Resources on Nutrition


Sunflower Wellness is pleased to present nutrition information provided to us by Natalie Ledesma, MS, RD, CSO, Nutrition Specialist with Smith Integrative Oncology and Oncology Dietician with UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco.

Sunflower Wellness thanks Cecelia Ottenweller for interviewing Natalie and contributing this page. The interview was conducted in May 2011.

Please click on the links below to read more on each section.

Natalie Ledesma was a godsend while I was undergoing my second wave of breast cancer treatments in 2007. I began working with her at my mother’s insistence… You’d think someone going through six months of chemo would fully embrace the idea of working with a nutritionist to help deal with the effects of all those chemicals coursing through my body, but my reaction was actually the opposite. I dragged my feet in calling her.

I was dealing with my second “cancer adventure” in two years. Between 2006 and 2009, I went through a lumpectomy, sentinel node biopsy, four rounds of “Red Devil” chemo, six weeks of radiation (my “boob-b-ques”), a follow-up mammogram that revealed another tumor in the original breast, a mastectomy and hysterectomy (my ovaries were doing me no favors!) six months of Abraxane and Xeloda, followed by a mastectomy of the left breast and a bilateral DIEP flap in 2009. When Mom suggested calling Natalie, I was only half way through this list. I was feeling more than just a little sorry for myself and was quite tired of folks’ “helpful” suggestions.

By the time I started my second set of chemo treatments, I was more than a little tired of dealing with insinuations that somehow I’d caused my cancer. As I’m sure some of you have experienced, people’s reactions to our having cancer can sometimes be a little…odd. I was young, appeared healthy (though overweight), I was active. Reactions ran the gamut after my diagnosis and at times I had to contend with a virtual Niagara of un-sought-after advice and theories, especially about diet:

  • “You’re not going to do chemo, are you? You just need to juice!”
  • “Well, you’re obviously overweight….”
  • “I knew this guy who went to Mexico and did an intense vitamin therapy and he’s in complete remission. You should do that…”
  • “A macrobiotic diet is the ONLY way to go!”
  • “You didn’t take your vitamins, did you???”
  • “Yeah. Don’t eat sugar. It makes cancer grow.”
  • “It was the milk. You had to have drank too much milk. And eaten too much beef. Yep, the cows are doing you in.”
  • “EVERYTHING you eat has to be organic!”
  • “Are you juicing???” (repeated because this was a comment I dealt with a lot…)
  • “I’ve got a book for you! ‘Alkalyze or DIE!’” (this last one delivered in my favorite coffee house, in front of a busy crowd, 3 days after I had to shave off all my hair… peachy.)

My reaction was to passive aggressively eat whatever the heck I wanted and mentally stick my tongue out at the world, which often included Natalie’s very sound advice. (But you should know, to be very honest, I had LOTS of support while I went through my “adventure”; comments like the ones above were not the norm, but the exception. When they did happen, however, they certainly stuck out like verbal sore thumbs.)

It’s impossible to avoid the discussion about the link between diet and disease. The subject appears everywhere, from Jamie Oliver trying to clean up the diet of Los Angeles school kids to Dr. Oz or some other health advocate appearing on TV or on the front of nearly every magazine in the grocery checkout line. (And, as a side note, have you noticed that the covers of those magazines usually have one “health” article listed, but the image is of some gooey, chocolately/creamy treat with some kind of rainbow sprinkles on it?? Talk about mixed messages!) I’d like to be around for at least a few more decades with no more medical “drama”. So, I reconnected with the great Ms. Ledesma and she very generously took the time to answer some basic questions I had about the connections between diet and breast cancer. She also gave me the bottom line on what the best changes I could make to improve my diet overall. Her answers are presented here.

Cecelia: How does specializing in oncology make you different from other dietitians?

Natalie: As a board certified specialist in oncology nutrition (CSO), I had to be a registered dietitian (RD) for at least 2 years, have over 2,000 hours of oncology experience, and pass an exam (every 5yrs).

Cecelia: I imagine I wasn’t the only person you’ve dealt with that had some baggage around food going into the experience. What do you tell people who are suddenly finding themselves dealing with a cancer diagnosis who are also dealing with guilt over maybe having caused their cancer with their dietary habits?

Natalie: Cancer is multifactorial. Empower yourself with what you have control of – diet, physical activity, and lifestyle. Over 70% of the contributing factors to cancer mortality stem from diet and lifestyle, including smoking. No one can take that away from you but yourself.

Many popular nutrition books out today advocate totally abandoning dairy. What about my getting enough calcium, which is a big issue since I’m post-menopausal and am on a drug that eliminates estrogen in my body. Am I increasing my chances of recurrence by drinking milk? Are milk substitutes like hemp milk, oat milk, almond milk, etc a good replacement? What about soy?

Natalie: The research with dairy and breast cancer is equivocal [suspicious]. If you’re a prostate or ovarian cancer patient, dairy has been more strongly linked with these cancers. We do know that dairy (and meat) increases insulin-like growth factor (IGF) and that IGF drives the development, promotion, and metastasis of breast cancer. And that casein, the protein in dairy, does increase inflammation. So, honestly, dairy is not a hot item on my list. Is there evidence that it will increase your risk of breast cancer or recurrence of breast cancer? Absolutely not.

Milk is a decent source of calcium, but certainly not the only source. You can get more than adequate calcium without consuming dairy if you choose. And yes, there are various non-dairy milks available. One thing to note with almond, oat, or rice milk is while they can match the calcium content of cow milk, their protein content is significantly less. That’s okay potentially, but good to be aware of. Soy and hemp milk provide calcium and protein.

And while soy presents a whole other hot-box of questions, the research suggests that eating 1-2 servings of soy foods daily for breast cancer survivors is safe and may even lower one’s risk of recurrence. So, depending on what other soy foods (i.e., edamame, tofu, tempeh, miso, soy nuts) you’re consuming daily, drinking soy milk daily may or may not be a good option.

I‘ve seen several articles that say we eat WAY too much meat in the Western diet and that it is a contributing factor in the development of cancer. What are your thoughts? How does consumption of meat – beef, pork and chicken – affect cancer recurrence?

Natalie: I agree that animal protein consumption in the US is too high. I would seek to get 80% of your calories from plant foods. Use meat as a condiment, not your meal. If you’re looking at your plate, pile high (50% of your plate) with veggies, 25% protein (animal or plant), and 25% whole grain/starchy vegetable.

Does meat increase recurrence? Not enough evidence to say, but as I mentioned above, it does increase IGF. Other theories of why meat is associated with the risk of cancer include its saturated fat content, HCAs/PAHs from grilling/frying meat, the lack of antioxidants/phytonutrients, nitrites in processed meats, and the nutritional ramifications of grain-fed meat (by far the majority of what Americans are consuming). I don’t think that survivors can’t eat meat nor do I think that they must eat meat. If you choose to, go lean, be reasonable with portion, have it less frequently, and opt for organic if you can.

You were concerned about my getting enough Omega 3, for which cold water fish is a good source. Are plant based sources just as good? At the time I was diagnosed, I was on an Omega 3-6-9 supplement and you asked me to stop it.

Natalie: While most seafood provides you some omega-3 fatty acids, the cold-water fish (i.e., salmon, sardines, trout, sablefish) is where they really are – and those I believe are important. If you don’t like fish or don’t eat enough of it, I would seriously consider taking a supplement. Plant-based omega-3’s (flax, chia, hemp, walnuts) are great too, but they’re not the same. I think evidence points to the need for both. There are vegetarian DHA supplements (DHA is one of the omega-3’s in fish) out there; note that you will have to take several of them.

You’re optimally seeking a 1:1 ratio between omega-6 fats and omega-3 fats, or at least closer to 1:1; 2:1 up to 4:1 could be acceptable, but the average American has a 12:1 to 20:1 ratio, which fosters inflammation, promotes cancer growth, and decreases immune function. Omega-6’s are found in meats, butter, egg yolks, cheese, and vegetable oils such as sunflower, safflower, and cottonseed oils.

Does sugar cause cancer? Are all sugars equal? Are there any “good” man-made sugars? Is honey a good substitute? What about agave nectar?

Natalie: While there are no studies clearly showing that sugar causes cancer, there are certainly no studies reporting sugar to prevent cancer. We do know that diets rich in refined carbohydrates and sugars lead to:

  • Increases Insulin (and IGF) levels and contribute to insulin resistance
  • Increases risk of heart disease, diabetes, obesity and cancer
  • Decreases immune system and negatively affects the way we metabolize carbohydrates

Higher serum insulin levels (>13 ng/ml) have been associated with poorer survival among breast cancer survivors.

Rather than emphasizing what may NOT be a great food choice, focus instead on fueling your bodies with nourishing foods – vegetables, fruits, beans/legumes, whole grains, nuts/seeds, and lean protein sources. Sugar-laden foods generally provide little to no true nutrient value. Limit or avoid products made from refined grains or flours (i.e., white bread, white pasta, white rice), alcohol, sodas, fruit drinks, and sweets, such as candy, cookies, cakes, and pastries. An occasional sweet is acceptable. Keep your portion reasonable and focus on health-promoting foods to nourish and strengthen your body.

If you’re to choose a sweetener, which one you say? My favorite sweetener is no sweetener, but realistically, I know you want more than that from me. We do have some decent options, including stevia, agave nectar (if true agave and not just labeled as so), yacon syrup, and recently on the market, coconut sugar. Maple syrup and honey are ok, but do have a much higher glycemic index, which is less preferable.

What’s the connection between alcohol consumption and breast cancer recurrence?

Natalie: Indeed, alcohol is associated with the risk of breast cancer and more recently with the recurrence of breast cancer. A recent study found that women who had 3 drinks a week had a 37% increased risk of recurrence. That’s only one study and we definitely need more, but clearly, alcohol should be limited for those with breast cancer. I recommend 2 drinks or less weekly.

Mechanism is unknown, but theories include how alcohol increases endogenous estrogen levels, lowers serum folate (a B vitamin), and/or carcinogenic effect on breast tissue.

Lots of popular nutrition writers say a plant-based diet is good for everyone including the planet. What are your thoughts on going completely vegetarian or vegan? Some suggest a minimum 80/20 (veg/protein) split. I’ve been getting my meat protein mostly from seafood with occasional foul or hooved meat. Is that bad?

Natalie: I agree with the plant-based approach. If one wishes to be vegetarian or vegan, by all means, go for it. As long as a vegetarian/vegan diet is well-balanced (and any diet for that matter), one can meet all of their nutrient needs. At the same time, I don’t feel that there is evidence to support that one cannot include a small amount of animal protein if desired. And if you’re going to include animal protein, fish, occasional poultry and hooved meat sound like a very reasonable way to go.

Remission and Diet – the bottom line: I’m sure everyone has an anecdote of someone they know being “cured” by cleaning up their diet. How often does this really happen? Is there anything to this?

Natalie: I’ve seen amazing results when one makes significant diet modifications – improved labs, increased strength & vitality, better sleep, eliminating prior symptoms, mitigating treatment side effects, 50lb weight loss, and more, but in all honesty, I virtually never see someone ‘cure’ their cancer with diet. ‘Cure’ is a very strong word. I have seen many prostate cancer patients be able to forego invasive treatment due to diet and lifestyle changes, but I wouldn’t say that their diet ‘cured’ them. Perhaps those that are ‘cured’ never walk through our door.

Some nutritionists say one of the big culprits in the development of cancer is having too acidic an environment in the body. What role does alkalinity play in the development of breast cancer specifically?

Natalie: There is a grain of truth to the concept that cancer is related to acid-alkaline balance in the body. There is not evidence that links acidic diets as a causative factor in cancer. However, research suggests that cancer cells may create excess acid and hence the areas around tumors more acidic. Whether or not this microenvironment near the tumors affects the entire body’s pH balance very well may not be the case.

That said, aiming to eat an alkaline diet certainly can do no harm and is generally a very healthy diet anyway. The biggest impact is to eat a more plant-based diet. In general, vegetables, fruits, legumes, and whole grains make the body less acidic while meat and dairy products make the body more acidic.

And just to clarify, an acidic food does not necessarily have an acidic effect on the entire body system. A lemon, for example, is quite acidic yet has a very alkaline effect on the body.

I know so many people who’ve gone “gluten-free”. It’s hard not to be disdainful of this as a “fad” and I’m pretty confused by it. Is there a value in not doing gluten? Does it contribute in the development of cancer?

Natalie: While it does seem to be becoming a ‘fad’, unfortunately, I do believe there is clout in a gluten free diet being quite beneficial for many. However, there isn’t any evidence to my knowledge linking gluten and cancer per se. Gluten, the protein found in wheat, rye, and barley, does have an inflammatory effect for many, if not all, people. And clearly, there is a direct link of inflammation to various types of cancer and any chronic disease for that matter.

I typically suggest a gluten-free diet for certain patients not because of their cancer itself, but more so to help with other symptoms (i.e., joint pain, gastrointestinal distress, weight management) that they may be experiencing. I have found on occasion that a medication (i.e., lupron) and/or chemotherapy treatment alters one’s ability to tolerate gluten.

I see tolerance to gluten on a spectrum; there are some that the tiniest amount of gluten completely disrupts their endocrine system, create gastrointestinal bloat, a headache, or whatever it may be and there are those that can eat gluten and not have a negative response. What I’m finding, however, is that there are very few of my patients who have absolutely no effect with gluten. And the true test, is to eat absolutely NO gluten for at least 4 weeks, if not 6 weeks, to find out if this is an issue.

I find that some people are wheat sensitive only, not necessarily all gluten. Some can even tolerate sprouted wheat (which is more easily digestible), but find that regular whole wheat or refined wheat is not as well tolerated.

How important is it to take additional supplements to stave off a recurrence?

Natalie: We don’t have evidence to suggest that supplements are going to reduce your risk of a recurrence per se. However, I do recommend supplements for certain clinical conditions (such as diarrhea, constipation) and/or to enhance immune function, decrease inflammation, improve glycemic control, all of which help control the terrains where cancer grows. Which supplements are best really vary by individual. [NOTE: Natalie advocates talking to a professional to determine what supplements a person should be taking.]

A number of my friends are “cleansing” their systems, like with the lemon/cayenne/maple syrup cleanse. Is this a good idea? Do I have toxins locked in my many-feet of intestines that will someday cause a recurrence or another cancer? Can you shed some (sane!) light on this subject?

Natalie: Hard science behind cleansing, I don’t think so. Can it be beneficial? Possibly. There are various types of cleanses out there, some of which are reasonable and many that are not. Eating a healthy vegan diet is essentially a cleansing diet. I generally do not advocate radical cleanses for cancer patients and even with a conservative cleanse, would suggest that patients be at least 6-8 weeks out of treatment (if not longer) before embarking on a cleanse. I do find that, for some patients, adhering to a healthy well-balanced cleanse for 3-4 weeks can be very helpful (reset the system after treatment if you will), but this is not a low calorie diet necessarily.

Cleanses/fasting can involve consuming freshly-juiced organic vegetables and fruit, juices diluted with water, raw or steamed organic fruit and vegetables, cooked whole grains (such as mung-beans and rice, often used by Yogis), legumes, nuts and seeds, micro-algae combined with vegetable or fruit juice or herb tea. It can also be an absolute fast, which is not recommended. Regardless of which type of fast is practiced, it is very important to have plenty of water, liquids, rest, and to work with a professional so that you’re being closely monitored.

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The site links listed above in the Cookbooks section offer an abundance of great recipes, but below are a few of the ones saved in my recipe boxes. Natalie adds that many recipes can be modified to improve their healthiness, such as substituting olive oil for butter and even cutting back on the amount of oil added.

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