Nutrition & Prostate Cancer: Exploring the role of diet Presented by Greta Macaire, MA, RD, CSO UCSF Helen Diller Family Comprehensive Cancer Center.

Nutrition & Prostate Cancer: Exploring the role of diet

Presented by Greta Macaire, MA, RD, CSO

UCSF Helen Diller Family Comprehensive Cancer Center

Nutrition & Prostate Cancer• Improved nutrition may reduce the incidence of

prostate cancer & the risk of prostate cancer progression (J Urol. 2005 Sep;174(3):1065-9).

• “Scientific evidence suggests that differences in diet & lifestyle may account in large part for the variability of prostate cancer rates in different countries” (CaPCure).

• “The increase in prostate cancer deaths in Asian and Eastern European countries has been thought to reflect westernization, including increased consumption of animal fat, obesity, and physical inactivity” (ACS. Global Cancer Facts & Figures, 2nd Edition, 2008).

Prostate Cancer Lifestyle Trial (PCLT)Ornish D, et al., J Urol. 2005 Sep;174(3):1065-70

• Randomized controlled trial: – 93 men (non-smoking) on active surveillance for prostate cancer.– Intervention (low-fat, vegan diet, w/soy and antioxidants, omega-3

fatty acid, moderate aerobic exercise, stress management, and group support) vs. Control (usual care)

• Results: – After 1 year, PSA ↓4% in the intervention group & ↑6% in the

control group. – Prostate cancer cell growth was inhibited ~8 times more by blood

from the intervention vs. control group.

• Conclusion:– Intensive changes in diet and lifestyle may affect the progression

of early stage prostate cancer and improve quality of life. – Further studies and longer term follow-up are warranted

PCLT - Two year follow upFrattaroli, et al. Urology. 2008 Dec;72(6):1319-23

• 27% of control patients vs. 5% of intervention patients underwent conventional treatment.

• Intervention group also had significant decreases in total cholesterol and LDL.

• 95% adherence to lifestyle program in the intervention group.

GEMINAL Study• Gene Expression Modulation by

Intervention with Nutrition & Lifestyle Study– Single arm, pilot study - 30 men, active

surveillance, biopsy at baseline and after 3 mos intensive lifestyle change.

– Gene expression in > 500 genes was affected:• Significant modulation of biological processes that

have critical roles in tumorigenesis.

– Total PSA did not significantly change, % free PSA, CV risk factors, & some measures of QoL improved.

Ornish, et al., Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369-74)

Guidelines for a Healthy Diet• Plant-based diet

– Plethora of colorful fruits, vegetables, herbs & spices – High fiber – whole grains and beans/legumes– Limit processed & refined foods avoid WHITE– Limit meats & dairy

• Low fat diet with emphasis on healthy fats

• Drink plenty of fluids

• Stop smoking if you smoke

• Limit alcohol consumption

• Be physically active to help achieve and maintain a healthy weight

• Meat Based– High in cholesterol– High in saturated fats– High in oxidants– Low in antioxidants– Pro-inflammatory– Low in fiber

• High in pathogenic substances

• Plant Based– No cholesterol– Low saturated fats– Low in oxidants– High in antioxidants– Anti-inflammatory– High in fiber

• High in protective substances

Benefits of Eating a Plant Based Diet.

Dewell A, et al. Am Diet Assoc. 2008;108:347-356.

Phytochemicals: Protective Compounds in the Food We Eat

Food sources of phytochemicals with anti prostate cancer activity

• Indole-3-Carbinol: – Cruciferous vegetables – broccoli, Brussels sprouts,

cabbage, cauliflower, collard greens, kale, kohlrabi, mustard greens, radish, rutabaga, and turnips.

• Lycopene/Other Carotenoids: – Cooked tomato products, raw tomatoes, watermelon – Carrots, sweet potatoes, peppers, mangos,

cantaloupe

• Organosulphur compounds:– Garlic, leeks, onions, shallots

• Ellagitannin:– Pomegranate

Food sources of phytochemicals with anti prostate cancer activity

• Isoflavones: – Soy foods

• EGCG: – Green and white tea

• Resveratrol: – Grape skins, peanuts, mulberries, cranberries, soy

• Curcumin: – Turmeric

• Quercetin:– Teas, onions, apples, berries, buckwheat,

cruciferous vegetables

Insulin, Glycemic Control, & Cancer

• A Western lifestyle -- characterized by low physical activity, & high dietary intake, animal protein, saturated fats, trans fats, & rapidly digestible carbohydrates -- is associated with ↑ risks of many cancers.

– May be mediated by alterations in the metabolism of the hormones insulin and insulin-like growth factors (IGFs).

– Insulin & IGF-I may promote tumor development by inhibiting apoptosis, stimulating cell proliferation, stimulating synthesis of sex steroids, changing gene expression, and inhibiting the synthesis of sex hormone-binding globulin (SHBG).

Insulin, Glycemic Control, & Cancer

• Recent studies indicate that high insulin & IGF-1 levels, & greater abdominal fat are associated with increased risk for various cancers.

• Additionally, hyperinsulinemia is associated with increased risk of heart disease, type 2 diabetes, ↓ immune system, & weight gain (obesity).

• Obesity & fasting hyperinsulinemia have also been associated with a poorer prognosis in cancer patients.

Dietary Strategies to Improve Glycemic Control

• Aim for 30-45 gm fiber daily – ↑vegetables, beans/legumes, whole grains

• Limit portions of starchy carbohydrates• Avoid ‘white’ foods • Limit caloric beverages (avoid HFCS) • Avoid eating starches alone; combine with

protein & healthy fats • Avoid evening snacking; ↓evening meal size

LEAN OR PLANTPROTEIN SOURCE

WHOLE GRAINS/STARCHY VEGETABLES

VEGETABLES & FRUITS

Healthy Fats

Healthy Plate = Energy & Balance

The 10:1 Rule For every 10 gm of total carbohydrate listed on the label, you want ≥1 gm of dietary fiber

Note that for most breads and cereals, look for 3 or more grams of dietary fiber/serving

Reading the Nutrition Facts Label

Finding Whole Grains

Inflammation & Cancer

Obesity and InflammationFat cells especially visceral fat (the kind around the waistline) are active cells secreting chemicals (TNF-alpha, IL-6, CRP, leptin) that promote chronic inflammation.

Essential Fatty Acids

Decrease Omega-6 Fatty Acids:

Meats (especially grain-fed), butter, whole milk, egg yolks, sunflower oil, safflower oil, cottonseed oil, corn oil, & processed foods made with these oils.

Increase Omega-3 Fatty Acids:

Cold-water fish (i.e., salmon, trout, sardines, herring, sablefish), DHA enriched eggs, flaxseeds, chia seeds, walnuts & pumpkin seeds.

Pro-Inflammatory Compounds:

Promote inflammation, tumor growth, progression

& angiogenesisSuppress immune function

Anti-Inflammatory Compounds:

Inhibit tumor growth & angiogenesis

Immune enhancing

Standard American Diet (SAD)

Ratio of Omega-6 to Omega-3 intake: 20:1

Traditional/Ideal ratio: ~2:1

Both types of fat are essential.

Imbalance of omega-6 to omega-3 oils can have negative affects on the metabolism of eicosanoids.

Omega-6 fatty acids Omega-3 fatty acids

Healthy Fat Recommendations• Keep saturated fats to 7% total kcals from fat.

– Limit or avoid fatty meats, whole milk dairy products, cheese, mayonnaise, butter, & baked goods.

• Avoid trans fat, AKA partially hydrogenated oils

• Aim for 1:1 to 4:1 omega-6:omega-3– Limit processed foods– If eating out often, inquire about type of oil used at

restaurants– Use olive oil, avocado, almond, macadamia nut or

canola oil for cooking/salads– Increase sources of omega-3’s daily

• Fish, chia seeds, flaxseeds, walnuts, pumpkin seeds

• EPA/DHA supplement if appropriate

Body Weight & Physical Activity• Obesity & inactivity = ↑ risk of prostate cancer & prostate

cancer progression.– A cohort study reported an ↑ risk of death from prostate

cancer:• Obese men ↑ risk by 20 %/ Severely obese ↑ risk by 34%

– A UCSF study of over 2,000 men found that maintaining a healthy body weight ↓ the risk of recurrence.

• Obese men recurrence by 30%• Very obese men recurrence by 69%

– Men with prostate cancer who walked briskly for ≥3 h/wk had a 57% lower rate of progression than men walking at an easy pace for <3 h/wk (Cancer Res; 71(11); 1–7. 2011 AACR).

Physical Activity

• Physical activity IN ANY FORM helps ↓ risk of cancer. – Influences hormone levels, ↑ immune

function, improves digestion, helps control body weight

• Any steps taken are beneficial. – Aim for 30-60 minutes of exercise most days.– Everything counts: All types/Cumulative

Dairy & Prostate Cancer

• A meta-analysis on 8 cohort studies found a 6% increase in prostate cancer risk per serving of dairy per day (AICR/WCRF - 2nd Expert Report. November 2007).

• In a 7.5 year prospective study of 43,435 Japanese men, those consuming the highest amount of dairy (=12 oz of milk/day) had a 63% ↑ risk of prostate cancer compared to men consuming the lowest (=2 oz of milk/day). (Kurahashi, et al. Cancer Epidemiol Biomarkers Prev. 2008 Apr;17(4):930-7).

Vitamin D• Vitamin D is known to inhibit prostate cancer in animals

& appears to have a similar effect in humans.

• Non-dairy sources of vitamin D include cold-water fish, fortified products (i.e., soy milk, cereals), & sunlight.

• A supplement of vitamin D3 (cholecaciferol) may be beneficial (1000 IU or more if needed).

• It is suggested to test serum 25-OH vitamin D level, especially if undergoing ADT &/or have darker pigmented skin.– Appears to be optimal at >40 ng/ml (AJCN 2006).

Parsons, JK Current Opinion in Urology. 21(1):1-4, January 2011. DOI: 10.1097/MOU.0b013e32834100c9

Lifestyle factors for benign prostatic hyperplasia (BPH) and lower urinary tract

symptoms

Supplements & BPH

• Saw Palmetto: – Studies conflicting about benefits for improving

symptoms. Dosage: 160 mg, 2 x day

• Beta-sitosterol: – Improves urinary symptoms. Dosage: 20 mg, 3 x day– Food sources: vegetables, fruits, nuts/seeds,

avocados, vegetable oils

• Pygeum:– Decreases nocturia, increases peak urine flow, and

reduces residual urine volume. Dosage: 50 mg, 2 x day or 100 mg, 1 x day

What can a healthy diet do for me?

• May help to inhibit prostate cancer growth

• Reduce risk of chronic diseases

• Enhance immune system

• Increase energy levels

• Facilitate recovery toxicities of treatment

Healthy Prostate Cancer DietPlant-Based• 8-10 COLORFUL fruit & vegetable servings daily

– Eat 1 cup or more vegetables with at least 2 meals– Herbs & spices daily– Lycopene (30 mg) from food 6 ½ tbsp tomato paste, ¾ C

tomato sauce, or 12 fl oz tomato juice– Pomegranate 1 oz concentrate or 8 oz juice

• Beans/legumes, whole grains & other high fiber foods – 30-45 grams of fiber daily– 2 T ground flaxseed

• Limit or avoid meats & dairy

• Limit or avoid processed & refined foods avoid WHITE

Healthy Prostate Cancer DietLimit alcohol consumption

Fats• Low in fat (20-25% of calories)• Healthy fats cold-water fish, flaxseeds, chia seeds,

walnuts, soybeans, olive oil, avocados

Green Tea 1-4 cups daily

Vitamin D (1000 IU or more if needed)– Consider serum 25-OH test Recommend > 35 ng/ml

Regular physical activity and avoid excess caloriesto achieve or maintain a healthy body weight.

ResourcesCookbooks• Cancer Lifeline Cookbook – written by Kimberly Mathai, 2004

• Eat to Beat Prostate Cancer – written by David Ricketts, 2006

• One Bite at a Time – written by Rebecca Katz, 2004

• The Cancer Fighting Kitchen – written by Rebecca Katz, 2009

Websites• http://www.aicr.org• http://www.caring4cancer.com • http://cancer.ucsf.edu/crc• http://www.consumerlab.com • http://www.cancerproject.org

http://cancer.ucsf.edu/_docs/crc/nutrition_prostate.pdf

Thank you