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Transcript of “Why Good Nutrition is So Important for Bladder Cancer Patients with Dr. Jill Hamilton-Reeves”

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Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle invasive bladder cancer, the proud owner of a 2006 model year Neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it, BCAN, producers of this podcast. This podcast is sponsored by Merck [inaudible 00:00:29].

Rick Bangs:

I’m excited to have Dr. Jill Hamilton-Reeves as our guest today. Dr. Hamilton-Reeves is an associate professor, dietitian, and certified oncology nutritionist at the University of Kansas, and she’s a member of the BCAN Scientific Advisory Board. She works with urologists and medical oncologists to foster the discovery of better diet and exercise approaches to benefit patients with cancer. She has a nationally funded research program focused on nutrition and cancer prevention, management and survivorship, with specific attention to bladder cancer. The intent of Dr. Hamilton-Reeves work is to toss aside the fear and anxiety around food and to help patients decipher evidence-based or science driven approaches to thrive. She hopes that you will eat and discover the great taste of wholesome foods.

Rick Bangs:

Dr. Hamilton-Reeves, I’m so pleased to have you here today to talk about nutrition and bladder cancer, and I love those last two sentences in your bio.

Dr. Jill Hamilton-Reeves:

That means so much to me, Rick. I am more than honored to get to spend this time with you. It’s been way too long since we’ve seen each other at conferences. So, thanks for inviting me in.

Rick Bangs:

I want to start by talking about the relationship between nutrition and bladder cancer, and how that evolves at various points in the bladder cancer journey. So, let’s assume that I was diagnosed today with bladder cancer, and I’d like to walk through the potential impact that nutrition might have and could have on my journey. So first, let’s start with a patient with low grade non-muscle invasive bladder cancer who wants to avoid recurrence or progressing to a higher stage bladder cancer. What nutritional advice would you have?

Dr. Jill Hamilton-Reeves:

I know you. I think my advice to you might not be the same as it would be to all of the listeners. I think what would be similar is really sitting down and listening to what’s a day in the life of Rick Bangs like. What kind of foods are you eating? What’s your movement patterns? What kind of other health issues are you facing at the time? And then we’d have a conversation about readiness for change and what would work with your life? And so, if we do that, and we’re looking at the evidence, and now I love the idea of walking with you specifically through the journey, not all these things would be specific to you though.

Dr. Jill Hamilton-Reeves:

I think that the strongest evidence, and it’s still, it’s not hardcore evidence, but there is some evidence that would suggest that people that are carrying extra adiposity or maybe have some metabolic health issues, they are the most likely to have a recurrence of their bladder cancer. So before sitting down, before you even start this journey of taking the different cancer treatments along the way, I think it’s an opportunity, a wake up call, to think of this as a chapter flip, and think about, okay, well, how’s your blood glucose control? Are you pre-diabetic or diabetic? Let’s get that figured out if you’re on board for that. Let’s make sure that we’re keeping your muscle mass on just in case, because today, we’re going to talk through the whole journey, and you’ll hear how important keeping muscle masses for being resilient for all the different obstacles and challenges that can be faced.

Dr. Jill Hamilton-Reeves:

So again, just to kind of reiterate, that seemed probably very conversational, but as far as the evidence goes, again, extra adiposity or prediabetes, metabolic health problems are the ones that I think I would focus on first, and that’s really where the evidence lies. We had a study where we helped people control their blood sugar and had really good adherence because again, it was like a wake up call of like, hey, I want to take care of myself, and that might work down the line.

Dr. Jill Hamilton-Reeves:

Usually people then ask, are there special vitamins or supplements or things that I can take? There have been some studies of high dose B6 and some other nutrients, but those results have been really mixed, and I think more of the return on investment is really just looking at overall health and then those two aspects. So do you have any questions about that?

Rick Bangs:

No. I love the personalization. I think that’s going to be reassuring to patients because I don’t think they think in terms of one size fitting all and themselves not being unique in this whole process. So, I think this is a good theme.

Dr. Jill Hamilton-Reeves:

I’m kind of glad that you opened with this question, Rick, because I kind of feel like I straddle two different worlds, one in the research world where we’re trying to ask very general questions. We try to do personalized approaches but our statistical approaches aren’t quite solid enough for really getting that done. Diet’s too complicated, so there’s that aspect of my life and reading evidence, but then there’s the other clinical wisdom and experience of working with patients, hearing their journeys and then kind of walking them through what they’re ready for.

Dr. Jill Hamilton-Reeves:

So, you might hear that kind of theme throughout the day. And if it ever gets confusing, please stop me so we can say, this is clinical advice or is this more research-driven?

Rick Bangs:

Okay, I promise to do that.

Dr. Jill Hamilton-Reeves:

It’s like the art and science, right?

Rick Bangs:

Exactly, exactly. So let’s straddle this a little bit more here and let’s talk about my diagnosis which was high grade muscle invasive bladder cancer. Many patients who are going to have that diagnosis are going to have chemotherapy. And so, what would be your advice to prepare for chemotherapy and also managing the side effects?

Dr. Jill Hamilton-Reeves:

So, do you mind me asking, did you get chemotherapy before your surgery?

Rick Bangs:

I did not.

Dr. Jill Hamilton-Reeves:

Okay, okay. That’s helpful. Again, I’ve learned so much from how differently people respond that sometimes I think normalizing that from patient to patient perspective is helpful. But if you haven’t, I’ll kind of share what we’ve learned along the way from working with our patients. So first of all, I want to put a plug in for the BCAN website. So, I’m not sure if that’s how most people found this podcast or not, but we have a nutrition education page in there that my lab group and some of the faculty that I’ve mentored over the years have put together, that really, really hone in on specific recipes and foods around chemotherapy and around surgery. So, I do want to direct our audience today to that.

Dr. Jill Hamilton-Reeves:

Big picture, I think just again, normalizing and talking about setting expectations for what could be. So, a lot of times, people are put on a platinum-based chemotherapy, and it’s usually cisplatin, although it can be different combinations. And that is a drug that tends to make people pretty nauseous. And the great news about that is that we have excellent drugs and medications that if people are on it and the healthcare is on it, which they should be if they’re following NCCN guidelines, they will pre-medicate people before getting their chemotherapy to handle that nausea. Now, people that are of a younger age, female gender, people that have a history of getting carsick and nauseous anyway, I think it’s important to talk with the health care providers and say, hey, that’s me. It’s more than likely that I’m going to have a rough go, so let’s really stave off that nausea from the get go, because once you get behind it, it’s really hard to power through and eat through it.

Dr. Jill Hamilton-Reeves:

So, I think that planning is important. Staying ahead of hunger. A lot of times, if you are fortunate enough to have caregivers around you, they want to do something, they’re action-oriented people. If they can make some meals and you can freeze them and have them ready to consume along the way, I think that’s really helpful.

Dr. Jill Hamilton-Reeves:

And then just a couple of other things. The platinum-based therapies, many, many people have taste changes with that. And they don’t realize that there are strategies to manage that. So metallic taste is probably the most common. We’ll work with people to use wooden eating utensils like chopsticks or wooden forks or spoons, or even plastic forks and spoons instead of metal because that makes it worse. We’ll also work with patients because chemotherapy will waste certain nutrients. So, magnesium and potassium tend to be wasted. Medical oncologists have been better and better over the years for monitoring that and helping correct it with supplements, and working with a dietitian to help encourage foods that are high in those nutrients like nuts and peas and beans and oatmeal.

Dr. Jill Hamilton-Reeves:

Another nutrient that will often go low during chemotherapy is iron. And so, really staying on top of the medical oncologist monitoring iron levels, you’re going to feel fatigued, but if you feel even more so fatigued, definitely think about looking at iron and thinking about eating more iron rich foods like red meats and white meats even. And then there’s other, if you’re vegetarian, there are things that we can manage.

Dr. Jill Hamilton-Reeves:

To say this most simply, chemotherapy can throw a lot of challenges a person’s way, and the best case scenario is that you’re going to a place where they have a dietician that you can meet with to kind of sketch out a plan, and also be involved periodically throughout your treatment to make sure that you are getting adequate nutrients to fight this cancer.

Dr. Jill Hamilton-Reeves:

So I think a dietitian would help with all of those things, but I just wanted to give some specific examples so people could see that it’s not going to set their expectations in meeting with the dietician, that it’s not going to be eat your vegetables, and that’s all. There’s actually very specific things that they can help with.

Rick Bangs:

Right. And this point about staying ahead of hunger and staying ahead of nausea, and you also hear that about staying ahead of pain I think is really, really important, right?

Dr. Jill Hamilton-Reeves:

Yes, and I am so glad you mentioned that because pain is one of those things that people don’t even realize how it’s affecting their ability to eat. And when you’re stressed because you aren’t getting enough energy, it can actually even increase the sensation of pain. So that’s actually something we’ll talk about my study a little bit later on. It’s not just my study, it’s an army of people that are involved in getting that study together, including you, Rick. But we’re actually looking at that in our study is how pain and being fed and nutrition status can be related as well as other things. That’s way down the list of the primary reason we’re doing this study, but that was a good point. Thank you.

Rick Bangs:

Good. So if I’m getting chemotherapy, and obviously, if I’m helping out with the nausea, I’m more likely to get the chemotherapy, but is there anything else I can do nutritionally that would improve the effectiveness of my chemotherapy?

Dr. Jill Hamilton-Reeves:

Yeah. I think given the chemotherapies that are approved right now with bladder cancer, there isn’t anything that I’ve seen that would actually make the drug more effective. But I think there’s a whole host of things, kind of what I was alluding to before, about really making sure that the human is well nourished as they are getting chemotherapy. So again, really thinking about monitoring and correcting or treating magnesium wasting, potassium wasting, or iron deficiency.

Rick Bangs:

That to me makes a lot of sense. So if I’m getting chemotherapy, is weight loss going to be a given for me?

Dr. Jill Hamilton-Reeves:

Yeah. What I have seen with most of our patients as they go through this journey is, I think because we are getting so much better at managing nausea, it’s not a sentence that you will definitely lose weight during chemotherapy. It doesn’t have to happen if you are on top of things. I will say that there is a stigma or a bias with obesity, it’s both socially and then sadly, I think sometimes it also happens in well-meaning health care professionals. And they may think, well, this person has some weight to lose or the person themselves come in with beliefs or attitudes of, hey, this is a good time to lose weight. I just really want to drive home the point that this is not the time to do that. And there’s no data available yet to suggest that it would be the time. Instead, it’s on the opposite side that losing muscle mass, losing weight is just going to start whittling away at your resilience to withstand the treatments.

Dr. Jill Hamilton-Reeves:

And one of the things that we talk about is this condition called sarcopenia, and what that is as we age, we normally do lose some muscle mass. It’s kind of part of our hormones changing, being a little less active. However, that can be accelerated substantially as you’re undergoing these treatments or with other medical conditions. And half of the patients at this stage of the game, when they come in for chemotherapy, about half the patients are sarcopenic. And the problem with that is there’s data showing that people that are sarcopenic are more likely to have, they will have to go through a dose reduction in their chemotherapy, which you think oh, that might not be so bad, but what that means is you can’t withstand the full treatment that you’re actually supposed to have because your body’s too weak.

Dr. Jill Hamilton-Reeves:

And so, we really, really don’t want people making themselves weaker, and people that are carrying some extra adiposity, their muscle can still be wasting away. So again, there’s a, in the sports world, I’m an amateur athlete, that’s how I kind of manage my stress and have recess. And one of the things that has really caught a lot of attention is this idea of relative energy deficiency in sport, which basically means that, we do this everywhere, so anytime you’re withstanding some sort of major physical challenge, your brain is going to run a body budget of how the energy is going to be used. And if your bank account for energy is running low, it’s going to borrow from somewhere else or it’s not going to be able to see this through.

Dr. Jill Hamilton-Reeves:

So when you’re facing cancer treatments, you don’t want to put your body at risk and having to eat into your muscle or extra tissue to fight when you could just as easily eat enough to get through, especially with the help of a dietitian.

Dr. Jill Hamilton-Reeves:

That was kind of a long answer. It’s something I’m a little bit passionate about though.

Rick Bangs:

Which is great, which is great. So this muscle loss, this is true for men and for women, right?

Dr. Jill Hamilton-Reeves:

Correct. Yeah. And it’s not just the mass of muscle that’s lost, it’s also the function and strength. And so, sometimes people realize, some people, we’re all so different, some people seem to hold on to muscle mass. Especially if they were an athlete throughout their life, we had a patient that was like a bodybuilder. People were so impressed when we took him to the DEXA machine for his body composition. He was an older gentleman, and they’re like, whoa, this dude has a lot of muscle. And good for him.

Dr. Jill Hamilton-Reeves:

And yet, going through this process, he lost his strength and function. He did get behind a little bit on some of his eating. And I’m not blaming him by any means because this is going to happen, again, normalize it. To people on the outside, they didn’t realize it was food because he looks so big and muscular. But he knew because he just couldn’t lift things and he was so fatigued. And so, we helped them increase what he was eating and he’s bouncing back. The eyes can really fool us sometimes, especially if we come forward with some bias, right?

Rick Bangs:

Right. And this another reason that this personalization is so important.