Colon Cancer Recurrence

good evening. on behalf of stanford health careand the cancer supportive care program, i would like towelcome you to our first lecture series in the southbay, survivorship, the importance of nutrition andexercise in the cancer journey. it is my pleasure tointroduce our first speakers of the evening, juliegrosvenor and regan fedrick. thank you.

[applause] hi everybody, thank you. thank you coming. i am an american collegesports medicine cancer exercise trainer, and so isreagan and we are pleased to be heretonight to speak to you about yourplan for exercise and through survivorship. so first question thatwe like to start with,

if you want to just raiseyour hand, how many of you are alreadyincorporating exercise into your weekly lifestyle? great, great. good. gives us a good start. thank you, good for you. true. yeah, i would saythe first-- the fact

that you showed uptonight is good, it means that you'reinterested in these two topics. so that's kind of like, at leastthe first step toward success, yes? and then hopefullyyou'll leave tonight with a few motivationaltips or we'll be able to plant few seeds thatyou can walk away with and then put some things into motion withboth nutrition and exercise. so to get started, we'regoing to talk a little bit

about the guidelinesof cancer and exercise. they actually just cameout a few years ago. three, are we on it? yeah. so they just, a couple of yearsago, had a specific guideline, some guidelineprotocols come out. and this was with thedepartment of human health and sciences or humanhealth and science, as well as american collegeof sports medicine, american

cancer society, andjust a panel of experts. so oncologists wereinvolved, epidemiologist. they based it on hundredsof research, or data from research that's beendone on cancer and exercise. strength training,two times a week, and i'll go into detail onfew minutes, a little bit more on the-- is it writtenanywhere or do i have to keep notes do you think?

um. because i won't remembera thing you're saying. ok, we will actuallyget your information-- that's a really goodquestion was, did we make actual printoutsof these slides. we did not, but wecan send them to you. we could do that through email. is that okay forme to say, sarah? so sarah has your emailinformation if you signed in,

and we will follow up witheverybody with the slides. is that ok? thank you, that's good question. so two times a week,strength training. that incorporates, trying torecruit all of the major muscle groups, and again i'll gointo a little more detail with that topic and few minutes. cardiovascular,150 minutes a week. so i always like to tell people,you take five days a week,

30 minutes and or yougo seven days a week, that's like 21, 22 minutesof exercise, right? i'd like to think that wecould all find 20 minutes a day or 30 minutes a day tojust move our bodies, to elevate our heart rate,to breathe more oxygen. and then flexibility,range of motion, every day. just stretch a little,just move the joints, i'll tell people likewith the spine, you know, fold forward, extend, moveyour shoulders a little bit.

but try to keepthe joints fluid, try to keep mobilityin the joints. and i guess go onto the next slide. sure, we're going to do that,you can roll it, there you go. ok, thank you. sorry, now i've got it. so benefits of exercise. so, so manybenefits, but we just wanted to kind ofhighlight a few of them,

and especially, which isfrom the years of experience and what we know fromresearch and data, things that canhelp with people who are going throughcancer treatment, and/or beyond treatment. so and over all, it improvesthe quality of life. so there are short termeffects of treatment, so while you're going totreatment and/or beyond, but improve yourquality of life.

so you're more functional,typically more energetic, because of just the generalbenefits of stamina, and endorphins that arereleased with exercise, psychological benefitsthat come with that. so typically, thepositive attitude and some of the feeling incontrol, the strength, the gains that you get. reducing fatigue and stress. there's tons of data on that.

so fatigue, stress,anxiety, helping to manage the fear thatsometimes can be associated with the diagnosis,and treatment plan with the diagnosis. and even after you go throughthe treatment, the worry. so just helpingto sort of create some calmness and stability. it helps with weight management. and we put weightmanagement, because it

help with weight gainand/or weight loss. we can use exercise kindof on both fronts there. supporting thecardiovascular health. so cardiovascular exerciseis one thing, and then like i said, strength training. but on a regular basis,doing cardiovascular exercise to support the heart, justto kind of on a regular basis bring in oxygen, the capacity ofoxygen. as we train over time, and we'll speak tothat some in a moment,

the importance of progressing asyou start an exercise program. so you can startwherever you are, but in time you want to makesure you continue to progress and challenge yourself. enhance sleep. there's a lot ofdata on that as well. it's just typically known thatpeople have a regular exercise program sleep better, orhave better patterns of sleep with more regular hours andsuch was less interruption.

and increasing bone density. strength training, especially,weight bearing activity. one. so that meansanything where we have our body weightin motion, that's considered weight bearing. also strength training programs. so using, for example,my bicep muscle part of my arm, when i'musing, doing this exercise,

as the muscle's contractingand then releasing, it's a little bit of tug thathappens in the joints that affects the bones and can helpincrease bone density over time with regular exercise. do you want to addanything to that? i will do it in a minute. so the next thing-- componentsof a good wellness programs. i love to talk topeople about this. i think, in general, whenyou think about your exercise

routine, it's important to havevariation throughout the week. but the five componentsi like to stress, one being strengthtraining, and i told you i'd come back to that. so, how many ofyou are currently doing a strength training orresistance training program? used to do and stopped. used to and stopped? used to and stopped.

but i'm going to startwith those pull ups and-- perfect. good is swimming part ofstrength training? is what? swimming? no. yes and no. i mean, some ofthe resistance that

comes from using thepull against water, but the challenge thereis your body weight, when your body's in water, sortof the negative effect of not having weight in the activity. but i think it's agreat-- in general, i recommend swimming in anoverall exercise program. i think if it's something thatyou do once or twice a week, or if it's part of youroverall routine, great. there are a lot ofbenefits to swimming.

so, strength training. you can use your bodyweight, for example, push-ups or squats, doing thosetype of things, that's one form of strength training. at home you couldhave set of dumbbells, you could use a resistance band. just, like those cost,i think, $8 or $10. you can find themkind of anywhere now, i think walgreenssells them, target, you

can get them online. so, a resistance band, to targetall the major muscle groups. if you have amembership to a gym, you can use equipment,resistance training equipment. yoga, for example, you're usingyour body weight in motion. so that's a form ofthe strength training. so, lots of differentways to incorporate that into your regular routine. and we want to try,basically, to target all

of your major muscle groups. so make sure you're doing thingsfor chest, for the shoulders, for the arms, for the back,for the midsection, the torso, the core, your abdominalmuscles, your legs, a lot of big musclesin the lower body. so, your quadricepsare in front, hamstrings in back, glutealmuscles, lower legs, calf muscles. so you want to try to,as you're designing

that program, whetheryou're doing it on your own or you work withsomeone to develop it, make sure that you're recruitingall of the major muscle groups in the body. so i typicallytell people to try to find a program with10 to 15 exercises, and you want to workthose muscle groups within kind of a zoneof 10 to 20 repetitions of certain exercise.

so for example, if iwere doing a chest push, i would want to dothat for at least 10, if not 15 or 20 times,with the weight i can manage withoutfatiguing myself completely. and over time, your bodywill respond and adapt, and you'll continue tosort of push with and grow. cardiovascular exercise, againwe said 150 minutes a week. that's the general guideline,the recommendation, a starting point.

so you know, but youstart wherever you are. if that feels like toomuch in the beginning, because of stamina, fatigue,and/or you're deconditioned, or you're justbeginning a program, anything is better than not. so if it's 10minutes a day, great. if i walk the blockfive times, great. whatever you can do, you do. and then the hope is ifyou consistently do it,

you'll get better. and it will, yourtime will grow. balance training,so that is, i think you're going to speak tothis a little bit more. but one of thepush there, we want to create morestabilization in the body, and ultimately preventinjuries, prevent falling, we hear way too often,so-and-so fell and broke a wrist or broke a bone, ora shoulder injury.

so if you train your bodyto be better balanced, it actually will getbetter, will respond, and you'll be morereactive and more stable, just as we sort of walk throughour daily activities of life. relaxation, well ishould say flexibility, we talked aboutearlier that earlier. so stretching, range ofmotion exercises, just trying to keep the body isas mobile as we can. and then relaxation rest.

so i think whatever you do,if that means reading a book, if that means taking a nap,taking walk on the beach, having lunch with afriend, having a cup of tea with someone. however you do it, justmake sure you don't lose that balance in life. you know we talk about like todo, with exercise especially, it's like go and do something. but i think a big partof the whole equation

is also to makesure you have time to slow down and relax, andjust sort of restore yourself. all right, so next slide. so we kind of laidout the framework that you be looking at fora general composition of, i need to do exercise. but then the next questioncomes, quite often for anybody, but especially if they'vefaced any type of change in their lifestyleor their body,

whatever's happened, howdo i get this started? and i think sometimesyour knowledge is there, you know, ok i got to do this,or i've done this before. but i'm tired, i've justgone through something major, how do i get this going again? where we want to comefrom, and certainly our choice in beingcancer exercise trainers, is saying surefind somebody who's got some knowledgethat can motivate you,

but it's also findsomebody who understands the path that you've been on. that doesn't meanyou have to spend all your time of thecancer exercise trainer, but it does mean find somebodywho is sensitive to the changes that your body has gonethrough, just like you are sensitive to the changesthat your body's gone through. and you need to havea safe place to begin. so before we wouldeven get started

in saying, thisday you're walking, we're going to want to knowwhere you've come from. so find a place andtime to get started, to acknowledge where you'vebeen, pat yourself on the back and say, i did it. here's my next goal, i'm goingto get started with exercise. and that's going to be, i'mgoing to step up the door and walk today like ihaven't walked before. i'm actually going towander down and see

what gym program there is. i'm going to pick upthe stanford catalog and see what i cando, or maybe i'll make an appointment withthe cancer exercise trainer. and the program--and we can help you layout that program, right? i mean, i kind of didthat in a fun way, but i'm actuallybeing quite serious. because sometimes, it justtakes a little bit more

planning to get thatfoot in front of you, that motivation totry this exercise. but over everything else,it's to keep you safe. ok? do no harm is thebiggest message that we want to send at the sametime they were saying, you can do it. all right? so part of this on thisslide is saying, mix it up.

as you're lookingat your plan and we looked at thedifferent varieties of, it would be walking,it would be swimming, it would be finding adumbbell at a target store and buying that two pounddumbbell and saying, ok twice a week i'mgoing to try it. because there's going tobe a place and time where you're going to have tokind of schedule this. so the getting startedis making a plan.

it's going to includesimple things of saying, i want to change my healththrough physical activity, i want to be strongthrough physical activity, i want to sleep better. it'd be all of thosegoals are going to come into deciding wherethat mixing it up and trying new things is going to come in. the balance and the stabilityexercises, i definitely want you to thinkabout, that's part

of what i need to start sayingto myself in getting started. chemotherapy has aneffect on our balance. you probably know thisif you're sitting there as a caregiver or a survivor,there's something that changes. it's not onlygoing to treatment, but sometimes it'sjust the rest, it's the inactivitythat we've had. your balance will change. a simple place tostart which, as you

would want to workon your balance, would be brushing your teeth. everybody has to brushour teeth, right? you've brushed in the morning,if you're a good boy and girl, and you brush in theevening, two minutes each. but the safety comes in,you've got a counter. so if i can challenge myself,i'm brushing my teeth, i can hold onto this counter,and i can hold my left foot up. electric toothbrush is alot easier, but come on,

you can handle it. and you have the safety ofbeing able to put that foot down or hand on the counter. that's my morning brush. my evening brush, brushing myteeth, my right foot goes up. again, safety. so this is kind ofthe simple steps. how do i get started? we say, we'll do abalance activity.

you're left going, wherewould that come from? start with brushing your teeth. so it's things like this thatwe need to start thinking about, how do i mix it up? how do i challenge myselfto return to the place that i want to bein as a survivor. it's different. this last piece, gettinga medical clearance. so this is unusual for uswhen we're training people.

it's not usuallysomething that you need to have when you're goinginto an exercise program, but we're putting it inbecause the place where we would want you to make sureyou've talked to your doctor is if you have the situationwith say a cardiac event. are you in combination of havinggone through chemo as well as statins? clear it with yourdoctor, talk to us. the biggest one isreally if you're

in a situation fromhematologic cancer and you need to bemore cautionary. that, we will say, make surethat your doctor knows which are doing, come backand tell us or show us a note that says it's ok. other than that, it'spretty much a choice that you're making, rightthen and there, to begin to take care or yourself. and most practitioners arepretty excited that you've

thought about it. and i would actuallyrecommended, in working with oncologiststhat you tell them, because sometimesthey completely forget that that'spart of the program. if we could have any impact,not only on survivorship, it would be an impacton the oncology world, that that becomes theprescription pad of you've done it, good foryou, your strong.

now we need to work onthe muscles and the bones, because regardless of how longor how much, any type of chemo is going to put a stresson that bone density. that's where that conversationwith strength training comes in again. no matter what journey you'vebeen on, but especially if it's that long termcare of chemotherapy, you have to find away to get resistance exercise into your life.

i can't tell youhow much that just makes me so excited tosit in front of somebody and they're interestedin lifting some weights. tends to be my wheelhouse,but still even beyond that, it means that you're workingon a place inside your body that needs you to focus on it. so if i can emphasizeanything, strength training is going to be a big one. let's roll-- oops, sorry,playing with the mouse.

next statement,exercise can be a part of every survivor's lifestyle. so it has no barriersto the type of cancer, has no barriers to age, ithas no barriers to gender. so why wouldn't we, right? we can go back definitelyto that medical clearance of saying, ok i might havea little barrier depending on the safety wherei am right now, but in every survivorslife there is something

that you can do in a formof movement or activity that will have an impact onthe condition of your body. it can be starting slow. and if i could usea mantra that's from our cancerexercise training. it's from dr. katie schmitz. it's kind of a play ona teddy roosevelt quote. and what she says is, youstart exercising by going slow. do what you can,use what you have.

what does that mean? it means that inmy plan today, i can just get up and walkaround the dining room table, that's all i've got. thumbs up from us, thatwas a choice to move. and maybe two days later, it'stwo laps around the dining room table. go slow. or if you're beyond that, andyou're able to take a walk,

you wouldn't startby saying, i'm going to go back towhere i was before. because if there'sanything that we've learned in example oflooking at cancer survivors, it is a new you. and it is a new choicesthat you need to make and you can, quitehonestly, i've seen survivors do this inthe training that i've done. sometimes you can comeout stronger and healthier

on the other side,post-diagnosis from the choice to exercise. but start in aplace that's safe. do what you can,use what you have, and then make an appointmentwith a cancer exerciser. but again, we goback to that phrase that anything is betterthan nothing, right? it seems kind of a flippantway to express it sometimes, but if we put somemeaning behind it and say,

it really does matter thatyou get up out of the chair to walk across the hall, oryou voice to your family, i need to go on a walktoday but it's only going to be half ablock or so, do that. we've had certainly, a differentexposure to different survivors and their needs. i've trained people where theprogram may go on for months, but it might take 2 and 1/2months to get in the front door to the back of the gym.

to me, that's success, becausethat's trying each time, and that's getting to aplace where you know where you are, and you'reable to say ok, i tried, i'm going to try again. that's a big part ofthat plan, and that's a big part of that choice. overall message fromamerican cancer society, from the american collegeof sports medicine, as well as theroundtable discussion

of what cancer survivorscan do in exercise, was what we talked about. it really is the generalinformation of 150 minutes, but backing up and going into,go slow and do what you can, the overall message is,just avoid inactivity. there are places in the journeyof cancer where you know that cumulative effects are goingto make it so you just can't. and that's ok. and that's where atrainer or a group

has the understanding toknow where you've been. it's a seriouscomponent of looking at either the person thatyou're helping taking care of, as a care giver, or asa survivor, that you listen to those days. pushing past it isn't worth it. and there's timeswhere you're just going to need to have the rest. one day, one week, onemonth, maybe three months.

that is completelyunderstandable, it really is, and it's ok. it's finding that place, again,in the mindset of when i can, i will try to do this. try often leads to do. my little yoda, that'smy star wars input there. so again, we've started with,how do i get my plan started? and then the nextpart are saying, let's talk about this,what are my goals?

and i think that's agood place to start. when we sit down withsurvivors and we're making a plan forexercise, that's one of the placeswhere we start. what is your goal? is it simply walking the block? is it returning toa marathon status? we have the whole variety. many times it's, i wasn'tdoing any exercise before,

now i've got to, you'vegot to get me started. so find out wherethose goals are. talk about them with yourdoctor, find a family member, find a friend to say, can ijust talk this out with you? i mean, i'm feeling like i justneed to organize my thoughts. use the people around you. quite often, there's peoplewho are wanting to help anyway, and maybe that'sthe conversation that you can usethat friend for.

i just need fiveminutes of your time. i've got these goals, canyou help me lay that out? is it two to three days aweek that i'm taking a walk? or is it making the goalof, when you come see me, you've committedto come visit me, will you make surethat i get outside, and i just go around the block? so this is part of whatwe're talking about of getting started and gettingconnected with exercise.

it's finding the plan, andthen the next step, of course, is, ok i made a plan,how do i stay motivated? so i think my usualdirection in that is finding what isa high value to you? what motivates you? is it times that you'regoing to see your friend, is that motivating you? you want to walk,and you want to talk. you asked that friend to changethat time you spend together

to incorporate some movement. whatever that might be,trying a yoga class, maybe that doesn'tsound very good. maybe it's just going on a walk. again, we keepsaying the walking, because the walking isthe most accessible. most people can handle that. but it's also incorporatingthe big picture that we talked about before,which is the bone density part.

win-win. so motivation is alsopart of the whole picture of how am i going to getthis exercise plan going. couple suggestions wetalked about together, walk and talk, making a playdate with grandchildren, with children. making a family plan, quiteoften that's very useful. you've got kids in yourhouse, old or young, and you can say to them, ihave to walk two to three times

a week, ok? ok! write it on the board,on the refrigerator, put it on the mirror. we need to get mom or dad outthe door, or brother or sister, out the door three times a week. it's a household thing. sometimes that's motivating. maybe it's theopposite thing of,

this is my time when ifinally get to get left alone. is that what motivates you? it motivates me. i get out the door, andi just go, and i'm quiet. my earplugs goin, or i'm walking my dog, that motivates me. if you have a dog,that's really useful because your dog always wantyou to go take them on a walk. so again, it's findingwhat's important to you,

and trying to finda way to make that intrinsic for thechoice of exercise. and the last one istrying something new. so a little bit of a back-upin trying something new. i'd love for peopleto say, look, i've never done yoga beforeand i'm going to try this. or, i just bought a weightset because i know i need to work on my bone density. again, an emphasis, go slow.

because above allthings, we want you to be safe, and findout what that's like. so if your enthusiasm is therein making the plan, right on. be spot on with just knowingwhere your safety is, and getting some advicefrom friends or doctor for a little bit ofhelp along the way. so i crossed intothis a little bit already, of finding thevalue of your exercise plan. by finding outwhat motivates you

and being sensitiveto what's actually going to help you get goingin the morning, in the evening or what's going to bein that travel time. when you think aboutit, we've given you a little bit of anexample in the back, is trying to write it down. as much as you're talking aboutit with family and friends, put in your calendar. aren't we all attached toour phones a little bit?

iphones? there's a great alert ona calendar on an iphone. even if you're looking froma week ahead, to two days before, to the day before. the hour before? oh yeah! i got to get out thereand i got to walk. use the tools, right? that's kind of whatwe're thinking about

with planning the exercise. because that's going to getyou back into your routine, your body is goingto get used to it. another side of thatplan is i'd like you to think about themind-body connection to where your goals are,and that healing process. which is when there's aday that it doesn't work, forgive yourself. it's ok.

i just think thatsometimes people can rob themselves oftheir initial goals by punishing themselveswhen it doesn't work out. no fair. there's good days and there'sbad days for everybody. and some days the schedulejust doesn't work, or my dog chewed ahole in my couch. i can't take awalk now, i've got to call-- whateverthat might be, right?

forgive yourselfwhen that happens. and just look at thatcalendar and make it a priority to try again. big part of exercise,especially when we're recoveringfrom something, is to say i'm just goingto try that again. if i could give you anywish, it would be having that internal voice change. to change your thoughts, tochange your mind, that one,

this is going to be good. potentially it'sgoing to be fun. in addition to the messagesthat say, i need to do this. my body says i needto do this, my doctor says i need to do this,these exercise trainers are constantly telling mei need to do this, please. it's having that whole picture. it's looking atexercise, as a survivor, as a mind-body-spiritconnection.

i'm going to work on my muscles. i'm going to workon my bones, i'm going to work on allthose different things that i have to do. but somewhere in that journey,i want that choice to be, it's going to make me feel good. and it will. it is one of thoseamazing things, that even when you're tiredand you're battling fatigue,

and we see ithappening all the time. putting out energy actually canregain energy within your body. it might take some time, butit's this wonderful cycle. and if we get reallylucky, we can find a place where we actually find whatthose endorphins feel like. that's a pretty high scale. sometimes those endorphinshave to switch, again, changing your mind. of saying, success!

last month it was justto the kitchen and back. this month, it'sto the front door. in three months, i'mgoing around the block maybe two or three times. progress, go slow. do what you can. use what you have. make a plan. talk about safetywith your doctor.

talk about a planwith your friends. find out what isgoing to motivate you. what's your value? and putting this into movement,putting it into exercise, i believe you willfind some success. and again, you always got us. through the cancersupportive care program we also havecounseling sessions. so if it comes toa time when you're

feeling like i justcan't make this plan, or it doesn't makeany sense to me, there is an option in bothpalo alto and in the south bay to come and meet with acancer exercise trainer. trying the classes,so certainly we're here as part of the programwith the catalog in the back. and we're here to answeryour questions in the end. think about what itmight take to get going. and that is where we're goingto close up, because we've

got a tight schedule tonight. and our next phase isthe other gigantic topic, is going to becancer and nutrition. and i'm going to welcome ericaand alaina back to the podium. my name is erica connor. i'm a registereddietitian and certified in oncology nutrition. and alaina? my name's alaina, and i'malso a registered dietitian.

and i'm certified innutrition support, and i've been working ongetting my knowledge up for certificationin oncology as well. excellent. so the topic ofnutrition, well we could talk about this for days. so we did our best tokind of consolidate things and try to make thingsas streamlined as possible. a couple things.

so what we'regoing to talk about as far as stagesof survivorship, we're going totouch on recovery. talk about proteins, peoplealways have those questions. go into survivorshipas far as nutrition with regard tosurvivorship specifically, and then sugar and cancer,which is always a hot topic. and usually, ifthis is a big forum, i guarantee that thatquestion would come out

within the first three minutes. usually less, so iknow everybody has it. so hopefully we touch oneverything and you guys get all your questions answered. so the stages of survivorship. typically, survivorshipreally actually starts, it sounds a littlestrange but it really starts as soon as you'rehit with a diagnosis. there are differentstages, though, obviously.

the active treatment,long-term disease-free living, where really people arejust like, ok now what? reducing risk for recurrence,and/or progression. so that sounds alittle bit confusing, but some people actuallytold, you have stable disease, and then it's just monitored. so that's kind ofwhere that fits in. prevention, and thenas far as looking at prevention and treatmentof the comorbidities.

which basically, issometimes your side effects, sometimes underlyinghistory that you already have prior to treatment. so things like heartdisease, diabetes, sometimes kidney disease. and whether you're dealingwith it before or after, but obesity as well. and then there'sadvanced cancer and end of life, which as youcan see and imagine,

in all of thosedifferent stages, there's oftentimesdifferent goals. and then alsodifferent-- well, first of all, sometimes evenhow you tolerate nutrition is a big one. so the reality as far as livingwith cancer, through cancer, and beyond cancer. so it just depends onwhere i am, what do i need, what works for me, and how ami feeling through the process?

these are quite a few--and this can definitely change-- common challengeswithin the survivorship reality. and this can happen anytime from right outside of treatment, throughtreatment, sometimes, actually, these things will happenseveral months after. weight loss or gain,and that literally is one extreme to the next. and they're bothincredibly difficult.

incredibly difficult.oftentimes in this adventure, as i usually willsay, people maybe have been fighting to keep theirweight down all their life. and then all of a sudden,the switch is flipped and they're fightingto keep weight on. and you never thinkthat you'd ever get-- i don't even knowhow to deal with this. it can be a veryfrustrating process. fatigue, which isusually number one.

taste changes, which actuallycan last quite a bit, quite a long time. swallowing difficulties,and that actually could include somethinglike a tube feeding or anything like that. diarrhea, constipation, andother digestive changes. so what that meansis bloating, it could be things likebloating and gas. it could be cramping,it could be noises.

it could be just noises. i know some people who say, ieat and then i have to get up and i have to walk away,because it's just so loud. so those all fall in theother digestive changes. but that's thereality of it all. so some solutions. the thing about itis, one of my goals, and i can speak for actuallyall of my colleagues, including alaina, and our crewup at palo alto.

i just want to help to reduceanxiety when it comes to food. oftentimes, people say, iread that this is good for me and i have to eat kale. and i have to eat this. but when you're dealing with anyof these possible challenges, it can be extremely difficult.and that anxiety kicks in because you'renot eating salads, or you're not able to eatthis for whatever reason. it taste terrible,you don't digest it.

so that's where we try to help. that's where we can come in, asfar as to help you, number one, think of solutionsto these challenges. and also help you move on. of what isn't working. and how can we findsomething else green that you can consume. so we're always lookingfor a healthy balance. just like with exercise,you want balance.

we want balance here as well. very, very important. so usually, smaller,more frequent meals. i tend to say that is the numberone solution to any problem. with regard to any kindof eating challenges. and it really is. i mean, whether you're dealingwith any kind of nausea, loss of appetite, diarrhea,constipation, you name it, that's actually the key.

weight loss or gain, that'salso-- it fits in there. so sometimes it's justsimply spreading out. realizing i can't meetmy needs in three meals. i need to spread things out. i give permission to graze. that's oftentimes what i'll say. finding a fiber level thatis appropriate for you. that's what a lot ofthis comes into play. this isn't about thefront page of the paper.

this isn't aboutan article that you read about thisextraordinary person who starts their day with kale andends with-- i don't know what. but that's the thing. it's important torealize that this is an individualized adventure. and a lot of timesit's just knowing that it's ok if your new systemhas to be brought down as far as with regard to fiber.

otherwise whathappens, is people have this perception ofwhat you should be doing. you keep pushing it, keeppushing it, keep pushing it, and all you're doingis taking steps back. meaning that you're ending upwith incredible diarrhea, which leads to dehydration,which leads to more fatigue and blah blah blah. so there's a lot ofreally important pieces of how to find a balancewith eating healthy,

and how things are allgetting along with you. fluids, often aneed for variety, meaning that there'slife beyond water. if water taste terrible, weneed to flavor that water. we need to find otherfluids, sometimes teas and things like that, to helpyou meet your fluid needs. whether you're in activetreatment or after treatment, and you still need iv hydration. so it's just trying to think ofa variety of things like that.

and then as far as changingthe consistency of food, also. fass, on this other side, isfats, acid, salty, and sweet. this is a conceptin rebecca katz. she has many, many books. and we actually haveall of her cookbooks listed on our resource list. whether you've picked it up inthe back-- handout in the back. this is also where wemanipulate the tastebuds. so if you are dealing withany kind of taste changes,

it's really, really importantto play around with that. because, oftentimes,what i will ask is, when you takea sip of water, what does that taste like? water is bland, right? or it tastes like nothing. if it tastes bitteror if it tastes salty, you're not going to drink it. so we need to manipulate thatin order to get the fluids down.

same thing as far as withregard to any kind of food. sometimes it is as far asadding a little bit of sea salt, sometimes it is addingsome maple syrup. but the other thingabout that is, it's not pouring the maple syrup on. it literally is a drop. in fact, my husband asksme to make kale now, because he likes it. and that's a little trickthat rebecca taught me,

putting a littledab-- and literally, i put a drop of a grade bmaple syrup on the kale. it completely changes andeliminates that bitterness. and my husband's like,what did you do to this? never mind, just eat it. so it's something that's, again,it all comes back to balance. ok, so that's really key. ok, so going into the proteins. we do absolutely want to focuson your plant-based-- plant

proteins. your nuts, yourseeds, your beans, vegetables, whole grains. now again, finding balancewith regard to that as well is super,super important. we want to chooselean animal proteins, organic chicken, organicand low-fat dairy is really important. and then as far as includingyour rich omega-3 fish sources,

salmon, herring,mackerel, sardines. those are all the top ones. with fish, however,omega-3 levels vary, so it's not that--you know, halibut, i could have listed that. it's just a littlelower on the list. but all of thoseimportant pieces. the other thing, too, isusing for omega-3 sources, things like your walnuts,your chia seeds, your ground

flaxseed. the only differencewith those is they are-- basically it's thealpha-linolenic acid, the ala, and your body-- we actuallyhave to convert that. which we're ok at, but we stillget some great, great benefits from those non-fish sources. so the key factor withregard to the proteins is we want people tolimit your red meat, which is beef, pork, and lamb.

pork is not theother white meat. they got in a lot of troublefor saying that, actually. looking at and avoidingprocessed meats. sometimes it actuallytakes that step back of how many-- what do i eat? how much do i eat? and what kind, likethe quality of it. quality and quantity are twosuper, super important factors when we're talking about-- asfar as red meat, specifically,

processed meat. i always say go aslow as you can go. if that's once aweek, if that's once a month, that kindof thing, that's really in your best interests. one reason, i'll giveyou just a little tip. everybody says, what'sthe deal with red meat, ? couple different things. the saturated fat.

red meat consumption is alsoassociated with higher weight. obesity. and actually, it's sort oflinked to all kinds of things. it's linked to inactivity,it's linked to all this-- the other thing is also howit's cooked, and the quality. i won't even go into theantibiotic-resistant stuff. so the quality is key. one thing that we willalways say about protein is, it's not necessarilya specific number

that you have to shoot for. one thing that peoplesay when i say protein, is they say, well i don't likemeat, or i don't like chicken. ok, well, let's talkabout the other proteins. and so this actuallykind of gives you a good example ofhow to fit it all in. now an important piece, too, asfar as based on serving sizes. oftentimes i say to people is,when you sit down to a meal or even a snack, justsimply ask yourself,

where's my protein coming from? it really helps youto kind of stabilize not only how you feelphysically, your blood sugar levels, but mentally, from mealto meal throughout the day. if you're trying to startan exercise regimen as well, that's also going tohelp keep your stamina, keep your endurance up. where's my protein coming from? is it coming from peanutbutter or almond butter

that i'm eating with my apple? is it coming from a yogurtthat i'm having as a snack? maybe it is fish orchicken, or maybe a good quality of red meatat a meal of some sort. oftentimes too, peoplesay, oh, i'm blending. i'm doing a blend, afruit and vegetable blend, or i have a big salad. i still want to throwout that question, where's yourprotein coming from?

are there beans? are there nuts orare there seeds? where's thatprotein coming from? very, very important,especially in this situation. and your goals, as far as toregain strength and exercise and all that. and now talk about survivorship. well, we've been talkingabout survivorship. all right, so there isa handout on nutrition

for healthy survivorship. so we're going to betalking through this handout and elaborating alittle bit on it. if you didn't grab one, youcan grab one on your way out. and so these aresome bullet points, and i'm going toelaborate on them. and some of themthere's some more slides that we'll chat about. the first bullet pointis plant based diet.

eat your colors. that's not your skittles. it's your fruits and veggies. so eating a variety ofdifferent fruits and vegetables. they all havedifferent benefits, they're all higher in certainvitamins and minerals. and so eating avariety of them, you get to experience andhave all those benefits. and i'll go more intothat in the next slide.

healthy fats. so that's talking aboutyour unsaturated fats. choosing those over yoursaturated or your trans fats. so unsaturated fatsare going to be, a lot of times comingfrom plant sources. so your nuts, your seeds,your avocados, your olives, your vegetable oils. all those are great sourcesof unsaturated fats. anything that'sliquid at room temp.

fish is also a good sourceof some of the really good unsaturated fats. and then again,the saturated fats are going to be coming frommore animal-based products, so your well-marbled deliciousmeat, your butter, your higher-fat dairy,and cheese and milk. and then ericaalready went over it. limit red and processed meats. there was even some big newsbreak about the whole processed

meat recently,and so some people might have questions about that. but the american instituteof cancer research recommends that youlimit these foods because of their connection withcertain types of cancer, particularly colorectal cancer. and some of the ways youcook them and process them can also increase their risk ofpotentially being carcinogenic or causing cancer.

limiting alcohol. so a lot of differentcancers have been associated with increasing the risk. or, a lot ofdifferent cancers have been associated with alcoholincreasing the risk of it. so some of those would bebreast, ovarian, endometrial, liver, colorectal, esophageal,and then head and neck cancer. so with some of the morehormonal-based ones, the breast and ovarian and endometrial,alcohol actually

increases the amount ofestrogen in a female's body. and that can turn on someof those cancers that have the estrogen-positiveconnection. and so alcohol isdefinitely a risk factor in limiting to maybe twodrinks per day for men, and one drink per day for women. or maybe even lessthan that, depending on if you are at high risk forbreast cancer or ovarian cancer.

next one is healthy weight. which has kind of been a themethroughout the whole night is maintaining ahealthy weight through a healthy, balanced diet anda healthy, balanced physical activity regimen. so having extra fattissue also increases estrogen in yourbody, so that again is going to putpeople who are at risk for estrogen-positivetypes of cancers,

the breast, the endometrialand the ovarian, potentially, at higher risk. so keeping your fat tissue down,maintaining a healthy weight, can help reduce theestrogen your body and put you at lower riskfor some of those cancers. and then the last one. being physically active. that is, of course,very important and it's alreadybeen emphasized.

you guys should, atthis point, understand why physical activity isimportant in reducing your risk of cancer and for survivorship. all right, the next slide. so this is about phytochemicals. and there is anotherhandout back there that was all about phytochemicals. it's pretty sweet. so what are they?

they are the plant chemicals. phyto means plant in greek. the plant chemicalsor nutrients that provide the color, odor,and flavor in our plants. so when you pick up thatmelon and you smell it, and it's like, yesthis is a cantaloupe. you are smelling someof those phytochemicals. and then you eat itand it tastes good, you are tastingthose phytochemicals.

and those little buggers havesome really great side effects. so i listed all the ones,they're listed on here, too. but just to reiterate. they can stimulatethe immune system. they can blocksubstances we eat, drink, and breathe frombecoming carcinogens. they can reduce thekind of inflammation that makes cancergrowth more likely. prevent dna damage andhelp with dna repair.

and so on and so forth. so this is just reemphasizingthat eating from the rainbow can be very important andthese are the reasons why. this handout really goesinto the science behind it, and the specific things thatare in those foods that actually are helping prevent cancer,and reduce our risk of cancer and recurrence. the back of it,there's a great list of what thosephytochemicals are called.

they're big long names. carotenoids might be oneof the more common ones that you've heard of. but if you can't pronouncethem, that doesn't matter. the more important thing islooking at the plant sources and putting them onyour grocery list and buying them whenyou go to the farmer's market or the grocery store. and then the last column goesover the possible benefits.

so again, kind of goingover this list and specific to each food sourceand figuring out, wow, if i eat red,orange, and green fruits, i may inhibit thecancer cell growth. so this is a coollittle handout. you can really get some meatinto why fruits and veggies are important for you. all right, so now we're goingto go onto the big topic. sugar.

so how many of you have heardof a connection between sugar and cancer? ok. how many of you have heardthat sugar feeds cancer? that's a big one. how many of you get anxietylooking at this slide? yeah, definitely. so those are all things-- iget asked this all the time. every day.

so i'm going to tryand keep it brief, but what's wrong with sugar? so let's talk about that. when you have foodslike refined grains, that's going to belike your white bread, or your white pasta, notthe whole wheat varieties. or concentrated sweets,that's going to be everything you saw on that last slide. your blood sugar spikes, itgoes up, and it comes down.

and that can be a prettyhigh-calorie blood sugar spike. you can get a lot ofcalories in there. and so when you go up,you're full up here, and then you're hungry whenyou get back down here. so you end up beinghungry more quickly, and so you end up maybeeating more calories. and so what happens when youget hungry a lot and eat a lot, is you tend to gain weight. so you get extracalories and your body

wants to store thoseextra calories as fat for when you no longerhave those calories available. so you get weight gain. when you start gainingweight, your body becomes resistant to theinsulin that it produces. and that puts you into thatstage of maybe pre-diabetes or diabetes. hyperglycemia justmeans high blood sugars. and so that situation whereyou have this insulin floating

around in your blood, and theseblood sugars that are high, are kind of what set thestage for potentially some other hormones, growthhormones being released. and that situation may beassociated with some increased risk of cancer. and that's lookingalso at obesity. there's a lot of factorsthat are contributing there. because when you're obese,you might be sedentary, you might not be havinga high-fiber diet,

you might not be doing someof the other things that contribute to having awell-balanced diet and well-balanced lifestyle thatreduces your risk for cancer. but the situation of havinghigh blood sugars and insulin resistance hasbeen-- there's been some associations with potentialincreased risk for cancer. so what's right with sugar? it tastes really good. when i'm not feeling well,it sits well in my system.

it goes through-- maybei'm having saltine crackers when i'm feeling nauseous. that's a refinedcarbohydrates, but that's what you're going togo for when you're not feeling the greatest, becauseyou know it's not going to make you feel more sick. nostalgia. my mom, every day, onmy first day of school, made me chocolate chip cookies.

i love chocolate chip cookies. i have a great memory, it'svery warm, makes me feel good. so there's a lot ofnostalgia with sweets. around christmastime, cookie day. there's stuff everywhere. so there is someright with sugar. and when you're going throughtreatment, what do you want? you want some comfort, right? you're feeling uncomfortable.

so there are some differentthings to look at. sugar is not all wrong. the bottom line is,going down to the bottom, it's not just sugar. it's the lifestyle. so having somesugar in moderation, and in that big pictureof being physically active and having a well-balanced meal. if you have a milkshake becausethat's what you feel like,

that's all youwant to eat, that's not the end of the world. i really liked whatjulie said earlier. she said if you have a bad day,it's not the end of everything. you haven't ruined it all. you can pick up and moveon, and the next day you can make better choices. but it's not even a badchoice to have that milkshake, if that's all thatyou're going to eat.

you need some sort of calories. so is there a connectionbetween diabetes and cancer? maybe. that is something thatthey're looking at, but it's more of thatpicture of insulin resistance and hyperglycemia thatcomes from obesity that is more associated withthe increased risk of cancer. it's not having thatmilkshake that one day that's going to give you anincreased risk of cancer,

or feed that cancer. it's about the lifestyle andhow everything fits together. so the usda 2015 dietaryguidelines just came out. and that was anotherbig news break on npr and all over the place. and it said, limit youradded sugar consumption to less than 10% of yourtotal daily calories. i thought this was awesomethat they were finally addressing added sugars inour government nutrition

recommendations. 10% of your totaldaily calories, what does that look like? i wanted to break itdown a little bit. so they always use this 2,000calorie per day guideline. not everyone needs2,000 calories per day. a lot of people don't. but 10% of that is about12 teaspoons of sugar, and 12 teaspoons of sugar isabout one 12-ounce can of soda.

so they're saying one12-ounce can of soda a day is what you should limit yourdaily intake of added sugars to. not very much, when youconsider some people have much more than that everyday, just with the soda. not including all their other. foods. what was that? if i don't drink soda,how many cakes can i have?

[laughter] you can look uphow many-- you can convert the grams to teaspoons. 12 teaspoons for a2,000 calorie diet. so if you're on a1,500 calorie diet, it's going to be 75% ofthat, which is what, 9 grams. so if you were on the oppositeend of the scale, where you're trying to gain weight, becauseyou've been losing weight, you shouldn't feel guilty eatingsome of those white foods.

like the milkshakes,or the white bread. correct. there's a time and aplace for everything. but still, when you'retrying to gain weight, incorporating all thosefresh fruits and veggies however you can, whetherit's in a smoothie. but if you can't toleratethem because you're having gi issues, and what youcan tolerate is the white food, then you need toeat the white food,

because you're in a betterplace being well-nourished than lettingyourself wither away because you can't eat the foodsyou think you should be eating. so that's a great question. bottom line with pictures, eatmore of this instead of this, but it doesn't say eliminatethis and only eat that. it just says eat more ofthat, instead of that. i see a brie cheese in there. balance.

remember, balance. it's a whole food. no, i'm serious. i love brie cheese. do i have permissionto eat a lot of it? you have-- not a lot, butpermission to eat some of it. that "a lot" just went overthe balance, the teeter totter. so cheese, one ounce, i alwayssay, is the size of your thumb. you can include the knuckle.

and that's about agood portion of cheese. so this kind of wraps it up. this is from the americaninstitute of cancer research, obesity and cancer. it goes through the cancersthat have been associated with being overweight or obese. and there's quite afew, like it says. and the aicr, the americaninstitute of cancer research, estimates thatexcess body fat is

a cause of approximately 112,000us cancer cases every year. and yet, almost 70% of americansare overweight or obese and half of peopledon't know that there's a connection between the two. and so they haven't reallyisolated the reason, but, like i said,there's this picture of hyperglycemia andinsulin resistance and sedentarylifestyle that they feel like might becontributing to that.

so protect yourself. move more, eat smart. and then this isanother summarization. i love these little images,because they're fun, and they reallysummarize everything. and focus in on the topicswe were mentioning today. and then the last one, funlittle-- make food fun! and there's a reallygood resource guide, like erica was mentioning.

these are allreally good websites and some of theseimages are pulled off of the websitesthat are on here. and you can go on there andget updated information, reliable information. there's goodcookbooks, newsletters, these are thingsthat we reference every day in our practice. and so they are things thatwe're sharing with you,

and if you take the timeto look through them, you can find some reallygood stuff in them. on the resourcelist, too, for those who do come to thecancer centers, whether it's the southbay or palo alto, the ones with theasterisks actually are available inthe health library. so you can come andborrow the books. not that you have to goout and buy a new cookbook,

but you can borrow those. you can also look onlinefor a lot of these, and get information. like rebecca katz actuallyhas a lot of her recipes online that you can access. so just as an example. no we move on to questions. i have a question, and it'sreally about smoothies, because i just starteddrinking a lot of smoothies,

to try to get that kale andspinach, and everything else. and when you put all that stuffin there, including, like, turmeric, and greentea, like the matcha green tea powder,and the nuts, is it as healthy for youas eating spinach, just eating thespinach and the kale? is it as healthy for you? and the frozenfruit, like if you've got frozen fruitin there, you've

got the proteinpowder, and all that? i'll start withthe frozen fruit, since you mentioned that. i love frozen fruits and veggiesbecause oftentimes they're picked at theirprime and they're higher in some of thevitamins and minerals. not all of them. and then they'refrozen, and they get thisunder-appreciated, they're

in the frozen food,processed aisle. but there are somegood ones in there, and they don't haveanything to preserve them except for just being frozen. so i like frozen fruit. you are reducing your fiberintake when you make-- or if you put flax, i doflax, ground flax and chia. yeah, that's great,so you're really, you're adding some extrafiber that's probably not

getting chopped up. so every time you takea food and process it, whether you cookit or you chop it, you're breaking downsome of the fiber and making it easierfor your body to digest. so it's a reallygood way to get some of your fruits andvegetables when you're not feeling very great. and then it's cold,which can also help

if you're not feeling great. you can make itreally nutrient-dense, and add lots of fats to it,healthy fats, hopefully, or you can make it alittle bit lighter. but it's still very much agood, nutritionally complete way to get all yourfruits and veggies. but the fiber contentdoes go down a little bit. you don't get as manyof the sticks and stones fiber, as i liketo call it, which

can be good for your colon. if you're doing it, like,just breakfast every morning, and then eating your saladand greens during the day. i think it's perfect. that's a goodexample of a balance. so i get nervous when somebodysays that they're blending or juicing several times a day. so the only thing to watchfor is, if your goal is not weight gain, is be carefulbecause that shake can

be a lot more caloriesthan you'd ever think by adding all that. oftentimes, i say, as you'readding it to the blender, think, would i eat this? and people say, well, no that'swhy i'm making the shake. however, would you beeating all of this? because it does blend up tobe quite a lot of calories for a lot of people. you mentioned organic.

how important is that? good question. there's a lot ofresearch with regard to what is importantwith regard to organic. i can't say everythinghas to be organic. i would probably breakeverybody's pocketbook. but the importantthing, a lot of people do suggest going organic whenit comes to animal proteins. i usually will say, goorganic when you can

with dairy, certainly withyour red meats, with chicken, with your eggs, so there'syour animal proteins. again, listed on ourresource list, as well as, actually, you can get it fromthe environmental working group, who puts out the dirtydozen and clean 15 every year with regard to produce. so that's alsosomething that i like to share with people becauseit's interesting to know which fruit and vegetables have thehighest amount of pesticide

residue as opposedto the lowest. so the number one onthe list is apples. so most of the things on what'scalled the dirty dozen list, they have thin skinor they're delicate, like your berries, yourpeaches, nectarines, your apples, lettuce. i think i've seen bananasthere, and i was wondering why. bananas actually fall in themiddle, towards the bottom. so the clean 15, which actuallyhave a lower pesticide residue,

tend to have a thickerskin, or i say, are gas producers,like your onions. those sorts of things. i say they have theirnatural pesticides, bugs are like, whoa! so those are someinteresting things to-- because again, inthe reality of shopping, i do always support localfarmer's markets too. so when you're going to farmer'smarket and you've got your $20,

most farmersmarkets are organic. but it's important to knowwhere do i spend that $20, whether i'm atsafeway or whether i'm at a farmer's market. so that's where i say gowith like your thinner skinned, delicate things,choose organic, i would suggest. and with a thicker thingslike your melons, avocados, those types of things,you can go conventional. would that eliminategmo-type foods?

if it's organic, yes. and that's actually-- that's awhole other topic, with regard to labeling andthings like that. that's also a bigger topic. but organic tendsto pull in that. can you explain, there's organiccottage cheese, organic yogurt. how is thatprocessing, how is that different from non-organic? no, go ahead.

so the organicindustry, actually, is very-- everybody's kindof on the same page with all the differentindustries, whether it's dairy, whether it's meat,and those types of things. so according to as far asthe organic regulations, like with organicdairy, the cows can only actuallyhave organic feed, so it starts with the feed. no antibiotics, or pesticidesor those types of things.

so it really kind ofstarts from the ground up, or whichever way you want to go. and so it actually endsup being less chemicals and less-- all those addedthings in the actual end result product. same thing as far as withregard to organic meat, is the no antibiotics,pesticides with regard to feed, and those types of things. a really important piece,especially depending

on what the mediawants to grab hold of, is issues withantibiotic-resistant chicken and meats and things like that. so organic actually stepsus away from those issues. does that? are those easier for thebody to digest as well? not necessarilyeasier to digest. what it does is it's exposingus to less chemicals, and things like that.

environmental risk factors. yeah, exactly. does that answer? i just-- with my body,organic dairy products seem to give me diarrhea. and the taste is different. the taste is different. in fact, most people say thatorganic, everything taste better.

some people-- my nephew says the opposite. and he lives up by redding. and i'm like, your neighborsgrow all this stuff, and, oh, we don't like it. it doesn't taste good. so i'm going togive him that list. it's really interesting toget people's perceptions. my turn?

sure. i tried every time,measuring with cup, one-ounce, several ounce,is there any better way? cooking something that'sa recipe, that's easy. but in my dailymeal, how do i know how many ounces i should eat? of protein? whatever. with regard to?

i-- he wants to knowhis daily measure. how would he measure, ameasuring cup for his ounces. [interposing voices] tablespoon, orget a small scale. did you like myhand thing, where it's like a piece ofcheese is about the size of your thumb with the knuckle? there's some guides to handmodels that you can use.

so for carbohydrates,a fist is about a cup. so if you have really bigfists, maybe use your friend's. or don't use a kid's fist,because then you'd be sad. so that's a good servingof carbs per meal, about a fistful. and hopefully you'rechoosing the whole grains if you can tolerate that. if not, choose the morerefined ones, that's great too. and then for meat, it'sabout the size of your palm,

is a good size. and we recommend three ounces,depending on what's going on. i don't know your history,but sometimes with diabetes we might actually encouragea little bit more protein. but lean proteins. for nuts, it'salways the small-- a portion size is aboutthe size of if you were to palm your hand likethis, just to fill that area. nuts you can eat likepopcorn, they're so good.

you just keep eating. so that's a good portion size. so you might evengoogle, because i don't have a guideto hand models, but you could googlehand model portion sizes. i shouldn't saygoogle, you could bing. you should research online. i shouldn't be plugging anybody. but you can research onlinedifferent portion sizes

using hand models. and that can really helpwhen you're eating out, if you're trying torestrict your portions and figure out what'sactually a good portion size. purple. just going back to the sugar. is fruit includedin that 10%, or is that in addition to the 10%? that would be in addition to.

added sugars are going tobe anything where you're adding this extrasugar, not sugar that's innately in our food. so milk has sugar,your grains are going to have sugaror carbohydrates, your fruit, yourstarchy vegetables. all them are sourcesof carbohydrates. but it's your soda,your cake, your cookies, you could even, maybe,cross into juice.

some of those are whatwe're trying to limit with that recommendation. included your honey, or anythingthat you add to tea, anything that you add to yourplain yogurt, maple syrup. yeah, that's exactly what'sconsidered an added sugar. thanks. in the back? how do you definea healthy weight? is it according to bmi,or how do you define that?

yes, actually. we generally will use thebmi, because it really kind of captureseverybody who we encounter on a day-to-day basis. it pushes out anybodywho comes in who is like muscle, weightlifting,that kind of thing. sorry, i was like word finding. or really the elderly,frail, elderly. that doesn't capture that.

they kind of are off the scale. but yeah, bmi chart is actuallyyour best resource-- reference. can i break in with that alittle bit, as a trainer? understanding the bmichart is a tricky thing, because you can be a verywell balanced body, muscle structure, bone structure. and some of that can begenetic, some of that can be the effectivenessof your exercise, and you can be inthe obese category.

that's when thebmi chart may not be the right answer, and doinga little bit more depth of size, lifestyle, diet, makesa little more sense than just findingthat one category. and that's where theelderly and the fitness-- hyper-fitnesspeople don't fit in. but also the averageperson can sometimes get in a funny categoryon the bmi chart. yeah, i actually--

in my opinion. absolutely. brings up a good point. i generally will saythat it's a guideline. what's important todo is to-- some people look it and be like, i've never! so there we go, is lookingback, to the future, where did you come from,where are you going, what is realistic.

but it's just a guideline,because we do get that, the i've never been that. it's tricky. it is tricky. oh, go ahead. one thing you haven'ttouched upon is soy products. and i'm coming at this from anestrogen-positive breast cancer survivor and i'malso a vegetarian. and i know, i've heardboth sides of the story.

and i made the decision myselfthat i didn't eat a ton of it before, i'm not goingto change anything now. i'm just going to leavethings as is in moderation. i just wanted to-- because iknow of the whole phytoestrogen end products of soyproducts, so i just wanted to hear what youhad to say about the topic. yeah, like i said,nutrition is a huge topic. we could talk about it for days. do you want to answer?

i could start and thenyou could maybe elaborate. the currentrecommendation is based on a large group oflong term studies that up to three servingsof whole food soy, so that's soy milk, tempeh,tofu, soybeans, edamame, per day, three servings,is considered safe, is potentially safe. that's what thecurrent research says. it's not, i don'tthink, conclusive,

but that's what it says. and there are some other studiesthat show that it potentially has a protective effectfor that specific type, the estrogen receptorpositive breast cancer. the things we don't know asmuch about are the supplements. so your soy proteinsupplements, or anything where there's soy that'sbeen concentrated, processed down and added. we don't know what effectthat has on that type.

so we tell people to avoid--encourage people to avoid those types of products. but maybe you canadd some more to it. well, it goes back to,again, balance, first of all. and also looking at justwhole foods in general. so when you bring up a soysupplement, it's processed. and it's heavily processed. your fake chickennuggets, your patties, especially when you look atthe ingredients, first of all,

it's a long list. and it usually starts withconcentrated soy protein. can you buy concentratedsoy protein? if you find a productthat is like a patty and it starts with tofu,bean sprouts, carrots, you go, well i couldmake this at home. there's a goodexample of something that, sure, has beenprocessed, but it's actually made of whole foods.

so same thing is, we'renot going to suggest that you have hot dogs. if you're going to have meat,have a good quality meat. same thing as far aswith your soy foods. start with the soybean, eventhough there is a processing to get to the soy milkand to get to the tofu, those are actuallyreally whole soy foods. they're minimally processed,and they can absolutely be in a balanced diet.

if you choose--here's the one thing i will say, segue, becausei'm looking at your face. this is where, number one,it's an individual choice. that is also whereanxiety is our enemy. if that makes you nervous,and some people will walk out from an hour withme, going mm-hmm, she didn't know whatshe was talking about. i do know whati'm talking about. but if you don't feelcomfortable with changing

something, don't. if you're not usedto having soy at all, maybe you're just usedto having it be edamame when you go out to a restaurantor something like that, then leave it at that. some people say i don't evenknow what to do with tofu. so leave it alone. focus on your other plant-basedproteins, and go that route. and that's decisioni've pretty much made.

i'm not eating anymore than i used to, which is not a whole lot. and just leaving it alone. and if i happen to havetofu in my whatever it is, tomorrow night-- there you go. don't be afraid ofit, but, again, you don't have to goseek it out either. yes.

as far as organic food,especially vegetable and fruit, i notice sometime when ibuy it, i read the label, it's made in mexico,or other countries. china, canada. how trustworthy is that? can you trust that it's reallyorganic, that came from mexico, or there is a doubt? that's a great question. do you want that one?

well, i mean, that's maybemore of a political question, because you're getting intohow we import our fruits and veggies, and howclosely monitored those farming practicesare in other countries. and the regulationsthat go with it. yeah, and the regulationsthat go with it. and i can't reallyspeak to that. the one side, for fish there'ssome really good guides out there as far as gettingyour fish from good sources that

might be internationalversus here, that's monitoredby the monterey bay aquarium, the seafoodwatch.org. but i know what you're talkingabout, when you go into a store and they label whereyour apples came from and it says it's organic. one thing i will--to be quite honest, i'm not going tonecessarily answer the organic piece of that,but the location where it came

from, that's a longer way away. so not only was itharvested, whatever it was, but then it had totravel to get to you. so oftentimes i'llsay to people, and i've actually done this,and this actually kind of segues into the frozen thing, too. i've been in that situationwhere i need broccoli or i want broccoli orwhatever, and i'm at the store, i'm not at a farmer'smarket, and i pick it up

and it's rubbery. and i think, thankyou, no thank you. that's telling me a numberof different things. it's probably, could be twoweeks old from the time it was harvested. it obviously wasn'tstored correctly. there's a number of things goingon with broccoli that i pick up and it's going. that's where, in that situation,if you need broccoli for,

maybe a dinner party, go frozen. absolutely, handsdown, go frozen. so again, that's a difficultquestion with regard to the organic and thedifferent practices, but the location is agood indicator of hmm, do i want that? we have just-- how are we doing? just a few more minutes. i have a question specificallyaround inflammation.

there's a lot written,and we've gotten a lot of detail aboutfoods and how they drive inflammation or cool it. what about exercise andthe benefits from that? is there a correlation? i haven't read it. of exercise and inflammation? yeah, inflammation, beingable to reduce inflammation. so the only thing i couldthink of is that being active,

and the exercise reduces stress,which fuels inflammation, and go down that road. but i wondered if there wasanything-- that's my opinion. i think in general,the body needs to move and so if you think aboutoxygenation, circulation, systemic support,we start there. so a body in motion,i think that working with anti-inflammation, i thinkthere are some studies that point towards that.

and that people who are active,again, healthier typically, healthier body weight orweight maintenance, rather. as well as less jointirritation, because joints aren't as stiff, they're morefluid, they're more mobile. more stability in the body. i think that thing toconsider is what are you doing with exercise? there are higher impactexercises would be harder for the body totolerate, and can

have a reactive orinflammatory response. so, for example, lower impact. so swimming programoccasionally, or making sure that you havevariation in your program. you're not doing thesame old, same old, same, so that's one of the keyswith a varied activity routine or weekly program. less wear and tear, lessstress on the body in general. i think those things canhelp you manage or help work

against inflammation withthe exercise routine. do you want to add to that? well, i guess i want to dissectthe question a little bit. is it going into exerciseto reduce inflammation, or are you wonderingdoes exercise contribute to inflammation? the benefits. so we see a lot and we're tolda lot about the benefits of diet for reducing inflammation,which drives cancers, et cetera.

so when you're dealingwith damaged cells and things on this part, iknow exercise is important. and i'm just wonderingif there aren't side benefits that come to bothhelping healthy cells grow. is it blood flow movement? it's all of that. so it's necessarily anecdotalin that type of answer because there's not actuallyspecific data per cancer. i mean, the diversity thatwe have in cancer also

goes with thediversity that we have to consider inexercise for survivors, as well as justregular population. the thinking is, as weknow, the oxygen that flows, the blood increase that'sgoing through the heart, you also may havethat benefit that goes into the mucosal system. so if we're thinking aboutall systems functioning and raising up andworking together, yes.

the theory is it'sgoing to help. just like it would help ina slow, progressive motion of helping lymphedema. so all of these variations-- side effects, iswhat i was wondering. right, ok, so if we gospecifically to that topic, it goes back tothe slow progress. but it also goes backto studies being shown, and this is now veryaccurate from a study that's

done with weightlifting for women, who tend to be at a higher riskfor lymphedema, inflammation, yes. strength training will benefit,but it needs to be progressive, and it needs to be builtup gradually to getting to that weight,to the point where you can lift a goodamount of weight, it's just not starting inat an aggressive place. the progress is wherethey're saying yeah,

we see these things. they've shown even some studiesthat are saying potentially with stomach cancers, gettingthose epithelial cells, getting the mucosal cellsgoing, is the same process that we're seeing in exercisewith the blood and oxygenation. so can i give you hardcore data? not really, it'sjust that yes, we believe that as weunderstand exercise and we understand thephysiological benefits,

it will aid in altering,changing inflammation. the flip side is if youdo too much too fast, and you know this, you'vemaybe even done it. i think we've all done itwhere you've got to go back. you can create inflammation. it doesn't mean that forever,you're just taking it slow, but it means being mindful aboutthe progress and the intention of where exercise is goingto come in your life. did that answer your question?

i've heard that doinghigh-impact exercise at shorter duration is betterthan doing exercise, like on a bike for 20 minutes. that's all overthe news right now. you want that one, regan? do i want that one? are we answering thisquestion in regards to survivorship, or as ageneral question for fitness? no, survivorship.

and i keep hearing theseare what athletes are doing, these are what the49ers are doing, how they're training them. right. not all of them are doing it. first of all, it'snever a place to start. you have to build up to any sortof tolerance for that level, because there will bea pretty high reactive response from your body instarting to train like that.

it's a big one. it is a big one. i heard that by doing that,you're killing cancer cells, you're killing cancer cells. ok, so the biggest,broadest thing i think that wecan say for sure, is that there'snot a cure, right? so when somebody comesout with any kind of book or any kind of theory, thiswill disperse cancer cells.

we'd be handing it out. i wouldn't have a job. that's going to be thebest day of my life, when i don't havethis job anymore. but we're not there. and so that alone should kindof pull us back in thinking, by looking at thebroader scheme of thing. where they're saying, yes you'regoing to burn more calories, all you need is that15 minutes every day.

sure, to a degree, you needto move 15 minutes every day. but do i want you to actuallypull out that three foot box, and stand thereand go up and down, up and down forthat high intensity? no, because the fallout'sgoing to be you're more likely to getinjured, and then not do any activity formonths past that. so when you're lookingat that article, and i read those articles, too.

you can have an efficientworkout quickly. yes, it's true. but you have todecide who's doing it, why are they doingit, and are they safe? to me. it's not sustainablefor everyone. so a way to begin, if youhave a walking program, let's say it's 30 minutes,every fifth minute, potentially, just to walk a little faster.

so you start workingwith intervals before you diveinto anything that's like a full program ata high intensity level. does that makes sense? so you start at a smallerscale and you just add like a 60-second, i callthem a boost, like a burst. so every fifth,like five minutes, 10 minutes, 15 minutes,just go a little bit faster, or go up a hill or walkup a flight of stairs.

and then carry on. and over time you'llstart responding to that. and your workout will havea higher intensity level. and that's part of the progresswe're talking about, too. when you're talkingto a friend, you're deciding on your walkingprogram, walk with intention. make that plan, make that goal. because we can stall. if we keep doing thesame thing every day,

the body's just goingto adapt and we're going to stayright where we are. you've got to mixit up a little bit, you got to walk alittle bit faster, or on one day ofthe week, you've got to take a load of a hill. challenge yourself. and that can beslow to progress, and again, know where you are.

be responsible forwhat you're feeling, and what you knowpotentially is a risk, or where thatvulnerability may come. surgery site, chemo,medication you're on, you're going to havea lot of variables. just be wise and talk about it. talk about it with a friend. thank you, guy!