(Guest Lecture) November 2022 - Nutrition for Myeloma Patients

Hi, everyone. I'm really excited to be here to talk to you all about nutrition and it's a good thing you finished eating your full and you know now you can listen. I think nutrition, you know, is one thing to remember is that when we're really hungry we don't make good decisions because we really need to feel like we want to eat. So often nutrition is a lot of like thinking ahead planning what your next meal will be so that you can actually make informed choices and not like scramble to find the meal just when you are hungry at that time. So these are my disclosures. And I just wanted to start out with, you know, with in this era of co with everybody is like, should we do the vaccines and the boosters and all of that's important and I'm not taking away from that but I think there's also something you can do in terms of empowering yourself with nutrition. And the reason I bring this up is because, you know, we don't really talk about it enough and this is one study but there is another one and in the interest of time I'm only going to show you one but you know in some of the healthy talks that I've given previously the other one I have discussed to, but what you can see here is that patient. And this was only healthcare workers but they did one in the general pop like another one's been done in the general population to. And what you can see is those who eat plan based diets seem to have less lower odds of moderate to severe coven and less coven as well so there is something that we can do in on a daily basis. Many times a day in terms of changing the severity or likelihood of outcomes of how you develop coven. And if you look low pro low carb and high protein diets actually had a higher risk of severe coven or moderate to severe coven so actually diet can can make a difference and here's So I think good nutrition is important for cancer at all stages and you know we think about it only in the survivorship setting and I'm going to show you some data why we should change that and think about it differently so in the survivorship setting we think like okay, you know to prevent the risk of other cancers medical problems and things like that, but also in the treatment setting, because in treatment setting. If many times we can give treatments because people have comorbidities or other medical conditions. So if you have cardiovascular disease, it might be harder to get the carfilzomib or if there is diabetes, the steroid doses are affected and more side effects related to that. So there, you know, during treatment and then with immune therapies now I think there's, you know, having a robust immune system is more likely to, you know, probably we'll see better responses that way and there is probably a diet microbiome connection there too. So I think, and then the third space would be prevention, where we reduce the risk of myeloma coming back but also prevent myeloma from developing in the first place for people with MGUS and smoldering or any other cancer in the future. So with that in mind we developed like nutrition intervention research program at MSK so we're doing studies around nutrition microbiome and the metabolism in myeloma. So I'm just going to talk a little bit about, you know, BMI, diabetes, nutrition, and the microbiome. And, you know, I think this is what food or supplements can I take is often the most likely asked question by our patients, and also the least likely to be answered because we don't have a lot of answers or so we think. So, obesity increases the risk, you know, the, this is just a quick summary but what you can see is obesity increases the risk of developing myeloma in the first place, and also increases the risk of progression from the precursor states to myeloma, and then post the diagnosis So BMI's are also associated with worse outcomes. So there is some data around BMI and myeloma, so having a healthy body mass index can be important. And these are the multiple mechanisms by which it may affect it. However, patients that also lose significant amounts of weight unintentionally due to myeloma diagnosis are 1.6 times more likely to do worse. So it's not just about, you know, losing weight that's not what I'm saying we want to keep a healthy weight and trying to maintain it so it depends on what stage or situation each patient is in. Diabetes is also associated with an increased risk of cancer. And we know that a lot of the US population is either diabetic or pre diabetic about 45% or so. When we look at diabetes and the risk in general, hem blood cancers and myeloma there seems to be a risk in some large population studies. What we don't know yet, and we're working on is, is diabetes and cancer caused by the same risk factor so like, you know, diet or age or weight genetics the same thing, or is it that diabetes, like what causes diabetes then leads to the high sugars high insulin and then leads to cancer. And that's the difference between what we think about as correlation or causation, and a lot of epidemiologic studies can only tell us about correlation that we associate two things together, but how does it really happen that doesn't come from epidemiologic studies. So we did a study with the health tree foundation this was published earlier this year, where we looked at patients needs for nutrition their perceptions and practices, and what you can see is that since their diagnosis about 82% of patients have questions, 57% say their oncologist doesn't address it, and 94% say that if an oncologist gave recommendations they made changes so I know that patients are interested in getting this information if it's there, and patients are interested in such research to what was interesting to me was that when we asked patients before and after their diagnosis if they've made any dietary changes. There was a significant improvement in diet quality in patients, where patients improve the consumption of plant based food and seafood and reduce the consumption of red meat and junk foods, and this was just, you know, obviously it's self reported so there is that bias but just to see that most patients did improve their diet. After a diagnosis in encouraging to show that people are making changes. And so this is the American Institute of Cancer Research or the World Cancer Research Fund recommendations, and what you can see this is general for all cancers, and only a third of myeloma or plasma cell disorder patients knew about it when we asked so I think it's important to be aware of the guidelines that are already there, because this is based on a lot of research and evidence that's already available. So, plant rich diets and limiting sugary foods and fast food and red and processed meat. So then we're looking at dietary patterns and cancer and this, I think is interesting because there are three large studies so these are population studies like one in France, one in the US and one in UK, and what they had huge populations of 40 to 60,000 And what they looked at is like they got all these patients to fill out dietary surveys and said, what are the different dietary patterns in this population, and who gets more cancers or less cancers, and all three studies very consistently showed that those who are eating more plant based foods have less cancer. So, we're looking at myeloma so there are two studies and myeloma to date. One is the nurses health study and health professional study and you can see that those who had healthier dietary patterns which are shown in green so those are healthier patterns had lower risk after diagnosis, and those who had an unhealthy pattern had a higher risk of death. So there is some, you know, diet can make a difference in the long term survival to have patients. So if you look at the epic Oxford cohort so it's the same one from UK that I showed you here. They actually looked at myeloma patients within their study granted they didn't have a lot of myeloma patients but they did show that there was a 77% relative risk reduction in patients on vegan or vegetarian diets compared to meat eaters and developing myeloma. So there is, again, a pattern. All these studies showing similar things. And then, recently we published a paper, this was an all cancers but we looked at what are the mechanisms by which diet may be affecting cancer risk reduction. And so we looked at multiple different studies and kind of summarized it into this figure. And what you can see is that, you know, the two common diets we looked at data for is the keto diet and the plant based diet and the keto diet we looked at because if you see, you know, at the bottom of the slide I've written there are currently in cancer 46 keto diet trials ongoing 20 active 10 completed and six terminated with five unknown status this shows that a lot of these dietary studies and keto diets are not, you know, being able to be completed because a keto diet is very hard to do. And there are only about eight plant based diet trials, despite the evidence I showed you on the previous slide where actually plant based diets associated with reduced cancer risk. And we are seeing this opposite where intervention trials are doing the opposite of what the epidemiologic studies are showing and keto diets also may have some benefits through weight loss inflammation and insulin, and the, and the key tone bodies that form that have anti inflammatory capacity. It's just that doing a keto diet requires it to be not just low carb but very low carb. And it's really hard to get to that state unless you're truly planning it for long term. And I think that's why keto diets are possibly, you know, somebody could do it if they feel like that's the only way that because they hate fruits and vegetables or there's some reason like there's a certain mutation or a reason that they need to do it. So I don't think a keto diet is a sustainable long term diet that can be used for long term, you know, patients and if you want to do it as a lifestyle, whereas I think plant based diets meaning more plant foods in your diet is something that inherently comes a little more naturally and can be done as a long term thing, and seems to have more mechanisms by which it can target cancer risk reduction as you can see in this figure. So this study is not in cancer or myeloma but I think it's a very interesting study and it's nine patients only, and five days on a diet, a fully plant based diet versus a fully animal based diet, and what and plant based diets obviously high in fiber so you can see their fiber intake change significantly between the two diets. And what you can see here is they show the difference in short chain fatty acids. So butyrate was higher in those on the plant based diet and so as acetate, whereas the branching fatty acids were different so this is in the stool, and we'll go into it a little bit more of why I think this is important. So short chain fatty acids have anti cancer and anti inflammatory properties especially butyrate so that's one of the mechanisms by which plant based diets may be affecting cancer and inflammation. So, this is a study again not in myeloma or cancer but it's a huge study of over 10,000 individuals, and what they showed is that if you eat more than 30 plant foods per week I mean 30 types of plant foods. So I'm not talking about, you know, eating broccoli 30 times in the week but I'm saying 30 different types of fruits and vegetables or even bean seeds nuts tofu any plant based food even spices. So more than 30 times per week is associated with better diversity in the stool, and there is a lot of studies and in the interest of time I'm not going to show you but there are previous health tree docs where I've discussed this, but higher diversity is associated with better survival better outcomes post transplant there are a lot of studies showing that. So this is one way that you could help your gut microbiome and diversity is by just eating a variety of plant foods and trying to get to that number of 30 and more per week. After I'd given a talk last month. Rosalind mentioned to me that some of the patients formed a group and they have a shared Excel that they count the number of plant foods they eat per week and I was really happy to hear that because it looks like they're making you know positive changes through that. Another paper that we have that you know going to be coming out soon is looking at patients who are on maintenance therapy so these are myeloma patients on Lenin little might maintenance. So what we did is we looked at diet, we looked at the microbiome, and we looked at their outcome so we were talking about MRT negativity so we looked at sustained MRT negativity in these patients. So what we showed is that patients who had higher diversity in their stool had higher likelihood of sustained MRT negativity patients who had higher butyrate producers in their stool also had higher likelihood of sustained MRT negativity, and those who had higher levels in their stool also had higher sustained MRT negativity. So, and then we associated this with dietary surveys, and what we did is we looked at patients who are so we showed that eating more healthier protein so like plant protein, seafood protein though I think the benefits coming mainly from the plant protein because you also see it with the dietary flavonoids, but we see flavonoids are plant chemicals that are only found in plant foods. So higher dietary flavonoids are associated with higher butyrate levels, and also the same thing in this. So we were able to correlate diet with the gut microbiome, and then with potentially myeloma control long term. So while this is a small study, it's encouraging that we're still seeing a signal with such a small study, and I think that this goes to show that there is an opportunity to make some changes. Other things is in terms of myeloma development, you know there are lots of studies looking at obesity diabetes the inflammatory diet, altered microbiome as risk factors for development, but what if we could try to tell the scale and see if we can make a change with these markers. And so we decided to do a study this was the new prevention pilot study, which opened to enrollment last year and we finished enrollment it's a 20 patient study with patients with an elevated BMI over 25 so if they have overweight or obese and they have M guys are smoldering myeloma they were eligible, we would provide the patients we ship them meals for three months, lunch and dinner and we give them recipe ideas for breakfast and snacks, and we follow them for a year on the study with coaching and visits with a dietitian very closely. And in this time we were collected samples and analyze some of this data so this is some of the early data that I'm showing you, which we presented at the myeloma meeting this year. What you can see is that we had a nice distribution of different races about 45% were minority which is I think big for most studies it's much much lower. Also, we had a nice distribution of different BMI M guys and smoldering and a third of a pre diabetic or diabetic. This is a compliance data and when we talk about compliance I'm talking about plant based diets but not just junk food plant based diets but unprocessed plant foods. So we were able to get patients compliance in those 12 weeks up from being around 22% before intervention to 90% during the intervention, So patients did really make a change and we see a feasibility here. And we also looked at things like BMI reduction so we had a 7% weight weight loss or BMI reduction, we saw an improvement in markers of diabetes so like a one C or glucose control. Ldl cholesterol insulin IGF one total adiponectin leptin ratio improved and no adiponectin leptin insulin and IGF one. There are lots of studies in the interest of time I'm not showing you but there are studies showing that these are associated with myeloma and myeloma progression. So we are able to show that we are able to change these biomarkers or markers that we know are associated with increased risk. We also looked at the microbiome and you can see as I told you why I think you traits important. We show that we were able to improve this in the patient's tool and improve the number of bugs also that are making butyrate. We also show some improvement in inflammation markers as well. So with that pilot study data we've worked on developing few other studies and this study is going to be opening through the health tree foundation in a few months. And, you know, this would is a big study of smoldering myeloma patients anywhere in the United States. What we're going to do is look at diet versus different supplements and the effect on the gut microbiome. This is a study that's going to open at MSK and also in this month actually so if anybody's interested with MGUS or smoldering myeloma, please reach out. It's very similar to the pilot study where we will be shipping meals and things but it's going to be a randomized study looking at diet versus supplement versus placebo. And it's a large study. It's also eventually going to open at Emory in a few months time so depending on where patients live, they would only need to come to one of these sites about five or six times in the year, but we're happy to have patients from anywhere. This is the Nutrivention IV study. This is a study in myeloma patients in remission on maintenance. So these are patients on either maintenance therapy but what we're doing is that we have a study open looking at daratumumab versus lenalidomide as maintenance therapy, and we're going to give some of the patients on this maintenance the diet. So at one year time so you have to be enrolled first on the maintenance study and then if you are on that study you have the opportunity to join the nutrition sub study. So with that and a few other studies we are doing is looking at dietary patterns in patients and supplement use habits through the health tree foundation. These surveys will hopefully be up in the next few months and we'd really love your participation in them so the more the numbers the better the data we can have. So just to summarize a few things, healthful nutrition habits. You know I think carbohydrates have been given a bad name because of the refined carbohydrates, but whole grains are associated with reduced cancer risk and actually very important in a healthful diet. So it's important to have those because they also have increased fiber so we need fiber in our diet which come through plants and no animal food has fiber. Protein, I would say prioritizing plant based protein sources like beans, tofu, tempeh, and reducing red and processed meats, improving unsaturated fats which come from nuts, seeds, fish oil, olive oil or avocados and reducing the saturated fat. So that's a good way to look at it. This is a Canadian food plate which I really like because 90% like actually only 12.5% of that plate has animal based foods and the rest 87.5 is about plant based and I think it's a very unbiased food plate. There are some things just like thinking about you know calorie counting and calorie restriction I don't think is a long term sustainable way of weight loss, or even managing a lifestyle because that brings a negative association with food and it's something that we're constantly like oh what can I not eat, but focusing on what you can eat and regular meal times meal planning in advance can actually be really good ways to do this. And if you think about what 500 calories look like this is quite important to understand calorie density. If you eat 500 calories of fruits and veggies you're probably going to be full but if you eat 500 calories of meat or cheese you're probably not going to be full because just fiber fills you up. So when I'm talking about plant based diets I'm not saying that somebody needs to be vegan. I'm not saying somebody needs to be vegetarian. I think it's important to understand that these diets can be very healthy if they are done right, but they can also be unhealthy if somebody is a junk food eater and eats only potato chips or you know desserts and that could still be vegan potentially. So what I'm talking about is a whole food plant based diet where we're talking about minimal animal products and we're focusing on unprocessed foods then that would be healthy. Just one thing to know is the fiber gap. So 67% of consumers so like if we surveyed all of you or maybe even the whole country 67% of people think that they're getting enough dietary fiber. In reality only 5% are. So we really have a fiber deficiency in the United States not a protein deficiency which is what everybody's focused on. So things that I would say is it's important to be whole food plant based whatever the diet you want to do that's fine with me but you know that the 80 90% should be coming from plant based foods. And again, when I say all of this I'm, you know, things to consider is, you don't need to make the changes tomorrow you don't need to make it immediately but think about what stage of your disease you are in and how you can do it in a gradual way that's more sustainable and long term, because we don't want to make these changes and realize like we can't do it and then go back to what we were doing because, oh, it's really hard to do this I'm never going to do it. So small switches and substitutions are more likely to make changes than trying to make, you know, just suddenly overnight saying I'm going to cut everything out. So with that I'll conclude that you know obesity, we talked about diabetes we talked about nutrition and how it's important in covert cancer and my Loma, and the microbiome, where diversity is important butyrate producing bacteria important. And in case you are interested in being a part of these trials you could scan the QR code and send us your information, and we can reach out. Or you can reach out to us at any time. With that I'd like to thank everybody who's made this research possible because I wouldn't have been able to do it alone. And these are some of the talks we have on the nutrition and wellness chapter that help tree has that I've given over the last few years, been the interest of time I've obviously not gotten to all the studies and details but if you're interested in knowing more and why we talk about this. These are some of the talks you could listen to. Thank you.