(Guest Lecture) February 2021 Modifiable risk factors that affect Myeloma Pt. 2

Hello everyone and welcome to the second session of Modifiable Risk Factors for Myeloma. We're excited to have you here and appreciate you sharing this virtual time with us. I'm going to go ahead and share some slides with you today. Let's see. For those that are new to this chapter, my name is Audrey Burton Bethke and I am the Myeloma Community Director. Today, as I said, we will be discussing Modifiable Risk Factors that affect myeloma. This is part two in Dr. Urvishal's series. We're so excited to have her with us today. We get to hear from her again. Her knowledge, her explanations are so clear and so just exciting. New information. And I will introduce her a little more formally later after a couple of announcements. This meeting will be recorded 24 to 48 hours after the event's completion. You will receive an email with the recording and the slides and some other resources that we have for you. All registrants will receive that email. We would like to thank our sponsors, AbbVie, Bristol-Meyer Squibb, Amgen Oncology, Genetech, CarioFarm Therapeutics, OncoPeptides, Adaptive Biotechnologies, and Takeda Oncology. Now I would like to introduce to you our speaker, Dr. Urvishal. She is faculty on the Myeloma Service Division of Hematologic Malignancies. Someday I'm going to learn how to pronounce that. Memorial Sloan Kettering Cancer Center, or MSK. Her research focuses on studying the role of diet, microbiome, and other lifestyle-related risk factors in plasma cell disorders, as well as identifying interventions to improve outcomes for these patients. She also studies immune therapies, including the new and upcoming CAR T cell therapies for myeloma. Being a lymphoma survivor herself, she is passionate about helping patients make wise nutritional and lifestyle choices as they face a plasma cell disorder diagnosis, as well as raising awareness about healthy choices to prevent cancer. Dr. Shah and I were talking right before this event, and we were just saying how wonderful it is to be able to participate in something so groundbreaking. The most common question we hear is what kind of nutrition is going to benefit me most as a myeloma patient, or even as a myeloma caregiver. And we're excited to not only have starting research, but to be able to participate in and, you know, develop studies that help us really find the answers to these questions. Dr. Shah will be focusing today on diet and supplements. This event is going to last for 90 minutes. Dr. Shah is going to present her information for 60 minutes, and then we plan to leave at least 30 minutes for you to ask your questions. If you have questions throughout her presentation, feel free to put them in the question and answer section, but we will not be answering any until the end of Dr. Shah's presentation. At this time, Dr. Shah, I'd like to turn the time over to you. Thank you, Audrey. I'm really excited to talk to all of you about this topic. In my practice, when I see patients, this is one very, very important question that comes up. And unfortunately, as I have progressed from being a resident and a fellow and a med student, I've always seen this question kind of dismissed or not answered clearly, and every patient still asks this question. So it's not like something that, you know, we should be ignoring anymore. And that's part of the reason why I would like to focus on it. I do think also that there is a lot of information out there about, you know, obesity and diet and cardiovascular disease and diet, but we don't have that much information about cancer and diet. Or even if there is information, it's not really shared that often with patients as it is with cardiovascular diseases and other disorders. So just to move forward. Sorry, this slide. Yeah, so I'll start with diet and then I'll talk about supplements, a little bit about vitamin D, turmeric, since those are quite often I see patients taking them. And then thank you for all of you who filled out the survey. I just wanted to give you a summary about that. About 88% of those who filled out the survey, we had like about 200 who responded, had questions about diet, nutrition since their diagnosis, and only 10% of those 88% felt that their questions were addressed by their oncologist. So it is a really small number and we need to do better. So I just wanted to start with this really big study that looked at health effects of dietary risks in 195 countries. So what you do see in 2017, they say approximately 11 million deaths were attributed to dietary risk factors. And what you can see here is, you know, the neoplasms or cancer is the one which is in this pink color. So you can see that there are a lot of, because it's also harder to attribute cancer to diet because it takes many years. And in this case, they're probably going to be on the conservative side and attribute the ones that they're very clearly sure about. But irrespective of that, you do see that there is a role here for diet and a lot of deaths that could be prevented. I showed this slide last time, but I just wanted to quickly mention it again, in case some of you were not present for the last talk. But as you can see, it's not uncommon for me to have patients like this, and many of them, and it's very hard to treat them. And I do think that there is a role, even if it's not for cancer, for the prevention of other diseases which contribute to the outcomes in cancer. And I've marked it in the slide, but I do think that there is a role for diet and for the prevention of other diseases which contribute to the outcomes in cancer. And I do think that there is a role, even if it's not for cancer, for the prevention of other diseases which contribute to the outcomes in cancer. And I've marked in green the ones that I think could definitely have been avoided or improved if a patient had long-term improved lifestyle and diet probably. So this study, again, shows you, you know, these are, I'm going to show you three large studies that basically looked at big populations and said who had less cancer. And what this study was, was in the British population, and they looked at 61,000 people, and they found that patients, people, healthy people who ate less meat and animal-based products and more fiber, tended to actually have less cancer. And they did look at myeloma, although the number of cases are really small, but, you know, myeloma is a rare disease, so we're not going to find really big studies with thousands just yet for dietary factors. So what you can see is that those who ate this way had less myeloma compared to those, and this would be a 77% reduction in the risk. This is the Adventist Health Study, which is based in the US, and what you can again see here is that those who ate predominantly plant-based diets had about 16% less cancer. So very similar to large studies. This is the third study from France, so I showed you one from the UK, one from the US, and this one from France. And what it is showing is that they didn't look at what meals, like, didn't categorize patients into like meat eater, fish eater, vegetarian vegan, but they categorized them into how much plant-based foods are they eating and not eating. And they derived a score from that and said that if you eat more plant-based foods, your score will be higher, and if you eat less plant-based food, your score is lower. And what they showed is that those who had a higher score, meaning eating more plant-based foods, had less cancer overall. This study didn't look at myeloma specifically, so I don't have that information to share with you. Now these are a few myeloma-specific large studies that we have that looked at. What they did is, you can see it's a very big study, over 116,000 women and 50,000 approximately men. There were about 423 myeloma patients and 295 myeloma-related deaths and 345 total deaths. So 295 out of these 423, they I think attributed to myeloma and 345 to other reasons. And what they show here is that those who had healthy eating patterns, so this is an index, like again a scoring system where they say if you eat certain foods, then it's a healthier diet. The Mediterranean diet, the DASH diet, and the Prudin diet, all of these are diets that are associated with, all of these are diets that are associated with decreased death due to myeloma. And the Western diet, inflammatory diets, have an increased risk of death due to myeloma. And associations for death were due to any cause were similar to myeloma-related deaths. So it's not just myeloma, but it's also other deaths that they are seeing are associated with this. This was another study which looked at a very similar population, but looked at it in a sort of different way, and they tried to look again to see are these dietary patterns associated with risk of developing myeloma. So that was associated with deaths. This was associated with risk of developing myeloma. And what they said is that these patients had no increased risk, but there was a suggestive increased risk or an increased risk for these patterns of diets. And this is a summary slide that I've shown you last time that I've created based on all the microbiome data. I just wanted to put it out here again to say that, you know, the microbiome changes that we have seen in myeloma and plasma cell disorders, very early studies, few patients shows increase in nitrogen producers, decrease in short-chain fatty acid producers, and decreased diversity. All of this we've talked about might have potential mechanisms through the butyrates especially and increased bile acids causing improved outcomes, mechanisms by which it would improve outcomes. So the decreased butyrates is bad and increased butyrates is good. So increased butyrates would increase MRV negativity or decrease myeloma based on those studies. So now I'm going to go into specific food components and studies related to that. I think it's helpful because patients always ask, should I eat this or should I eat that? So I'm looking at studies that have given this information. So this is specifically fruit and vegetable intake. And this was again a massive study with 14 other studies that they combined the data from and looked and said, who has less cancer? And they said that those who ate, so you can see that as you eat more fruits, these are the servings of fruits, and this is the relative risk. So add fruits and vegetables. So as they ate more fruits and vegetables, their risk dropped. And then beyond appointed plateau because how much effect could be. But at the optimal based on this study would be seven and a half servings per day. And the USDA recommends five to nine servings. So not very different than what this study is recommending for patients to prevent cancer. Now these are specific myeloma specific studies, but you have to again, they're smaller numbers, fewer patients. And what these studies looked at is, does consumption of fruit reduce the risk for developing MGUS, meaning the precursor to myeloma? And does it reduce the risk for MGUS to become myeloma? And what you do see is that any number less than one means it is decreased risk. So here it's when an odds ratio of 62, meaning 6.62, it's almost a 38% reduced risk. Here it's almost a 76% reduced risk of death for hazard ratio. And as long as these numbers don't cross one, it is statistically significant. So it's not crossing one, both of these numbers and nor is this. And so based on these two studies, they said that those who ate, and this is not much, you know, it's only three times per week we're talking about, but it's surprising how few people even make it an effort to think about, you know, including it three times a week in their diets. And the previous study was seven and a half servings per day. So we're talking about very small numbers here, but still, you know, there is a benefit with even a little bit. Vegetable rich diets, what they looked at, and again, this was another study, very small study, only 100 controls and 100 myeloma patients. They said there's a 60% reduction. Here there's a 50% reduction with cruciferous vegetables, more than two times per week. So what you can see here is, again, plant based foods, fruits and vegetables are reducing the risk. Another thing to think about is how many types of plant foods per week do you eat? So what's the diversity in your diet? And the reason I bring that up is based on the talk from last time where we showed that microbiome diversity is based on the diversity of the foods you eat. And the authors of that paper felt like more than 30 types of plant foods per day is associated with better diversity. So it would have been a good exercise to do after this talk to think about how many different plant foods in a week you eat. So what about carbohydrates? Everybody says carbs are bad, that's sugar, that feeds cancer, those are some of the questions that are commonly asked. But there is a major difference between carbohydrates and refined foods. And you can see that the fat is going to be different because these are fried and the quality of the nutrition changes significantly. So potato fries are not the same thing. And you can see that the fat is going to be different because these are fried and the quality of the nutrition changes significantly. So potatoes aren't bad, but french fries are and that's the difference. So I want to bring your attention to this concept of nutrient density and calorie density. So we don't think about this often and we just think about oh, this is too many calories and this is too little calories, but we're not thinking about the calories. So nutrient dense foods are foods which are high in nutrients, low in calories, high in fiber and vitamins, minerals, antioxidants. And most of those high fiber foods that are low in calories are going to be our plant foods. And so you can just see here, I'm talking about the same amount, one ounce of broccoli and one ounce of chips. And you can see this is 10 calories versus this is 150 calories. The sodium is much lower, the sodium is almost the same as the protein. So even though it's the same amount, the nutrient profiles of these two foods are obviously very different. The processed foods are much higher in the protein, the protein is much higher in the protein, the protein is much higher in the protein. So the calcium here is higher in the broccoli, the potassium is higher. So even though it's the same amount, the nutrient profiles of these two foods are obviously very different. The processed foods tend to be very calorie dense. And so even though you might be eating a small amount, you can meet your calorie requirement and surpass it very quickly and with calorie dense foods. It's almost like being overfed and undernourished. So you're getting too many calories, but you're not getting enough nutrients. And we tend not to think about nutrients often and we focus more on just the macronutrients and we think about, oh, am I getting enough nutrients? We think about, oh, am I getting my carbs and where's my protein and where's my fat? And we need to stop thinking about those as much as we need to think about where are we also getting our micronutrients from? And so thinking about fruits and veggies, the question on everybody's minds is always like, what about organic? What about the pesticides? Is this going to be a risk for me and should I, that's why, reduce my consumption of plant-based foods? And so I wanted to, you know, I found this website that I think is interesting where you can put in a specific fruit or vegetable and whether it's a male or a female and then look at the risk even if it's the highest pesticide residue recorded by the USDA. So here they show you that the risk for, you know, having side effects or even developing toxicity from it, we would have to have over a thousand servings of spinach to have toxicity in a day. And that's really not possible for anybody to do. So, you know, even though these are long-term risks or might be there, it is a very, very tiny risk compared to the benefits that you will see. So this is, you know, just some more from that website where you can see that, you know, these are all different fruits for women and men. And I just put it here so you can see how many servings you would need per day to basically have toxicity from these foods. So that website is based on this study, which I thought was interesting. They looked at the fruit and vegetable consumption of the U.S. population. And then they looked at the pesticide residues on these fruits and vegetables and said, if they increase fruit and vegetable consumption, how much cancer would they reduce? And if they increase fruit and vegetable consumption, how much more likely are they to have cancer because of the pesticides from it? And so what they did find is that if one half of the U.S. population were to increase fruit and vegetable consumption by one serving per day, not much, an estimated 20,000 cases might be avoided each year. And then in contrast, the pesticide residues on those fruits and vegetables might result in up to 10 additional cancer cases per year for that one serving per day excess. So yes, I'm not saying that pesticides don't cause cancer. And there are studies within myeloma and MGUS2 showing that it's beyond the scope of today's discussion for me to bring it up. But I just wanted to say that you shouldn't be afraid of eating fruits and vegetables because you're afraid of the risk from the pesticides. This study looked at, you know, was a large French study and said that organic food decreased cancer risk. And they showed that, you know, those who ate the most organic food had a 25% reduction. So, you know, this is not crossing one and 0.75. Hazard ratio means a 25% reduction in death. But you also have to understand that some of these studies might be confounded by the fact that patients who are buying organic food are already thinking about their health or being healthy. So it's a little bit harder to sometimes, you know, tease out what the effect of what is. But I think that if you really want to go that extra step and consider organic foods, that's okay. But if you don't have the funds to do it, I think you should still eat conventional foods and not worry about the organic because organic doesn't mean it has no pesticides inside. It's just that it can use a little bit lower levels of it. And there is something called a dirty dozen, which you can Google. It's by the environmental working group where they come out with this list of the 12 foods every year that have the highest pesticide contamination. And so strawberry makes that list. Spinach makes that list. And so if you wanted to say that I only want to eat some organic food, you can actually pick those 12 and think about it. But really, I don't think you should. If you go to a supermarket and can't find the organic version of it, I would still recommend eating it than not eating it. So this study is looking at whole grains. And again, like I told you, carbs have got a bad reputation, but not all carbs are the same. So we need to think about that. And so does whole grain intake reduce the odds of myeloma? And what you can see here again, a small study, but it whole grains more than three days per week reduce the risk by 40 to 50 percent. 0.6 is 40 percent and 0.5 is 50 percent reduction. And then they also another study looked at does whole grain intake reduce the odds of development of Angus? And they showed that more than five times a week reduce the risk by 25 percent. So the recommended daily intake for whole grains is about 90 grams, about three servings of whole grains. I think very few people actually meet these requirements because most of us are used to eating white rice, white bread, wheat bread, which may not be whole grain bread. So we're really not getting the whole grains. And then we're blaming it on all the carbs. So this is what I wanted to explain to you. Whole grains are more than just fiber. They're more than just carbs. They have a lot of other nutrient components that we don't think about vitamins, zinc, selenium, copper, antioxidants. These have anti-cancer properties. They bind cancer carcinogens. They regulate your blood sugar levels and they reduce chronic inflammation. So this figure here is a nice explanation of what a whole grain is and a refined grain. So you have the endosperm and the germ, which is inside. A whole grain has all of these three components, whereas the refined grain basically doesn't have a bran or the outer layer, which is the layer that's filled with the vitamins and minerals. So my suggestion would be switching from white rice to brown rice, red rice, black rice, any other rice, but white rice. Same thing with other grains. Buy whole grain, multi-grain breads if you're eating bread. Thinking about switching and diversity in the grains that you eat. So finding millet, finding buckwheat, whatever works for you, but switch it up. Don't eat the same thing. So I think a lot of our problems as a population is also that we don't have diversity in our foods. We've gotten used to a particular food and then we just end up eating it all the time. Like all of us, you know, the one grain we eat is wheat. The one fruit we might pick would be our favorite. Suppose it's banana or whatever your favorite is, and the one vegetable might be broccoli or whatever it is. But that diversity and pushing yourself out of your comfort zone to eat the different fruits and vegetables and grains I think is important. Same thing with beans. Everybody eats black beans, but there are hundreds of other beans. So think about, you know, buying those as well. So how does fiber prevent cancer? And there are many mechanisms. I've tried to summarize it in this slide where I'm showing you each different line and color is a different mechanism. So increase fiber and remember fiber only comes from plant-based foods. You're not going to get fiber in any animal foods, not even dairy and not even eggs. So fiber binds estrogen in the colon and decreases estrogen levels. Estrogen is associated not so much with myeloma, but could be, but with other hormone dependent cancers. Fiber also decreases blood sugar peaks, so it makes a more steady sugar, blood sugar levels, and this reduces insulin resistance, reduces IGF levels. Fiber also alter the microbiome and diversity, and this is what I had talked to you about at the last talk, and this increases carbohydrate fermenters and butyrate producers, thus increasing short chain fatty acids and decreasing proliferative effects, inflammatory effects, and also decreasing endotoxins and improving the intestinal integrity. Fiber is bulk. Bulk means there is decreased time that the food sits in the colon. That's intestinal transit time. And as the food moves through our bodies faster, there's less time for it to become old and sit there and be close to the colon wall and read to changes in the colon mucosa. So actually having regular daily bowel movements than being constipated improves, and that's why we say, you know, have fiber and things. So a lot of people will take fiber supplements. But again, like I said, fiber supplements, yes, you can do that if you're not going to eat fiber any other way, and that's probably better. But if you're willing to switch your diet or at least improve the content of the foods that have fiber, then that's better because, you know, different bacteria feed on different fiber, and so you're improving the diversity as well. The increased fiber means you absorb less fat and you have less of these bile acids, which have also been associated with increased risk of cancer. So what's the recommended daily intake of fiber? About 30 grams from food sources. I'm not talking about, you know, fiber supplements or Sena. But the fiber gap, so 67% of the population believes that they meet their fiber needs, and in reality, only 5% do so. So what we're talking about is 95% of the population is really not even getting enough fiber, and you saw all the mechanisms I talked about in terms of why it's important. I'll actually go through a scenario of different foods and show you how you can meet the fiber requirement later in the talk. So this is not a myeloma specific study, but I thought it was very interesting, and that's why I'm showing it to you. So what this study did is they took African Americans and rural Africans, and they assumed that because they're of the same racial background, they would have similar genetic factors, and then they looked mainly at the diet based on that. And so the 20 African Americans were basically given a two week diet, which was same as the 20 rural Africans. So the 20 African Americans got a native African Western, native African diet, and the African Americans got the Western diet, sorry, the African American got the native African diet, and the rural Africans got the two week diet. And the rural Africans got the Western diet, so a very high in fat and animal products and things. So they, and the African Americans got the high fiber good diet. And what they're showing here is they did biopsies of the colon because your colon mucosa actually, you know, the cells divide quickly so it's easy to see changes quickly. So they put a device placed to look at dietary changes. And we know based on you know colon cancer is affected by diet and everything. So what they saw is one and when they did the colonoscopy, they found polyps in the African Americans where they didn't find them in the rural Africans. So they found that you can see the marker Ki 67 written here. It's a marker of tumor proliferation or cell proliferative capacity meaning how quickly a cell divides, and more brown means more of that marker. So having more marker means your cells are more quickly dividing and in cancer, this marker is almost always elevated, and it correlates with how aggressive a cancer is so a very aggressive cancer might have a very high level of this. So what you can see here is this is the baseline colon biopsy you can see a lot of brown here, and this is the Ki 67. And then after two weeks of only two weeks of this African diet, you can see that Ki 67 went down. And this was statistically significant. The Africans, the rural Africans who had two weeks of the American diet, you can see that they had an increase in the proliferative capacity of their cells. And here what you're seeing is there are also immune changes, which in relation to the diet. So it's not just proliferative capacity of cells, but the immune changes. And then they also looked at microbiome changes and they showed that as well. So the study showed changes in cells, changes in immune profile and in the microbiome. And in the microbiome you can see that the native Africans on the Western diet had a decrease in butyrate producers. This is the native Africans on Western diet. The African Americans on the rural African diet had an increase in butyrate producers and I told you those are better decreased risk of cancer and have better outcomes generally with the short chain fatty acids. And these are the bad bacteria, the bile acid contributors and they saw the exact opposite. So very interesting study, not in myeloma, but gives you a picture of what could be. Now this is I thought I'll talk a little bit on meat. We don't have much data with myeloma again, but overall with cancer, I wanted to share a few papers that have looked at this. And this was looking at carcinogenicity of consumption of red and processed meat. This was a big study by the International Agency for Research on Cancer where 22 scientists and experts met in France to evaluate this carcinogenicity effect of red meat and cancer, the cancer causing effect of this. And what they decided based on this is that the largest body of epidemiologic data concern colon cancer. So most of it is related to colon cancer, but there might be some related to cancer of the stomach and other things. But overall, they basically after this, they said that red meat and processed meat are carcinogens. So these were their recommendations where group one means it certainly causes cancer, group two is it probably causes cancer, and group four probably not a cause. So they classified processed meats as a group one carcinogen and red meats as a group two way carcinogen, which probably causes. So processed meats, even this is a relative risk, so it's not an absolute risk. So it's a smaller number in terms of a day to day life of how it would affect you. But you can think about 50 grams a day or one serving a day, like when 18% increase in colorectal cancer versus red meat, which led to a 17% increase risk. So the next question, the next idea I want to show you was again very similar, really looked at relative risk or risk of cancer based on the number of servings of different, you know, processed meat and red meat. And what you again see is that there, every, it's all about one so there is an increase in relative risk. I don't have data for myeloma in this study. This is just an association, I want you to know this is not causation, it could have many confounding factors but this has been proposed in many papers where they look at the incidence, each dot is one country, and they plot all the countries based on how much meat per day the population consumes, and the number of cancer cases, and then they look at who has more, you know, is there a correlation, and you can see there's a pretty good correlation, those that consume more meat have more breast cancer. So this one was for breast cancer, not for myeloma. So, these are some of the mechanisms that are linked to meat and cancer where the heme iron, lipid oxidation products, the aromatic amines, nitroso-combined advanced glycation end products, and the main thing I think is the no fiber altered gut microbiome could be affecting. So these are two studies I found for myeloma specifically and here you see that, I explained this to you last time, but anything less than one means decreased risk, anything more than one is increased risk, if it crosses one means it's not statistically significant. So here we have multiple myeloma, it is suggestive of an increased risk but it crosses one, but you know your condition myeloma is rare, so the number of patients are few, so that's why this whole line means the confidence intervals, and the way that statisticians can state with confidence is not very much there because there are too few cases, but the average lies on the increased risk side. This was a study on foods of animal origin and risk of myeloma, they looked at lymphoma as well but I'm just focusing on myeloma, the risk with lymphoma was a little stronger than the risk with myeloma. What they said is that fish and seafood had a reduced risk, but there was a trend to an increased risk with red and processed meat, you know more than one I said is a trend, but because it crosses one, these numbers, it's not statistically significant. So this is protein, animal source or plant source, is it the same should you consider what type of protein you eat or does it not matter because like I showed you carbohydrates, it matters what type of carbohydrate you eat, I think for protein it also matters what type of protein you eat. So this study is basically showing you that it showed higher intake of animal protein was positively associated with higher mortality, but the inverse proof for higher intake of plant protein especially among individuals with at least one lifestyle risk factor. Again, decreased risk if it crosses this line, there is none of them were on this side of the line if you see, which if it was on this side of the line it would favor animal protein but you don't see that every study favors plant protein, every food group favors plant protein as the reduced risk. So I thought this was an interesting study again not related to myeloma but I wanted to share it with you because it was published. So what they looked at was, what about you know all these new plant based foods that have come out here you have Beyond Meat and Impossible Foods and things, and people who eat, and they try to match or mimic animal based products right so they made these plant products which are beef crumbles and breakfast sausage and Italian sausage and things but these are not with any animal products, but they have they're made with you know plant products. The issue with it is it's all very new we don't have long term data with you know these new plant based products and they are processed they are made with a lot of other ingredients than just the plant foods so I don't specifically recommend them but I wanted to show you this in terms of comparing what's better between the two of them. So what they did is they had two eight week phases about two months on a on a plant based diet which had these processed foods that mimic animal foods but they are plant foods, and then you had the animal based food which is the regular beef, pork and sausages and you know chicken and all of that. There are 18 patients in each group, and these are the you know carbohydrate protein fat content of each of these products. And what you can see is they're about similar for the most part the protein content, not very different. The carbohydrate can can maybe a little more here because these have some plant foods so they are going to also have fiber right so they have fiber they have carbs, because fiber goes under carbs, but animal foods zero fiber and almost zero carbs. And maybe the sodium was higher in these plant foods because they're trying to match the taste of the animal foods, but you know it depends on how much sodium, the animal foods you prepare them and cook it with so it can vary whereas this is set because it's what's in the product. So, what they showed was that the sodium intake was not very different. The fat intake was more in the animal phase than in the plant phase, even though they were similar and that's probably because of, like I said there is some fiber in the plant meats as well. And then you here they look at daily fiber intake so there was the light gray is the plant phase and the black is the animal phase and you can see that fiber intake is higher with the plant products, and then they looked at protein intake not any different. What they did look at this is not a study related to cancer so these are healthy patients and what they showed is that this marker which is associated with cardiovascular disease and maybe cancer was reduced significantly this is statistically significant and all the blue boxes are statistically significant in the patients who had the plant based foods even though they were mimicking animal foods. They also lost weight, despite them eating processed plant foods and these fake meats they actually lost more weight than they ate equal amounts of animal foods and they also showed that their cholesterol was lower in the plant foods than the animal foods despite it being processed. So, I don't know the long term effects in terms of the cancer is the editors they have a lot of other ingredients So, I can say that, you know, based on this study, the plant foods actually compare pretty well. So this is just, I did some calculations just to give you a sense you know I think as a society we've all become very protein focused and we're very much like, where do I get my protein how do I get my protein and we need more protein so everything centered about foods being healthy equating to foods having more protein so that's how most of most of the population thinks of it. So, the recommended daily intake of protein is point eight grams per kilogram, I'm assuming the person is 60 kilograms, and so they need about 48 grams. In cancer patients who are losing weight because of cancer or on chemotherapy or things like that. We do say that okay maybe you need a little higher amount of protein maybe so maybe we say one gram per kilo, and then that would be 60 grams of protein. So now I'm going to show you just back of the envelope calculation in terms of if it's an animal based diet and a plant based diet, other plant based diet patients or individuals eating that getting enough protein or not. And contrary to most people's knowledge there is protein in oatmeal, there is protein in broccoli, there is protein in lentils, beans, avocados, almonds like everything has protein because these are macronutrients so they are going to be there and everything. And then, even potato has protein. So what I did is I just added up all of this and you could think about and see where your diet fits into this and how similar or different it is and maybe this is extreme compared to what you eat, but it might help you understand, you know, what is the protein content in each serving of how we eat. And what you can see is this animal based diet has way exceeded the protein requirements for our day. So we don't need more protein, we need healthier protein and we need less protein because more protein actually also is associated with increased mortality and cancer risk and other things. And I'm not saying, you know, the patients are losing weight if you're having issues with all of that, I'm not saying you shouldn't eat your protein. I'm talking about if you're able to maintain your weight, you're in remission or you're preventing cancer, those are the situations. I don't want patients to feel like they should stop eating because they are, you know, I'm saying all of this, but, you know, think about it in the context of what phase of your treatment you're in when you think about the changes you want to make. And you can see this plant based diet with absolutely no animal based foods met the protein requirements and actually exceeded them also. And then looking at fiber requirements, like I told you, most individuals don't meet their fiber requirements. I took that exact same diet in the previous slide and I looked at the fiber in each of their meals. So what I've calculated is here is this person, if they followed this meal plan, it had only 20 grams of fiber in their meal, which is way below the requirement. And this person, and this is also, you know, like there are many people in the population who don't even have this much, you know, plant foods or things and so their fiber content would be even lower because it's processed. But I'm saying suppose they got 20 grams, but it's still lower. And then this one has way exceeded the fiber content, but there's not a ceiling limit on what fiber requirement is. So more is always better. This is the minimum requirement that should be there. And yes, fiber can cause a little bit of bloating and some of those side effects, but that's just because the microbiome is not adjusted to it. So usually if your microbiome adjust to it and you have eaten it for long enough periods of time, that will actually improve. I'm just going to skim through this quickly, but there was a nice article, a review paper published in the New England Journal in 2020. Now, the New England Journal is one of the top BISM journals. And so if something's published there, it is very prominent and high profile. And what does the summary of that paper is, is that the recommended intake amount has been justified, like of dairy has been justified to meet nutritional requirements for calcium and reduce the risk of bone fractures. However, the health benefit of a high intake of milk products has not been established and concerns exist about the risk of possible adverse health outcome. So if you are interested, then you could go back and read this paper. But from this paper, I just pulled out some of these figures and some of them are, I think, also in other papers. But what they're again showing is that the milk consumption versus the cancer incidence of four of these hormone dependent cancer. And you can see there is an increased correlation in the countries that have more milk actually have more cancer. And they show a similar correlation with osteoporosis too. So it's not ultimately clear whether the calcium in milk is the right way to get your calcium. But I think the advantages of milk is that it has high amounts of calcium, which other foods may not have as high. So this is how these are, you know, these plots that you can see, just look at the red lines in there and focus on those. The red lines means there's an increased risk and the number like one, two, three, four, five means the number of studies showing an increased risk. The black lines are there's no association and the green line means there's a decreased risk. So while some studies did show a decreased risk of breast cancer with dairy, but with prostate cancer, it was overwhelmingly an increased risk with dairy. So, yeah, and these might be some of the mechanisms by which I think dairy might be involved in the increased risk for myeloma. We don't have data. And so I don't have any recommendations specifically, or I won't say that you have to follow a certain thing for myeloma, but just something to consider. And all that I'd say is that a lot of, you know, we as a population, we've also moved towards having too much dairy in all our foods. Everything has cheese and everything has milk and everything has some amount of yogurt or dairy in it. So I think it's okay if you know that's important to you and you want to include it in your nutrition because there are some good things with dairy, but the issue is that you want to maybe cut down and balance it a little bit with other foods. So the reason, the way it looks at IGF-1 might be the link between it. So serum IGF levels were much lower in those who didn't have dairy compared to those who had a lot of dairy. And you can see the numbers here and the cancer risk from IGF-1. So does fish consumption decrease myeloma risk? This study is looking at five studies combined in a meta-analysis where what they looked at was five studies where did fish decrease risk? And they did show that fish might decrease risk by about 35%. And then, but the lowest risk they felt was only consuming once weekly, anything more might be increased risk. And so I don't know why this might be. It kind of doesn't make a lot of sense, but it could be that the omega-3 fatty acids and vitamin D in fish might have a beneficial effect. But increasing amounts might also have the toxicities from mercury and other things that come with fish consumption. And so how do omega-3 fatty acids work? And what you can see here is omega-3 are less inflammatory compared to omega-6, which are pro-inflammatory. In general, Western diets have too much omega-6 and too little omega-3. And that's why this balance is altered and we have more information. So I think it's important to think about where you're getting your omega-3 from and think about that. There are some studies that showed that this is all in cell lines and things. And not in humans, the studies in myeloma, but some of them showed that omega-3 fatty acids might reduce growth in myeloma cell line, reduce nerve toxicity, and microbiome changes may be altered and inflammation may be reduced. So where do you get omega-3 from? Oily fish have it. But where do oily fish get it from? They get it from seaweed and algae. So they are also getting it from plant sources. So there's no reason stopping you if you wanted to get it from seaweed, algae, edamame, pumpkin seeds, chia, flaxseed, hemp seed. So I would recommend thinking about this actively and at least having some of these plant-friendly omega-3 in your diet daily. Or you can consider a supplement if that's something you prefer. I always prefer the foods than a supplement, but it's up to you. The concerns with the fish, which I suggested or alluded to, was maybe it's the mercury poisoning with the large fatty fish and some of that. But that's certainly an option for some if they prefer that. Now, vitamin D, vitamin D is mostly where we get it from the sun because that's what in the skin, the sun, light, the UVB rays convert vitamin D in the skin to the active forms. And that's where we generate our vitamin D from. But we also get it from dietary sources. Unfortunately, dietary sources have very little vitamin D. So most of the population is deficient. And I'll show you the data in myeloma. So in myeloma, these are all studies related to myeloma, not any other cancer. I specifically put myeloma studies here. And what you can see is that there is a hypothesis. This is not proven, but maybe countries where there's less sunlight, like higher latitudes, have increased myeloma because maybe they have decreased vitamin D. And what this is telling you is 40 percent of the myeloma population is deficient, 35 percent is insufficient, and only 25 percent are normal. So out of 100 people, only 25 percent have normal vitamin D levels in plasma cell disorder patients. This was a big study of almost 2000 myeloma patients showed that those who are deficient had a decreased survival. This study showed that there's more inflammation, higher creatinine, higher myeloma stage, increased neuropathy. This study showed increased plasma cells in the bone marrow when the vitamin D levels were low. But it's a very tiny study. So I don't know that it truly is, it's truly there, there is, but it's interesting. And then, you know, low vitamin D means also risk of osteoporosis, fractures, and all of that with myeloma, there's an increased risk. So I think in all ways, vitamin D is important for myeloma, and I would recommend at least keeping the levels over 30, if possible, at least over 20 for sure, and if possible over 30. Now I'll go to curcumin. The reason I'm bringing this up is I see a lot of patients on it. And the reason they're on it is because there were a few studies related to it. And those studies are what have caused patients to take it, though we don't have a lot of data with them. So there is some thought that curcumin has anti-inflammatory, anti-cancer effects. However, its poor absorption often limits its usefulness. So cooking with it is one way and there is some thought that you heat with it and like it gets cooked, it actually might be improving the absorption. But in plasma cell disorders, there are two studies. So the one study, this study looked at MGUS or spoldering myeloma and curcumin. They did a randomized study where they gave 18 patients, finished nine months of the study where they got four grams of curcumin for three months, placebo for three months, and eight grams of curcumin for three months. So in total, they only got six months of curcumin, but none of these 18 progressed to myeloma. I don't know how much to make of that because often patients don't progress to myeloma in such a short time. So none of them progressing doesn't always mean that it's because of the curcumin. What they did say was that the ratio of the free light chains changed, but there was no worsening of any of the myeloma proteins over this period of time. And some patients did have an improvement. They then published a long-term follow-up of the curcumin-treated MGUS and spoldering myeloma patients. And these are patients who took curcumin for a really long time. You can see that they have improved their myeloma. So they did a randomized study where they gave 18 patients, finished nine months of curcumin, and they got four grams of curcumin for three months, and eight grams of curcumin for three months. They then published a long-term follow-up of the curcumin-treated MGUS and spoldering myeloma patients. And these are patients who took curcumin for a really long time. You can see here, three years, five, six, seven, up to nine years. I have highlighted in yellow the ones that you can see this is baseline protein, like my M-spike level and the end of study M-spike level. So just look at these two columns. The M-spike went from 26 to 13.6. 26 meaning, you know, usually you see it as 2.6 to 1.36, but that's a pretty big drop. This one also saw a drop, and so did this patient and these two. So a five out of the 13 that they published saw a drop. But you have to understand there could be some bias because those who are seeing an improvement are those who are going to continue long-term maybe. So we don't know, is it truly that five out of 13 are actually experiencing this long-term effect, or is it just the ones who are experiencing an effect are continuing it long-term? What you can see here is that three patients, the patients who took it for three years, didn't yet show much difference. So is it because they need to be on it longer term, or is it that only some patients respond? I don't know. What was also interesting is that, you know, in myeloma we look at the M-spike, but we also look at the free light chains, right? So the free light chains actually went up in those who, even in those who M-spike went down. But what happened is both the free light chains went up, you know, the involved one and the uninvolved one. So I think it's just some immune stimulation, which actually may not be a bad thing. So what I'm saying is we have very little data to support the use of curcumin, even though a lot of patients use it. I think it's overall safe. There aren't too many side effects with it. So if you want to, you could based on this study. But it's also a lot of commitment to be taking these pills because you would want to take at least two grams twice a day or something. So if you're thinking to match this study, and that's quite a high dose. So, and a cost also. So all of those things need to be balanced. This is just a slide showing you, you know, you can go here in terms of this website. If you want to look at supplements and the data that's available for generally for cancerous, I think it's a good website with more supplements included there. And then foods that fight cancer. This is taken from the American Institute of Cancer Research. What you can see is that foods that are high in, there's not one animal based food here that they say it fights cancer. They're all plant based foods. This is the American Institute of Cancer Research. And the reason they say it is because, you know, these are all the components of micronutrients that we often don't think about in all of these foods. And foods to a limit. This is what they suggest. And basically, you know, what we've talked about that sugar sweetened. So why plant based foods have these effects? I've kind of alluded to it all in the talk, but these are all the reasons why it might be beneficial. So this was a Lancet, you know, the Eat Lancet Commission on Healthy Diets from Sustainable Food Systems. So they met in I think 2019 January. And these are again experts from all over the world. And what they said is that the consumption, you know, this is their food plate based on it. And what you can see is half of the plate is fruits, veggies. A lot of it is whole grains. A lot of it is plant source protein. This red one is animal source protein and this blue one is dairy. So you can see the amount that they are recommending and the amount that we generally eat is very different. This is also the Canadian revised food plate. And what you can see here, so this came out also in 2019, the Canadian food plate I think matches what the, you know, science or data is more than the American food plate. And again, it's very similar to that food plate from the Eat Lancet Commission showing 50% of your plate should be fruits and vegetables, whole grains will be 25%. And mostly plant based proteins in this less, less 25%. So really what animal based foods they are recommending is like 10% or less if you want to. And so, or 20%. So if that's the plate you're looking for, then you know, this whole thing about what kind of diet is good for me. Is it Mediterranean? Is it plant based? Is it keto? Is it, you know, something? I think whatever one you want to pick, that's fine. You want to pick whatever you want to eat. If you want to pick, that's fine. You want to be omnivore, vegetarian, vegan. But I think you need to be a whole food plant based whatever. So plant based keto, plant based Mediterranean, plant based omnivore, whatever you want to do for that last 10, 20%, I think you can pick. But for the 80%, I think it's very clear what should be done. And this is also the recommendations from the World Cancer Research Foundation fund that is very similar. And so we need to think about food as medicine, at least sometimes. And we've developed a research program to study nutrition, microbiome and metabolism in myeloma. And this is a study that we're opening in March and looking for patients in case you're interested. But some of the things is you have to have amygdala or small ring myeloma with a BMI over 25 and being willing to come at least for some visits to MSK in New York. Some of them can be telemed, but you have to be able to come for some of them. We're going to provide meals for three months, where patients will get a plant based diet. And then for three months, they will just get nutrition counseling and then we follow up for the next three months. And then we'll have a study for a year. We're also planning a study through myeloma crowd through the support of Audrey, Jenny and all of you. This is going to be crowd funded and we're working on developing this and looking forward to your suggestions, involvement and contribution in any way possible. So some of the things to consider in terms of pantry staples, I just put this here, you know, if you want to think about moving to eating more plant food. If you have these things in your pantry at all times, then it's easy to do this because you can use them. Nutritional yeast, not a lot of people have heard of, but it's actually got a nutty cheesy taste sort of. So it kind of works well if you want to make a meal with, you know, get that creamy sort of taste, but like put it into pasta, sauces into salads and things like that. I think other things everybody knows about. A lot of you asked about plant based diets and kidney health and said that what about kidney health and you know, you have to restrict very specific foods and how do you manage eating healthy on that because it is a very restrictive diet. So actually the National Kidney Foundation had updated their recommendations I think last year or a year before saying that they recommend a plant based diet for kidney disease too. So this is not just myeloma, this is even for kidney disease and you can actually go to this website and read more about it. There are a lot of papers published on this too now. Here are some helpful links. I know some of you asked about like what about the cost of plant based foods and it's more expensive in terms of how do we manage. So there is this website, you know, helping with patients in terms of how do you manage eating on a budget, but a lot of foods like beans, grains and things are very cheap. So I don't think plant based meals are expensive if you just buy the non processed things and you know, eat it's probably cheaper in some ways. So with that, I will end and happy to take questions. Awesome. Thank you so much Dr. Shah. That was amazing and I took so many notes and I'm excited to see what my journey is going to be and just another plugin for that nutritional yeast. I've started to use it and it really is yummier than I thought it was. I also think you have to get used to the taste. Some people like it right from the beginning, but some might feel it's a little different. But now I actually really like the taste. I used to have a lot of dairy and then I decided based on you know all of this experiences and my personal experience and everything that I want to cut down on it. And then I was looking at substitutes and things and I didn't include that in a lot of cooking and meals and things and I do actually like the taste a lot now with it. So I know that there may be people who won't like it, but it's worth a try. Yeah, yeah for sure. If you want to stop sharing your screen so they can see more of your face. Oh sure. If you do need your slides, you can obviously pull them up to answer a question. But I just wanted them to be able to see you more clearly. So let's start. We have a lot of questions and I'm excited to get to them. So what do you know about vitamin K2, MK4 and MK7 to help with bones? So I think you need all of these things to help with bones. Meaning I don't know about MK4 and MK7 much, but I know that vitamin K is important. Vitamin K is present in a lot of plant based foods. That's why patients on anticoagulation like the old warfarin, we would tell them you know you have to have a certain amount of plant food because if you keep varying it, your vitamin K levels change and then the warfarin efficacy changes. So you eat the same amount every day of like green, beefy vegetables. So I would say in terms of vitamin K, if you eat well, you're going to get your vitamin K from that and not be deficient in it. Awesome. Let's see, can you speak to the nutritional difference between fresh and cooked fruits and vegetables? Yeah, so that's a good question. I think that both cooked and fresh have different nutritional value. There are some things that are better absorbed when they're cooked and there are some things that probably are not destroyed by cooking and so better when it's raw. And it's very hard to tease out that because every food has so many different micronutrients. So the best solution is I don't recommend being completely raw because I think a lot of absorption would actually be hindered by that because you know cooking actually breaks down some of the fiber and everything to make it easier to absorb and also you can eat more. So I would say that if you eat more, like if you had to eat a cup of cooked spinach versus a cup of non-cooked spinach, you're going to be able to eat more spinach if it's cooked. So I do think that we are getting more greens in if it's cooked and at the same time you have a different nutrient profile. So I would say that have some raw foods like have salads, have all of that, but also have your cooked meals. So I don't think you should need to do one or the other. A healthy balance between the two. All right, we have a question here that says my PCP discussed new diet guidance, GPS, which is limit all grains, potatoes and sugars. He said this included oatmeal and quinoa and sweet potatoes and I've actually heard this from more than one myeloma patient that this new thing is coming out that the sugars are too high in these things and that we need to alter and I know you and I talked about it before so I don't know if you want to share that with this group. Yeah, so like I mentioned, you know, people have given good carbs, a bad reputation. We have refined carbs that are not good and whole grains that are good. And that's part of why, you know, like yes white rice you might want to limit, but not brown rice or red rice or black rice so that's the issue with greens is that and wheat, for instance, like everybody Most people don't have white flour, they're not going to have whole wheat. So everything's cooked with like the bread and white flour even if they say brown bread, it's not always whole wheat bread. There's a difference between brown bread and whole wheat bread. So you want to pick whole grains, whole wheat. Those are different. I showed you the difference in the grain. When you talk about this, so I would and sugar is yes everybody shouldn't have sugars that are refined and processed. So yes, I agree with that. But when we're talking about sugars like From fruits. I don't think those are bad if you want to have fruit, have as many fruits as you want, but obviously green leafy is priority then comes the fruits, but you can have a few servings a day and that's not an issue because they come with fiber so they automatically get regulated. Awesome. Can you discuss bile acid malabsorption seems to be a side effect of Revlimid and it may be the cause of lower GI issues. Yeah, that's a good question. It's not a lot needs to be done with that. There has been some studies showing that eating more fatty foods leads to more of these side effects. So moving towards a less fatty diet. There was one study that showed that might actually help with the Revlimid induced Malabsorption and that's why a lot of doctors prescribe well call, which is a bile acid sequestrant or binder for diarrhea associated with Revlimid and that And that medication basically is binding bile acid or fatty foods. So if you're eating less fatty foods, then you might have improvement. Now, I also do think that sometimes maybe there is an association many, many people are lactose intolerant and just don't know it. And because it's very slight or, you know, mild those symptoms, they don't really realize it but post a transplant or on maintenance Revlimid, those can exacerbate already that underlying mild intolerance. And so try experimenting with low fat foods, no dairy foods, thinking about those things and see if it helps. And if none of those things help or you don't want to change your diet, then I think well call is a drug that is an option. That's so interesting. Just a personal note. I did not know I was lactose intolerant until I birthed my son. And then after pregnancy was when my body finally let me know. I think that's normal to be lactose intolerant, right? Like we're not, we're grown up as a species that we should not be having a cow's milk. That's why I think, you know, our bodies are not made for it, but we as a society have just increased this consumption. Along those same lines, there's a question about almond milk. Is that something you recommend or is that something that is okay to use as dairy or I guess calcium intake? Yeah, so a lot of these milks are fortified with calcium so that's I think good. I think almond milk is good. The way I think about it is what I do is I switch it up a bit. I'll buy almond milk and I buy soy milk or I'll buy flaxseed milk or cashew milk and like different ones and so oat milk. So I'm using different ones at different times. There are also some that, you know, like if you can make it with just the almonds and not have all the processed things in it, it's obviously probably better. I don't know how data based on that, but I think there are some companies that are now actually selling just the almonds blanched and you get as a paste, an almond paste that you mix with water and blend and then you have almond milk, but it has no preservatives in it. It's called JOI one company, Joy, which has done that, which I thought was interesting. But then it's more work. You have to actually make the milk. Yep. All right. Does it make more sense to take optimized curcumin, is that how you say it? I don't know how to say it. It's like a proven absorption if one would take curcumin. So the study of curcumin C3 complex, which is, there are many different curcuminoids and things and that study which was done in M.Govson's mooring myeloma was with curcumin C3 complex. I would say if you're taking it, probably try to take that. And then there are a lot of supplements that come with pepper in it. Like they actually have black pepper inside the supplement. It's black pepper and curcumin together because it's not that black pepper enhances absorption. So if you're cooking with curcumin and you want to add black pepper, you might actually improve absorption that way too. Interesting. Can you, let's see. There's just a lot of questions. I'm not sure which one to choose. Are you doing virtual consultations about diet or treatment for relapsed myeloma? I think the answer is yes. We do telemed all the time too. Since COVID and I think it's here to stay. So if somebody is not in New York, that's fine. We can still see them. And if it's helpful to you to talk about diet, I'm happy to because once it's a visit, we can talk about whatever is right for you. But I do also treat myeloma. So, you know, whatever works for each patient. Okay. Yeah. So Dr. Shah again is at MSK in New York City, right? Yeah. Okay. Just want to make sure. Should poultry consumption be reduced? We talked a lot about red meat and processed meat, but what about poultry consumption? So the data is a little bit mixed on it. And that's why most guidelines just decide not to talk about it and keep it out. And also because if they talked about it and they said, don't eat that too, then there's going to be a lot of backlash in terms of industries and all in terms of like, what do people eat? And most people eat a lot of that. So I think they want really strong data before they're going to say anything or have a stance on it that's significant. I think there are some studies that show that there might be some viral markers in poultry and things that might increase risk of lymphoma. There are some studies. Again, it's not mainstream like a lot of studies. So I don't know. And so I would say again, if you want to limit it, but that would be my recommendation. Awesome. Is tofu okay? Does it have a high soy content? Is soy recommended? Yeah. So that's a good question. A lot of breast cancer patients feel like they can't have tofu because it has estrogens in it and there's a risk of increase. But there's a difference between the phytoestrogens or plant estrogens and estrogens in our body or estrogens even in milk that we drink. So the phytoestrogens are weaker estrogens than our own estrogens. So actually they compete and they actually reduce the risk of breast cancer. So those who have more tofu and soy products actually have less breast cancer in studies. Okay. So I would say they are very healthy foods. Asian populations that do eat a lot of it actually have less of a lot of these issues or diseases. So this is an interesting question. Are there any studies regarding mushrooms in myeloma? Specifically, I think is she talking? I don't know how to pronounce it. So mushrooms have high calcium content, high vitamin D content, maybe calcium not sure, but vitamin D. So they are a good plant source of vitamin D. They have selenium so they're good for that. I think mushrooms have a lot of health benefits. So if you like mushrooms, definitely recommend cooking with them. They're not fattening. They have a lot of good benefits. Awesome. Okay. Someone's asking, do you mean to limit sweets like cookies, brownies, ice cream, etc. When we're talking about sugar. I think, you know, again, when you want to, I think all of us have a sweet tooth. It's not like I don't eat sweets. I think everybody does. But the question is the amount and the quantity and the type, right? So I now make it a point that, you know, if I'm picking a chocolate to eat, I'll pick a dark chocolate and I actually like it or I'll pick a dark chocolate with nuts in it. So it has some other fiber and benefits. I think it's a good idea. I know it still has the sugar in it, but it's got some things. And then if I'm picking, like, you know, making a baking something or something, I would pick trying to find recipes that have multiple greens or whole grains have sugars that are natural sweeteners or less sugar, not like cane sugar and refined sugar, maybe maple syrup or agave or something. So you're trying to limit but also picking things that are on the healthier side. So and a lot of like ready made outside products have very, very high contents of sugar. And I think our bodies have gotten used to thinking that we need that much sugar to enjoy it. But if you even reduce the sugar, contain your taste buds are going to get adjusted to that and you will start liking it with less sugar too. And it's so interesting, as you said that, you know, in recipes like a banana bread recipe that calls for two cups of sugar, try it with one. Exactly. Or try it with like switching it to instead of sugar, put maple syrup or do something, try it, but always reduce it. I find personally like I like less sweet sweets, if that makes sense. So I actually, if I'm making something, I would preferentially put less sugar from whatever the recipe is because that's how I like the taste, not just because it's healthy. So and that's part of how your body gets adjusted. Yeah. What about the use of coffee and caffeine? So I think coffee is actually there are some studies that show it's health, it's got health benefits. So if you like coffee, I wouldn't say you have to stop it and having a cup or two a day is fine. There was one study that showed coffee had beneficial microbiome changes to similar to other plant foods and things. Would you recommend organic spices? Since we can keep spices for longer periods. Organic spices are not meaning, again, if you have a budget and you want to spend, you could on organic, but if you don't, I would still recommend spices either way. I think they're important, whichever way. Awesome. We have a couple questions about the presentation slides from today and recording. Because you registered for this event, you're attending, you will receive an email 24 to 48 hours after this event, and that will have the slides and that will have the recording. So we'll be able to share that with you. I see a question about what can help nerve pain. So nerve pain is, I think a couple things that I generally do with patients for nerve pain is I'll check vitamin levels. So B12, B1, B6. It's surprising how many patients actually deficient in this and sometimes it may be related to while they're in chemotherapy, they're not eating well or something and then they develop these toxicities and then I repeat those to normal levels. And so sometimes that just helps. It's a very simple fix, but and it may be related to just poor nutrition at that time too. And then if that doesn't work, then I think sometimes we have to go with the medications or things like that. Omega 3 maybe will help. I'm not like there may be some data out there could be tried. Okay, I have a couple questions about green tea. People have questions about green tea. Is that beneficial? So I would suggest you go to the website of American Institute of Cancer Research, the one that I showed you, Foods That Fight Cancer. One of them was tea on that and tea and then if you click on that, you'll get the whole details on how tea helps and why tea helps. But some of it would be like the contents of the tea that have anti-cancer properties. But green tea is probably good. Like that's what I would suggest if you're picking something and having it as a cup or something. But again, take the sugar out. A question about alcohol. Is wine red in moderation? Okay. So the reason red wine got a good reputation is because of the grape content in it and the red, you know, from the grapes, the content. So if you can eat grapes and get that, why do you need wine? But if you want to have wine because you feel like that would be, I think it's okay sometimes. But technically, the alcohol has been associated with a lot of cancers and an increased risk. So I think it's fine a few drinks sometimes, but not regularly. One mile of a study though may have shown a decreased risk with alcohol and that I thought was interesting, but it was a tiny study. Okay, awesome. Do you know, I don't know how to pronounce this word either. Do you know anything about woe vinson enzymes? No. Okay, we don't know what that is. We apologize. What grains do you recommend is best for people who are gluten free? That's a great question. Yeah, so I think there are millets, a lot of them that you can think about. There are many types of millets, so you could consider those as options. I think buckwheat oats can be without. So those would be the ones and I think. Let me think about it. So if you think about the names. Yeah. Millet, oat, quinoa, quinoa is very good. Amaranth, teff flour, buckwheat flour, those could be. So thinking about all of those and including them. But the thing with that is also like many gluten free things will always have rice flour or something else, right? So switch it up. Try to bring these other greens into your life. Awesome. Is there any evidence using artificial sweeteners that they're problematic or artificial sweeteners problematic? So artificial sweeteners, there is, I think there is some data that it is a bit problematic. One is that because they have more, for some reason they increase their sugar cravings because they are much higher in terms of like what they, how they alter their brain to like sense the sugar or things like that. So for some, I don't fully recollect, but it is related to that. And so because of that, you actually crave more of these artificial sweetener rings. And so you end up having more and they are not truly, you know, completely without any other issues. Okay. Is hemp oil good for cancer? So hemp seeds, flax seeds, all of those are good. So I would say hemp seeds have a lot of omega 3 in it. I think rather you pick the hemp seed than the hemp oil. But I don't know, maybe the hemp oil is good. So hemp seeds actually don't have much of a taste. It's a mild like nutty taste. What you can do is buy hemp seeds when you're making a sauce or a lentil soup or something, just put a spoonful of hemp seeds into it and you will know the difference probably, but you will at least get your hemp seeds in, even into a smoothie or something. And they have omega in them. Can you talk about improving the biodome with a purchased product like a probiotic or yogurt with lab culture in case we can't manage the 30 diverse plants a week? So probiotics also have a few strains. They're not going to have like 100 different strains and then they'll have three, four, five strains at max usually. And so even if you are even a yogurt, if you look in the ingredients, there are many times they'll say these are the three strains in the yogurt. And there has been some study that showed that maybe dairy reduces the risk of colon cancer compared to the increased risk that I showed you with all the other cancers. So yeah, you could potentially do that where you have dairy or non-dairy yogurts also you get with these live cultures in it that have the same effects probably. And so it's up to you, but I don't think it's exactly the same as the diversity because every bacteria needs a different food kind of if you think of it like that. So if you eat more food, you have a more diverse bacteria than if you eat the same thing. And I will mention you talked quite a bit about that in your first session. I will be including her first session and her session on this follow up email in case there are people attending this session that weren't able to see her first session. All right. A couple questions about vitamin D. So do you recommend vitamin D tablets? So I would say the vitamin D supplements, you can basically take whatever works for you, but just make sure you check your levels and get them up. So right, like you take 12 weeks after once weekly high dose. Suppose you have really low levels, sometimes you can take 50,000 weekly for 12 weeks. If you take that and after 12 weeks, your levels are still lower, then you want to again supplement with another 12 weeks or start a maintenance. And then maintenance could be like 1000 daily or 2000 daily. I don't think I have a set number. I think it depends on where patients are starting and what they need to maintain their levels because too high levels can also cause toxicity. It's a fat soluble vitamin. So you don't want your levels going over like 60 or 50. And it's very hard to get there. There are very few patients I've seen with like elevated levels. So mostly you won't be that person, but you should watch and you don't want to go overboard. We actually have a question about that. Is it detrimental to go over? So it sounds like the answer is yes. Yeah. Okay. I see a question about SARS-OV-2. I think there were some data on SARS-OV-2 and anti-cancer effects, but I don't think there's anything for myeloma. Again, I would refer you to that MSK website on herbal supplements and integrative. They actually have, I think, SARS-OV-2 on that. And then you can read all about what the evidence is behind it. Not for myeloma, but in general. Do you want to answer the asparagus question as well? I don't think asparagus is contraindicated. At least I'm not aware of any study like that. If you have a study, feel free to share it and I can give you my thoughts on it. I think there actually have been studies showing that asparagus has some anti-cancer properties. So I would be surprised to see that. Okay. While on Bortizomib, I need to learn how to pronounce it. While on Bortizomib, avoid orange, grapefruit, tangerines, strawberry, or just grapefruit. Thanks for all the recommendations from Barcelona. That's nice. For joining us. So yes, I think grapefruit is a cytochrome inhibitor and has a lot of interactions. Everything else doesn't really have those interactions. It's grapefruit that usually does. So I don't think you need to limit anything else. Just grapefruit when you're on many drugs, you might just want to check the side effect profiles and see if any of those drugs interact with grapefruit like you would with checking different drugs. And you can ask your doctor to do that. Okay. I think that's what we're going to end for now. And we do have a list of these questions. We do have a lot of people thanking us. We have people from New Zealand. That's super exciting. People from Barcelona, people from all over the world. This is so exciting. Thank you for taking the time to be with us today. That's great. I'm really happy to talk to all of you and I hope it helped in some way to make changes that might benefit you in your disease course. I am sure that it did. So let's get back and just finish up here. Thank you all for participating today. That was amazing. Dr. Shah, again, thank you. Thank you for your knowledge and thank you for everybody that participated. If you are interested in participating or contributing to Dr. Shah's study, make sure to take the survey listed on the slide. Although if you took the survey, you're not automatically enrolled in the study. So like she was talking about the studies earlier, you do have the option to enroll in that crowd funded study. And you actually have the option to donate to that crowd funded study as well. If you want to go to the link that's on here, of course, that's optional. But we wanted to let you know about that. Again, these slides are going to be sent out to you. And just I would say if you haven't filled out the survey on nutrition, I think it would be helpful. I think that's the data that I'm going to show other Loma doctors to bring it to the attention of what patients want. And that's what the survey is going to be used for. So the more that fill it, the more data I have to bring it forward. And that would be helpful. Yeah, yeah, it's going to be a game changer. If you have any questions about today, you're welcome to email Audrey at healthy.org I can pass those along to Dr. Shaw. Our next nutrition and wellness chapter meeting will be on March 23 2021 and 11am Mountain Time 1pm Eastern. We will plan on discussing how we can use nutrition and wellness practices to lower cholesterol and lower the risk of heart disease. We are really interested in other events that we have upcoming in our my Loma community program. Tomorrow, February 17 at 1pm Mountain Time 3pm Eastern is our connect with the my Loma crowd event. We will be discussing the creation of health through university and looking for input on what free new classes we should include in our curriculum. Thursday, February 18 at 11am Mountain Time 1pm Eastern will be our newly diagnosed my Loma patients chapter event. We will be discussing why physicians are optimistic about newly diagnosed my Loma. Dr. Sarah Lee from UW Medical Center will be moderating the Q&A. On Wednesday, February the 24th at 11am Mountain Time 1pm Eastern will be our Cell and Excer support group. If you are using Cell and Excer as a part of your treatment or have a loved one using Cell and Excer or you just simply want to know more about the drug, come join our Cell and Excer support group. And then on Thursday, February 25 at 12pm Mountain Time 2pm Eastern will be the launch of our African American my Loma chapter. And we will be discussing how to be your own best advocate. If you want to sign up for any of those events, the link is listed on this slide. I will include it as well as the slides and this recording in the follow up email we will send 24 to 48 hours after the completion of this event. Another thank you to our sponsors, AbbVie, Bristol Myers Squibb, Amgen Oncology, Genetech, Perial Pharma Therapeutics, OncoPeptides, Adaptive Biotechnologies, and Takeda Oncology. And another huge thank you to Dr. Shaw for sharing this time and for knowledge with us today. And thank you to you for sharing this virtual time with me and growing our my Loma community. And we will see you next time. Thank you so much.