Nourishing strength: Managing energy and wellness through food

Transcript

Erin Pellegrin, RD, LDN (00:00:07):

I’m glad that we can dive a little bit into nutrition this morning and just really talk about nourishing yourself, nourishing your strength, but also looking at our relationship with food and how we can really just live with compassion and love for ourselves.

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I’m very excited to be here.

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Our topic for today, Nourishing Strength: Managing energy and wellness through food. I want to start by acknowledging that living with breast cancer comes with its own ongoing demands, both physical and emotional. Many of you are balancing treatments, appointments, family, work, and simply trying to take care of yourself. So today our session is not about food rules. It’s not about being perfect. It’s not about cutting things out. This session is about how food can be your support, can be your strength, can give you energy, can be your comfort and looking at food in ways that are realistic and adaptable to your life and what you need.

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Some days we’ll feel easier and that’s OK. And today we’re going to talk about some flexible approaches that you can use based on how you’re feeling on a given day. So let’s dive right in.

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Our goals for today. We’ll be talking about supporting energy, especially when fatigue feels overwhelming and we’ll be kicking off with talking a little bit about fatigue. Managing appetite and taste changes. We’ll be looking at easing digestive discomfort, navigating weight changes without shame, and most importantly, learning how to nourish yourself without added stress.

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I want to take a moment and just have you reflect on these and think about what feels most relevant to you today and where you are right now.

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And I want to say that not every topic that we cover today will be equally appropriate for all of you. It may not be something that resonates with you, but I invite you to take what’s useful and carry with you some information that may be helpful and then leave the rest behind.

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So let’s start diving into why nutrition matters. So long-term treatment, your body is constantly working hard. Inflammation, medications, overall stress, all of this can increase your nutritional needs, even if your appetite doesn’t reflect that increase. So one important focus always is muscle preservation.

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Muscle, when we’re talking about it, isn’t just about strength, but remember muscle, protein supports balance, mobility, immune support, even how well you tolerate your current treatment regimen. And research suggests people in cancer treatment need 20% to 50% more protein than the average adult. But this isn’t necessarily about increasing volume. This is about, and I want you to take this with you. This is about making every bite count.

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Not about volume, making every bite count.

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So when we talk about eating, we’re not talking about growing large quantities. We’re talking about protecting our strength, creating resilience. It’s not about dieting. It’s not about restriction. So let’s dive in first and foremost to a topic I know resonates with probably most of you: supporting energy and dealing with fatigue.

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I want to first check in with all of you here. How many of you — and you can raise your hands — experience fatigue that feels different than anything you ever experienced before your diagnosis. Yep, absolutely. This is a good way to just normalize what you’re experiencing and what you’re feeling.

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Cancer-related fatigue is recognized as a distinct clinical syndrome. It is not just being overly tired. It is not something that’s cured by rest, by willpower. I always say you cannot out-nap the fatigue that you are feeling, as much as you may try. It can feel heavy and it can feel persistent.

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Treatments like chemotherapy, immunotherapy, hormone therapy, they affect your energy level through a variety of mechanisms. And I want to say food won’t eliminate your fatigue. I do not want to overstate this, but we know that steady nourishment can prevent energy crashes and support more consistent stamina as you’re moving through your day.

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So one key nutritional point: A person that is dealing with cancer related fatigue who skips meals will more likely feel worse than someone who eats consistently. Even if what that person is eating is not “perfect” or “healthy.” It really is about consistent nourishment to get you through the day. Regular eating prevents that energy drain, those energy spikes up and down so you want to focus on consistency.

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What does this look like? How do we build steady energy? One of the most effective strategies is eating small amounts throughout your day. Ideally, 3 to 4 hours if possible, but remember we’re being gentle with ourselves so this is a general guideline. And of course pairing protein with carbohydrates to stabilize blood sugar and prevent those energy crashes, and then adding healthy fats to provide sustainable long-term energy.

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Again, this doesn’t mean that we’re like upping our meals. We’re eating these large volumes. But these small changes, these small incremental additions can make a really big impact. Maybe we’re thinking about having some yogurt with berries. Maybe we’re having some multigrain toast with peanut butter. Maybe we’re having some cheese and crackers, just a little something. And if you are trying to increase your volume but that’s feeling a little bit overwhelming on some days, know that small frequent nourishment is a more gentle, approachable way to provide sustainable energy as you move through your day.

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I want to make a note for those who may have issues with their appetite. Maybe your appetite is reduced, maybe you’re having some blunting with your appetite cues. A reminder or something that you can try is setting cues for yourself, using that — what did Kevin call it? Our designated rectangle? On Friday night. Is that what he called it? I love that. But using your phone to set reminders as opposed to just leaning on your own hunger cues. Setting a schedule and building that behavior when your appetite is decreased can be a good way, a good reminder to just have a few bites. It doesn’t have to be anything large, few spoonfuls, a few fork fools, but that can be a good reminder for you.

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If you’re dealing with nausea, especially in the morning, try even leaning into something like a smoothie. Sometimes drinking something versus having something solid feels better on your belly and can soothe some of that nausea so that can be a good way to kick off the day.

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Now let’s talk about the nutrient that I have mentioned many times that is really important, and that is protein.

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It is especially important during treatment because it does help to preserve muscle mass. And I want you to think of protein more than just working to build muscle, but this is your insurance. This is your strength insurance. And you don’t necessarily have to count grams specifically. I know members will often ask us what their protein goals may be — and we’ll certainly give that a range to work towards — but sometimes seeing those numbers, because they might be higher than perhaps what we’re getting in currently, can be overwhelming. Right? Like, “Oh my gosh, I’m never going to get there.” So we use that sort of as a gentle guide in the back of our mind, but one thing you can do is just add protein to all of your meals and snacks. And if animal proteins don’t feel approachable to you or that is not a food choice that shows up in your day, try things like eggs, beans, dairy, tofu, making smoothies, they all count to adding protein.

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You can also keep a list of your preferred low-effort protein sources. So things that don’t require cooking. Easy to prepare, easy to bring together. Things like rotisserie chicken, single-serve cottage cheese, tuna, canned fish, hardboiled egg. Things that you know work well with you, that you like, that are really easy, that are not going to zap your energy through the end of the day. And remember, convenience is a strategy. It is not a compromise.

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At the end of each section, I did include some recipes, some of our favorite recipes at Unite For HER. Sort of leaning into … I included some QR codes. Feel free to scan them. I’ll give this a moment. There’s a really delicious very berry avocado smoothie. I love this because we’re adding some healthy fats. With avocado, there’s a lovely creamy texture. We’re getting some omega-3s, and it’s providing some of that satiating energy. And then we’re getting some salmon bowls. Again, omega-3s, vegetables, some carbohydrates, healthy fats. So it’s a nice little mix of everything to support our protein, support our energy, easy to throw together, good for leftovers, good for meal prep. And if you don’t scan these, all of them are available at uniteforher.org on our blog. We’ve got a gazillion recipes.

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Plenty more to come moving on.

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Now let’s transition to something else that I’m sure you have dealt with or are dealing with and that is just overall appetite and taste changes.

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Regarding a reduced appetite, I do want to acknowledge the emotional weight of eating by obligation versus eating for pleasure. This is a real shift, and it is OK to grieve this shift.

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When your appetite is low and you know you have to get some sort of nourishment in, let’s go back to perhaps eating by the clock. Eating [on] a little schedule, setting a reminder for yourself, having a little something. Remember those hunger cues are likely reduced so we want to lean into other strategies to help remind us to get in a little something.

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In addition, you might find if you’re dealing with reduced appetite that perhaps your appetite is better mid-morning, early afternoon, leverage that. Use that as an opportunity to front-load your nutrition during those times when your appetite is best. Learn to strategize and leverage those opportunities. You can also make small additions that are energy dense, calorically dense without growing in volume. Adding a little drizzle of olive oil on top of your dinner, savory dishes is a great way to add some healthy fats. Adding a tablespoon of nut butter to your oatmeal or your yogurt, great way to add some in. Using full fat yogurt versus a skim or a 2%, great way to make every bite count.

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For the caregivers in the room, I do also want to make a note to offer small amounts of food without pressure. Try saying, “I made you just a few bites. Why don’t you have a little bit?” Rather than saying something like, “I need you to eat.” And we know that when we say that it is coming from a place of love, but a little bit of reframing in approach of how we say that can help reduce mealtime pressure, which can be an added stress. And that can actually help improve a person’s appetite. So just think about a little bit of reframing as you’re helping and preparing and supporting your loved on.

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Even when appetite returns, your taste may not. So taste changes are wildly common. Metallic taste, bland, sweet, salt, all of them and on any given day. Right? Any and all can certainly occur.

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And chemotherapy affects and medications affect all of those rapidly dividing cells, especially those that affect our GI tract. So our taste receptors in the mouth, one of the most common things because of their high turnover rate, but that also means that they regenerate. And that’s why some of you may find, depending on what your regimen schedule is like, you do see some improvement in between treatments and infusions. It’s because of that quick turnover and quick regeneration.

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A couple tips. If your food is tasting metallic, I’m sure many of you have tried or heard this, but we’ll review this together again. If your food tastes metallic, try using plastic utensils or leaning into tart. Adding a little bit of lemon can balance some of that metallic flavor so maybe you’re using an acid to your benefit.

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If things are bland, again, we’re going to try to punch up those taste buds a little bit. We’re adding some fresh herbs, we’re adding citrus, we’re adding vinegars, we’re adding acids to provoke our taste buds a little bit to bring on some more flavor.

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If, again, meat or animal proteins are not really speaking to your palate currently, shift to other proteins instead. You can get high quality protein from eggs, dairy, beans, tofu, all of that. And remember, taste changes fluctuate. What doesn’t work, these sort of strategies, what doesn’t work today may work next week. So try to be flexible and just do the best you can on a given day. And again, leaning into that designated rectangle box, you can keep some notes on what worked for you or what didn’t work for you. So as you’re sort of reflecting and moving through, you have some reminders versus trying to have to remember on your own, but this can be a great way to just keep note of what worked and what didn’t work.

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With that, let’s look at a couple more recipes that we have. Oh, I totally missed that slide. That’s OK. You got all of it.

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Here’s some of our favorite recipes. We have some chicken noodle soup, really nourishing, good for hydration. We added some turmeric and coconut for some really lovely flavor. And then we’re leaning into those herbs. We’re leaning into that acid with a beautiful herby vinaigrette for a salad. We use champagne vinegar for that, but you could use anything. It really helps to like brighten the palate, brighten the flavors, and really provoke those taste buds. So here are some of our favorite recipes that you can scan. They will all be available afterwards, I am sure.

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All right, so let’s get into the fun stuff. The stuff that nobody likes to talk about, but as a dietitian, we always ask. People are like, “TMI!” I’m like, “Never TMI. I want to know.” I want to know.

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Oh, nausea. All right. Nausea’s tough. The key with nausea is small amounts. When you’re eating, when you’re drinking, small amounts, little bit, much more tolerable. Nausea is often worse on an empty stomach. So try eating and keeping things nearby before the nausea wave hits you. Waiting until it passes can make it more challenging to deal with and get through. So try to stay ahead of the game. Keeping dried foods like carrots — not carrots — crackers, toast, things nearby that are bland can be good to keep something in your belly.

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One practical tip some of you may realize just in your own experience is how wildly increased your sense of smell is when you’re nauseous. That is so, so, so heightened and can be a trigger for your nausea when you are experiencing it. So if you are preparing food, if you are in the kitchen, if you are around someone that’s cooking, make sure things are well ventilated. Make sure a fan is going. If you’re preparing something warm, hot foods tend to be more aromatic than cold. Maybe you’re asking someone else to prepare that food for you, or you’re waiting until it cools down to room temperature just because it will have less of an aroma. So really be mindful of that.

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You can also lean into things like ginger and peppermint that can ease nausea sometimes. So sometimes that works.

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Although I will say reflux is one of those symptoms that can also present with nausea. And so you really want to be aware if you have other things going on, other digestive issues that may be aggravating your nausea. And in fact, if you are dealing with reflux, be aware of peppermint and mint. So while nausea by itself, it may be soothing, if you’re dealing with reflux, that can actually make it worse because what happens is it relaxes that lower esophageal sphincter between your esophagus and your stomach, that relaxation can cause the acid to come up.

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You really want to talk with your oncology team and be aware of sort of what’s going on. Are there other underlying things that you can address that in turn can help improve your nausea?

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And then on the other side of the coin, the lower GI. I think any time we’re dealing with lower GI, first and foremost, always thinking about hydration.

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Hydration is critical whether you’re dealing with constipation, whether you’re dealing with diarrhea. Something good to look for unless you have a medication that is altering, the color of your urine is a good indicator of hydration. You want to shoot for it being pale yellow. It doesn’t have to be crystal clear, but as long as it is lightening up as your day goes on, you can use that as an indicator for how well hydrated you are. For most people, this may look like 8 to 10 cups, 1 to 2 liters, but again, with certain regimens, being on a chemotherapy long term, those needs may go up. So you just want to be aware and connecting with your oncology team if you want to be extra conscious about your hydration.

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Constipation in particular, we know how prevalent that can be, especially with pain medication. If you’re dealing with this, likely medications are part of this conversation as well, but other lifestyle things that you can try. Going for short walks, a little bit of movement can help with digestion. Of course, using medications, talking to your oncology team as you need it. A little tip that you could try. Kiwi fruit can help with constipation. Generally, I recommend having two per day so you’re getting some hydration, you’re getting some fiber, but trying that. And in addition, I always lean into the tried and true prunes. When I worked in clinical oncology, like our oncology nurses swore up and down, they’re like warm prune juice or prunes. So I also lean into that as well. Not to say that it’s going to make things improve overnight, but I think if that is a chronic issue that you’re dealing with, just start to build that into your routine, to kind of support your bowel habits.

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And then on the flip side, if you’re dealing with some diarrhea, we’re really diving into hydration. All of that fluid and electrolyte loss can happen quickly, and dehydration can happen quickly. And dehydration can make you feel terrible. So really looking at replacing your hydration, replacing electrolytes. Lowering your fiber intake. So this is where we tend to take a break with fiber if you’re having a particularly difficult day or a couple days and then slowly bringing that back in.

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And of course, if any of these are persisting, please make sure you are communicating with your oncology team to make sure there are not other things going on.

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Some of our favorite recipes, ginger greens smoothie. So you’re getting some ginger for some nausea, greens for some fiber to help with digestion. These morning glory muffins are amazing. They have some dried fruit, they have some carrots and cinnamon and oats. They freeze beautifully. They’re light, but you get some fiber with it. So they’re just like a perfect light breakfast to have in the morning. There are two really great recipes.

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Let’s go on to a topic that is, I hear often, quite frustrating to some of us that are just dealing with body changes that are out of your control.

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So first unintentional weight loss. This is absolutely something to be monitoring and aware of because most concerning can be the loss of muscle. And when we know that there is unintentional weight loss and, in turn, loss of muscle, it can absolutely affect your strength and your overall energy. So in this instance, we’re really leaning into making every bite count. Energy dense foods, getting your protein in as best as you can.

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I want to dive a little bit deeper into this muscle loss in particular. Medically it’s what’s known as sarcopenia and it is a clinically significant indicator and associated with poorer treatment tolerance independent of total body weight. In other words, a person that may be losing muscle, even if the scale doesn’t shift, that can be a dangerous indicator for how well you tolerate treatment and if you’re able to stay on your regimen.

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So if you are noticing signs that you are losing your balance, your mobility through your day is declining, you don’t have the strength to get through your activities of daily living. That can be an indication that perhaps you’re losing some muscle mass, worth talking to your physician about how you can improve that.

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This is where focusing in on protein, certainly some gentle movement if you are cleared by your physician, is really worthwhile. That can help to maintain that lean muscle mass. And remember, if you’re trying to get those calories in, just adding in a snack, adding in a few bites in between meals, makes a difference. It all adds up at the end of the day.

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On the flip side of the coin, weight gain during treatment. This can happen as a result of a number of things: medications, hormone therapy, reduced overall activity. This is not a personal failure. There are lots of specific reasons why you may see this change. Things like corticosteroids during your infusion causes an increase in appetite, fluid retention. Hormone therapies, aromatase inhibitors. That can slow metabolism. It increases fatigue; that can reduce your physical activity. All of this is the product of treatment. It’s not the product of personal choices. So give yourself some grace.

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If you are looking to work towards a healthy weight, it’s always best to talk to your oncologist because it may not be appropriate just trying to reduce your overall calorie intake. We want to take it on a case-by-case basis. It may not be appropriate because if someone has a low appetite to begin with, we potentially worry about how that could affect your overall energy-treatment tolerance. But if that is something that your oncologist is like, “Absolutely, you can work towards it.” Working with someone like a dietitian so that you can find that balance of working towards a healthy weight without compromising your health and treatment tolerance is a really good avenue. So if your oncology center has a dietitian, of course, Unite For HER, we’ve got four on staff. We can help you along when that is appropriate.

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But at the end of the day, always just remember: Your body is navigating a lot. It is dealing with a lot. Give yourself some grace and lean into those that can help and support you.

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Some of our favorite recipes. These are some meal prep ideas. So these are some of my favorite meal prep, just easy things to throw together for breakfast. There’s a really lovely egg bake that is great for leftovers, some overnight oats and almonds, cherry overnight oats, which I make pretty consistently. It’s delicious. Some lunches. We have a warm quinoa bowl, that’s a meal prep that’s really fun, a salad, but just things that you can do when you’re feeling your best that you can prep and set yourself up well throughout the week.

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Let’s think about how do we take this flexible approach. When we’re trying to think of things that may resonate with you, how do we bring it all together?

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First I want to acknowledge the noise. A cancer diagnosis often brings an avalanch of advice from well-meaning friends and family about … Yeah, right. You’re like, “I didn’t answer this door to be open.” Yeah. But well meaning, well intentioned, talking about miracle foods, foods to avoid, extreme diets. It is OK, and in fact, it is protective for you to set a boundary around what you will listen and accept and take in. And for those that may be offering, remember they are offering because they love you and they care about you and they want to support you. So it is well intentioned, but sometimes you just have to listen and let it go and set that boundary for yourself as a means to preserve your well-being and to preserve yourself.

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In fact, even things that we’re seeing online, so those supposed anticancer diets, those miracle cures, there’s much less evidence to support the things that we see on social media. But in fact, what we know actually works is consistency.

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Consistency meaning the foods that show up every day, consistently, are what make an impact on a person’s health and well-being. It’s not the stuff that shows up once a week, once a month. It’s not the ice cream you have at the boardwalk on the summer. The indulgent foods that show up here and there and you can lean into that to give you that sense of control. Focusing on the things that show up regularly are what make a difference.

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In a healthy diet, all foods fit. Of course we want to be consuming more of the things that are nourishing and energizing and a little bit less of the foods that are indulgent and a little more fun to eat. Perhaps what we had at our pajama party, but this is not about taking an all-or-nothing approach.

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And in fact, this is good because you can recognize the ups and downs of your day. Some days all you can get in is soup or liquids or toast. Other days you’re like, I’m feeling good, I’m doing some meal prep, I’m getting in some protein, I’m getting my hydration in, the ups and downs. So don’t let the ups and downs sort of frustrate you, knowing that that consistency, the long-term patterns are what make a difference.

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So how can we bring this into play?

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We like to take this flexible approach. And I like to use a plate because I am a visual learner. So as I’m sort of envisioning meals and putting things together, I like to envision my plate. So really basic structure and it’s basic because that means each and every one of you can take it and tailor it to your own preferences: what you like, how you’re feeling, who does the cooking, who does the shopping. This can be applied to all of you.

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First, anchor it with protein. Think about your protein foods. And then we’re going to add some color. Eat the rainbow, fruits and vegetables, antioxidants. It’s all about variety. So adding in some color, and then we’re adding in some energy. Carbohydrates, healthy fats. We’re supporting our heart health. We’re getting those omega-3s. They’re also antioxidants. So we’re using this as a basic outline.

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It seems pretty simple, but we tend to overcomplicate nutrition. We’re really good at making it difficult and challenging and complicated and fancy and expensive and it just does not have to be that way. So we’re using this basic model and it can be tailored and nuanced to each and every one of you.

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And again, patterns over time matter much more than just one single meal. So if you have a “perfect day” followed by 3 days of skipping meals, not getting in your hydration, that does not behoove you. Whereas regular patterns, getting in some consistent nutrition, that’s where the magic happens.

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All right, let’s talk about anti-inflammatory. I am often asked: “I want to eat anti-inflammatory. I want to follow an anti-inflammatory diet.” And there’s good evidence that a Mediterranean style diet emphasizing whole foods, plant diversity, healthy fats, lean proteins do in fact support our overall health, support overall immune health, support our heart health, support our bone health. There is very good evidence behind it. However, anti-inflammatory in the cancer context is so wildly over commercialized.

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Again, we’re really good at making things complicated and fancy and expensive and restrictive. And eating an anti-inflammatory does not have to be that way. It is very approachable.

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Give yourself practical permission as you follow this sort of flexible plate model. If your treatments are making vegetables or fruits a little bit less tolerated, it’s OK to set them aside for a moment. Come back when you’re feeling better. Changing things up like utilizing frozen fruits and vegetables. They’re equally as nutritious. They’re great on the wallet. They’re super versatile. They’re oftentimes more easily digestible. Remember convenience is a strategy, not a compromise.

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Using things like canned salmon, sardines, a great way to get in some omega-3s. And again, I want to reiterate it’s not about extreme elimination diets. It is about taking that approach of adding in, adding in what feels good to you.

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Food and emotional wellness, because we all have a very close relationship with food in one way or the other. Oftentimes when we are gathering, we’re hanging out with family at the end of the night, where do we end up? In the kitchen. Right? So we all have that close relationship with food.

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Oh my gosh. I have 2 minutes left? OK. Oh my gosh. I was afraid I was going to be under. That’s OK.

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Let me ask you a question because this is really interesting. Has anyone found that food has taken on a different meaning, more or less, since your diagnosis? Yeah. Right? We look at it differently.

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Many of you feel that eating right is one of the few things that you can control. Others may feel guilt about what you’re eating or not eating. I want to assure you both are completely normal responses to have. It’s OK to feel all the things.

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Acknowledge that grief around food. Not being able to taste your favorite food, feeling too sick to attend or eat at a family gathering, having to avoid some of your favorite foods, these are real losses. So understand and give yourself compassion with that shift.

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And if you find that these emotions are really heavy and they’re really weighing on you and it’s causing you a lot of stress, this is a great opportunity to reach out for some help. Talk to a social worker, talk to a dietitian, talk to your oncology team. We want food and nutrition to be something supportive, not something that’s weighing on your shoulders. And sometimes it just takes a little extra support or working with someone that can help you.

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I will share this very quickly. Oh, I forgot that slide again. OK, that’s all right.

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I do want to hit on this: body kindness. We talk a lot at Unite For HER about body kindness. My colleague Michelle did a really fabulous presentation recently for an education segment. I included the QR code to see the link to watch that video. It’s all about treating your body with compassion, with respect and gentleness. Just showing yourself some love and grace as you’re navigating the space and you’re just trying to do the best that you can make every bite count. So showing yourself a little bit of love. And that not only includes nutrition, but it also includes movement, what feels good physically.

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Putting it all together. Can I do it in 19 seconds? Probably not. OK. That’s fine. That’s OK. We’ll get through it. We’ll get through it together. OK.

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Gentle framework. Very quickly, before we wrap things up. Gentle framework, know that there are going to be good days and there are going to be hard days. Good days, you have some snacks, you have some meals, you focus on hydration, everything is great. Hard days, you give yourself grace. You say to yourself, “I’m going to do the best that I can today.” Maybe you’re leveraging those good days when you feel best to set yourself up for success when you know you’re going to have some hard days coming. But we just give ourselves some grace.

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Both days are valid, just honor them and do the best that you can.

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When to seek extra help. These are probably obvious and I’m sure your team has gone through many of these with you, but if you do have ongoing weight loss, if you have persistent symptoms, GI symptoms, nausea, difficulty swallowing, fatigue is limiting your day, please speak with your oncology team. Connect with a dietitian.

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And lastly — I promise I feel like the orchestra’s going to go. When to seek extra … I’m sorry, key takeaways. Whoops.

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Remember, food supports strength, not perfection. Small, frequent nourishment does help with steady energy. It’s not a problem solver for fatigue, but it does support as you move through your day. Focus on protein. It protects our muscles as well as all of the other amazing things proteins do in the body. Flexibility matters more than rigid plans. And finally, and I think most important, kindness towards yourself may be the most important of all.

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Small consistent action matters more than just one perfect day.

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So with that, I will leave some points for reflection and then I believe we will take some questions, but thank you.

Lynn Folkman (00:38:01):

Thanks Erin. Thank you for distilling it down. And boy, we do complicate things.

Erin Pellegrin, RD, LDN (00:38:09):

We do. We’re really good at complicating everything.

Lynn Folkman (00:38:12):

One thing I want to say before my first question is these slides are going to be available on lbbc.org. So no worries if you didn’t capture everything and the QR code, so relax about that. All right.

(00:38:25):

You talked a lot about hydration and someone had a question and I know you mentioned electrolytes, but they’re having trouble finding one that they like. And do you have any suggestions?

Erin Pellegrin, RD, LDN (00:38:37):

Oh, that’s a great question. There’s a lot of ways that you can approach this. So there are a lot of different brands out there. You want to pay attention to the electrolyte quantities that are included in the particular product. For example, there are some brands that are much higher in sodium. So for those that may run lower on the blood pressure ends, this may be appropriate for them. Whereas those that might have higher blood pressure, you want to kind of do a little bit of comparing and contrasting and find a middle of the ground. So typically electrolytes will have sodium, potassium, little bit of magnesium. They might throw a little bit of calcium in there, but slim to none. And those are your primary electrolytes. We lose those mostly through fluid losses.

(00:39:28):

You just want to pay attention. I think any products that have like extreme electrolyte quantities aren’t necessary for most of us. So just pay attention to the particular brand and of course finding one that you like. You can always make your own sort of electrolyte mixture on your own. Coconut water is a really great source of potassium, so that can add some of that. You can add a little bit of salt on your own, some fruit juice or some fresh fruit to add a little bit of magnesium, so you can certainly create that on your own.

(00:39:58):

And then I will say if you are not having excessive fluid losses and your appetite is good, chances are you’re getting your electrolytes from your food. Remember, we get sodium, potassium, magnesium from foods that we’re eating as well. So unless you have excessive fluid loss through sweating, diarrhea, vomiting, if you have a good appetite, you may not always need an electrolyte replacement. Great question.

Chelsey Pickthorn (00:40:29):

Thank you so much, Erin.

(00:40:30):

I just want to acknowledge how much I appreciate the approach that food is not static and that we are ever changing and changing treatment lines, different things, we have different side effects, and everything like that. I just really want to acknowledge how much I appreciate that approach. So thank you so much.

(00:40:58):

I was curious if, someone asked, if the recipes are available in Spanish. And I thought that that was very important.

Erin Pellegrin, RD, LDN (00:41:08):

Some of them are, some of them are not. However, Katheryne on our team leads our Latina program. So if there is anyone that is looking in particular for a recipe that is not available in Spanish, we can absolutely have her translate for that person.

Chelsey Pickthorn (00:41:24):

Amazing.

Erin Pellegrin, RD, LDN (00:41:24):

Yes.

Chelsey Pickthorn (00:41:25):

I just want to double down on another one here. Are there any suggestions or foods that are more tolerable for someone who has liver metastases?

Erin Pellegrin, RD, LDN (00:41:38):

Ooh, great question. OK. When your liver is involved, there’s a couple of things to think about. One, we want to just understand the degree of involvement. So is it affecting your liver function? Or are things pretty normal? LFTs are normal? OK.

(00:41:56):

When we think about food and nutrition, we’re going to look at this two ways. Number one, we want to think about refraining from things that may put added stress on your liver. Of course medications, over-the-counter medications, your team will review that with you, but also what comes to mind most prevalently is alcohol. If there is liver involvement, absolutely we know the relationship with alcohol and several cancers, but especially when the liver is involved because it is broken down through the liver, that is something that we want to avoid.

(00:42:28):

On the flip side, we want to think about nutritionally how we can support our liver health. Number one, we’re focusing on hydration absolutely. Number two, cruciferous vegetables. The sulfur compounds that are found in all of our cruciferous vegetables have been very well studied in terms of supporting liver health. So as you’re getting in your color, as you’re getting in your fruits and vegetables, whether they’re raw, cooked, steamed, roasted, however, throw in some cruciferous vegetables if you can as a means to support your liver health. Omega-3 fatty acids are very important to supporting liver health as well and making sure vitamin D is within normal limits. So if you are having routine lab work, many of us are deficient in vitamin D anyway. If that is something that you need to supplement with because it is not found in many foods, just making sure that those values are within normal limits.

(00:43:19):

And then green tea, that was the last point I wanted. Green tea, so the antioxidant found in green tea also has been supportive of liver health. I always recommend adding a cup of good quality green tea or two into your day. If you enjoy a matcha, having some good matcha once a day is a great way to get that healthful antioxidant. You’re welcome. Great question.

Lynn Folkman (00:43:44):

OK. You talked a lot about protein.

Erin Pellegrin, RD, LDN (00:43:47):

Yes.

Lynn Folkman (00:43:47):

How about protein powders? Thoughts?

Erin Pellegrin, RD, LDN (00:43:49):

Oh, great question. Yeah. I think it’s all about the way we approach protein powders. They should never be a replacement for getting whole food protein in, but they can be — we’re going to go back to that convenience is a strategy, not a compromise. If you are working towards getting your daily protein up, this can be a good strategy to help boost you a little bit.

(00:44:16):

You just have to find one that works best for you. So if you prefer a whey-based protein, they usually are the most well tolerated, but there’s lots of plant-based proteins that have a mixture of seeds and nuts and pea protein that can be a nice plant-based combination. So you want to find one that you like.

(00:44:35):

In addition, I want to remind us, especially if we’re using it in things like smoothies, we can very naturally add foods that are a good source of protein without the supplement. So think kefir, yogurt, our seeds like flax, chia, hemp are a great way to add in some omega-3s and plant protein. You can add in some nut butter to it, a tablespoon or 2. So there’s other natural ways if a supplement is not necessarily your preferred method that you can create something that’s a quality source of protein.

Chelsey Pickthorn (00:45:06):

Amazing. As we all know, white blood cell counts take a hit through a lot of treatments. Do you have any suggestions for foods or activities or things that can help boost our white blood cell count?

Erin Pellegrin, RD, LDN (00:45:22):

I love this, and I’m glad you mentioned activity too. This is tough because usually when this happens, the driver is a medication regimen that you’re on, a treatment regimen. Food, unlike sometimes when we see with red blood cells, it can be difficult to really make a dramatic difference when we’re looking at lifestyle and food and nutrition approaches. However, I do think it is still really important to do what we can to support our immune system. So what do we talk about? The majority of our immune cells are created in the gut. So we want to think about supporting our gut health. So plant foods, fiber, antioxidants, omega-3s, all of which support our gut health, support our immune function. Number two, we’re thinking of protein. So immune cells are proteins. This is another reason why getting in those protein foods throughout your day is so important because it does in fact support immune cell creation.

(00:46:20):

Hydration is a big part of this as well. And then movement, gentle movement supports our immune system. You may be really compromised so going to a place where there’s a lot of other people may not be realistic, but you can do things at home, you can do yoga at home, gentle movement, things within your safe space where you’re not at risk for illness or getting sick or just being in contact with germs. But definitely some movement. Walking, getting fresh air is another way to support your white blood cells, your immune support.

Lynn Folkman (00:46:54):

OK. This is always a popular one. Does organic produce matter? And where do you stand on that? And if so, do you have a recommendation for a produce wash for non-organic?

Erin Pellegrin, RD, LDN (00:47:07):

Great question. So our approach to nutrition, our goal for everyone is to eat fruits and vegetables. Period, end of story, whether they are organic or conventionally grown. We want you to get the fiber in. We want you to get the antioxidants in. We support members, as LBBC does, from all across the country. And we understand food access and the cost of food absolutely affects our choices. So we want you to get in any type of fruit and vegetable that you can. The nutritional value is there. It is not compromised as a result of conventional versus organic. The goodness that we want you to consume is there.

(00:47:50):

Now, if organic is important to you, there is a really strategic way to make choices that can help work along with your food budget. If you’re looking to shop organic, the first thing I say is identify the foods that you consume regularly. If there are certain things, two or three fruits or vegetables that are showing up all the time. I often give the example of an apple. I personally eat an apple pretty much every day of my life. I love them. I always buy organic apples because they show up all the time. Things that don’t show up all the time, don’t worry about spending the investment if it’s not a priority for you. So number one, what you consume regularly.

(00:48:30):

Number two are the things that have a soft skin that might hold on to some of those pesticides that may be more difficult to clean. So leafy greens, your berries, things like peaches. If you consume them regularly, that can be a good area that you can focus in on buying organic.

(00:48:50):

It is worth noting, I’m sure you know, organic produce is also treated with herbicides and pesticides, so it’s not that it goes without, and we should always be washing our produce. I personally prefer a combination, a 1 to 3 ratio solution of white distilled vinegar, 1 cup, and 3 cups of water. And I just soak my berries or my grapes for 8 to 10 minutes. I give them a good rinse and then they’re nice and clean. If you need something that has a harder skin and you use like a produce brush that you can give it a little bit of a clean, that’s a great way to do that too. Great question.

Chelsey Pickthorn (00:49:25):

I just have a, curious, personal question. How do you feel about the dirty dozen? Do you ever use that at all or are you familiar with it?

Erin Pellegrin, RD, LDN (00:49:35):

I am familiar with it. I use those kind of recommendations just as a loose guide. It is not a be all end all. I don’t live and die by that list in particular. I look at it every year. I kind of see what they say, and I kind of let it sit in the back of my mind.

(00:49:52):

I get nervous with lists like that because I think sometimes they can create a lot of fear and anxiety around food choices. And like I said, what I want for every single person that we connect with is to eat your plants, eat your fruits and vegetables, and get them in because you will in fact reap the benefit of all of the nutrients that are in it. So use that as information gathering.

Chelsey Pickthorn (00:50:12):

Absolutely. And that leads into this next question about, again, a similar situation of when family and friends are commenting, making suggestions. Do you have any recommendations on how to gently maybe respond or give some kind of boundaries around that?

Erin Pellegrin, RD, LDN (00:50:31):

Yeah. This is hard. This is hard because what we want to say is not what we should say.

(00:50:43):

I think it’s about approaching with compassion and speaking up for yourself, but in a way that is not disrespectful. I think it’s OK to say, “I appreciate you sharing that. It’s not really helpful or what I need right now, but thank you.” End of story. “I would appreciate if you did not share that sort of information.” Or that opens up, sometimes those comments can open up the door for conversation for you to just be vocal about what is important to you. “I appreciate you sharing that. I am focusing on my health. I’m working with my dietitian, my oncology team. They are monitoring my nutrition status and my health closely. I got this. Thank you very much.”

(00:51:32):

So I think it’s OK to be firm but gentle and really just use it as a means to communicate your own boundaries as a form of self-protection.

(00:51:41):

It’s tough. That’s tough.

Lynn Folkman (00:51:46):

What is the current school of thought on consuming phytoestrogens if your breast cancer is hormone positive and how that relates to, again, tofu and tempeh.

Erin Pellegrin, RD, LDN (00:51:59):

Absolutely. Love this question. This is so good. It’s perfectly safe to consume.

(00:52:02):

Here’s what I will say again, when it comes to food and food choices, your preferences matter. You are the driver of the bus and this matters so much, especially around conversations about soy and phytoestrogens because historically what we may have initially been told, we make that decision and we’re like, “Never again, I’m never having tofu. I’m never having tempeh. I’m never having edamame again.” We just make that decision, and we respect that.

(00:52:33):

What we do know is that it is perfectly safe and healthy to incorporate soy foods among other foods that can contain phytoestrogens, they will not cause cancer growth, even hormone receptor-positive cancers. In fact, studies show that they may actually have a protective effect, and phytoestrogens are antioxidants.

(00:52:58):

You really want to make sure that you are incorporating high quality, whole food soy foods, so that is edamame, tofu, tempeh, miso, even unsweetened soy milk is a great option, and not having soy supplements. But it is perfectly safe and healthy, great source of protein and fiber.

(00:53:17):

But again, even with what we know, it comes down to your comfort level. And if the thought of consuming soy foods is anxiety provoking, it’s not worth it. There are other things that you can incorporate that are just as nutrient dense that you can feel good about.

Chelsey Pickthorn (00:53:38):

Thank you so much.

(00:53:41):

You mentioned that muscle loss can be an indicator that treatment is, I don’t know the word you used exactly, but that it’s not responding well, basically. What is the way that muscle mass is being measured first and foremost? And, the question is, should I be bringing up the idea of starting a routine DEXA scans?

Erin Pellegrin, RD, LDN (00:54:10):

Oh, great question. OK. So DEXA dealing with bone density, we’ll answer that second, but that’s sort of like a separate thing.

(00:54:17):

In terms of measuring muscle loss, there are calculators that your oncology team, your clinical dietitian can use to assess muscle loss. Some visual things that you may notice are like some temporal wasting you might see here. If your collarbones are protruding a little bit more, they can all be indicators that you’re losing some muscle mass. Also, again, if you are finding it more challenging to move throughout your day, to stand, to keep your balance, to lift a laundry basket, to put stuff away in your kitchen. Some of those ADLs are becoming more challenging because you don’t have the strength to do them, to sustain them, more so than just when you’re feeling fatigued. That is an indicator that there may be some muscle loss.

(00:55:05):

So there are a couple ways to look into that and that answers the first question. Right?

(00:55:10):

Then moving over to DEXA, that’s looking at bone density and you could definitely speak to your physician. If you are on an aromatase inhibitor, if you have hormone receptor-positive cancer, chances are you are getting a DEXA scan every 2 years depending on what your bone density is. If you have not had one, maybe you have triple negative, you are not on an aromatase inhibitor, but if you are of age where estrogen is declining and you’re at increasing risk for developing bone disease, it’s always worth asking. Is it appropriate to get a DEXA scan? I haven’t had one? Or how often do you have them? Bone density changes happen very slowly, which is why they don’t order them very often. It’s like every 2 years, unless there’s something that prompts it to look at a little bit sooner.

(00:55:58):

Thank you. Great question.

Lynn Folkman (00:56:00):

Thank you. Are there foods that help reduce hot flashes?

Erin Pellegrin, RD, LDN (00:56:09):

I would be a billionaire if I had that answer. All right. Oh my gosh.

(00:56:18):

Here’s what I know. Oh gosh. All right. Hot flashes, that’s tough. I’m hot already. Oh gosh. OK.

(00:56:28):

We look at this two ways. So yeah, number one, you look at the foods that tend to provoke hot flashes. So alcohol, spicy foods, acidic things, it’s so nuanced person to person. So these are just some things that we think about. OK, maybe a little bit of food journaling can help what may bring them on for you, but oftentimes they just come on hot and heavy. Pun intended.

(00:56:51):

On the flip side, interestingly enough, there is some evidence that looks at the consumption. There was a research study that looked at the consumption of soy milk. So going back to these phytoestrogens and it actually helped to improve vasomotor symptoms.

(00:57:10):

I think in this study, participants consumed an 8-ounce glass of soy milk, whether it was a smoothie or a yogurt or however they had it. And over time, with consistency, they found their hot flashes and night sweats were reduced. They did not go away, but the intensity had reduced.

(00:57:29):

And that goes back to the phytoestrogens and that protective effect that they may have on our receptors in our body. They may actually help to reduce some of those medically induced menopause symptoms, most specifically vasomotor symptoms.

(00:57:46):

With that, what I would say is if hot flashes are something that is really plaguing you, certainly try to bring in some wholesome daily soy foods, phytoestrogen foods, to see if over time you notice an improvement. In addition to that, other things may also be helpful. Things like acupuncture or reiki may be helpful with that. Exercise may help to lessen it. Again, it’s so nuanced, for some individuals it helps, for others, it doesn’t. So it’s a little bit of a hit or miss, but hopefully that helps.

(00:58:19):

That was some really exciting research that my colleague Aubrey and I were looking at recently, so there’s a little bit of promise there.

Chelsey Pickthorn (00:58:27):

Amazing. Thank you so much. I know for myself, I actually lowered the amount of fried food that I took in, especially just throughout the years now. And what are your thoughts on seed oils?

Erin Pellegrin, RD, LDN (00:58:42):

Oh, great question. Oh gosh, seed oils.

(00:58:47):

This is where it gets very trendy that seed oils get a really bad rap. I say, let’s not vilify one particular ingredient, but especially in the conversation of seed oil, what I often say is let’s take a step back. So let’s look at the product in which we are finding seed oils. They’re often found in foods that are ultraprocessed, lacking in nutrition, lacking in fiber. These are some of those indulgent foods that maybe we want to have a little bit less of, remember we’re not all or nothing, versus what we want to have show up regularly. And so when we’re consuming foods that are ultraprocessed, highly refined, like have things like seed oils in them, they, with regular consumption, can contribute to a lot of different health disparities. Diabetes, overweight, obesity, heart disease.

(00:59:38):

I think as opposed to trying to identify one ingredient like a seed oil and saying, “This is the problem.” It’s not. Let’s take a step back and look at the bigger picture and say, “Oh, well, the Doritos that it’s in, maybe that’s the problem.” It’s not the one particular ingredient.

(00:59:56):

Be cautious when you’re seeing specific ingredients being called out. And again, take a step back and look at the big picture, and we use our common sense. I know when I pick up Doritos, I’m not eating it because it’s healthy. I’m eating it because they’re delicious. So use that as a little bit of judgment as you’re moving through the grocery store.

Lynn Folkman (01:00:20):

Great. Thank you. OK. How strong is the evidence that nutrition can influence outcomes, progression, survival, quality of life in metastatic cancer?

Erin Pellegrin, RD, LDN (01:00:31):

Oh, great question. So the evidence sadly enough is like moderate. Really looking at nutrition and breast cancer, metastatic breast cancer in particular, when we’re looking at linking the two.

(01:00:46):

The strongest evidence with nutrition and food choices is actually with colorectal cancer. However, this does not mean that we don’t want to lean into nutrition to support overall health. We know the benefit of good nutrition, plant forward way of eating, heart healthy fats to support our heart health. And we know estrogen plays a big role in heart disease risk. So for those that are on hormone therapy, many medications have cardiotoxic effects long term. So we want to think about heart health. It supports a healthy weight, supports our gut health.

(01:01:28):

So while that direct link, sadly enough, is more in a moderate range, it does not mean that focusing on nutrition, supporting overall health is not important and can make a difference in overall quality of life.

Chelsey Pickthorn (01:01:44):

Thank you so much. Thoughts on bone broth?

Erin Pellegrin, RD, LDN (01:01:48):

Fine. Great. Not a magic food, but if you like it, it can provide some collagen, it can provide some hydration, some electrolytes. I love sipping on a bone broth or a vegetable broth if I am having a little bit of unease, if my belly is upset, if I need something warm and comforting. So yeah, fine.

Lynn Folkman (01:02:10):

Thank you. OK. I’ve heard to eat full fat yogurt, but what about cholesterol in full fat yogurt? And is that bad for people who have high cholesterol?

Erin Pellegrin, RD, LDN (01:02:20):

Yeah, great question. When we’re looking at lipid cholesterol levels, we know that the biggest driver — from a nutrition perspective, saturated fat is the biggest driver of lipid cholesterol levels. Overall you really want monitoring your dietary saturated fat intake versus dietary cholesterol. Like eggs are off the hook.

(01:02:44):

You have to look at, I guess your individual scenario. If you are a person that has a history of heart disease, hyperlipidemia, so your cholesterol’s already high, then yeah, you may want to choose a lower fat yogurt just to lower some of that saturated fat as terms of a heart healthy approach. But if you do not have any issues with your lipids, your heart health is fine, then having a full fat yogurt I think is fine.

(01:03:11):

And of course you want to look at that in context of other things that you’re eating. Are there other areas where you’re consuming a lot of saturated fat that you might be able to make a healthier adjustment to support your overall heart health? So you really have to, again, look at the big picture of what else you’re consuming throughout your day.

Chelsey Pickthorn (01:03:28):

Thank you. Hot topic. GLP-1.

Erin Pellegrin, RD, LDN (01:03:34):

Another session? Yes. Oh gosh. How do I pare this down? We are like moving towards a really promising way of health with GLP-1s. I think there’s a lot to learn. It’s not for everyone. I have found most compelling the positive impacts on heart health that being on a GLP-1 medication may provide for those in which it is warranted.

(01:04:11):

If you are considering a GLP-1 and looking at your overall health, we do know overweight obesity can be a contributor to breast cancer risk or disease progression. If working towards a healthy weight, other strategies have not worked, it may be worth having a conversation with your physician. It’s not for everyone. It should not be looked at as a magic medication. There should be lifestyle and exercise habits that come along with it as opposed to just leaning into medication. But I think that it can make a positive impact and especially as the thousands of members I’ve talked with over my years with Unite For HER, I hear the frustration of the body changes that happen, especially with medications, hormone shifts and the frustration with trying to do everything you can and just not seeing a change and really trying to play a role in your health. And this is where GLP-1s may be part of that conversation.

(01:05:24):

I think there’s still a lot to learn, a lot to be studied. There are some instances, like I said, especially with heart disease, there’s some good evidence and studies that have come out in terms of supportive of heart health, but it could be worth a conversation.

Lynn Folkman (01:05:42):

Thank you. Actually, I think we’re going to end it there because my next question was more about body kindness that you already talked about, which I think leads into what you just talked about.

(01:05:56):

Such great information. I have many notes, so thank you. And just so many tidbits, but I love that convenience is a strategy, not a compromise. And I think the patterns over time matter. And isn’t that with everything?

Erin Pellegrin, RD, LDN (01:06:20):

It’s with everything. I know. Anything that promises an overnight and immediate, it’s a red flag to go up. Like I say, nutrition, we are really good at complicating it. Good nutrition and approach, no matter what that looks like, generally is pretty not sexy. And as much as we try to make it really sexy, what works is consistency, plant forward, hydration, but also taking food and enjoying it with others, spending time using it as an avenue to connect and show love and support. So it’s so much more than just we’re putting in our bodies, although that is important and impactful on health, but we want to think about it on a bigger scope as well.

Chelsey Pickthorn (01:07:13):

Thank you so much, Erin. This has been an incredible session and I just—

Erin Pellegrin, RD, LDN (01:07:18):

Thank you.

Chelsey Pickthorn (01:07:18):

I just am so grateful.

Erin Pellegrin, RD, LDN (01:07:20):

Thank you. I appreciate it.