Nutrition, Fitness and Breast Cancer: Making Healthy Diet & Exercise Decisions

Lifestyle and Breast Cancer Risk

A healthy diet and lifestyle are associated with overall wellness. Studies show diet and lifestyle may play a role in breast cancer and its recurrence (when cancer comes back).

Keys to overall good health include:

• Achieving and maintaining an appropriate body weight
• Eating a balanced, mostly plant-based diet
• Exercising regularly
• Getting enough sleep

Certain factors that make a person more likely to get breast cancer cannot be changed. These include:

• Female sex
• The age at which you had your first period
• Increasing age
• Family history
• Genetics

Other factors that make a person more likely to get breast cancer can be changed. These include:

• Being overweight or obese, especially for women who have gone through menopause
• Lack of exercise
• Drinking too much alcohol
• Smoking

Breast cancer and men

Breast cancer is about 100 times less common in men than in women. Risk factors for breast cancer in men are similar to those for breast cancer in women. They include:

• Increasing age
• Family history
• Obesity
• Inherited gene mutations
• Heavy alcohol intake

Most of the breast cancer research and clinical trials have been done in women. However, most of the diet and lifestyle guidelines and recommendations in this resource are appropriate for both men and women. If you have questions about specific information, ask your doctor, nurse, or dietitian.

Maintaining a Healthy Body Weight

Achieving and maintaining the right body weight is one of the most important things you can do for your health. Excessive body weight (specifically, body fat) is associated with an increased risk for some diseases, including certain types of cancer, type 2 diabetes, and heart disease. In fact, obesity may soon become the number one lifestyle factor that contributes to cancer in the United States.

Women who have gone through menopause and are overweight or obese have a greater risk for breast cancer. Research suggests that unnecessary weight gain during or after breast cancer treatment can increase the risk of disease recurrence as well as the risk for developing other primary cancers.

Body mass index

Body mass index (BMI) is a measure of body weight based on height. It is one way to measure body weight. It may or may not indicate overall wellness and does not measure body fat versus muscle mass. However, it can be a useful tool in determining health and disease risk. An ideal BMI for an adult is between 18.5 and 24.9.

Find your BMI on the chart below. First, find your height in the left-hand column. Go across to the next column on the same line and find your weight. Next, look at the corresponding BMI at the top of your column. This is your BMI. For example, if you weigh 130 pounds and you are 5 feet tall (60 inches), your BMI is 25.

You can also calculate your BMI using this tool: www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

The table below shows weight classifications according to the National Institutes of Health (NIH).

Source: www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm

Keep in mind that BMI is only one health measure. Other measures include waist-to-hip ratio and waist circumference, which look at weight in your abdominal area. Extra weight in the abdominal area is associated with an increased risk for certain illnesses even in people with an ideal BMI.

Managing weight gain after diagnosis and treatment

People often gain weight after breast cancer diagnosis and treatment. This is not seen as often with other types of cancer. Premenopausal women seem to gain more weight than postmenopausal women.

There are a number of reasons why people may gain weight during treatment, including:

• Eating too many calories
• Decrease in physical activity
• Early menopause
• Depression and anxiety
• Increased appetite from steroids
• “Comfort” eating or “emotional” eating
• Increased eating due to side effects of treatment like fatigue or nausea

It may be difficult to lose the weight gained during treatment. Therefore, it is important to try to maintain a healthy weight during treatment.

Use the guidelines below to help prevent weight gain. Work with your dietitian on your weight goals.

• Choose a balanced diet.
• Decrease the total amount of food you eat.
• Exercise regularly.
• Control portion sizes.
• Always place food on a plate so that you know how much you are eating.
• Avoid eating while watching TV, during “screen time” (such as checking email or watching a movie), or while talking on the phone.
• Drink 8 (8-ounce) glasses of liquids per day. Choose water or other drinks without calories such as seltzer.
• Limit your intake of fruit juice to no more than 1 cup per day. It’s better to eat whole fruit than drink juice.

Balancing your plate

The balance of foods on your plate is important when trying to eat healthy. Keep in mind the picture of the plate in Figure 1. This can help you choose the appropriate serving sizes of different foods.

Two-thirds (or more) of your plate should be vegetables, fruits, whole grains, or beans.

For your vegetables, try to choose non-starchy ones such as:

• Broccoli
• Cabbage
• Cauliflower
• Leafy greens (e.g., spinach, lettuce, kale, collards, bok choy)
• Mushrooms
• Asparagus
• Zucchini
• Peppers
• Tomatoes

Your grains, fruits, and other fiber-rich carbohydrates include:

• Whole grains (e.g., brown rice, whole-wheat pasta,  quinoa, barley)
• Starchy vegetables (e.g., potatoes, sweet potatoes, corn, pumpkin)
• Whole fruits (e.g., berries, apples, pears, kiwis, oranges)

No more than one-third of your plate should be animal protein. Some good sources are:

• Fish
• Non-fat or low-fat dairy products (e.g., plain yogurt)
• Eggs
• Poultry

For protein, you can also substitute plant proteins, such as beans.

Your meal might not always look exactly like the plate shown here. You could have a cup of lentil and vegetable soup and a small apple, and you’d be getting a similar kind of meal and proportions. Also, you might get more vegetables at lunch and dinner than at breakfast. Just keep in mind the ideas of “mostly plant based” and “portion controlled” for all meals.

Managing portion sizes

It is important to think about serving sizes. Serving sizes of bottled, packaged, and restaurant foods and drinks have increased over the years. The table below lists the amount of food that is equal to 1 serving size.

Use the following examples of everyday items to help determine your serving sizes:

• 3 ounces of meat, poultry, or fish is about the size of a deck of cards.
• One cup of fruit, vegetables, or cereal is about the size of a baseball.
• 2 tablespoons of peanut butter is about the size of a ping-pong ball.
• A medium size bagel is about the size of a hockey puck.
• A medium baked potato is about the size of a computer mouse.
• 1 ounce of cheese is about the size of a domino.
• 1 ounce of nuts is about 1 small handful.
• A teaspoon of butter is about the size of a die.

Common measurements

Use measuring cups and spoons to measure your portions. Here are some common measures that may be helpful to remember.

• 3 teaspoons = 1 tablespoon
• 4 tablespoons = ¼ cup
• 4 ounces = ½ cup
• 8 ounces = 1 cup
• 1 cup = ½ pint
• 2 cups = 1 pint

Understanding food labels

Reading and understanding food labels can help you make wise food choices.

There are new food labels coming out on foods that will provide more information and be easier to read. These changes include:

• Listing added sugars. The World Health Organization (WHO) recommends that most people limit added sugars to 25 grams per day.
• The amount of vitamin D and potassium that is in a serving of the food.
• The serving size for foods and beverages will be changed to reflect amounts that people actually eat.
• The number of calories and the serving size will be in larger, bolder numbers, making them easier to read.
• The percentage of daily value for nutrients such as sodium, fiber and vitamin D are being updated based on newer scientific evidence.

Here is an example of the current food label and the new food label.

How to read food labels

The label below lists the nutritional content of a 1 cup serving of macaroni and cheese. The arrows point to the boxes on the right, which explain what each line means.

Keeping a food diary

Tracking what you eat and drink with a written food diary helps you be more aware of your choices. It can improve your mindfulness and awareness of what, when, and why you eat. For example, you might find you eat too much late at night when you’re more tired than hungry. You might notice that you have certain snacks because you are stressed or bored.

People who keep food records over time are often more likely to achieve their nutrition and body weight goals. Keeping a food diary can also help you be more accountable about the foods that you eat.

To keep accurate food records, it is best to write down what you eat right after you eat it, including the portion size. Be as detailed as possible. For example, rather than writing “cereal and milk,” write “1 cup bran flakes and ½ cup lowfat milk.” You might also include how you were feeling at the time you ate. See the sample food diary in the “Sample Food Diary” section for an example. Your dietitian can help you use these records to meet your nutrition goals.

Many people find writing a food diary by hand with pen and a small notebook works best. If you prefer to use your smartphone, many apps can help you track your eating. You may also use the “Notes” section in your smartphone. Any method of keeping a food diary is fine, as long as it works for you.

Keep in mind that you do not have to change your diet all at once. Set one or two goals each week. If you have setbacks, you can learn from them. Small changes add up to big results over time.

Designing a Healthy Diet

The guidelines below can help you design a healthy diet. Remember there is no “one size fits all” diet to promote wellness or cancer risk reduction. However, most healthy diets do have some common characteristics. Work with your dietitian to find the diet that is best for you.

Control your calories

Choose foods that naturally contain less calories for their volume. These include whole vegetables, fruits, fiber-rich carbohydrates, and lean proteins.

• Watch portion sizes at all meals and snacks.
• Avoid all-day snacking. Eat your set meals and have snacks only if you need them.
• Avoid sweetened drinks such as sodas and soft drinks.
• Limit juice to no more than 1 cup a day.
• Limit how much alcohol you drink.

Choose plant-based foods

• Vegetables, fruits, and other whole plant foods should be the largest part of your diet.
• Choose a wide variety of vegetables and fruits. Choose ones with different colors, such as dark green, purple, orange, yellow, red, and white.
• Aim to eat about 3 cups of vegetables and 1 to 2 cups of fruit each day. Be sure to stay within your caloric needs.

Limit total and added sugars

• There is no clear evidence on how sugar affects cancer risk. However, it is wise to limit added sugars for many reasons. Foods and beverages with added sugars often add too many calories to the diet. Over time, they can contribute to overweight or obesity, chronic hyperglycemia (high blood sugar) and hyperinsulinemia (too much insulin circulating in the blood), and insulin resistance. These conditions are associated with an increased risk for developing cancer.
• The World Health Organization (WHO) recommends limiting added sugars to no more than 5% of total calories. This comes out to 25 grams (or 6 teaspoons) of added sugar for someone eating 2,000 calories a day.
• You don’t need to limit naturally occurring sugars as much as added sugars. Naturally occurring sugars are found in foods such as fresh fruit and milk. Eat these these foods in the right portions. It is possible to get too much sugar from eating too much of these foods.
• Read food labels. Ingredients are listed in descending order. This means that the product has more of the ingredients that are listed first, and less of those listed last.
• Sugar is sugar whether it is raw, brown, white, organic, or powdered. If you are concerned about the sugar content in packaged foods, check the label. Make sure it is not one of the first few ingredients on the list.
• If you have other health concerns, such as diabetes, prediabetes, insulin resistance, or obesity, talk with your dietitian.
• Food labels list added sugars in many ways. Some names to watch for are:

Fiber in your diet

Fiber is good for your health and may help to:

• Stabilize your blood sugar.
• Improve your cholesterol levels.
• Improve your bowel function.

Most adults should consume at least 25 to 35 grams of fiber per day. To reach fiber goals each day, most adults need:

• About 2 ½ cups of vegetables or legumes, and
• 2 cups of fruit, and
• 3 servings of whole grains (this is equal to 1 ½ cups of whole-grain cereal, oats, whole-wheat pasta, millet, quinoa, brown rice, or other cooked whole grains, or 3 slices of whole-wheat bread)

Increasing your fiber over a short period of time can cause gas and bloating. Therefore, increase your fiber intake slowly and drink plenty of water. This will help your body adjust to the change.

Vegetables, fruits, beans, and whole grains are usually high in fiber. They also have many vitamins and minerals. Whole grains include the entire grain seed. They are better for you than refined grains. Examples of whole grains are:

Read the labels on your foods to find those that are high in fiber. Labels that list the word “whole” or “whole grain” before the first ingredient are good fiber sources. For example, look for “whole wheat flour” as the first ingredient in bread, not just “wheat flour.”

Some foods such as yogurts and snack bars now contain added fiber, such as inulin. There is not enough evidence to suggest that these added fibers have the same health benefits as those present naturally in food.

In general, a high-fiber food has at least 3 grams of fiber per serving. The table below lists some good food sources of fiber.

Fats in your diet

Some fat in our diets is necessary and healthy. There are different types of fat. Some are healthier than others.

Fat is calorie-dense. One gram of fat has more than 9 calories, while 1 gram of a carbohydrate or a protein has 4 calories. Therefore, high-fat foods have a lot of calories in a small amount of food. If you are trying to lose weight or maintain weight loss, this is important.

For some medical conditions, limiting fat may be helpful. However, for most people, there is no need to avoid fat. What is important is to avoid eating too many calories and to choose healthier types of fats.

Eat less saturated and trans fats

These fats may raise unhealthy types of cholesterol levels. This is associated with heart disease.

• Saturated fats are naturally occurring fats. They are found in meats (such as pork and beef) and full-fat dairy products (such as cheese and butter). Most of the saturated fat Americans eat comes from foods like burgers, sandwiches, pizza, and desserts.
• Most trans fats are made when liquid fats turns into solid fats through a process called “hydrogenation.” The Food and Drug Administration (FDA) has recognized that trans fats are a health threat. Food manufacturers are being required to remove trans fats from packaged foods. However, as they are phased out, you may still see them occasionally. Read the nutrition label, also known as the food label. Trans fats are sometimes listed as “partially hydrogenated oil.”
  • Foods that may have trans fats include coffee creamers, some margarine, microwave popcorn, and processed or packaged cookies, cakes, chips, and crackers.

Choose mostly monounsaturated and polyunsaturated fats

Studies have shown these types of fats are healthier. They are found mostly in plant foods and fish and other seafood.

Good sources of healthy essential fats include:

• Fish and other seafood
  • Salmon
  • Sardines
  • Halibut
  • Mussels
  • Cod
  • Herring
  • Anchovies
• Nuts, seeds, and oils
  • Almonds
  • Olive oil
  • Walnuts
  • Canola oil
  • Pumpkin seeds
  • Flaxseeds
• Vegetables and fruits
  • Avocados
  • Brussels sprouts
  • Bok choy (Chinese cabbage)
  • Seaweed

Reduce your alcohol intake

Research has shown a link between alcohol intake and increased risk for breast cancer.

Women who drink, on average, more than 1 serving of alcohol per day are at an increased risk of breast cancer. The risk is higher the more alcohol you drink. Drinking a lot of alcohol may also increase the risk of breast cancer in men. The type of alcoholic drink does not matter.

Drinking too much alcohol is also linked to other health problems, such as:

• Liver disease
• Cancers of the mouth, pharynx, larynx, and esophagus
• Inflammation of the stomach and pancreas
• High blood pressure

If you drink, do so in moderation. Try to save it for special occasions. If you have any questions about alcohol, talk with your doctor, nurse, or dietitian.

Pay attention to the size of the wine glasses you use at home or in restaurants. Some wine glasses hold 20 ounces or more—up to 5 times the amount in 1 serving of wine. Keep in mind that “light beer” has fewer calories—but not less alcohol—compared with regular beer.

Each of the following is 1 serving of alcohol:

• 4 to 5 ounces of wine or champagne (about 100 calories)
• 12 ounces of regular beer (about 150 calories)
• 1.5 ounces of hard liquor, for example, 1 shot of tequila (about 100 calories).

To help dilute alcohol, use club soda as a mixer.

Limit salt and sodium

Eating foods with a lot of salt may raise blood pressure and increase the risk for stroke, heart failure, and kidney disease. Consume less than 2,300 mg of sodium (about 1 teaspoon of salt) per day. Fresh food that is not processed is usually lower in sodium.

Read food labels to find out the amount of sodium in the product. Choose foods that are labeled “low sodium,” “very low sodium,” or “sodium-free.”

Here are some tips to reduce how much sodium you eat.

• When cooking, flavor foods with fresh herbs and spices instead of salt.
• Limit canned foods.
• Limit packaged, processed, pickled, and cured foods.
• Do not add salt to food at the table.

Eat foods with phytochemicals

Phytochemicals are compounds in plant foods that may be good for your health. There are thousands of phytochemicals. Some are vitamins and minerals, but there are many others. We have not identified them all and are still learning about them. Some phytochemicals you may have heard of include:

• Anthocyanins
• Beta sitosterol
• Capsaicin
• Carotenes
• Catechins
• Curcumin
• Ellagic acid
• Isoflavones(see “About phytoestrogens” for more information)
• Lignans
• Lutein
• Lycopene

The best way to get phytochemicals is to eat a wide variety of plant foods. Choose different vegetables and fruits from day to day, week to week, and season to season. Phytochemicals work best together.

You get more benefits by getting phytochemicals from whole foods rather than supplement pills. Taking pills or dietary supplements with phytochemicals may not have the same benefits as eating the foods themselves. In fact, some dietary supplements with phytochemicals may cause more harm than good.

About phytoestrogens

Soy and phytoestrogens

Many people have questions about soy foods and cancer risk. Do soy foods promote breast cancer? Do they help prevent breast cancer?

Soy contains phytochemicals called isoflavones. Isoflavones are one type of phytoestrogen—plant compounds that are similar in structure or function to the estrogens made in our body.

Some of the concerns you may hear about soy foods and breast cancer are based on early studies in mice. However, as more and more studies look at soy intake in humans, we can make better recommendations. Research suggests it is safe and may even be good for you to eat up to 1 serving a day of whole soy foods (see table below). This includes studies done in women with hormone-sensitive breast cancer.

Some soy ingredients do not contain a significant amount of isoflavones. They are unlikely to have significant estrogen-like effects. These foods are:

• Soybean oil
• Soy lecithin
• Soy sauce

You do not have to avoid these ingredients due to any estrogen-like effects.

Other soy ingredients contain a higher amount of isoflavones. These include:

• Soy protein isolate
• Soy protein concentrate

You may see these ingredients in foods such as canned soups, frozen entrees, protein bars and drinks, meat replacements, and packaged snack items. The effects of these ingredients have not been studied well. We recommend limiting your intake of them. By limiting these foods, you are not missing out on any significant beneficial nutrients. In fact, you will probably decrease your intake of processed and packaged foods, which are often high in sugar, sodium, and other less healthy contents.

Soy foods may offer health benefits. For example, tofu is a good source of protein and calcium. However, it is unlikely that any one food, all by itself, will either cause or prevent breast cancer. For most people, a healthy diet is one that contains mostly whole foods, including a wide variety of plant foods.

Soy and isoflavone supplements

While eating whole soy foods is fine, we do not recommend that you take soy isoflavone pills, soy protein powders, or other concentrated soy supplements. Some studies suggest they may increase breast cancer risk in certain groups of women, but we aren’t sure yet.

In many cases, research shows that eating certain whole foods is beneficial, but eating isolated extracts or high-dose supplements of compounds in these foods may be harmful. This seems to be true with soy. Too much of any substance, even if it is natural, is often unsafe. If in doubt, eat the foods, but don’t take the pills.

Flaxseeds and phytoestrogens

Whole and ground flaxseeds contain compounds called lignans. Like soy isoflavones, lignans have phytoestrogenic qualities. In other words, they have natural effects that weakly resemble human estrogens. You do not have to avoid all flaxseed. Some research suggests a benefit with eating flaxseed in moderation. Keep in mind, the best way to get the health benefits from seeds and nuts is to eat a variety of them. Flaxseeds may have health benefits but so do walnuts, almonds, pumpkin seeds, and many other nuts and seeds.

Flaxseed oil does not contain lignans. Therefore, it does not have phytoestrogenic properties.

Other plant compounds and phytoestrogens

Some other plants have phytoestrogenic qualities. There is no need to avoid any whole food with regard to potential estrogenic properties. You may see lists of foods cited as “estrogenic,” but there is no research suggesting you should eliminate any actual foods from your diet.

However, people who have had a history of breast cancer should avoid certain plant compounds in concentrated or dietary supplement form. These include (but are not limited to):

• Red clover
• Chasteberry
• Black cohosh
• Evening primrose
• Dong quai
• Licorice

There may be other plant compounds that you should avoid taking in supplements that are not on this list. Speak with your doctor, nurse, or dietitian before taking any dietary supplement.

About supplements

There are many supplements on the market. Americans spend about 30 billion dollars a year on dietary supplements, even though there is very little evidence that they are helpful for most people.

A balanced, mostly plant-based diet provides the right amounts of vitamins, minerals, and antioxidants for most people. This is generally the healthiest and best way to get them.

Some people may need to supplement certain nutrients. You may need supplements if you:

• Have certain medical conditions
• Are on certain special diets
• Are vegan (do not eat any animal products)
• Are 65 years of age or older
• Are pregnant or plan to soon become pregnant
• Have a known nutrient deficiency or insufficiency (you don’t have or get enough of a certain nutrient)

Ask your doctor or dietitian for more information if you think you might need to take supplements.

Supplement makers are not required to have standards for the safety, content, and quality of their products. They do not have to prove that a supplement is safe or effective before it is sold. Just because a product is “natural” does not mean it is safe. The FDA only spot tests 1% of the 65,000 dietary supplements on the market.

Keep in mind the following precautions with dietary supplements:

• They may interact with medications, including chemotherapy and endocrine therapy.
• They may interact with each other.
• They may cause serious side effects.

It is important for your entire healthcare team to know about any supplements you are taking. This includes vitamins, minerals, herbs, botanicals and other supplements.

You may receive conflicting information from family, friends, health food stores, and the Internet about supplements. It can be hard to find reliable information. Your dietitian can help you sort through any advice you get.

To learn more about supplements, ask your nurse for the resource Herbal Remedies and Cancer Treatment.

You can also visit the MSK Integrative Medicine Service website at: www.mskcc.org/cancer-care/integrative-medicine. Click on “About Herbs, Botanicals, and Other Products” for detailed information about different dietary supplements. There is also a free MSK iPhone app called “About Herbs” that you can download.

Other resources include the American Cancer Society (www.cancer.org) and the American Institute for Cancer Research (www.aicr.org)

Organic food guidelines

Many people choose to eat organic foods over conventional (not organic) foods. Organic plant foods are grown without the use of synthetic pesticides or herbicides. Organic animal foods are made from animals that have not been given growth hormones or any antibiotics, and have not been fed any animal by-products.

Foods labeled organic are made without bioengineering. That means that the genes in them cannot be changed, so they can’t have genetically modified organisms (GMOs). Ionizing radiation, which is a process to sterilize food, cannot be used.

Before foods can be labeled “organic,” they must meet certain guidelines. The government must inspect the farm or facility where the food is grown or animals are raised.

The US Department of Agriculture (USDA) has 4 categories for labeling organic products.

• 100% organic: must contain only organic ingredients.
• Organic: must contain at least 95% organic ingredients.
• Made with organic ingredients: must contain at least 70% organic ingredients. Organic ingredients may be listed on the display panel. There are certain restrictions on the other 30% of ingredients (e.g., they cannot contain GMOs). The USDA organic seal cannot be used on the package.
• Products that have fewer than 70% of organic ingredients cannot use the term “organic” on the front label. Organic ingredients may be listed on the ingredient list.

Placing labels on these food items is voluntary. You may also see the words “natural,” “free range,” or “hormone-free” on food labels. Do not confuse them with “organic.” Only foods with the USDA organic seal have been certified as meeting USDA standards.

An organization called The Environmental Working Group publishes lists of what they call the “Dirty Dozen Plus™” and “Clean 15™” fruits and vegetables. The Dirty Dozen have been found to contain the highest amounts of pesticides if they are grown conventionally (not organic). The Clean 15 are fruits and vegetables that have the least amounts of pesticides when grown conventionally.

If you aren’t able to get organic vegetables and fruits, it is still better to eat conventional ones than none at all.

The Environmental Protection Agency (EPA) and FDA consider pesticides, herbicides, and growth hormones to be safe. The USDA makes no claims that organic food is safer or better than non-organic food. Organic foods usually cost more and are not always readily available. There is no research to show whether organic foods can reduce cancer risk. If you are concerned about your intake of added hormones from food, you may wish to choose animal products (e.g., chicken, eggs, meat, milk and dairy) that are labeled “organic” or “no added hormones.” For more information, speak with your dietitian.

Tobacco

Tobacco increases the risk for:

• Lung cancer
• Heart disease
• Bladder, mouth, and throat cancers

If you smoke, try to quit. If you need help, please ask your doctor or nurse for a referral to the MSK Tobacco Cessation Program, or call 212-610-0507.

Eating Well During Your Breast Cancer Treatment

Treatment for breast cancer may include surgery, chemotherapy, radiation therapy, immunotherapy, biologic therapy, other therapies, or a combination of these. Eating well during your breast cancer treatment can help you:

• Feel stronger
• Maintain energy
• Manage side effects
• Prevent or reduce undesired weight gain or weight loss
• Get the right nutrients
• Reduce risk for food-borne infections
• Avoid dehydration

During chemotherapy

Food safety

If you are being treated with chemotherapy, you are at an increased risk for getting an infection or foodborne illness (food poisoning). This is because the treatments can lower the number of white blood cells in your body. These cells fight bacteria (germs) and keep your immune system strong. Avoid foods that are not prepared, stored, or handled correctly. This can happen where you shop for food, eat out, or even at home.

Symptoms of food poisoning may include:

• Abdominal (belly) cramps
• Nausea
• Vomiting
• Diarrhea
• Fever

Food poisoning may go undiagnosed. This is because some side effects of cancer treatments may cause similar symptoms.

Follow the food safety guidelines below to help prevent food poisoning.

Shopping

• Do not buy packages that are torn or leaking, or canned goods that have dents, bulges, or leaks.
• Choose fruits and vegetables that are not bruised.
• Do not buy foods past their expiration date.
• Pick up frozen and refrigerated items last when shopping so that they spend less time outside of the freezer or refrigerator.
• Only buy pasteurized dairy products. Avoid unpasteurized, soft cheeses, such as Brie, Camembert, fresh raw mozzarella, and some blue cheeses.
• Only buy refrigerated eggs.

Storage

• Keep the refrigerator temperature between 33° F and 40° F.
• Set the freezer temperature to 0° F.
• Keep the temperature of your pantries and cupboards between 50° F and 70° F.
• Keep your pantries and cupboards clean, dry, dark, and cool.
• Cook or freeze fresh poultry, fish, and meat within 2 days.
• Do not leave perishable foods out for more than 2 hours.
• Avoid overloading your refrigerator. Cold air needs room to circulate.
• Do not keep leftovers for more than 2 to 3 days.
• Store fresh meat, fish, and poultry in separate plastic bags. Put them on the bottom shelf of the refrigerator so they don’t leak on other foods.
• Keep hot foods at a minimum temperature of 140° F.
• Keep cold foods at a maximum temperature of 40° F.

Thawing

• For slow, safe thawing, place frozen meat, poultry, and fish in the refrigerator.
• For faster, safe thawing, place frozen food in a plastic, leak-proof bag. Then, submerge it in cold tap water.
• If you are thawing meat or poultry in the microwave, be sure to use a microwave-safe container. Defrost on the “low” or “defrost” setting. Cook meat and poultry right after you thaw it in the microwave.
• Do not thaw frozen items by leaving them out on the counter. This allows bacteria to grow.

Preparation

• Always wash your hands thoroughly in warm, soapy water for at least 15 to 20 seconds before preparing food.
• Use an antibacterial cleaning spray to clean surfaces or spills on appliances. Look for products that have bleach or ammonia and follow the instructions for use. Rinse towels, sponges, and dishcloths in a bleach and water solution. Keep them dry when not in use.
• Thoroughly rinse fresh fruits and vegetables under running tap water before cutting or peeling them.
• Never use bleach or detergent to wash fresh fruits and vegetables.
• Use separate cutting boards, plates, trays, and utensils for cooked and uncooked meat, poultry, and fish.
• Never use the same cutting board or utensils to slice raw meat and vegetables.

Cooking, serving, and eating

• Cook all meats and other animal products to the minimum internal temperatures shown in the table below. The juices should run clear and there should be no pink flesh visible.
• Avoid eating raw or undercooked seafood, meat, poultry, or eggs. This includes:
  • Sushi made from raw fish
  • Tuna tartare
  • Ceviche
  • Lox
  • Rare steaks, burgers, or other meats
  • Poached, over-easy, soft-boiled, or sunny-side up eggs
  • Some fresh or homemade Caesar salad dressings and mayonnaises
• When cooling hot foods, divide larger portions into smaller portions. Place them in shallow containers so that they cool faster.

Managing body weight

During chemotherapy, some people gain weight and other people lose weight. It is best to maintain a healthy body weight, avoid weight gain from too much fat tissue, and preserve muscle mass during chemotherapy. For more information on avoiding weight gain and losing weight, see the section “Maintaining a healthy body weight.”

If you are losing too much weight as a result of your chemotherapy treatment, you may want to change your diet. You may not have as much of an appetite due to side effects of treatment, fatigue, anxiety, and depression. If you lose your appetite, follow the suggestions below:

• Choose your favorite foods.
• Eat small, frequent meals or snacks.
• Eat with supportive friends or family.
• Ask for help with food purchasing and preparation.
• Listen to music you enjoy while eating.
• Plan meals on a set schedule so you don’t forget to eat.
• Try homemade smoothies with nutrient-rich ingredients.
• Don’t force yourself to eat a large amount at one sitting but don’t skip meals entirely.

Ask your nurse or dietitian for the resource Eating Well During and After Your Cancer Treatment which has more information about maintaining your weight during your cancer treatment.

Staying hydrated

It is important to stay well hydrated during chemotherapy. Drink at least 8 glasses of water or other non-caloric or low-calorie beverages (i.e., seltzer, tea) each day. Not drinking enough liquids can cause lightheadedness, dizziness, nausea, constipation, fatigue, and urinary tract infection.

Try to limit sweetened drinks, soft drinks (such as cola or ginger ale), and juices.

Keeping up your energy

Fatigue is a common side effect during chemotherapy and may get worse over time. While there is no one food to prevent or reduce fatigue, following a balanced diet, getting regular exercise, and getting enough sleep can help. In addition, try these suggestions:

• Limit your intake of refined sugars, such as candy, baked goods, and regular soda. Too much refined sugar and sweets can cause fatigue due to sharp changes in blood sugar levels. They can also add too many calories to your diet.
• Try to choose small, regularly-spaced meals containing protein-rich foods at each. Good sources of dietary protein include nuts, nut butters, eggs, quinoa, beans and legumes, fish, plain yogurt, and lean poultry.
• It is fine to have 1 or 2 cups of coffee or other caffeinated drinks a day. Do not have caffeine to stay up late, or to replace healthful meals.
• If you feel sluggish during the day, try going for a short walk instead of eating, if you are not actually hungry.
• Limit or avoid alcoholic drinks.
• Stay hydrated.

Managing side effects

You may experience different side effects during chemotherapy treatments. Side effects vary from one person to another. They also vary from one day to the next, even in the same person. The following table shows some possible side effects during different kinds of chemotherapy.

Dietary supplements

Do not take most vitamin, mineral, herbal, and other dietary supplements during chemotherapy, unless recommended by your doctor or dietitian. For most people, a balanced diet supplies the right amount of nutrients.

You may need to take a supplement of vitamin D (see the section “Managing Your Bone Health”) It is usually safe to take vitamin D during chemotherapy. Talk with your doctor or dietitian about whether you should take vitamin D and what amount.

Large doses of antioxidants may decrease the effects of some cancer treatments. This is one reason it is important to avoid most vitamin and other dietary supplements during chemotherapy and radiation therapy. You will not get too many vitamins or antioxidants from a diet rich in whole foods such as fruits and vegetables.

During chemotherapy and radiation therapy, limit green tea to no more than 16 ounces per day and juicing to no more than 8 ounces per day. Also, limit or avoid vitamin- or antioxidant-enhanced drinks such as Vitamin Water^®.

For more information on dietary supplements, see the section “About supplements”.

During hormone therapy

Hormone treatments include tamoxifen, leuprolide (Lupron^®), and aromatase inhibitors such as anastrozole (Arimidex^®), exemestane (Aromasin^®), and letrozole (Femara^®). These may be used for short or long periods of time. If you are on this kind of treatment, review the following guidelines.

Medication-nutrient interactions

Grapefruit and grapefruit juice interact with a number of medications. Avoid eating or drinking them if you are taking tamoxifen.

Certain dietary supplements interact with tamoxifen and other hormone treatments. Always check with your doctor or dietitian before starting any dietary supplements.

Managing body weight

For some people, hormone therapies can make it harder to maintain a healthy body weight. See the section “Maintaining a Healthy Body Weight” for more information on weight management.

Diet and hot flashes

Hot flashes are a problem for some women during menopause and for people getting treatment for breast cancer. Hot flashes vary from person to person. They may last for different periods of time. How often they come and go may also be different.

Research shows maintaining a healthy body weight or losing weight if you are overweight may help with hot flashes.

A stressful or warm environment can trigger a hot flash. Some foods and beverages can also trigger or worsen hot flashes. If you are experiencing hot flashes, avoid or limit the following:

• Caffeinated beverages
• Chocolate
• Alcohol
• Spicy foods
• Hot beverages

Many dietary supplements are marketed to help relieve hot flashes. They often contain potentially phytoestrogenic botanicals, such as red clover and black cohosh, or soy isoflavones. There is not enough evidence to show these supplements are effective in reducing hot flashes or safe for people who have or have had breast cancer. It is best to avoid them.

Managing Your Bone Health

Over time, all adults experience some degree of bone loss. However, some people have a condition called osteopenia, in which your bone mineral density is lower than normal. Having osteopenia can lead to osteoporosis, a disease in which your bones become weak and more likely to fracture (break).

Osteoporosis is often called a silent disease because there are usually no symptoms unless you have a fracture. The fractures usually occur in the spine, hip, ribs, and wrist. They can occur from doing normal, everyday activities.

Primary osteoporosis can be caused by the normal process of aging, menopause, or both. Secondary osteoporosis can develop as a side effect of cancer treatment. Taking aromatase inhibitors, a form of endocrine therapy, can increase bone loss and therefore increase the risk for osteoporosis and fracture.

To help keep your bones strong and reduce fracture risk:

• Eat calcium-rich foods.
• Get enough vitamin D.
• Do exercises that are weight-bearing, strengthening, and improve balance and flexibility.

Calcium

Calcium is a mineral that your body needs to build and maintain your bones and teeth. If there is not enough calcium in your diet, your body takes calcium from your bones.

The recommended amount of calcium a person needs depends on age and sex.

For people with osteoporosis, the recommended amount of calcium is 1,500 mg per day.

Dairy products are one good source of calcium. If you are lactose intolerant, you may want to try yogurt and lactose-free milk. Also, there are now many foods and drinks available that have calcium added to them. Add up how much calcium you are getting in your typical daily diet. This will help you know if you need to take a calcium supplement.

Food sources of calcium

*Calcium content is for tofu processed with a calcium salt. Tofu processed with other salts does not provide significant amounts of calcium.

**Check food labels, as amount of calcium varies.

Source: USDA National Nutrient Database for Standard Reference

Available at: http://ndb.nal.usda.gov

Taking a calcium supplement

It is best to get calcium from food. However, not everyone can get enough through food alone. Therefore, you may need a calcium supplement. You do not need a prescription to buy a supplement. Your doctor, nurse, or dietitian can recommend the amount of calcium that is best for you.

There is no benefit to taking more than the recommended dose of calcium. If you are getting enough from foods, you do not have to take a supplement. Taking more than the recommended amount of calcium can have health risks.

Choose a brand-name supplement. Look for labels that say “purified” or have the USP (United States Pharmacopeia) symbol. This helps ensure the supplement meets certain standards for quality and purity.

Tips for taking calcium supplements:

• Check with your doctor before taking calcium supplements if you:
  • Take diuretics (water pills)
  • Take large amounts of antacids for indigestion
  • Have ever had kidney stones
  • Have had problems with your parathyroid glands
• Take your calcium in divided doses for the best absorption. Do not take more than 500 mg at a time.
  • Most calcium supplements are best absorbed when taken with food. Calcium citrate is a form that can be taken either with food or on its own.
• Take calcium supplement pills with a glass of water.
• Don’t buy calcium tablets that are made from bone, coral, or dolomite. They may contain lead or other harmful metals.
• Calcium supplements can cause constipation. If you have this side effect, increase your liquid and fiber intake. If the constipation does not go away, call your doctor, nurse, or dietitian.
• Calcium supplements do not replace other treatments for osteoporosis. Even if you take a calcium supplement, you should also eat foods that are rich in calcium. You should also continue to do weight-bearing exercises, such as walking.

Vitamin D

Vitamin D helps your body absorb calcium. It is important for maintaining strong bones. Your body makes vitamin D after being exposed to the sun. Vitamin D is also found in some foods, such as fatty fish, cod liver oil, eggs, and fortified milk. However, it may be difficult to get enough vitamin D from sunlight and foods alone. Your doctor or dietitian may tell you to take vitamin D supplements. These can be prescription or over-the-counter vitamin D supplement pills, or calcium supplements with added vitamin D.

Some people have an increased risk for having low levels of vitamin D. They include:

• People who don’t spend much time outside of the house.
• People who spend little time in the sun or regularly cover their body and face with sunblock.
• People who are overweight or obese.
• People with darker skin.
• People with certain medical conditions, such as celiac disease.
• Older adults.

Talk with your doctor, nurse, or dietitian about how much vitamin D you need. Ask if your blood levels of vitamin D should be checked.

Being Physically Active

Regular physical activity is important for good health. Most studies suggest that 30 to 60 minutes per day of moderate- to high-intensity physical activity is associated with a reduction in breast cancer risk. Staying active can also:

• Help you achieve and maintain a healthy body weight.
• Improve heart health.
• Keep your bones strong.
• Help prevent falls.
• Build lean muscle mass and reduce fat tissue.
• Improve cognitive function, including memory, thought-processing, and speech.
• Reduce fatigue and increase energy.
• Reduce depression or anxiety.
• Prevent or relieve constipation.
• Improve joint pain.
• Reduce the risk for other types of cancer and many chronic health conditions and diseases.
• Improve overall health.

Researchers have found other benefits of exercise for people with cancer. If you are receiving chemotherapy, you may feel tired during the day. Exercise can help reduce fatigue and boost energy. Exercise may also help you get through your treatments on time and improve your self-esteem. It can strengthen your immune system, increase fitness, and help prevent weight gain.

Talk with your doctor before starting any exercise program or increasing your current exercise.

Adding exercise to your daily routine

Find physical activities you enjoy. This will make it more likely that you will do them regularly. Remember that any small increases in activity will help. Set small goals and gradually work your way up.

Exercise can be broken up into 2 or 3 sessions. For instance, if you don’t have 1 whole hour to exercise, try walking for 30 minutes twice a day. Try the following ideas to increase physical activity:

• Take the stairs instead of the elevator or escalator.
• Get off the subway or bus one or two stops early and walk the rest of the way.
• Go for a walk after dinner.
• Do some gentle stretches when you first get up in the morning.
• Bike, walk, or rollerblade to the store or to work instead of driving.
• Walk the dog several times a day instead of hiring a walker.
• Get up from your desk and take short walks around the office throughout the day.
• Instead of sending an email or calling a coworker, walk to his or her office.
• Park your car a distance away from your destination and walk the rest of the way.
• Plan active social activities with friends and family. For example, instead of meeting for lunch or coffee, go for a bike ride. Instead of watching a movie with your children, go to the park with them.
• When golfing, walk instead of using a cart.
• Walk or play Frisbee at the beach or in the park instead of lying down or sitting.
• After going out for dinner, go out dancing.
• Make walking or biking date nights with your spouse or partner.
• Clean your house or apartment.
• If it’s raining or snowing outside, walk laps inside a mall.

The table below will help you determine how much exercise you need each week, depending on your goals.

Sources: US Department of Health and Human Services, the American Cancer Society, and the American College of Sports Medicine.

Check the table below to see how many calories you can burn during 1 full hour of exercise. These are estimates for a 150-pound person. If you weigh less than 150 pounds, you will burn fewer calories. If you weigh more than 150 pounds, you will burn more calories.

Physical activity log

Use a physical activity log to help you keep track of how much exercise you do each week. If you have any special health considerations or questions about designing an exercise program, talk with your doctor.

Frequently Asked Questions

What is the best anti-cancer diet?

There is no one type of diet that can prevent or cure cancer. However, a diet with a variety of whole plant foods, low added sugars, and the right number of calories for you is probably the best diet for overall health and disease risk reduction.

You may have heard of the Mediterranean Diet, which is associated with health benefits. The Mediterranean Diet includes many vegetables, beans, fruits, seafood, and healthy plant oils such as olive oil and nuts. It includes very little refined carbohydrates (such as white bread products), sugars, and meats.

Reaching and maintaining a healthy body weight is one of the best ways you can reduce your cancer risk. But even someone who follows a “perfect” diet can develop cancer or have the cancer recur (come back). Cancer involves many more factors than diet alone.

What foods are good for a person with cancer?

The best foods for any given person depend on that person’s individual needs and tolerances. These vary widely from person to person.

For example, someone who is trying to lose weight might benefit from eating a variety of fresh raw vegetables and high-fiber grains. But if someone has diarrhea during chemotherapy or radiation therapy, those foods would not be the best choices. Speak with your (or your loved one’s) dietitian to determine what foods might be good to eat and what might be good to limit or avoid.

Is it true that sugar feeds cancer?

Although this sounds like a simple question, the answer is quite complex. The truth is, all of the cells in our bodies use a form of sugar (glucose) for growth and energy, so sugar feeds all cells, not just tumor cells.

Still, it is a good idea to limit sugars from foods and drinks, as well as limit total calories. Eating too much sugar – or too much of any food – contributes to extra body weight in the form of fat. We do know that overweight and obesity increase the risk for developing cancer.

Diets with too much sugar (and too many calories overall) can also lead to increased levels of insulin and other hormones that may contribute to tumor development. However, if you eat an overall healthy diet, having an occasional cookie will not in itself cause cancer growth.

For more information, see the Academy of Nutrition and Dietetics article about sugar and cancer at www.oncologynutrition.org/erfc/healthy-nutrition-now/sugar-and-cancer/.

What is the relationship between red meat and cancer?

Eating processed red meat, such as bacon, hot dogs, ham, and sausage, is associated with an increased risk for certain types of cancer. Research shows eating 50 grams a day of processed meat (about 2 slices of ham or bacon) increases colon cancer risk by 18%. However, you don’t have to eliminate all meat from your diet. Keep portion sizes small and be sure to fill most of your plate, at most meals, with whole vegetables and other plant foods.

Are coffee or other drinks with caffeine okay to drink?

It is fine for most people to drink moderate amounts of coffee or other caffeinated drinks such as black or green tea. In fact, research suggests that there are possible health benefits associated with drinking moderate amounts of coffee. Avoid or limited sweetened beverages with added caffeine (“energy” drinks) and don’t drink alcoholic beverages with added caffeine. Also remember that some coffee shop drinks have a lot of calories and sugar.

Which foods or supplements boost immune function?

Research has not shown that any single food or oral dietary supplement can improve your immune function. Your immune system relies on many factors. However, a balanced diet can help make sure that your body is strong enough for treatment. Regular exercise can also help you have healthy immune function.

Other ways to support your body and immune system during treatment or any time include:

• Avoiding smoking or other tobacco use.
• Getting enough sleep.
• Maintaining a healthy body weight.
• Limiting alcohol intake.
• Managing stress.
• Managing blood pressure.
• Washing your hands appropriately.

During chemotherapy, make sure to follow food safety precautions, such as cooking meats thoroughly and avoiding unpasteurized foods. This will help your body when it is less able to fight off infections.

What is the best diet for weight loss? Are there any foods that speed metabolism?

Research shows that limiting the amount of calories you eat is the best way to lose weight and keep it off. Weight loss and weight maintenance  require a lifestyle change rather than a “diet”. Cutting out whole food groups such as fats or carbohydrates isn’t likely to be effective and is almost impossible to keep doing over time.

There are no foods that boost metabolism. However, by exercising, you can increase your lean muscle tissue. This will increase the rate at which your body burns calories. Exercise regularly to keep or increase lean muscle mass and decrease fat mass.

Sample Meal Plan

Here is a 1-week sample meal plan. Each day’s menu has about 1,600 calories. These plans are not right for every person. Individual needs and tastes vary, so you don’t need to follow the plans exactly. However, they may give you ideas for healthy meals and snacks.

Sample Food Diary

MSK Support Services

The following services are offered at the Evelyn H. Lauder Breast Center

• Breast medicine and surgery consultation
• Diagnostic imaging
• Chemotherapy
• Social work services
• Psychiatry services
• Nutrition services
• Occupational therapy
• Special surveillance breast program
• Survivorship program
• Genetic counseling
• Art therapy

To make an appointment with a dietitian, please call 646-888-4880.

The Integrative Medicine Service offers complementary therapies to cancer care. These include touch therapy, mind-body therapy, acupuncture, creative therapy, and nutrition counseling, as well as exercise programs to improve strength and promote relaxation. Their services are available to anyone receiving cancer care, whether at MSK or elsewhere, as well as to the general public.

External Resources

Has information about the latest nutrition guidelines and research and can help you find a dietitian in your area. The academy also publishes The Complete Food and Nutrition Guide, which has over 600 pages of food, nutrition, and health information.

Has information on diet and other cancer-related topics.

Has information on variety of health and fitness topics and can provide you with names of certified fitness professionals in your area.

Has information on healthy eating and general exercise guidelines. They also publish several heart-healthy cookbooks that can be found in most bookstores.