Nutrition and Breast Cancer

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org senior editor Jamie DePolo.

Jamie DePolo: As always, thank you for listening. This podcast is the audio from a special virtual community meetup, featuring registered dietician and oncology nutrition specialist, Hillary Sachs. Hillary helped Community Director Melissa Jenkins lead this meetup on nutrition and breast cancer. We hope this podcast answers many of the questions people have about eating healthy after being diagnosed.

Hillary Sachs: Thank you, all, for having me here and inviting me into your space and your group. I'm really honored to be here, and just a little bit about me. I am a board-certified oncology dietician, and I've been in the field for about 15 years now. Snd it's really a passion of mine, both the science and chemistry, but also seeing the big impact that different nutrition choices can make, and you know, nutrition is such a loaded word and is so different for different people.

The word “healthy” is a loaded word. What's healthy for one individual is not necessarily healthy for the next. So, while there are overarching themes, one size definitely does not fit all when it comes to nutrition, and that's also why I think nutrition information can be so confusing, because one day, one thing is good, the next day, we shouldn't do it, and there's so many variations depending on the individual.

And maybe we're only looking at from one lens, from a science lens, but then when we look at nutrition from a whole-person lens, and fitting in things, cultural foods, family foods, celebration foods that are important to them is a whole other psychological lens, which is important to being healthy and living a full life.

So, I'm really excited to be here and start the conversation and kind of talk about foods and answer questions to kind of help you be where you want to be. So, Melissa, do you want to start off by kind of asking some of the different questions that came in, or tell me a little bit where we want to go. Okay.

Melissa Jenkins: Yeah. Well, we can begin with, I guess, about finding that happy medium between the joy of eating and the wanting to prevent any kind of future development of cancer. Sort of how do you find that happy medium between, like, I ate healthy all the time and I still ended up with metastatic breast cancer. Now I want to eat what I want to eat, but yet I also want to do the best for myself?

Hillary Sachs: Right. It's a good question. You know, again, eating healthfully means different things for different people, and I always feel, in the nutrition field, that it never should be all or nothing. As human beings, when we create strong rules around food, this is what I need to do, this is what I can't do, at some point, we always rebound and relapse or kind of get obsessed about what we can't do.

So, when I'm working with people, one-on-one, we kind of always strive to see what foods they like, what foods they enjoy, what foods they're thinking about, and work those into a health-promoting, cancer-fighting diet in the best possible way. Now, one of the points you brought up was, and I hear this from people, you know, I ate so well, I took care of myself, and I ended up with cancer.

It's a really hard thing to sit with. Nutrition is something we sort of have a piece of control over, where there's other factors where we have less control over, but I will say for people who are taking care of themselves, eating as well as possible, exercising, moving their bodies, you're starting from a stronger, healthier place. 

Your body is nourished, and that usually helps to kind of get through treatments, which are difficult. So, it's not all for naught. It does still help, and there are so many studies that show that meeting with a dietician regularly can help kind of promote better outcomes, throughout, as well, regardless.

Melissa Jenkins: Another question that came in, would like to know how sugar and protein affect cancer.

Hillary Sachs: Yeah. This is a common one, a common question that I get a lot. So, if you don't mind, I'm going to separate it into the sugar, and then we'll get into the protein, because they're both kind of loaded with tons of things. So, so many times, I hear, does sugar feed cancer? You know, what's the relationship between sugar and cancer, should I go on a low-carbohydrate diet to starve the cancer?

I get this question a lot, and one of the links that I'd love to put in the chat, at some point, is to www.oncologynutrition.org. It's a website through the Academy of Nutrition and Dietetics, and on the top, they have different tabs, and one of the tabs is called like healthy eating now, frequently asked questions. They have an amazing summary to the sugar causing cancer question, with studies in it 

So, you can always take a look at that, as well. So, all of the cells in our body, muscle cells, blood cells, all, every cell, brain cells, everything, cancer cells, too, use sugar in the form of glucose for energy. There are a few exceptions of other cells that of other areas of our body that use other pieces of fuel or that can use other pieces of fuel.

Our brain is an exception. The brain primarily uses glucose, but it can also use ketone bodies from the breakdown of fat. Every other cell in our body needs glucose to operate and run. So, if you were to cut glucose out of your diet, or sugar out of your diet, completely, your body would start to have to use its storage form of glucose, called glycogen, and it would have to convert proteins, fats, into carbohydrates so that our body could use it.

Now, cancer cells are using glucose faster than other cells because they're growing and dividing quicker, generally speaking. So, that's why, when you go for a PET scan, for example, and you drink the super sugary drink, if there's cancer present, it lights up because it's using the sugar much quicker than other cells in our body. Interestingly enough, there's not a lot of studies to support that sugar is feeding the cancer directly.

But there are studies to support kind of the indirect relationships around it. For example, if somebody's eating a diet with tons of sugars in their diet, very carbohydrate-heavy, not a lot of fiber, not well-balanced with protein or fat, they tend to get high rises in something called insulin. Insulin is a hormone that we usually produce to kind of get the sugar out of our blood and into our cells.

Insulin is a hormone that makes cells grow. So, if you're eating tons and tons of sugar, there might be very high levels of insulin, and insulin is a growth hormone. So, if there's a lot of growth hormone there, all the time, you may see people a little more predisposed to cancers. We also know that for people that eat a lot of foods with added sugars, consistently, they're not necessarily focusing on a lot of the foods that we find promote a healthier lifestyle.

The American Institute of Cancer Research actually has a page -- I don't actually know if I sent you this link -- but it's called Foods That Fight Cancer. A lot of the foods on that list make sense, fruits, and vegetables, and whole grains, and beans, and nuts, all the things that we think about. Those foods don't have, usually, added sugars. So, if you're, you know, and this is an extreme example, but like if you're having a candy bar for breakfast, every day, consistently, you're kind of missing out on the opportunity to have some of those cancer-fighting foods in your diet.

And then, lastly, there's an epidemiological or observational relationship between body weight and cancer. So, this is a really tricky spot because, first off, everybody's body weight is different. What's right for you is not right for the next person, and our frame sizes are all different, but for people that are much higher than what their set point should be and is right for them, there is a relationship between higher body weights and higher rates of cancer.

They think that's because of, again, resistance to the hormone insulin and higher levels of circulating insulin or growth hormone, higher levels of inflammatory markers, but there is that indirect relationship, too. So, perhaps for people that are eating a lot of added sugars, they may or may not have higher body weights, as well. So, there's kind of those more indirect ways that it's related.

There's a couple of definitive studies showing that very low carbohydrate or even ketogenic diets are cancer-fighting. The most consistent studies are related to fighting brain tumors because of the way that the brain uses ketones, but a true ketogenic diet is a little bit difficult to follow. It's very high in fat. It's kind of low in protein and low in carbohydrates. So, people might have a hard time following it for a long period of time. Because it's so low in carbohydrates, it's also low in fiber, which sometimes causes some other issues, stomach issues, constipation.

They're just starting to touch on research for use of ketogenic diets in other sites, but there's not a lot of large studies showing that they're effective for fighting cancer in other sites, to date. So, I'll pause there, first, but before we jump into anything about protein, just to take a minute to digest, and you know, Melissa, if there's any thoughts or questions that came up in the chat about...

Melissa Jenkins: If anybody has a question, at any time, please feel free to raise your hand if something doesn't make sense to you.

Hillary Sachs: Yes. Yeah, or if you want me to slow down and repeat it, I'm happy to.

Melissa Jenkins: Yeah.

Hillary Sachs: And you can always stop me, Melissa, if I just keep going and don't stop.

When it comes to protein, so, the American Institute of Cancer Research finds that a plant-based diet is most protective, most cancer-fighting, but that doesn't necessarily mean being a vegetarian. They kind of frame it like the bulk of the foods on your plate are plant-based, so, whole grains, vegetables, perhaps you're having some beans, and perhaps you have your animal protein or not.

They find that this kind of plant-based model has been shown across multiple studies, multiple cultures, to be the most cancer-protective. So, what does that mean for protein? So, when it comes to animal proteins, we know that processed meats, anything with nitrates, hot dogs, sausages, deli meats, have a relationship with increasing certain kinds of cancer, like colorectal cancer, if eaten regularly.

The recommendations, right now, are to eat those foods just as sparingly as possible. When it comes to red meat, pork, lamb, veal, beef, the recommendation is to eat no more than 18 ounces per week, and you might be surprised at that. So, if you've ever heard about like the size of your palm, or the deck of cards, does anyone know how big that is, how many ounces that is? Three. Yeah, I see Maureen.

The size of your palm is about three ounces. So, the recommendation is to have up to 18 ounces a week. That doesn't mean that you should, but that's kind of like the maximum. So, that's six palms, or six decks of cards, that you can eat without necessarily increasing your risk of cancer, according to research. So, that's kind of interesting.

The way you cook meat protein is also important. If there's char marks, you're burning it, it has more of these heterocyclic amines, which are chemicals that form on the meat. You can actually decrease some of those by the way you cook and with spices you use. Spices like rosemary actually decrease the amount of heterocyclic amines that form on the meat. So, it's great, if you're grilling, to put some of that on there, not cooking directly on a hot, hot surface, like a grill, putting it in a pan, instead, can help, or stewing, using slow cookers, baking. Those are all other ways to make animal protein.

As of yet, there's not a strong relationship between eating poultry, like turkey or chicken, and the increased rates of cancer. So, it has a neutral effect, but there are lots of benefits and cancer-fighting properties to plant proteins.

Beans, so, chickpeas, black beans, kidney beans, have a great amount of plant protein. They also are rich in prebiotics, so the kind of fiber that feeds the good bacteria in our guts, and we're learning so much more about gut health and its relationship to decreasing inflammation. So, that's really positive, and nuts and seeds have their own health benefits to them, as well. 

So, increasing the plants and the plant proteins always has an extra kind of benefit. Poultry is kind of neutral, and red meat up to the 18 ounces a week, and cooked in a certain way, could be incorporated as part of the diet. So, I don't know if that I see a lot of things came into the chat. So, I'll pause for a minute and then I'll jump over there.

Okay. I see the question about albumin levels, so, and I know that question came in ahead of time. So, I think the question was, and I'll pull it open directly, “Why does my albumin levels go down with treatment?”

I'm just pulling it open so I can read it verbatim, and “Is there anything I can do for this? Some cancer drugs cause low protein and albumin levels, and increasing my protein intake did nothing to improve my levels.”

So, it's interesting and very noteworthy that you noticed that. So, kudos to whoever submitted that question because you're noticing things, and that's like starting to notice things and creating that connection is really important. So, actually, between 10 and 20 years, they found that albumin is actually not a great marker for nutritional status. Sometimes, you know, people think if my albumin low is low, that means my protein status is low, but that's not actually the case.

Using a level called pre-albumin is more accurate. Albumin levels change drastically with any kind of inflammation in the body, and that's not to scare you, but while you're on treatment, you might have higher levels of inflammation just as your body's natural reaction, and so, your albumin levels may be going lower, at least temporarily, due to that. Better measures of nutritional status, are, again, something called pre-albumin, looking at your iron levels, transferrin, and ferritin.

There's also a nutritional questionnaire. It's three questions. You can, I'm sure we could find a link to it. It's called the Subjective Global Assessment, or SGA. It's a very strong marker and predictor of malnutrition. There's also another screening tool called the Malnutrition Screening Tool. 

These are better measures and better tools of nutritional status than albumin is, which, again, is affected by other things in the body, which is why it may be going lower. I think I'll backtrack because I see a few questions that came in while I was talking.

Melissa Jenkins: Actually, you know what, I think we could move to one other... 

Hillary Sachs: Sure.

Melissa Jenkins: We talk about a lot of side effects, obviously, that include joint pain, fatigue, sometimes brittle nails and hair, but one of the ones that we hear over and over and understand is the fatigue and like the fatigue and just the general malaise, the bad feeling, and what kind of supplements, vitamins, foods, would you recommend to add or actually also to avoid in order to help with fatigue and then also with joint and bone pain? And then we can move on to some of the other side effects.

Hillary Sachs: Yeah. Okay. So, fatigue is 100% definitely a side effect of going through treatment, and it can be so debilitating. It can affect all areas of your life and just be a big challenge. There are some things, from a nutrition perspective, and I'll talk about foods first, and then we'll talk a little bit about supplements and get into that. 

One thing that is really first, most important, and you may be doing this, but making sure you're keeping hydrated is really important because, sometimes, when you're tired, and you're resting, we forget to drink. So, I usually calculate people -- I like that Ann is taking a sip of water there. I usually calculate people's fluid needs by taking their weight in pounds and dividing it in two. That's about how many ounces you need in a day.

So, if somebody is 150 pounds, they need about 75 ounces of fluids a day. Now, that number can change, you know, if somebody is losing fluids, a lot of sweat, or you know, diarrhea, vomiting, which does happen. Your fluid needs might be higher, but that's kind of like a baseline number, and lots of things count for fluids besides just water. Sometimes, people develop an aversion to water.

It tastes funny, or it's just not pleasant to drink. Broth counts for fluids. Jell-O counts for fluids. Ice pops count for fluids. Watermelon has tons of fluids. So does yogurt. So do cucumbers. So, there's also lots of ways to kind of fill in the gaps and supplement, any herbal teas, anything without caffeine counts for fluids. So, that's first.

Second, and this one might be challenging as I usually work with people to kind of break it down and make it accessible, but trying to get a protein with a fiber at each meal and/or snack. The reason is, is that the fiber and the protein kind of keep your blood sugar steady and your energy as steady as possible throughout the day. When you eat something without the protein and the fiber, your blood sugar can spike up and spike down, and that could lead to a lot of those crashes.

Again, we know that the feeling of fatigue is there for other reasons, but it does help. So, for example, if somebody is taking -- I'm making this up -- crackers as a snack, maybe they can take some peanut butter with their crackers and slice up a piece of fruit, or have some frozen fruit with it. This way, you're adding fiber and protein. The protein is the peanut butter, the fiber from the fruit.

So, there's always little, more accessible, ways to do that, but that's important for kind of keeping the blood sugar level, and also getting a wide variety of nutrients that you need to replenish to make yourself feel better. If you're feeling really tired and it feels debilitating, I would encourage you to talk with your doctor about getting certain bloodwork done, too, next time they have to do bloodwork, anyway.

For example, I mentioned iron before. Iron, an iron panel, with ferritin and transferrin, that's important to just see if you just need some extra iron, and you're a bit anemic. Anemia could be caused from a lot of reasons, and iron is just one. Another one is B12. So, there's a measure of B12 called MMA in your blood, and MMA shows how much B12 is actually inside your cell, rather than what's just floating around your blood, and that's important because B12 can also be linked to varying energy levels.

So, those are just two of many that might be helpful. The third thing that there's been so much research on, and again, can be challenging, is movement. There's so much research that movement, moving your body, even if short, helps to decrease fatigue, and that kind of seems counterintuitive. You know, you're tired, the last thing you want to do is move, but there is so much to back up the fact that moving helps to decrease fatigue related to treatments.

Moving doesn't mean you're breaking a sweat and going to the gym. Moving could be getting up and walking around after eating for five minutes, or you're watching a show, and during the commercials, you're moving your arms and legs, or you put on your favorite song, every hour, and you dance to it. It doesn't have to be exercise as you might traditionally think of it, but moving really does help to decrease fatigue.

Now, when it comes to supplements, I will say that, unfortunately, supplements are not regulated in the same way that pharmaceuticals are in this country. So, what's on the label may or may not be accurate. So, we have to be careful. It's tricky, and there's, you know, always reports of contamination, and this and that. There are some things that I look for on a nutrition label to help decrease that.

There's something called the USP label. USP shows that it's been third-party tested, that what's in it is what's on the label. Nature Made, on TV, always advertises that they're USP-verified, and then there's like GMP-certified is another third-party test. So, there's a number of pharmaceutical-grade supplements you can get. If it's something that you're going to be taking regularly, it may be something to prioritize.

And there are some there is some research on certain supplements that help fight fatigue, which is interesting. The first one that I think about is ginseng. Now, into the chat, we could I think you may I'm not sure if we put it yet, but there yeah, I think it might be in there. There's a great website through Memorial Sloan Kettering called About Herbs and Botanicals, and what's nice about it, it's free, and you can search most supplements, not all, but most.

And it will tell you any interactions with drugs, because just like drugs have interactions, supplements can, too, and if you're taking other things, it's important to check. Ginseng, there's different forms of ginseng. If you've had a history of estrogen-positive breast cancer, it may be contraindicated. If you've had estrogen-negative breast cancer, it's something that you can still take. It does thin the blood, however, so if you're on blood thinners, or your platelets have been low, it's something to consider.

There's another supplement called adaptogens. There's many different types that work in different ways. So, there's one called tulsi, or holy basil, and you can buy that in tea form or in pill form, and that really helps with decreasing stress in the body, which we could all use, right? And then, there's another one called rhodiola, which helps kind of, again, make us feel good and help with energy, and a popular one you may have heard of is ashwagandha, which also helps, again, boost energy.

But all of them have interactions with medication. So, if you're thinking about taking something, I always encourage you to check with your medical team or check with a registered dietician. You could check that website through Memorial Sloan Kettering. Again, it's called About Herbs and Botanicals, just to check that, you know, what you're taking isn't causing an interaction with something else.

I think one other question, while I'm on this topic, had come in about like supplements versus tea, and so, teas usually are much more diluted, much more mild. So, if you're thinking about trying something, and you're not sure how it will affect you, tea is a great way to do it, and tea, itself, has so many health benefits to it. Ginger tea is great for nausea and as an anti-inflammatory. I mentioned holy basil tea. We can get into green tea, also, which is a whole thing.

Green tea is on the list from the American Institute of Cancer Research for foods that fight cancer. Green tea does have some interactions with a medication called Velcade [chemical name: bortezomib], which is usually used for certain blood cancers, and it could interact with a few other medications. So, it's good just to check. The tea, itself, also has something called theanine, which is relaxing, just much more mild in effect compared with supplements. Supplements will give a more potent effect. 

Melissa Jenkins: This is a tough one, alcohol.

Hillary Sachs: Yeah.

Melissa Jenkins: We all talk about alcohol as, you know, it's a hot topic. So, can you shine a little light onto that?

Hillary Sachs: Yeah. Sure. So, alcohol is an interesting one, and again, you know, we drink alcohol for so many reasons. So, it's something to think about. Alcohol, in certain forms, like, we always hear that red wine is good for heart health, and whatnot, but when it comes to cancer, especially breast cancer, the relationship between alcohol and risk, there seems to be an increase in risk as we increase our alcohol intake. So, what does this mean?

So, there's two connections that we find. The alcohol, itself, has acetaldehyde in it, and our bodies have to metabolize and digest that, and that is an oxidant, we know, and as it digests and metabolizes in the liver, it also can raise estrogen levels in the body. So, alcohol, it doesn't matter, necessarily, the form, because it's the alcohol, itself, that there's a relationship with.

Just for a mental picture, a single serving of a drink is about five ounces of wine, 12 ounces of beer, or about 1.5 ounces of hard liquor. The recommendation, right now, is to kind of have no more than one drink a day for women and no more than two drinks a day for men, with the, you know, drinking the least amount of as possible. So, there's always going to be times or occasions where you want to drink alcohol, or maybe you want to drink a little more alcohol than usual.

So, you just, again, one, have to take into account, you want to enjoy your quality of life, too, and enjoy, and not be worried or having fear in you, and if it's something once in a while, it probably is okay, but two, it's always good to have that conversation with your doctor, as well. Again, we take everybody as an individual, looking at their lab work, their kidney health, their liver health, to see like what is healthy, if anything, for them.

I always encourage people to just try to, again, to drink the most minimum amount as possible. Now, in my explorations of this, I have tried a number of non-alcoholic beverages, and I think I sent one link to you, Melissa, from a company called Grüvi. They make a lot of non-alcoholic rosés and proseccos, and they come in cute bottles. 

So, if, you know, you're at an event, or you're hosting something at your house, and it's more social that you want to be drinking, but you don't actually want the alcohol, they're a kind of a fun thing to keep on hand to feel like you're participating, and they also taste good, and they're not super high in sugar, and just to feel part of what, you know, the community is, but that, the link there, I happened to try a lot of them, and that one, I like a lot, personally.

Melissa Jenkins: What are the effects of anti-oxidant supplements, such as coenzyme Q10, selenium, and vitamins A, C, E? Can they really help to prevent cell damage?

Hillary Sachs: Yeah. Good question. Now, a lot of the studies that have been done have been done for foods and not necessarily supplements, which is interesting, and the form in supplements, particularly for vitamins A, C, and E, is different in supplements than it is in food. So, I always just want people to keep that in mind because taking the supplement may not be the same as taking the food, as eating the food.

When it comes to CoQ10, CoQ10 is something that is really important to take particularly if you're on cholesterol-lowering medication, like statins, or you are on or have been on Adriamycin [chemical name: doxorubicin}, that red medicine. It's very heart-protective. There's different forms of CoQ10, ubiquinol CoQ10. They're all fine. So, that one's a good one to take, less so for the cancer relationship and more so for the heart protection.

When it comes to vitamins A, vitamin C, vitamins E, vitamin A and E, in particular, have had very mixed results when it comes to different cancers in supplement form, you know, not always the best. Like, there was a study on prostate cancer, showing that people that took high levels of vitamin E did not have the best outcomes compared to people that didn't. Again, in nutrition, it's hard to control a lot of the outside factors, but I always encourage people to see if they can get some of those things from food.

So, for example, when it comes to derivatives of vitamin A, beta-carotene and lycopene, we're looking at red, orange, yellow fruits and vegetables. When it comes to vitamin C, if you're able to eat any sort of fruits and vegetable every day, you're probably getting enough vitamin C. It's hard, fruits and vegetables, whether they're cooked, raw, lots of vitamin C in them. Vitamin E is a little tougher. It's a fat-soluble vitamin, so is vitamin A, but it's a fat-soluble vitamin. It's found in a little less places, but if you eat nuts, or seeds, or avocados, you can get some natural sources of vitamin E that way, and when it comes to ACE, I always encourage people to try to get them through food as much as possible. 

Quercetin is a natural polyphenol found in onions, found in apples. There's a lot of relationships with having cancer-fighting properties, which is great.

I have one picture that's like all the polyphenols and benefits that you find in an apple, and like it's a whole page filled with little words, and you can't even read what's in it, and kind of that's the point. In foods, there's so many different nutrients, and they all kind of work together in different ways, that food is usually better, when possible, compared with supplements, because taking one out of context may or may not be a good thing.

There have been some studies on quercetin, also, for allergies. So, taking it for a short term is perfectly fine, especially for that reason, but if it's something you want to take for a long term, I always encourage people to kind of look at the foods that it's in and try to incorporate them regularly. They'll be getting more benefits that way.

Melissa Jenkins: And what about vitamin D?

Hillary Sachs: Yeah. That's a good question. So, vitamin D is one that I think we are learning more and more about, and right now, the recommendations for what is normal is really based upon bone health. It's not necessarily based upon other types of disease prevention, or immune health, or anything like that. So, according to, again, what the standards say, anything higher than 30 is considered normal, but studies have shown that blood levels closer to 50 to 80 is more ideal.

Now, vitamin D is fat-soluble. So, you really need to take it with food, and optimally, a source of fat in order to absorb it. We're really not going to absorb a ton of it otherwise. If you're someone that, for whatever reason, is compromised in your fat absorption, then sometimes people need to take the water-soluble form of vitamin D to absorb enough of it. It's not found a ton in foods.

You know, it's fortified in some dairy products, but not a lot, sun-dried product, like sun-dried tomatoes, and things like that, have a little bit in it naturally, but mostly, we make it from the sun. So, depending on where you live, if you live in the Northeast, that's where I live, we actually don't make the physical rays from the sun between about October and just about now, March, that we need to make it.

So, we're using our body's stores during that time, or we're relying upon supplements at that time to kind of keep those numbers up. The other thing about vitamin D, in order to make it, you need to have sun exposure for about 15 minutes without sunscreen. So, there's that piece of it, too, that you need to consider. So, many people end up needing to supplement with vitamin D for either they don't want to go out without sunscreen, they don't physically have the rays they need to make it, or they're still low for whatever reason.

I usually base supplementation recommendations on what people's blood levels are, and then there's recommendations based off of that in terms of how much you need to raise your blood levels. I think if you take 10,000 units of vitamin D, it'll raise your blood level by about 10 points. I'm pretty sure that's what it is. If it's any different, I'll email you, Melissa. That's from the top of my head, but I'm pretty sure that's what it is. So, it takes a lot to raise your blood level, and then once you raise it, you can kind of take a maintenance level that we can figure out.

Melissa Jenkins: One addition, just to the vitamin D, if I'm on steroids, does that affect how much vitamin D? Is there an impact with steroids and vitamin D? 

Hillary Sachs: Good question, but not that I know of, that vitamin D and steroids don't necessarily interact as far as I've ever read, and I see the post, also, that there's been recent studies showing that low vitamin D levels increase risk of chemotherapy-induced neuropathy, which is really interesting.

Melissa Jenkins: Marilyn just asked what are your thoughts about protein shakes? We talk a lot about protein shakes. What kind of protein? Should it be milk protein versus plant protein? When should they be used, and how often, if at all? We do have people who need to, of course, use that because it's hard to get all the calories in, for some people, or all the nutrition in and need an easy method.

Hillary Sachs: Absolutely, and I will say that I've recommended many different types of protein shakes to people, almost every day, for various reasons, but not everybody needs a protein shake. So, let's backtrack a little bit. So, first off, there's premade nutrition drinks, and then there's also ones that people make on their own, at home. So, we'll start with some of the premade ones. 

So, you know, again, sometimes, for various reasons, you have an appetite but maybe aren't eating as much as usual, or you're eating as much as usual, and you're still noticing that you're losing weight, or you know, you're going to so many appointments, and you just like are out of the house for hours and can't keep up with your nutrition, or you're tired and don't feel like preparing things.

Nutrition shakes can be a really convenient way to make sure you're getting what you need in terms of calories, in terms of protein, in terms of vitamins and nutrients. There's many different kinds, and a part of it is also like what is most accessible. So, in most grocery stores, they sell at least one type or one kind of nutritional shake. The most common one that I see people using or on the shelf is probably Ensure and Boost.

I see those a lot, and then there's also Glucerna and Boost Glucose Control for people who have diabetes or elevated blood sugar, which is just, again, the lower-glucose or lower-sugar versions of Boost and Ensure, but there are newer nutrition shakes that also have come out for people that don't like the ingredients or don't like the taste of those, and I'll go through what those are, but they're a little less accessible, from what I've seen. Like, they don't if you walk into a grocery store, you don't always see them.

So, for example, there's another nutrition shake called Orgain. They sell it. I've seen it at like BJ's and Costco. They sell it in shake form and powder form, and they sell an adult version, and a kid's version, and the taste is definitely different than Ensure. I personally like it better. Just, again, that's just a preference, but everybody is different in terms of what they like. It has like different fruit and vegetable extracts in it, as well, which is kind of nice, and it comes in chocolate and vanilla, also.

There's another one called Kate Farms, which is another big one that's come out. Kate Farms is also like a more natural-focused brand, and they're also like shake-like. So, they make one for lower sugar, and they make standard ones, but they're a little more natural. I'm pretty sure on Kate Farms' website, you can go on and request samples, which is nice, as a, you know, as a person, not necessarily as a practitioner.

Now, there's also some savory shakes, which is kind of nice for people who don't want the creaminess, or they're sick of it. So, there's one that used to be used for tube feeds, but I've had a lot of people just warm it up as soup. I know that sounds a little strange, but they're called Real Food Blends, is one of the brands that I've used, and it's just food that's like basically blended like a soup or stew, and it's another nice supplement or complement if you're sick of shakes.

There's a few other brands that are similar to that. So, if I think of some other names, I'll throw them out there. Now, you could also make your own shakes, if you're up for it, and again, having some premade ones is a nice option for when you're not, but what I always say when I'm talking with people about making their own shakes, make sure, again, if you're putting fruit in it, keep it to about a cup. Make sure you're getting a source of protein.

It could be food. It could be like nuts and seeds, or peanut butter, or whatnot. It could be a protein powder. So, we kind of work together to figure out which protein powder is right for them, based on their digestive system. Some people prefer like a plant-based one for health reasons. Other people like the taste and of the milk-based ones. Either one is, in terms of nutrition, is fine. It's really a preference in terms of taste and digestion because not everybody tolerates both of those.

Some people don't tolerate the plant. Some people don't tolerate the milk. So, I can go into all so many recommendations based on how to look for a protein powder, but that could be, also, a conversation for another day. I see there's some more questions coming in. So, I just want to pause to see if I should elaborate or answer something else.

Melissa Jenkins:  I'd like to just ask, real quick, in terms of soy, real quick, soy milks, soy protein, and breast cancer, estrogen.

Hillary Sachs: Yeah. Yeah. 

Melissa Jenkins:  It's always a hot issue.

Hillary Sachs: Yeah. Yeah. For sure.

Melissa Jenkins:  What do you suggest?

Hillary Sachs: It's definitely a hot issue, and it is an evolving science, but what I will say is through epidemiological research, or observational research, where scientists are looking at communities or places in the world that eat a lot of soy-based products, whole soy foods, like edamame, or tofu, or soy milk, these communities tend to have lower rates of breast cancer, but there was a study that was done in rats, where they implanted a breast cancer cell, and they fed them a very, very high soy protein diet, and they found that the breast cancer cell grew.

Now, based off of that, there was a lot of fear, naturally, a lot of concern. We do know that rats metabolize estrogen very different from humans. So, it makes it a little bit convoluted, and then the other piece that makes it a little convoluted is that there's different forms of soy, and there's different types of soy that are out there. So, when you distill a lot of the science and the information, we found that whole soy foods, tofu, tempeh, soy milk, edamame, are fine to have one to two servings of regularly, every day, perfectly fine.

We don't necessarily recommend having soy supplements. Sometimes people take soy supplements for different reasons, menopause and things like that, don't recommend soy supplements or concentrated sources of soy, like texturized soy protein, soy chips, soy protein bars, soy protein powder. We don't necessarily recommend to have that regularly, and we find that that balance is the most safe, health-promoting option.

Melissa Jenkins: Could we talk about some of the other side effects we were going to get back to about brittle nails and hair?

Hillary Sachs: Yeah.

Melissa Jenkins: And one question came in about bone broth, and I'm relating that to it because sometimes we talk about collagen, and what can we do for to help with that?

Hillary Sachs: Yeah. Good question. So, when it comes to hair, hair health is multi-factorial, like everything else. So, first off, we know that hair could be affected by medications, but having the nutritional store to draw upon to help rebuild hair, help regrow hair, is helpful. So, when I'm talking with someone about their hair health, the first thing that I'm looking at is the micronutrients that they're eating. Are they eating enough iron, and how is their iron levels?

If your iron levels are low, your hair health suffers. So, make sure that your iron levels are within normal limits. You also want to be eating like high amounts of vitamin C, every day, as well. Secondly, how are certain levels of your hormones, which might be altered because of everything going on? For example, your thyroid, your thyroid health is out of whack, or you're having hypothyroidism, which, again, a lot of the symptoms of hypothyroidism can become convoluted, feeling cold, feeling tired, weight gain, hair changes.

So, sometimes, doctors or health practitioners aren't always thinking about the thyroid, but making sure your thyroid is working well is important to hair health. Are you eating omega-3s regularly? Omega-3s are found in fish, we most commonly think of, but it's also found in nuts, like walnuts, and seeds, like hemp seeds and chia seeds.

Are you taking in enough calories and protein? If you're not, your body is not going to prioritize putting the energy into hair and nails. Your body's smart. So, it's not going to prioritize that.

There are other hair health supplements that are on the market. I'm just always caution with some cautious with some of the herbal blends. Just make sure there's no interactions with the medications that you're on. Some of the supplements also have something called boron, which is a little controversial with certain kinds of breast cancer.

So, it's just important to kind of keep tabs on, but the tulsi, the tulsi tea, is good for hair health, also. Something called Indian gooseberry is good for hair health. The ashwagandha is good for hair health. So, again, as long as those are checked for interactions and discussed with a health practitioner, those are things you can consider to help. Biotin is one that people think of. Biotin helps if you're deficient. If you're not, it's water-soluble. So, you kind of flush it out, but it may not be helpful above a certain level. 

Yeah, and then, I think and then, you brought up collagen and bone broth. So, bone broth these days is all the rage. It's don't forget, broth counts for fluids. So, if you're struggling with getting fluids in, you can get some fluids in that way, and bone broth can be a useful tool because it's high in protein compared with other broth.

There's something like 14 grams of protein per cup, compared with maybe two or three in regular broth. So, from that perspective, it's really great. If you're struggling with eating, and specifically eating protein, you can boil your rice in it and make a high-protein rice, or boil your pasta in it and make a high-protein pasta. So, it's a really great tool to use.

Bone broth, specifically, if it's something that you're having all the time, or regularly, there have been some reports about lead in bone broth, because it's coming from bones. It's not as much a concern for adults but can be more of a concern for the younger adult or child population.

And then there is somewhat of a controversy around collagen and breast cancer, right, and there's different kinds of collagen, and we're not exactly sure about the relationship with regards to breast cancer. So, at this point, I'm okay endorsing bone broth, but I'm not necessarily okay endorsing collagen supplements until we learn more.

Melissa Jenkins: Rose was told by her oncologist to avoid fresh fruit because, being immunocompromised, there are foods one should avoid due to risk of infection. What do you suggest?

Hillary Sachs: Yeah. Good question. So, I probably I should've sent you this link, actually, but there's a great guide I think it's put out by the FDA, and it's called Food Safety for People With Cancer, and they have a number of guidelines for foods to be careful with to help the increased risk of infection while you're immunocompromised on chemotherapy. So, when your healthcare practitioner told you to avoid raw fruits and vegetables, that, to me, is very similar to something called the neutropenic diet.

Interestingly enough, there have been lots other studies. We can, again, we can probably post a link here about how the neutropenic diet hasn't been validated in the sense that it doesn't protect more against infection compared with the guidelines for food safety, and I'll go through what those guidelines are. There are certain situations where a neutropenic diet is really important, for example, after stem cell transplants or certain kinds of blood cancers, where the immune system is completely knocked out and rebuilding.

Those are the cases where the neutropenic diet can be important, but in most other cases, research supports just following the food safety guidelines. So, the food safety guidelines say, besides like just trying not to cross-contaminate meat on the same cutting board as vegetables, and things of that nature, they talk about foods to be careful with that tend to have more bacteria, so, for example, undercooked meat, undercooked eggs, undercooked fish.

Everything should be cooked to at least medium well. In the guidelines, they have specific temperatures. If that's something that's really helpful for you, that's fine, but otherwise, the medium well standard is kind of okay. They recommend avoiding certain places, like salad bars, buffets, and deli counters, you know, where we just don't know how the food has been handled, you know, in terms of bacteria.

They recommend being careful with certain kinds of cheeses which are not pasteurized. So, that usually applies to some of the crumbly cheeses, which may or may not be pasteurized, feta cheese, blue cheese, goat cheese. Those are all ones to check that they're pasteurized. You want to make sure that they are, when possible.

Sprouts is one that you got to be careful with raw, and I don't necessarily mean Brussels sprouts, although not many people eat them raw. I mean more sandwich sprouts, like alfalfa sprouts, broccoli sprouts, bean sprouts. Those are ones that you want to make sure are cooked before eating because they're very moist and tend to harbor a lot of bacteria.

Those are the main recommendations that are protective when your immune system is compromised that come out of that. I mean they also have a list of like how to store your food, how long in your fridge does something last, and whatnot, which is probably helpful for everybody, to be honest.

But again, there's many studies that have come out that those recommendations are just as protective as the neutropenic diet, and the neutropenic diet is a bit more restrictive. So, something to always just talk about with your practitioner, but…

Melissa Jenkins: And wash, wash, wash your fruits.

Hillary Sachs: Yes, and definitely wash fruits and vegetables before you eat them. I even wash like the melon before I cut it because there once was an outbreak, a few years ago, and whatever the bacteria was, was actually on the rind. So, when people were cutting it, they kind of cut whatever bacteria it was, and it touched the inner layer. So, I just always wash before I eat it.

Melissa Jenkins: Estella asks, many foods have palm oil. What is the impact, if any, on breast cancer, that you know of?

Hillary Sachs: Yeah. That's a good question, and I'll be honest. I'm not 100% sure on the relationship between palm oil and breast cancer. I know palm oil is rich in vitamin A. So, that's a positive. I know that it's beneficial, and you can cook with it at high heat, which is good. I believe it is a source of saturated fat. Saturated fat is a little less heart healthy compared with other kinds of fats, like avocado oil, or olive oil, or things like that, but I don't, I'm just not aware of any relationship with breast cancer.

Melissa Jenkins: Any thoughts on intermittent fasting?

Hillary Sachs: Another really good question. There's a lot of research on intermittent fasting that's come out of Valter Longo's research. He's done a lot on this subject. Again, it's very individual. There are some metabolic changes and health benefits for some level of fasting, but I'll go, and I'll go into what that means, but there may it may or may not be right for different individuals depending on what's going on.

So, a 12-hour fast is kind of a moderate amount that seems to have the most benefits but the least amount of potential downsides. So, if you eat your dinner at 7 o'clock, have your breakfast at 7 o'clock, sort of thing, and again, that kind of helps the body use up a lot of its glycogen stores, so it can kind of reset for the day, and has positive metabolic changes overall.

Then there's different levels of fasting, also, but fasting may not be appropriate for people who have diabetes and are at risk of low blood sugar. You know, hypoglycemia or low blood sugar could take the form of feeling dizzy, or confused, or sweaty, and it's really important that people that have a tendency towards low blood sugar or diabetes are eating regularly to prevent that from happening.

Also, if you're someone that's struggling with getting in enough during the day, and your meals are much smaller than usual, it is really important to do that small frequent meals, and so, fasting may just take a window of time away from you that you really need and your body is depending on to just get enough nutrition in. So, it may or may not be appropriate for everyone, but if it's something that is, it could be potentially healthy.

Melissa Jenkins: Is wheat perhaps better, truly, than white or other flours, or grains, and grains in general?

Hillary Sachs: Yeah. So, when it comes to like 100% whole grains or 100% whole wheat, and I say 100% because if it's not labeled at 100%, in terms of breads or things like that, it only has to be about 55% whole grain. So, when it comes to whole grains, it's actually made from the same thing that the white flours are. So, they start out with the whole, well, in the case of wheat, the whole kernel, and it has the outer layer, which is the bran, the fiber, and the B vitamins are in it. It has this middle layer called the endosperm, which is mostly the starch, and it has an inner layer called the germ, which is mostly the healthy fats and the vitamin E.

So, when they take that whole grain and they make a white grain, they take away the bran, or the fiber and the B Vitamins, and they take out the germ, which is the vitamin E and the healthy fats, and they leave you with the starch.

So, you're definitely getting more benefits from having the whole grain, whether it's brown rice, or quinoa, or 100% whole wheat bread. You're getting more nutritious nutrition. You're also getting more fiber, and again, fiber and protein kind of help to regulate your energy and your blood sugar levels throughout the day, but for some people, that's not possible, and it may not be possible for a variety of reasons.

Let's say, also, you're having looser bowel movements. You're having diarrhea. Having white flours may be a little more binding. So, you want to go for that, at least then. You don't necessarily need all the fiber, which may promote more bowel movements, which you don't need, or maybe you don't have access to whole grains. So, you want to maybe get your fiber from other places on your plate. Maybe you want to have beans on your plate to get some fiber in along with it. So, yeah, hopefully that answered that question. Was there a second part of that question?

Melissa Jenkins: What about gluten-free flours or pastas?

Hillary Sachs: Yeah. So, gluten-free flours or pasta, there's no real benefit to eating gluten-free unless you need to, and people with celiac disease need to. There's also some studies showing that people with autoimmune diseases can benefit from eating gluten-free. Gluten-free doesn't necessarily mean healthier. It could, but it doesn't necessarily mean that. 

For example, French fries, potato chips, are gluten-free. White rice is gluten-free. So, that may or may not be a healthier option. Corn is gluten-free. It's all fine, but it may or may not be a healthier option. There are grains that are naturally gluten-free, buckwheat, quinoa, amaranth, gluten-free oats. So, there's those.

So, again, I'm always kind of looking at the fiber content when it comes to grains because choosing a grain that's high in fiber, as long as that's appropriate for you and your medical history, is probably the healthiest thing you could do.

Melissa Jenkins: Christy still, said, I'm still a little confused about the percentage of sugar in your diet. If you have three cookies, and four servings of fruit, and three carbohydrates, along with lots of vegetables and some protein, is that okay? There's sugar in cookies, fruit, and carbohydrates, so where you can how much sugar, overall, can one really tolerate?

Hillary Sachs: Yeah. I think about it in two ways. So, right now, a healthy diet is about 50% carbohydrates. So, that's higher than what some people think. Don't forget, again, carbohydrates come from fruit, carbohydrates are in beans, a little bit, carbohydrates are in vegetables, too, but when I'm thinking about sugar and carbohydrates, I'm less thinking about them in isolation. Like, over the course of the day, I had three cookies and fruit.

I'm thinking more about what the balance of your meal looked like, or your snack looked like, at that sitting. So, for example, let's and this is also great to do with kids, if there's any like little ones around, let's say someone wants a cookie, you or a family member. You could put a cookie on the plate, but then you also want to put some other things on the plate to balance it.

Again, we're thinking protein and fiber. This is going to satisfy us better, too, than just focusing in the cookie, when possible. So, you take a cookie, maybe you want to put a handful of nuts and a piece of fruit on your plate along with it. Probably going to feel more satisfied from all those things than just having the cookie. May or may not, but you're not denying yourself the cookie, either. You're just, you're enjoying having it.

If you're having fruit as a snack, again, think about ways you can balance it with protein and there's already fiber in fruit, but you can always add some more. So, for example, maybe you want to add some fruit to a plain Greek yogurt and some seeds to that, or you want to have an apple with peanut butter, something like that. 

When you add the protein with the fiber at each individual meal, it's going to blunt the blood sugar rise and the amount of insulin that's released, and you get a more level blood sugar, which helps sustain your energy. It's also just a little more nutritionally balanced. You're getting a more wide range of nutrients, as well.

Melissa Jenkins: Can you talk about cannabis and treatment and any potential, you don't need to go too long, but you know, is there a negative effect there and also in terms of nutrition?

Hillary Sachs: Yeah. So, on my website, I wrote a blog on CBD. So, cannabis contains two things, THC and CBD. THC is more of the hallucinogenic sort of effect of it, whereas CBD doesn't have that, but THC also helps to stimulate the appetite a little more than CBD does. So, when it comes to marijuana, there's a lot more medical marijuana dispensaries around, which is great because it's more controlled than buying because, again, supplements aren't regulated, than buying it from another source, where we don't necessarily know what's in it, if it's accurate.

The form also does matter. There are still risks to smoking in terms of inhalation and lung health. There's also a number of benefits just to the CBD aspect. CBD is great at decreasing stress, and there's studies to show that it's cancer protective and preventive. So, it's one of those old kind of medicines that's been around for a long time, and I think society's kind of rediscovering some of its benefits. It's definitely a conversation, I think, that you can have with your medical team and perhaps even get a prescription for, if appropriate. It can be useful and supportive in so many different ways, with pain, with appetite, and all that sort of stuff.

Melissa Jenkins: Thank you. I think we're coming to the end, so I wanted to end with Kadi's question, I wondered if there's a link to studies to show that meeting with a dietician increases positive outcomes of cancer.

Hillary Sachs: There are lots of studies. I would be happy to Melissa, do you want me to send you some, or?

Melissa Jenkins: Yeah. That would be great. 

Hillary Sachs: Okay. Yeah. Definitely. I will definitely do that. Yeah.

Melissa Jenkins: Is there anything else that hasn't been addressed that you would, please raise your hand if you are missing if we're missing something that you've put in? I was trying to keep track. Susan?

Susan: I think when you were addressing the side effects, one of the maybe you said it and I didn't hear it, was the joint pain and bone pain.

Hillary Sachs: Yeah. No. Actually, I think you're right. We never actually got into a lot of that. We were talking about the hair, and we were talking about a few of the other things. So, in terms of joint pain and bone pain, again, there's different exercises that can be done, but from a supplement perspective, or even from a food perspective, there's some anti-inflammatories you could consider. Fish or fish oil is a powerful anti-inflammatory, which, again, you can see if it's appropriate for you and your medical plan.

Glucosamine chondroitin may be, you know, is beneficial, but there are some interactions that you have to just be careful with, and just, again, creating an anti-inflammatory meal plan. You know, blueberries, and grapes, and nuts and seeds have a lot of these anti-inflammatory components, which could, in turn, help with some of that, as well.

Melissa Jenkins: Wendy?

Wendy: Yeah. What would be your definition of high-dose vitamin C?

Hillary Sachs: So, it's interesting. Your body only absorbs a certain amount of vitamin C by mouth, and then it flushes it out through urine, water-soluble. If you want to achieve a super-high level, you need to take it intravenously. It's the only way that you can get those high levels into your system. At lower levels, it works as an antioxidant, which we always hear about being, you know, beneficial, helping to stabilize unstable cells.

At super-high levels, it can work as an oxidant, which isn't a bad thing. It has been used in conjunction with certain treatments to kind of help get rid of bad cells, and there are some studies on a treatment called mesna, I think it's usually used for blood cancers, how high-dose vitamin C IV could be helpful, complementing it. In terms of the levels, I think anything by mouth more than about 1,000 milligrams is like a lot.

I don't know that you're actually going to absorb that much beyond that. There are certain forms by mouth, like liposomal form by mouth, which you may absorb more of, but beyond that, you may not even absorb it. So, there might not even be a point.

Wendy: Follow-up, but chemotherapy, you're often advised not to indulge in high-dose vitamin C or antioxidants. So, what would be a safe level if you wanted a daily supplement that's not high-dose? 

Hillary Sachs: Yeah. Well, again, I encourage you to speak with your practitioner, because I know a lot of places say to avoid the antioxidant supplements the days around your treatment. So, they usually, this has been my experience, but it may not be true of where you go, but usually they say to avoid the antioxidant supplements the day before, the day of, and for two days after treatment. So, they're kind of not in your system in the same window, and then you can kind of resume them.

Ninety milligrams is like the daily recommended amount. A thousand would probably be the cap to what you would absorb. As you get higher, like towards that thousand, some people get like looser bowel movements, which may be a good thing. Sometimes it's helpful, but sometimes it's not. So, just keep that in mind, too.

Melissa Jenkins: There aren't any other questions. Hillary, do you have some just quick takeaways or closing that you'd like to share with us?

Hillary Sachs: Yeah. Well, again, thank you guys for having me and just being, you know, it's always nice to connect with people and just hear what questions you have, and what kinds of things you're hearing, and where you're coming from. So, I really do appreciate you inviting me into your space, and your group, and having me here today.

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