Transcript Nutrition After Treatment Ends

FIGHTING CANCER
WITH A FORK
DOES SUGAR
FEED THE TUMOR?
Colleen Gill, MS, RD, CSO
Nutrition Foundations
303-810-8612
[email protected]
9/15/12
RESOLVING THE CONFLICT
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Goal: Perspective on Carbs and Cancer
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Research: Carbs and Cancer
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The plate model as “the big picture”
Priorities at different stages
Carbohydrate Metabolism
Sugar or Insulin? Insulin Resistance
Glycemic Index and Cancer
Carb Choices/Options
◦
Glycemic Index Details
Influence of Lifestyle
and Medications
“DON’T GO NUTS”
NUTRITION WITHOUT STRESS
STRESS = Novel
Unexpected
Threat to self or ego
Sense of lack of control
Focus on the “Big Picture”
Keep diet empowering; Not a new
stress
 American
Institute for Cancer Research;
www.aicr.org
 Free monthly Classes, University
Two goals at a time: 1 diet, 1 exercise
FOOD "TALKS" TO CELLS
WHAT WE ADD = WHAT WE LIMIT
2/3 of your plate should be plant based
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50% vegetables, legumes; daily cruciferous
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Fiber sources slow stomach emptying
Healthy fats and carbohydrates
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Less refined, processed foods
More fish, olive oil and healthy fats, impacts receptors
Exercise and ideal body weight
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Impacts blood sugars and insulin resistance
Make exercise a scheduled priority
Sleep well!
Impacts insulin resistance, weight
PRIORITIES CHANGE
IN FAILURE TO THRIVE
 Set
up a schedule! Eat often
 Post a list: “Things I Tolerate”
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Normalize/(lower) expectations
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With small volumes, nothing is problematic
 Start
“healthy”, but calorie dense
Educational materials can be targeted
to different groups & purposes
Are insulin levels likely to be high
with small meals and snacks?
NUTRITION STUDIES CAN BE
“SOFT” (AND CONFUSING)
 We

are all eating
No +/- to exposure; “Shades of gray”
 We
are all unique!
Individual genetics impacts how we handle
what we eat. Subgroups may benefit
Weight, insulin resistance, activity level
 Human studies are expensive
 And complicated by human subjects
Placebo effect; Pleasers; Self interest
 Motivation differences: survivors versus prevention

THE SUGAR CONTROVERSY
Controversy and Confusion = Stress
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Books/internet warnings against sugar
Staff promoting use to limit weight loss
Family members anxious about both!
Anxiety builds with PET scans
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IV infusion of radioactively labeled sugars
Increased receptors on rapidly metabolizing cancer cells
can make them “light up”
Yes, BUT . . . Sugar feeds EVERY cell
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Blood sugar cannot be eliminated and live
Excursions in blood sugar/insulin can be limited
Taken in
Broken down
Absorbed
Used for fuel
L Schiller Nutr in Clin Practice 2006;21:34
Mouth
•Amylase/starch
Glucose absorption
raises blood sugar
Stomach
Paces emptying
Pancreas
Releases Insulin
Insulin
Connects?
Jejunum
Messages Sent
•Transport sugar
•Food is abundant
•OK to grow
Intestines
1 - 4 hours
www.ibsresearchupdate.or
•Lactose
•Maltose
Colon
24 - 48 hours
•Water (1 – 2 L)
FRUCTOSE, SUGAR AND CARBS
Fructose
in evolution
 Fall
fruit created a degree of IR,
Triggers fat storage for winter survival
 HFCS? Agave?
Sugar
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= Fructose + Glucose
Empty calories, leading to weight gain
Consumption is up 15# since 1986; to 90#
Carbs: Rice versus Fructose

Does the lack of fructose in rice minimize risk
despite the higher carb Asian diet?
Howarth et al, 2008; Am J Clin Nutr 88(4): 1074-1082
INSULIN IS
THE REAL ISSUE
Yes, cancer cells like sugar as “fuel”
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Basis of PET scans to detect tumor activity
But tumors can make their own glucose (fat, protein)
Large volumes, high GI, fructose?
 Higher blood sugars
Real Concern
 More Insulin (if IR)
Primitive Growth Signal
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Stimulates growth directly and through IGF1
Increases inflammatory hormones
Suppresses immune function
Limits normal cell death/apoptosis
DIABETES INCREASED CANCER RISK
INFLAMMATION, HYPERINSULINEMIA
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Doubled risk: Liver, Pancreas, Endometrial
Increased exposure to insulin (liver, pancreatic)
 Impact on NAFLD, cirrhosis may contribute
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Consensus statement, Cancer J Clin 2010; 60:207-21
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Colon, bladder, post menopausal breast 1.2 – 1.5x
Larsson et al, 2006;2007
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Diabetes + ER- BC doubled risk & mortality
NJ Cancer Res Clin Oncol, 12/2010
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Increased aggressive nature and recurrence rates of
many other cancers
AICR Science Now, 2008
Consensus statement, Cancer J Clin 2010; 60:207-21
DIABETES INCREASED
MORTALITY* IN CANCER
Meta-analysis: Increased mortality of 1.41
compared to those with normal blood
sugar levels
 Endometrial 1.76, Breast 1.61, Colorectal 1.32
 Non-significant increases in Prostate (1.51),
gastric 1.36, liver 1.3, lung 1.15, pancreatic 1.09
JAMA 2008 300(23): 2754 – 64
*Cause? DM, hyperglycemia, IR,
Inflammation, Diabetes Drugs, Obesity…
OBESITY TRENDS* AMONG U.S. ADULTS
*BMI 30, ABOUT 30# OVERWEIGHT AT 5’4”
2000
1990
2010
no data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
© 2010 Sports Cardiovascular and Wellness Nutrition (SCAN)
* BRFSS: Behavioral Risk Factor Surveillance System, www.cdc.gov/brfss/
INSULIN LEVELS AND BREAST CANCER
DIAGNOSIS AND RECURRENCE
WHI:
Highest versus lowest quartile fasting insulin
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HR of 1.46 (2.4 in women without HRT)
J Natl Cancer Inst 2009; 101: 48 – 60
535 women with Breast Cancer
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 Fasting insulin levels  Higher stage/grade
Highest quartile fasting insulin 
Double recurrence
◦ Triple mortality
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J. Clin Oncology 20 (1): 42; 2002
Metabolic syndrome in Breast Ca
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 recurrence three fold
Int J Cancer, 2006
IMPACT OF HYPERINSULINEMIA
IN BREAST CANCER
6
– 10 x number of insulin receptors 
“growth advantage”
Papa, et al. J Clin Invest 86 (5): 1503; 1990
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Insulin  increased Estrogen/Signaling
Increases receptor expression
 With estradiol, increases cell growth
 Stimulates aromatase activity
  Levels of sex hormone binding globulin
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Lann D, LeRoith D; J Mammary Gland Biol Neoplasia 2008
CONTROLLING INSULIN LEVELS IN
INSULIN RESISTANCE
IR = Fasting Glucose > 100
Triglycerides > 150; HDL <40 M/50 F
 Better
carb choices:
“Gentle rain versus thunderstorms”
Total carbs: covering ¼ of the plate
 Type of carb: Glycemic Index
 Timing and combination with protein/fat/fiber
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 Exercise
GLYCEMIC INDEX: NEW TERM TO
COMPARING CARBS IMPACT ON BS
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Volunteers eat 50 grams of carbohydrate
from the tested food
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Amounts of food varied!
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Blood sugar levels were plotted @ 15 minutes
Exposure to sugar (AUC) is determined
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Compared to the increase obtained from glucose
or white bread in the same volunteer
Food is ranked on a scale
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Compared to glucose or white bread as 100
GI ISN’T PERFECT
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Nature is variable
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GI can vary with growing conditions
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Glucose response varies with time of day
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Testing is limited
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Combination foods often difficult to predict
Glycemic response = only 23% of the
variability in blood insulin levels
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Impaired glucose tolerance is major factor
Glycemic load takes serving size into account
CANCER RISK
LOW VERSUS HIGH GI
Breast
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Two studies negative
Holmes et al 2004; Nielsen et al 2005
1.5 RR in those with BMI > 25
Nurses Health Study II
2.3 RR in inactive pre-menopausal
Higginbotham et al, 2004
1.35 RR in overweight postmenopausal (null overall)
1.08 overall; 1.37 RR highest waist circumference
1.87 RR in post-menopausal
Navarro Silvera et al 2005
Estrogen mitigates insulin resistance, may
explain some of the difference in pre and post
menopausal
Ovarian 1.7
McCann et al, 2003; Silvera et al, 2007
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1.24 OR with highest GL; more if overweight
Nagle, et al, Annals of Oncol 2011 22: 1332
BMI, ACTIVITY AFFECTS
RISK OF A HIGH GL DIET
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Pancreatic Cancer Risk by GL Quartiles
1  1.2 with BMI <25
 1  1.8 with BMI >25 (overweight)
1  1.1 with high activity level
 1  1.8 if sedentary
BMI < 25, active: 1  1
 BMI > 25, inactive: 1  2.7
Carbohydrate in diet will not affect risk
IF you are lean and active
WHAT AFFECTS
GLYCEMIC INDEX?
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Type of starch, speed of breakdown
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Particle size/processing
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Easily attacked by enzymes =  GI
More surface area for enzymes
=  GI
Heat and moisture =  GI
Factors that slow stomach emptying
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Meals/foods with fat, fiber, protein = 
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Acid content =
 GI
GI
A CARB IS A CARB, BUT. . .
35 carbs, 1 fiber
38 carbs, 5 fiber
CARB QUALITY: + FIBER/-SUGAR
Check total amount of
carbohydrate
+ Fiber Content
•Reflects processing
•Slows emptying
- Sugar
•Natural/Added
HIGH GLYCEMIC INDEX FOODS
> 100 ON WHITE BREAD SCALE
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Refined breakfast cereals (100 – 132)
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Most breads (100 – 130)
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Minimally processed, whole grain: 9 Grain, oat bran,
rye/pumpernickel are lower at 60 – 66
Potatoes (115 - 120)
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All Bran (60), Oatmeal (64), Special K (75), Shredded
Wheat (94) are lower
Waxy/new potatoes are intermediate at 87;
sweet potatoes lower at 75
Polished, sticky rice (120 - 156)
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Basmati/Converted/Brown rice 72 - 81
LOW GI FOODS
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Dairy products (20 – 46)
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Beans, peas, lentils (20 – 60)
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Custard (60) and ice cream (85) moderate
Green peas (65) and baked beans (70) moderate
Pasta (52 – 64), but watch the volumes
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Al dente or thick pastas lowest, thinner higher
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Barley (35)
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Vegetables
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Most fruits (31 – 59)
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Warm weather fruits are moderate: Melon 91-100;
Kiwi/Mango 70’s; banana 84; pineapple 92
BEVERAGES AND
GLYCEMIC INDEX
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Gatorade @111
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Sodas @ 90 – 97
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Juices @ 43 – 68
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Soy Smoothies @ 43 – 49
Oral supplements with higher protein, fat
and fiber content are likely best
Remember that foods/fluids high in sugar
are often “empty” calories
SUGARY DRINKS GET LARGER
There are 17 teaspoons of sugar in a
20-ounce bottle of soda.
 The 7-Eleven Double Gulp, a
64-oz soda, contains nearly
800 kcal—an amount 10 times
the size of a
Coca-Cola when
it was first
introduced.
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29
1960
© 2010 Sports Cardiovascular and Wellness Nutrition (SCAN)
1970
1980
1990
2000
CARBS AND INSULIN CONTROL
TOTAL AMOUNT, TYPE, TIMING
When there is insulin resistance
Fasting Glucose >100; TG > 150; HDL <40/50
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Watch the total carbs (1/4 plate!)
Mix higher GI foods with lower GI
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Goal <1/2 high GI foods/meal; www.mendosa.com
“Eat it raw, eat it whole” for a lower GI
Avoid “naked carbs” on an empty stomach
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Eat sweets less often, with meals that contain
protein, fiber and fat to slow stomach emptying
ANY EXERCISE HELPS
Aerobic Exercise
Strength Training
Makes good estrogens,
limits growth signal
Maintains muscle mass, increases
calories burned
Weight Bearing Exercise
Any Exercise
Prevents osteoporosis
•  Weight gain  estrogen release
•  Fatigue, depression and stress
•  Blood sugars which  insulin levels
and  immune function
GOAL: 30 – 60”, MOST DAYS
AEROBIC
+ STRENGTH TRAINING REDUCED IR
Controls weight
↓ blood pressure, stress,
Insulin resistance ,
fatigue
Increases HDL, ↓ LDL
Break it into
10 minute
bouts
Pedometers
offer great
feedback!
(When used)
www.digiwalker.com
© 2010 Sports Cardiovascular and Wellness Nutrition (SCAN)
CARBS, EXERCISE AND WEIGHT
LIMIT HIGH INSULIN LEVELS
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Maintain a healthy weight
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Exercise and be physically active
Eat it raw, eat it whole
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Less processed foods
Avoid “Naked Carbs”
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Low carb limited weight regain NEJM 363: 2102, 2010
Mix with protein and healthy fats
Eat small, frequent meals
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Keeps blood sugar stable,
 fatigue, hunger
Insulin Resistance
Insulin Resistance
- Components -
Genetics
Genetics
+
Obesity
Genetics
+
Obesity
+
Glucose
Toxicity
Insulin Resistance
Insulin Resistance
- Reversal -
Genetics
Genetics
+
Obesity
Genetics
+
Obesity
+
Glucose
Toxicity
Glucose
Control
Glucose
Control
+
Weight
Loss
LIFESTYLE INFLUENCES IR
Genetics loads the gun (~1/2)
Lifestyle pulls the trigger (~1/2)
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Physical activity, weight
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Sleep deprivation  insulin resistance
1 – 2 hours less sleep than 1970
O Buxton et al. Diabetes 2010; 59:2126-33
Increased diabetes
◦ Increased fight/flight response; IR
◦ Increases weight
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Sweet preference; more late snacking
Less motivation to exercise
1 night  21% lower insulin sensitivity in Type 1 DM
Donga et al. Diabetes Care 2010; 33:1573
Donga et al. J Clin Endocrinol Metab 2010, 95(6):2963
SUPPLEMENTS THAT MAY
LIMIT INSULIN RESISTANCE
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Fish Oil, anti-inflammatory
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Magnesium 250+ mg
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Diabetes 1/2011
Lowered fasting BS, insulin resistance
Cinnamon, source of manganese
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3,000 mg Omega 3 (EPA + DHA) a day
Lowers triglycerides
1- 3 g/day lowered BS, LDL, TC, TG
Vinegar, slows stomach emptying
Vitamin D
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Higher levels = 40% lower risk of DM
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Liu et al, Am J Clin Nutr 2010; 91: 1627
METFORMIN SEEMS PROTECTIVE
+Decreased risk of breast cancer; OR 0.44; p = 0.01
+ survival pancreatic cancer
Hsu, JOP 2011;12(4) 330
Lower cancer mortality vs sulfonylureas P =0.012
Bowker et al, Diabetes Care 2006; 29: 254 - 258
Mechanisms:
Science 2012: 335: 29
 Lower liver production of glucose; sensitivity to insulin
 Anti-inflammatory; anti-angiogenic;  apoptosis
  enzyme AMPK  lowers insulin/IFG levels
 Blocks mTOR; kills cancer stem cells
-Insulin, decreases normal cell death
-Sulfonoreas, increases insulin secretion
NCIC MA32 trial, Metformin v Placebo x 5 years
Consensus statement, Cancer J Clin 2010; 60:207-21
Kourelis and Siegel, Med Oncol 2011
DOES SUGAR FEED THE TUMOR?
. . ONLY WITH INSULIN TOO
Yes, sugar feeds EVERY cell in the body
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Address anxiety with prioritization
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Blood glucose cannot be eliminated (and live)
Stage/diagnosis/therapy side effects/risk of IR
Allow more simple sugar where/when:
 There are no signs of IR and volumes are limited
Excursions in blood sugar/insulin
can be limited
 Spread
◦
carbs through the day with small, frequent
meals/snacks; a “gentle rain”
Use lower GI carbs, combined with protein/fat
Our goal is not to
eliminate entire food
groups
Rather to make
better choices
in all of them
The Plate Model
(+Details/GI)
THE PLATE MODEL =
OPTIMAL BLOOD SUGARS
 The
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
Right Amounts
¼ carbohydrate sources
bread, pasta, potatoes, rice, cereals
¼ protein (and fat) sources
~ ½ fruit (fist size), vegetables, beans
 The
Right Mix
No Naked Carbs
Eat sweets as part of a mixed meal
 With protein, fat, fiber to slow stomach emptying; rescue

 With
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The Right Type
Limit processed/”white” foods, high glycemic index options
Eat Food
Not too much
Mostly plants
Oliver
Michael Pollan
Questions?
Answers?