Truths & Myths of Nutrition in Cancer

Truths & Myths of Nutrition in Cancer

MIB Agents OsteoBites Welcomes Natalie Ledesma to discuss Truths & Myths of Nutrition in Cancer.

With almost 25 years of experience as a registered dietitian nutritionist, Natalie is a well-seasoned practitioner. A board-certified specialist in oncology nutrition, Natalie is the founding dietitian for the nutrition program at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center and is the clinical nutrition specialist at Smith Integrative Oncology in San Francisco. On a daily basis, she works with patients through her integrative & functional nutrition private practice.

Ann Graham: Welcome to OsteoBites. My name is Ann Graham. I'm an OsteoWarrior and executive director of MIB Agents. Today on OsteoBites, we are talking with Natalie Ledesma, a clinical nutrition specialist. The topic today is truths and myths of nutrition in cancer.

And on this conversation is Kara Skrubis, Junior Advisory Board President, and Christina Ip-Toma, Director of Scientific Programs for MIB Agents.

Really excited to have Natalie on today. Natalie is a board-certified specialist in oncology nutrition. She is the founding dietitian for the nutrition program at the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, and is the clinical nutrition specialist at Smith Integrative Oncology in San Francisco. She works with patients through her integrative and functional nutrition private practice.

This episode today is we're so excited and happy to have BTG Specialty Pharmaceutical on board as our sponsor. BTG provides rescue medicines typically used in emergency rooms and intensive care units to treat patients for whom there are limited treatment options. They are dedicated to delivering quality medicines that make a real difference to patients and their families through the development, manufacture, and commercialization of pharmaceutical products. Their current portfolio of antidotes counteracts certain snake Venoms and the toxicity associated with some heart and cancer medications. Their drug, Voraxaze, is for high-dose methotrexate toxicity. So, thanks to BTG Specialty Pharmaceuticals. And Natalie, would you get us started please by introducing yourself?

Natalie Ledesma: Sure. Excited to be here. Thanks for the invite. And definitely, I'm passionate about the connection of nutrition and cancer and any way that we can help individuals during and beyond cancer treatments. Something that I've been involved with and working in almost twenty-five years, makes me feel really old. But it also, I think hopefully provides a lot of experience to really help individuals, and my goal, of course, helping individuals to increase energy and enhance mental clarity and reduce systemic inflammation and balance blood sugar, and optimize digestive health, working to kind of mitigate side effects from treatments and augment therapies using other types of things, and just helping, hopefully, overall to improve quality of life and the sense of well-being for each individual that we work with.

So, hopefully, we give you some information today that helps to empower you to take a little more control over how you're nourishing yourself. So, thanks again for the invite.

Kara Skrubis: Hi, everyone. My name is Kara Skrubis. I am twenty years old from New York. In January 2020, I was diagnosed with osteosarcoma. I'm a left above-the-knee amputee and the MIB Junior Advisory Board President for 2022.

Christina Ip-Toma: Hi, everyone. I'm Christina. I am a mom to Osteo Angel, Dylan, and director of scientific programs for MIB Agents. And I am really looking forward to hearing from Natalie today. I know this is an area where a lot of people have a lot of interest, but sometimes like the care team doesn't get too deep into this area. So, great to kind of get some expertise and direction from Natalie. So, thank you so much, Natalie.

Natalie: Let's dive into some truths and myths of nutrition in cancer. We could make this an 8-hour seminar, but we don't have 8 hours today. So, we'll make it more brief than that and perhaps we'll go back and do a two-part or a three-part component. So, I thought before I dive into some of the myths, I'd start with a short history of medicine. Some of you may be familiar with this, but I think it's appropriate in the term of how things kind of cycle through and change through history. So, here's somebody who was an earache, and in 2000 B.C., we said here, eat this root. That changed in 1000 A.D. to say, "No. no, no. That is Heathen." Instead, we say a prayer. 1850, that became a superstition. So, instead, we drink a potion. Then, we get another 1900s with that is snake oil. So, we swallow a pill. 1965, but that's enough ineffective. We got to take an antibiotic. And now, the antibiotic is artificial. Let's eat this root. And we could argue that nowadays like is that a low carb root? Is it a plant-based root? What kind of root is this? But I think, again, we kind of see some history that seems to come full circle. And I feel like I would be remissed to not at least talk somewhat about vegetables, in terms of a truth and miss and this is one that people are like, "Yeah, yeah, yeah. I'm pretty confident that vegetables are indeed good for us."

So, certainly just to kind of reinforce the importance of some of these different plant foods in terms of vegetables, even in terms of some fruit, in terms of beans or legumes and nuts and seeds and perhaps whole grains. And our goal here is number one, to hopefully provide a good amount of nourishment in terms of vitamins and minerals and dietary fiber. And then, also, just being a host of a variety of different plant-protective phytochemicals. But also, if we fill up our bodies with a lot of these nourishing foods, we don't have enough space for content, we're satiated. So, we don't end up then over-consuming in the way of animal fats and animal protein and processed foods and sugars and things that, not that we can never ever have, though we want to not, not necessarily be focusing on so much.

So, that's always an area that I like to kind of push. This was a trial, is a breast cancer trial, that unfortunately is not a lot of osteosarcoma diet trials out there yet. anyway, so hopefully that will come with time, but just kind of showing the importance of those incorporating vegetables and fruits and exercise, even just simple exercise of walking 6 days a week that it significantly reduced risk of death after early-stage breast cancer. So, just kind of an extra focus on making sure we're getting in good amount of plant foods into our daily diet.

I'm here just to kind of have a gist of what a plate should be looking like. Not that these little carrots here are supposed to be moving but they are apparently in this little graph or a little picture, but the idea is that we want the majority of our food on our plate to be of plant form. And then, we want to make sure we're incorporating some sort of protein with every meal. Maybe that's 25% of the plate, maybe it's a little bit more than that depending on kind of what the needs may be. And that could be a plant protein source, or it may be an animal protein source of fish or pasture-raised eggs, organic poultry, or something like that.

I do feel that with saying plant-based for the past twenty-plus years and it seems like in the last year, plant-based is all of a sudden in many people's mind, equated with being exclusively plant-based and vegan. And I just want to differentiate that when I say plant-based, I mean, a base, a foundation of having a lot of plant foods, but I'm not meaning, an exclusively plant-based diet. I think it's okay to incorporate some of these animal-based products in there. We'll be careful in terms of having clean, high-quality animal proteins or animal fats in there. But definitely, I don't feel that we have enough evidence to say that it must be exclusively vegan. And then, potentially, depending on blood sugar regulation, you know, incorporating some sort of starchy vegetables, things like sweet potatoes and other kinds of winter squash, other kinds of whole grains quinoa, brown rice, wild rice, even opting for corn tortillas rather than the white flour tortilla, and so forth.

We hear a lot about  making sure there were aiming for having a rainbow assortment of foods, and that's something to kind of look for not only within the plant, you know, all the plant foods but only in terms of produce, but even in terms of even like black beans, for example, have more antioxidants than a white bean. Thinking, again, in terms of vibrant color. But color is oftentimes a kind of a sign of phytochemical content. So, the richer in color, generally, is a sign that we're going to have a greater concentration of different kinds of these protective phytochemicals. Just want to kind of point out that when I say in terms of kind of white here is kind of an exception of saying, yeah, like having some cauliflower and some garlic and you may argue mushrooms are white would be one thing, but not meaning white, in the sense of white refined, you know, cookies and cakes, and pastries, and donuts, and those types of things.

So, this slide helps to illustrate the different types of colors. This is more of a reference kind of based slide. What particular phytochemicals are in each of those different color types of foods, for example, lycopene in the red foods or
we hear a lot about beta carotene in the orange foods or even in green foods, too. And then, kind of which foods would be, and then, kind of what those functions may be. But there are hundreds of different types of phytochemicals, having different kinds of functions, whether that's in it to inactivate a carcinogen, whether it's to strengthen our immune system, it's to work more from a hormonal perspective. You know, they work in a variety of ways, and generally speaking, we want to have a variety of different types of phytochemicals in our diet and one easy way to achieve that is having different types, different colors, incorporated into your daily diet. What Color Is Your Diet is a book that Dr. David Heber has written from UCLA, there's a new reference there. So, not surprisingly, we want to have those vegetables. Also, I feel like in terms of, probably, one of the top questions, if not the number one top question I get is, tell me more in terms of sugar, right? And I think we would definitely be able to easily say, we know that sugar is not providing any nutritive properties in terms of adding protection against cancer. We know it's not going to be helpful. At the same time, we don't yet, anyway, have evidence to say that sugar is truly causative in increasing one's risk of getting cancer in the first place.

The area in terms of recurrence and modulating cancer, I think is an area we definitely need more research on and something that I think we want to look at more carefully. If I just kind of look at quickly from a nutritive perspective. Generally speaking, if we're thinking about Skittles or chocolate chip cookies or donuts, they aren't going to probably provide a lot of nutrient value in terms of the vitamins and the minerals and the fiber and those phytochemicals that we were just saying you want to make sure having a good amount of. From a metabolic perspective, one of the concerns is that sugar, particularly high fructose corn syrup, which is, of course, in a lot of processed foods, definitely in a lot of sugar-sweetened beverages that can not only lead to increased fat mass but definitely has been linked with a lot more of metabolic disease. So, sometimes, we're getting worried in terms of a metabolic component, in terms of triglycerides, in terms of
even increasing blood sugar, along those lines. Hormonally, it could lead to insulin resistance, which then also then puts us back into not only from a diabetes and a blood sugar, glycemic regulation challenge, but we know that with insulin resistance that that is not going to be favorable for those that are working with cancer. And thinking of our focus today being more of an oncology focus.

Probably, many of us could say, "Yeah. We also know that if we have sugar, it definitely drives us to this relentless drive for more and more and more." Even if it's a tiny bit of sugar, we have typically then want to have it again the next day and the next day and the following day. So, one way I find I kind of not having such a strong desire is if we're able to then be able to really eliminate or limit it for, you know, kind of these added sugars. And here, I am talking just to kind of clarify more in terms of added sugars. I'm not saying you can't eat the apple that has some natural sugars in it or the blueberries or the carrots or the beat. But I'm thinking here more in terms of added sugars. And if we even look in terms of mortality, we do see that a higher sugar intake has been associated with a greater mortality risk. So, if we think about more of our lifestyle of kind of where sugars come into play in the western diet and how that correlates more in terms of cancers, we see that a western diet in kind of this even lifestyle because this tends to also be characterized by lower physical activity. But a western diet that oftentimes is characterized by having lots of calories, typically, a higher concentration of animal protein, probably poor quality animal protein, higher amounts of saturated fats, things with cheese and ice cream and butters, and things of that sort, trans fats and also a lot of rapidly digestible carbohydrates. So, what do I mean by rapidly vegetable carbohydrates? The white bread, the white rice, the white pasta, the sugars, the cakes, the desserts, and things of those sorts.

We know that that lifestyle is definitely associated with a variety of different types of cancers, long list there. Why that may be the case is it could be that it's mediated by the metabolism of insulin and IGF or insulin-like growth factor. And it is possible to even measure in your blood on insulin and IGF levels, and that could be something that would be appropriate for some to be measuring, what are my levels? And would that be something that would be providing me some sort of protective effect to see where am I at?

Generally speaking, we want to have a lower amount of insulin and we want to have kind of a lower amount of insulin-like growth factor because we see that if we have higher insulin, if we have higher IGF levels, that those are also associated with the increased risk of different types of cancers. Again, sarcomas are typically a tough one, but I wanted to at least provide you a few resources here and I have seen some trials where they've linked higher insulin with poor prognosis. So, in my mind, it's not necessarily that we can say, "Oh, well, if we have a lower insulin level, it's going to definitely give us a better prognosis." But it certainly wouldn't be to anyone's benefit to have a poor prognosis.

So, what can we do? What can we look at from the start? And do we need to modulate and be more aggressive to bring down those values if they're elevated? Or is it not one of our areas of focus? We know, of course, having higher levels of insulin also is an issue in terms of heart disease and diabetes and immune functions, weight gain, obesity types of things and that partially depends on kind of where somebody is, if those comorbidities are a significant concern or if we really are focusing on just the immediate oncology inner piece and at front.

So, just to kind of give you a picture here of kind of, when we say insulin resistance, I think you probably hear that term relatively regular, what does that actually mean and I hope that this illustration can be helpful. As you can see there, the top picture of the normal cell, you have the glucose by the little red circles and the insulin there in terms of the blue hexagons. And what happens is when we eat, naturally, our
blood glucose values are going to go up, should go up. It's appropriate for those to go up and that's going to signal our bodies to secrete insulin. And then, the insulin attaches to those insulin receptors, those little navy blue channels and when the insulin attaches to those navy blue channels, then that allows the channel to open and let the glucose from out here in the blood to getting inside the cell. So that you then, feel nourished, you feel satiated and you're feeling in a good position.

In an insulin resistance cell, what happens is that you still eat, that glucose goes up, the idea is, okay, the insulin is supposed to come over here and attach to our insulin receptors and that happens, but oftentimes it doesn't happen as efficiently as we would like. And you can see here that only, for example, in this picture only 2 of the 6 actually allowed the glucose to get into the cell. It's almost like you're trying to put this one's, you know, the circle and the hexagon, but it's almost like the hexagon there, these little receptors are square and then the hexagon doesn't fit on top and we can't open that channel and that leads to a surplus of glucose out here in the blood. At the same time, you're like, "I'm still hungry." or "I still feel really weak." Because the cell
is not actually nourished. And then, additionally, then the body and cell, "Well, I better put out more insulin because we've got too much sugar out here, too much glucose out here." And then, we end up with too much glucose and too much insulin in the blood and not enough that are actually getting inside to truly nourish the body and getting it here into the cell.

So, that's how we don't want to have kind of this insulin resistance component. And from a food perspective, why do we hear so much about sugar? Is it because so much of our food is spiked with sugar, and yet sugar is this direct correlation with insulin. It's not the only correlation we can talk about hormones and other factors, but for our time's sake today, we're focusing here, in terms of the sugar-insulin connection.

So, in terms of sugar and cancer, like I said, there aren't studies that are saying that there's actual causal action in terms of sugar and cancer. We definitely see correlations. We definitely see diet intake, as well as those who have higher glucose, those who have higher hemoglobin A1C values, which is a marker that looks at your blood sugar over the previous two to three months, higher levels of insulin, higher levels of IGF, all of those are definitely correlated with the development, the growth, the promotion metastasis of multiple different types of cancers. So, that's where you want to think. "Okay. That's probably not going to be the healthiest situation if we're trying to modulate a disease."

So, my focus is not like you can never ever have a cookie again in your life. That generally doesn't work very well. Whether you're talking to a child or an adult, maybe more obstinate as an adult. But instead, "Okay, let's change our focus of are you getting in enough nourishing food?" So, I typically say not that you can't eat a cookie, but I want to make sure, did you have vegetables with at least two or more of your meals today? You know, did you have a little bit of fruit? Did you have some healthy fats? Are you having other, did you have protein with your different meals? And if it's like, "No, I didn't do these or these." Then, maybe you don't have the sugar. You got to go back and eat these healthy foods first before you're kind of allowed to add in these other things. But as soon as we make a rule of saying, "Oh, no, you can't have something." We know how that works. It just generally doesn't work, and we're likely more to sabotage our efforts and if it's more of a parent-child relationship, I think we're going to make things more challenging rather than work to kind of have that relationship be a little smoother front.

So, one thing you can use is what I call the 10:1 Rule and the 10:1 Rule is for every 10 grams of total carbohydrates that are listed on the label, you want to make sure that there are at least 1 gram of dietary fiber. So, in this nutrition facts label here, you can see that there are 9 grams of carbohydrate total and less than 1 gram of fiber. So, you could argue that it would work. If we're looking at something that has hypothetically, forty grams of carbohydrate, you want to make sure that there are a minimum of 4 grams of fiber to at least know that there's some sort of a balance. If there are only 2 grams of fiber, put it back on the shelf and choose something else. And granted, a lot of the foods that are really healthy, don't even come with a nutrition facts label. But for those things that do come with a label, you can kind of have that 10:1 rule in mind when you're at the market or when you're shopping online or however, you may be doing grocery work these days. If we're looking at a bread, if we're looking at a cereal, aim to have a good 3 grams of fiber per serving. That can be kind of a general ballpark, as well. And if we're thinking about, well, how do I know if my body is metabolizing carbohydrates appropriately? That's where we could say. "Well, let's take a look at some of the different blood markers and see where things are." These are some basic markers. I would say that definitely pretty much everyone is having their glucose tested. Maybe not in a fasting condition depends on when you're having your blood drawn, but it may be worth at least sometimes having that tested in a fasting condition to see, "Am I indeed under ninety for a fasting glucose? But I would say for a hemoglobin A1C marker, that is another marker that I would request. That's a marker that looks at your glucose over the previous two to three months, which is a much more stable marker because if you have your glucose tested and you're fasting, if you had your glucose tested and you ate an apple, if you had your glucose tested and you ate a piece of chicken, your glucose could be very normal, but it could be also very, very different. Did you eat an hour ago? Did you eat 4 hours ago? Did you eat ten hours ago? It can definitely really influence that glucose value. So, that A1C is a much more stable marker. I think that's a marker that I would say I would request pretty much for most individuals to have a sense of where things are.

If I was like, wow, we know that there's really an issue and/or we have a medical team who's very open, I would also request to do a fasting insulin. C-peptide is kind of pushing it up an envelope, they may or not, be open to running that, but I think the glucose, the A1C, you have an open team, even adding an insulin. You're not so sure if that team's pretty conservative, don't even ask for the insulin because otherwise, we don't want them to close the door too soon. Even just getting in that A1C value could be certainly of a value. When we talk about these different blood biomarkers and just generally kind of how your body is metabolizing glucose and sugars, it's not just sugar and it's not just one nutrient that we're paying attention to. You can see by this infographic from Spectracell that, and this is saying diabetes, but I really was kind of thinking, sugar glycemic dysregulation, but you can see that there are multiple vitamins, minerals, compounds that influence our bodies' carbohydrate metabolism. So, it's not that we can say, "Oh, I'm going to just take vitamin D and that's going to make sure my glucose is perfect. I'm going to just take zinc or I'm gonna just take alpha-lipoic acid because it's looking at all of these different factors that potentially have that kind of an impact. And so, it could be that if we know that glucose is an issue, that we then start to get more specific and say, "Okay. Well, where are our deficiencies?" Where are things on that lower side so that we know how we can best personalize recommendations to hone in on how we can best help this particular individual.

Some basic kinds of dietary strategies, somehow I keep losing my cursor. So, sorry if I like someone's hesitating as I'm circling around to find it. Dietary strategies to help improve glycemic control naturally, kind of really being careful of how many of the refined, flours, and grains and sweets were incorporating, instead focusing on getting in healthy fats, particularly the omega-3 fatty acids are helpful to improve insulin sensitivity. I think I put those in here as we talk about inflammation, but that's going to be your cold water fish and your flax seeds and your chia seeds and your walnuts. They're making sure that when we're eating carbohydrates that we don't just have them alone. So, we don't want to maybe just have an apple by itself. We don't want to have just a piece of toast for breakfast. We want to make sure that we combine that carbohydrate with some protein and/or some healthy fats, so that we don't have a spike and then a crash. But we have more of these, like little rolling hills in terms of our glucose and Insulin values.

If carbohydrate regulation is a challenge and we know that A1C value is higher than 5.4%, I'd say, do we want to be careful in terms of how many carbohydrates are we incorporating? Do we want to limit our portions of some of these starchy kinds of
carbohydrates? Tip, definitely, I want to limit different kinds of sugars and sodas and juices that have a lot of added sugars to those teas that may have added sugars, even being aware of our terms of like our evening snacking. Partly, it's a timing thing, and partly it's the reality as when somebody goes for a snack at nine o'clock at night, they probably don't pick out broccoli and hummus. They're probably going for something that's more refined, and empty carbohydrates there. So, that's where I'm more concerned. Although we do see even evening snacking, potentially having a negative effect on a C-reactive protein, which is a marker for inflammation as we talk about inflammation in a moment.

So, there could be other influencing factors there, too. Being mindful of caffeine intake, as we do know that caffeine and coffee, they can increase our catecholamines, our stress response that elicits cortisol and that increases insulin and insulin increases inflammation and that has you not feel very well altogether there. And then, definitely, knowing that we want to limit or avoid alcohol in relationship to our glycemic in a regulation as well.

If I look at another area, in terms of, I think it's crucial, kind of what I would consider a nutritional terrain of many different types of cancers. If one of those is glycemic management, glycemic regulation, inflammation is certainly another key nutritional environment that we want to see what we can do here because if we can modulate inflammation, I definitely think it can not only help to reduce our risk of cancer but also help to work with managing cancer getting through treatment and beyond. This is a quote that is an older quote, but I love it, as in terms of that tumor microenvironment being largely orchestrated by inflammatory cells as an indispensable, participants, and our neoplastic process, fostering proliferation, survival, and migration.

So, we know that inflammation is definitely linked with cancer. We know it's linked with virtually all different kinds of chronic diseases and that too is one of the reasons we want to look at these inflammatory biomarkers. Certainly, we're going to encourage an anti-inflammatory diet, but how picky we become and how particular oftentimes is somewhat dictated, how much does your biochemistry suggest that we need to be really looking at this? So, these are two basic systemic markers of inflammation that I also think are valuable to assess, and these markers, by the way, are not something that I want to assess every other week. If they look fantastic, I may not look at them again for 6 months. I may not even look at them for a year. If they're elevated, I'm probably going to say, "Hey, let's take a look, maybe in a few months." There could be some, sometimes that I may say, "Hey, let's look at it in a month." But definitely, you want to allow some time to implement some changes to, then see differences, hopefully, within these values a few months down the road.

C-reactive protein, that top one in the fibrinogen. That's like, I want to talk about those briefly. C-reactive protein is kind of an overall, systemic marker of inflammation. It can definitely be an important prognostic marker for a long-term cancer survival. And, that's something again that we are often times looking at. So, we want to see, where is that CRP? Can I get it to being less than 1.0? That's definitely my goal. Noting, too, that if you happen to take, if you're having a bad case of diarrhea, it's, yeah, then we don't test CRP today because it's going to be elevated. Even if we were to sprain an ankle, it's possible that can lead to inflammation. If we have a dental issue, that can lead to inflammation. So, it's not that CRP is only linked to cancer. It's linked to a variety of different types of inflammatory processes, but being mindful as we start to incorporate or interpret that value, if we are measuring that, where that is. But overall, I'm thinking, "Okay, let's take a look at CRP. Can I get it to be under 1.0?" As we see that higher levels are not so favorable in relationship to any kinds of diseases, and they're definitely also in relationship to cancers.

Similarly, fibrinogen also has a direct association with different kinds of cancer risk. So, we're wanting to kind of keep that in a more moderate pace. So that 260 to 310, 320, in a kind of range. And like carbohydrates and like sugars, If we look at different kinds of nutrients, it's not that one nutrient is going to be our Panacea, and our answer to everything. Here, too, you can see that inflammation is influenced by a variety of different vitamins and minerals and different kinds of compounds. So, it's not that we're going to say, "Oh, here. I'm just going to take the anti-inflammatory supplement because you could be taking a whole handful of different things." And so, there we want to make sure we are treating kind of accordingly to what things would be the most important for that particular individual.

From a food perspective, we can definitely say, "Hey, we want to focus on an anti-inflammatory diet and that is going to be one that you can see here is based in a lot of plant foods, having those vegetables in their fruits at the base. This is a pyramid developed by Andrew Well, this is just kind of for overall health. It is not an oncology specific pyramid. And so, that's where I would say that in some scenarios, we may kind of say, "No, we don't want to have wine in there on a daily basis." Because wine has definitely, alcohol has been linked to a variety of different types of cancers, not sarcoma, specifically.  I haven't seen it, not be associated, but I haven't been seeing it be associated, but just to kind of point out that this is kind of a general anti-inflammatory diet. But I think having those plant foods, getting in good sources of those omega-3 fatty acids of the fish in there, I think is important. I'm having lots of herbs and spices. I think that's an area that we often times overlooked in the United States. So, using plentiful amounts of garlic and ginger, and turmeric, or cinnamon, rosemary, basil, kind of whatever things that you enjoy, even using things like green tea, even white tea for those added anti-oxidants and polyphenols, strong anti-inflammatory properties. And Andrew Well definitely likes chocolate. So, he's going to definitely put it at the tip of that. Some dark chocolate for that antioxidant, polyphenol load. Again, just being very mindful of that sugar component.

There are definitely, even now, dark chocolates out there that don't have added sugars to them. There are the 100% for those that are like the true gurus that can kind of really handle that. I think the 100% can be good if you have a little bit of almond butter on it. Even for me, it's like it's a little bit extra bitter if it's just eating it straight. I personally loved one that a patient showed to me, it's called Pure Love Chocolate and they are a small company. I order them online and I don't have any connection with them, but I find that their chocolates are good and they use a little bit of stevia, but there's no sugar alcohols, there's no other things in it. And one thing I like about that kind of getting back to our desire for sugar is it if we have sugar even that little tiny piece of dark chocolate. I feel like we then want that dark chocolate again the next day, and the next day, and the next day. If I really take that sugar out entirely, I find that that desire definitely drops considerably. So, I find that that is something that can be useful.

One other thing I want to point out here, I don't think that necessarily like, "Oh you have to have pasta two to three times a week." If you want to have some pasta in there and we're getting it in a whole grain version, nowadays, we can get garbanzo bean pasta, we can get at a mommy pasta, we can get lentil pasta, other kinds of whole-grain ones. I think it can be okay to have in there. I think what Andrew was trying to point out here, is that when you cook pasta al dente, then it doesn't have kind of the same glycemic effect, as if we cook it over and kind of overcook it, it becomes that little bit more gelatinous kind of mix, that tends to have a greater effect on blood sugar, which kind of a greater effect on inflammation. So, just being aware of that. If we keep not crunchy per se, but right, when it gets softer, we can kind of stop that cooking then that could be beneficial, overall.

One thing that's definitely crucial to inflammation is our essential fatty acids, and essential fatty acids are both omega-6 and also, omega-3 fatty acids. The problem that we tend to have is we get way too many Omega 6s and not enough Omega-3s. So, that's where it's important to say, "Okay. Can we get a better balance of omega-6 to omega-3?" And I would say, in a perfect world, particularly like thinking in terms of cancer, can we even get a 1:1, maybe a 4:1 ratio of omega-6 to omega-3 fatty acids?

So, what foods provide omega-6 fatty acids? You can see here by this slide. Meats, particularly grain-fed meats, grass-fed meats will oftentimes have a little bit more omega-3. Butter, whole milk, egg yolks, a lot of processed vegetable oils, things that we're not trying to have very much of. The concerning thing is if we get too much of those, it creates an inflammatory process, it releases more of those inflammatory cytokines that foster tumor growth progression, angiogenesis, or fueling more pathways that cancer could possibly be able to develop. It suppresses immune function, where you can see here with the omega-3 fatty acids, the opposite occurs, since we want to encourage more of those omega-3 fatty acids to have that more inhibitory effect on inflammation being able to possibly reduce risk or inhibit the growth of cancer as to be able to strengthen the immune system, and even be able to complement chemotherapy and radiation. So, those are factors to kind of keep in mind. It isn't that you could have no omega-6s, we will get omega-6s. We just want to have a bit better of a balance.

There is also a test called Omega check. Some of the different like LabCorp, Quest, I think do run them. If you have, again, an open medical team, you could say, "Can I run omega check, its through Insurance mainstream?" And see, "Do I need to have more omega-3 fatty acids definitely in my diet and/or as a supplement to help make sure that my balance is a little bit more equitable?"

So many other things that we could definitely dive into, but timewise, I'm going to kind of wrap up with a couple more slides and then I definitely will open up to Q&A. Because we could spend hours, I feel like, what about this? What about that? You know, a lot of different fun, common questions and topics. So, ultimately for I think, kind of a healthy diet, why are we going because sometimes it's like, "Well, is it really going to make a difference?" Sometimes you'll hear docs say, "Just eat whatever you want." The problem with that is that if we eat, and that's why we're going to say, what do you want. But if you're eating and living on Pop-Tarts and french fries and chocolate shakes, you're going to definitely promote an insane amount of inflammation. We know we're going to have our glycemic regulation be awry. We know you're going to be devoid in having a lot of those nutritive properties. So, I would say that, do we have enough evidence to say that we're going to definitely prevent cancer or, definitely, reduce cancer recurrence? I wish. And I really would hope we could eventually kind of get there. But I definitely think that it may help. And so, we have "may help", let's go for it. We know it can reduce the risk of different kinds of chronic diseases. We know it can reduce inflammation. We know it can improve glycemic regulation. We know it can strengthen immune function. We know it can help improve energy and lessens fatigue, which is one of the overriding symptoms that individuals face on different kinds of treatments. We know it can help one get through treatment and have lesser toxicities, two different kinds of treatment. We can even modulate genetic expression to lower our risk. We don't have time to talk about genetics. But definitely, that could be another factor, and it's something that you have control over. So, it's very empowering and I think that is something that you don't want to let somebody take that away from you, you want to be able to have some power over, kind of what's going on, some control over different things and I find that that is very uplifting of having that empowerment there.

If I were to put kind of, what do I really eat then? What should I not eat on one slide in a reasonable font size? And that's kind of where I got to this slide. And so, ideally I'd love to load you up with tons of vegetables and fruits. I'd love to see you have double, triple the amount of vegetables and fruit. So, not nine fruits and one vegetable. I want lots of vegetables, two or three fruits. If we can kind of get in vegetables a couple times a day, you'll be able to get there. If you wait until dinner to get everything in, it's all big, bulky kind of dinner. If you get in all those vegetables and fruits and you add in some sweet potatoes, some chia seeds, some flaxseed, a little bit of beans, you're going to get that fiber goal without a problem. That fiber is going to help to keep you satiated, that fiber is going to help to bind the sugar, the fiber is going to keep your bowel regulation in a better place and fiber helps to bind to toxins and get those out of your system. We want to limit as much as we can in terms of the added sugars and white foods and so forth. We want to be mindful of kind of limiting more of our fatty and processed meats and dairies. But instead kind of going for healthy fats, including clean, lean proteins, make sure that we're having some sort of protein with all of our meals. I definitely think it's wise to incorporate plant protein on a regular basis, doesn't mean that can be, again, exclusively, but just that you're having it on a regular basis. As I mentioned earlier, lots of herbs and spices. In terms of whatever your palate allows, possible, even looking at flaxseed and chia seeds as a way to get in more omega-3s on a daily basis. Fish is fantastic. It's just that we probably don't eat it every single day. So, that's where the flax or chia can be more of a typical kind of daily routine.

The green tea may add in some added polyphenols and antioxidants. I'm getting that vitamin D level to be above 40 nanograms per milliliter. I definitely think it is wise, maybe even closer to 60 for oncology, but definitely, above 40. So, don't just let that somebody tell you, it's normal. What is that number? Because some of those ranges are ridiculously broad limit alcohol consumption, again, we don't have research with sarcoma specifically, but just in terms of watching things overall. And then, definitely, having some sort of daily physical activity, not only for overall stress mechanisms but certainly also to help achieve and/or maintain a healthy body weight.

So, it's not that we're looking at food to cure a cancer, but we know that what we eat is certainly going to be so crucial just to kind of how we feel every single day. And we want you to feel as well as possible even while going through treatment and even in some of the most dark circumstances, we want you to feel as well as possible. So, that's definitely, hopefully, where nutrition and nourishment can really lead you there. If you want to get into my newsletter, kind of get more information,  if you want to read a little more in terms of different blogs and different things of green juices, or what about fasting, or what about this, or what about that. I definitely have various articles that I posted on my blog which is basically kind of my newsletter because I send out a couple times a month. I don't spam you. I don't sell anything off, but just be one information. If you don't want information, that's perfectly fine, though. No need to tap in, but definitely, I'm happy to have you and happy to have you as part of the team to really help fight fight cancer. So, I will turn it back over to you all moderating and answer any questions that may have come up.

Christina: Thanks so much, Natalie, and we do have some questions coming in from the audience and there are many facets to this question. But one is, I love the idea, in general, of getting all your nutrients through food, but if you're on chemo and you don't have the greatest appetite, and then oftentimes when you're on chemo, you're also trying to keep your counts up to stay on schedule with your chemo. And so, supplements seem like they might be helpful in that situation. Yet, oftentimes medical team will say, "No supplements during chemo." And then, I also heard other things like, yes on vitamin D before surgery, but no on omega before surgery. So, there's kind of a bunch of different directions, I think, sometimes with the medical team. So, we wanted to get your general thoughts on supplements during chemo.

Natalie: So, I could, again, probably spend at least an hour, if not 8 hours answering that kind of big question but a few different pieces, and help me unpack it, as I may forget different aspects or I'll not remember all of them. One in terms of pre-surgery, we're looking at those things that are going to, of course, have a blood thinning effect. So, Omega 3 fatty acids, mushrooms, CoQ10, things like that, that we know have a blood thinning effect. We are going to pull 7 to ten days pre-surgery. Do we have to? We may not need to, but the last thing I'm going to be is the dietician who might cause some sort of a massive bleed. So, I'm going to say, yes, follow suit and pull things out for that 7 to ten days prior to surgery. There could be things like vitamin D, magnesium, probiotics that are not going to have a blood thinning effect in terms of surgery.

In terms of related more to chemotherapy, that again, a loaded question in terms of one, I don't think that I would say that, "Oh, chemo, supplements. Yes. No," It's what chemo are you taking? When are you taking that chemo? When would I suggest something? When would I not suggest something? And then what would I suggest and what would I not suggest for that particular chemotherapy protocol? Because there are trials to suggest in certain situations and that, for example, curcumin may help to, you know, be one that can even, and curcumin is the active component in turmeric. Maybe that helps to enhance the effect of cisplatin or melatonin has been shown to help enhance the effects of different kinds of chemotherapy or coenzyme Q10, does that end up actually using with adriamycin, or what about selenium and taxol. So, there are different ones that I want to kind of say, "Well, let's wait and kind of see for certain situations, would we want to consider some specific ones at that particular time?"

So, some things I think are definitely chemo-drug specific. I would also say that for some vitamin D, I think you could pretty much kind of do even everyday, not all have around the clock, but kind of even around the clock to a certain extent. I would say that certain things that have an antioxidant load just to be very careful. That doesn't have any contraindicated effect. So, I'm likely going to hold it. Oftentimes, I really like to look at the half-life of that drug and then multiply that half-life of the drug, even by five, to kind of see, yes, it's out of the system. We can add in something else, it's not going to be contraindicated. But typically, just for kind of a ballpark, I would say that oftentimes, you're going to hold things a day of treatment and a couple of days after treatment, if there are at all concerns. So, then, like, even omega-3s or CoQ10 or curcumin, I may hold it temporarily, right around that chemo, but if the chemo isn't going in every 3 weeks, I don't think you cannot have any chemo, or excuse me, any kind of supplements, for the whole 3-week time period. But I may hold it, right around that particular treatment.

There are also things, like omega-3 fatty acids, that may actually be able to enhance the effects. Like in certain chemo, it could be helpful, but I may hold it a little bit for those days, right around chemo, and then add it in thereafter. And that not only is, number one, to not interact with the chemo in a negative way. But at number two is. typically, if you don't feel well from a chemotherapy, not always, but frequently, day 2, day 3, are typically kind of that hardest day. So, if you're at all like, "Hmm, I don't really feel very well." I don't want to load you up with ten different supplements on day 2 or day 3 for that purpose, as well.

And then, this is another caveat piece, are we doing any kind of fasting around chemotherapy to have a greater effect on the cytotoxic cells, have a lesser effect on the normal cells? If that's occurring, then we have to also be mindful in terms of supplements because taking certain supplements on an empty stomach, that's a whole another element there. But I think in terms of counts are low, I would say, meaning kind of like of white count's low, we know like, okay, you need zinc to generate white blood cells, and if we test zinc, and zinc is low, I'd say, "Well, yeah, absolutely. Let's add some zinc to get the zinc higher, to get the white blood cells higher, so you can continue on your treatment as it is supposed to be designed," Because if the white counts go too low and you end up having to have longer breaks between chemo or you can't handle a chemo, the outcome is not going to likely be as favorable. So, there are times that we kind of measure and we see, okay, in your specific situation right now you are deficient in A or B, then those are appropriate to utilize at that particular time.

If we found though, hypothetically, with zinc and really zinc because, I'd say, zinc, red blood cell, that'll be a better marker because it's really kind of what's in that cells, zinc plasma. If you take zinc, you take measures using plasma. Did it get into there? Maybe it got in there, but it may not really be how much you're utilizing, but that's another in a question there. So, if that zinc, red blood cell level though was really, really robust and strong, do you need to have extra amounts? Probably not, right? So, that's where, too, like, even if we're looking at a more thorough assessment of different kinds of labs, and even looking at some of those specters or reports that we saw in terms of related inflammation and what if we looked at all of those different markers and we saw that somebody had robust values of, basically, A through P, but they were really low in Q, R, and S,  then, let's look at Q, R, and S and would those be appropriate? But we probably don't need to go from the 90th percentile or the 95th percentile, probably not going to gain any therapeutic value.

So, I'd wish it was more simple of, "Oh, yeah, take this, don't take this." But there's so many nuances that it's hard to say, everyone should do this or everyone should not do this, which I know is not as sexy of an answer, but it's, you know, harder to get to.

Ann: We've got to do some quick, we want to get to a couple of questions if we could get through them. Just, if you don't mind, kind of a rapid fire, let's go through a couple of them.

Natalie: Fire away.

Kara: We have another question from the audience. What are your thoughts on more extreme approaches to a diet like Keto?

Natalie: So, I would say two different things. So, I would say in terms of higher protein, that's different than keto, which I would say, is high fat, but actually kind of low-moderate protein. Ketogenic diet, I think, definitely for glioblastomas could be appropriate. For a lot of other types of cancers, I don't see it necessarily being necessarily the best mark. Again, unfortunately, there's not a lot there in terms of sarcomas. So, it's a little bit trickier and this particular situation, but I would say that the ketogenic diet, for example, for a prostate diet cancer, I think is the absolute wrong thing. I think what we're probably going to find is we need to get down to the molecular pathology of these different types of cancers and how are they being driven? And can we then see if it's being driven by glutamine? Are we careful there? If it's being driven definitely by glucose, what do we do there? If we can do something in terms of some of these areas, how do we help to kind of really look at some of these proteomics tests that many people are running to see chemo sensitivities and what can we learn from those, I think, to be able to give us a more personalized approach. So, I wouldn't be like, "Oh, yeah. Everyone should do keto. No one should do keto." Generally speaking, and I think it also depends on kind of where somebody is. But for a sarcoma, at this point, particularly pediatric, what I say,  "Oh, yeah,  you should definitely do sarcoma." I don't think the research is there. I would want to look at genomics. I'd want to look at kind of what we're finding in terms of some of those pieces, but I don't think it's just kind of an automatic piece. I do think we want to make sure you're getting in enough protein, but I don't think that there's an evidence that we have to have super high protein or we want it to be super low protein, and kind of look at bodyweight-wise, are we getting in a good amount there?

Christina: Natalie, I have two questions that I'm going to throw out. One is about mushrooms, specifically, I know you referenced them when you were talking about blood-thinning, but a question about their role in healthy diet and anti-cancer properties. And then, also the best mode of intake, powder, or a pill. And then, somewhat related, are there specific supplements that can be taken long term after treatment to reduce risk of future osteoporosis?

Natalie: So, in terms of the mushrooms. Therapeutic mushrooms, I'd say definitely are good in relationship to excellent for immune system and definitely a lot of anti-cancer research. Definitely some in terms of different kinds of mushrooms, like maitake, PSK Turkey Tails that have been shown to enhance the effects of certain chemotherapies and radiation therapy, as well. And those you could kind of vary whether it's maitake or turkey tail or cordyceps, and some of them have like an extra little bonus. So, this one's you know, chocolate is good in terms of skin or lion's mane in terms of cognition. From a supplement perspective, typically, they're done and tinctures or in capsules. Definitely, I'd say, you can go for food sources. Sometimes finding and eating an ample amount of maitake mushrooms is difficult and pricey. So, that can be a little sometimes with mushroom supplements, you want to make sure you're getting high quality because if they take mushrooms, and they just break them and put them on little capsules, is it really getting in true value? So, having a hot water extract want to be more valuable in terms of its potency. And there are different kinds of teas and just kind of mushroom, cooking kind of the herbs down, but typically, I'd say most are going for capsules or tinctures or eating them straight out. And even there, I would say I'd hold it a few days around chemo because I think, do you think there could be something. But I think it could be a
good thing to incorporate, as well.

And the second part of the question was related to long-term for osteoporosis, did I hear you say? Okay. D3, you know, Deflamin. Your bone-building nutrients are going to be D3, K2, magnesium, zinc, calcium. It's going to be a lot of different things. So, I think sometimes calcium gets overrated. It's like, "Oh, I have to have calcium for bone density." But I think it's kind of a balance of all of these different nutrients. In a perfect world, I'd say, let's measure them and see which things you particularly need, but I would say that I think, generally, kind of long-term, vitamin D3 is something we probably all need in our system on a daily basis. Magnesium is something that because it gets depleted with stress, it can be so beneficial in a lot of different ways. It's oftentimes a good thing to have in for most people. And K2, I would do a D3 that has K2 in it or I would opt for a multivitamin that has D3, K2, even little B vitamins, has the zinc in it, and maybe even has a little bit of magnesium in there, as well. But I think, in terms of do you have to have calcium? Maybe, maybe not. But I think the D3, K2, would be, absolutely, let's kind of get it in there. Unless, we knew your levels were just super robust and possibly, that magnesium and zinc typically to start because their counts tend to be lower to start because you just use it to generate white blood cells.

Ann: Okay, great. Well, we are out of time. We knew we were going to run out of time on this one. So, thank you so much, Natalie, that was [crosstalk] informative.

Natalie: You're welcome.

Ann: It was awesome. More information on this OsteoBites and all OsteoBites can be found on our YouTube channel,, or your podcast place. If you registered for this session, you're going to be emailed the final version of this Osteobites, as well as any of the links that we've discussed. So, if you didn't have your pen handy, you're going to be just fine. Next week, we get to have one of our favorite kinds of OsteoBites with one of our favorite people. It's a Q&A on osteosarcoma with Dr. Matteo Trucco of Cleveland Clinic, an expert in osteosarcoma. He's also on our scientific advisory board. He's leader of our scientific advisory board and a member of our board of directors. He'll be our speaker and our question answerer.

So, join us next week and bring your questions. Until then, thank you again, Natalie Ledesma, and our panelists, Kara Skrubis and Christina Ip-Toma. Thanks to our sponsor as well,  BTG Specialty Pharmaceutical. We get to do this because of their support which we are very grateful for. So, thanks, everybody. Thanks for joining today. We'll see you next time.


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