Nutritional and
Lifestyle Influences
on Multiple Myeloma
Providence Integrative Medicine
Program
Loch S. Chandler, ND, MSOM, LAc
July 7, 2006
What is Integrative Medicine?
A health care model that blends
individualized, evidence-based
complementary and alternative
medical modalities (CAM) with
conventional medicine in a patient
centered and whole-person
approach.
What is CAM?
CAM is Complementary and Alternative Medicine
Examples of CAM include:
·
Acupuncture and Chinese Medicine
·
Naturopathic Medicine
·
Nutrition
·
Botanical (Herbal) Medicine
·
Homeopathy (European medicine)
·
Reiki, Therapeutic Touch
·
Mind-body techniques: meditation, counseling
·
Massage
Conventional Medicine & Cancer
Common conventional therapies include:
Surgery
Chemotherapy
Radiation therapy
Biotherapies like genetic, hormonal and
immune therapies
Goals of Integrative Medicine in
Cancer Therapy
Mobilize the person's healing capacity immune
function, mind, body, spirit
Improve tolerance of conventional therapy by
decreasing side effects of radiation,
chemotherapy and surgery
Improve survival, decrease risk of cancer
recurrence
Improve quality of life issues (pain, sleep,
appetite, stress management, bowel problems
etc.)
Our Discussion Today
Nutrition
Lifestyle Choices
Supplements
Integrative Medicine treatments
· Acupuncture & Chinese Medicine
· Naturopathy
· Massage
· Mind/Body Medicine
Addressing side effects of conventional cancer
treatment with Integrative Medicine
Nutrition, Lifestyle and Cancer
Risk
We can't easily predict who will get cancer
Cancer has many causes, some are
outside of our control
People can do everything right (exercise,
diet, etc.) and still get cancer
Best to take an individualized CAM
approach
Focus on the best evidence available at
the time
How Nutrition and Lifestyle May
Affect Cancer Risk
Exercise and certain foods and food components
may:
Help the body break down cancer-causing
substances, detoxify
Decrease levels of hormones that can stimulate
cancer cell growth
Reduce blood supply to abnormal cells
Turn on, or better balance, the immune system
Improve the body's healing and recovery
capabilities
The Mediterranean Diet
A beneficial dietary pattern, and the model for
our diet recommendations:
High in vegetables, legumes, fruit, nuts,
unrefined (whole) grains, olive oil, fish
Dairy (mostly as cheese and yogurt)
Regular but moderate alcohol, and low in
meat, poultry, and potatoes
The benefits:
Studies on this diet show many benefits: less
obesity, heart disease and a 60--70%
reduced risk of cancer
The Mediterranean Diet
Lyon Heart Study (4-year follow-up):
More vegetables, fruit, legumes, grains, fish,
olive and canola oil
Less meat (especially preserved meats),
cream and butter
70% reduction in cardiac events
60% reduction of all cancers
deLorgeril, Arch Int Med, 1998;158:1181-87 (n=605)
Fish intake may help decrease risk (myeloma
n=287) Fritschi, Cancer Epid & Biomarkers, 2004;13(4):532-7.
The Mediterranean Diet and
Survival
Greek EPIC study
22,043 people, average 44 months follow up
Followed Mediterranean Diet: high in
vegetables, legumes, fruits, nuts, unrefined
cereals, olive oil, fish, dairy (mostly cheese and
yogurt)
Regular, but moderate, alcohol, low in meat,
poultry and potatoes
Trichopoulou, NEJM, 2003;348:2599-608 (n=22,043)
The Mediterranean Diet and
Survival
Compliance to a Mediterranean diet rated on a
0-9 scale (9 = highest compliance)
For every two point improvement in the diet,
there were 33% fewer deaths from heart
disease, and 24% fewer deaths from cancer
Also noticed a 60-70% reduction in cardiac and
cancer incidence
Unadjusted death rate was halved in those with
the addition regular exercise
Fruits and Vegetables
Many studies show that fruit and vegetables protect
against cancer
Vegetables seem to have more benefit than fruit
Fresh (raw or cooked) & frozen better than dried or
canned
Juices appear less beneficial -- more sugar/calories,
less total nutritional content, can cause weight gain
How much fruit and vegetables should we eat?
Minimum 5 servings daily; 9 is the goal!
Possible mechanisms for benefit: Low calorie density,
rich in nutients (vitamins/minerals), water & fiber
Powerhouse Vegetables
Cabbage (Brassica) Family Vegetables:
Arugula, bok choy, broccoli, Brussels sprouts, cabbage,
cauliflower, collards, cress, horseradish, kale, kohlrabi,
mustard greens, rutabagas, turnips, wasabi, broccoli
sprouts
Associated with lower rates of breast, prostate, lung and
colon cancer. Murillo Nutrition and Cancer. 2001;41:17-28
Reduces tumor incidence or delays onset in animal
models. Finley SE. J Ag Food Chem. 2000;49:2679-83. Murillo Nutrition
and Cancer. 2001;41:17-28
Indoles favorably shift hormone breakdown
pathways. Ca Epid, Bio & Prev. 2000;9:773-79
Induce enzyme detoxification of carcinogens
Fahey. Proc Natl Acad Sci USA. 1997:94:10367-72
More frequent intake may reduce risk for myeloma.
Brown, Cancer Causes & Control, 2001;12(2):117-25.
Powerhouse Vegetables
Onion (Allium) Family Vegetables:
Garlic, onions, scallions, leeks, chives
Improve body's ability to detoxify cancer-
causing chemicals, may help suppress tumor
growth
Associated with lower cancer risk. Steinmetz, Iowa
Women's Study, Am J Epid 1994;139:1-15. Nutr Onc, 1999.
Enhance carcinogen detoxification, and
are associated with suppressed tumor
growth Sengupta, 2004.
Brassica Family Vegetables
Powerhouse Fruits
Berries:
·
Especially raspberries and blueberries
·
High antioxidant levels
·
Reduce growth of colon and prostate cancer cells
Tomatoes:
·
Contain lycopene protective against prostate, lung,
colon and breast cancer
·
Cook tomatoes and eat with fat (i.e. olive oil) for better
absorption of lycopene
Whole Grains
Whole wheat, corn, oats, rye, hulled (not pearled) barley,
brown rice, millet, quinoa, amaranth, spelt, kamut...
Contain more minerals, vitamins, antioxidants, fiber
than refined grains (such as white flour, white rice,
most pasta, bagels, breads)
Whole grains are associated with:
Lower risk of breast, prostate and colon cancer, heart
disease and type 2 diabetes
Rose, Nutrition,1992;8:47-51. Jacobs, Nutrition and Cancer,
1998;30:85-96. Levi, Br J Cancer, 1999;79:1283-7.
How might they work?
Promotes lower insulin levels, which may reduce cancer
risk
Promote regular bowel movements and the removal of
harmful substances
Whole Grains
Legumes
Dried beans (pinto, kidney, white, lima,
black, red), lentils, split peas, black-eye
peas...)
Inexpensive and easy to cook
More than 2 oz (1/4 cup) per day of
legumes associated with reduced risk of
breast cancer
Legumes
How might legumes work?
High in antioxidants and micronutrients
High in fiber, which traps potential bowel toxins,
preventing reabsorption. AJCN, 1991;54:520S
`Healthy' weight loss, while maintaining lean
muscle mass
Lower insulin levels
Protease inhibitors have been found to decrease
rate of abnormal cell division and ability of
abnormal cells to expand into surrounding tissues
Lignans associated with lower breast, prostate,
and colon cancer risk. Bowen, Nutrition Today, 2001;144-158.
Ingram, Lancet, 1997;350:990-994
Dietary Fats - Fat Facts
The total amount of fat in the diet may not be a
risk factor for cancer or obesity - total energy
(calorie) intake may be more important
Rock, Cancer, 2001;91:25-34
Total dietary fat appears to NOT be a risk factor
for cancer, though some dietary fats appear to
be more protective against cancer than others
Not all fats are created equal good fats are
good for you! Wolk, Arch Int Med, 1998;158:41-45
Healthy Fat Choices
Omega-3 fats (EPA, DHA, and ALA [alpha linolenic
acid]) found in fish, flax, canola,tree nuts, particularly
walnuts, and some green vegetables
Fish and olive oils tend to be anti-inflammatory
Olive oil (Extra Virgin is best) appears to be protective,
and countries in which olive oil is the predominant fat
have lower rates of cancer
Trichopoulou, Ca Epid Bio & Prev, 2000;9:869-73. Wolk, Arch Int Med,
1998;158:41-45.
Raw nuts are `healthy fats'
Butter is the best `solid' fat, used in moderation.
Consider "Better Butter": combine ˝ butter and ˝ olive oil.
Healthy Fat Choices
Healthy Fat Choices
Most studies suggest fish is protective
against cancer, reduce tumor growth
Hardman, J Nutr, 2002;132:3508S-3512S
Omega 3 Fatty Acids (most studies use
fish oil) are associated with:
Less cancer cachexia (wasting)
Gogos, Cancer, 1998;82:395-402
Improved cancer survival with radiation
therapy (with bioflavonoids in melanoma)
Gramaglia, Anticancer Res, 1999;19:5583-56
Fewer infections
Tepaska, Lancet, 2001;358:696-701
Fats to Limit
Omega-6 fatty acids found in: soy, corn, cottonseed,
sunflower, safflower, peanut
High in Western diets, may be associated with more
cancer.
Lee, Ann Rev Nutr, 2000;29:221-48. Ip, Am J Clin Nutr, 1997;66(supp):1523S-9S.
Current evidence does not suggest that high intake of meat
causes cancer, but countries with low rates of cancer tend to
eat less meat. Lee, Ann Rev Nutr, 2000;29:221-48. Willett, Cancer
cer Biology,
1998;245-253.
The data concerning dairy foods are similarly inconclusive,
though cheese and yogurt are probably the best choices.
Potter, ed. Food, Nutrition and the Prevention of Cancer. AICR, 1997.
Keeping meat intake low allows more room for
protective foods: like vegetables, fruit, beans, whole
grains
Dietary Fats - Recommendations
Extra virgin olive oil is the best general purpose oil,
canola & soy are reasonable second choices
Minimize use of other vegetable oils
Butter is ok if used sparingly
Enjoy raw nuts in moderate amounts
Limit portion sizes of red meat
Emphasize cold-water fatty fish (wild salmon, trout,
mackerel, sardines, tuna)
Avoid hydrogenated and partially hydrogenated oils
(Trans-fats), oils heated to smoking
Flax
Flax meal (whole ground flax seeds) is
preferred over flaxseed oil (especially in men)
Contains lignans, associated with less breast,
prostate, and colon cancer
Flaxseed are high in fiber and rich in healthy
omega-3 fats
How flax might work:
Encourages normal cell differentiation
Antioxidant
Reduced supply of blood to tumor (reduced
angiogenesis). Kurzer, Ann Rev Nutr, 1997;17:353-81
Flax
Basic Diet Recommendations
5-9 servings daily of a variety of fruits and vegetables
Whole and not juiced is preferred
red and orange vegetables, berries, cabbage family foods,
onions, garlic, mushrooms
Choose whole grains over refined grains...at least 1X per day!!
Include beans/legumes, oats, rye, corn, millet, quinoa, barley,
brown/wild rice...
Limit simple/refined sugar
Choose olive oil (extra virgin is best) as your main cooking oil,
butter is ok if used sparingly
Canola, soy are second choices, minimize other vegetable oils.
Butter is probably best `solid' fat, use in moderation (make Better
Butter!)
Basic Diet Recommendations
Limit portion sizes of red meats, avoid processed meats
Enjoy fish 2-3 times per week (salmon, tuna in water,
halibut, herring, sardines)
Saw no relation of red meat intake and myeloma
(n=120) Tavani, Internat J Can, 2000;86(3):425-8.
Regularly enjoy cooked dried beans, peas and lentils
Enjoy raw nuts...in moderation (ground flax seed,
almonds, walnuts, filberts, pecans, Brazil nuts, etc)
Achieve/maintain a healthy weight (healthy BMI)
Limit alcohol intake to 3-5 drinks per week
Basic Diet Recommendations
Avoid:
Refined flours: low in nutrients, low in fiber,
high in calories
Refined sugars, juices: high in calories.
· Use less sweets overall, substitute honey, maple
syrup instead.
Artificial sweeteners: especially food with
high fructose corn syrup (HFCS)!!!
Partially hydrogenated oils: contain "trans"
fats, which are associated with more cancer,
heart disease and diabetes.
· In most restaurant food, commercially fried foods,
breads, packaged crackers, packaged foods.
Basic Diet Recommendations
Avoid (continued):
Processed or cured meats (e.g. lunchmeats,
bacon, ham)
· Associated with more cancer, heart disease and
diabetes Willett, JAMA, 2005;293:233-4.
Foods to Avoid
Green Tea
Appears to inhibit the growth of many cancers:
colon, breast, lung, prostate, melanoma, and
leukemia
Does not appear to inhibit non-cancerous cells
Anti-angiogenic:
Inhibits VEGF Sartippour J Nutr, 2002;132:2307-2311.
Caffeinated appears MORE beneficial
Green and black tea have 10-25% of the
caffeine of coffee
Recommendation:
Aim for 3-12 cups (20 - 72 ounces) a day
Green Tea
Can improve insulin sensitivity when
used continuously. Kao, Mol Nutr & Food Res,
2006;50(2):188-210.
In vitro studies have shown
epigallocatechin (EGCG) induces
apoptosis in myeloma cells. Nakazato, Clin Can
Res, 2005;11(16):6040-9.
Also reduces hepatic glucose
production in DEX-treated hepatoma
cells. Waltner-Law, J Biol Chem, 2002;277(38)34933-
34940.
Dexamethasone
Increases serum glucose concentration
The use of glucocorticoids can worsen pre-
existing blood sugar issues (i.e. diabetes, chronic
illness) and precipitate new steroid-induced
diabetes (SDM)
Found to also decrease serum thyroid hormone levels.
Affect pancreatic beta cell function (insulin)
Alters carbohydrate metabolism and lipid (fat)
metabolism...increasing lipid levels
Dose amount and duration may be most
important as a cause of SDM. Raul, Arch Med Res,
1998;29(3):259-62.
Dexamethasone
Tests: blood sugar values (before and 2 hours
after a big meal), hemoglobin A1c (HA1c)
Herbs may help
Inula racemosa (Puskarmool) and Gymnema
sylvestre extracts found to decrease serum blood
sugars in SDM (DEX-treated) mice
Influencing factors: age, dose amount and
duration
If have a history of shingles or chicken pox,
consider Acyclovir as a preventative
Consider a preliminary bone density test if
osteopenia is a risk factor
Diabetes
As weight increases so does risk of diabetes.
An increase in BMI from 25-35 is a 40-90 fold
increase in risk of diabetes.
Consider macronutrient composition, energy
density and portion size. U.S. Dept of Health, Dietary
Guidelines Advisory Meeting, Sept., 2005.
Physical activity is vital (weight bearing, to
tolerance).
Short bouts have benefit...total 30-60 min per
day.
An individualized plan is best...each one's
needs are different.
Meditation even helps with type II DM. The
Oregonian July 5, 2006, Kaiser Study, Dr. Charles Elder.
Diabetes
The number of people worldwide with Diabetes
has grown from 30 million to 230 million in the
last 20 years
June 10, 2006 International Diabetes Federation
7 of the 10 countries with the highest numbers
are in the developing world
Juices and other sweet drinks are significant
contributors to obesity and insulin resistance
Colon cancer more likely with higher fasting
glucose JAMA, 2005;293:194-202
Insulin resistance also shown more likely with cancers
of the pancreas, esophagus, liver, cervix and breast
Diabetes
Nurses Health Study:
83% less Heart Disease, 91% less Diabetes:
Walked 30 minutes per day
Increased fruit, vegetables, whole grains, fish
Reduced sweets, refined carbohydrates and partially
hydrogenated oils
Reduced BMI to below 25 (getting a waist) Pan, Am J Epid,
2004;159(3):259-68.
Consumed less than ˝ glass of alcohol per day
Didn't smoke
NEJM, 2000;343:16-22; NEJM, 2001;345:790-97
Mediterranean diet and exercise are associated with less
insulin resistance and lower inflammatory markers (Reuters
Health, March 8, 2006, reg C-RP, Stanford-Kaiser Heart, Health and
Heredity Study; n=911 for 1 year).
Glycemic Index (GI)
The Glycemic Index scale ranks carbohydrate-rich
foods by how much they affect blood glucose levels
compared to glucose or white bread
The speed at which food increases blood sugars is
the Glycemic Response (GR)
Influenced by how much is eaten, how the food is
processed and even prepared
High GI ratings (>70) raise blood sugars quickly =
BAD!
Low GI ratings (<55) raise blood sugars slowly
Low ratings are better for many reasons!
Glycemic Index
Low Glycemic Index Foods:
Skim milk, plain yogurt, apple, sweet potato,
oatmeal, hummus, nuts, cherries, broccoli, lettuce,
yams, Chana dal, green peas, lentils, pinto beans
Medium GI Foods:
Banana, raisins, popcorn, brown/wild rice, rye bread
High GI Foods:
(HFCS), Watermelon, white bread, dried dates,
cheerios, baked white potato, parsnips, corn flakes,
bagels, french fries, ice cream, potato chips, beets,
scones, gatorade
Sources: lowglycemicdiet.com, diabetes.ca
High Fructose Corn Syrup
In many foods: soda, processed/packaged
foods, canned fruits/jellies, dairy products.
Try to avoid due to metabolic effects
Relationship with increase in U.S. obesity
Reduces glycemic response
Does NOT stimulate insulin secretion
No "full" feeling generated. Bray, Am J Clin Nutr, 2004;79:537-43.
May make foods "tastier" but certainly not
healthier
Natural fructose is not the issue
Glycemic Index
Base your food choices on overall nutrition
Choose a variety of foods from all food groups
Watch portion sizes (larger meals increase
blood sugars greater)
Check blood glucose levels before a meal
and 2 hours after
Eat at regular times
Limit sugars, sweets, refined/processed
foods
Glycemic Control
Glycemic control:
Hyperglycemia and insulin resistance are common
in critically ill patients, as a result of stress-induced
insulin resistance and increased glucose production
or gluconeogenesis
Study looking at attaining normoglycemia in surgical
ICU patients (n=1548) found reduction in
inflammation, quicker recovery, less secondary
infections and anemia, and decreased likelihood
of polyneuropathy by 44% (28 vs 52%) Van den
Berghe, Crit Care Med, 2003;31(2):359-366. Van den Berghe,
NEJM;345(19):1359-1367.
Glycemic Control
Another study found balancing blood sugars
normalized mitochondrial function. Vanhorebeek,
Mech of Dis, 2005;365:53-59 (n=1548). (see ALA)
Cell functions require energy or ATP
If mitochondria don't work...affects all organs
and tissues
Structural changes in hepatocyte
mitochondria were restored with improved
blood sugar control
Preventing hyperglycemia helps mitochondria,
which helps the liver and all cells...nerves
Fiber
Fiber generally reduces: glycemic index and
load, obesity, insulin resistance, transit time and
can help bind carcinogens
Insoluble fiber (e.g. wheat bran)
Decrases bile acids
Increase butyric acid production, and other SCFA
Soluble fiber (e.g. oat bran, fruit and vegetables)
Decreases postprandial blood sugar and insulin levels
High in micronutrients and antioxidants
Fiber
Butyric acid is a fermentation byproduct of
some fibers.
Suppresses growth of colon cancer cells
Regulates cell adhesion
Inhibits proto-oncogene expression Dietary Fiber
in Health and Disease, 1996.
Requires presence of probiotics, or
beneficial intestinal `microbiota'
Chromium
Many studies with a variation in results
Appears to help balance blood sugars, increase insulin
sensitivity and improve carbohydrate and lipid metabolism
in DEX rat studies. Kim Metabolism: Clin & Exp, 2002;51(5):589-94
Corticosteroids may increase urinary loss of Chromium.
Ravina, Diab Med, 1999:16(2)164-7
Chromium appears to increase insulin binding to cells,
insulin receptor number and activates insulin receptor
kinase leading to increased insulin sensitivity. Anderson, Diab
& Met, 2000;26(1):22-7
Relatively safe and inexpensive
Recommendation:
200-300 mcg 2 times per day (with two largest meals of
the day) or
1-3 tsp of Brewer's yeast (selenium too!)
Lifestyle: Benefits of Exercise
Reduced cancer incidence, may reduce risk of
recurrence and improve survival
Improves mood, sleep, immune function, weight
regulation, productivity
Decreases blood pressure and risk of
developing Alzheimer's
During cancer treatment:
Improves energy, mood, quality of life, sleep
Reduces nausea Friedenrich Clin J Sports Med
1996;6:237-44. Segal J Clin Oncol, 2001;19:657-65.
Improves blood counts Dimeo Blood, 1997;90:3390-94.
Lifestyle: Exercise
Study: 707 nonsmoking, physically
capable Honolulu men 61-81 years old.
12 year follow up
Mortality halved in those who walked >2
miles per day vs. <1 mile per day, results
were `dose related'
Cancer deaths were 57% less
NEJM, 1998;338:94-99
Lifestyle: Exercise
Recommendations:
Start low, work up to 30-45 minutes daily, 5-7
days/week
Break up activity into shorter sessions
The world is your gym: stairs, sidewalks,
chopping wood, parks, pools, puddles, hula
hoops, jump rope...
Manual labor and vigorous recreational exercise are
the most beneficial. Thune, NEJM, 1997;336:1269-75
Buy a pedometer and aim for 10,000 steps daily
Any exercise is better than no exercise!
Exercise and Myeloma
Study found a person's beliefs and social
context were very important with myeloma
patient's exercise regimen to help reduce fatigue
with treatment Coon, Onc Nurs For, 2004;31(6):1127-35
Exercise during active & off-treatment were
positively associated with QOL. Jones, Supp Care in
Cancer, 2004;12(11):780-88 (n=86).
Exercise appears to help decrease fatigue and
mood disturbance and improves sleep (n-24)
Coleman, Cancer Nursing, 2003;26(5)410-409.
Incorporate aerobic and strength/resistance
training...be flexible and simply and use a
support system Coleman, Clin J Onc Nurs, 2003;7(5):529-34.
Lifestyle: Exercise
Will help lose weight.
Obesity is associated with:
increased insulin levels ("insulin resistance")
tendency to Type 2 (Adult Onset) diabetes,
heart disease, breast and colon cancer
Higher insulin can spur abnormal cell
division Norman AICR, 2001
Lifestyle: Exercise
Exercise will help in many ways!
Be honest about your priorities, set goals
Schedule exercise...but be flexible and simple!
Plan food, don't bring junkfood home, limit meals
out
Make changes gradually...to the level that does
not fatigue you
Get the whole family involved
Use buddies, partners, dieticians, physical
therapists...your Support System!
It takes time...what are you going to say "no" to?
What About Supplements?
Studies show nutritional supplements can benefit
and harm. Potter, Ed., Food, Nutrition and the Prevention of Cancer
AICR, 1997. Labriola Oncology, 1999;13:1003-12. L'Esperance. Breast
Cancer Res Treat, 2002;76:137-43. Prasad JACN (Supp), 2001;450S-63.
Vitamin C may interfere with Velcade according to a
cancer cell study. Zou, Clin Can Res, 2006;12(1):273-80.
However, frequent intake from food and supplements
was found to be protective (not associated with
Velcade). Brown, Cancer Causes & Control, 2001;12(2):117-25.
Supplements should be chosen with great care, and with
consideration of evidence, cost, and complexity of dosing
routine
Best to take an individualized approach based on situation
and needs
Seek professional advice
Supplements?
Higher nutrient intake from whole
foods is associated with better cancer
outcomes
Nutritional deficiency is common
during cancer treatment
Animal studies suggest supplements
improve outcomes
Human data is very limited Kucuk Integrating
Nutrition into your cancer program Mar/Apr, 2002.
Cancer and Selenium
Study (RCT): Selenium 200 mcg per day
vs. placebo (n=1,312) Clark JAMA 1996;276:1957-63. British J
Urology 1998;81:730-34.
Source was Brewer's yeast, 6 ˝ yr
followup
50% reduction in cancer deaths; 37% less
lung, colon and prostate cancer
Also found in: garlic, onions, whole grains,
Brazil nuts, nutritional (Brewer's) yeast
and mushrooms
Peripheral Neuropathy (PN)
Most commonly described as numbness,
pain (sharp, stabbing, burning or ache),
tingling and weakness
Mostly recognized in fingers and toes
Affects sleep; often worse at night
Affects quality of life
Very common in people with nutritional
deficiencies, cancer, those receiving
cancer treatment and diabetics
Peripheral Neuropathy
Cause?? Need to consider:
Nerve compression (carpal tunnel syndrome)
Neurotoxicity of treatment (chemotherapy
and/or radiation
Metabolic and nutritional deficiencies, which
can exacerbate oxidative stress (leading to
mitochondrial dysfunction and ischemic
nerve damage)
Results in axon loss and demyelination,
which causes a reduction in conduction
velocity and a decrease in amplitude
Peripheral Neuropathy
With Multiple Myeloma, neuropathy may
be mediated by an immune response
(anti-neuronal antibodies)
One-third of patients show signs of
peripheral neuropathy, which usually
precedes diagnosis, but only 5-10%
develop symptoms
Allopathic Treatments for PN
Often include:
Non-steroidal anti-inflammatories
Tricyclic anti-depressants
SSRIs
Anticonvulsants, anti-arrythmics, nerve blocks,
implant devices
Medications can result in side effects that
include neuropathy
Neuropathy is one side effect of statin drugs
(cholesterol-lowering medication)
Our GOAL...prevention is key!
History of PN
Began with studying `beriberi' in the 19th
century and polished rice
When the vitamin-rich husk was removed,
deficiencies occurred (especially Vitamin B1-
thiamine)
Also occurred in other nutritionally
deficient people: POWs, alcoholics,
Cubans
Strong correlation to nutrition,
celiac/sprue, dysbiosis, low stomach acid,
B12 deficiency, etc.
Peripheral Neuropathy
Glutamine: 10 gms 3 times per day after
paclitaxel significantly reduced severity of
neuropathy (Paired cohort study, n=35, Clinical Cancer
Research, 2001;7:1192-7).
Evening Primrose Oil: 480 mg per day J Nutrition,
2003;133:3785S-3793S.
Alpha Lipoic Acid: 800 -1,800 mg per day
Vitamin B6: 50 mg 2 times per day
Vitamin B12: 1 mg per day (oral or injection)
Vitamin E: ???
Acupuncture:
Water:
Peripheral Neuropathy
Some benefit shown with calcium and
magnesium supplementation also
Alpha Lipoic Acid (ALA):
Anti-oxidant (universal anti-oxidant)
Enhances glucose uptake in type 2 DM
Improves nerve damage, and reduces
associated pain
Found to increase apoptosis in human colon
cancer cells. Wenzel, 2005;10(2):359-68.
Used for oxaliplatin-induced neuropathy.
Cersosimo, Ann Pharmaco, 2005;39(1):128-35.
Peripheral Neuropathy
Vitamin B12:
Deficiencies are more likely due to absorption
difficulties rather than a dietary deficiency
Deficiencies may be more likely in people taking
proton pump inhibitors (PPIs) for reflux/heartburn
(Prilosec, Prevacid); also H2 antagonists (Tagament,
Pepsid, Zantac) and Metformin (for diabetes)
Found primarily in fish, meat, poultry, eggs, milk and
milk products and fortified foods
Necessary for the production of red blood cells and
health of the nervous system Source: dietary-
supplements.info.nih.gov
Tests: CBC (MCV), MMA (methylmalonic acid)
Peripheral Neuropathy
Vitamin E (RCT): 31 total patients
Receiving 6 courses of cumulative cisplatin,
paclitaxel, or regimens.
Two Groups:
Group I (n=16): oral Vit E, 600 mg per day
(during chemotherapy and 3 months after)
Group II (n=15): controls (no supplements)
Neuropathy incidence of 25% in Group I,
73.3% in Group II (p=0.019) Neurology. 2005 Jan
11;64(1):26-31.
Recent research indicates caution. Miller, Ann Int
Med, 2005;142(1):37-46.
Peripheral Neuropathy:
Acupuncture
43% of 77 patients in one study used CAM
therapies
Used: vitamins (35%), acupuncture (30%),
magnets (30%), herbal remedies (22%), and
chiropractic manipulation (21%)
27% (17 people) found symptoms of neuropathy
were improved by these therapies.
Small number of patients involved in the study
and multiple modalities were used. J Neurol Sci, 2004
Mar 15;218(1-2):59-66
Peripheral Neuropathy:
Electroacupuncture (EA)
HIV patients with drug/treatment-induced
neuropathy
7 patients received EA for 20 minutes per
day for 30 days
All 7 reported improvement...less pain, felt
better, increased physical strength
Small study J Alt Comp Med, 1999 5(2):135-42
Vitamin D
Inverse relationship between Vitamin D and
cancer risk (colon, breast, prostate, lung,
leukemia)
Commonly deficient in Northwestern U.S.
Enough time spent outdoors??
Shown to have direct inhibiting effects on cancer
cell growth.
800 i.u. (international units) per day is a
reasonable and safe amount. Hansen, Frontiers
Bioscience 2001;6:d820-848.
Vitamin D
Deficiency is associated with an increased risk
for cancer, especially GI cancers (April 5, 2006, J of the
NCI).
Health Professionals Follow-up Study.
Analyzed 25-hydroxy-vitamin D [25(OH)D] of
1,095 men (as representative of 47,800)
Found would have 17% lower total cancer
incidence, 29% reduction in cancer deaths with
25(OH)D levels of 25 nmol/L (about 1,500 i.u.
per day). J Natl Cancer Inst. 2006;98:428-430, 451-459.
Curcumin
May act by inhibiting cyclooxygenase-2
(COX-2) isoenzyme and inhibit
prostaglandin E2. Lev-Ari, J Soc Integ Onc, 2006;4(1):21-6.
In other words, anti-inflammatory
Recommended dose: 500 mg three times
per day
Curcumin
A lot of studies...not a lot of human studies
Most studies are cell studies (in vitro), mouse/rat
studies
Contraindications:
avoid in patients with bile duct obstruction or
cholelithiasis (gallstones)
avoid in patients with gastric or duodenal ulcers, or
with hyperacidity disorders
Caution:
can inhibit platelet aggregation
may inhibit cytochrome p450 detoxification enzymes
(rat studies)...'inhibit' means could make more
cytotoxic by slowing degradation.
Interference with Therapy
Using nutrients, herbs and chemotherapy
together may increase or decrease the
effects of all
May increase toxicity or decrease
effectiveness
Interference mostly occurs due to altering
detoxification routes in the liver (cytochrome
P450 isozymes)
See the attached list
Chinese Medicine
· 2500+ year old system of medicine
Includes therapies such as:
Acupuncture
Chinese herbal formulas
Moxibustion
Cupping
Bodywork/Shiatsu (similar to massage)
Diet and lifestyle changes
Acupuncture
Use of sterile, (typically) single-use
needles to optimize flow of energy (Qi) in
the body
Used to treat pain, injury, illness
Promotes relaxation, deep rest
Stimulates release of helpful hormones
and neurotransmitters
Fatigue: Acupuncture
Phase II study, Memorial Sloan Kettering
Cancer Center in New York
31 patients at least 2 years post
chemotherapy treatment for breast cancer
Two Groups, received acupuncture 1 or 2
times per week for 4 weeks
Mean improvement after acupuncture
31.1%
Minimal difference between groups J Clin
Oncol, 2004 May 1;22(9)1731-5 (n=31)
Nausea: Acupuncture
Numerous studies showing the benefit of
acupuncture or electroacupuncture in
reducing nausea and/or anti-nausea
medications. NIH Consensus Statement, 1997 Nov 3-5;15(5):1-
34. JAMA, 1998 Nov 4;280(17):1518-24. Palliat Med, 2002
May;16(3);235-9. J R Soc Med, 1996;89(6)303-11. Am J Obstet Gynecol,
2002;186:S244-7. JAMA, 2000 Dec 6;284(21):2755-61. Cochran
Database Syst Rev, 2006 April 19(2):CD002285.
Most studies use PC-6 (Pericardium-6)
Always consider ginger too
Naturopathy
· Blends ancient, pre-modern, and
biomedical philosophies and therapies
· Roots in European "Nature Cure" diet,
hydrotherapy, therapeutic fasting, herbal
medicine, lifestyle changes
· NDs practice as primary care providers, or
as specialists in natural therapies
Benefits of Massage
Gentle therapeutic touch, tailored to patient's
situation
Benefits: relaxation, decreased pain, better
sleep, release of tissue and scar tightness,
increased range of motion
Patient experiences of massage:
· Provides a positive physical experience during
cancer treatment
· Something positive to look forward to during
cancer treatment
Massage Therapy
Massage therapist should have special
training for treating people with cancer
Treatments should be modified for:
Fragile tissue
Medical devices like PEG tubes and IVs
Patients with lymphedema, or at risk of
lymphedema
Massage should decrease pain, nausea
and fatigue, not make it worse
Mind-Body Therapies
Examples:
Individual and family counseling
Support groups
Mindfulness-based stress reduction
Art therapy
Music therapy
Guided imagery, meditation
Hypnotherapy
Benefits of Mind-Body Therapies
Assist with stress management and relaxation
Become a partner in your healing
Activate your body's own natural healing ability
Help family members with issues around the
cancer diagnosis
Connection to other people living with a cancer
diagnosis
Research has shown that use of guided imagery
before surgery results in decreased blood loss
and quicker healing
Integrative Medicine for Treatment
Side Effects
Individualized approach works best
Treatment depends on diagnosis and situation
Help with:
Peripheral neuropathy
Pain
Fatigue
Weight loss/muscle wasting (cachexia)
Diarrhea, nausea & vomiting
Mouth sores (mucositis)
Lymphedema
Skin redness and irritation from radiation
Insomnia
Using Integrative Medicine
Choose a qualified practitioner:
Licensed Naturopath (ND) or acupuncturist (LAc) with
a degree from a 4-year accredited school
Have experience treating people with cancer
Massage therapist (LMT) with cancer training
Counselor or Social Worker (LCSW, MSW, LPC):
· Masters level, licensed
· Graduate of accredited mind-body program (for example:
certification from The Center for Mind-Body Medicine, the
Harvard Mind-Body program)
· Experience with chronically ill patients
Interview prospective practitioners
Are you comfortable with them
Using Integrative Medicine
Tell your oncologist about your use of
alternative treatments
Tell your conventional care providers
about all supplements, vitamins and herbs
you are taking
Ask your Integrative Medicine practitioner
to consult with your oncologist and vice
versa
Providence Integrative Medicine
Services provided:
Acupuncture
Naturopathic Medicine
Massage
Nutrition diet counseling, therapeutic foods,
nutritional supplements
Mind/Body therapies, counseling, support
groups
Public lectures on Integrative Medicine and
cancer care
Providence Integrative Medicine
Clinics
Westside
Eastside
9155 SW Barnes Rd.,
5251 NE Glisan St.,
Suite 331
Suite 300A
Portland, OR 97225
Portland, OR 97213
Phone: 503-216-0246
Phone: 503-215-3219
Located in the East
Located east of the
Pavillion (Medical
Providence Portland
Office Building) next
Medical Center on the
to St. Vincent Hospital
corner of 53rd St.
Come See Us
Integrative medicine is individualized
medicine
If you would like help applying this
information to your situation, please make
an appointment to see one of our
practitioners for an individual consultation
For licensed and credentialed
Naturopathic physicians outside of Oregon
go to www.naturopathic.org
"Striving to meet the health needs of
people as they journey through life."
Mission Statement, Providence Health System
Books
The Mediterranean Diet Cookbook, Nancy
Harmon-Jenkins.
Body Mass Index (BMI) Calculation
Aim for a BMI < 25
Calculate your weight in kilograms (kg):
Take your body weight in pounds and divide by 2.2
(e.g. 150 lbs / 2.2 = 68.18 kg)
Calculate your height in meters:
Take your height in inches and multiply by 0.025 (e.g.
5'9" = 69" X 0.025 = 1.725 m)
Divide your weight in kg by height in m, then
divide by height in m again (e.g. 68 / 1.725 =
39.47 / 1.725 = 22.8 BMI)
A BMI of 18-25 is considered a healthy weight.
Calorie Counting for a Healthy
BMI
Walking 1 mile per day = 100 calories = 10 lbs
loss/year.
Pace while on phone...4 cal/min (10 min per
day) = 4 lbs loss per year.
8 ounces of water vs. juice daily, saves 90
calories per day...and 9 lbs per year.
Remember...increase exercise and vegetables and
reduce portion size
Reduce refined carbohydrates (pasta, bread) and
partially hydrogenated oils
Drink Water!!
Serving Sizes
All of the following are 1 serving size:
1 medium piece of fruit
˝ cup chopped fruit
1 cup of raw leafy vegetables
˝ cup chopped vegetables
Remember:
Fresh (raw or cooked) and frozen are better than
dried or canned
Juices may be less beneficial: more in calories, less
total nutritional value/content, increased weight gain.
Healthy Fats
Omega 3 Fats: EPA, DHA and ALA
EPA and DHA: found in oily fish such as wild
salmon, trout, mackeral, sardines and tuna
ALA: found in flax seed oil or meal, canola
and soy oils, some green vegetables and tree
nuts (especially walnuts).
Microwaving?
Cooking methods can influence important
food nutrients, such as phenols
Many studies focus on phenol content of
food before and after cooking
Microwaving appears to decrease phenol
content (up to 97%)
It is best to steam, baking and boiling are
intermediate
Further studies are needed J Sci Food Agric,
2003;83:1511-16
Celiac
Gluten-free foods:
Corn, potatoes, rice, tapioca, amaranth,
arrowroot, millet, quinoa, sweetpotato, yams,
taro, teff, etc.
Tests (need to be eating wheat/gluten):
Anti-gliadin antibody
Salivary immunoglobulin A (sIgA)
Tissue transglutaminase
More information:
www.csaceliacs.org/gluten-grains.php
American Cancer Society
Guidelines
5-9 servings of a variety of fruits and vegetables
per day (vegetables better; fresh or frozen better
than canned or dried)
Choosing whole grains over refined grains
Limit red meats, especially high fat, processed,
and preserved meats
Achieve/maintain a healthy weight
30-45 min of movement/exercise per day
Limit alcohol consumption CA, Cancer J Clin, 2002;52:92-
119.
Interference with Therapy
Herbs that inhibit CYP
enzymes:
Hypericum (St. John's
Trifolium pratense (red clover)
Wort): avoid with all
Grape seed: caution with high
chemotherapy
doses
Echinacea
Matricaria chamomilla
(chamomile)
Ginseng
Gingko
Piper methysticum (
Silymarin (milk thistle)
Hydrastis canadensis (
Quercitin
Glycyrrhiza glabra (licorice)
Valerian
Uncaria tomentosa (Cat's
claw)
Grape fruit
Interference with Warfarin
(Coumadin)
The following items may interfere with blood thinning
medications:
Asian Ginseng
Dan Shen
Devil's claw
Dong quai
Feverfew
Garlic
Ginger
Gingko biloba
Reshi
Vitamin K
Dan Shen
Eat how you would eat, and let your Coumadin levels be
adjusted to your diet