Connecting Patient/Family Library Patrons to Information, Ideas, and Resources

The Duke Patient/Family Resource Center is:

• A lending library offering books, audio and video tapes, magazines and free brochures dealing with cancer and certain blood disorders and with issues of coping, survivorship, caregiving, and grieving
• Open 8:30 a.m. to 5 p.m. every day the Morris Clinics are open
• Located in the White Zone, first floor, of the Morris Cancer Clinic, Room 15123.
• Our phone number is 919-684-6955. Our e-mail address is FamilyLibrary@mc.duke.edu

Resource Center Coordinator: Harriet Whitehead, PhD
Cancer Patient Education Program Director: Kerry Harwood, RN, MSN

Weight Control, Fitness, and Cancer

This month, we offer our latest update on the lifestyle adjustments recommended to help prevent cancer or its recurrence and to fortify the person undergoing cancer treatment.

We feel that a shift of emphasis is underway in lifestyle advice. Away from chasing the magical "cancer-fighting" foods and toward controlling the consequences of too much food. And away from the more passive ways to control your cancer risk, such as gulping supplements, to the more active ones such as increasing your fitness and breaking bad habits.

As we did last month, we will again be giving up pictures in order that those readers with slow internet connections may have an easier time downloading and reading.

Cancer and Nutrition? Not as Easy as We Thought

The most recent studies have not been very supportive of either the heavy use of antioxidants for cancer protection or the reliance on a high fruit and vegetable diet by itself. (See November 2004 The Journal of the National Cancer Institute; November 2004 Journal of the National Cancer Institute, 96:1)

Yet none of these studies has overthrown the large study by the American Institute for Cancer Research (AICR) in which it was found that adherence to their nine recommended cancer guidelines -- which include the fruits and veggies diet -- had a significantly protective effect. These are:

• Be no more than 11 pounds. heavier than you were at age 18
• Exercise daily
• Eat at least five servings of fruits and vegetables daily
• Get enough complex carbohydrates from whole grain
• Limit alcohol
• Avoid red meat
• Avoid salt
• Avoid fat
• Avoid, most especially, tobacco

They cite the fact that in a 13-year study following 29,564 women between the ages of 59-65, it was found that those who were least compliant with the guidelines (following one or none) had a 35 percent greater incidence of cancer than the ones who were most compliant (following "most" of the guidelines).

It appears that the real key to these guidelines lies in the whole package, and not in one or two isolated features. Put one feature, such as the fruits and vegetables, under the microscope of further tests and its magic seems to vanish.

The recent studies also undercut many of those tentative theories, so far tested only in the petri dish or on mice, that certain substances in certain fruits and vegetables retard or even destroy cancer cells. It's true that the plants of the world have provided medical science with many useful cancer fighting drugs. But the dose at which plant-based chemicals have been found to successfully fight cancer in living creatures, when they are found to do so, is often way beyond what the home kitchen can provide. In fact, there's a word for those plant-based substances that have been proved effective against cancer. They're called "chemotherapy." Your oncologist prescribes them, you don't get them in the supermarket. Taxol, from the Pacific yew tree, is one such example. An excellent chemo. Not a very nice snack.

Weight Control and Cancer: Getting Warmer!

This does not mean that fruits and vegetables can be ignored in favor of meats, sugars and carbs! Quite the contrary. Probably the most certain thing that a high fruit and vegetable diet can do for you is to provide you with belly-filling portions of tasty substances that at least do no harm and may do some good while enabling you to avoid the things that have been shown to do real harm, at least in the quantities that Americans now consume them. These are fatty meats (especially red meats), sugars and the non-complex "carbs" like white bread, white rice, potatoes, pasta, and sugary fat-laden baked goods.

The typical American family consumes these bad guys in staggering proportions, often because having little time to cook, they do the fast-food drive-in on the way home from work, or pick up the phone for pizza delivery. One study, the write-up of which is taped to my doctor's exam room wall, showed that high consumers of french fries have a statistically much higher incidence of breast cancer than non- or low consumers. And that's just the fries, folks.

In a word, the AICR guidelines that may be having the biggest impact on the cancer rate of those they studied are those relating to weight control, bad food avoidance, and working on unhealthy habits like smoking, drinking, over-eating, and neglecting exercise.

And indeed, the trend in current cancer prevention advice seems now to be less about looking for magical substances and more about weight control, fitness and avoidance of the harmful categories of food. This trend is even apparent on the AICR website, where the highest layers of the website, that is the stuff that's easiest to find, concentrate on fitness and on the revamped diet as a whole: no meat for dinner larger in portion than a deck of cards, avoidance of saturated fats and trans-fats (advice on reading the food labels in the grocery store is included), reduction of alcohol consumption to one drink a day for women, two for men. And, of course, elimination of tobacco use in all its forms.

This trend arises from the fact that studies point over and over again to the same harmful triumvirate behind most of the age-related chronic diseases, such as cancer, heart disease, and diabetes. These are: tobacco use, alcohol consumption, and excess fat on one's frame.

We already have heard about tobacco use. It is associated with lung cancer, head-neck cancers, bladder cancer, kidney cancer, breast cancer, and cancers of the gastrointestinal tract. Alcohol consumption is linked to the promotion of solid tumors of all sorts. And rather like alcohol, fat already on your body should be thought of as a pharmacologically active substance. It produces hormones and growth factors that pervade the body and can become the favorite food of a budding cancer. The common cancers most often linked to excess weight are the hormone sensitive cancers such as breast, ovarian and prostate. Overweight in combination with tobacco use seems to heighten the risk of kidney cancer in men. Excess weight and heavy consumption of the "bad fats" -- that is the saturated fats and trans-fats -- are linked to colorectal cancer.

In addition to causing disease, excess weight on one's frame makes one medically vulnerable in other ways that people seldom take into account.

• Heavy people recover more slowly from surgery and are more prone to infection in their surgery site.
• Heavy people are much more difficult for caregivers to assist when they need help getting around. (I know of nurses who have quit nursing or moved to more specialized facilities because their own bodies could not handle the strain of dealing with the current crop of hospital patients).
• Heavy peoples' level of fitness is very often lower than average, and may disqualify them from trials of cutting edge experimental therapies.
• People perceived as "fat" tend to get less respect than those perceived as normally weighted. It may be a subtle effect, but it is one that can impact medical service at a number of levels.

The upshot is that if we want to get serious about avoiding a cancer diagnosis or a recurrence diagnosis, and if we want to be able to handle the rigors of treatment should we fall sick anyway, then we need to get serious about weight control.

Getting Weight Down

There's a lot involved here and for the greatly overweight, it can be overwhelming. But keep in mind that a reduction of as little as 10% of one's body weight (say, 28 lb. for a person weighing 280) can take you off the diabetes pathway, and that alone is a huge step toward a longer, healthier life. Studies also show that successful dieters on average lose only 5% of their body weight in the first year. This is not a defeat; it's a win! Be patient. Keep your mind on your health, not on your appearance. That size 6 might be several years away, but the health benefits begin in the very first year.

Other pointers:

• Crash dieting doesn't work -- don't even go there. While it is gratifying to see a lot of weight come off in a hurry, the effect is not going to last and discouragement and cheating will set in. Watch a season of "The Biggest Loser," and you'll see what I mean. Also, when food denial is too severe, people will (a) become fatigued, depressed and weepy, and (b) lapse into fugue states where they don't remember even opening the pantry door but now all the Oreos are missing.

• Get scales and use them daily. Easier to knock back the 2 lbs you gained on Thanksgiving the day after rather than letting them stabilize and blossom into more pounds.

• Start with small steps. Give up only one tough thing at a time, e.g. the soda pops, or the sugary treats, or the fries. You'll see results within a month or two usually. Continue with this until your scales tell you you're compensating in new ways -- it may take a year -- then give up the next tough thing.

• Upping the ante: do not let others do your cooking for you. You need control. You will never lighten up if your cooking is being done by Hardees or Golden Corral, or indeed any restaurant. Their specialties are the fat-saturated salt bombs and the gooey delights. That's what brings in the customers and that's what they'll keep on serving. Don't be fooled by their salads, either: they've managed to turn most of these into fat-saturated salt bombs too. At home, even your indulgence in extra helpings of wholesome food cannot do as much damage as even one bucket per week of Kentucky Fried.

• Find a program. It's hard to figure out what to cook at home if you're not used to cooking. It's hard to figure out how to break a snacking habit if you've never had to break one. And there are a million little tips about what's quick, what's easy, and what's liable to undermine you, that weight loss experts can explain better than us. Weight Watchers has consistently beaten or matched most of the other plans out there, but new programs are developing all the time. Some people have had good success with Internet and email guided plans.

For reviews of many current weight loss programs, go to http://www.consumersearch.com/www/health_and_fitness/weight-loss-programs/reviews.html

• Touch base with your doctor on any plan. He/she is the logical person to suggest programs in the first place, as well as to help you manage your diet in relation to any other existing health conditions. When new medications appear claiming to aid weight loss, your doctor's advice will be essential.

• Calculate your body mass index (BMI) to see where you stand in relation to obesity, the most unhealthful level of overweight. Go to Google.com and search "body mass index calculator."

• Include exercise. It's healthy in it's own right, not just in weight control. Speaking of which...

Exercise and Cancer

We all have learned that regular physical exercise is essential to regain or maintain cardiovascular health, but how many of us realize that there is also a strong positive relationship between regular physical exercise and improved chances against cancer? Studies have shown that:

• There is a 37 percent reduction of breast cancer risk among women who exercise regularly, even when all other risk factors are taken into account; in fact, former college athletes under the age of 45 have only one-sixth the risk of developing breast cancer as their non-athletic counterparts.
• Regular exercise protects against colon cancer under any circumstances and actually improves the protection that a cancer-healthy diet (i.e. those fruits and vegetables) affords.
• Cardiorespiratory fitness reduces cancer mortality in men, even in men who smoke.
• After high-dose chemotherapy (the most severe form of cancer treatment), aerobic exercise speeds recovery and enhances well-being.
• Not just post-surgery, but pre-surgery exercise programs serve to speed surgical recovery.
• Physical exercise has a positive effect on quality of life following cancer diagnosis, including physical and functional well-being and psychological and emotional well-being. This includes lessened pain and nausea, and for many cancer patients, increased longevity.

Traditionally, people struggling with cancer fatigue, pain or treatment side effects have been told to take it easy. But with evidence of the benefits of exercise mounting, we wouldn't be surprised if one day oncologists, like cardiologists, start putting their patients on an exercise regimen as a routine part of follow-up care.

At present, however, fitness concerns are left to the individual, and many individuals, especially those who are under treatment or in the early stages of recovery, find themselves unsure of how to proceed. How do you exercise when joints hurt, surgical wounds may be not completely healed, chemo has drained you, and a post-lumpectomy arm requires coddling?

The quick answer is: Gently and, if possible, under professional supervision. We're not trying to imitate Lance Armstrong here. No one is shouting at you to "drop and give me twenty!" You shouldn't be ashamed if all the force you can muster the first time takes you only two laps around the couch on which you have been practicing potato-hood. The point is to start a routine, however modest, and stick with it, making gradual increases.

Your first move should be to ask your doctor whether he/she will fix you up with a regimen, or prescribe physical therapy. (Prescribed physical therapy with realistic functional goals is usually covered by insurance.) A physical therapist can work out a plan for you that circumvents disabilities and strengthens specific weaknesses as well as keeping you well-exercised. As recovery proceeds, you may increase the repetitions of these exercises and take on new ones. If for some reason, you don't have access to a physical therapist, you might want to try out some of the "gentle fitness" videos that are available from our library. Also search out local programs of modified yoga or seated, gentle exercise that take place in nearby shopping malls or at the Y. Joining with others is a wonderful way to alleviate tedium.

If you're starting out relatively well and unimpaired, or if you have attained full recovery, you have the full range of options that most people pursue: sports, walking, swimming, jogging, taking classes in yoga, tai chi, chi gong, pilates etc., hitting the exercise machines in the gym or at home, or just upping your level of housework and yardwork. Personal trainers are readily available these days, and several programs that we list below offer personal training. Research has not yet determined that any one type of exercise is more geared toward cancer fighting than any other, so simply a good balance between strength training, aerobics, flexibility enhancement, and stress reduction is probably the wisest goal. Once again, get something started - anything - then stick with it while gradually increasing the levels.

Recommended local resources:

Cornucopia House Cancer Support Center
Overlook Building, Suite 220
111 Cloister Court
Chapel Hill, NC 27514
Phone: 919-401-9333
email chsupport@mindspring.com

Take the East Towne Rd turn just opposite Blue Cross Blue Shield on 15-501; then left onto Providence, then enter Cloister, a cul-de-sac.

Cornucopia House is an independent cancer support facility offering support groups and counseling and different types of restorative exercise. It is the only place listed here that does not charge for services. Classes include Chi Gung, Restorative Yoga, Compassionate Touch Massage, and soon to come Neuromuscular Integrative Action.

Duke Health and Fitness Center at the Center for Living

Located on Erwin Rd just off Cameron Blvd, the Center for Living houses a number of wellness and fitness programs. One of their personal trainers, Stacy Herrera, (formerly Stacy Smith) director of the C.A.R.E. program, is herself a breast cancer survivor. She will work with cancer patients to put together a program of exercises tailored to their individual needs. Contact her at (919) 660-6810, or smith352@mc.duke.edu

For weight control, the Center for Living offers the two programs, Getting on Track, and Staying on Track, both of them featuring weekly group meetings and the supervision of a professional dietician, a psychologist, and an exercise physiologist. These same three professionals will also do individual consultations. Contact Kara Mitchell at 919-660-6818.

Rex Wellness Centers

Rex Healthcare has a Wellness Center in Raleigh, in Cary, and soon to come in Garner. At any of these there will be health promotion classes in yoga and other forms of restorative training. The Raleigh Center specializes in pulmonary rehab. Contact them at 919-784-1380.

For locations and contact numbers for any of the Rex Wellness centers, go to http://www.rexhealth.com/centers/wellness/index_wellness.htm. While the Wellness Centers charge for their services, some scholarships are available and they will go through social services for other options.

Body Renewal, Inc. of Apex

8517 Burnside Drive

Apex, NC 27539

919-454-8895

The two specialists here, Jennifer Eatmon and Gail Weiner have both been touched by cancer; Jennifer is a survivor of breast cancer, while Gail has had cancer in her family. They work with cancer patients and survivors to provide exercise programs that will promote recovery, fight lymphedema, and bring people back to their former activity level. Both one-on-one training and group sessions are available, and guided at-home programs can be arranged.

C'mon! Isn't There at Least One Magical Substance Out There?

Well, OK. There is one substance on which the "buzz" is still increasing rather than decreasing. This is Vitamin D. The cancers most often mentioned in which a relationship between vitamin D insufficiency and cancer have been observed are prostate and colorectal. But breast, ovarian, pancreatic and, paradoxically, even melanoma get mentioned. What is the story here?

As you may know, Vitamin D is produced in the body when ultraviolet B light hits a precursor molecule in the skin. Since a certain amount of Vitamin D is essential for bone health, populations prehistorically settled in the northern climates where the rays of the sun are weak and the winters long, have evolved the fairest skins of the world's populations. Their skins are uniquely open to whatever sunlight is available to stimulate the production of Vitamin D. Conversely, populations ancestrally settled in the tropics, used to getting more sun than they really needed, have evolved a natural "sun-block," melanin, which darkens the skin while protecting against the skin damaging, and carcinogenic effects of the sun.

Nowadays, of course, we have populations from everywhere living everywhere and this has produced some intriguing epidemiological statistics. Dark-skinned people living outside the tropics are less able to acquire the necessary levels of vitamin D from the sun because their melanin blocks much of the locally available UV rays. As it happens, certain cancers, notably prostate, are more common in no-longer-tropical dark-skinned folk. Moreover, very fair-skinned people nowadays are given to using lots of sunblock when they go outside and as a result also have a higher than average rate of prostate, and other hormone related cancers. People closed up in offices, mines, labs and other sun deficient areas all day long are reported to have a higher average cancer rate than other people. The list of tantalizing findings goes on.

Scientists are still trying to determine the mechanism of action of vitamin D in regard to cancer, and until they do find it, or prove that the whole idea is mistaken, it looks like we should dutifully either supplement or get outdoors a lot more often - with some skin showing. Vitamin D does not occur in many foods, but it is found in egg yolks, butter, and cold water fish such as salmon, cod, mackerel and herring. Many orange juices, milks, and cereals are fortified with Vitamin D, but the amount is low and the type and quality may be in question. The biggest Vitamin D bang for your buck is codliver oil. Just a tablespoon a day should be enough, but swallowing the stuff, with its long-lingering intensely fishy after-taste, is definitely not fun. Unless specifically marked, fish oil supplements do not contain vitamin D.

If you choose sunlight as a source and are fair-skinned, spend at least 15 minutes a day out in the sun, with arms and/or legs exposed, and without sunblock. You might switch to sunblocking after around 30 minutes if you are very fair-skinned. If you are a dark-skinned African-American, make that the minimum 45 minutes to 1 hour.

For a fuller discussion of vitamin D and your health go to:

http://www.newhope.com/nutritionsciencenews/nsn_Backs/Mar_00/vitamind.cfm

Exercise Videos and Books in Our Collection

• Catherine MacRae's Gentle Fitness. A charming and evenly-paced instructor. You can do the majority of her exercises seated in a chair in your living room. Pick and choose which routines are best for you.
• One Move at a Time: Exercises for Women Recovering from Breast Cancer Surgery. There are seven basic flexibility and strength motions illustrated, very slowly and precisely on this video. All the featured demonstrators are breast cancer survivors.
• Get Up and Go after Breast Surgery. An organized, gentle and enjoyable program.
• Alicethenics. Alice Saland is the very fit young survivor guiding you through these post breast-surgery exercises, some of which are her innovations.
• The Force Program: The Proven Way to Fight Cancer through Physical Activity and Exercise by Jeff Berman, Fran Fleegler, MD, and John Hanc. This book spells it all out for you: Exercise regimens, stress-reduction techniques, special plans for the different common cancers, and a plan for children with cancer; plus diet advice and recipes. Highly recommended.

Recommended Web sites:

The American Institute for Cancer Research (AICR)

Check out their ideal eating plan, called "The New American Plate," and search "exercise" for a series of important studies.

Georgia State University Exercise and Physical Fitness Page

Sometimes in order to get started, it helps to have some notion of what the basic exercises look like. Surprisingly, its very hard to find good illustrations on the Web. But one decent source is the GSU page above. Right on the home page, you'll see a list of buttons that includes "aerobic exercise," "strength training," and "flexibility." Under strength training and flexibility, you will find illustrated exercises with written instructions for each. Under aerobic exercise, there is a list of types and clicking on the type will bring up a page of explanations and elaborations with one or two photographs. (Not every page loads).