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good evening to everyone and thank youfor coming out and it's great to be hereand I've got a short presentation onnutrition and colorectal cancer focusingmainly on eating well during and aftertreatment and so let's start so a bit ofan outline what I'm hoping to do todayis just talk a little bit about thebenefits of eating well looking at whattypes of foods you should be eating somestrategies to kind of help one maintainintake diet and health guidelines justgeneral guidelines and then to look atsome frequently asked questions so whenwe talk about good nutrition the goalideally is that we're eating a balanceddiet that includes the necessarynutrients of protein carbohydrates fatsvitamins and minerals and of coursevital nutrients and multiplexing and ourfamiliar with what we callphytonutrients which are just naturallyoccurring and plant compounds that arefound in foods so things like yourantioxidants would be considered vitalnutrients and those are naturally foundin a lot of plant foods and of course weneed calories and in preparation fortreatment but also just to help usmaintain overall good health of courseone of the key things is that you alwaysneed to consider adaptations that haveto be made to healthy eating guidelinesand that might be necessary beforetreatment because sometimes peopleactually have symptoms before they evenhave a diagnosis and that might impacton their ability to eat well but alsoduring and after treatment sometimessome of those issues are still a factorso what are the goals we when we thinkof you know someone progressing intohaving that treatment and throughrecovery so one of the key things isobviously we want to provide optimalnutrition despite the challenges thatmay exist we want to try and help youmaintain your nutritional health and ahuge part of it is to help to prevent ormanage some of the eating relateddifficulties that can arise duringtreatment the benefits of eating wellwell asyou're probably all familiar with whatthose are so ideally we want to have youmaintain your weight and preserve leanmuscle mass as much as possible maintainyour strength and energy protect yournutrient level so if you come in inpretty good nutritional status we'rehoping to have you maintain that orimprove it if we need to to bettertolerate the side effects from treatmentwe know that if you go into treatment inpretty good shape generally you're ableto withstand the treatment better tohelp support your immune system alsoeating well promotes faster healing andrecovery so if you've had surgery oragain in terms of recovering fromtreatment good nutrition is important inthat respect and then along with otherhealthy lifestyle practices goodnutrition helps maintain and manageother chronic diseases so you use had adiagnosis of colorectal cancer butperhaps you're also a diabetic or you'vegot osteoporosis or you've got someheart health issues so we have to lookat the total picture we can't just lookat it in isolation so in terms of whattypes of things ideally we recommend yoube eating so cancer and cancer treatmentas I said can make eating more difficultunfortunately but we still try to focuson having you eat the best diet that youcan so nutritional requirements doincrease during treatment and in generalwe tend to focus especially on proteinfor ensuring that you're getting enoughprotein and quite often when we doassessments with patients people aresurprised that they're actually noteating as much protein as they thoughtthey were eating and protein is veryimportant also calories become importantparticularly if you've had some weightloss if you've not lost weight then it'snot as much of an issue but if you've1had weight loss then making sure that1you're perhaps having more calories1would be important fluids1ensuring that you're getting enough1fluids and then of course other1nutrients aswer like vitamins and1minerals so with respect to protein1protein is important because it's really1an essential component of helping you1maintain a strong immune system1it's also responsible for growth and1repair of body tissues and particular if1you're on chemotherapy where chemo1affects all cells not just the healthy1cells so for the other cells to be1repaired and rejuvenated you actually do1need some extra protein and protein also1helps prevent muscle breakdown so1generally speaking the recommendation is1that if you're undergoing treatment you1should ideally be having between 1 to11.5 grams of protein per kilogram of1body weight and like I said quite often1when we do assessments we find that1patients aren't necessarily meeting that1requirement good protein choices again1were fully familiar with most of what1those are just listed a few there so you1know meat chicken fish dairy products1are those who include dairy nuts and1seeds nut butters eggs tofu these are1just some examples of good quality1protein choices yes you can get a little1bit of protein from foods like quinoa1for example but the amounts will be1minimal so it's important to look at1some of these kinds of choices if you're1really trying to maximize your protein1intake in terms of the calories so it's1important to be getting enough calories1to maintain your weight so particularly1if you've lost weight we want to focus1on looking at ways to kind of try and1help you regain some of that weight back1we do suggest checking your weight1regularly and in general in terms of1what's required1generally speaking you need about 25 to135 calories per kilogram of body weight1so the person who is at there you know1usual a normal weight then we only need1about 25 calories per kilogram but if1you had a significant weight loss then1you actually may need about 35 calories1per kilogram again particularly going1into treatment where we're trying to1have you boost yourself high-calorie1food some examples would be things like1whole milk and cheese and yogurt sour1cream ice cream yes ice cream and I'll1talk a little more about that nuts seeds1nut butters avocado these are just1examples of some higher calorie foods1that if you're particularly struggling1to regain your weight or maintain your1weight you might want to focus on how1having these fluid intake sometimes1that's a challenge as well for1individuals and it's really important to1be drinking enough fluids as you undergo1the treatment sometimes patients will1complain of being fatigued and sometimes1part of that fatigue is related to not1getting enough fluids so to being1somewhat dehydrated so fluids it's1important it's important if you're1undergoing chemotherapy as well to help1flush the chemo through the system so1and also if you're if you're having1difficulty with eating then we actually1do rely on fluids quite a bit to provide1you with nutrition so in essence we want1you to really drink your nutrients if1you're really having a difficult time1with eating I'm in that case you really1want to choose less water so quite often1patients will focus on water and say oh1I should be drinking you know eight to1ten cups of water a day and that's great1if you're not having an eating1difficulties if you're not needing to1gain weight but if you're needing to1gain weight or you're not eating as well1as you would normally and then it's1really important that rather than1drinking all that water that a good1portion of that would be fluids that1would provide you with calories and1protein as well so these are just a few1examples of again when we focus on2fluids that provide protein and calories2so soups that I made with legumes or2fish or meat would be good choices milk2and milk products soy beverage beverages2like almond beverage coconut milk etc2are not good sources of protein so2that's why they're not included on this2list but soya milk is a good source of2protein so that's a great option2smoothies and to smoothies you can2certainly add things like a protein2powder a whey protein powder or a2vegetarian type of protein powder so2there are some options there and then2for those who like the liquid2nutritional supplements they're2certainly ready readily available as2well so if you're not eating well then2we want you to focus more on the fluids2that provide protein and calories if the2next category would be those that at2least provide you with some calories2even though they don't have protein so2there are a few examples listed there2and then the ones that provide you2neither calories or protein we certainly2want you to minimize those if you're not2eating well or if you're if you've had2weight loss and trying to regain some2weight so in terms of other nutrients of2vitamins and minerals so we want to2focus really on getting vitamins and2minerals from a variety of foods and I2know sometimes that can be a challenge2for individuals with colorectal cancer2just having had surgery or maybe you've2got an ostomy or and those are2challenges that we can work with2patients to try and end them and sort2through but ideally we want you to rely2on on food for your vitamins and2minerals and if you're not eating well2then generally through treatment check2with your physician most physicians are2okay with you having like just a basic2multivitamin so something that has a2little bit of all of the different2vitamins and minerals and certain2vitamin D would be okay as well but we2really do discourage supplementing with2large of large doses of the antioxidant2vitamins so vitamin C vitamin A selenium2zinc etc those are not recommended for2use during treatment and Mark will2probably speak a little bit to that to2that topic further to that so in terms2of trying to maintain your intake these2are just some general tips so before2treatment stars try to stock your pantry2and freezer with some of the favorite2foods things that you know that you you2know generally enjoy eating even if2you're not feeling so well it certainly2is okay to use your freezer like2sometimes individuals aren't sure2whether they can actually you know2whether it's okay to have frozen2vegetables for example so we encourage2you to do that stock your freezer with2some of those options if you buy fresh2vegetables and you have them sitting in2your fridge and you don't use them for2weeks then you're losing nutrients over2time anyway whereas fruits and2vegetables for example are frozen at2their peak so they retain all their2nutrients and if you're essentially just2using them in a smoothie or in the case2of vegetables will suggest putting them2in a soup or just steaming them not2boiling them2and throwing away the water because you2lose some nutrients that way but if you2just steam them or if you're adding them2to suits etc then you're going to retain2the nutrients that we do some cooking in2advance if you can and fries in smaller2portions so that it's just it's easy2when you're going through treatment if2you're having some challenges and this2is a great time to ask family and2friends to help with shopping and also2with meal preparation and also consider2prepared foods there are some meal2services where the meals are actually2quite good nutritional quality and quite2tasty so look at that as an option as2well other strategies to help maintain2intakes or trying smaller meals is2always helpful sometimes just having a3really large meal just looking at a3really large meal if your appetites not3that great sometimes that in itself is a3turn-off so just to see all that food on3a plate you're just not interested in3trying to have anything at all so3smaller meals is always a good strategy3snack as needed and do it frequently3even if generally you're a three meal a3day type of person if you're having some3challenges eating during treatment we3really do encourage trying to eat more3frequently sometimes that's a preferred3way of eating for example maybe if3you've you know got some GI issues3sometimes if you have a large meal that3can trigger your diarrhea or bloating3etc for smaller meals more frequently is3recommended for many reasons have3protein at each meal and snack so again3we generally tend to think of having a3protein with supper and sometimes with3lunch not always with breakfast but to3do try to have a protein with each meal3and also a bit of protein with your3snack for maybe your snack could be3something like a Greek yogurt which is3higher in protein or some cheese and3crackers or hummus with vegetables etc3so try to have a little bit of protein3with your snack as well as I mentioned3before pay attention to fluids and in3particular if you're needing to gain3some weight look at ensuring that you're3getting fluids that will provide you3with some addition3nutrition high calorie high protein3beverages are available commercially or3as I mentioned many people do enjoy3making their own smoothies and you can3put all sorts of great combinations of3products in that managing treatment side3effects now there's some great resources3available speak to your healthcare team3these are just some examples of some of3the brochures that we have available or3in the Odette3so there's definitely help if you're3having difficulty speak to the team they3can refer you to certainly to ourselves3as dietitians and/or nurses etc can3provide you with some assistance in this3regard as well so one of the general3tips for healthy eating and ideally I3mean prior to treatment we're3encouraging you to eat healthily and3once the treatments are all finished and3you're moving beyond your treatments3then again the idea is that you would3resume your healthy eating practices so3what what we encourage is to first and3foremost try to have a variety of foods3unless even within some of the3constraints that you may have so for3instance maybe you have an ostomy and3you're finding that certain vegetables3just aren't working so well for you try3to focus on the range of the other3vegetables that you're able to have3again include protein at meals drinking3lots of fluids eating more of a3plant-based diet is what's recommended3eat more vegetables and fruits choose3healthy fats and oils make whole grains3your preferred carbohydrates and try to3limit high calorie high snack3sorry high fat snacks and we encourage3limiting processed foods and salty foods3and this little diagram just shows when3we look at the plate ideally what we're3encouraging is that you kind of have3half your plate of vegetables and then a3small portion of your your starchy3vegetables or things like potato rice3etc and then a quarter would be your3protein foods and then with a little bit3of some type of dairy or other calcium3rich food and fruit as well don't forget3as well we would encourage that you try3to3you know do other light assume other3lifestyle habits that are good for3limiting alcohol general the3recommendations for men is no more than3two drinks a day for women no more than3one try to again maintain a healthy body3weight moving forward we know that3maintaining a healthy body weight is3important and of course try to engage in3right at regular physical activity and4now with respect to physical activity4even during the treatment patients are4encouraged to maintain their physical4activity levels and they're actually now4some cancer exercise guidelines that are4available for patients and you can speak4to your healthcare team about that as4well so just quickly what some of the4frequently asked questions that we get4as dietitians so one of them is just4this whole idea of where there's so much4emphasis on plant-based diets and eating4lots of fruits and vegetables and it4sometimes really is a challenge for many4of our patients who have colorectal4cancer again perhaps with surgery or an4ostomy or just the side effects on4treatment it is challenging so these are4some of the suggestions that we make4peel your fruits and vegetables to4decrease the fiber content because4sometimes a little bit less fiber makes4it a little bit easier make less easy to4tolerate fruits and vegetables cook4vegetables and fruit try to use4unsweetened canned or jarred fruit to4sort of help you automate your intake4fruit and vegetable smoothies don't4forget vegetable juices or blended you4know vegetable soups so these are some4ideas to sort of help you include more4fruits and vegetables red meat is always4a big one with colorectal cancer and so4again our general guideline I'll just4skip this essentially what the studies4have found is that diets high in red4meats for more than 18 ounces a week are4links with increased risk of colorectal4cancer so the recommendations we suggest4patients follow is the recommendation4from the American Institute for cancer4research and what they suggest is that4we limit cooked lean red meat to no more4than 18 ounces per week so that's like4your deck of cards and that would be six4of those if you choose to have red meat4you don't have to but if you choose to4these are the guidelines and that we4avoid proof4meat and red meat is beef pork some4people see pork as a white meat but it's4also a red meat lamb goat veal etc and4then processed meats well we don't know4what those are um one reason why we4sometimes say if you don't object to4excluding red meat entirely one benefit4of having a little bit of red meat4through treatment is that it one of the4side effects from treatment can be to4drop red blood counts and the nutrients4that are important to heat comment keep4the blood healthy our protein iron4folate and b12 and here are some4examples of foods that contain them and4you can see that meat fish poultry eggs4etc are included they're a good source4of protein also a good source of iron4along with other foods of course folate4and also in particular vitamin b12 is a4little bit challenging to get enough if4you're not including red meats in the4diet you have to look at other ways to4make sure that you're getting b12 so if4so you're not adverse to having it then4it's certainly okay to have it what we4do suggest keeping it to smaller amounts4should I avoid there is another key4question that we get and again our4suggestion is that if you don't suggest4that you exclude dairy from the diet but4if you choose to4there's certainly alternatives I think4from our perspective the more important4thing is that you do get enough calcium4and vitamin D so this just highlights4what the requirements are you can4certainly get the calcium and vitamin D4from Dairy if you choose to include4dairy these are some examples of choices4but there's certainly many non-dairy4choices that are available as well so4again the important thing is that you do4get enough calcium and vitamin D and you4can get it at the from dairy or not very4choices another popular question is4again the whole idea of sugar and cancer4and I guess I'll skip to the bottom line4is what we're suggesting is that you do4try to decrease your added sugar so a4lot of table sugar you know corn syrups5honey maple syrup agave even the healthy5sugars in moderate amounts so we're not5suggesting you exclude them but we do5suggest maybe having lesser amounts of5those and focusing more on whole foods5like fruit or 100% fruit juice if you do5include fruit juice yogurt that might5have a little bit of added sugar in it5because they've got other nutrients in5them as well you can get protein you get5your vitamins and minerals etc in terms5of added sugar the American Heart5Association they've come up with a5recommendation that we say you can use5as a guideline and what they're5suggesting is that for women we try and5limit our added sugars to about six5teaspoons per day and for men nine so5again that's just a guideline the5important thing I would say that when5you're undergoing treatment the key is5to get you through the treatment and if5that means that perhaps what works at5this point in time is that you might be5having5maybe pancakes with maple syrup or ice5cream or you know things that naturally5contain some added sugars in them that's5not a problem in moderation it's not an5issue I think the concern is when the5diet is one that consists of a lot of5high fat high sugar foods but if you're5eating healthily and including small5amounts of these foods that really is5not an issue again if you're including5some sugars one of the ways in which you5can sort of have5lessen the effect of the increase in in5blood sugar levels is to pair as sugars5with protein so again if you're having5maybe fruit you can have that with some5nuts or a piece of cheese or cottage5cheese and fruit etc so that helps and5do choose it's important to choose5carbohydrates because sometimes we find5patients are really trying to limit5their carbs but remember in choosing the5carbohydrates what we're encouraging you5to do are to choose the carbs that come5from our vegetables and fruits and whole5grains and legumes not to be excluding5those if you need help5like I said we the dietitians can be5accessed through the patient and family5support program at here at the OCC if5you're not a Sunnybrook patient5and wherever you're going there usually5a dietitian services available we're5available to help answer questions and5concerns and more importantly our goal5is really to work with you to work with5you to help manage any eating challenges5that you might have thank you5[Applause]

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