Diet & Physical Activity in Cancer Prevention & Survivorship: The Science and Practice. 

We shouldn’t be surprised that program time ran out before we could get to anywhere near all the questions from such a large group on an exciting and ever-evolving topic like this. We’ll be looking at how we can address these questions in a variety of formats in the future.  Meanwhile, today I’ll get a start and answer a few of the many excellent questions posed….

In the webinar, Cheryl Rock, PhD, RD, a renowned researcher leading major studies on promoting the health and wellbeing of breast cancer survivors, provided insights to help participants (mainly health professionals) interpret previous studies on diet, physical activity and cancer.  Dr. Rock shared some of the details of the studies that are key to understanding their results. As I often say, you can’t go by a study’s title, the media blast about it or even its abstract (brief summary) and think you’re getting the whole story.

I presented the second half of the webinar, reviewing research behind current recommendations to reduce cancer risk and their practical implications.

So, now to a few of your questions….

What foods support the colon bacteria that seem to be cancer-protective?

In the webinar, I talked a bit about the booming field of research involving how the trillions of bacteria in our gut may help reduce cancer risk.  A strong colony of healthy bacteria seems to promote immunity and prevent growth of bacteria that produce cell-damaging substances associated with inflammation. These health-promoting bacteria produce substances that protect colon cells, and in many cases are absorbed out of the colon and circulate through the body providing apparent cancer-protective benefits.

♦ Certain types of carbohydrate are used to produce a fatty acid called butyrate, which seems cancer-protective in the colon. Bacteria use and are nourished by inulin (which we get from onions, garlic, asparagus, Jerusalem artichokes, bananas, chicory and artichokes) and the fermentable dietary fiber and resistant starch you get from dried beans and peas and certain whole grains.

♦ Compounds called lignans from beans, whole grains, nuts and seeds are converted to a form that can be absorbed. As they circulate through the body, they seem to have protective effects on estrogen hormones and anti-cancer effects on cell metabolic pathways.

♦ Phytochemicals, such as the glucosinolates from cruciferous vegetables, and ellagic acid from fruits and walnuts, are converted, respectively, to active and absorbable isothiocyanates and urolithins. Laboratory studies suggest they may reduce cancer as antioxidants and through direct effects.

♦ Diets high in red meat seem to inhibit growth of health-promoting bacteria and  stimulate growth of bacteria that promote production of sulfate compounds that damage colon cells.

For people who have lost healthy bacteria due to certain health conditions, surgery or particular medications, probiotics — food and supplements that provide healthy types of bacteria — seem to help. These include fermented dairy products (yogurt, cheese, and kefir), sauerkraut, kimchi (a spicy Korean condiment made from fermented cabbage) and the fermented soy products miso and tempeh.  However, studies show that probiotics alone don’t change gut bacteria long-term nearly as much as when other dietary choices support growth of healthy bacteria, and their impact on cancer is not clear at this time.

What role does a gluten-free or lactose-free diet play in reducing cancer risk?

For those who have celiac disease or other gluten sensitivities, strict adherence to a gluten-free diet seems to be vital to protect the colon from damage that could increase risk of cancer.  However, for others, research shows no advantage to avoiding gluten, and whole-grain foods containing gluten can be good sources of a variety of antioxidant phytochemicals that may be cancer-protective.  Research also shows no reduction in cancer risk by avoiding foods with lactose (dairy products) by those who are not lactose intolerant.  In fact, quite a few studies link consumption of dairy products with lower risk of colon cancer.

Is grass-fed beef included in the recommendation to limit red meat?

Yes. Grass feeding increases meat’s content of omega-3 fat two- to four-fold compared to grain feeding. However, compared to the amount of these fats we get from eating eight to twelve ounces of fish per week, the 0.02 to 0.03 milligrams (mg) in a three-ounce portion of grass-fed meat is extremely small, so the importance of this difference is not yet clear. Some analysis reports grass-finished beef contains as higher in CLA (conjugated linoleic acid) as grain-finished beef, but results on this are inconsistent, as is the cancer protection beyond that seen in preliminary lab studies.

Current research suggests a key reason for the link between risk of colon cancer and excessive amounts of red meat consumption is the high content of a particular form of iron in red meat, called heme iron.  This iron is very easy for the body to absorb, which is an advantage for people not getting enough iron in their diet.  However, this heme iron can also promote formation of certain carcinogens within the gut, cause direct damage to colon cells and generate highly reactive free radicals that can damage cell DNA and begin cancer development. Since grass-fed beef and lamb are just as high in heme iron as grain-fed forms, they are also included in the recommended limit of no more than 18 ounces (cooked) red meat per week.

By the way, the correct term in discussing this is “grass finished”.  All beef comes from cattle that graze on pasture most of their lives. Conventionally produced beef (“grain finished”) comes from cattle that spend the last four to six months of life in a feedlot eating a mixture of grains and soybeans, whereas “grass-finished” beef comes from cattle that spend their entire lives feeding on pasture. People choose grass-finished beef for a variety of reasons, but we really don’t know yet how much health impact the difference in fat content provides.

With all the steps identified to lower cancer risk through eating and lifestyle choices, how do we set priorities?

This may be the most important question of all.  Through the webinar we tried to provide participants with state-of-the-science information regarding many ways our food and physical activity choices can increase or decrease cancer risk.  Science is clear that we don’t need to live “perfect” lifestyles to make a major difference in our risk.

We do need to stay focused, and make sure that regardless of where the world’s hype focuses at any given moment, we keep focused on the choices that matter most.  The AICR Guidelines form an excellent basis for that focus:

Choose mostly plant foods, limit red meat and avoid processed meat.  Make vegetables, fruits, whole grains and beans the largest part of your plate each time you eat.  Focus on variety in your vegetables, and choices that are not processed in ways that remove nutritional value or add excess calories and sodium.  And learn to prepare these so deliciously and easily that they are not just part of your eating when you’re “on a diet”, but become the highlight of your meals.

Be physically active every day in any way for 30 minutes or more.  Forget about how many calories you burn and what that entitles you to eat.  Regular physical activity is key to supporting long-term weight control, but you won’t see that after one walk, or even one week of walks.  Whether or not you walk (or get other activity) today impacts levels of insulin and other hormones and growth factors that affect cancer risk today. Every day’s movement matters.

Aim to be a healthy weight throughout life.  Cancers that are among our most common, like colorectal and breast cancer, and most deadly, like pancreatic cancer, are related to excess body fat.  If you’re far beyond recommended weights, you may think it’s too late to matter, but losing even 15 or 20 pounds (and keeping it off) makes a difference in the hormones and inflammation that promote cancer development. If you think that your weight is still “ok” despite gaining 15 pounds and watching an expanding waistline, research suggests you, too are at risk and should take action now.

Add up changes that total about 500 calories per day cut from current habits by decreasing portions and avoiding sugar-laden drinks, and substitute bigger portions of vegetables so you won’t go hungry.  Find some small changes and make them today. Don’t wait for perfection.

Thanks to all of you who joined us for the webinar.   A big thank you goes out to the California Walnut Commission for sponsoring the webinar.  AICR is planning to post the webinar on its website. Stay tuned here and at the AICR website for further updates and plans to address your many important questions on this vital topic.  Please comment below with questions you’d like me to address here in the future.  I love to give presentations to groups of health professionals, cancer survivors and “regular folks” who want to know about what today’s research shows about how we can lower our cancer risk.  You can reach me through the Contact section of my website regarding my availability for speaking engagements.

What supports a healthy lifestyle?

It seems to me that a lifestyle that promotes good health is like a stool.  A stool resting on just one or two legs is easily knocked over.  A three-legged stool is stable.  Sure, you can still fall off, but it takes a lot more to knock you off a three-legged stool.

The seat of the stool: Personal Choice

Lifestyle choices are personal, and what is “best” or “smartest” involves fitting together many pieces of the puzzle.  Making lifestyle choices that work for us as individuals means both:

Information: Do you know the impact of your choices? Do you know that options other than your current choices are possible? Do you know how to execute the “healthy” choices (how to cook healthfully, how to put together a balanced meal, how to try a sport or strength-training option, how to identify lower-calorie swaps for current choices)?

Decision-making: How do you balance short-term and long-term results? Are you comfortable including how your choices affect YOU as you make lifestyle choices? Have you thought about how your choices reflect what is urgent, what is important and what reflects, “the squeaky wheel gets the grease”?

Leg One: Social Support

Dan Buettner pointed out in the first half of our conversation about the healthy lifestyle choices identified in The Blue Zones that your “tribe” has a tremendous impact on your lifestyle choices.  If the family, friends and co-workers with whom you spend time are inactive, choose unhealthy foods, and eat until the food is gone (rather than until they are no longer hungry), it makes it more challenging for you to choose differently.

So, what can you do?  What would it be like to live “as if” you already are the healthy person you want to become?

~You might join a fitness center or take dance classes that are a good match for you. Find a spot that endorses active living for all without focusing on perfection or extremes.

~Look around for people in your workplace, community organizations, place of worship and among your neighbors and children’s parents who seem to live out a particular life choice you’d like to nurture. If you’re like me, it’s not easy to reach outside your current circle to invite people to meet for a meal or go for a walk.  But when I have, the results have often been tremendously rewarding.

Face it, if the people you spend the most time with now aren’t living the way you want to live, you are paddling upstream trying to be the only one you know making healthy choices.  How will you meet and spend some time with people who share your vision?  If you have taken steps to reach outside your usual circle, please use the comment section below to share your tips of what you did so that others may be inspired and see some new ways to do this.

Leg Two: Professional Support

If the reason that you keep turning back to follow-the-number “diets” is that you don’t really know how to pull together balanced meals or have few ideas of how to prepare healthy food that is also delicious, economical and quick-to-fix (yes, it can be all that!), get some help to learn how.

~Check out websites that provide sound information on healthy eating and physical activity choices, such as the federal ChooseMyPlate (including the Super Tracker that helps you create personalized plans), the American Institute for Cancer Research (including the Foods that Fight Cancer section and Recipes from the AICR Test Kitchen), the Whole Grains Council (including Whole Grains 101 and Recipes) and Oldways’ information on the Mediterranean Diet and other approaches to healthy eating choices.

~You don’t expect your teeth to stay clean without a periodic check-up and cleaning at your dentist, do you?  Invest in a session or two with a Registered Dietitian (RD) who can help you set up eating patterns and food choices that will really work for you.  You can find an RD in your area in the “Find a Registered Dietitian” section of the website of the Academy of Nutrition and Dietetics.

Leg Three: Community Support

This is the big challenge that Dan Buettner addresses in this portion of my interview with him.  He noted that while we can work to make healthy lifestyle choices and align ourselves with others who make healthy choices, it makes a huge difference whether we are living in an environment that makes the healthy choices the easy choices or the difficult choices.

When I asked what he recommended for people living in the latter type of community, he said, “Move!”   To me, there are two ways to address the impact that community has on our lifestyle choices:

~We already choose the section of the community in which we live based on the area with the best school system, the best resale value, the closest commute time and a whole range of factors.  What if we at least consider how different areas support healthy eating and physical activity choices?

~For those not ready to move from where they currently live, as you consider how you can make this world a better place, how about looking at all the spots you already have a role: workplace, community, school system, social organizations.  Run through the nine principles of a healthy lifestyle we discussed in our first discussion of Blue Zones, and see if you can find one or two areas in which you can make the healthy choice easier through your current involvements.  See the resources below for information about creating communities that support lifestyles that lower cancer risk.

Dan Buettner says it takes a “perfect storm” to create a community that supports optimal health.  He notes it’s not easy to change our communities….But since the option to move is not something many of us can or will choose in the present moment, let’s get started on being and supporting the change we want to see!

Let’s talk:  What do you think about the impact of personal, professional and community support for healthy lifestyles?  Please share any tips based on your experiences, too.

Resources

Check the Blue Zones website for information about how Dan Buettner’s organization is helping communities change to support health and longevity.

For ideas about changes communities and the schools, workplaces and organizations in them can make to support healthy living, check the Executive Summary of the report, Policy and Action for Cancer Prevention, from the American Institute for Cancer Research.

You can see a summary of suggested action points in the section, Recommendations for Community Action, in the American Cancer Society Guidelines for Nutrition and Physical Activity for Cancer Prevention.  

So what are these Blue Zones of the world that researchers identified where people live so healthfully so long?

• Sardinia, an island off the coast of Italy
• Ikaria, Greece
• Okinawa, Japan
• Nicoya, Costa Rica
• Loma Linda, California (yes, there’s an American blue zone!)

Here are the nine key lessons that Dan extracted from his time with the people of the Blue Zones:

~Move naturally….People don’t “exercise”, but they walk everywhere, most garden, and they tend to continue in physically demanding work long past the age of eighty.

~Eat until you’re 80 percent full….Another way to get at portion control, maintaining a healthy weight affects a whole slew of hormones and growth factors that impact our health.

~Choose a predominantly plant-based diet…. On the surface, meals in Okinawa don’t look like anything like meals in Costa Rica or Italy, but the basic proportions of food choices are very similar.  People eat red meat only on special occasions, with day-to-day protein needs met by plant options such as beans and nuts.  Specific choices of grains, vegetables and fruits differ, but they are important parts of the diet.

~Alcohol, often wine, in moderation….We know moderate amounts of alcohol are linked with lower risk of heart disease and type 2 diabetes.  I haven’t traveled to these spots, but it sounds like these people enjoy a little alcohol in the company of others, often with a meal.  Excessive consumption or binge drinking do not sound like the norm.

~Slow down…. These cultures have through the years built into the lifestyle times for everyone to decompress and relax. For some people it’s prayer or meditation, for others taking moments to be grateful, taking naps or enjoying time with family and friends.  How we do it doesn’t seem to matter as much as that we do it.

~Loved ones first….In his book, Dan talks about how elderly people in these cultures are respected as sources of wisdom, and they live with their family members, continuing as valued sources of help in the family cycle.  It must be quite a different experience to grow old in such a culture compared to ours, where one can so often feel outmoded and less-than-useful.

~Participate in a spiritual community….It doesn’t seem to matter for health what sort of community it is, but actively participating in a faith-based community (not just being a “member”) seems to bring wide-ranging benefits.

~Identify your life’s purpose….In these cultures, people can reportedly easily articulate theirs. Knowing that you have a reason to get up in the morning and that you have a valuable contribution to make in this life makes a difference.  Finding ways to use your abilities and gifts for things about which you are passionate gives life meaning.

~Hang out with the right tribe….People in the Blue Zones often have as part of their culture the norm of belonging to social circles where you know that people have your back.  Dan Buettner urges us to look at whom we hang out with.  He says, “Proactively surrounding yourself with the right friends will do more to add years to your life than just about anything else.”

This is fascinating stuff!  Check back for the next section of our conversation, when we explore how much we can do through individual choices, and how much of longevity is community-based environment.  Dan says, “I know this is not what you wanted to hear!”, and he was right!  Check it out and join the discussion.

Meanwhile, you can go to the Blue Zones website to learn more about the project.  While you’re there, take the Vitality Compass.  It’s a short online quiz that will give you an estimate of your longevity based on your current lifestyle, and based on your answers, suggest how you might improve your habits and environment to live even longer.

Let’s talk:  Dan Buettner advises that we pick the five easiest from his list of nine longevity-promoting habits.  Which would be the easiest for you?  If you’re already working on them, what changes are you trying to put in place? Please share your thoughts!

Receiving SCAN award for Excellence in Practice in Wellness Nutrition from Carol Lapin, MS, RD, CSSD

Receiving an honor like this from my peers, and listening to the heartwarming tribute given by Carol Lapin, MS, RD, CSSD, has been truly humbling.  It’s an occasion for gratitude to the many people who have supported, taught and mentored me throughout my career and personal life.

For those of you who are unfamiliar with SCAN, it is a dietetic practice group of the Academy of Nutrition and Dietetics.  This 7,000+ member group is made up of nutrition professionals who specialize in eating disorders and sports, cardiovascular and wellness nutrition.  I am deeply touched to be chosen by these colleagues, a group that truly sets the bar high for excellence in practice, and a group I hold in high, high esteem.

 “Tips from the Trenches”

As an award recipient, I was asked to give a short presentation with some “Tips from the Trenches”.  For a unifying theme, I used hints of effective gardening practice – not something you might necessarily seize as a metaphor for effective practice as a nutrition professional, but I think it worked well.  After I completed the talk, I realized that these tips represent my thoughts on more than just professional success.

Here was my final tip: Allow yourself to bloom by surrounding yourself with what nurtures you. Surround yourself with excellence. Dan Buettner, best-selling author of Blue Zones and Thrive, says that if you cultivate relationships with people who are thriving, you are more likely to thrive as well.

♥ I talked about the importance of volunteering, which provides a chance to be nurtured while doing good.

♥ I talked about surrounding yourself with people who live the example of whatever it is you want to do or be.

♥ I talked about the value of people with a positive attitude who will help you keep focused on looking through barriers in your path.

My Gratitude Binge

It was reflecting on the ups and downs of my career for this presentation that kicked off my Gratitude Binge, as I realized that whatever I’ve accomplished, it’s been with the support of many, many others.

• To my colleagues past and present from whom I have learned so much, and who add fun to our professional journey…
• To my many patients through the years, who I hope learned half as much from me as I did from them…
• To the organizations that have given me the chance to try a wide range of exciting projects…
• To the staff of the American Institute for Cancer Research, for the many opportunities they have given me, and for the joy of working with a group so committed to excellence in their important mission…
• To my friends and family, who believe in me and have always been there to support me in ways large and small…
• To SCAN for awarding me this tremendous honor…

My heartfelt thank you, thank you, thank you!

What’s next? Watch for video interviews coming soon with some fascinating speakers from the SCAN symposium:

~ Dan Buettner, author of Blue Zones noted above, with insights on what long-lived healthy populations around the world have in common and what we can learn from them…

~ Barry Braun, PhD, with what you need to know about how exercise and inactivity each affect appetite…

~ Lynette Craft, PhD, with insights on how exercise affects depression and mood.

Sign up to receive Smart Bytes™ blog posts by email or RSS feed so you don’t miss a thing!

Not-So-Boring-Broccoli from the American Institute for Cancer Research http://www.aicr.org/health-features/test-kitchen/six-on-the-side-dishes.html

Exotic tropical fruits come and go as “super foods” in the spotlight, but for years broccoli has maintained a place on the A-list of healthy vegetables.  Is it really justified, or just another example of nutrition hype?  Do some of us benefit more than others?

No single vegetable can provide all the compounds found in plant foods that seem to play a role in reducing cancer risk.  Broccoli – along with its other cruciferous vegetable “cousins” – really does seem to rank among the all-stars.

Although broccoli literally brings a lot to the table,  what I find especially intriguing is its impact as a cruciferous vegetable. This is a larger family of vegetables than many people realize, including not just broccoli, cabbage, Brussels sprouts and cauliflower, but also bok choy, collard greens, kale, rapini, radishes, and more.  When the vegetable cells are disrupted by chewing or chopping, an enzyme is released that converts the inactive glucosinolate compounds they contain to isothiocyanate and indole compounds that seem to have significant anti-cancer effects.

In cell studies and animal research, these compounds:

• Protect us from carcinogens by inhibiting enzymes that activate carcinogens and stimulating enzymes that detoxify them
• Decrease the inflammation that creates a pro-cancer environment within the body
• Turn on tumor suppressor genes that slow cell growth so that cell damage can be repaired and stimulate a process called apoptosis in which damaged cells self-destruct
• Decrease growth factors necessary for cancer cells to be able to spread
• May also shift estrogen metabolism to favor a weaker, less cancer-promoting form.

Some questions people often ask about broccoli and other cruciferous vegetables:

Most of the studies showing benefit are lab studies.  Does human data support a benefit?

Population studies do link greater consumption of cruciferous vegetables with lower risk of lung, colorectal, stomach, breast, prostate, and other cancers, although not consistently.

♦ One year-long small intervention trial showed that men who ate 14 ounces of broccoli a week showed changes in insulin and growth factor signaling that would be expected to be cancer-protective.

♦ Yet in one study, although total cruciferous vegetable consumption was not strongly linked to risk of breast cancer, women estimated to consume the largest amounts of isothiocyanate compounds showed an 18 percent lower risk of breast cancer, and a 32 percent lower risk of postmenopausal breast cancer.  In the same group of Chinese women, when researchers assessed exposure to cruciferous vegetables by urinary excretion of compounds that form as the body metabolizes the active protective phytochemical, women who excreted the most later developed only half as much breast cancer as women who excreted the least

Why do the findings from human studies seem so inconsistent?

♦ Isothiocyanate compounds from broccoli and other cruciferous vegetables come in a variety of forms; we don’t know how they may differ in effects.

♦ Even if they eat the same amount of broccoli or total cruciferous vegetables, people will vary in the amount of isothiocyanates they get based on how much they chew the vegetable (exposing more of it to the enzyme that breaks down the inactive glucosinolates into the active compounds) and the particular types of bacteria in their gut (which also break down the inactive compounds to the active forms).

♦ Genetic differences make some people metabolize and eliminate the active compounds from the body sooner than others, leaving them with less time exposed to their protection. In one study, among women with particular forms of genes that control how cruciferous compounds are metabolized, those with highest levels of isothiocyanate compounds in their urine showed a 50 percent lower risk of colorectal cancer than those with lowest levels of the compounds; other women did not show protection.

Does it matter if I eat cruciferous vegetables like broccoli and cabbage raw or cooked?

♦ Cooking, even briefly blanching the vegetables before freezing, inactivates the enzyme that converts the inactive glucosinolates to active compounds.  Studies show that people get more isothiocyanates from raw rather than cooked forms.  That doesn’t mean you get nothing from cooked forms, however; those friendly gut bacteria do help break down the glucosinolates to provide protective isothiocyanates.

♦ Glucosinolates are water-soluble compounds that may leach out into cooking water. Boiling cruciferous vegetables from 9-15 minutes resulted in 18-59% decreases in the total glucosinolate content of cruciferous vegetables. So when you cook these vegetables, cook lightly to crisp-tender in methods that use little or no water, such as steaming or microwaving, to reduce glucosinolate losses.

Keep in mind: There’s more to broccoli than its glucosinolate compounds. Like many other dark green vegetables, it’s loaded with

• beta-carotene, which provides antioxidant protection to our DNA and promotes cell-to-cell communication that helps control cell growth;
• vitamin C to provide further antioxidant power;
• folate, a B vitamin that helps maintain healthy DNA and keep cancer-promoting genes “turned off”; and
• magnesium, which seems to keep insulin functioning properly, important to reduce risk of type 2 diabetes and probably cancer, too.

Some of us may get more benefit from cruciferous vegetables than others, but for all of us they are a choice that makes sense to include regularly as part of a wide variety of other vegetables and fruits.

Let’s talk: What are your favorite ways to prepare broccoli and other cruciferous vegetables?  If you have children or others who have trouble with the slightly bitter flavor, how have you overcome it?

References

Navarro SL, et al. Mechanisms of action of isothiocyanates in cancer chemoprevention: an update. Food Funct. 2011 Oct;2(10):579-87. Epub 2011 Sep 21. PMID: 21935537

Kim MK, & Park JH. Cruciferous vegetable intake and the risk of human cancer: epidemiological evidence.  Proc Nutr Soc., 12/2008.  8:1-8.

Traka, M., et al., Broccoli consumption interacts with GSTM1 to perturb oncogenic signalling pathways in the prostate. PloS one, 2008. 3(7): p. e2568.

Lee, SA et al. Cruciferous vegetables, the GSTP1 Ile105Val genetic polymorphism, and breast cancer risk.  Am J Clin Nutr., 2008.  87(3):753-60.

Fowke, JH et al.  Urinary isothiocyanate levels, brassica, and human breast cancer.  Cancer Res., 2003. 63(14):3980-6.

Yang, G., et al. Isothiocyanate exposure, glutathione S-transferase polymorphisms, and colorectal cancer risk. Amer J Clin Nutr, 2010. 91(3): p. 704-11.

McNaughton SA, and Marks GC. Development of a food composition database for the estimation of dietary intakes of glucosinolates, the biologically active constituents of cruciferous vegetables. Br J Nutr. 2003;90(3):687-697.

Song, L. and Thornalley, PJ. Effect of storage, processing and cooking on glucosinolate content of Brassica vegetables. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association, 2007. 45(2): p. 216-24.

Vermeulen, M et al. Bioavailability and Kinetics of Sulforaphane in Humans after Consumption of Cooked versus Raw Broccoli.  J Agric Food Chem, 2008. 56(22):10505-9

Conaway, CC et al. Disposition of glucosinolates and sulforaphane in humans after ingestion of steamed and fresh broccoli.  Nutr Cancer, 2000.  38(2):168-78.

Rungapamestry, V et al. Effect of meal composition and cooking duration on the fate of sulforaphane following consumption of broccoli by healthy human subjects. Br J Nutr. 2007. 97(4):644-52.

The National Cancer Institute has declared April as Cancer Control Month, so it’s a good time to remind ourselves of the obvious: tobacco avoidance saves lives.  That good news about cancer deaths prevented compared to expectations based on prior statistics is due to a decline in smoking. The researchers’ calculations that quantified the cumulative impact of changes in smoking produced a bittersweet note: if all tobacco smoking had ceased, 1.7 million American lung cancer deaths that did occur during this time would have been avoided.

One obstacle: some people don’t quit because they’re afraid of gaining weight. That’s a valid concern, since modest weight gain is not unusual when someone quits smoking.  However, weight gain is not universal.  Reaching and maintaining a healthy weight is a key step in reducing risk of cancer. First things first, however: the multiple health benefits of getting away from tobacco outweigh the small gain that may occur, and researchers are studying what people might do to avoid or limit weight gain related to smoking cessation.

Here’s what research has uncovered so far.  Please pass this along to smokers you know.

What’s behind a weight gain?

Physical and behavioral reasons can promote weight gain related to smoking cessation.

• When people quit smoking, metabolic (calorie-burning) rate drops as it returns to normal without nicotine’s rate-raising effect. The impact on metabolic rate might amount to burning about 200 calories less per day on average.  Over time that can add up to gradual weight gain.
• Beyond that, people may tend to eat when they previously would have smoked, increasing calorie consumption beyond their norm.  In one study, people who quit smoking increased calorie consumption an average of 227 calories per day, which researchers calculated to account for 69% of the weight gain observed at three months.

What to do?  

Physical activity is a multi-purpose helper.

One analysis notes that whether or not it’s enough to prevent short-term weight gain, physical activity does seem to pay off in reduced gain at one year.

        √ Two or three ten- or fifteen-minute blocks of activity should burn up enough calories to compensate for that drop in metabolic rate.  Spread those blocks throughout the day in a pattern that fits your lifestyle.

        √ Regular exercise can decrease emotion-based eating by reducing stress and improving mood. Usually this is demonstrated in studies of moderate aerobic activity, such as brisk walking. A study is underway to test potential help from yoga. Most forms of yoga don’t burn as many calories as the same amount of time spent in more active exercise.  It certainly burns more than lying on the sofa, though, and by reducing stress, it could act through changes in eating behavior or stress-related hormones to reduce weight gain.

Re-program urges to eat

        √ Smoking becomes intertwined with many activities, from deskwork to ending a meal.  Instead of concentrating on what you don’t want to do (smoke), concentrate on new habits to build into those times when you used to smoke.  For example, you might sit and savor a cup of tea after a meal.  If coffee or tea is a trigger for you to smoke, however, switch to another drink, such as ice water, club soda or ice tea. Some people find it helpful to replace smoking with something less harmful they can put in their mouth (such as sugarless gum).  Others find it helpful to try to break the “oral” habit and turn to other replacement habits.

        √ Nicotine withdrawl’s effects in the brain can lead to increased cravings for foods high in sugar or fat.  Some people find the urge to smoke or overeat easier to handle if they eat small amounts of food several times a day to avoid letting their blood sugar drop too low.  The key is to choose balanced snacks, not just sweets or chips.

Change counter-productive thinking patterns

        √ Is feeling stressed what pushes you toward either smoking or eating?  Don’t expect stress to end. Set the goal of learning new ways to respond to stress.  In addition to going for a walk or doing yoga, try deep breathing, listening to or playing music, praying, meditating, journaling, cuddling a pet, or calling a friend.  Based on these trial runs, create a portfolio of options that work for you, and teach yourself to act when you first start to feel stressed rather than waiting until the urge to smoke or eat seems unbearable.

        √ Don’t let fear of weight gain deter you from the top priority of quitting.  One study found that among smokers given standard smoking-cessation counseling, those who also received counseling to reduce concerns about gaining weight were significantly more likely to succeed in quitting at a one-year follow-up than those who were given diet advice to prevent weight gain or those given smoking-cessation help with no attention to weight.  The funny thing: the group given help in avoiding concern about weight gain and discouraged from dieting gained less weight than either the group that did not address weight or the group focused on avoiding weight gain.

This is only one study, but does suggest that there’s a difference between adding stress by acting out of fear and focusing on self-care in a positive way.  Make quitting the priority, and use physical activity and smart eating to keep you feeling good through the process.  The truth is, we just don’t know whether long-term overall health benefits are greater if you avoid or limit weight gain while you quit, or if you deal with one thing at a time.  Focus on the priority to quit smoking and you know you’ll have done something really big!

If you’re not a smoker, please share this with a smoker you care about who might be ready to think about this.  And consider, what big or small step can you take to protect your health today?

Resources:

Quit Tips from the federal Centers for Disease Control and Prevention (CDC) offers 5 tips for those who want to quit smoking.

The Smokefree.gov website has a great section on Stress and Smoking, and a service, SmokefreeTXT, to provide text messages to your mobile phone to support you as you quit.

How To Handle Withdrawal Symptoms and Triggers When You Decide To Quit Smoking, from the National Cancer Institute, provides some great ideas for handling those tough urges.

Focus on a positive goal of adding up at least 30 minutes a day in moderate physical activity.  You can track time or miles on smart phone apps or websites such as America On the Move.

If you decide you want some help to keep nutritional balance in your eating habits, or if you’re looking for help in awareness of how much food may be right for you, you can track your food choices with the Choose MyPlate SuperTracker. Just be sure this is supporting you, not distracting you from the priority of quitting tobacco.

References:

Moolgavkar SH, et al. Impact of the Reduction in Tobacco Smoking on Lung Cancer Mortality in the U.S. over the Period 1975-2000. J Natl Cancer Inst. 2012.  104(7):541-8.

Audrain-McGovern J and NL Benowitz. Cigarette Smoking, Nicotine, and Body Weight.  Clin Pharmacol Ther. 2011.  90(1): 164–168.

Stamford BA et al. Effects of smoking cessation on weight gain, metabolic rate, caloric consumption, and blood lipids. Am J Clin Nutr. 1986. 43(4):486-94.

Farley AC, et al.  Interventions for preventing weight gain after smoking cessation. Cochrane Database Syst Rev. 2012 Jan 18;1:CD006219.

Bock BC, et al.  Yoga as a complementary treatment for smoking cessation: rationale, study design and participant characteristics of the Quitting-in-Balance study.  BMC Complement Altern Med. 2010 Apr 29;10:14.

Perkins KA, et al. Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. J Consult Clin Psychol. 2001. 69(4):604-13.

Is chocolate a help or a hindrance to health? Does it really pose no barrier to a healthy weight? For me, the answers lie in the study details that you don’t get from looking only at the headlines.

Do sweets cause cancer?

You may have heard that “sugar feeds cancer”.  It is true that growth of cancer cells is fueled by sugar.

But let’s be clear that this is sugar circulating in the blood, which is fuel to all our cells.  Even if you ate no sugar – even no carbohydrates at all — you would still have sugar circulating in your blood. When blood sugar dips low, body processes in the liver and muscles automatically switch on to produce blood sugar from sources such as protein and glycogen. Years ago, people with diabetes were told to avoid all sugar.  Today, we have many studies showing that sugar consumption alone does not drive blood sugar levels.

In a healthy person, as soon as carbohydrate is eaten (before it’s even been absorbed from the gut), we are beginning to get insulin ready to handle the rise in blood sugar that’s coming. Studies that involve large amounts of sugar consumed all on their own may have implications for people who are guzzling gigantic bottles of regular soda all day.  But normally when we consume sugar, especially if it’s part of a meal with fiber-containing food, the resulting rise in blood sugar is moderate and brought back to normal relatively quickly.

The role of insulin is a super-hot field in cancer research today.  Beside insulin’s role in helping sugar move from the blood into cells where it is used, insulin also promotes growth and reproduction of normal cells and, yes, cancer cells.

“Insulin resistance” is a growing problem occurring in association with overweight and sedentary lives.  As I wrote in last week’s post on Diabetes & Cancer, insulin resistance means that when blood sugars rise, despite plenty of insulin, cells are unable to use it.  As a result, blood sugars continue to rise and the pancreas pumps out more and more insulin. We need further research about the impact of excessively high blood sugars, but overall, research suggests that high levels of insulin are a far clearer concern.

We reduce insulin resistance by reaching and maintaining a healthy weight and keeping active. A balanced diet focused around vegetables, fruits, whole grains and beans supplies dietary fiber that slows blood sugar rise and provides antioxidants that help avoid chronic low-grade inflammation that can lead to insulin resistance.

Chocolate & a healthy weight

A widely publicized study that showed no link between frequency of chocolate consumption and weight has raised all kinds of questions about whether phytochemicals in chocolate might mean that calories from chocolate don’t impact weight the same as calories from other sources. Contrary to some commentaries on this study that you may see, the researchers did analyze chocolate’s link to weight both with and without adjusting for overall calorie consumption.  Either way, eating chocolate more often was linked with lower weight.

Before you make the jump of concluding that chocolate poses no problem for weight management, a few details do need attention:

√ Although analysis adjusted for how often subjects engaged in vigorous activity, there was no adjustment for moderate activity.  Moderate activity includes things like a brisk walk, gardening and many other options that are far more common among most adults than vigorous activity, and it plays an important role in long-term weight control.

√ Amount of chocolate eaten – how many ounces per week – was not related to being overweight.  Authors of the study did not include this information in the abstract of the study, but it’s there in the overall results. In contrast to the “so chocolate might help weight loss” argument, if anything, this suggests that chocolate consumption itself neither helped nor hindered a healthy weight.

√ This is an observational study, not a controlled trial. It doesn’t show the effect of chocolate on weight; it could just as well be that leaner people give themselves “permission” to have a small amount of chocolate more often than do obese people.

√ Note that this is about “chocolate” as a candy, not chocolate in the many forms we consume it, such as chocolate donuts and chocolate cake.  We’ll come back to this important point.

√ A problem for this and all studies comparing what people say about their eating and some outcome like weight is that people aren’t accurate about what they eat.  What’s more, it’s widely documented in research that the more overweight someone is, the more they underestimate how much they eat – sometimes by 40% or more – and this is particularly true for a food that might be considered “bad” or high-calorie.  Whatever the reason, this could be especially problematic for something like chocolate, often eaten in situations in which we are not paying attention to our eating.

Chocolate for Antioxidants?

Chocolate contains natural compounds called flavonoids that show powerful antioxidant effects in laboratory studies. They are from the same family of compounds that includes health-protective compounds like the resveratrol in grape juice and EGCG in green tea.  So what’s the evidence about chocolate’s impact on overall health?

*Reduction in heart disease risk of 24 to 37 percent compared to those who rarely or never eat chocolate is reported in several human studies. Chocolate consumption decreases LDL (“bad”) cholesterol and increases flow through blood vessels. It also slows the oxidation of LDL cholesterol to a form more damaging to blood vessels.

*Reduced blood pressure is linked with long-term consumption of small amounts of chocolate. An analysis of 13 different short-term randomized trials shows that chocolate or cocoa, especially in forms rich in flavonoid compounds, can reduce elevated blood pressure several points.

*Reduced markers of inflammation, such as CRP, are seen in limited population studies. For example, among healthy Italian adults, consumers of dark chocolate showed 10 percent lower levels of CRP than those who did not eat chocolate. Note the catch: this effect was seen with one small serving (less than an ounce) about every three days. In this study, those who ate more than about 1½ ounces per week had no lower levels of CRP than those who ate no chocolate.  However, in a controlled trial, cocoa powder decreased other markers of inflammation, but the amounts translate to amounts of chocolate likely too large to fit into an overall healthy diet; we don’t know whether long-term use of more moderate amounts might have equal impact.

*Impact on overall circulating antioxidants is uncertain.  One study comparing total antioxidant activity from single servings of cocoa, green tea, black tea and red wine, reported cocoa markedly higher than the rest.  However, according to an analysis of 19 controlled intervention trials, although cocoa products decrease LDL cholesterol oxidation, they do not necessarily affect blood measures of overall antioxidant defense. We need more research to identify what factors in the chocolate product, diet or individual might affect chocolate’s overall antioxidant impact.

Practical Points on Chocolate Choice

The flavonoid content of chocolate is highly variable.  Dark chocolate, usually 60 to 85 percent cocoa (which includes cocoa bean solids plus cocoa butter), is higher in flavonoids and has a more intense flavor.  It is less sweet, because as cocoa content goes up, sugar content drops.  Milk chocolate can range from 7 to 50 percent cocoa, so flavonoid content is lower.  White chocolate contains no cocoa bean solids (and therefore is not a source of flavonoids).

The fat content of chocolate is not the problem that some people consider it to be. Seventy percent of chocolate’s fat is either monounsaturated or a particular type of saturated fat called stearic acid that does not raise blood cholesterol.  Both dark and milk chocolate are heart healthy options, especially if they are replacing other sweets.

Research suggests health benefits from drinking cocoa, too.  However, most widely available cocoa mixes contain cocoa treated with alkali to produce a richer taste. Unfortunately, this “Dutch cocoa” is substantially lower in antioxidants.  Gourmet cocoa mixes are available made with natural (untreated) cocoa.  You can also make a flavonoid-rich cup of cocoa with natural cocoa from the grocery store plus your own sweetener and milk.

So we’re back to the impact of a chocolate fix on your weight….

• One ounce of dark chocolate (1/3 to ¼ of a 3- or 4-oz bar, or 4 small pieces) 135-165 calories
• One ounce of milk chocolate (1/4 of a 4-oz bar or 4 small pieces) 150 to 165 calories
• One tablespoon of natural cocoa 20 calories; combined with varying proportions of nonfat milk and water with a little sugar or non-calorie sweetener makes a cup of cocoa to savor for 50 to 130 calories

◊  ◊   ◊   ◊   ◊   ◊   ◊   ◊

• Dunkin’ Donuts chocolate donut 370 calories
• Five Oreo cookies   265 calories
• A third of the package of Oreo cookies (don’t think nobody does that!)  690 calories
• 1 cup Ben & Jerry’s chocolate fudge brownie ice cream  520 calories
• Starbucks Venti Caffè Mocha with whipped cream  410 calories

Chocolate doesn’t replace vegetables and fruits.  Flavonoid content of vegetables and fruits such as spinach, garlic, raisins and oranges can be 8 to 16 times higher per serving than even dark chocolate. And we get those health-promoting phytochemicals in a serving of fruits and vegetables for 25 to 80 calories, and in tea for no calories at all.

With overall smart food choices, most adults can maintain a healthy weight while consuming 120 to 350 calories a day from foods that don’t add much nutritionally.  Flavonoid-rich chocolate and cocoa could be great ways to “spend” those calories instead of foods that are negative influences on health, such as doughnuts or regular soft drinks.  Savor small portions of chocolate itself that provide flavonoid benefits, not chocolate cakes and pastries that are loaded with extra calories, sugar and unhealthful fats.

Bottom line: Whether you’re concerned about weight or overall health, it looks like modest chocolate consumption a few times a week or so is not a barrier, and could even be healthful.  Don’t assume, however, that  “more is better” applies here.

Let’s talk:  What does chocolate in moderation look like for you?

To make sure you don’t miss insights from behind future nutrition headlines, sign up to get future posts by RSS feed or email.

References

Golomb BA, et al. Association between more frequent chocolate consumption and lower body mass index. Arch Intern Med. 2012 Mar 26;172(6):519.

Winkler JT. The fundamental flaw in obesity research. Obesity Reviews, 2005. 6:199.

Lewis JR, et al. Habitual chocolate intake and vascular disease: a prospective study of clinical outcomes in older women. Arch Intern Med. 2010.  170(20):1857.

Buitrago-Lopez A, et al. Chocolate consumption and cardiometabolic disorders: systematic review and meta-analysis. BMJ. 2011 Aug 26;343:d4488.

Hooper L et al. Effects of chocolate, cocoa, and flavan-3-ols on cardiovascular health: a systematic review and meta-analysis of randomized trials.  Amer J Clin Nutr, 2012. 95(3):740.

Taubert D, et al. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide. JAMA. 2007;298:49–60.

Ried K, et al. Does chocolate reduce blood pressure? A meta-analysis. BMC Med. 2010. 28;8:39

di Giuseppe R, et al.  Regular consumption of dark chocolate is associated with low serum concentrations of C-reactive protein in a healthy Italian population. J Nutr. 2008. 138(10):1939.

Monagas M, et al.  Effect of cocoa powder on the modulation of inflammatory biomarkers in patients at high risk of cardiovascular disease. Amer J Clin Nutr. 2009. 90(5):1144.

Lee KW et al.  Cocoa Has More Phenolic Phytochemicals and a Higher Antioxidant Capacity than Teas and Red Wine.  J Agric Food Chem, 12/2003.  51:7292.

Scheid L, et al. Antioxidant effects of cocoa and cocoa products ex vivo and in vivo: is there evidence from controlled intervention studies? Curr Opin Clin Nutr Metab Care. 2010. 13(6):737.

Last week I was fortunate to speak on this topic as part of a webinar for the American Association of Diabetes Educators (AADE).  My co-presenter was the distinguished Canadian researcher in this field, Michael Pollak, M.D.  Don’t get me wrong – the diabetes-cancer link is worrisome, since the skyrocketing rates of type 2 diabetes in the U.S. suggest that in years to come, rates of diabetes-related cancers could soar as well. Today, though, let’s focus on the silver lining: if we act now to create a few basic changes in lifestyle and eating patterns, we might still turn this Titanic around in time.

The Diabetes-Cancer Link

Numerous studies now make it pretty clear, people with type 2 diabetes are at increased risk of several cancers.

The most dramatic increases in risk seen in people with type 2 diabetes:

• Liver cancer is about two-and-a-half times more common
• Pancreatic cancer is about 73 percent more common
• Endometrial cancer is about 60 to 100 percent more common

In addition:

• Bladder cancer is about 43 percent more common
• Non-Hodgkin lymphoma is about 41 percent more common
• Colorectal cancer is about 29 percent more common
• Breast cancer (especially the postmenopausal type) is about 20 percent more common

The latter two, colorectal and breast cancer, are particularly worrisome since, although the increase in risk is not as great as for some other cancers, because these are among the most common cancers in the U.S., even a modest increase represents many additional cases of cancer.

What’s behind the link?

Extensive research has identified several of the metabolic and hormonal changes that occur as type 2 diabetes develops that may also promote cancer development.

*Insulin Resistance refers to decreased ability of body cells to respond to insulin.  When blood sugar rises after we eat, insulin is the hormone that allows sugar from the blood to enter cells where it can be used for fuel.  When cells don’t respond to insulin, sugar level in the blood rises, so the body pumps out more and more insulin to handle it.

Insulin is not a carcinogen that creates the DNA damage that starts a cancer cell.  However, a high level of insulin promotes growth and reproduction of cells, and may be an important influence promoting the growth of pre-malignant lesions into invasive cancer.  Cancer cells seem to be even more responsive to insulin than normal cells.

*Inflammation is highly associated with type 2 diabetes, and as you’ve read in other Smart Bytes™ columns, seems to increase cancer development and progression, too.

So where’s the good news in this?

Cancer is a disease that usually develops over many years, which makes it challenging to conduct studies testing how much our lifestyle choices can actually change cancer risk. As evidence becomes stronger and stronger about the significance of insulin resistance and inflammation to cancer risk, studies from the diabetes field now have added significance.

Large studies of people with early signs of insulin resistance and inflammation have shown that lifestyle changes decrease both insulin resistance and markers of inflammation.  For example, in the Diabetes Prevention Program, people targeted a 7% weight loss (14 pounds for someone who weighs 200 pounds) and 150 minutes/week of moderate physical activity.  In the early years of the study, people in this program were 58% less likely to develop diabetes than people who just continued their usual lifestyle.  Even after 10 years, those in the program were 34% less likely to develop diabetes.  That’s impressive, since these were people clearly on the road to develop diabetes, which is a progressive, chronic disease. In addition to the decrease in insulin resistance that causes type 2 diabetes, a marker of inflammation called CRP was reduced in program participants, too.

The Mediterranean eating pattern is also consistently linked to lower levels of inflammation, and in several studies, it decreases insulin resistance and indicators of unhealthy blood sugar levels. This is an eating pattern that features an abundance of delicious vegetables and fruits,  limited amounts of meat and a focus on healthy sources of fat (such as olives and olive oil).

Even when these changes come in middle age and beyond by people who have not been eating well or getting recommended amounts of physical activity, blood tests show that metabolic and hormonal changes occur with healthful changes in lifestyle.  Of course, we need more research to better understand how this plays out regarding cancer risk.

Lifestyle choices that matter

So among all the large and small changes we see recommended for a healthy lifestyle, which are the ones research most strongly supports for reducing insulin resistance and inflammation?

*Weight loss provides one of the most significant opportunities to make a difference for those who are overweight.  Don’t be discouraged if you are far beyond “ideal” weight.  Weight loss of 5 to 7 percent has been enough to make a difference.  Once you get started on a healthy lifestyle, if you lose additional excess weight, health impact may be even greater.  However, better to aim for and achieve a 10 to 15 pound loss and maintain it, than to aim for a weight lower than you can maintain, or to be so overwhelmed at the thought of a huge weight loss goal that you never get started.  Choose a target you can realistically reach in six months, and then focus on steps that bring a bit of progress each week to get there.

Look for one or two concentrated sources of calories that have become part of your everyday routine, or consider whether your portions have crept up to excessive size.  Either of these spots can be the sources from which you add up a total cut of 500 calories a day from your normal choices.  This is enough to get you started on significant weight loss at a reasonable rate.

*Physical activity acts directly and immediately to reduce insulin resistance, as well as acting over time to reduce inflammation and insulin resistance.  It’s easy to put off taking a walk when you’re busy, since you know you won’t come home from that walk any thinner than when you left.  Remind yourself that the walk you take today is acting today to fight insulin resistance!

Besides the changes in insulin resistance and inflammation, regular physical activity helps support a healthy weight  — which we already identified as a major influence to decrease risk of both diabetes and cancer.  Regular walks or other physical activity also seem to have healthful impact on levels of estrogen, and could thus provide another way to reduce risk of breast and endometrial cancer.

Since this change in insulin resistance lasts from a day up to three days, create a mantra that reminds you that you just don’t go more than two days without a walk or some form of moderate physical activity.

*Whole grains, vegetables, fruit and dietary fiber are often ignored in the ongoing debates over high-carbohydrate versus low-carbohydrate diets.  The missing piece of the puzzle in this discussion is that where the carbohydrate comes from may make a crucial difference.  Dietary fiber slows absorption of carbohydrate out of the digestive tract, leading to a slower rise in blood sugar and thus less stimulus to the insulin resistance cycle.  In addition, some dietary fiber is fermented by normal gut bacteria to produce short chain fatty acids that have anti-inflammatory effects.

Whole grains supply some of this fiber, of course, but research suggests additional anti-inflammatory benefit, probably from the antioxidant phytochemicals they provide.  Whole grains also supply magnesium, which provides further benefit for maintaining proper insulin function.

Include at least one cup of some combination of vegetables and fruits at each meal.  Their protective benefits  go way beyond weight control .

The trick: don’t simply add these healthful foods to an already full diet.  Rather, look for a couple of your refined grain choices to switch to whole grains, aiming for at least three servings daily (preferably more). Decide what foods you might be eating in excess portions, and as you cut back on them, add vegetables or fruit to keep the meal or snack filling.

Why act now

You may be used to hearing of the complications of diabetes, such as kidney failure and blindness, following years of this disease.  So what’s the rush? The link between type 2 diabetes and increased risk of cancer is seen in the early years following diagnosis.

If insulin resistance is a key element of the diabetes-cancer link, that means that metabolic conditions are favoring cancer development even in the years before diabetes diagnosis, during what is now called prediabetes or impaired glucose tolerance.  In people without diabetes, the insulin resistance of prediabetes has been linked with liver, colorectal, and pancreatic cancer in particular, although much more research is needed to clarify this picture.

Diabetes can bring changes in immune function and organ damage that may also influence its cancer connection. However, with the strength of evidence showing early changes such as inflammation and insulin resistance to be key players, this only adds more reason to find some lifestyle changes on which you can get started today.

Let’s talk: News of this diabetes-cancer link is new to many people, including health professionals and the general public. Please comment below with your thoughts. Share your questions, and I will address them in a future blog post.

Are you a health professional? I’ll be speaking on this subject at several conferences in the months ahead.  Of the many important and interesting aspects of this link, what would you most like to hear about?  I’d love to have your input!

References:

Giovannucci E, et al. Diabetes and cancer: a consensus report. Diabetes Care. 2010 Jul;33(7):1674-85.

Sun, L and Yu, S. Diabetes Mellitus Is an Independent Risk Factor for Colorectal Cancer. Dig Dis Sci. 2012 Feb 1. [Epub ahead of print]

Diabetes Prevention Program Research Group, K. W.-F. (2009). 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. , 374(9702):1677-86.

Learn More:

For health professionals, a peer-reviewed research paper, The Diabetes-Cancer Connection, that I wrote for the American Institute for Cancer Research is available on the Health Professionals and Educators section of the AICR website.

On a conference call recently, my valued colleague Bridget Swinney, MS, RD shared one of the take-home messages from a writers’ conference she recently attended: “Sloppy Success is better than Perfect Procrastination.”  That may have been said regarding writing, but I think it’s relevant to much more. Let’s look at how some imperfect changes to your eating habits and lifestyle might be the answer to replace “Nutrition Distraction Disorder”.

These five steps below are each backed by research showing multiple health benefits. Give up waiting until the right time.  While you’re waiting until you can do it all perfectly, the inner metabolic disarray from a lifestyle out of balance is taking a toll.  Choose even one of these strategies and start today, however imperfectly, with Sloppy Success.

Eat more vegetables

You’ve probably been hearing this since you were five years old, so it’s easy for this message to become background noise that gets overlooked as other messages get the headlines.  But the truth is that cultures around the world with low incidence of heart disease and cancer all include plenty of vegetables.  They flavor them differently and include different varieties, but a common thread is vegetables in abundance.

I grew up with vegetables that were limp and overcooked — decidedly not foods I enjoyed. What a surprise when, as a registered dietitian determined to find ways to enjoy such nutrition essentials, I found that vegetables can be prepared in so many delicious ways that make them the highlight of my meals!

Do vegetables help you lose weight? Barbara Rolls, PhD, professor at Penn State, has done some exciting research uncovering how vegetables can play a key role in weight control.  When you swap proportions of ingredients in a stir-fry, casserole, pasta dish or other food – boosting vegetables and decreasing others proportionately – you’ll end up with substantially fewer calories in the same portion of food.  Studies by Rolls and others show that doing this consistently reduces calorie consumption without increasing hunger, and is linked to a healthier weight.

They’re for more than just fiber. Vegetables are, of course, a source of dietary fiber.  They also provide a wide range of antioxidants – not only as vitamins like C and E, but also through thousands of phytochemicals. Depending on specific choices, vegetables can be good sources of magnesium, which helps decrease insulin resistance and has been linked with lower risk of Type 2 diabetes, and the B vitamin, folate, which is important to produce and maintain healthy DNA, the starting point of cancer development.

In addition to the antioxidant effects of phytochemicals, some seem to act directly to reduce cancer development.  For example, allyl sulfur compounds in garlic and onions and isothiocyanates formed from compounds in cruciferous vegetables seem to stimulate enzymes that detoxify carcinogens before they even get into cells and damage DNA.  A growing area of research is how these phytochemicals can also change the expression of genes, for example, turning on tumor suppressor genes that slow cell growth so damage can be repaired.

~Learn how

You can read about the approach to nutrition and weight control developed by Barbara Rolls, PhD, which includes abundant use of vegetables, in this US News & World Report’s overview of Volumetrics.  It garnered high ratings for nutrition, weight control, heart health and diabetes. Get started right away with tips on boosting vegetables in the free brochure from the American Institute for Cancer Research (AICR) called More Food, Fewer Calories.

Choose whole grains

Whole grains offer far more than fiber.  They’re higher in several nutrients (such as magnesium, and vitamins B-6 and E) compared to refined grains, and they provide antioxidant phytochemicals such as phenols.  Greater consumption is linked to lower risk of colon cancer and heart disease, and seems to decrease the insulin resistance that’s part of type 2 diabetes. Several studies show drops in markers of inflammation with greater whole grain consumption, and that may help explain whole grains’ link to so many aspects of health.

Greater whole grain consumption also seems to decrease fat around the waist, which is the fat particularly linked to health risks. Don’t just add whole grains to your current diet, though.  Look for refined grains you currently eat that you could swap for whole grains.

 ~Learn how

Whole grain products are more widely available in grocery stores than ever before.  Food labels don’t make it easy to figure out which are truly whole-grain, however.  Check this information from the Whole Grains Council on how to make sense of whole grain stamps you may see on foods,  easy ways to use whole grains, and a list of whole grains you can try for more variety in your meals.

Go for Beans

Dried beans and peas are among our most concentrated sources of dietary fiber.  What’s more, up to 35% of beans’ starch is what’s called “resistant starch”, which is fermented in the colon to particular fatty acids that reduce inflammation and seem to have direct protective effects on cells in the colon.  Furthermore, dried beans provide folate and natural compounds called flavonoids that are antioxidants and seem to also act directly to reduce cells’ development into cancer.

Different cuisines around the world tend to favor different varieties of dried beans, peas and lentils, but they’re a regular feature in populations around the world known for their good health.  Perhaps you already add kidney or garbanzo beans when you see them at salad bars. Move beyond that, and use black beans, navy beans, pinto beans, split peas and lentils in soups, casseroles and salads, and blend them into dips and other appetizers.

~Learn how

Go to your library and check out some cookbooks focused on beans. Or look for a cookbook about almost any style of ethnic cooking you like, and I practically guarantee that if it’s about the authentic cuisine, you’ll find recipes using beans as a main dish and in side dishes.  Meanwhile, check this free brochure from AICR, Beans and Whole Grains (in the New American Plate series) that offers some delicious preparation ideas and recipes.

“Hara hachi bu”

This is the mantra traditionally said before meals in the Okinawan culture, known for healthy longevity. It reminds them to eat only until they are 80% full. They’ve known for generations something that modern researchers have validated: your hunger will be satisfied with less than you think you need when you’re in the midst of eating. It’s a shift in mindset: eat until you are no longer hungry, not until you are “full”.

We live in an environment where food is around 24/7 and big portions have become so common that they now look normal.  Regardless of our food choices, when we habitually overeat, it spells trouble for our weight, and often for blood sugar, blood cholesterol or other lipids called triglycerides, and blood pressure. We need to readjust our perception of what’s “enough”.

~Learn how

Slow down as you eat to give yourself a chance to recognize signals that you’ve had enough.  Eating away from television and other distractions makes it a lot easier to hear this quiet inner voice. Think of ways that you can turn eating less into the easy choice: serve smaller portions, keep serving dishes off the table, have each person get second portions on their own rather than encourage each other to eat more.  Sometimes it’s the obvious: unless you want to have leftovers for use at another meal, purchase and cook smaller amounts of food.  For inspiration, read about the Okinawan use of “hara hachi bu” in Dan Buettner’s book, The Blue Zones, which examines healthy eating and lifestyle choices in cultures around the world where longevity is unusually common.

Walk

Whether you walk as a means of transportation to get to a particular physical destination, or whether your “destination” is stress-reduction, weight management or more specific health benefits, it’s hard to top walking.  Not once a week…make time for some walking every day.

Don’t expect moderate walking to lead to major weight loss without making changes in eating habits, and certainly don’t use it to justify having that donut that’s calling your name. However, in studies of long-term maintenance of weight loss, regular moderate activity like walking is almost always a key habit.  For me, when I am attentive to getting my daily walk, the effect it has in reducing non-hunger urges to eat may do even more to help balance my weight than the calories I actually burn walking.

Research now shows that exercise directly helps lower blood sugars, and it’s linked to lower levels of inflammation, too.  That’s key, because chronic inflammation seems to be behind development of our major health problems, including heart disease, diabetes and cancer.

~Learn how

Don’t wait to find time.  Make time.  Even 10 or 15 minutes of walking will bring some benefit.  Aim to stack up a total of 30 minutes or more of walking and other physical activity each day, and if you can total up an hour, the health benefits will be even greater. Check the America’s Walking website, where Mark Fenton offers ideas for a variety of walking programs, including a “20% Boost Program” to realistically build up to 10,000 steps a day, as well as walking and fitness personality quizzes and stretching exercises (and information on when to do them!).

Bottom line:  Are you ready to put aside distractions? These five “simple” strategies – eat more vegetables, switch to whole grains, include beans, cut portions, take a walk daily – offer multiple health benefits and make you feel great.  No behavior change is “simple”, but these are worth it. Hopefully the resources I’ve listed here will help you get started.  Remember, even Sloppy Success is still success!

Let’s talk! If you have strategies that help you in any of these areas, please share them.  Share stories of progress you make, too  – we can all inspire one another!

While I was speaking in New York City recently, I was delighted to get some time with my long-time friend from graduate school at Cornell University, Jeri Nieves, PhD.  Dr Nieves is Associate Professor of Nutrition and Epidemiology at Columbia University and Helen Hayes Hospital, where she is known for research on bone health and osteoporosis.

Here is video from the third and final section of my interview with Dr. Nieves about nutrition for healthy bones.

Take-home points from Dr. Nieves

Are you getting enough protein for healthy bones? Protein is important for building and maintaining bones.  Most U.S. adults get plenty, however.  Current federal protein recommendations for children up to age 3 call for slightly more protein when expressed “per pound of body weight”, but because such young children are small, even “high” protein does not mean they need large portions of protein-containing foods.

Older adults may need somewhat more protein as they age to combat not only tendencies to lose muscle and bone strength.  Frail older adults sometimes tend to eat diets low in protein because of issues related to chewing, financial, food preparation and more.  One caution: older adults may be more likely to have reduced kidney function, and overdoing on protein a real burden on kidneys.

Do you need to cut back on protein?  You may have heard concerns that too much protein changes the pH (acid-base) balance in our bodies, which leads to calcium leaching from bones to neutralize the pH and thus weaker bones. Many Americans do consume protein far above the Recommended Dietary Allowance (RDA), and the consequences of this are still under study.  Dr. Nieves reports that as long as you are getting adequate calcium and not greatly exceeding protein recommendations, this is probably not a significant bone health issue.

Additional tips

You might see the current RDA for protein for adults listed as 46 grams/day for women and 56 grams/day for men.  That’s a rough average based on a formula of 0.8 grams/kg of body weight, which means that about one-third of your weight expressed in pounds is a reasonable personal target for adults for grams of protein per day.

For example, some daily targets for adults could be:

120 pounds = 44 grams protein           150 pounds = 54 grams protein

175 pounds = 64 grams protein           200 pounds = 73 grams protein

*Note that this is a basic recommendation for average adults to maintain good health.  Heed your doctor’s recommendations for higher or lower amounts of protein because of various health conditions.

Look at the big picture

For most adults, as long as kidney function is good, protein consumption with grams of protein equal to anywhere from one-third of your weight in pounds to almost equal to your weight in pounds can support healthy bones and muscle and overall health. (This is 0.8 to 2 grams of protein per kg weight.)

Two considerations:

*Getting enough of the nutrients, phytochemicals and dietary fiber in plant foods such as vegetables, beans, whole grains and nuts is strongly linked to many aspects of good health.

*Excessive amounts of meat and dairy products may pose some health risks.

So for overall health, especially at higher levels of protein, get a significant amounts of your protein from plant sources.  In other words, don’t assume that higher protein diets necessarily mean loading up on massive amounts of meat.

What about older adults?

Older adults are most likely to face conditions that bring these issues to the forefront: more likely to have osteoporosis, to lose muscle, and to have falls that can lead to hip fracture and its serious complications. Research suggests that older adults – which in some studies includes those over age 55, but mostly involves those over age 65 or 70 – may need somewhat more protein than younger adults to avoid the loss of lean body tissue like muscle and bone that can otherwise occur as we age.  This does not require huge amounts of meat or protein supplements, however.  Quite a few studies in recent years suggest that older adults lose less muscle, and gain muscle better if they do strength-training exercise, if they consume protein equal to their weight in pounds divided by two.  (So a person who weighs 160 pounds might target 80 grams of protein per day.)   Studies do not show any further benefit in maintaining or gaining muscle with protein consumption beyond that target.

Most adults, even those over age 70, already meet that slightly higher target.  However, about 25 percent of those over 70 may be getting less than the long-time protein recommendation, and another 25% may be getting less than this proposed higher target for seniors.

Making it doable

You can reach even this higher target with five to six ounces a day of lean poultry, fish or meat plus three servings of dairy products or dairy alternatives as part of a balanced diet that also provides protein from whole grains, vegetables, beans, nuts and seeds, and some eggs. Those who prefer to omit or minimize meat or dairy products need to include multiple servings of vegetarian sources of protein.  If you don’t eat meat, just having a half-cup of beans or one handful of nuts a day won’t do it.  Also, some research suggests that we use protein more efficiently when we spread it out through the day.  Let’s not forget: for both bone and muscle strength, as important as protein seems to be, research also emphasizes the vital role of weight-bearing and resistance (strength-training) exercise.

Next? In weeks and months to come, we’ll look at conflicting news stories about other nutrition questions. Sign up to get future posts by RSS feed or email  to make sure you don’t miss a thing.

Resources:

You can see how protein in your diet adds up from a variety of sources, check the MyPlate national website’s SuperTracker.

For general information about osteoporosis, check the Bone Health section of the National Institutes of Health website and the website of the National Osteoporosis Foundation.

References:

Bonjour, JP. Protein intake and bone health.  Int J Vitam Nutr Res, 2011. 81:134-42.

Fenton, TR et al. Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill’s epidemiologic criteria for causality.  Nutr J. 2011. 10:41.

Cao, JJ et al. A diet high in meat protein and potential renal acid load increases fractional calcium absorption and urinary calcium excretion without affecting markers of bone resorption or formation in postmenopausal women.   J Nutr. 2011. 141(3):391-7.

Paddon-Jones et al. Role of dietary protein in the sarcopenia of aging.  AJCN, May 2008 vol. 87 (5):1562S-1566S

Campbell and Leidy. Dietary Protein and Resistance Training Effects on Muscle and Body Composition in Older Persons.  Journal of the American College of Nutrition, 2007.  26: 696S-703S.

Symons, TB et al. A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. J Am Diet Assoc. 2009 Sep;109(9):1582-6.

Gaffney-Stomberg et al. Increasing Dietary Protein Requirements in Elderly People for Optimal Muscle and Bone Health. Journal of the American Geriatrics Society, 2009.  57:1073–1079