(Guest Lecture): March 2024 - How to Optimize Your Health as a Myeloma Patient

How to optimize your health as a myeloma patient. We chose this topic because nutrition topics are highly requested by you, and we understand the role that lifestyle and nutrition play on our outcome when we're in our journey with myeloma. We have Dr. O'Donnell that will share her insights about this topic, and you can ask your questions about if we have any tips or research or whatever we can participate to see better outcomes. Sorry, we have the wrong picture there. I was like, that's a very pretty person, but it's not me. Yeah, sorry. I don't know why that happened, but I'll just change this. Dr. Elizabeth received her medical degree from Vanderbilt University. She completed her residency in internal medicine at the Beth Israel Deconest Medical Center, where she served an additional year as a chief resident. She completed her fellowship in hematology and oncology at Dana-Farber Cancer Institute. She's the director of early detection and prevention at Dana-Farber and assistant professor of medicine at Harvard Medical School. She specializes in plasma cell disorders with a particular interest in lifestyle, lifestyle medicine and patient and caregiver quality of life. So thank you for being here, and I'll stop sharing so you can share your screen. All right, you can see the big screen. Yes, great. Good afternoon. Thank you so much for inviting me to speak with you. As noted, my practice is in plasma cell dyscrasias, but I am board certified in lifestyle medicine, and this is a passion of mine that I think is very important to patients, to all patients, and specifically those with cancer and precursor diseases. And so I'm going to talk a little bit about what lifestyle medicine is. This is evidence based practice. So how we study cancer drugs, we apply to other types of medicine as well, where we do clinical trials and evaluate the efficacy of different interventions. And here specifically, we look at things such as healthy eating habits, exercise, stress, relationships, sleep, and the use of risky substances with the ultimate goal of improving and maintaining health and preventing disease. And so why do we care about people's lifestyle and these considerations? Because it is because there are data that support that attention to lifestyle can improve quality of life, can improve or potentially mitigate side effects from treatments, can help with physical function, with mood, with fatigue, and even potentially with cancer outcomes. And so there are six pillars of lifestyle medicine that I briefly noted, exercise, sleep, social connections, stress management, substance use and nutrition. And I'm going to go through each of these and talk a little bit about the evidence and just give some practical tips that may be useful in your life. And so why exercise? So there are actually evidence that demonstrate that exercise, even during treatment, can improve quality of life. Exercise is the only thing that's been shown to improve cancer related fatigue. So it may sound a little bit counterintuitive that when you're tired, exercising will help, but it actually does. It can improve anxiety. And we know that in patients with plasma cell disorders or multiple myeloma, depression, anxiety can be quite significant. It can improve libido and can help with sleep. So if you're a little bit more tired, you may actually have better sleep quality if you've exercised and exerted yourself and may improve social functioning as well. And so this is an update of a controlled physical activity trial on cancer survivors. It was a very large review and showed improvements in patient reported outcomes, as noted quality of life, fatigue and anxiety, as well as improvements in physiologic parameters such as body mass index, muscle strength and fitness with low risk. And so we'll talk a little bit about the types of questions that you need to ask your doctor before exercising. But overall, exercise is safe. So the American College of Sports Medicine is the group that puts out the exercise recommendation and the American Cancer Society typically follows what the ACSM puts out. And so overall, and I'm speaking primarily to people who may be on the call with precursor conditions like MGUS or smoldering, the recommendation is for one hundred and fifty minutes of moderate intensity exercise or seventy five minutes of vigorous intensity plus resistance training two times per week. If you have multiple myeloma and you have bone disease, we're going to get into that. Those are different considerations. And so in 2019, these guidelines were actually updated and these are expert consensus panels saying from the ACSM saying that even three times a week, thirty minutes, there's benefit to exercise specifically in cancer patients. And so the ACSM says that even three times a week, thirty minutes, there's benefit to exercise specifically in cancer patients. And so when you think about exercise and we talk about moderate or intense exercise, you know, what are the different differences and what are some simple ways to think about how hard you're exercising? So if you're doing going for a walk and your exercise is light, then you may not notice a change in your breathing pattern. Modern intensity is where you could get to where you can still have a conversation, but maybe fewer words and not where you could sing a song. And then finally, vigorous is where you can just get a few words out without having to stop to catch your breath. And so what are some tips in general to something you enjoy? And so very often people get notions that they have to do something really rigorous, and that's just not the case or try to adhere to things that they don't enjoy. If you don't like running, for example, don't don't choose that as your activity. Do things that you enjoy. Don't try to jump right in. If you're not currently active, we'll talk about physical therapy in just a moment and other guided exercises, but start slowly and build up to that goal of 30 minutes, 10 minutes, three times a day. It gives you the equivalent benefit of a 30 minute block. So think about starting incrementally and building your way up and setting goals for doing so. Try to do some consistency every other day if you're first starting out. And again, try for that moderate intensity as you build up and also try classes and find people to do these types of activities with. And so I think it's particularly important for cancer patients to have some oversight and support. So talk to a fitness expert, set goals that could be very motivating. Find a training partner or a friend. Use apps. So a lot of people use smartphones or wear smartwatches that calculate your steps. Set a goal. Some people say 10,000, but if you're not there, pick a goal and incrementally build up. These are simple things that you can do that will help you. And in general, one of the most important principles is to avoid inactivity. There may be times where you don't feel well enough to exercise, but I encourage you to try to say, stay active and continue to do your activities of daily living, especially when people are first diagnosed with cancer. There's often a rush of help. Let me do this for you. But try to continue to do the things that preserve your function, such as things like cooking or emptying the dishwasher. If you're on the phone, for example, try that's a time when we all use cell phones to try to limit your sedentary time. Get up and walk, even for some portion of the conversation, move around. But to the extent that you can, if you don't feel well enough to exercise, then try not to be inactive completely and continue to do the things that you've always done. And so for people, and this is really important. So if you have multiple myeloma, if you're actively undergoing treatment, if you have bone lesions, it is really important to talk to your provider first. To do an assessment of what you can and cannot do. And in some cases, it does not mean that you can't exercise, but that you might actually need some supervision, whether it be cancer rehabilitation or physical therapy. And so cancer rehabilitation is available at many cancer centers, but not all. And when it's not available, physical therapy is a tremendous alternative, which can be covered by insurance. So you don't need to have a torn ACL or a broken bone to do physical therapy. You can get a prescription for cancer related fatigue or for deconditioning. So cancer rehabilitation is a new field over the past couple of decades, which really integrates cancer care with physical medicine. And so here again, you can get the benefits of improved physical functioning with quality of life and symptom improvement. So if your cancer center offers this, this may be a great way to integrate safe physical functioning into your cancer care. For those who do not have it, physical therapy is a very good and underutilized option. So, you know, there's a lot of burden financially to cancer care. Not everybody can afford a trainer. Not everybody wants to go to a gym because of germs or concerns. But physical therapy is often done in a safe environment with a prescription covered by insurance. And your provider can send that prescription with any limitations that you might have tailored to your unique condition. And so you can work on unique things like compression fractures, work safely around those weakness, cancer related fatigue. And these are customized, supervised plans that you can then take home and feel confident that you're doing the right exercises for you. So before you start, you should be screened by your physician. Please do not embark, especially if you have active myeloma and an exercise regimen without first having a conversation with your care team. And we just want to make sure that you prevent injury and do the right exercises for you. However, there have been multiple studies in myeloma that do show exercise can be safe and beneficial. And now we're going to move on to a very important topic, which is sleep. And something we talk about a lot of things in our patient care, but very often we don't talk about sleep and sleep quality. And particularly in multiple myeloma where we use the medication dexamethasone frequently, which can alter people's mood and sleep habits. This is a critical conversation. Sleep is incredibly important. We spend up to a third of our lives asleep and we need it. And a lot goes on when we sleep. We're not just turned off. Actually, our brain is turned on and there's a lot of important activities going on. So trying to protect sleep can be critical for our well-being. And so thinking about how much sleep does the average person need, most of the people who are in the adult age group require seven to nine hours of sleep per night as a recommendation. And we know that patients who have cancer are more prone to have disrupted sleep. I talked about dexamethasone, but also other things can affect your sleep quality, like pain, for example, which is also very common among multiple myeloma patients. Side effects of therapy we mentioned, also the stress. Sometimes it's hard to turn off your mind and go to bed. And so really thinking about what are the different ways we can combat each of these factors to help ensure patients have good quality rest. And so some things that you can do is establish a routine, something called sleep hygiene. Try to go to bed at the same time every day and try to wake up at the same time every day. It takes a week or two to settle in, but you will find that your body gets ready to go to bed and have a preparation for that. So using blue light or using your phone, which emits blue light, can stimulate the part of your brain and suppress your melatonin, which is the natural sleep hormone. So trying not to be on your phone, trying not to watch TV and do things that stimulate, find a routine to wind down so that your brain can settle down before you get into bed. Thinking about the timing of eating and drinking things, trying to have a three hour window from consumption of food and specifically alcoholic beverages too. Even though you may fall asleep more quickly if you've had something that contains alcohol, ultimately it actually disrupts your sleep later into the sleep cycle. And if you exercise during the day, you will have better sleep quality at night. So what are some things you can eliminate? Again, caffeine, so try not to have caffeinated beverages after three or four in the afternoon, depending on what time you go to bed. Avoid nicotine and alcohol later in the evening, high sodium foods, eating late at night, and the screens that I mentioned. And so I touched on this before, but the blue light emitted from your phone activates the brain, suppresses melatonin and interrupts the circadian rhythm. So trying to avoid the use of your phones right before bed or if you wake up during the night, trying to get on your phone to pass the time will actually make it harder for you to fall back to sleep. Some nice routines that you can think about incorporating, taking a warm bath or shower, doing some gentle stretches. You can read a book or newspaper, just not something that emits light and trying some guided meditations. There's a lot on free content on phones in particular, so not looking, but listening to guided meditation or putting together a playlist of songs that you find to be soothing. Music can be a great tool, calming the body, distracting you from anxious thoughts and preparing the brain for sleep. And specifically, if you pick the same playlist and use that same playlist, it becomes part of the sleep ritual. So now I'm going to move on to social connections. So we all need support. It's a critical part of life and it's a very critical part of our cancer experience. The most important predictor of human happiness and longevity is having strong social connections. There's even been data that shows that health related measures like blood pressure and heart rate can be improved even with short positive social interactions. One of the challenges of cancer is it can be very isolating both physically and emotionally, whether it be because of the treatment sessions. You know, we're all coming out of COVID now, but that was a very isolating period of time, particularly for those who are immunocompromised. And so not being able to go to activities, not being able to participate in group events that were once meaningful could be very challenging for people who are immunocompromised. And I think emotional isolation is also really important to acknowledge. Many cancer patients are having a different experience than their friends and their loved ones, and this may create a feeling of isolation. So finding peer groups that can help share and mitigate that feeling of isolation can be very valuable. And social support is needed throughout the cancer journey, not just when you're diagnosed, but during treatment, after treatment and part of survivorship and also at the end of life. It's important community can, the value of community cannot be underscored more prominently. Social support and laughter can alleviate stress. It's important to have someone to confide in, people to help with decision making and also to decrease the feelings of loneliness and isolation. So some silly things potentially, but that may make you feel good, are just saying a quick hello or nodding, making eye contact with people who you pass. It's a form of connection. Spending time with people, whether it be virtually or from a distance, helping other people too. So very often when individuals are sick, they're being helped by others, but there's a fundamental need in humanity to help others. And so sometimes helping other people, despite the fact that you're sick, whether that be listening to a friend or making a meal for someone else who might be in need, these can actually make you feel better and less isolated. And being supportive, dialing into what the other people in your lives are doing can create foster connection and decrease isolation. Social media has, you know, obviously taken over our world and there are some good things that come out of it. But, you know, there are, there is the concern for increased risk of depression. So be mindful how you use technology to support connections in life. The grass is always greener. People's Facebook or other posts typically are highlight reels of their lives. I think we all know that based on what we post ourselves. So be mindful of that. The truth is most people are probably going through their own struggles too. And so finding those aspects to connect with other people can probably help more. Talking about stress. So I always thought that this was an interesting image and they've done this for other presidents as well. This is the before and after. And yes, eight years passed, but a lot of those gray hairs are from the stress inherent to the job. Stress and fear affect many different parts of our body, whether it be our central nervous system, our autonomic nervous system. So those are things like your heart rate, your blood pressure, and then our muscle system as well. The tension we feel on our muscles, grinding or clenching our jaws. All of these are kind of our fight or flight instincts are exacerbated or stimulated by increased stress. So how do we work against that? Because it is stressful. I think acknowledging the stress is important and then finding things that are specifically helpful to you. We're all different. So mind-body therapies can be helpful to many people. Meditation, yoga, Tai Chi, and prayer. For me, exercise is what works. It relaxes me the most as opposed to something like yoga. But I think it's all an individual process to find what's going to help you. And it may be different on day to day, given where you are. Eating well, and we'll talk about that in a few moments, can also help. Positive emotion, humor, gratitude. All of these things can help to mitigate stress. Social connections and sleep as well. The other thing is to be aware of your stress. Name it, claim it. Know what is causing those stress signals and then take steps to alleviate or eliminate the stressors in your life. I think everybody can learn to have better boundaries. And particularly when you have a cancer diagnosis, it's okay to say no and to do what's best for you so that your overall wellness is the priority. What you think, you become. What you feel, you attract. And what you imagine, you create. These are very wonderful words to be mindful of as you go through your experience in life. Meditation can be a wonderful thing to do and it can take on a variety of forms. We think of some of the more classic meditation styles, but even just a walk in the woods. What I say is protected time, protected daydreaming time. A space that you create, whether it be 10 minutes, an hour, whatever it is, where you allow yourself time to just let your mind be at rest. And we know that this can have valuable effects on the body, including lowering blood pressure and heart rate, improving bowel conditions, the inflammatory responses, or mental health, specifically less anxiety, depression, and can change your brain chemistry. Yoga is a great activity across the spectrum because you can really choose the degree of challenge that you put into it. And so we just have to be careful again if there are any structural considerations, but can really think about that as a time to stretch, improve flexibility, strength, and also get mental relaxation. And so now I'm going to talk about substances because this comes up a lot. All right. So we know that alcohol is a carcinogen and the less you drink, the lower your risk for cancer. So there are six cancers that are associated with alcohol specifically. And this is really true of all types of cancer. So when you drink alcohol, your body breaks it down into a chemical called acetyl aldehyde, which damages your DNA and prevents your body from re-impering the damage. And your DNA is basically architecture, the structural instruction manual that controls your normal cell growth and function. And so that's kind of the hypothesis behind alcohol and cancer. It is okay to drink. It is okay to have a celebratory beverage, but there are recommended limitations to this. So the American Cancer Society recommends that men drink no more than two drinks per day and women no more than one drink per day. And what you see below is an illustration. Not all volumes of alcohol are the same, not all alcohol has the same alcohol content. So being mindful of that and trying to mitigate that. And it's also important within the context of oncology, alcohol can lower your platelet counts. So if you're on medications that are also lowering your platelet counts, this is important just in terms of risk of bleeding and other things. So it's not to say that you can't enjoy an occasional glass of wine, but it is best to know how that interacts with your treatment and have a conversation with your physician and also be mindful of the Cancer Society recommendations. And so, again, as I just said, it's best to check with your health care provider and they may be able to give you treatment specific advice. A topic that comes up very frequently is the use of medical marijuana. And so really there are two parts to the marijuana. There are two chemicals and within the marijuana there's the THC and the CBD. And the reason that we cannot study medical marijuana or marijuana in general is that it's a schedule to drug and so it is not allowed to be studied per our guidelines. There are some countries that have different guidelines around the study of marijuana, but it's not allowed to be studied. And so we do have some studies that come from those populations that showed that marijuana can be helpful in treating nausea and vomiting and we have created other drugs that are similar to those to help with that. And a few studies have shown that marijuana can be helpful for neuropathic pain and they have shown that it can be helpful for the treatment of nausea and vomiting. And so we do have studies that show that marijuana can be helpful for neuropathic pain and that the use of medical marijuana can decrease the amount of pain medication used. But again, we do not have high quality studies in the United States because on a federal level marijuana is not legal. And it's important to note that while most common effects of marijuana is that it can create a feeling of euphoria, that is not for everybody. Some people it can increase feelings of anxiety or paranoia and marijuana delivers THC and other cannabinoids to the body, but it also delivers substances to users. The smoke and inhale to one's lung. And it's also to know what you're taking in because marijuana plants come in different strains with different levels of active compounds that can make each user's experience hard to predict. And so ingested marijuana can also vary based on absorption and other foods depending on the person and what else they've had to eat. And obviously people can develop dependence. So these are all really important factors to consider in the discussion of medical marijuana. There are two chemically pure drugs based on marijuana compounds that have been approved in the US for use, Maranol and Nabalone. And so they are like THC and they are intended to mitigate nausea and vomiting. And so the medical decision making about pain and management should be something you discuss with your doctor and subject to the rules of the state in which you live and apply. And there are specialists who you can engage for consultation to best advise you should you go down this route. And so last I'm going to talk about nutrition. And so we look at what a healthy eating plate looks like. And so you can see that the biggest area on this plate are vegetables. The more the better, the richer in color, the better. Potatoes and french fries do not count as vegetables, unfortunately. Fruits, again, are a great source of nutrition, particularly of varying colors. You see here that the beverage is not a glass of milk, but water, trying to hydrate as well as possible and limit the use of added sugars or sweeteners to beverages. Eating whole grains. So what is a whole grain? It's something that has not been processed. So things that we would try, what are the refined grains are like our white breads, our white rice where they have stripped the color and nutrition from the product. And focusing finally on healthy proteins, trying to limit red meat no more than once per week are the American Cancer Society guidelines, trying to avoid heavily processed foods such as cold cuts, sadly bacon, a favorite food of many. And trying to choose leaner meats like chicken, fish, beans and nuts are a great source of protein as well. And so here are some of the specifically American Institute for Cancer research guidelines. Again, they highlight many of the things I've just mentioned, you know, talking about other processed foods, though, I think is important. So fast foods are usually heavily processed, high in fats and starches and sugars. So really trying to eat as close to the root as you can. I once had a boss back when I was in college working in a restaurant who said if you can't shoot it or pull it out of the ground, it's probably not good for you. And that was back in the 90s a long time ago. But I think that those those words actually ring so true today as we understand more and more the importance of nutrition. And so community support is key to finding people, whether they be in your life or in your community who make the same healthy choices that you do can be so important to help promote your lifestyle changes. Perhaps you're not currently choosing some of these types of foods, and it may be hard if you live in a household, especially one with young children where diets may be varied. But to the extent that you can try to find companionship and community and the choices you make to support improvements in your lifestyle. And, you know, do look at the contents of the beverages that you drink. Really try to avoid added sugars. You can you can definitely try unsweetened seltzers, add mint, lime, lemon, and try to spice up your drinks that way. But really do avoid sugars and also the, you know, the substitutes, sugar substitutes as well. Again, limiting red meat to 12 to eight ounces per week, avoiding the processed foods and replacing red meat with other protein sources. And really, put a priority on adding vegetables. Some people love vegetables, others do not. If you can start small and even just add a limited quantity of something that appeals to you and buy it, you can start small. And if you can't find vegetables, others do not. If you can start small and even just add a limited quantity of something that appeals to you and build it in that way. It's a great way to incorporate vegetables. So things like roasting and vegetables in the oven is very easy in terms of preparation and tastes delicious. So finding ways in which you enjoy eating vegetables and incorporating as many as you possibly can. And focusing on the food quality, again, I touched on this before, but really the whole grains are very important, trying to limit the amount of processed foods we eat. So this is another quote that I like, eat food, not too much, mostly plants from Michael Pollan. All good words that we can live by as we think about all of our nutrition, not just those who have cancer or a precancerous condition. And there's been a lot of appreciation over the past couple years or decades in terms of what a plate should look like. Many of us grew up with the old American plate, meats, potatoes and peas. In fact, that looks just like something I might have had on my own dinner table. We transitioned away from meats, excuse me, from the size of meat to smaller portions. But now what you can see is really a colorful plate replacing potatoes with unprocessed rice and adding in two servings of vegetables and a small quantity of protein. Another tip in terms of eating is trying to be mindful, thinking about why you're eating. Are you hungry? Are you stressed? Are you socializing? So that's the thing to do. Is it because you're tired and you're trying to stay awake at work? Think about food as a gift, give gratitude as you eat it, try and eat without distraction, chewing slowly, thinking about what the food tastes like, gauge your senses. What does it look like? What does it smell like? How does it make you feel after you eat it? Think about, be conscious of what you're consuming and when you're consuming it and the way in which you're consuming it. You know, trying to give yourself a serving versus eating out of a bag can limit what you're doing and make you aware of the quantity of food that you're consuming. And thinking about the timing of your meals, how might the timing so There are differences in when we consume food and so there was one study that showed that lean women were randomized to eating early versus eating late and those women who ate later in the day found to have metabolic alterations that were detrimental. So trying to think about the timing, not eating too close to your bedtime. There have been data that show that prolonged overnight fasting greater than 13 hours may improve metabolic health. And finally, one of the things that I'm particularly interested in is the role of the gut microbiome, the bacteria that line our GI track in our health and overall wellness and it's been demonstrated that having a diverse microbiota or bacterial diversity is good for your general health. And so I'll talk a little bit about some of the interventions that we're thinking about in in pre-cancerous conditions, angus and smoldering where therapies drugs are not recommended but are there things that we can study and learn and do for people who have precursor disease that may limit the risk of progression. And so one study that we have is a 13 to 14 hour overnight fasting study for our patients. This is randomized for prolonged overnight fasting versus an educational control. That study is currently ongoing at Dana Farber. We are also very interested in the gut microbiome and there are growing evidence in terms of the microbiome and human cancers. And so this is something that we are actively studying and anybody who wants to participate can be part of our P crowd and we'll send you a kit for free. It's a one time sampling. And what we know is that there are certain bacteria that have there have been very few studies thus far that have been associated but there are certain bacteria that have been associated with progression looking at patients from precursor disease. And why this is particularly interesting is if we can understand this and we can potentially intervene and come up with specific recommendations or potentially probiotics that may alter the course of disease progression. And so we're collecting samples on 100 patients with angus, smoldering myeloma and 50% of patients with angus. We're also studying the microbiome in response to immunotherapies. So at Dana Farber we have clinical trials of the by specific agent, clistococcal, and we're also studying the microbiome in response to immunotherapies. And so we're collecting samples on 100 patients with angus, smoldering myeloma and 50% with multiple myeloma, sequencing the genome of the bacteria and comparing that with the immune signatures, the T cell repertoire of patients who have each of these different phases of disease. We're also studying the microbiome in response to immunotherapies. So at Dana Farber we have clinical trials of the by specific agent, clistomab and cilticell for patients with high risk smoldering. And these are both approved drugs for myeloma. And so we're looking at the microbiome in terms of disease response. Again, potentially you can if you there are data from other cancers, specifically lymphoma that showed that the microbiome may be involved in response to immunotherapies. And what is exciting about this is this is something that we can potentially transform or improve just by diet alone. We also have a randomized study of netformin, which was historically approved for type two diabetes and has been shown to have some activity and prevention of cancer progression and other cancers. So we are studying it in angus and smoldering as well. And so some of the eligibility criteria for people who might be interested is having high risk mGus as defined by an m protein of 1.5 to 3, an abnormal free light chain ratio or IgA type protein or low risk smoldering. And this is again a randomized study as well. And so I've come to the end. I'm a little over my time. I just want to thank our team here at Dana Farber and the health tree team for inviting me to participate and to all of our patients who for whom we're so passionate and really think about these types of considerations and really trying to make the experience of going through a plasma cell disorder as good as we can possibly make it. Thank you. Thank you. Thank you for this presentation. As we have like a hard stop I'll just read some of the questions, so we can try to get to some of them right so. We have a question, any evidence for benefit of one hour of moderate exercise versus 30 minutes of vigorous exercise. So it's a great question. The recommendation comes down at 45 minutes. I don't know that those two have specifically been compared and definitely I don't think that they've specifically been compared within multiple myeloma. If you can tolerate an hour of vigorous activity then there's no restriction to doing so. But again, the literature is very limited and specifically limited within multiple myeloma. I wrote a review article now it's about four years ago on lifestyle considerations by each of these pillars and it was it's pretty remarkable how limited are high quality evidence is for this. Thank you. The computer monitors give off blue light or is on the cell phones, and they ask if also the computer, the television. Yeah, so I think they all do the one that we're, you know, most dialed into is is the phone and so there are even these little glasses that you can wear blue light glasses. You can buy them at CVS, and they can limit that. And so but that type of light is. Okay, perfect. Any tips to regain desire to eat and drink. Yeah, so it's hard and it really depends on the type of treatment sometimes let's say you've had a transplant. You know the that melphalan is designed to kill rapidly dividing cells and so some of the rapidly dividing cells are those that can line our oral mucosa and our GI tract. And so sometimes it's a matter of time till you fully recover from the side effects of a therapy like that, and the nausea, but there are medications that doctors can prescribe. There are low dose steroids something called Megase Remeron or Mirtazapine can be useful so there are some medications that your doctor might have in their armamentarium. And, you know, also, trying to find the types of foods that appeal to you and allowing yourself the freedom to eat what appeals to you is okay to do too if you're having a metallic taste as a result of a therapy you can also try using plastic utensils, which may help that Thank you. That's a great tip. Um, I see one about beer, it says, I can drink beer, but what about non alcoholic beers and winers are they equally damaging compared to regular alcoholic beverages. No, so the non alcohol ones don't have that acetyl aldehyde. So, you know, to the extent of my knowledge I think it is, you know, it's the alcohol itself. That's the carcinogen. And so the there's a whole industry now of non alcoholic beverages that is cropping up you see at the grocery store. But again, they don't contain the, the toxin so they should be okay. Perfect. Thank you. No bone lesions but three compression fractures on my spine. Who would someone go to, who would someone go to find out what is safe to do spine MD or neuro MD. I think they're fine. And it depends what your program has and then I would go to a physical therapist for that. So if you've had that's a great example and a very common one in the my little community. So that's an example of where you would talk to your spine doctor and then have them refer you to a specific physical therapist, who can work with you. Okay, perfect. Thank you. Are all of the genes such as a show on them. I think milky seeds, she's she's Sandra Barry, holy basil oats recommended for him goes patients for anxiety stress or sleep. I'd have to say I'm not familiar with a lot of those those haven't been studied. And so supplement conversations come up very often. And, you know, so some important things to understand about supplements. So when we give you a drug for the treatment of your myeloma, that's gone through rigorous study and has met the standards of the FDA for approval. And so whatever is labeled on that bottle or that vial is what's inside. We don't always know what the contents of a supplement are and they haven't been studied in terms of the correct dosing. Not only that we don't know how they interact with this important therapies are on and I'll give you a good example. So if you're on a drug called Velcade, green tea interacts and limits the efficacy of Velcade. So hopefully if you're on that medicine, someone has told you not to drink green tea when you're on it. And so it is very hard, you know, to know how each of these that is not FDA approved what mechanism it's digested through your system and how that interacts. So if your team has a pharmacist, it is fine to ask them, ask them these types of questions, but there may not be available data. Okay, yeah, I think we had an event about this I'll try to find it and add it to the resources on the follow up email so we can check what we have. I see a question. How do you feel about feeding the microbiome with with probiotics, especially after chemo drugs? Probably. Yeah, so we don't have good data. I'm very interested in this. I think it's a really important question. And, you know, so there are probiotics that are available and especially if you're having difficulties with digestion. If you've been on antibiotics. I don't think it is wrong to do probiotics. Are there specific probiotics that are better for your microbiome after these I don't know the answer to that. But I think this is a really important question and something that is a very active area within myeloma research. Okay, perfect. They're asking how can we sign up for the clinical trials, and where can they find the link regarding that those trials. Yeah, so those those are all at Dana Farber. You can they're available on our website and say clinical trials, peak route, and we can get you those in for that information. I'm sure if we can provide that. Okay, perfect. Thank you. What can we do to promote our microbiome as well protein is talked about a lot as needed for aging and muscle loss. There are sources of outside of red meat outside of red meat so fish, fish is a great one. Chicken, beans and nuts. So all of those are great sources of protein to choose from. And then in terms of microbiome. So the goal is to have a diverse microbiome so if you're always eating the same foods from the same sources, then you have the same type of bacteria, and what you actually want is diverse bacteria so having a broad diet and particularly one rich in fruits and vegetables will broaden the diversity of the microbiome. And that will broaden the diversity of the flora or the bacteria that you have in your gut which is felt to be beneficial. Yeah, thank you. Yeah, I think that's one of the main problems right we the same every day. Exactly. Yeah, I see some comments on plant based food or vegan food and do you have an opinion about multiple myeloma and that type of diet. I think having, you know, having a plant based diet is advisable for anybody having a vegan or exclusively vegetarian diet. We don't know what of my colleagues or be shot at MSK and Memorial so I'm cutting is interested in this question and has been studying vegetarian diet as an intervention. I think that we need to, I think it's great that people are getting interested and taking the same type of academic rigor that we do for our drugs into, you know, the content of our food. So I think that that is an interesting on a population basis. I think there have been very mixed data about vegetarianism and risk of m guess and progression to multiple myeloma so some suggestion but all retrospective and cohort studies. So, um, I think it's, we know, as a general thing that a plant based diet is better for you but specifically, I would say that there's limited data, but that we are actively looking at that question. Perfect. Thank you. An early dinner, say, five p.m. and nothing overnight is this consider a fasting. Yes, that's, that's time restricted eating and that's advisable so that's what one of those studies is. And that's also there are recommendations not just from a cancer perspective because that's actively being studied there have been benefits demonstrated and breast cancer for example for prolonged overnight fasting or time restricted eating. We're studying it right now and precursor disease but cardiovascular health there have been demonstrated benefits in the past. Things like blood sugar control are better. It's been demonstrated. Perfect. Are there concerns for vegetables with lectins, I think, increasing progression for smaller myeloma in a plant based diet. Don't data for that that's a really interesting question I don't know the answer to that. Okay, thank you. The sugar feed cancer cells. Yeah, that's a, you know, really important question. I mean, we have to have a certain amount of can't have sugar in our system, you know, and so the type of sugar that we consume matters the additive sugars that we consume matter, I mean, everything body grows through taking in some type of calorie or the most common form sugar. And so it's, it's, you know, advisable it's not that the cancer is being fed by the sugar because we have it is it is taking resources from your body to feed itself. But additive sugar in your diet is generally not good for you and there's a complex myriad of ways in which too much sugar can affect your metabolism, your blood sugar levels the insulin pathways and cell growth pathways. It's a little bit of a complicated answer. I think the bottom line is, you know, trying to limit excess sugars is generally good for your health. Yeah, thank you. I think we also had an event about that but it's a really interesting question. Yeah. I think you can take one last one. What do you think? Sure. Okay, perfect. Any lifestyle techniques to reduce peripheral neuropathy. Yeah, and so that's a challenge and can be a challenge if depends on the extent of your peripheral neuropathy in terms of balance and exercise. So, um, you know, it depends on the extent of your peripheral neuropathy. And then, you know, are there techniques such as massage or cocoa butter or things you hear all these anecdotes and that there are lots of different medicines that you can try to try and help with peripheral neuropathy. And so it can be a benefit worth trying, but the very specific in terms of the type of sensory or motor neuropathy as well. Thank you. So the last one it says, can nutrition habits reduce the likelihood of multiple myeloma coming out of remission. So it's so great question we do not know the answer to that these are all things that I think need to be studied. So, what I can tell you in other cancers. So, and each cancer is different and the things that drive these cancers are different. We know that obesity is a risk factor for the development of multiple myeloma. So that is something we've known that's a New England Journal of Medicine paper. In other cancers that are obesity associated such as breast cancer, exercise, weight loss can lower the risk of disease recurrence by up to 50%. Actually, if we look at the AC, if you just meet the ACM guidelines, but that's a cancer where we very well understand that fat causes peripheral conversion of estrogen estrogen stimulates cancer, so we don't know the mechanism yet of which by which obesity stimulates progression of myeloma. But presumably if we improve our lifetime, then that will be a risk reducing strategy that we see in other cancers to like breast cancer and colon cancer which I didn't go into but also show similar benefit. Thank you. That's really interesting. Well, I know we have just a few minutes more so do you have any closing remarks or any comments you want to share with the group before you leave. I think it's so great. Thank you so much for coming and listening to this. This is a passion of mine. And my closing thought is that we need more research in this area within multiple myeloma so that I can get on the screen and give you answers based on evidence, just like we try to do for everything else in your myeloma care. And so there is a growing awareness where we are now compared to where we were five years ago and way more than where we were 10 years ago. And I think my only plea to anybody listening is to ask your doctors these questions and encourage them to engage in this so that the physicians recognize the importance of this so that the type of research that we need to give you the best information will become available over time. Yeah, thank you so much. Thanks for your time so I'll share my screen again to give some outro announcements but thank you for being here and answering all these questions. Thank you. Have a great day. For everyone here. I'll just give some announcements in the pictures updated. Our next meeting will be in July and it will be about fitness, not nutrition, it will be a topic, the topic will be shared yoga maybe so as soon as we have the information will send you the link to register. And we have two upcoming events, we have one next Thursday for the black myeloma community about CAR T therapy for treating relax refractory myeloma in the black myeloma community. And on April 11 will have the newly diagnosed myeloma group, and the topic will be diagnosed with high risk myeloma. What now, the link to sign for this events and others we have it's at the bottom of the screen and it will be sent out with all the slides in the, in the In the follow up email. I want to remind you we have a little survey at the end. It takes two minutes to answer it's like three questions so if you can take this survey and give us your suggestions for future topics or formats or whatever you you want to see here in this events please take the survey we we highly appreciate that. And another thank you to our sponsors, Regeneron, Sanofi, Johnson and Johnson, GSK and BMS. And thank you all for being here as part of this community. Hope you have a great rest of your day. Bye bye.