Nutrition: Your Questions Answered

Participants:    

Dr. Angela Fleischman, UC Irvine

Kathleen Boss, Gilda’s Club Chicago

Lindsey Whyte, Leukemia Research Foundation

Hi everyone. Thank you so much for joining us today. We're going to get started in just a minute. We've got a lot of people coming in!

Okay. I'm just going to jump in because it's a tight timeframe today. We've got a lot to cover in an hour!

So welcome everyone! Thank you for joining us for Leukemia Research Foundation's webinar which is co-hosted by Gilda's Club Chicago. We're joined by Dr. Angela Fleischman from UC Irvine in California, who will share information about what's currently known about our bodies, and specifically our blood and how we react to the food we eat. And she'll also respond to questions that have been submitted previously through the registration or also potentially some questions that you submit during the session.

My name is Lindsey Whyte and I'm the Director of Programs & Partnerships at the Leukemia Research Foundation. The Foundation's mission is to cure leukemia by funding innovative research and supporting families and patients. The Foundation has raised over $90 million in support of our mission since our founding in 1946, and we funded research grants to over 750 investigators worldwide. Our support programs for leukemia patients and their loved ones include information on our website and resources on our website, education programs like today's, financial assistance and a directory of other helpful organizations and resources that you can find also on our website.

I would like to take a moment to thank our webinar partner, Gilda's Club Chicago, and with us today is Kathleen Boss who will say a few words about her organization and how they also support cancer patients.

- Go ahead. Okay. I'm Kathleen Boss, I'm the Chief Program Officer of Gilda's Club Chicago. We are part of a national organization called the Cancer Support Community. We provide psychosocial support and build community for anyone impacted by cancer. We do that through a variety of programs, support groups and individual counseling, healthy lifestyle options, educational programs like these, social events and resource and referrals. As I mentioned, we're part of a national organization- an international organization- that includes locations in in the United States as well as Canada and other locations. So if you can access us, we have a helpline that's available that can provide those resources that refer you to different, to different locations and I can provide that I can provide that in the chat for more people to check out.

- Thank you. Yes, that'd be great. And we also have some information that we'll be sending out after the webinar to folks that participated or registered that will include all that information about Gilda's Club as well. So thanks.

Okay! Quick few housekeeping items for today. All participants will be muted throughout the program and if you already submitted a question in registration, know that we have the questions. There's just a lot of them, so we're going to probably be grouping some of them to kind of get through as many as we can. You know, kind of going through them by topic after Dr. Fleischman first presents a few slides about what we know based on the research that's been done so far, et cetera.

After today's program, you'll be sent a brief evaluation through email. Please take a moment to just complete that evaluation so we have feedback as we think about future programs. And this program, as I mentioned, will be recorded and a link to the recording will be sent to all participants afterwards.

Now onto our star, guest today... we are grateful to have Dr. Angela Fleischman from UC Irvine, who is a physician scientist investigating hematologic malignancies. She integrates her research with the clinical care of patients with these diseases. Dr. Fleischmann's longstanding interest in blood cell development began during her PhD graduate studies at Stanford. After completing her MD and PhD at Stanford in 2005, she moved to Oregon Health and Science University for her internal medicine residency and medical oncology fellowship. She joined UC Irvine in July 2013 and her laboratory focuses on the role of inflammation in MPNs (myeloproliferative neoplasms, which is a related blood cancer). She plays leadership roles in UC Irvine's Cancer Center, including the Hematologic Malignancies Disease Oriented Team Co-leader and Systems Pathways and Targets Program Co-leader. In addition, she's dedicated to training the next generation of physician scientists. She's the hematology oncology fellowship research director and the MD PhD program associate director. Her research program spans the entire translational research spectrum. She has published over 50 peer reviewed journal articles, is the recipient of multiple grants. She's now translating her scientific discoveries from the lab into therapeutic benefit for patients via investigator initiated trials. She has completed two trials investigating the impact of a Mediterranean diet in MPN patients with the intent of reducing inflammatory cytokines and improving symptom burden and plans to expand these studies to reach a much larger population. She's expanding her activity in trials to include a phase I/II study investigating the antioxidant n-acetylcysteine in symptomatic MPN patients, which stems from preclinical findings from her laboratory. Her translational work in the lab and interventional trials will continue to expand over her career. To strengthen her fundamental knowledge [as if she wasn't already busy enough] she is now undertaking an integrative healthcare integrative health fellowship. This is a two-year program designed to give doctors a strong working knowledge of nutrition and other integrative treatments. I'm really grateful that she's taken the time to join us today. Thank you so much, Dr. Fleischman, and please take it away.

- Well, well thank you. Thank you very much Lindsey for that very nice introduction and I'm happy today to present on nutrition and blood cancers. And I think it was a great opportunity for me over the past few weeks while preparing for this webinar to really delve into the data behind, you know, there's a lot of claims and we talk about day to day about certain things being good or bad for cancer. But it was a great opportunity for me to go and delve into the literature about where those claims are coming from and what concrete data we have about nutrition and blood cancers. And really emphasized to me the key importance of doing really well-structured and large studies, asking important questions about nutrition, both in the prevention of blood cancer, how it may impact our response to therapy, and then also how it impacts survivorship and potentially could, you know, modulate somebody's risk of relapse.

So I'll go briefly over these slides, but also, you know, I particularly enjoy the questions section the most because then that gives us an opportunity to really address questions that you want to hear about rather than aspects that I thought was interesting from, from my review of the literature.

So just to begin with, when, you know, when we're talking about nutrition and how we can use diet to improve our health or improve our control of a particular disease, we think about this concept of calling food as medicine. And I think that it may sort of be misconstrued that utilizing properties of foods does not necessarily mean you can eat whatever you want and then you can sort of negate that with some magic mushroom. That's really not the concept that we're going for with nutrition and our health. More realistically it's a more holistic approach. It's honestly just as important, the things you don't eat and the things you do not put into your body as the things that you do eat.

So want to emphasize that the point of the this talk today is not, you know, adding on a specific food or a specific supplement, but more talking about our nutrition more holistically. I mean with, with some aspects of specific data for specific things like fiber or vitamin D. So when we talk about nutrition and blood cancers, like we can think about using nutrition in many, many different ways. But when I'm thinking about it, I sort of put things into to three categories.

Number one, prevention of blood cancer and how can we do that? We can, by promoting healthy blood production, theoretically we would be preventing development of blood cancer.

Second way we can use nutrition is how do we optimize our nutrition during blood cancer therapy? Meaning how do we make the treatments work better? Which I will give some specific examples which are emerging really interesting on the role of the gut microbiome and fiber in response to specific immunotherapies.

And then also just more in general, how do we optimize our body's health during chemotherapy, which can be a very challenging time for our bodies?

And then after, you know, you've received treatment for your blood cancer, how can we utilize nutrition to reduce one's risk of relapse?

So with regard to the first aspect of promotion of healthy blood and prevention of blood cancers, I think this is the sphere where we have the most data and it mostly spans from, you know, things that we know that are applicable to the general population in terms of what things promote healthy blood production and can sort of extrapolate those recommendations towards prevention of blood cancers. And we, over the past two years, have really learned a lot more about the development of blood cancers, in part because of our abilities to do sequencing and the cost of sequencing going down and the sensitivity also going up in terms of the ability to detect minute numbers of mutant cells in somebody's blood years or decades before they develop a hematologic malignancy.

So I wanted to introduce here this concept of what's called clonal hematopoiesis. So when we're born, we're born with a pool of "hematopoietic stem cells." Those are your blood stem cells that reside in your bone marrow and you're born with them and they need to stay with you your entire life. But as all of our body ages, our stem cells age, our stem cells age as well, and an inevitable consequence of aging and cells dividing is cells make mistakes, they have mutations. That's just a fact of life, a fact of cells dividing each cell division is going to create some mutations. And a very common consequence of middle age upwards of 20 to 30% of people over the age of 60 will have a condition, a situation called clonal hematopoiesis of indeterminate potential. Meaning that they have mutant cells in their blood. And this can be thought of potentially as a precursor for blood cancers. Now everybody who has CHIP does not turn into a blood cancer, but it's thought that likely this sort of precursor state called CHIP is required to then transition into a blood cancer. And so wanted to emphasize that, you know, there can be decades of somebody having CHIP and potentially most likely not knowing it where that may be a time in their life where it's particularly critical to have good, make good lifestyle choices. Because in the next slide I'll talk about our evidence of a specific lifestyle choices, increasing one's risk of this clonal hematopoiesis and making it turn into a blood cancer.

So when these cells expand more, then they turn into a blood cancer, either a chronic blood cancer or, in the worst case scenario, an acute leukemia. So with this CHIP, it's a relatively newly recognized phenomenon, although it's been present in humans from our beginning and is also interestingly present in all animal, or at least in laboratory mice, but based on large epidemiologic data where, for example, we follow large groups of people asking them about their lifestyle choices and then later on seeing whether they have these CHIP abnormalities, it's clear cut in all of the studies that smoking is associated with CHIP, obesity can be associated with CHIP, poor diet quality. So again, I know probably just telling you what you've heard multiple times that you know, lifestyle choices are important and this is just another representation demonstrating that lifestyle choices that we know to be unhealthy are also increasing one's risk of developing these mutant cells in your blood that could go on to develop, to turn into a blood cancer. And this is just, as I mentioned, we need studies to evaluate this.

So this was a large study where they took a large group of people, I think in this specific one may have been specifically in women and then they asked questions about diet quality. So with surveys about what people were eating and found that the people in the study with the most unhealthy diet were the most likely people to have these mutant cells in their blood. And then also epidemiologic studies. Obesity, we know obesity is tied to inflammation and we also do know that inflammation allows these mutant cells to grow more readily. So it's not unexpected that obesity and the inflammation associated with it is tied to increased risk of multiple types of blood cancers as well as the blood cancer precursor called CHIP. And so again, if we say that inflammation may, and you know, based on laboratory studies, inflammation does promote expansion of multiple mutant cells with different types of mutations that all can lead to leukemia or other types of chronic blood cancers. Could we, the thought is, how do we modulate inflammation?

As I mentioned, one way is to maintain a healthy weight, but how can we modulate inflammation to reduce our risk of developing a blood cancer. So thinking about very common diets, one that's been highly advertised as being a generally healthy diet is the Mediterranean diet. And just wanted to go into a large study on cardiovascular disease where we're getting data for its impact in inflammation and outcomes as well as go into a little bit of information on some studies that we've done in patients with a chronic blood disorder myeloproliferative neoplasm.

So the large study of comparing a Mediterranean diet to a control diet was called the PREDIMED study. And the primary endpoint in that was cardiovascular disease endpoints. And this study found that people on a Mediterranean diet had fewer cardiovascular bad outcomes as compared to the control diet. And also in that study they measured inflammatory proteins in people's blood and found that the people on the Mediterranean diet had lower levels of the inflammatory proteins. So what is a Mediterranean diet? Really has no, people may think it's eating things from the Mediterranean but really can include food from any culture. But the central theme is to focus on whole and plant forward foods and healthy fats such as olive oil and fish and less so things like butter or red meat. So I won't go into the content of the Mediterranean diet all that much, but you can get the gist. So we wanted to know in a disease where we know that patients do have high inflammation, could we apply a Mediterranean diet study to these patients with myeloproliferative neoplasm? And it's thought that a lot of the symptoms associated with myeloproliferative neoplasm are related to the increased inflammation. And wanted to emphasize that this study was simply feasibility, that we need to establish that these patients can follow a diet before really delving into much larger studies to look at specific clinical endpoints.

But we did want to look at symptom burden because that's a common endpoint seen in all myeloproliferative neoplasm clinical trials. So basically we put patients on either a standard US diet or a Mediterranean diet and wanted to see if patients could follow it. And then also as what we call exploratory endpoints, looked at things like their gut microbiome and their inflammatory cytokines. So the primary endpoint was following a Mediterranean diet for which there is actually a very discreet scoring system with a questionnaire called the MEDAS. And we did achieve the endpoint that myeloproliferative neoplasm patients, if they're given dietary counseling, can change their diet. So you may think that's simple, but I think it's an important first step.

And then this is symptom burden. These types of plots are called waterfall plots, which are seen in all myeloproliferative neoplasm clinical trials. But the pink is the people on the Mediterranean diet and a bar going down is good, meaning their symptom burden went down. So can see that people on the Mediterranean diet had a better symptom burden reduction than people who are given standard dietary counseling. And other things that we measured but won't go into blood counts, cholesterol, high sensitivity CRP [C-reactive protein], which is another measure of inflammation in the blood as well as additional inflammatory proteins, and the gut microbiome. And I'll go more into the gut microbiome, again, this is because it's a hot topic these days, so wanted to focus on that in a few slides.

But also wanted to emphasize another innovative study done by an investigator named Urvy Shaw who looked at a plant-based diet in patients with what's called MGUS, which is a multiple myeloma precursor, and found that a plant-based diet, which is associated with this increase of butyrate, which is a chemical made by beneficial bacteria in your gut can improve outcomes in a multiple myeloma precursor condition. So this does give some legitimate information to state that a plant-based diet, at least in this specific disease, makes a very healthy gut microbiome, which then may modulate the immune system such that your body can appropriately control a precursor condition such that it doesn't get out of hand and turn into a more harmful blood condition like multiple myeloma. And so how can this happen? Because I know there's a lot of emphasis on probiotics and we're not really sure there's pros and cons of probiotics, but in terms of diet, how does the diet help our gut microbiome? Well, basically what we eat is going to give food to our gut microbiome. And you want to give food to your gut microbiome that's going to encourage the growth of good bacteria and discourage the growth of bad bacteria and high fiber foods and whole foods will encourage growth of good bacteria, which will then produce nice chemicals that are beneficial to our body and reduce chemicals that are not good for our body.

And so we also asked in our study, how does the microbiome change with diet in patients with myeloproliferative neoplasm? Again, this was a preliminary study, so we basically took stool samples at four different time points during our diet study and looked at the gut microbiome. And the point of this is really just to show that each person is very different. So microbiome studies are very difficult to do because my microbiome is a lot different than your microbiome. And so we reemphasized that the major difference was a person-to-person difference and with the diet could really see minimal differences over time, which is not unexpected. So it really emphasizes that if we want to look at a specific bacteria that we think is important for a specific disease, instead of doing a global investigation of a microbiome, we may want to hone in on a specific bacteria. But one thing that we did find that was interesting is there are three types of myeloproliferative neoplasms with myelofibrosis being the most progressive disease, the most severe disease. And we did find that patients with myelofibrosis had reduced microbiome diversity, meaning diversity is good because you have, so you can have a lot of different types of bugs in your gut. And the myelofibrosis patients had less diversity. Whether this means that the less diverse microbiome can make somebody get myelofibrosis or because somebody had myelofibrosis, they were in general not as healthy and that caused the reduced diversity is yet to be seen.

So then moving on to nutritional needs for healthy blood production, I think it's important to, to sort of separate when you have anemia or have low blood count, white count, red cells or platelets to dissect why that is. We do need for healthy blood production we need iron to produce red blood cells. That's a key component but also do need a lot of different vitamins to produce healthy blood cells. So it's clear that if somebody has vitamin deficiencies they may not be able to produce good blood. But it's also important if you have a blood cancer, not just to jump to the conclusion that it's because of lack of iron or something like that. So one thing as a physician that I commonly encounter with patients is the misconception that the word anemia means iron deficiency. The word anemia means too little few red blood cells. So if you have anemia, that does not mean you have iron deficiency. The most common cause worldwide of anemia is iron deficiency. So I think it's important to [distinguish] anemia does not mean iron deficiency. It could, but they're not equivalent.

So then what does cause low blood counts in blood cancer? This word called, it's a big word, ineffective erythropoiesis, which occurs many times in somebody with something like MDS where you have lots of precursors in your bone marrow that are supposed to make red blood cells, but they're just having a problem with maturing. So they're not getting out into the blood to give you your nice red blood cells or white blood cells or platelets that you need. Another thing that can occur is in the bone marrow, that's where we make our blood, but that's where unfortunately sometimes the leukemia cells stay in the bone marrow, myeloma cells stay in the bone marrow or lymphoma cells can go in the bone marrow and sort of crowd out your good blood cell production. Also, treatments can suppress blood counts like chemotherapy. And then also with many blood cancers there's chronic inflammation and another common cause of anemia in the general aging population is a thing called anemia of chronic inflammation, which means you have lots of iron in your body but you just, your body just is not able to utilize it because of, won't get into details but because of increase in hepcidin, which is probably an evolutionary mechanism for us to try to avoid bacteria, but that's not important here.

So how can we use diet to optimize response to chemotherapy? And I just wanted to first just talk about the basics. During chemotherapy many times classical chemotherapy will kill not only your malignant cells but also kill your good cells. So you need time to regenerate. So you need, you have increased needs during the time of chemotherapy, so important to have the good building blocks. So these are sort of just common sense- you need extra nutrition during chemotherapy. But specifically what sort of studies have been done? And there is a lot of interest in, because immunotherapy is an emerging tool for blood cancers. This specific paper, which is a very high profile paper and a high profile journal focused on melanoma. But I want to emphasize that, you know, we can probably take clues from this and apply it blood cancers. So they asked whether, in people with immunotherapy, and immunotherapy leverages our own immune system to try to fight the cancer, can we modulate, by giving somebody high fiber or probiotics, will that allow their immune system to work better to fight the cancer during immune therapy? And the answer is yes.

So one can, I think a reasonable suggestion would be if you're getting immunotherapy, I think it would be important to focus on some high fiber foods. We know that that's healthy anyway and there is evidence that it may be quite helpful for responses to immunotherapy. Another specific thing that we do have some good literature for is vitamin D in lymphoma. There have been studies looking at many of our population is vitamin D insufficient and patients with vitamin D insufficiency with lymphoma have worse outcomes. So I think during chemotherapy for lymphoma it is important, there's no harm in making sure that you have good vitamin D levels because there is some concrete data to suggest that having vitamin D deficiency will lead to worse prognosis.

And then the big question that always comes up is, does sugar fuel cancer? And actually this was a very interesting topic for me to go and delve into the literature. I want to emphasize that there's a difference between information and data that you get, you know, when you study cancer cells in a dish and add certain ingredients in a dish and watch the cells grow, or not, and extrapolating that into human beings. I really want to emphasize that there is a significant caution that should go into that. So cancer cells do metabolize things differently than our normal cells and are able to take up nutrients and utilize them in different ways that our normal cells do. But I don't think that there's any discreet evidence that cutting out sugar altogether really impacts cancer per se because we, our bodies can, from whatever nutrients we take in, can break it down and, you know, turn it into glucose that our cells can use. So I don't think there's discreet evidence that totally getting rid of sugar will help cancer. But you know, sugar, increased sugar intake, the literature that I did find, links increased sugar intake to obesity, which then increases risk of cancer. So all of the claims about sugar and cancer I think should be regarded with caution as to is it sugar itself or is it somebody who's eating a high sugar diet is more likely to be obese or more likely to have other health problems, which then will increase one's risk of cancer? But nevertheless, it's obviously good not to eat too much sugar.

So here's our all cells use glucose, both, you know, our normal cells and our cancer cells use glucose. So it would be really impossible to, you know, starve if we starved all of our cells of glucose, we'd also be starving our normal cells. But just wanted to emphasize that. And then just to end, take home points, you know, really common sense that healthy lifestyle choices will reduce risk of cancer, improve outcomes during treatment and data is starting to emerge. But really our key knowledge of how to use diet during cancer treatment is really in its infancy. And so very important to have ongoing research to really ask specific questions about diet and specific treatments. But I think that these things are slow but are coming through the pipeline. Okay.

- Great. Thank you for that. That was very helpful. I think just for people on online right now, you know, I think the focus here was to go through what is known about any linkages between diet and blood cancer generally. And so Dr. Fleischman did a great job of just summarizing what we know based on studies that have been done. And a lot of the questions that we've received are focused broadly on, you know, what can people on this webinar today or loved ones do if they already have blood cancer and they want to either feel better or increase the likelihood that they will have a good outcome from their treatment or various things. So one question that came in already was do you have any recommendations on places to look for good Mediterranean diet foods or recipes? Do you have a recommendation or…

- So that actually is a very good question. I mean one thing that, when we were developing the diet was thinking, well should we make a little recipe book? But looking online, you know, there's a lot of recipe books I was particularly impressed by. Oh it's called Fully Mediterranean is a website, which I think you do need to, you have to, I think it's a paid subscription, which I haven't paid for. But you know, so I can say looking at what's available in terms of free content, I was quite impressed with that. But you know, realistically there's a lot of information out there. I mean realistically it's the same thing that you're going to hear from everybody. You know, whole foods, whole grains, minimize processed foods, have your proteins come from beans, fish and a teeny bit of red meat. So I think that it's sort of common sense on how to follow a "Mediterranean diet" and, maybe to be more culturally aware, maybe we should change the terminology from Mediterranean to maybe plant forward or whole food, plant forward because it really can be adapted to any culture.

- Okay. And then while we're on the subject, one person asked, and this was a specifically a CML patient, but I think it applies to pretty much anyone, can a person with CML have a glass of wine on special occasions? How do you feel about alcohol? It generally sounds like everything in moderation.

- Yes, exactly. So everything in moderation. I mean there is data in terms of, so I will address the specific, so there are some medications, you know, that people take for, you know, for example some oral chemotherapies where it really interacts with alcohol. So in those certain circumstances with specific drug interactions, probably not a good idea. But in general, where we were talking about Mediterranean diet, actually a glass of red wine, one per day, is actually part of a Mediterranean, well if you drink anyway, that is part of a Mediterranean diet. So personally, I don't think there is discreet data other than drug interactions to say that, you know, mild or you know, I don't say moderate drinking, because you don't know what really that could mean a lot different things to different people, are really harmful. But one, an occasional, drink in celebration of something, I don't see any problem with. There is data about moderate or excessive drinking in terms of increasing one's risk of developing cancers. So I mean, that's all I'm going to say about that.

- Okay. And how about, I hate this word, but comorbidities, so other things that go along with your blood cancer. So a couple people mentioned different things. One person has high cholesterol, another person has, you know, different kinds of cancer. Can you talk a little bit about how those, those things may play into diet?

- Okay, so one aspect that I didn't bring up in terms of the precursors as well as we do know this to be the case with myeloproliferative, some chronic blood cancers that simply by having these mutant cells in the blood that increases risk of atherosclerosis or cardiovascular disease. So one thing that I have encountered in my practice is, if somebody has a blood cancer, then potentially their primary care physician would say back off, I'm not going to address your cholesterol or your high blood pressure because of your blood cancer. But it should be the exact opposite that having a blood cancer or a blood cancer precursor gives you an additional risk for other problems such as cardiovascular disease. So it's even more important to be on top of managing cholesterol, managing your glucose, managing your high blood pressure because the blood cancer may modulate those. So I think that's how I'm going to answer that question. And also another, you know, it just makes things a little more logistically difficult, if somebody has a lot of comorbidities and they're on a lot of medications and then they're adding a chemotherapy agent, you know, there could be some drug interactions that they may need to change the dosings of their other medications during chemotherapy to address drug interactions or their body may be changing during chemotherapy. And then this issue with solid tumors in terms of many blood cancers do go along with it a risk of increased solid tumor. Why that is? Probably, it's the predisposition that led you to have a blood cancer is also, if it's present, may also lead you to have a predisposition of a solid tumor. Not necessarily that one leads to the other, other than in the situation of treatment induced myeloid malignancies, one complication of some chemotherapy for a solid tumor is increased risk of blood cancer. So I don't think that person's talking about that specific situation.

- Okay. There's several other food items on the list people were asking about, for example, high protein drinks or smoothies.

- Okay, actually I saw that question and interestingly I am really, I’ve been learning a lot in, I'm taking an integrative fellowship which teaches physicians how to approach patients more integratively. And actually that question came up about protein shakes during chemotherapy. And it was a concept that I didn't really realize before that during chemotherapy or you know, when you have cancer, a lot of times you're not really in the mood to eat a lot. So we recommend, you know, just get any calories you can in any way you can, including protein shakes. So I feel like there's pros/cons. An issue that was brought up last night at our integrative grand rounds is many times these protein shakes are not really whole foods, may have very modified ingredients. So I mean, from my perspective, it's sort of a risk/benefit. If you can get your protein and your calories from actual whole foods, I think that's ideal. But you know, if you're nauseated, you don't feel like eating and the only way you can get those in is, and it's going to facilitate you to get those in with a protein shake, by all means, I think a protein shake is better than nothing. But I think that, you know, getting your nutrients with whole real foods is the optimal approach.

- Okay, great. And I love this question. What's the worst food you can eat? Oh, let's point a finger right now. Is it chicken?

- I don't know.

- Fried chicken?

- Well I mean I guess fried chicken, well I guess it's got some protein in it, but I would say probably foods that have no nutritional value, you know, just pure sugar or pure, you know, pure fat. Foods that have no nutrition, empty calories. I mean, I don't know if soda, you know, a soda probably it's got nothing but sugar water there.

- Well it's water.

- Yeah, I guess.

- Okay, great. Well I think we've kind of covered a lot of the questions that are sort of on this general list and then you covered the microbiome pretty well. So I think we can move on to some of these other questions that we got. I have them categorized. So here's one. My mother died of leukemia when she was 32 years old. I'm fearful that I can get it. What diet changes can I make?

- I think, I guess we will, we'll sort of go to that question in twofold, having a strong family history of a blood cancer and for some blood cancers can increase one's risk of blood cancer. But I want to emphasize just because a family member had a leukemia doesn't necessarily mean that that's your destiny too. But it is a very appropriate approach to try to modulate your diet. I would say, clearly the evidence shows do maintain a healthy weight, so probably the best thing you can do is not be overweight, not smoke. We do know that smoking increases one's risk of development of mutant cells in the blood and then subsequent development of blood cancer and maintaining a healthy diet. But I don't think there's any specific food or a specific supplement that really can be recommended at this point in time to prevent a blood cancer.

- Okay. Let's see, there were two questions on specific diets. Vegan and keto. The keto question was specifically relating to CLL patients and then also intermittent fasting.

- Okay. And I sort of intentionally left the keto and the fasting off because I think that there's a lot of enthusiasm for those but I think, before making any clear statements, I mean there is a lot of preclinical data to suggest that there may actually be some benefits of fasting in terms of cancer before there are clear cut clinical trials. I just don't know if it's really appropriate to make statements. Also with keto it’s depending, I know there are ways to do keto that it doesn't involve large amounts of bacon and know that one would try to emphasize with extreme diets if it's including, you know, unhealthy foods, you may be counteracting the benefits of ketosis with, you know, all of the unhealthy foods that you're taking in. But I just want to say I think it's too premature to really make discreet statements about those types of diets.

- Okay, great. Okay. How about this, we had this question in a previous call as well and I accidentally missed it so I'm not going to miss it this time. If someone has diarrhea, do you have any recommendations? They say, this person said “I try to eat plenty of fiber to keep from it,” but they have the symptoms every couple of days and they can't afford over the counter fiber supplements. Is there anything else they could do?

- I mean, I don't think that it's necessary to do. Again probably better to get fiber through foods. I think it's important to ask why the person has diarrhea? Is it, that's just the way that their gut is and that's, they're just a type that's getting diarrhea or is it from treatment? Certain oral treatments for example, for myeloproliferative neoplasms can cause some diarrhea and to prevent that, sometimes we would give some antidiarrheal medications, but that doesn't really sound like this situation. What I would recommend, it sounds like it's occurring every few days. Is there something that's triggering it in terms of a specific food that one's eating before they're getting diarrhea and is it negatively impacting one's, you know, are you getting dehydrated or, I guess I don't want to say what's the problem, but I guess how is it impacting your life? And if it's negatively impacting then you may need to do something about it.

- Such as ask the doctor if there's a medication.

- Yes and, maybe ask why? What could be causing the diarrhea? Is it treatment related? Is it, you know, is it something that you've had your entire life and this is just the way that your gut acts and could then try some experiments with trying different things in the diet and seeing if the diarrhea goes away or not?

- Yeah, I think food diaries I think are always a good place to start with issues that are being triggered regularly. Okay. So there was this question that came in, a couple of people asked about foods and how they can help with energy. Obviously we know that fatigue is a major issue for people with blood cancer. So any suggestions on that?

- I mean, I don't think, I feel like I want to get away from like, oh, eat this food and it's going to give you more energy like in terms of caffeine or something like that. But, you know, just from me personally, I feel like when I have, you know, when traveling and, you know, eating fast food, I'm always feeling sort of tired after I eat a donut I feel like I want to go to sleep. So I don't ever eat donuts. I just feel like having a very healthy diet will, you know, and not having the high sugar bursts, you know, with a high sugar but low glycemic index, you're going to get a boost of glucose and then you're going to crash. So by eating, you know, less sugary foods, things that are more high fiber and sort of digested more slowly may have that sort of steady energy rather than the peaks and then you just crash.

- Okay. And we had a few questions that were on either food additives or toxins that we encounter in other things like skincare, that kind of thing. So do you have any suggestions on that?

- In terms of, because I know there was also a question about like skin creams and things like that. You know, there are a lot of emerging concerns about additives, particularly things like dyes in our foods. I think a good approach is, I mean, I'm not going to say, you know, don't eat any foods with any additives. That's probably not a realistic approach, but by choosing things that are real, actual, real foods and not processed by default, they're not going to have additives in them. So I think that's, you're basically killing all the birds with one stone by choosing whole foods. But I think that, again, I'm sorry, I'm saying it's too premature, but I just don't feel comfortable making claims without clear cut data to back it up.

- Okay. And then one person specifically asked about a drug they're taking called Tasigna and they asked about seasoning. So we had a little bit of a conversation before we started this call and I wanted to make sure that we give a shout out to support groups and you know, kind of working with peers to get some ideas.

- And so I think that's a great question and we'll broaden it, and I think maybe what they're trying to get at is, certain chemotherapy agents may change your taste buds. Things that you may have liked before you don't like. So what I'm going to respond to is how to address things like when a treatment is changing your taste, which is a very common scenario with a lot of chemotherapy drugs. We really encourage people, or I think it's important, for the patient to understand that having taste changes with chemo is a very common scenario. And to acknowledge that unfortunately things that you liked before, maybe now they're not going to taste good to you. But then on the opposite end, maybe things that you didn’t like before now you like, so you're sort of going to have to re-explore what things you like and what things you don't. So I think my recommendation is what spice, I don't know, maybe try things, try spices that you didn't think of before or maybe spices you didn't like before. And see if you're going to now be tasting them differently. Sometimes having things that are sort of more pungent and more sort of strong flavors, things you thought maybe were too strong flavors before, now are not going to be too strong and maybe you'll enjoy them. So I guess try some very strong spices that maybe you don't like before,

- All of a sudden Brussels sprouts taste great to someone, right? When they couldn't eat them before. And then the other thing that we talked about, which I think is important, is just you know, ask around, talk.

- Oh yeah, exactly! Because the best, the best knowledge is going to be from somebody who has gone through the same thing that you did. And so I think that's where support groups and talking to other patients is great. You know, that's a great use of Gilda's Club where people can come together and discuss things. And I think it's a, you know, say, "Hey what did you try?" Or if you did find a great tip, you know, share it with your peers and say, oh my God, I found this, I loved it. I think this, I'm going to share this tip with you. So I'm saying that your peers, people who have gone through the same thing that you have, are the best resource for things like that.

- And if I can just add, I know a lot of people don't realize that there are dieticians within their cancer centers and that you can ask your doctor for that referral and they can make recommendations for taste or side effects or things like that, that are current.

- Thank you very much Kathleen. That is a wonderful, a wonderful point. At our cancer and many cancer centers- well I hope in many cancer centers- because it's such, an important aspect is offered as free of charge. So, and I guess, you don't know unless you ask. So maybe don't wait for your doctor to recommend it. I don't think that there is any harm or probably the doctor would be delighted if you, you know, if you said I think I would really like some help with a nutritionist counseling. Great. And then many times it's free.

- Yeah. And I think that's really important to point to land on because I think, you know, people don't realize that the care team is not just your doctor or your nurse. It extends, you know, in many cases well beyond that and maybe at some of the smaller hospitals, but for sure at the academic medical centers that a lot of folks go to, your care team can include people with many different specialties. Whether it's mental health specialty or pharmacist or a social worker who can help you accessing maybe some financial support, all sorts of different things. Diet and nutrition is definitely one of them. I even heard of an academic medical center who has a masseuse!

- We have massage. We offer massage. Yeah. And acupuncture and acupressure.

- Right! Well hey, it's 12:59 and I think we've covered a lot. We didn't get to everything, which unfortunately I knew was going to happen because we had so many great questions that were submitted. But I really appreciate everyone's thoughtful contributions to today's event. I think obviously there's so much about this and you know, it's possible that we will host another one that will be more focused on, you know, kind of recipes and cooking. So this certainly something that we can consider in the future. As I said at the beginning, we will be sending out a survey to everyone and would love it if you would share your thoughts about what you're interested in in the future for webinar programs. And ladies, would you like to say any closing thoughts?

- I will make one plug that Gilda's Club Chicago, and I know many of our affiliates across the network, do have cooking classes and talks on these topics. We have a monthly online cooking class that is run by a dietician. So if you check out https://www.gildasclubchicago.org/, you can join our dietician and she's from Northwestern, so she works within oncology and she's very knowledgeable.

- And those are virtual, right? So you don't actually have to be there.

- Virtual.

- Absolutely.

- And you can be from out of state. That's fine.

- And I echo that and I think that, hearing all of the questions I, one of my things on my list to do is to develop sort of a curriculum and resources for our blood cancer patients. Because I know there's a lot for, you know, healthy cooking and, because I know there's a lot of information out there, but what to listen to, what not to listen to. I think there's just like too much information. So I want to have a source for specific, you know, guidance for blood cancer patients.

- Yeah, that's a great idea. I mean we have a lot of resources on our website, but we definitely don't have links to, for example, the best podcasts out there or, you know, recipes and that kind of thing. So good thinking for creating a list of resources.

So thank you both so much and thank you everyone for your participation and as I said, we'll be making this video available on our website in a couple weeks’ time. So please be on the lookout for that. And that's about all for today.

- Thank you.

- Thanks everyone