October 2009: Nutrition Through the Holidays

Does drinking affect length of survival?

Question from Bonnie: Do you think drinking alcohol has a big effect on your length of survival, if you have too much? Especially during festive periods?

Answers —Larissa Korde, M.D., M.P.H.: Studies have looked at alcohol and breast cancer and the risk of developing breast cancer; those studies seem to show that there's a dose response to that, meaning the more you drink the higher the risk. But I don't think anything has addressed the question of drinking during the holiday period rather than looking at your average in general. So I don't think we can use the data out there to look at drinking differing during one period or another.

Diana Dyer, M.S., R.D.: Recent data has shown that alcohol intake also can impact breast cancer survivorship with the same dose-response relationship, so the more you are drinking, the higher your risk of recurrence.

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Should I limit kids' candy at Halloween?

Question from Rissa: I had stage II breast cancer and am a year out of treatment. My daughter is 11 and going trick-or-treating soon. I'm worried about her breast cancer risk -- I know weight gain is a factor. Should I limit the amount of candy she eats?

Answers —Diana Dyer, M.S., R.D.: Personally, I still consume my favorite candies on Halloween, but only on Halloween night and I limit myself to just one piece of only my true favorites.

Larissa Korde, M.D., M.P.H.: In response to the specific question, whether in childhood or adulthood it's important overall to maintain a healthy diet and weight every day. It's important to focus on your daughter's lifestyle year 'round rather than just one day.

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Should I eliminate sugar from my diet?

Question from Liana: I often hear that sugar feeds cancer. I'm curious about your opinion on that; and as a 3-year survivor, to what extent should I entirely eliminate sugar from my diet? Or in other words to what extent should I panic or be concerned with minimal intake?

Answers —Diana Dyer, M.S., R.D.: I don't panic about eating small amounts of sugar. I, again, reserve foods that are high in sugar such as Halloween in candy or holiday desserts as very special treats. I eat small portions and truly savor them. I have absolutely no worries about sugar in foods like fruits as a natural substance. I think the larger worry is the overall dietary patterns of consuming processed foods high in sugar that are essentially empty calories and empty weight gain and thereby increasing the chance of breast cancer and breast cancer recurrence.

Larissa Korde, M.D., M.P.H.: I absolutely agree. And just stress that if you're going to completely cut one thing out of your diet it becomes very difficult to maintain that kind of control or rigor, so allowing yourself a sweet treat every now and then I don't think should cause worry or panic.

Diana Dyer, M.S., R.D.: This gets to what I call intentional eating: eating in a style that helps you actually decide you are nourishing yourself. Food is more than biochemistry, more than molecules, more than nutrients. Food nourishes your body but it also nourishes your soul. So, in a very intentional way, I do look at special foods, whether they be Halloween candy or a special dessert at a traditional holiday meal, and decide "Is this nourishing my soul?" And if it's worth it, I then decide "How much do I really need to eat?" Do I need to eat the whole box of cookies? No. So, I very, very deliberately eat and savor every bite. It's thoughtful selection; it's not deprivation.

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Can I postpone chemotherapy treatment during the holidays?

Question from Donder: I'm starting chemo in early December, and there is a special Christmas party I love to go to every year. I'm worried that the doctors will insist I get my chemo treatment right before the party. Can I reschedule the chemo treatment if that happens?

Answers —Larissa Korde, M.D., M.P.H.: It's hard to give specific medical advice like that without knowing the specifics of the situation and having met the patient. I recommend discussing this with your physician, tell them your concern, and see whether that can be accommodated. Also, just discuss with the physician what to expect in terms of side effects from chemotherapy so if the treatment can't be rescheduled, you know what to expect.

Diana Dyer, M.S., R.D.: You may even want to bring that up now, or sooner rather than later.

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Is loss of taste/smell for over 2 years normal?

Question from Esther: Appreciate your web site. Has anyone experienced loss of smell and taste after chemo/radiation for a long time? It has been over 2 years for me. It is very depressing. Thank you.

Answers —Diana Dyer, M.S., R.D.: I lost my normal taste for a full year after I finished with chemo, so I did not have the 2 years you're experiencing and did not lose sense of smell. It was a full year, which I think is longer than usual. On the other hand, no one in my oncology practice ever specifically asked me that, so I don't know where the full spectrum is of normal. Yes, mine did eventually come back.

Larissa Korde, M.D., M.P.H.: I'm not sure I know what the full spectrum of normal is either, but I would encourage you to discuss this with your physician to ensure there's not something else going on that could be causing this.

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Are raw eggs in eggnog safe to consume?

Question from Lisle: What do you think about eggnog — are raw eggs really that good for you?

Answer —Diana Dyer, M.S., R.D.: I would turn that around — are they really that bad for you? I would not recommend eggnog or raw eggs at all if you're on chemo or radiation or whenever the immune system would be potentially repressed, from a food safety standpoint.

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Strategies for stress-eating and concern for diet?

Question from McC: Help! I'm a stress eater. Now that I know a leaner diet is better for preventing a recurrence of my estrogen-positive cancer, how can I combat this vicious cycle: When I eat chocolate and other junk out of stress, now I get the added stress of worrying that my eating will make my cancer come back. The result is more stress and more eating. I need some strategies, please. Thank you.

Answer —Diana Dyer, M.S., R.D.: First of all, it sounds like you're already aware of your response to a stress situation. And by knowing that, you have an opportunity to develop your own response to your triggers. For myself, I always ask myself if eating X in this situation is really more important than my long-term health. It takes a half-second to do that, and yet it is a habit I've developed for myself every time I find myself reaching for something on autopilot. I back up, pull my hand away, and ask myself if eating that food is more important than my long-term health. That's my personal strategy.

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How to prevent gaining weight back during holidays?

Question from Paramedic: I just lost 15 pounds. Could I really gain back 15 pounds after a month of holiday eating even though it took me 6 months to lose the weight? Give me a reality check.

Answers —Diana Dyer, M.S., R.D.: First of all, congratulations on all of your hard work. You've lost 15 pounds — I say don't let the holidays and thoughtless eating ruin a good thing. I don't know if you'll gain back 15 pounds, it depends on how the holidays are determined. I think they start now as we're surrounded by candy with Halloween and it's a long stretch through New Year's. And Valentine's Day. Then St. Patrick's Day. And Easter.

Larissa Korde, M.D., M.P.H.: You clearly did something right to lose 15 pounds already so I would encourage you to continue what you're doing.

Diana Dyer, M.S., R.D.: I think a reasonable goal for during this stretch of parties and excessive food and candies is weight maintenance as opposed to continued weight loss.

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Can losing weight reduce risk of first-time breast cancer?

Question from Annie: How does weight affect your risk of getting breast cancer? Could slimming down help reduce the chances?

Answers —Larissa Korde, M.D., M.P.H.: Studies have shown that women with a higher body weight have a higher risk of breast cancer, particularly post-menopausal breast cancer. And intervention trials have shown a reduced risk of recurrence with weight loss. One large study suggests a reduced risk of breast cancer incidence with a dietary intervention. In addition to that, we also know that there are plenty of positive health consequences of a healthy diet and body weight. I think we can feel comfortable encouraging that.

Diana Dyer, M.S., R.D.: Those additional consequences are true for those women who both have not had breast cancer yet and for breast cancer survivors. The example being that breast cancer survivors also do die of heart disease.

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Thoughts on research on fat in diet and breast cancer?

Question from SW: As a statistician, I looked at existing research on fat in diet and breast cancer, and I do not think there are good studies that prove the link. The issues such as type of fat, women actually remembering what they ate and when, etc. Comments?

Answers —Larissa Korde, M.D., M.P.H.: Studying diet and its long-term health consequences is extraordinarily difficult for exactly the reasons you point out. There are issues with how best to collect the data and how best to analyze the data. I would say that the preponderance of data suggests that both a lifestyle that includes moderate physical activity and a healthy diet does seem to reduce the risk of breast cancer.

Diana Dyer, M.S., R.D.: The other two factors that data are strongly showing to reduce the risk of breast cancer are maintaining a healthy body weight and breastfeeding. And again the advice to have no more than one alcoholic drink a day.

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Foods to boost energy when fatigued?

Question from Constance: I've had fatigue ever since I finished chemo a few months ago. I get tired at events and functions, but I'm "tired of being tired." What foods should I look for, or bring to a party, that can help boost my energy so I can stay the whole time?

Answers —Diana Dyer, M.S., R.D.: I don't know that there's any one food or recipe that will impact the overall fatigue related to the aftereffects of chemotherapy. But a general healthy diet along with exercise will help to reduce the length of time that you are experiencing it.

Larissa Korde, M.D., M.P.H.: I would encourage you to discuss this with your physician to ensure there is not some other medical cause for your continued fatigue.

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What should survivors eat to stay cancer-free?

Question from LSw: Should we as survivors eat no red meat, eat only organic chicken, avoid coffee, consume no sugar products or eat no soy products? What should we be eating everyday to stay cancer free?

Answers —Diana Dyer, M.S., R.D.: At this point, the large amount of data clearly show that a plant-based diet can improve overall health, can reduce the risk of cancer — breast cancer — and focusing on one particular food and eliminating it completely is probably not necessary.

Larissa Korde, M.D., M.P.H.: As Diana said, sticking to a healthy dietary pattern rather than focusing on one food is a good idea.

Diana Dyer, M.S., R.D.: In regard to coffee, a study several years ago looked at the coffee consumption for the women in Sweden because they are the highest coffee consumers in the world, and tried to see if there was a correlation between coffee consumption and breast cancer and found none. I still drink coffee, in addition to green tea.

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Is milk okay for cancer patients?

Question from Emma: Is milk okay for cancer patients? I read somewhere that it isn't? But maybe this is wrong information one gets from the Internet.

Answers —Diana Dyer, M.S., R.D.: I still consume a small amount of dairy products on a daily basis. It's usually organic yogurt, but again small, reasonable amounts and this is an area where I consider there are some unanswered questions. So I err on the side of caution and stick with organic.

Larissa Korde, M.D., M.P.H.: It's important to note that calcium intake is important. So, if limiting milk intake, it's important to supplement it.

Diana Dyer, M.S., R.D.: Particularly because osteoporosis is a common outcome for breast cancer survivors.

Larissa Korde, M.D., M.P.H.: And can be a side effect of certain treatments as well.

Diana Dyer, M.S., R.D.: I'll just personally add that I'll be really mad, bummed, if I die of complications of a broken hip due to osteoporosis versus cancer.

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OK to eat soy foods, or best to avoid them?

Question from Linda: Just got here. Have you discussed soy yet? Is it OK to eat soy foods, or best to avoid them?

Answers —Larissa Korde, M.D., M.P.H.: Some studies have looked at how soy affects the risk of breast cancer. And those studies tend to suggest that a diet high in soy is protective against developing breast cancer. The concern in cancer survivors is that soy has some estrogenic properties, so to women with hormone-receptor-positive cancers there's some concern that soy could actually contribute to recurrence. So, I usually tell my patients that they don't need to avoid soy completely after a diagnosis of breast cancer, but I would not recommend megadoses of soy or specific supplements that include soy.

Diana Dyer, M.S., R.D.: I would add that, at this point, soy foods in moderate amounts, of intake which would be typical of an Asian intake of 1 to 3 servings a day of soy foods such as tofu or tempeh are considered part of a healthy diet and even acknowledged by the American Cancer Society as being safe for breast cancer survivors.

Larissa Korde, M.D., M.P.H.: I absolutely agree with that.

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How to eat better/organic on a budget?

Question from Annie: Ms. Dyer, do you eat ONLY organic food? I know it's best, but man, that really adds to the grocery budget. Can you suggest a way to eat better that's not so hard on the wallet?

Answer —Diana Dyer, M.S., R.D.: I eat primarily organic foods, when they're available and when they're affordable. I don't limit myself to organic foods because of the affordability issue and the stress involved with seeking only organic foods, either in the grocery store or in restaurants. But there are particular fruits and vegetables in particular that have higher concentrations of pesticides than others, so I do focus my limited budget on those with higher levels of pesticides. That list was determined and is available on the website for the Environmental Working Group. It's a great reason to grow your own.

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What to eat to improve bone strength?

Question from Gaff: I have osteopenia after 2 years of being on Arimidex and don't want to take any meds to deal with this but would like to use increased exercise and improved diet as well as taking vitamins to help. Could you talk about diet and helping bones? Thanks.

Answers —Diana Dyer, M.S., R.D.: The most important vitamin, of course, is vitamin D — and I would recommend that all breast cancer patients have their vitamin D levels checked by either their primary care physician or oncologist and use that level as a guide for vitamin D supplementation. Other nutrients of importance, of course, are calcium, magnesium, and protein.

Larissa Korde, M.D., M.P.H.: I would say weight-bearing exercise and balance to prevent falls are probably the most important as far as exercise.

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Is turkey okay for people with fatigue?

Question from Carleen: Is it true about the tryptophan in turkey? Should people battling fatigue avoid turkey?

Answer —Diana Dyer, M.S., R.D.: Again, moderate amounts of any one food item are perfectly fine and the fatigue that you're experiencing either from chemo or treatment is not going to be affected by any one portion of any one food.

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Foods to avoid to prevent diarrhea?

Question from Marshall: Chemo has been giving me diarrhea. Are there any foods I should avoid at parties to prevent an episode of diarrhea?

Answers —Diana Dyer, M.S., R.D.: Well, know what foods already induce diarrhea and avoid those. High-fat foods are going to make it worse. High-fiber foods are going to aggravate diarrhea. It's possible that very spicy foods may also. So, my recommendation would be to bring something to the party that you know you can eat.

Larissa Korde, M.D., M.P.H.: And if you're experiencing diarrhea, make sure you stay hydrated. Alcohol can cause you to be dehydrated so be careful about that.

Diana Dyer, M.S., R.D.: I would recommend if this is an ongoing problem to ask to speak to the registered dietician at your cancer center, who can more than likely figure out a way to help you.

Larissa Korde, M.D., M.P.H.: And if it's an ongoing issue you should talk to your physician to see if there needs to be something done to adjust your treatment.

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How to reduce weight after chemotherapy?

Question from Luann: I gained 12 pounds during chemotherapy. I am continuing on this high vegetable/fruit, low amount of low lean meat diet; however I am now about 20-30 pounds heavier than I want to be. How do you recommend I reduce my weight?

Answers —Diana Dyer, M.S., R.D.: I would start by asking for a referral to a registered dietician at your cancer center or through your primary physician; someone who can sit down with you and look at the big picture. Not just your recent weight gain, but your full medical history, eating patterns that might be lifelong, emotional factors that have to do with food intake that might be lifelong. And pull all of this together to help you develop strategies for realistic and reasonable strategies that are going to lead to weight loss.

Larissa Korde, M.D., M.P.H.: Exercise is an aspect of any healthy lifestyle and can contribute to weight loss, but starting any new exercise should be done in a staged program and with the help of a health professional.

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Ways to boost appetite while on chemotherapy?

Question from MarthaB: I have metastatic breast cancer and am on chemo a lot of the time. Well, an acquaintance of mine has a catered dinner every Christmas and the courses just keep coming out. The chemo really takes away my appetite sometimes, so I try to force feed myself to be polite. Is there any way I can boost my appetite if this happens again??

Answers —Larissa Korde, M.D., M.P.H.: That's a really hard question. There are medications that are used in oncology that are used to stimulate appetite, but not specifically in the case of one particular meal. So, I don't know of anything specific that can be used on that kind of a short-term basis.

Diana Dyer, M.S., R.D.: The current trend especially in gourmet dining is not large portions of anything but is tasting and very small portions of every single food item. And so maybe the host of this particular party could adjust the serving sizes to be very small, and let those who wish have extras if available. In this case, you would not look or feel any different than the rest of the guests.

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How much should I exercise after eating holiday favorites?

Question from RachelInNY: If I eat all my favorites — stuffing, mashed potatoes, pie, coffee, etc. — how much time should I put in on the treadmill the next day, or maybe I should be asking about the next week or so?

Answers —Larissa Korde, M.D., M.P.H.: The key to healthy living is not to focus on one particular day or one particular experience, but to focus on keeping up with your exercise routine as much as you can over several months, not just 1 week. So, knowing that the holiday season is coming up, I would just encourage you to stick with your exercise program as you're doing it and not just focus on 1 day.

Diana Dyer, M.S., R.D.: Enjoy your favorite foods, but be thoughtful about portion sizes. Start with small portions of each of your favorite foods and give yourself time to see how full you get and how full you feel before automatically filling your plate so full it's spilling over the edges.

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Portions or ingredients more important for weight loss?

Question from Lydia: What's more important if you want to keep the weight off — portions or ingredients?

Answer —Diana Dyer, M.S., R.D.: I think they're equal. And again, looking at the whole dietary pattern, which includes ingredients and portion sizes. So I think they both need to be taken into account. But if you're at a party where you don't know the ingredients, you only have control over the portion size.

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Avoiding grapefruit while getting chemotherapy?

Question from LiChang: Should we avoid punch that has grapefruit juice in it if we're doing chemo?

Answer —Larissa Korde, M.D., M.P.H.: It depends; there are some individual medications that grapefruit juice can interact with so each person should check with their physician regarding the medications they're on.

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Safe to eat seafood at holidays with mercury concerns?

Question from Melissa: I'm Catholic and we're doing our traditional Seven Fishes dinner this year for Christmas. With all the mercury issues, is there a safe way to do this or should we alter it somehow??

Answers —Larissa Korde, M.D., M.P.H.: Good question.

Diana Dyer, M.S., R.D.: Know the fish that are considered high in mercury and try not to eat those. Swordfish is one of them. Tilefish (also known as golden or white snapper) is one. There are four and I don't remember the other two [they are shark and king mackerel]. The names of the fish that are highest in mercury are readily available at Federal government websites such as the Environmental Protection Agency’s Fish Consumption Advisories page, so just make sure those fish are not being used. I would also, though, if they happen to be locally caught fish, each state has their own individual fish advisory statement/notice about which lakes and rivers have mercury contamination and people should be cautious about eating fish from those sources.

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Foods to avoid to prevent hot flashes?

Question from Peg: I am constantly getting hot flashes from the tamoxifen!! I don't want to embarrass myself at a party. Are there foods I should steer clear of so my hot flashes won't get triggered?

Answers —Larissa Korde, M.D., M.P.H.: I believe caffeine and alcohol are triggers.

Diana Dyer, M.S., R.D.: Yes, they are, and I believe you should already know your triggers and you should avoid those. Hot peppers and other spicy foods may be triggers. Again, this is something I do for a variety of reasons, I always take something to a buffet or party that I know I can eat that is either very healthy or won't cause problems. Plus, it's very delicious.

Larissa Korde, M.D., M.P.H.: And dress in layers.

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Possible to minimize genetic risk with certain foods?

Question from Annie: I'm the daughter of a breast cancer survivor. My mom had breast cancer twice, 15 years apart. Can I minimize my genetic connection to breast cancer with eating certain foods?

Answers —Larissa Korde, M.D., M.P.H.: Great question. I don't think we know the answer to that. I would say that we know that there are certain genes that increase the risk of breast cancer, but even in women who carry those genes, the risk of developing cancer is not 100%. So, probably there are other factors involved within those women at genetic risk that determines who develops breast cancer and who doesn't. It's an area of active research, but I don't know that we have answers yet. In the absence of data, I would make the same recommendations we've been making throughout this conference. Healthy, low-cal, low-fat diet, plenty of fruits and vegetables, and moderate exercise most days of the week.

Diana Dyer, M.S., R.D.: And to the fruits and vegetables I would add whole grain, beans and legumes, nuts and seeds, and healthy fat such as omega-3 and monounsaturated fatty acids such as those in olive oil.

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Don't eat after 8 p.m. to lose weight?

Question from Hockey Mom: I was told not to eat anything after 8 p.m. if I wanted to keep the weight off. Is that really true?

Answer —Diana Dyer, M.S., R.D.: Ideally, calories in equals calories out over a 24-hour period. However, I do think that snacking after supper is a huge, unintended source of extra calories — and unappreciated calories in the big picture. So, if that's a weakness, I think that's a good self-strategy to not eat after you've already had your supper.

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What are non-sugary beverages you can recommend?

Question from Cheesehead: Are there any non-sugary beverages you can recommend?

Answers —Larissa Korde, M.D., M.P.H.: Water.

Diana Dyer, M.S., R.D.: I drink green tea, which is unsweetened. Regular iced tea at a restaurant or if you make it at home is unsweetened. Even just plain water. Club soda at a party. Those are some suggestions.

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Which dips are more fattening?

Question from Cyn: How do you know which dips are the most fattening? For example, is spinach dip more fattening than hummus? What about guacamole?

Answers —Larissa Korde, M.D., M.P.H.: It's going to depend on the ingredients in the dip, so if you're eating at a restaurant you might not know that necessarily.

Diana Dyer, M.S., R.D.: I consider all dips to be a source of extra calories, simply because people tend to eat them unthinkingly. So, there's nothing wrong with eating a couple tablespoons, which is probably 100% fat, as long as you stop at that and don't eat the whole bowl — which is easy to do because it's so good.

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What does red meat do to the body that makes it unhealthy?

Question from Patricia: Dr. Korde, can you talk about red meat and breast cancer — is it really dangerous to have a holiday roast beef or ham? What about in general — what does red meat really do to the cells in your body? You hear that it's dangerous but you don't know what it really does to a person.

Answers —Larissa Korde, M.D., M.P.H.: I think as we've both been stressing today, focusing on specific contents of one meal, such as one holiday roast beef or ham, I think is less important than focusing on dietary patterns in general. Overall, I think there is evidence that a diet high in red meat is not as healthy as a dietary pattern that includes other more healthy sources of protein. I think there's not much scientifically collected information on the effects of red meat at the cellular level. There have been some studies looking at charred, barbequed, and cured meats, suggesting that those are not healthy and potentially can contribute to cancer risk.

Diana Dyer, M.S., R.D.: I think the data are strong that red meat on a regular basis, meaning daily, has an associated risk with several types of cancer, let alone heart disease and other health problems. There are probably multiple reasons why regular consumption of red meat increases cancer risk, much of which we have not fully been able to understand. Grass-fed beef, beef that is 100% grass fed from start to finish does have some healthful properties to it, such as the types of fatty acids in the fat of this meat that actually may be more than just fat, but may actually be helpful. That's 100% grass fed. Again, portion size, portion control is still important.

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Does eating food with grill marks increase risk?

Question from Annie: My sister, another child of our breast-cancer surviving mother, refuses to eat food with 'grill marks' because of the cancer risk. I LOVE to grill and I do like a bit of char...not completely blackened, but black grill lines. Who's right? Me or sis?!

Answer —Diana Dyer, M.S., R.D.: Grilling does lead to carcinogens, but there actually are some studies that show that marinating the meat for as little as 30 minutes ahead of time, and it doesn't matter what marinade, pretty significantly reduces the ultimate amount of carcinogens formed when the meat is grilled.

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What are indulgent but healthy buffet menu items?

Question from Franetic: What's a seemingly indulgent but nutritionally sound buffet menu for a cocktail party? What would YOU serve at such an event?

Answer —Diana Dyer, M.S., R.D.: I always take to every buffet a black bean salad. The recipe is on my website. I always have some hummus with whole wheat bread and a variety of different types, different flavors of hummus. Fresh fruits and vegetables. I let people use either guacamole or hummus as a dip. Carrot bread, cranberry bread or something like that that's made with whole grain. I'd add flax seeds to a cranberry recipe, things like that. I'd take typical holiday foods and make them healthier by adding different healthy ingredients. That's a good start; I'm sure there are more.

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Recipes for healthy, tasty holiday classics?

Question from Treina: Where can I find holiday classic recipes with healthy substitutions — that taste good?

Answer —Diana Dyer, M.S., R.D.: Certainly my website and my blog are filled with recipes that are beautiful, taste good, and filled with healthy ingredients. And they are all family-approved and tested before going up. Each family's traditional recipes are going to be unique to them, so it's difficult to make a blanket statement, but that's a good place to start. Just for color, you can take your typical recipes and add a touch of red or green for holiday color.

Along that same thing, you can take any recipe that's traditional to your way of celebrating the holiday and garnish it with something festive that's red or green: tomatoes, red or green peppers, some kiwi fruit, or green melons or green apple slices, green pepper strips. Work on decorating the food or the tray it's being served on.

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Does it increase risk for patients to eat anything they want all month?

Question from Holiday Gal: What is the risk to a breast cancer patient or survivor if they let themselves eat whatever they want in December — all the stuffing, mashed potatoes, pie, cookies, chocolate, and wine you want — as long as you quit it all in January? What would be the effects on your risk of recurrence?

Answer —Diana Dyer, M.S., R.D.: I don't think anyone can quantify that. I think the risk of weight gain is there. All the data shows that weight gain increases the risk of recurrence. Again, I always use that self-mantra "how important is this to me compared to my long-term health?" I still might eat everything, but I don't think I can ever see myself eating as much as I want with abandon. One tip that people do use is to weigh themselves daily and you'll always have daily fluctuations, but if you see an upward trend it's time to nip things in the bud in terms of eating habits and exercise.

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What foods taste good after chemo changes senses?

Question from NancyR: Chemo has altered my taste buds. Have you heard from others about what kinds of foods taste better to them when this happens? Or is it individual to the person?

Answers —Larissa Korde, M.D., M.P.H.: I think it is pretty individual and I generally encourage my patients to eat what tastes good to them. One tip I've heard from patients on chemo and that I suggest is things that aren't too hot or cold but more room temperature. In terms of bland versus spicy, I usually tell people to go with what appeals to them.

Diana Dyer, M.S., R.D.: From personal perspective, in addition to taste alteration, a previous question touched on smell alteration. For myself, having strong smelling foods would also cause the food to not taste as good. So, cooking with the fans on, cooking with lids on your food can help to keep that smell out of the house and minimized. I also had, with my chemotherapy, a metallic taste in my mouth and I found eating with plasticware instead of silverware helped cut that down. Also with that metallic taste, what helped me was to actually put teriyaki sauce on practically everything. It really cut that metallic taste that seemed to override any other food taste that I was expecting. So, for a few months, a lot of my foods tasted the same because it tasted like teriyaki sauce, but at least I could eat it so it was nourishing my body.

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How do I follow a special diet on a cruise?

Question from DAL: My husband and I are planning a cruise over Christmas. After I was treated for stage II last year, I was advised to limit sugar and dairy and eat lots of vegetables and grains. Who do I talk to about my special dietary needs as I get ready for our trip?

Answer —Diana Dyer, M.S., R.D.: I would really push the cruise company and see if they have a registered dietician who might be able to help guide you with the specifics of what's available on that particular cruise and maybe have some special food options available to you. I don't know if any cruise lines have a registered dietician as a consultant. I would guess that this is not an uncommon question and someone associated with the cruise line is going to be able to give you some advice on what options will be available to you.

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What is a baking substitute for white sugar?

Question from Annie: I love to bake and I see “refined white sugar” is a no-no...what would you suggest as a replacement for that in say, a cake or cookie recipe?

Answer —Diana Dyer, M.S., R.D.: First of all, in every recipe I use I cut the sugar in half. Sometimes it turns out perfectly all right and perfectly the same, and other times it doesn't. But I don't worry about it. I also think about portion sizes. If it says it makes 35 cookies, I try to make 60 cookies. So, you're reducing, reducing, reducing. You're still enjoying, but you're being thoughtful about how much you're eating.

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Which cheeses are better than others?

Question from Sangita: Is cheese the enemy? Are there any kinds that are better than others?

Answer —Diana Dyer, M.S., R.D.: Having significant loyalties to the state of Wisconsin, even though I live in Michigan — cheese is not the enemy. Again, I consume organic cheese. I consume cheese from cows that were grass fed, which actually improves the fatty acid profile to helpful fatty acid. Yet, I still don't eat it with abandon. I limit my cheese. In addition, feta cheese is lower in fat overall than most other cheeses. Because flavor is still important, most low-fat cheese on the market have reduced flavor. So, I like a regular cheese that happens to be lower in fat but still packs the punch of regular cheese and feta fits that bill.

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Is pita bread healthier than nacho chips?

Question from MROSS: If there's pita bread and plain nacho chips on the table, is one better for you than the other?

Answer —Diana Dyer, M.S., R.D.: Pita bread would be lower in fat than the majority of nacho chips. So, in that sense, it's likely better for you.

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Suggestions for easy-to-make, healthy recipes?

Question from Carolyn: I'm 2 months out of treatment and want to celebrate, so I'm having a party! I'm now worried that I made a mistake and that the cooking might be too much for me. Are there any easy and healthy recipes that go over well, that won't tax my energy to make?

Answers —Diana Dyer, M.S., R.D.: Reconsider having to do your own cooking and ask your friends if they would enjoy helping you celebrate by bringing something to this festive occasion. If you really still don't have the energy, then consider having it catered.

Larissa Korde, M.D., M.P.H.: I think the recipes that Diana mentioned for the buffet earlier are nice options in terms of healthy and delicious-sounding food.

Diana Dyer, M.S., R.D.: And beautiful.

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What to eat to 'cleanse' after indulging?

Question from Marlene: If I have a day of gluttony, is there anything I can eat the next day to "cleanse"? Wheat grass, etc.?

Answer —Diana Dyer, M.S., R.D.: I don't do that. I would say, every day is a new day to succeed. Don't define or limit your today's or tomorrow's success by slip-ups that may have happened yesterday. I think it's far smarter to exercise a little more than to look for a specific food to make up for yesterday's indiscretions.

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Stop tamoxifen over holidays to minimize nausea?

Question from PennyLaB: I had stage 1 breast cancer, 2 lymph nodes positive, had lumpectomy, chemo, and radiation, and am currently taking tamoxifen. The tamoxifen makes me feel nauseous sometimes so I don't feel like eating. Can't I stop taking tamoxifen for a couple of weeks over the holidays, so I can enjoy eating at dinners and parties?

Answer —Larissa Korde, M.D., M.P.H.: Again, I don't like to give advice on specific medical situations without knowing the specifics of a patient's history. But for hormone-receptor-positive breast cancer, generally, the most effective treatment in terms of recurrence is hormone therapy. I would suggest that if you're feeling a lot of side effects from taking the tamoxifen to see your physician to see if you can work together to get around this issue. The usual dose of tamoxifen is 20 mg a day and it comes in 10 mg tablets. So you can split that into a morning and evening dose and that sometimes helps when people experience the side effects. But I would talk to your doctor about that.

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Small change anyone can make to improve health?

Question from QLyle: What one small nutritional change would you recommend for everyone — in treatment, trying to improve their health long-term, and just to feel better?

Answers —Diana Dyer, M.S., R.D.: Study after study shows that people do not consume enough vegetables. I would work on increasing vegetable intake, both portion size and variety. Get beyond your typical corn, potatoes, etc. and take advantage of fresh vegetables in grocery stores and at farmers' markets. The leafy greens in particular are where you get the bang for your buck in terms of molecules to help fight cancer and optimize overall health.

Larissa Korde, M.D., M.P.H.: If I were to give one piece of advice, it would be to focus on a healthy dietary pattern rather than beat yourself up over one meal or one indiscretion. And to maintain a healthy diet, a healthy body weight, and physical activity.

Diana Dyer, M.S., R.D.: I would also suggest that you seek a consultation with a registered dietician at your cancer center to help individualize diets during treatment to both optimize treatment and improve the odds for long-term survival and overall health.

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