Nutrition & Prostate Cancer: Exploring the role of diet

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

2. 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). Nutrition & Prostate Cancer

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

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

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

6. 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 Guidelines for a Healthy Diet

7. 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.

8. Phytochemicals: Protective Compounds in the Food We Eat

9. 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

10. 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 Food sources of phytochemicals with anti prostate cancer activity

11. 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

12. 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.

13. 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

14. Healthy Plate = Energy & Balance LEAN OR PLANT PROTEIN SOURCE VEGETABLES & FRUITS Healthy Fats WHOLE GRAINS/ STARCHY VEGETABLES

15. Reading the Nutrition Facts Label 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

16. Finding Whole Grains

17. Inflammation & Cancer

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

19. Essential Fatty Acids 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 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. Standard American Diet (SAD) Ratio of Omega-6 to Omega-3 intake: 20:1 Traditional/Ideal ratio: ~2:1 Pro-Inflammatory Compounds: Promote inflammation, tumor growth, progression & angiogenesis Suppress immune function Anti-Inflammatory Compounds: Inhibit tumor growth & angiogenesis Immune enhancing

20. 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 Healthy Fat Recommendations

21. 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). Body Weight & Physical Activity

22. 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

23. 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).

24. 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).

25. Lifestyle factors for benign prostatic hyperplasia (BPH) and lower urinary tract symptoms Parsons, JK Current Opinion in Urology. 21(1):1-4, January 2011. DOI: 10.1097/MOU.0b013e32834100c9

26. 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

27. May help to inhibit prostate cancer growth Reduce risk of chronic diseases Enhance immune system Increase energy levels Facilitate recovery   toxicities of treatment What can a healthy diet do for me?

28. Plant-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 floz tomato juice Pomegranate  1 oz concentrate or 8 ozjuice 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 Diet

29. Limit 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 calories toachieve or maintain a healthy body weight. Healthy Prostate Cancer Diet

30. Cookbooks 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 Resources

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

32. Thank you