your way at 23% body fat. You're much healthier than most. Keep up the good work! That's not a high body fat.
- Question from Heatonjorenby: I have Stage IV metastasized breast cancer of the bone that appears to be in check. What is the nutritional diet you would recommend for someone like me? I am currently 45 lbs. above my ideal weight and would like to lose it.
- Answers - Cyndi Thomson, Ph.D., R.D. Although you're overweight and are interested in losing weight it's also important to ensure you have a healthy protein storage and a healthy immune system. Therefore, any efforts to reduce weight should be closely supervised by a registered dietician so that your protein stores can be closely monitored and the weight loss is very slow and steady, thus not reducing your immune response in the process.
- Marisa Weiss, M.D. It is possible that medications like the aromatase inhibitors can help protect the overweight person from the risk that goes along with higher estrogen levels produced by fat. These medicines stop the production of estrogen by fat cells. This is an important area of study. Even with the benefit of these medicines, it's still important to try to get as close to your ideal body weight as possible. As Dr. Thomson has said, it really does take a combination of healthy eating as well as building increased activity levels into your everyday life.
- Question from Carrie: I've read that there has been an increase of breast cancer in women in Singapore and China as their diets become more urban and westernized. Are researchers getting closer to identifying a nutritional cause or deficit in the diet of women who develop breast cancer?
- Answers - Cyndi Thomson, Ph.D., R.D. Diet is thought to contribute to about 30 percent of all cancers. Although it is a considering factor, it alone is unlikely to be the "cause" of cancer. However, it is clear that the native diets of Singapore appear to be more protective than the westernized diets of the U.S. The take-home message should be to maintain your native diet as much as possible. There are many other factors that can contribute in the culture, not the least of which is reduced physical activity. In addition, Singapore, like most countries, may be experiencing an increase in cases partially because of improved screening and longer life expectancy.
- Question from Emms38: I have been 2 years out of treatment. I have put on 8 kilos and can't seem to lose it. I exercise and eat a low fat diet—please help!
- Answers - Cyndi Thomson, Ph.D., R.D. First and foremost, I would get some individual counseling from a registered dietician. It may be that you are someone who's not as responsive to a low fat diet as other women in terms of weight loss. In this case, you may need to modify your approach to determine if a different lower carbohydrate plan might work better for you. There is evidence that our genes or genetics can influence our responsiveness or ability to see a benefit from certain diets or even physical activity. Thus, there may be some trial and error in finding the best eating plan for you to achieve your goals.
- Question from Toronto Karen: I'm working out 5 times a week and can't lose that additional 20 pounds. Some say I need more protein in my diet. How much protein do we require and from what sources?
Cyndi Thomson, Ph.D., R.D.
First of all, it might be worth your while to have your body composition evaluated since you may not be able to reduce weight, but you may be reducing body fat and increasing muscle mass. This is best done through a measurement abbreviated DEXA. Talk to your doctor about having this test done. This will also give you information on your bone mass, which can be of value.
We need 0.8 grams of protein per kilogram of body weight daily. For a woman who weighs 60 kilos, that would be about 50 grams of protein a day. Most of us get plenty of protein. Seek out protein sources that are lean, such as egg whites which need to be cooked, white meat poultry, or fish. Even beans are a good source of protein for the diet. Dairy products as well, but they have carbohydrates also.
- Marisa Weiss, M.D. Protein leads to a more controlled level of blood sugar and this can make you feel better than taking in foods that are high in carbohydrates. For me, even chicken broth (fat free) is a good way to satisfy your hunger or get you to the next meal.
- Question from VickieG: I have had breast cancer twice in two years and have had bilateral mastectomies, chemo, radiation and continue taking tamoxifen. I lost a lot of weight during chemo due to nausea and vomiting and now I continue to have an aversion to food. I have gained my weight back but I have to work at maintaining it and eating! When will this go away?
- Answers - Cyndi Thomson, Ph.D., R.D. I am also a cancer survivor and at the time that I had surgery on my colon, I began to have a suppression in appetite and irregular bowel movements. Be patient — my symptoms lasted a year and a half, but eventually they did resolve. So give yourself time and continue to integrate activity into your lifestyle as it may enhance your appetite. In addition, there are several web sites that provide guidance or tips for improving appetite. The American Cancer Society has tips and many of the major cancer centers' web sites have tips. I know at the University of Arizona Cancer Center, our web site has a section called Nutrition Ways.
- Marisa Weiss, M.D. Breastcancer.org also has information on maintaining weight.
- Question from Jill M46: What foods and/or supplements can help thwart the energy drain of radiation?
- Answers - Marisa Weiss, M.D. I'm a radiation oncologist so I'm familiar with this issue. A lot of times women start radiation after finishing chemotherapy. When you add up the fatigue that goes along with the initial scare of diagnosis, uncertainty, surgeries and anesthesia and one cycle of chemotherapy after another, by the time a woman starts radiation these days, she can usually feel quite tired and also possibly fatigued. Once you get into the routine of radiation and you get a chance to relax, some of the accumulated fatigue can hit hard. Also the inconvenience of daily radiation can make you tired. The extra task each day can disrupt your daily rhythm and you might have to get up early to work the radiation treatments in before work, for example. Radiation itself when given just to the breast has a small impact on fatigue. But all the things I just mentioned, plus a lower activity level and possibly weight gain from along the way can contribute to your feeling of lower energy. Please see the section on eating to reduce fatigue.
- Cyndi Thomson, Ph.D., R.D. It's important to stay physically active. Sometimes this means scheduling a daily walk into your day planner and making yourself get going. Daily walks can be shared with friends or family members or even your dog. In terms of foods, avoid too much caffeine or alcohol at night that can disrupt your sleep as we suggested earlier. And avoid bingeing or high sugar intakes that can cause an initial short term increase in energy but within an hour a lull that lasts for several hours. Avoid fatty foods.
- Question from Trish: I have been diagnosed with hypercalcemia and osteopenia. How can I improve my bone strength if I should avoid calcium?
- Answers - Cyndi Thomson, Ph.D., R.D. Weight bearing exercise is one approach. It's also important to remember that other nutrients are important to bone health, including vitamin D, phosphorus, vitamin K, magnesium and recent reports indicate that iron may also be important.
- Question from Grits: I have switched to hormone-free dairy and meats since my breast cancer diagnosis. I have two daughters and want to eliminate any possible hormone influence. Is there any study to back this up?
- Answers - Cyndi Thomson, Ph.D., R.D. No. However, if you can afford it and it gives you peace of mind, continue to do so. But we have no studies to support this practice.
- Question from Flashdif: With the onset of menopause during chemo (age 43) my metabolism has shut down. All the dieting and exercise I normally do to lose weight are ineffective, and the pounds are slowly but steadily growing. Help!
Cyndi Thomson, Ph.D., R.D.
I can relate, particularly in this age group of 40 to 50. Basically, effects of menopause that many women would experience over several years you are experiencing over a very short time frame. But don't give up. You may need to build in more physical activity, either by scheduled exercise twice a day or by scheduling exercise once a day and then looking for opportunities to increase energy output throughout your day. For example, climbing stairs, parking your car farther from the entrance of your work place, doing extra gardening. Those would be some examples.
I would recommend you meet with a dietician and look at measuring other aspects of your health beyond body weight. For example you should look at body composition, circumferences of your waist, upper arms, thighs, etc. or biochemical markers of health such as your lipids or things such as blood pressure or respiratory rates that indicate a healthy being that may be independent of your body weight.
- Question from Toronto Karen: I'm still confused about soy products and phytoestrogens and how safe or unsafe they are for ER+ breast cancer patients. Are there any current updates or studies on this?
- Answers - Cyndi Thomson, Ph.D., R.D. There are no recent updates that I'm aware of and the current recommendation from most cancer centers and oncologists and dieticians in the area of oncology is to avoid high intakes of soy products if the cancer that you have is estrogen receptor positive. This is particularly true for soy concentrates and supplements However, you don't need to be a fanatic. If occasionally you like to enjoy some fresh soy beans, feel free to do so.
- Question from Adrian R: If I have to choose between a healthy product with preservatives and artificial colors and not to consume this kind of food at all (e.g. yogurt, low fat cheese, vegetables, soy based products), what is worst?
- Answers - Cyndi Thomson, Ph.D., R.D. I would argue toward the healthy diet and washing your produce thoroughly. But controlling body weight or achieving a healthy body weight is probably the most important of all.
- Marisa Weiss, M.D. Wait—before you go, what about chocolate!?
- Cyndi Thomson, Ph.D., R.D. In terms of chocolate, none of us should deprive ourselves of our favorite foods. But the dietician in me would recommend a sampling of dark chocolates over other chocolates due to the higher antioxidant content.