In this informative show, Jenny Ahlstrom interviews Dr. Urvi Shah from Memorial Sloan Kettering Cancer Center about her pioneering NUTRIVENTION studies examining how diet impacts multiple myeloma progression and treatment outcomes. 

Dr. Shah shared results from her completed NUTRIVENTION study, now published in Cancer Discovery, which showed that a high-fiber plant-based diet significantly improved key cancer risk markers in MGUS and smoldering myeloma patients. Over 12 weeks, participants' plant-based food intake increased from 20% to 90% of calories, leading to reduced inflammation (C-reactive protein levels dropped), improved microbiome diversity, decreased insulin levels, and better quality of life. Two patients with previously progressing disease showed trajectory slowdown.

The interview also covered Dr. Shah's three active studies: NUTRIVENTION 2 (closing soon, 100 patients nationwide studying microbiome changes with supplements vs. diet), NUTRIVENTION 3 (150 patients at MSK or Emory comparing diet alone vs. diet with omega-3/curcumin), and NUTRIVENTION 5 (200+ newly diagnosed patients examining whether diet during initial treatment improves outcomes and actively recruiting).

In the show, Dr. Shah compared a whole foods plant-based diet with a ketogeneic diet and discussed the need for more fiber in the typical American diet. 

The discussion also addressed five common nutrition myths:

• Myth 1: All carbohydrates are bad and should be avoided for cancer patients
• Myth 2: Diet can't meaningfully change the gut microbiome during cancer
• Myth 3: Plant proteins are incomplete and this is why we need a lot of animal proteins
• Myth 4: You should only eat organic fruits and vegetables
• Myth 5: Soy increases the risk of breast cancer

 Additional commonly asked patient questions were also answered during the show. If you are interested in participating in these  groundbreaking studies, please contact shahNUTRIVENTION@mskcc.org.

Jenny: Welcome to today's episode of the HealthTree Podcast for Multiple Myeloma, a show that connects patients with myeloma researchers. I'm your host, Jenny Ahlstrom.

March will be here before you know it and March is Myeloma Awareness Month. This month, we're spotlighting innovation in myeloma and how education, research, technology, and community are transforming myeloma care. So don't miss out on our upcoming patient stories, expert webinars, and practical tools to help you take control of your care to move awareness into action because innovation starts with you.

I also want to share that we've been building something new at HealthTree and it's almost here. It will be one place to track your care, get answers to your myeloma questions, and connect with your community because we know how complicated myeloma can be, but navigating it will be easier. So stay tuned for our future announcement from us.

Now onto our show today. There's one researcher who has made diet and nutrition her specialty in multiple myeloma.

The challenge in cancer research for diet nutrition is that you have to do controlled studies to really determine the impact of dietary changes in order to come to scientific conclusions. Our guest today will be talking about some of these studies she has already run and some that are in progress to delay the occurrence of myeloma if you have a precursor condition and maintain longer remissions if you've already had myeloma by changing your diet.

HealthTree has been privileged to be involved in some of these studies and we are very happy to share Dr. Urvi Shah's work in this area. So Dr. Shah, welcome to the program.

Dr. Shah: Thank you so much, Jenny. It's always a pleasure to chat with you and really appreciate your support and sharing this information with patients.

Jenny: Great, well, let me give an introduction for you before we get started.

Dr. Urvi Shah is an Assistant Physician in the myeloma service at Memorial Sloan Kettering Cancer Center and Assistant Professor of Medicine at Weill Cornell Medicine. She completed her residency in internal medicine at Tufts Medical Center, fellowships in hematology and oncology at Montefiore Medical Center and in cancer immunotherapy at MSK and the Parker Institute for Cancer Immunotherapy in New York.

She is board certified in internal medicine, hematology, and medical oncology, and she's received a master's of science degree in clinical and translational cancer research in 2024. Now her own personal experience being treated for Hodgkin lymphoma during her oncology fellowship in 2016 led to her interest in studying the role of these modifiable risk factors like diet, the metabolism, and your microbiome in cancer prevention treatment and survivorship.

She opened the first pilot nutritional trial in plasma cell cancers in 2021, and that has completed. And she has many other NUTRIVENTION studies completed and currently enrolling.

Dr. Shah has been supported by career development awards from the National Cancer Institute, Health Tree Foundation, International Myeloma Society, and American Society in Hematology Scholar Award.

She has also received the ASH CRTI Award, the ECOG Akron Young Investigator Translational Research Award, the Henry Moses Prize, the Celgene Future Leaders in Hematology Award, the NCI Early Investigator Advanced Program Award, Clinical Cancer Research Early Career Award, and the ASH David M Goldenberg CRTI Award. Dr. Shah has published first authored papers in prominent journals like Blood and Clinical Cancer Research.

So now in our show today, Dr. Shah will be sharing what she's learned from her past NUTRIVENTION studies, what she's working on to learn in her open NUTRIVENTION studies. And then we will cover myths and facts about nutrition and answer some of your writing questions on very common questions and topics.

So Dr. Shah, again, welcome to the program. And maybe we want to begin by just talking about what you have learned so far about high fiber plant-based diets from your recent paper on the NUTRIVENTION study.

Dr. Shah: Great. I'm really excited to share. Like so far, we've always talked about this study as like in abstract form in the sense that it wasn't yet published, but it's now finally published in Cancer Discovery. So the whole manuscript's available for anybody to read and available online.

In this study, we were looking at a high fiber plant-based diet to see if patients with MGUS and smoldering myeloma, whether it could potentially delay progression and also if it could improve key cancer risk markers that are known to be associated with progression. What we saw was very encouraging and promising results.

And we did pair this with a collaborator from Italy, Matteo Bellone's lab, where he did mouse studies looking at a very similar kind of dietary pattern to truly understand mechanisms. What we did see was that amongst the 20 participants who were enrolled on the study, they had a BMI over 25 with MGUS or smoldering myeloma, and they got three months of a high fiber plant-based diet.

So we actually shipped them lunch and dinner for 12 weeks and then we provided coaching and recipes and ideas for their other meals. So there was no calorie restriction. And what we did see was that participants had an improvement in quality of life, their adherence to the diet or a healthy dietary pattern improved.

So when we look at things like healthy eating index scores, those went up adherence from their unprocessed plant food intake at baseline was similar to a standard American diet where it was only 20% of their calories. On the intervention, this went up to 90%. And then one year later, it was still high at 60% compared to 20% when they started, suggesting that these changes were indeed long-term too for many patients.

Additionally, we saw like their dietary fiber intake increase as well and quality of life improved. Then when we look at key cancer risk markers such as inflammation, the microbiome, insulin resistance, we saw that insulin levels dropped and we saw that the microbiome health improved. And some of the ways we measure that is looking at things like microbiome diversity.

Higher diversity is generally considered better because there’s more variety of bacteria or species think about like a rainforest compared to a plantation. So the more diverse is a healthier environment. And we also saw these good bacteria called butyrate producers increase to suggesting even the function and composition.

When we look at different enzymes that these bacteria make, even those shifted. like carbohydrate active enzymes are a type of enzymes that these microbes make to digest carbohydrates, complex fiber rich foods, and that also increased suggesting the function of the bacteria and the types of bacteria shifted.

And then when we looked at inflammation, one of the common markers you probably all are aware of is something called C-reactive protein. This number dropped significantly by the end of one year.

And we looked at it two ways. We looked at it only in the participants who were, it was elevated, the seven participants, and we saw it drop in half. But what's more interesting is we looked at it in all 20 participants and said, what if it wasn't elevated at baseline? Do we still see a significant trend over time? And we saw that amongst all 20 participants, the inflammation levels dropped over time, even when we include normal inflammation markers too. Suggesting a shift.

We saw neutrophil levels drop a little bit and that was significant, but I think that when there's less inflammation, they're going to be less circulating white cells like neutrophils and that's expected. And we looked at the bone marrow to say like the cells that make these neutrophils, are they also reduced or increased?

And what was interesting is actually in the bone marrow where these cells are made, the granular site progenitors or the ones that make the neutrophils, they were actually increased. What it tells us is that the bone marrow is actually making more or is able to make the cells, but they're just not circulating because there's less inflammation that they don't need to be out in the blood and they can stay in the bone marrow.

Also, we looked at different other immune subsets or different types of cells and we see a shift in monocytes that are more inflammatory, these are types of white blood cells, they reduced. And the monocytes that are more anti-inflammatory, they increased. So all in all, I think we are seeing a significant immune shift, a significant microbiome shift, and even a metabolic health shift in these participants. The question for all of us would be, did this affect the M-spike or can it affect trajectory?

And what I'd say is progression from a pre-cancer state to cancer is a balance between genetics of the cancer and the immune system. So if we're doing things to strengthen the immune system because we can't really change the genetics of the tumor, then can we kind of delay progression? Because progression can take decades and sometimes it's progressing so slowly, it's a bit harder to study this because we need to follow patients long enough.

We did have two patients on the study whose numbers were progressing for a few years before they went on the study. And then we looked at the rate of change of this spike, like how quickly it's changing over time before they went on the study. And then we looked at it after and during the study. So we looked at 20 months before and 20 months after.

And we see a significant change in the trajectory, meaning it looks like it slowed down the progression for these two participants. For other participants, sometimes the protein levels were too low or we didn't have any numbers before they went on the study or they had really stable disease for many years. So it was hard to see a difference because it was low amounts. But I think this suggests that maybe in some cases, some situations, this may actually help and we can start even seeing those numbers.

But because this is not a randomized study, because patients think there are so many factors that confound it, sometimes people may say, is this true or did it really make a difference? And it's hard to fully tease that out in humans, but we can say the intervention led to all of these key cancer risk markers improving and so the delay.

And then I just want to add one more thing is the mouse data basically confirms or makes us understand these mechanisms much better because in a mouse you can control everything except the diet and then look at it. So for example what we did is we took mice who were given who were diagnosed with small ring myeloma and then half the mice got a regular mouse diet. It wasn't a western diet, it wasn't a high fat diet but a regular mouse diet and the other half of the mice got what we call a high fiber diet.

What we saw is that the mice on the standard diet all had progressed to myeloma by the end of the experiment, but the mice on the standard diet, half of them had not. Now this is of course mice and not humans, but it allows us to look at mechanisms. We then looked at the microbiome, the immune system, and we show that it's actually driven through the microbiome changes and immune system changes that this may actually be happening.

And then I feel like all of you may have this question, and it's a common question I get when I present this data is, what about do you think it's all the weight loss? And is it really the diet or is it the weight loss? And so we did additional experiments to basically answer this question.

And the way we did it is we give mice either the high fiber diet or we give them a control diet which is basically the same calories as the high fiber diet. So it's what we call an isocaloric or same calories diet but without the fiber and now we basically look at how the mice are doing over time with that and what we see is that the mice that got the high fiber diet had a delay in appearance of the spike had had better gut health and less adipose tissue, meaning less fat tissue.

So even though they were eating the same amount of calories, the calorie restriction did not lead to as significant a metabolic shift and change in M-spike as did the high fiber diet. And you can see a different significant weight changes, adipose tissue changes, gut health changes, and also M-spike appearance despite the same number of calories.

So this tells me and us that it's not just about just eating less or eating less calories. It's a lot about what we eat as well and diet quality. And we go on to show some other experiments, but I think this is basically the crux of it.

Jenny: It's great. And there are two questions that I had. My first thing was, should I just go look at my C-reactive protein level in my chart? Because now I want to know what my level is and what men track it over time, potentially. But also, let's just talk about fiber for a minute as well. So should patients, first of all, be looking at their C-reactive protein level?

Because I think as a patient, you always want to know, OK, what can I do? Which things of these should I be looking at? And we were talking about the inflammatory monocytes and that can get kind of complicated, but I've seen my C-reactive protein number before and I know that I can probably go take a look. What is that gonna tell me?

Dr. Shah: Yes. So that is actually a standard test that can be drawn. I agree with you. It's an easy marker to get done. I will say that if everybody starts asking their oncologist to draw it, they'll wonder why. And they think that, OK, I'm telling everybody to. But I would say that it is a marker of inflammation. And that can give you some insight into what's going on. It is nonspecific, though. So it doesn't mean that always it is driven like the inflammation by diet, like suppose somebody has a bad infection, it can also be elevated.

So like during COVID, it could go up. But there is a baseline level of like inflammation or our immune state that's there. So if we're feeling well and doing good, and then we check it and it's still elevated, or that's our best baseline, then we know from that, like if we made changes, does it change over time? So it is a good indicator of inflammation, but it's not the only indicator. There are other ways to measure inflammation which may be missed with a CRP, but that CRP is an easy way to start, I think.

Jenny:  Okay, well, we have a start then, listeners. And we can get into more detail later if you want to about what other things patients can take a look at. But let's just talk about fiber in more detail. So this is fascinating what you found in the study that fiber is so critical is all fiber the same. So you think about fiber supplements people can take or you're talking about a whole foods plant-based diet. So tell me more about fiber.

Dr. Shah: Sure. So when we think about fiber, and I will say this because I've found like sometimes med students or even people in healthcare don't know where fiber comes from. But first thing is fiber comes only from plant foods that are unprocessed. So that's where we get dietary fiber from. Then the second thing is that less than 5% of the US population get enough fiber. So actually 95% of people in the US and probably the world now are fiber deficient.

Chances are even in the myeloma community, it's something like that. Then when we think about fiber, we can say, OK, how about we just take a fiber supplement and not change our diet at all? Fiber, the issue is that there are many types. And when they come in whole foods, they come with other nutrients and packaged together. So when we think about a food that is a good source of fiber, it also comes with plant chemicals called flavonoids. It comes with vitamins. It comes with minerals.

And it comes with that structure where the fiber actually, like if it's a fruit, you know, the sugar is not like directly like a refined source of sugar because it's coming with the fiber that prevents the absorption quickly. So there are other aspects to the food when it comes in the food matrix compared to if we're just eating the fiber. And if we're eating only fiber, we're not getting the vitamins, minerals, other aspects. Next thing is that fiber, like you said, is many different types.

So you have cellulose, you have inulin, you have psyllium, and all of these different kinds of fibers. There's things called soluble fibers, insoluble fibers. I think each fiber source kind of feeds different bacteria. And so we want that diversity of fiber to have that diversity of a microbiome. And often the supplements are going to be one type of fiber.

In some studies, fiber supplements have also led to increase in inflammation for people with their microbiome. So it's not always just because it's fiber, it's always good. And that's why I think when it comes as a food package, it's very different than when it is an isolated supplement. I think some patients do find benefit with fiber supplements. And I think, you know, of course everybody needs to individualize.

These are general guidance, but I think if you're somebody who would never change their diet and you're not getting enough fiber from foods, then maybe it could be something to think about a supplement. thinking about a supplement that includes multiple types of fiber may be better than one type of fiber. But there's a lot of caveats to that. It may not work in everybody.

I think whatever we see with science and data, whole foods seem to be much better sources than fiber supplements. And I was recently at a meeting just talking to a food scientist who basically with his research too came across and felt the same thing like fiber supplements is not the same thing as whole foods.

Jenny: It makes sense and you're just saying eat more fruits and vegetables and these whole grains. So you're going to keep talking about that. And I know people want the easy way out, but it's better to just change your diet over time. And I don't think it's ever too late to change. I have a question about how many grams of fiber should the average person be getting a day?

Dr. Shah: So general guidance recommends about 25 to 30 grams per day. If we think about food sources, a cup of beans or lentils would have probably 15 grams of fiber. The US population is generally at an average of about 10 grams per day. So if you add a couple cups of beans or something, you may be able to actually get about 25 or 30 grams per day.

Yes, so that would be the recommendation. But I don't think there is a clear ceiling limit to say like we need only 25 and we shouldn't have more. And I think fiber rich diets often can go much upwards of that, like 40, 50, 60 grams too.

Jenny: Okay, that's good to know. So yes, I've been using an app to track some of this stuff and I think it's helpful to be able to see what you're actually doing because what you think and what you're actually doing can be two different things. Well, let's talk also about the open studies that you have. I think you gave a great summary of the study that you've completed and now published on, but you have three other studies that you're working on right now. So do you wanna talk about the first one, NUTRIVENTION 2?

Dr. Shah: Yes, sure. So NUTRIVENTION 2 is the one we're doing actually in partnership with HealthTree Foundation. This study is really born out of the collaboration and also understanding how to do studies on a national scale in a decentralized fashion so we don't have to have patients actually travel to us in New York and we can actually bring the intervention right to their doorstep.

So we're also trying to understand the microbiome in MGUS and smoldering myeloma. And there is no real big study looking at that beyond, you know, small data sets, 5, 10 patients, 20 patients here and there. And now we have our NUTRIVENTION study published, but that's also 20 patients. With NUTRIVENTION 2, we are collecting microbiome at weekly intervals over four time points for participants, but we're also providing a short intervention for two weeks, whether it is different kinds of supplements that we're looking into how they affect the microbiome like curcumin, omega-3, probiotics, and then diet as well.

And there four groups, so patients get randomized into either one of those groups. What's more important is also it's a 100 patient study. So we will have data on microbiome in 100 MGUS and smoldering patients at the end of the study to understand like really how does that compare to the general population, to myeloma patients, different aspects as well.

Jenny: So if you are a smoldering or MGUS myeloma patient, you can join this study today, no matter where you live, and you'll get sent food or supplements or whatever cohort you get assigned to, correct? And it's for two weeks? Yes.

Dr. Shah: Yes, as long as you’re within the United States, so we are not able to do this internationally as yet. And the study is close to completion, so we will be closing it in the next few weeks. So if somebody wants to enroll, they should sign up quickly because otherwise we're not going to be able to enroll.

Jenny:  Okay, great.

Dr. Shah: So the next study is NUTRIVENTION 3, and this one is very similar to NUTRIVENTION in the sense that it is a long one-year study, whereas NUTRIVENTION 2 is like much shorter. In NUTRIVENTION 3, we do require participants to either come to Memorial Sloan Kettering in New York or New Jersey or go to Emory in Atlanta, and they would have to come about five times spread over a year to one of those sites.

We have three groups in the study where we are looking at diet alone, diet with supplements like omega-3 and curcumin, and then placebo supplements with diet. So basically, are three groups, supplements, placebo supplements, and diet. And then the groups that get the supplements after 12 weeks also get the diet.

So basically, everybody on the study who enrolls will get a 12 week dietary intervention and some people will get dietary supplements. We want to understand how these supplements in addition to diet make a difference or alone without the diet make a difference and maybe they don't make a difference but we're trying to study that and understand it. This study will include 150 patients so it's a large study but we are about probably 70-80 percent enrolled.

Jenny:  Wow, impressive.

Dr. Shah: So I don't think that this study will be open beyond probably the end of this year or early next year. So if you are interested in this study, I would also reach out sometime this year.

Jenny: And tell me again, what kind of patient this is also smoldering or every, okay.

Dr. Shah: MGUS and smoldering, as long as the M-spike is over 0.2 or the free light chain ratio, if it's a light chain MGUS or smoldering is over 10. And the inclusion criteria or the eligibility criteria are pretty broad. So if you're not sure or you would like to know if you're eligible, just send us an email at shahNUTRIVENTION@MSKCC.org and our team will review your eligibility and let you know whether it's worth making the trip or traveling to come.

We unfortunately do not cover travel, so that is something that the participant needs to think about. But we've had about 20% of our participants or more come from outside the tri-state area and either fly in or travel in for the study.

Jenny: Okay, great. And then NUTRIVENTION 5.

Dr. Shah: So many of these studies were in the precursor setting before myeloma develops, but one common or important question is, what about patients who have myeloma? So we just finished the NUTRIVENTION 4 study in myeloma survivors, but we've not presented the results yet, but we are actively analyzing that now. So we should have that for you all in the next year.

But NUTRIVENTION 5 is a study for newly diagnosed myeloma patients. So if you know anybody who is diagnosed and just starting their treatment or started it, but within the first two weeks of starting treatment and they are getting the quadruplet therapy, which is daratumumab or isatuximab, bortezomib, lenalidomide, and dexamethasone.

So they have to be getting those four drugs then they can reach out to us and we can enroll them. As of now, we are enrolling across the country, but at only certain sites that use EPIC. So if your doctor is at a site that uses EPIC, then we can enroll. If you are at a site that doesn't use that, then we probably will not be able to enroll you, but you can reach out and we can see if there's a center nearby that you could go to or we could figure something out.

The study is short. It's only 12 weeks that we're providing food for. It is a randomized study. So half the participants will do what they would normally do and get a $200 gift card at the end as long as they finish all the follow-up on the study and finish all the tests according to the study.

The other group will get meals for 12 weeks where we would actually provide food shipped to them for 12 weeks, as well as coaching and guidance with a dietitian. Even in the group that I'm mis-mentioning, but the group that gets the gift card and is in the usual care group, we will provide individualized coaching, but we'll just provide it after the chemotherapy.

So what we're trying to do is look at if we provide coaching during treatment versus if we provide coaching after treatment, is there really a difference in things like quality of life and response during treatment? This is a large study. It'll enroll over 200 participants and it has just opened in the last month, last two, three months. So if you know of anybody, please spread the word and they can also reach out through shahNUTRIVENTION@mskcc.org.

Jenny: Okay, so this is again for newly diagnosed patients just starting therapy. And when you mentioned the four drugs, patients might know that as Dara-RVD or Isa-RVD. So if your doctor is telling you about those four different drugs, you would qualify. And I think this answer, if this asks such an important question, does a diet change when you're first starting out in therapy have an impact on your first line of therapy?

Dr. Shah: Yes.

Jenny: And if there's any first most important thing you do as a patient, doing that at that time is a great idea.

Dr. Shah: Thank you, Jenny. Yes, and also to add, and I so agree, it's a very important commonly asked question, and it's a really hard question to answer. So to do the study, we need the support of patients who are interested and want to take part.

But I think both groups will benefit in some way because we're providing guidance to both groups. I also think that it's a low-risk study. There's no real downside. If you don't like the food or you don't like the study, you can leave anytime. So there's no pressure to continue and finish it if you don't like it.

And also, in blood cancers and most cancers in general, don't really have too much data on what happens if we change our diet during treatment. And this is really trying to answer that fundamental question. And it's probably the only study in myeloma or blood cancer is really trying to answer this question. So I hope that we're able to answer it in a way that helps patients down the road and would love the support of any patient who is interested in taking part.

Jenny: Yes, absolutely. know, sometimes I remember being first diagnosed and just thinking, you know what, tell me to eat anything and I will do it because I am not excited about going into chemotherapy to do this. And if there's something that I can do to make a difference in my outcome, I would love to do it, especially during that treatment. And this is a very reasonable timeframe to test this out and then you'll know.

Dr. Shah: Yes.

Jenny: And this is part of the challenge with these types of diet and nutrition studies. If you don't have that control, then you never know.

Dr. Shah: And another challenge that comes up is like when you do a drug study, the one group gets the drug, the other group doesn't get the drug. It's very clear when you do a dietary study, people are eating all the time anyways.

So the group that we provide the food, we would like them to really follow what we're telling them. And the group that's the usual care, we'd like them to really stick to what they were doing anyways before so we can really see is there a difference.

If both groups start making changes, then we're not able to compare between groups. And the point of the study is we don't know if it's good to do it during treatment, and that's what we're trying to answer.

So I think it's very reasonable for both groups to do what the group they are in. And then after the intervention both groups are getting that information and if they want to change, they can.

Jenny: And do you have a list of facilities that are currently open? Because I can share that list in this link. You don't have to mention it now, but I can share a list of institutions that are participating just so you know if you're close to one or not.

Dr. Shah: Yes. Definitely can do. I think it's almost over 20 institutions and we've tried to be broad across the country. So chances are there would be one in the state you are or near where you are. And if there isn't, we can partner with a new institution or doctor. So if your oncologist is open to it and they're using EPIC, reach out. We can talk to them and see if this could be something they would be open to, like at least working with you because we're working directly with the patients, but the oncologist just has to be open to making sure that you're getting the treatment according to what the standard would be.

Jenny: Yes, sure. Okay, well, I think it's a great idea. And I think that especially for people who are going to support group meetings, or they're chatting with people in social media groups, you always see these newly diagnosed patients come up and just say, I'm starting treatment on Friday. This is an opportunity for you to share some information and insight of something that's potentially great for all of us to learn about.

So please, once we have this finished, you can share this link and you could learn more about that study and contact Dr. Shah. let's talk for a minute about diet styles.

So you recently wrote a paper on plant-based versus ketogenic diets and what did you learn?

Dr. Shah: So the reason I wrote that paper was because when I was designing our first trial and I was looking at all the dietary cancer trials available online, what surprised me was that when we look at population studies, just observation, like huge thousands of patients, tens of thousands of patients, what dietary patterns lower cancer risk? We see that more fiber-rich plant foods seem to have less cancer.

So then I thought the natural extension of that would be that we would do interventional studies to test that. But what surprised me was that the number of studies looking at plant-based diet interventions in cancer were very few. And the majority of studies were actually around ketogenic diet trials.

So then I thought, as oncologists, we're studying ketogenic diets more than we're studying plant-based diets because what's the reasoning and what's the mechanism? And could there be similar mechanisms or differences in that.

Just to back up a little bit, a ketogenic diet is basically a very, very low carbohydrate diet. So it's like not physiologic levels, but like extremely low. And with that often it's a low in protein too, but high in fat, like the main focuses around that too. So what ends up happening is that what we're trying to achieve with a ketogenic diet is that ketone bodies similar to in starvation are produced in the body. And these ketone bodies are considered like beta hydroxybutyrate have anti-cancer, anti-inflammatory effects. So if we have these ketone bodies circulating, maybe it could control inflammation, control cancer.

Now moving to the plant-based diet, we talked about butyrate very briefly and butyrate is a short-chain fatty acid or a molecule that has anti-cancer, anti-inflammatory effects.

So with a ketogenic diet, have a ketone bodies with the plant-based diet, we have the butrate, but they both are doing kind of similar functions around cancer and inflammation. What is similar between the two diets is any healthy diet is going to tell you avoid refined carbohydrates.

So when somebody's on a ketogenic diet and they're avoiding carbohydrates, they automatically even avoid refined carbohydrates. So they're going to feel better because they've avoided refined carbs.

The same way a plant-based diet, when we talk about a high fiber or an unprocessed whole food plant-based diet, we're asking people to reduce refined carbohydrates. So there is that similarity between both diets. So what we do see is that there is improvement in weight, improvement in insulin, inflammation, probably with both diets. However, there are some key differences.

Because the plant-based diet is high fiber, there's much more fiber. And so there is going to be much better influence on the microbiome or gut microbiome health through all of that. Usually when people are on ketogenic diets because it's a high fat and low carb diet, they end up not eating enough dietary fiber and it's more animal based diet. So it ends up being low in fiber rich foods. So that mechanism around fiber probably and the microbiome doesn't play into it.

Additional things is that when we eat, science not around cancer, but in general health of populations, low fat is considered good because that reduces risk of cardiovascular disease, high cholesterol levels, and other chronic conditions. When we do eat a high ketogenic diet, there are now studies showing that actually the plaque size or cardiovascular disease risk can increase. So if we're doing it for a short term to lead to weight loss, maybe that's okay.

But if we're doing it long term, for years and years, maybe we are increasing cardiovascular disease risk and people with cancer already have a higher risk of cardiovascular disease than people without because just the treatments and everything else. So I worry a bit that if we do this long term, are we increasing our risk even more? Whereas a high fiber plant-based diet is known to reduce cardiovascular disease risk. So, you know, there's a difference there.

And then the last difference is when we think about body composition. So there was a nice study from Dr. Kevin Hall. He's a scientist at the NIH previously, now not working there anymore. But he showed that when he put participants, it was like a short study and a metabolic chamber. Means what? That the patient is admitted for the whole period of the study and every food they eat is monitored.

Like they're not allowed to leave, so you know exactly what they ate - and he put half of them on a ketogenic diet and half of them on a plant-based diet. So he was trying to compare a low carbohydrate ketogenic diet with a low fat plant-based diet and how do they affect weight, how do they affect the immune system and all of this. What he saw is that there was a loss of weight in both. So both had weight loss, which is a good thing, but the type of weight loss was different.

So in the plant-based diet, because it's low fat, the main weight that they lost was fat or adiposity whereas in the ketogenic diet because it's high fat the weight that they mainly lost was fat free mass and what is fat free mass either muscle or water

So that to me in a cancer patient is a little bit more concerning too and something we need to think about. So I would say that if people are doing ketogenic diets or studies, we want to understand the trajectory of their body composition too. How is muscle mass changing? How is all of those aspects changing? So we're not inducing like, you know, muscle loss or things like that. And lastly, they had looked at the immune system between these two diets and showed that there were immune shifts between both diets and the plant-based diets seem to enhance what we call innate immunity or like our basic immunity around viruses and infections and other things.

And the ketogenic diet maybe had a little bit more effect on what we call the adaptive immunity, which is another aspect of the immune system. all that it's, simplify that it's both are affecting the immune system in slightly different ways. But I think that there could be benefits as long as it is done in a more methodical way and it depends what the diet is.

Jenny: those are fascinating findings and it's great to compare. you hear about all these different diets that you should go on for weight loss And you just really never know who to trust. So it's very nice to compare the two side by side and see the pros and cons of each. And I agree about the heart issues. That's a big concern for my lower patients. So we don't think we need to do anything to increase that. We already have issues. Okay, well let's move on if you don't mind to these myths versus facts.

Myth one: all carbohydrates are bad and should be avoided if you're a cancer patient.

Dr. Shah: Yes, sure. So this is a very common issue or question and that's what feeds also into like the ketogenic diet where people think that's the right diet because they need to avoid the carbohydrates. And another thing that comes up is that, okay, sugar feeds cancer so I should not eat any carbohydrates.

But I think when we talk about, need to understand the difference between carbohydrates and sugar and not throw the baby out with a bath water in some ways. So when we talk about carbohydrates, fats, and protein, they are the three building blocks or the macronutrients of food. And they're probably present in almost all foods in different proportion.

But carbohydrates, when you actually break it down, there are simple carbohydrates or refined carbohydrates. So that is like your simple sugars or glucose and fructose and sucrose, like the sugar basically. And then you have the complex carbohydrates that come within fruits, vegetables, beans, seeds, nuts, grains, and those are fiber rich as well.

And whole grains are especially a good source of complex carbohydrates too. So when we look at studies, complex carbohydrates are actually associated with reduced cancer risk, not increased. So getting at least three servings of whole grains a day is associated with a reduced risk of cancer. Whereas refined sugars like cakes and cookies and all of the things we like are associated with inflammation and probably increased risk of cancer. And we had done a study looking at dietary foods and risk of MGUS.

And this study, what we saw, of course, this is an observational study. We're not really intervening. But we see that sugary foods and drinks are associated with an increased risk of MGUS because probably through like inflammation and other aspects where insulin resistance, whereas complex carbohydrates, so like fruits, vegetables, whole grains, broccoli, all of those foods were associated with a reduced risk of MGUS. So it's carbohydrates in both places, but very different kinds.

Jenny: Okay, that's a great explanation. So eat your carbohydrates because those are fruits and vegetables. Just not prepackaged, sugary, white flour kind of foods.

Dr.Shah: And also the other thing is like cancer can adapt. So sometimes we think like, okay, we won't eat this so the cancer will not feed. But there are studies that have shown like, if you reduce just the carbohydrate, maybe the cancer will now depend more on the fats or other aspects. So it's not so much about just, okay, we eliminate one of those food groups and we're going to be able to prevent it from growth.

Jenny: It seems like you just cannot do one thing. You can't just cut out sugar and then expect to have great health. You have to cut out sugar potentially or lower your sugars, your refined sugars, but also add in all these other things. So you're not just doing one thing at a time.

Dr. Shah: So true. And actually, if you look at the US population, again, the average intake of sugar is about 17 to 19 teaspoons a day. But if you ask anybody, they will say, I don't eat that much, because a lot of the sugar is hidden sugar, where it comes in. A donut you eat, or a cookie you eat, or a muffin, and you don't even realize it has sugar.

So if you try to look at the actual sugars in the ingredient label. Like if it's written in grams and it says like 20 grams, that's already like five teaspoons of sugar. So you want to reduce the teaspoons because one teaspoon is about three and a half to four grams. So you want to try to get that below like I would say seven per day at least or six per day. So that can be hard if you you you put a few teaspoons in the coffee or the tea you're having and then you have one or two desserts or things, it easily adds up. Even a can of soda, for instance, will have 10 teaspoons of sugar.

Jenny: There are 33 grams of sugar in these sodas. It's insane.

Myth two, diet can't meaningfully change the gut microbiome during cancer.

Dr. Shah: Yes. That's a great point and often people assume like, okay, it doesn't matter what I eat because we already have cancer and we should just do, you know, whatever we want to. And I think before this advice was right, because, you know, we didn't have that many good treatments, patients didn't live as long. Of course, if we're not able to help them with the treatment, then maybe, they do whatever they want in their other life.

But now that we have immune therapies, especially that rely on the immune system, and we know the microbiome directly impacts the immune system, there is much more understanding of why the microbiome may be important for therapies.

So for example, melanoma, which is a skin cancer, with checkpoint inhibitors, which is a type of immune therapy, they have seen that people who eat again, more fiber rich diets actually respond better to that treatment compared to those who do not. So it's a simple, short, small dietary change, but it could actually enhance response as well. So I think that while if a patient is overwhelmed, they have lots going on, they're having toxicities or side effects. Sometimes I'm not saying everybody needs to do it all at once because that can be overwhelming.

See at what stage you are, how receptive you are, whether it's the right time to do it, or if you're getting very intense treatment and a lot of side effects, then maybe it's time to finish that and then think about it later. But overall, dietary patterns can change microbiome in as little as a few days.

Jenny: I've heard you say that before and I think that's a fascinating thing that you, it doesn't take months and months and months to make a diet change and then see a result from your testing anyway.

Dr. Shah: Yes.

Jenny: Okay, myth three,

Plant proteins are incomplete and this is why we need a lot of animal proteins.

Dr. Shah: So often people assume that we have these essential amino acids and non-essential amino acids. And so it's thought that plant proteins don't give us all the essential amino acids. So we need the animal protein to get that. Otherwise, we will not be getting enough of the building blocks for making protein and muscle.

But actually, even plant proteins have all these essential amino acids. It's just that the proportion is different in different foods. And we are not creatures that just eat one food. Like nobody here is living on rice all their life. So if they just eat rice, maybe they would be deficient in a few amino acids. But we are always going to eat rice with some other fruits, vegetables, beans, grains, other things. And so when we eat that combination, and we don't have to really plan it out because if we're just focusing on eating that variety, you're going to get all the amino acids from different foods in your diet.

Jenny: Great answer. Myth number four:

You should only eat organic fruits and vegetables.

That can get pricey for people.

Dr. Shah: So there's a nice study that looked at this and said, what if people just changed their diet and ate one more serving of fruit and vegetable and not worried about organic? Would that reduce cancer risk? And they show that just increasing one serving of fruit and vegetable can reduce cancers by many thousands in the US population.

But that one serving increase of fruit and vegetable even if it increases cancer risk due to pesticide exposure, it will be a handful of cases. So you can see that like the actual reduction because of the healthy part of the fruits and vegetables is much, much more significant and many magnitudes greater than the risk with the pesticides. So what it tells me is that, yes, if you have the means and you want to spend on it by all means, like, you know, maybe it could help in some ways.

But if money is a factor or it's things that you want to look into, you don't need to avoid fruits and vegetables or these healthy foods to say like, I can't buy organic and I'll buy something else because I'm worried about the pesticides. I think it's more important to just eat them, whether organic or not. If you want to spend on the organic aspect, maybe there is a slight increased benefit. Like some studies may suggest there is a benefit, but it's very hard to tease out is it truly the organic that's causing that benefit or is it because they're also exercising or they're eating more plant foods or other things because people who focus on organic are probably people who also live healthier lifestyles, maybe don't smoke and other aspects.

Jenny: Well, and I also think just adding one extra serving or fruits and vegetables or whole grains is pretty realistic. I think everybody could do that. So that's good to know.

Myth number five and our last one, soy increases breast cancer risk.

Dr. Shah: Yes. So as an oncologist, I see this often. know that sometimes other oncologists will tell their patients too that you have breast cancer and you shouldn't eat soy. I want to bring this up because breast cancer is common and soy is a common food. So I think we should truly understand this myth. There are studies that have actually looked at soy consumption and cancer risk and breast cancer risk.

And what they've actually seen is that people who eat more soy foods tend to have less cancer and less breast cancer and even less recurrence. And that is because when we eat soy foods, they come with fiber, they come with flavonoids, and they come with these phytoestrogens. And these phytoestrogens, meaning plant estrogens, is what scares people. And they look at them and say, OK, if you have breast cancer, we don't want estrogen, so phytoestrogen would be a problem.

So phytoestrogens are actually milder and weaker estrogens than our own estrogens. So actually, when they bind to the estrogen receptor, they actually probably have a positive effect because they are preventing our own estrogen from binding. So they do not actually increase cancer risk.

And what's more is if you say soy increases risk, we should also be thinking about the other foods that we're eating, like dairy or meat. They also contain estrogens, but they contain animal estrogens, which are as potent probably as human estrogen. So in some ways, if we're using that argument about estrogen, we have to also think about it in the context of other foods and not just soy, because they also have estrogens, especially dairy when it's from mother or a pregnant cow that is making dairy or milk for their child. So just something to think about in context.

And then lastly, I think some of that myth came from mouse studies where they gave like very concentrated soy ⁓ to the mice and then said like, okay, maybe the mice had increased cancer risk.

But again, mice and humans are not the same. They used also soy protein isolate. So it wasn't really like the actual food as a soy food, but actually like the isolated form. So because of that, and we don't have not fully been able to study that in humans, I would say if somebody has breast cancer, maybe they want to avoid like ultra processed soy food like soy protein isolate or processed meats like plant-based processed meats that are made from soy, but even small amounts should be okay. What I mean is like really eating that all the time every day, like that would be something maybe they want to avoid.

But tofu, tempeh, soy milk, these are considered minimally processed soy foods and I don't think there's any problem with somebody with breast cancer eating them. And this is not just me saying it, there's a lot of data around.

Jenny: Okay, great. Well, I like the clarity and I like backing you backing it up with the data that you have and that you've studied. So it's, it's just so fantastic that you're leading the charge on this. I think it's wonderful. Okay. I'd like to ask a few color questions. know we're close to time, but I still want to do that. we, and we had so many that I don't think I can ask them all, but we'll ask a few that are kind of combined with how other people are asking questions as well.

So Liz is asking, is it helpful or harmful to eat foods with high iron content to reduce anemia?

Dr. Shah: It's a tough question and interesting one. So remember, anemia can be caused from many things. It's not just iron that is needed to solve anemia. Anemia can be due to myeloma, where there is increased myeloma cells. And how much ever iron you take in, it's not going to fix the anemia if the myeloma is not under control. Anemia can also be due to vitamin B12 deficiency, folate deficiency. Inflammation can cause anemia. Some treatments can cause anemia. So there's a lot of reasons for anemia.

So what's most important is first to find out is the anemia clearly due to iron deficiency. If it is due to iron deficiency, then we want to replace that iron and replete it because that is important because iron deficiency is also not good for overall health. However, some thought is there or studies that maybe the heme iron, which is iron that comes in more animal foods, maybe slightly more inflammatory than non-heme iron, which comes in plant foods.

And so maybe that's the question that's coming up is like, if we're eating more foods that are rich in heme iron for anemia, then maybe it could be like, there's slightly more inflammation taking place too. Plant foods also can be good sources of iron. The absorption is a little less from plant foods. But if we're getting enough, it will absorb is non-heme iron which is considered less inflammatory.

Jenny: Okay, fascinating. Tracy's asking a question. She was vegan for four years, had a transplant and she has IBS kind of like issues after the transplant. She does not tolerate well, beans and tempeh and things like that. So it was hard for her to get enough protein. And she's using more like organic and pasture raised kind of foods. And just wondering about your input on that.

Dr. Shah: So I'm sorry that she's having difficulty or you're having difficulty around eating some of these healthy foods. What it tells us is that the microbiome seems to be quite perturbed after the transplant or after the treatment, and it's going to take some time to restore the gut. There are lot of things that can be done to restore the gut, but sometimes gut microbiome, while some changes can happen fast, some changes may need some time.

Some common things that people often might have like undiagnosed and chronic things that could be there and sometimes develop new over time would be things like do they have indigestion because they have an H. pylori infection that they need to see a GI doctor and get controlled or and that's causing their indigestion or do they have developed a gluten intolerance that's causing their indigestion or could it be some other food whether it's soy or dairy or something else that's driving the intolerance.

And sometimes it's very hard to tease that out because, you know, we all like when we're eating, we eat all of these foods together and we sometimes don't realize which one's actually causing it. So doing like a few weeks of an elimination, trying different things can sometimes help. What I would say is that, of course, if every we need to individualize this data for everybody.

So if you feel that getting some of the food from organic pasture is just helping you and you think that's the best for you, then who am I to say like we should not do that? And I think if that's working for you, that seems fine. But I think if you can just try to understand why you're not able to tolerate these foods and figure out what is causing it, then it can help you slowly increase them over time. Additionally, some things that can help with microbiome health and gut health is looking at like any deficiencies in vitamins like vitamin D can help also with gut health. So making sure that's good.

Zinc is another one that some people feel can also be if the levels are low. So just looking into some of these things can help whether if there's any other cause. So it can take some time to tease out and it's a bit of just trying over time. Fermented foods is another good source to really help with digestion. The probiotic foods really like not supplements, but the foods.

Jenny: I've had friends who have done fermented foods and it really reset their microbiome and it changed things because they were struggling with lots of different foods.

Okay, we have a question from Luz. How should diet be modified for smoldering myeloma or multiple myeloma patients who have kidney issues, early stage versus later stage?

Dr. Shah: So I like to point patients to the National Kidney Foundation and they have a whole section on diet for kidney disease. And actually, interestingly and finally, their focus is on plant-forward diets for kidney disease because there is a thought and research that shows that plant proteins are a bit easier on the kidneys than animal proteins in terms of filtering and all of those aspects.

So they actually have a whole section on why we should avoid processed meats and why we should focus on plant proteins to get our sources of protein when we have advanced kidney disease. I will say anecdotally in my clinic, I've had a few patients who I've shared this information with. They've had very advanced kidney disease, but they don't want to end up on dialysis.

So they've kind of made these changes and been able to really see improvements in their creatinine or be able to delay the progression of their disease for some time, their kidney disease. of course, the cause of kidney failure or kidney disease is also important. There are many causes and this may not work for everybody, but I think the National Kidney Foundation giving that evidence, you can look at their website and really understand that.

Jenny: That’s a great resource. Thank you for sharing it. That is such a big problem in the United States. There are over 34 million people with chronic kidney disease. Okay, Christina is asking, basically are any supplements, bad that you shouldn't be taking?

Dr. Shah: I think supplements, often we think like, if it's a supplement, it's natural. It would be good. Like, there's no downside. But remember that even many chemotherapy drugs have come from natural substances that have been refined to find the active ingredient and made into a chemotherapy. So just because it's a supplement doesn't mean it is harmless. Why supplements are often the issue is because they're not as regulated sometimes you don't know what you're getting in the bottle if it's not a good brand but also when you do take it Sometimes your doctor may not know or you're on many other drugs and there can be drug interactions when these drug interactions happen.

Sometimes people can end up with liver failure or liver disease or things like that which we don't want happening because that can really set you back. What I generally say is that if you’re taking many supplements you want to talk to your doctor or even if you're taking any, especially while you're on chemotherapy, because they are already on drugs that can interact with each other and you want to basically make sure that they are aware and they've looked into it. There's one good app that's run by Memorial Sloan Kettering. It's called About Herbs. And it's both a website and an app on like your phone.

And it basically has a list, like all the common supplements, and it summarizes the data that's there, the indications, contraindications, potential benefits, and uses. And so it's a good place to look, like if you're saying, OK, berberine, why do people take it? Like, this is a good source that might explain to you why, or why do people take curcumin, or things like that. And what are the cases where you should avoid it or be contraindication?

So I would look at that. I would talk to your doctor or a pharmacist at your doctor's practice who can actually look through all of the drugs, especially if you're on treatment. It's hard for me to say that there is one supplement that's contraindicated, but we know there is a little bit of data around bortezomib and green tea, for example, that maybe too much green tea might affect its efficacy and the same way vitamin C may affect its efficacy.

So in such situations, maybe we don't want to take those supplements. And we only know that with bortezomib because somebody decided to study it, right? Like we don't know it for all other supplements because there aren't enough studies around it.

And that's what we're trying to change to with some of the studies we've done with HealthTree Foundation, where we surveyed patients around supplements and we'll probably share that data soon.

And we were also doing this study with the NUTRIVENTION 2 to understand how these supplements affect the microbiome, the common ones patients take.

Jenny: Yes, that's great, it's just such a great study. We were so happy to help support you on that.

Okay, Manon is asking a very common question. Now you're probably hearing it more and more about GLP-1 use in relapsed refractory patients, but this could really apply to any myeloma patient, precursor condition patient, doesn't matter. Tell me about your thoughts about GLP-1s.

Dr. Shah: Thank you. So it's a great question and it is a bit complex.One thing we know is that in observational studies, like population studies, people who do take GLP-1 drugs seem to have a lower risk of progression from MGUS to myeloma.

That kind of is consistent with knowing that an elevated BMI doubles the risk of progression. So maybe a drug that leads to weight loss may lower the risk of progression. And it also fits in well with our new prevention results showing if we change weight and these biomarkers, we may affect progression.

We also know that the GLP-1 drugs they can lead to profound weight loss and what they're doing is like literally leading to some calorie restriction because you just don't feel hungry and you eat less.

In a patient who's relapsed, refractory or is already having advanced disease, we need to be very careful to make sure that we are not leading to too much weight loss or in a situation where the patient's now cachectic, where we say like they're losing muscle and weight and all of those things simultaneously. So I would be a bit cautious.

However, if a person is very overweight or obese and feels like a diet is not working for them and they just cannot make headway with it, a GLP-1 drug could be a way to kickstart it. But it would be important to do it when you're on stable treatment. You don't want to do it when you're starting a new treatment or when the disease is progressing because there's too many changes or shifts happening at the same time.

And in our study, we have seen that like with the GLP drugs, I think, they work through one mechanism of leading to weight loss, but they may not affect the microbiome. They may not affect other aspects. And in our study, we had one patient who was on, who had diabetes and was on a GLP drug. But during that period, their M-spike continued to rise.

Then they went on our study, changed their diet, were able to stop insulin, continued the GLP drug because they were on it anyways and then we saw that stabilization of the spike so it seemed like the GLP1 drug alone didn't do enough to be able to change it but once the microbiome the immune system other aspects also change with the diet maybe we were able to see some of these effects so what I'm saying is that GLP1 drugs could be effective as one mechanism but dietary patterns probably affect many mechanisms and are probably important to do in conjunction even if we did a GLP.

Jenny: Also, I think just changing your habits is something that you end up changing when you change diet and it's harder and sometimes it's longer term, it's longer term.

Dr. Shah:  Yes, and with GLP, if you stop the drug, most people gain their weight back very quickly. And most people don't want to be on these drugs long term. So what ends up happening is if you feel good, like you've lost the weight and you think, OK, I'll stop the drug. And if you've not really worked on building lifestyle changes and habits, then you just gain that weight back.

And weight cycling, meaning losing weight, gaining weight, losing weight is also not good. And there is one study in Myeloma suggesting that that actually before myeloma is diagnosed, if people have a lot of weight cycling, that also increases risk of myeloma.

Jenny: Wow, fascinating.

Okay, Lanet is asking, is it true that following a plant-based diet and taking metformin, if you don't have diabetes, can slow progression in myeloma?

Dr. Shah: So with the plant-based diet, all the data that we have, we just talked about with the NUTRIVENTION trial and then also just population studies, but we don't have any more interventional. NUTRIVENTION 2 and3will give you more answers around it, but that's what we have. With metformin, we have a study that's being done by Catherine Maranac at Dana-Farber.

I don't believe we have the results yet of that study, but they're looking at smoldering and MGUS patients with giving the patients metformin to see how it affects the disease and also the immune system. So we will have more data from that. We are looking at certain aspects of this, and I'll be able to share more eventually, but I do think that maybe metformin can affect the immune function, but we need to understand it better before recommending it to all patients without diabetes.

Jenny: Great to know. I'm going to combine several questions because we had a lot of questions and you covered this already in terms of reducing sugar, but Armani, Doreen and then Nurdane were asking about sugar, alcohol and blueberries.

Dr. Shah: So sugar we talked about with like refined versus complex and how to think about it. And I think that in myeloma specifically, we have again these studies population and it's important to think about.

With alcohol, the population studies again, it's hard to do an interventional study and say, okay, you drink a lot of alcohol after you're diagnosed and you don’t, but we can look at it as just what people do and like risk of myeloma. What we see is that actually surprisingly that patients who drink or people who drink a bit actually have less risk of myeloma than more risk.

So it doesn't seem to be that it's increasing risk, but at the same time, alcohol is clearly associated with 11 types of cancer. So it's not like we should be recommending that people drink because maybe it lowers myeloma risk because it's increasing 11 other cancers risk.

But also that lowering of myeloma risk or things, we have to understand it in context, is that usually studies around populations around alcohol and cancer or lifestyle things will group patients into three buckets:

1. Those who never drink alcohol or are not drinking currently,
2. Those who drink but maybe one drink or two, like socially drink, and then
3. Those who drink a lot, maybe few drinks and more.

What happens is they sometimes see that the people who drink a little bit do better than people who don't drink at all in lowering whatever it is. And the ones who drink a lot don't do well, and the ones who don't drink don't do as well. But those who drink a little bit maybe do slightly better. And the reason for this, think, is multi-fold.

One is because people who may be drinking may be more social and we know in lifestyle medicine there is an importance of social connection to overall health and having that know interactions having a support group having people like support groups that's why I'm important things like that so it could be that that's playing a role another thing is it could be that people who were drinking or drank a lot and then they had significant health issues, they stopped drinking. So now they're in the bucket of people who don't drink.

So anybody who's had a past diagnosis of something, they will be like, okay, I want to be more healthy and so I'm not going to drink. And so they might fall into that bucket of never drink, not drinking. And if they are in that bucket, that bucket is going to do worse than the bucket that's drinking a little bit socially.

So it looks like not drinking is worse, but that's just because the people who used to drink may have now fallen into that bucket or they have other health issues, which is why they're not drinking.

So short answer is I would not encourage people to drink, but if it is something that is really important for you socially or you enjoy it or it helps you in a way to calm you down, that you feel it's quite important for your quality of life, I think a drink here and there is okay.

Jenny: Okay.

Dr. Shah: And blueberries were all for them. They are high in antioxidants, fiber, everything. So I would say as many as you like. a good thing.

Jenny: Great. Well, Dr. Shah, thank you so much for taking the time to dispel all these different myths, to share all that you're doing in your studies. We wish you well. We want to help support you. We want patients to know what you're working on. So we're very excited about that. And just thank you for joining the show today.

Dr. Shah: Thank you, Jenny, such a wonderful chat with you and really enjoyed talking about all these different aspects and hopefully it helps patients as well.

Jenny: Yes, it's good all around and you're a delightful person. So thank you so much.

Thank you for listening to the Health Tree Podcast for Multiple Myeloma. Join us next time to learn more about what's happening in myeloma research and what it means for you.