Episode 5 Part 1: Nutrition and Cancer

[0:00:00 Speaker 0] We’re

[0:00:02 Speaker 1] a resource for learners, including every member of the live strong cancer institutes on track. Educational pipeline from middle school to residency. We’re growing collection of interviews, talks and experiences the uncover the myths and the uncertainties of cancer and careers in cancer in order to empower and inspire generations of thinkers and leaders. Thistles, cancer uncovered, uneducated in and empowerment podcast by the live strong cancer institutes.

[0:00:40 Speaker 2] Welcome back to cancer Uncovered. My name is Kristen Win, and I am part of the live strong Cancer Institutes and Emerging Academic Cancer Center at Del Medical School at the University of Texas at Austin. This month. We’re uncovering cancer and nutrition with two in house experts. Alejandra de Angulo, PhD and research fellow with the Livestrong Cancer Institutes Developmental Therapeutics Lab, and Crystal Zuniga, registered dietitian for the Live Strong Cancer Institutes Clinic With UT Health Austin. The study of nutrition is layered and fascinating, especially when you think of it in terms of preventing cancer or being used as an incredible tool to help a person with cancer to support their physical and mental health through their treatment. Unfortunately, access to professional dietetic support for cancer patients is severely lacking. According to a study by the National Cancer Institute, up to 80% of cancer patients suffer from malnutrition at some point during their treatment, depending on tumor type and stage of cancer. And malnutrition is responsible for one in five cancer related deaths. And yet Medicaid and most insurance companies currently don’t cover nutrition for cancer patients. Theus Association of Community Cancer Centers, in a study conducted in February of 2020 shows that an outpatient cancer centers places people go to get cancer treated. Other than a hospital, the ratio of registered dietitians to cancer patients is 1 to 2300. We’ll also take some time in this episode to address the lack of diversity in the field of nutrition and dietetics itself. What are the barriers to becoming a registered dietitian? In this episode, we’ll also talk with Crystal about her role as the registered dietitian at the Livestrong Cancer Institutes clinic. But first, let’s break it down. What is nutrition Besides eating food?

[0:02:43 Speaker 0] Nutrition is so much more than food. Nutrition is a science, and nutrition is a science that involves the study of the nutrients in food, how the body digests absorbs, uses excretes those compounds in food and then the relationship between diet, health and disease. So it’s really the study of what on Lee is in food, but what our body does with those compounds and how the pattern of the food that we eat impacts our overall health and risk of disease. That’s

[0:03:24 Speaker 2] Crystal Zuniga, registered dietitian at L. C. I.

[0:03:28 Speaker 0] Nutrition is important in that the nutrients in the food we eat becomes in effects, every single cell in the body. So we literally are what we eat. We cannot function without the energy and the nutrients that food provides. What we get from our diet is needed for growth, maintenance, repair and other vital functions in the body. So when there is a change in function of the body, like in chronic disease such as cancer, nutrient needs changed because the demands and the functions within the body have changed. So we need to understand how to make dietary adjustments based on what the needs of the body are during cancer.

[0:04:18 Speaker 3] If you think about it throughout our life, I don’t know. We have something around. I think one of my textbook once said, like around 100,000 meals through our life. That means that every day you have to make food choices right. And those choices, maybe not one but over time can potentially influence your health to better and worse. So if you’re very, very careless about those food choices over time, that can lead to chronic diseases, and one of them that now we have enough research is cancer. So, for example, it’s well known that nutrition is quite important for cancer prevention. So there’s research that suggests that having lower consumption of processed foods and red made and alcohol can actually significantly reduce your risk. So that’s one of the reasons why it’s important. That

[0:05:20 Speaker 2] was Alejandro de Angulo, who is currently a research fellow with Elsie I but is also an adjunct professor at UT Austin who teaches an online graduate course in cancer and nutrition, now more on prevention with crystal

[0:05:34 Speaker 0] for the prevention of cancer. Yes, there is quite a research in this area. Several lifestyle factors, including diet, are associated with a reduced risk of developing cancer. It’s actually has been estimated that up to 50% of cancers could be preventable through lifestyles and avoiding exposure to environmental carcinogens and some long term infections. So there are lifestyle factors that are associated with the risk of developing cancer. Cancer is caused by DNA damage in the cells from carcinogens and our environment or viruses, inflammation or sometimes just missed aches the cell makes during normal cell division. Our diet can impact our cancer risk through some of those mechanisms on how cancer develops so several ways. One of them is that food from our diet can actually be a vector for exposure to carcinogens. For example, heterocyclic amines, which are formed from grilling meats. This is a known carcinogen. We’ve also learned how nitrates and nitrates that are in process. Meats are also listed as a probable carcinogen, so food itself could be a way of introducing carcinogens that could damage DNA but also nutrients. And our food could help enhance some of our mechanisms in place in the body. Already to defend against DNA damage, for example, there are nutrients and other antioxidants that can come from food that support the body’s ability to detoxify carcinogens that could damage DNA. So, for example, they’re involved in detox systems in the liver, or they can fight against free radicals that could damage DNA as well. Also, nutrients from food are absolutely required for the function of some of our DNA damage. Repair mechanisms and then another area of a growing research is the role of obesity and how obesity can lead to chronic low grade inflammation or alter hormone levels that could create an environment that is more conducive to cancer development. So that’s broadly just a few examples of how nutrition, not Onley, impacts our exposure to things that could damage DNA. But it impacts the body’s defense against stressors, and it also influences the environment in the body that can promote cancer development in growth. So we see the role of nutrition not only in prevention but also in the development of cancer as well. In

[0:08:40 Speaker 2] my conversations with Crystal and Alejandra, we talked about the common misconceptions, the myths around nutrition as well as cancer and nutrition.

[0:08:50 Speaker 0] There are so many, I feel like whack a mole in what myth I’m gonna here. Really, I think one of the biggest ones is that there is one anticancer diet. You know, there is really no one diet for anything. There is not one disease several 100 types of cancer, and even cancers that come from the same tissues can have different mutations or subtypes. So just like there isn’t one treatment for all cancers, there is no single diet one patient should follow, and

[0:09:27 Speaker 3] that’s kind of

[0:09:27 Speaker 0] in reference to. There’s a lot of attention about the Keto diet or intermittent fasting in cancer, and there is some interesting stuff coming out there, but we simply do not have enough. Human studies on their benefits are role during cancer, and we don’t change our diet recommendations based on one study or even a small handful of animal studies. So we really need more human trials to change our general recommendations about diet and cancer. So there is no one diet that someone should be following during cancer and really recommend that patients focus on foundational needs of the body. You know the body does not need tumeric as one example, but it absolutely needs adequate calories, protein fluids and essential nutrients, so also not want anticancer diet. We do know that everyone should try to meet those foundational needs of energy, protein nutrients and fluid, so nutrition in cancer is not about rigid dietary restrictions and that diet should not be regarded as a tour for cancer, but rather a tool to help us support the individual under treatment and that we can help use nutrition as a way to enhance quality of life and the nutritional status of a patient. So I think a common misconception is that it’s either diet or cancer treatment when really we should be looking at how diet can support cancer treatment.

[0:11:18 Speaker 3] And I think that’s why a lot of people are confused, too, because they may say in the news they just pick up one study that said it was good and then three months later there’s one that actually contradicts and people are so confused. That’s why we read those analysis that encompass all of them. Sometimes we call it meta analysis it just all together. It was like, Okay, this is enough to us to establish that. Yes, eat your whole grains, eat your fruits and vegetables, and then maybe have more moderate consumption of processed meat, red meat. And I think people think about diet as a restrictive meal pattern, and they think about the oh, I’m gonna diet. But they weren’t diet. Actually means what do you eat doesn’t mean a restricted pattern or a restricted diet, and I think that’s a big difference. So when you eat, if you think literally, when people say I’m gonna diet, they’re saying I am in a eating pattern s Now that

[0:12:26 Speaker 2] we’re more aware of some of the myths surrounding cancer and nutrition, let’s talk more about the role that nutrition plays in cancer care.

[0:12:34 Speaker 0] Oncology and nutrition is a very complex and complicated field, and cancer treatments are designed to kill cancer cells, but they can also damage healthy cells. And this can cause side effects, leading to difficulty eating, such as nausea or vomiting. Taste changes, lack of appetite. So many nutrition impact symptoms and then also surgeries can impact directly normal digestion or absorption of nutrients, so the treatments and surgeries could make it difficult to eat. There are also during treatment, increased calorie and protein needs and nutrient needs for recovery of these healthy cells during and after treatment. So we have this problem of needing more nutrition but having more challenges in eating. So that’s really where the role of the dietitian comes in tow. Help patients eat well during treatment. Good nutrition can help patients maintain their body weight and prevent muscle mass loss. So prevent malnutrition, reduce side effects of treatment, prevent treatment delays are brakes, reduce the risk of getting into the hospital and impact treatment response. And really, I think an important role that we shouldn’t forget is how it can help support the quality of life of the patient through good nutrition. So people with cancer often need to follow diets that look different from what they were eating before or what many people think of as healthy. So healthy diet. We would be promoting fruits and vegetables, whole grains, limited animal products. But when a patient is having trouble during treatment, maintaining their strength, it’s really a challenge. Thio eat enough, and so a dietitian helps them navigate. How can we get the most bang for your buck nutrition wise and help them choose foods that are high in calories and nutrients with maybe low volume or not worsening some of their side effects. They’re already experiencing so really helping our patients cope with common eating problems faced during treatment. Another thing in the role of a dietitian is some patients may require nutrition through a feeding tube, either through their stomach or a part of their intestine. Or some might even require getting nutrition through their veins. So dietitians help patients learn how to use some of these feeding tubes and manage writing the prescription for the nutrition order and monitoring how a patient is tolerating this very different forms of nutrition. Also, depending on where an oncology dietitian works, if we could help prepare patient for surgery. So some patients might need to lose weight or gain muscle before surgery toe have better outcomes and reduce their risk during surgery. Also after surgery, they may have changes in their ability to digest and absorb food, so a dietitian needs to help them navigate how they might need to change their diet based on what was removed or modified during a surgery. Monitor labs and nutrient deficiencies. We recommend supplementation when it is necessary, help modify diets based on what’s going on with the patient. And really, we are working collaboratively with the providers to support the treatment plant. I might be making medication recommendations for symptom management or digestive enzymes to the provider so the provider can prescribe that so diet is important during treatment, but also after treatment. So cancer and recovery doesn’t end when they disconnect from their final chemo. There are side effects that can continue after treatment. Some may find it hard to lose weight, or some may find it hard to gain weight after treatment and get back some of that muscle loss. So still after treatment, helping them manage side effects get back to a diet that could be good for their overall health. Really key in our role is that, as I mentioned before, there is no one anticancer diet. We personalize nutrition care plans to the specific needs of each patient, which can change throughout their journey with cancer. And our goal is to help our patients build strength, combat fatigue, minimize symptoms and help them navigate making informed food choices because eating can look so different during cancer than what they were doing before eso. What I really love about this role is that we are we’re helping were guiding. This is very different. I think a lot of us eat and don’t even pay attention to. What we’re doing is all. Normally eat what you want when you want, and during treatment that’s not the same. And so I can help them navigate addressed to help reduce stress around food. And they’re eating experiences, education with the patient with their care providers, the family and really helping support the patient through good nutrition.

[0:18:01 Speaker 2] So you’ve heard the terms used to describe experts in this field as nutritionists and dietitians. One might think it’s all the same, right? Tomato tomato. Let’s talk more about the difference between a nutritionist and a dietitian.

[0:18:17 Speaker 0] So the difference between a dietitian and nutritionist what does it take to be a nutritionist is to simply call yourself a nutritionist. There really is no regulation on that term, and that is really dangerous and confusing for the public. Also, terms like health coach or health and wellness coach that’s still not a dietitian, and that is a self proclaimed title. A dietitian requires the training of nutrition in a formal setting, so a dietitian in our training requires a four year degree from an accredited program at University. There are standardized courses that we need to complete, including food, science, biochemistry, organic chemistry, exercise with theology, anatomy, nutrition counseling, nutrient metabolism, community health, even food policy and food service. So we’re getting everything from understanding global policies Thio, how food is grown, cooked and then the science of how all that happens, What goes on in the body. So a lot of science I don’t think many people under stand how much a science training is in dietitians formal training. Then there’s a required supervised internship could range anywhere from 900 to 1200 hours of supervised clinical practice, and this is usually unpaid, and it could take anywhere from six months to a year to complete that internship and also to know that not everyone who completes that undergrad degree actually gets matched to an internship. So it is very competitive kind of thinking like medical school. Not everyone who’s premed gets into medical school. Not everyone who does that for your degree gets into an internship, and you have to complete that internship before you’re eligible to take the exam to be a registered dietitian and then continuing education is required. We have to complete 75 continuing education credits every five years, so also, some states require licensure, and that could also come with continuing education requirements or some examination. In 2024 is being proposed to require a masters degree to be able to sit to be eligible. Thio take that exam so kind of in some it is four year, college degree supervised, usually unpaid internship for that experience and then taking an exam and then required continuing education to maintain that title of a dietitian. So it would be

[0:21:07 Speaker 3] it would have

[0:21:07 Speaker 0] been much easier to just call myself a nutritionist. But the level of education is so different.

[0:21:16 Speaker 2] Alejandra has an incredible career, researching and teaching about dietetics and nutrition and now cancer, specifically multiple myeloma. Here, Adele, See, I. She brings a genuine passion for investigating the answers to tough questions. And yet, when we talked about her career path and trajectory, Alejandra was graciously open about the journey, having a few bumps in

[0:21:40 Speaker 3] the road, One of the reasons why I didn’t finish or I didn’t do my certification and didn’t finish my I didn’t become a registered dietitian, so I took all the courses necessarily to become a registered dietitian. The only thing missing for me waas, the internship and the exam in order to become a dietitian. It’s actually very expensive, so you have to work as an intern from nine months and pay for it. So your tuition and you’re working nine months as an intern in most of these internships except, like to our own pay. And then after that you have to take this exam that for Ah, lot of students may be expensive because it cost, like, $200 or around that it’s very hard for you to work. I always work. I always had, like, a site job. As a student. Austin is very, very expensive, so I always support myself a little bit. I worked as a receptionist. I worked in the restaurant, whatever. I need it to be able to live in Austin. And when I thought about that internship, I was not going to be able to work. And then I had to pay tuition. Starting jobs is that dietitians don’t pay that much, so you still have your student loans. So I think that’s one of the problems there. The lack of access for everybody, I think, is this internship, and one of my professors was like, Hey, just do your research, your pH, ph. D. And maybe while you’re doing your PhD, you conduce your internship, but this program was not really set up, so it never really worked for me. So I have everything. But I just haven’t have done that internship just because it was just not didn’t make sense for me like I never found a time. Hey, I have enough money safe so I can not work for nine months and do this internship.

[0:23:48 Speaker 0] We need more diversity in our field. Okay, patients and clients are becoming more diverse, but the demographic profile of dietitians has been essentially unchanged over the past decade or two. It does not resemble the community that we have to serve. The field is about 94% female and 85% white, not representing our population at all. And we need an ethnically and culturally diverse profession to better serve our community. Also, that’s impacting our pipeline when we’re adding another layer of a master’s degree that they’re gonna have to pay for it. So that’s six years of education, plus an unpaid internship. So that is creating barriers to enter into the profession. And programs have already noticed a drop in enrollment in a change in their applicants because of already if someone says they want to be a dietitian. They see what they have to dio. You might not even begin that route and they might look at maybe just be coming on nutritionists. And so then creating a problem worsening a problem we already have in our field. And we need to help open up opportunity for mawr diverse populations to pursue a degree in dietetics and become a dietitian. Yeah, we’ve got have a problem.

[0:25:18 Speaker 3] So on Li, like approximately 5% registered dietitians are Latina or Latino, and then around 2.5% are African American and around 5% Asian. But that’s not really how the country looks like, Ah, lot of us. We look for health practitioner that looks like us. So I think it’s very important to diversify the field because we want to maybe go to a dietician that understands our cultural background, that we look for that, and we also know that historically, people of color receive different kind of cares. So I think one of the ways that we can we can work to eliminate that disparity in access to dietitians and nutrient treatment is to have a more diverse field there is disparity in in access to dietitians, decks to healthy foods. If you are white and you come from a higher sister economical status, you’re more likely to go to a dietitian. And we know that nutrition during cancer it is very important, and some people have access. But not all insurance cover that. So no. All centers like what we do have in the Dell Medical School, have a dietitian. That’s not something that everybody can access. So I think there’s a lack of diversity and lack of access. I will say those two things make it less likely to somebody be able Thio access, you know, nutrition advice that, as we have learned, you know, with this conversation, it’s it’s so important.

[0:27:11 Speaker 2] In the very first episode of the podcast, we discussed the call model of whole person care that the live strong Cancer Institutes clinic has implemented for its patients so patients can receive wrap around care for the many facets of their dynamic lives in one place, from mental health to fertility considerations, pain management and dietary needs, as well as receiving treatment and care from an oncologist, we would encourage you to go back and listen to that episode two HearMe or on the calm model. Crystal is the registered dietitian at L. C. I. And we wanted to hear all about her role in this multifaceted team.

[0:27:49 Speaker 0] Well, my typical day has changed now because of telehealth. But before Windows and Clinic, I was part of our room where all of the providers were would be during clinic so we could easily have conversations about patients and things like that. Now, during telehealth we’ve got. Thankfully, Zoom has kept us really well connected with patients. But I am part of any of our huddles that we have. When we talk about patients, I am. They’re learning what is going on in their treatment plan, learning if they are having some increased side effects so that I can connect with that patient and have an individual console with them. Also, what I really love about our team here, Elsie, is how much we work collaboratively. We might have joint visits. I am in that visit so they don’t have to meet with me separately and answer the same questions. For example, with Emily Macleod, one of our advanced practice providers, we had a patient who was having lack of appetite. So we had a meeting to discuss if an appetite stimulant or nausea medication would be helpful, and then my role was, How can we help you eat well when you are having these side effects? So we work in conjunction. It’s not Onley medication. We could do medication and diet modifications. So we’re working together literally in the same visit, so my appointments could look different depending on what’s going on. But usually I try to meet with the patient before they start treatment to address some things like if they have already lost weight, we need to help them get some weight back on, figure out what’s going on before they’re gonna be ready to start treatment. So in my role, I try to get in connected with the patient as soon as possible and then continue to monitor throughout treatment. The earlier the better, the more collaboratively, the better and really get to do that here at l C. I. I love that because they get to see how what I am giving recommendations about. I get to hear what the provider is saying and so we can get on the same page and that it also displays to the patient. When I’m in the room with that provider that nutrition is important. The provider I thought it was important enough to bring a dietitian into the visit, so it really helps elevate the role of nutrition through our collaborative appointments.

[0:30:16 Speaker 2] Please make sure to join us next week when we’ll release the second part of this episode with a deeper look at Crystal and Allah, hundreds backgrounds, career paths and their advice for those interested in the field of cancer and nutrition. If you have questions for the L. C. I or more cancer questions that we can uncover, please reach out an email us at LiveStrong cancer institutes at del med dot utexas dot e d u. Please make sure institutes is plural. You can follow our chair and director Dr Gail Eckhart on Twitter at s scale. Eckhart Eckhart is spelled e c k h a R D t. If you enjoyed this episode, please consider subscribing. This is cancer uncovered. Thank you for listening.