between myeloma progression and diet. We often get the question from precursor myeloma patients, what can I do to decrease my risk of myeloma progression? And while there are some speculations about how fitness or proper diet could possibly slow progression, Dr. Irvi Shah has made it her mission to study the relationship between diet and myeloma to find real answers for precursor patients anxious to do more. Dr. Shah is a faculty on the Myeloma Service Division of the Hematologic Malignancies at Memorial Sloan Kettering Cancer Center. And 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 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, I'm so excited to have you join us and excited to hear your presentation. So the time is now yours. Awesome. Thank you so much, Audrey. And it's really a pleasure to be here again. Are you able to see my slides? Yes. Great. So I'm gonna speak for about 35 to 40 minutes and I'm really excited to speak to all of you about this topic, which is near and dear to my heart. So we're going to talk about studying the relationship between plasma cell disorders and nutrition. These are my disclosures. Before we talk about plasma cell disorders, I wanted to bring to your attention two studies around COVID that were done. And I think this question comes up for all patients with cancer or plasma cell disorders or anything with an immune related issue, where what can I do differently to reduce my odds of getting COVID and the severity of COVID? So there were two really nice studies looking at diet and I thought that this is the right time to discuss it briefly. So this study looked at frontline health workers from six countries, France, Germany, Italy, Spain, UK and the USA. And what they did is they asked them to fill out dietary questionnaires and looked at what kind of diets they were eating. They divided them into plant-based diets and non-plant-based diets. And what you can see here is the significant differences in wherever you see the P less than 0.01 means that that is significantly different between the two groups. So vegetable, legumes, nuts, poultry, red meat, sugar, sweetened beverages, that's different between these two groups and alcohol. Then they looked at those who got COVID and what severity, whether it was moderate to severe or mild COVID. And what they showed is patients on plant-based diets or plant-based or pescatarian diets actually had, so anything less than one is a reduced risk of developing severe COVID. And anything more than one is an increased risk of developing severe COVID. So the low carb, high protein diets had higher risk of severe COVID, whereas the plant-based diets had a lower risk in all the different ways they analyzed it. And if one study wasn't enough, here's another study and this is a much larger study. This is over 500,000 participants and they had 31,000 cases of COVID in this. What they did is they again asked patients to fill out a questionnaire and then calculated an index called the healthful plant-based diet index, meaning how many plant foods are they eating? And what they showed is that healthy plant-based diet was associated with a lower risk of COVID. So you can see when it's one, it's the least risk and then anything towards the right of one where you see the red arrow, it's an increasing risk. And those with unhealthier diets, meaning a low score, as you can see in red, had a higher risk of developing COVID and severe COVID as well. So that's one thing, not just for cancer, but even infections and things, especially COVID. This is not a myeloma study, but I just wanted to bring it up because it brings home the point of like genetics is not everything. And many times patients will feel like, okay, I have bad genes, what can I do? I'm getting cancer or whatever because of my genes and I can't do anything about it. This is a colorectal cancer study, but as you can see, what they did is they calculated a healthy lifestyle score and they calculated a genetic risk score. So meaning looking at what genes are there and seeing which genes are higher risk to develop cancer and which are lower risk. Then they categorized them into the high gene score, intermediate and low gene scores. And then in those same categories, they looked at their lifestyle and said the black bars are unhealthy lifestyles and the white bars are healthy lifestyles. And as you can see, even in the low risk or in each of these groups, it's not the same if the lifestyle was different. So those with unhealthy lifestyle had an excess risk over those with a healthy lifestyle in the high risk group. So there is a high genetic risk patient could benefit more from lifestyle modification than those in the low risk group, as you can see here. Of course, this is colorectal cancer, but I just wanted to bring it, discuss this with you as I think it's important as we think about it. So I think good nutrition for cancer is important at all stages. Survivorship of course, after somebody gets it for treatment, and I had shown an example in my talk last year, which you could refer to. And then in the prevention setting, which is what we're here to talk about in the smoldering myeloma and MGUS stages as well. So these are the talks that I had given last year with myeloma crowd, and you could go to the YouTube site and watch them. I tried not to repeat everything from then. So some of it, if you haven't watched it might be helpful. So at MSK, we have developed a research program to study nutrition, microbiome, and metabolism in myeloma. And we'll talk a little bit more about that. So I think the most commonly asked question by patients is what food or supplements can I take? And it's also often the least answered questions. We'll talk briefly about obesity, diabetes, nutrition, and the microbiome. So I had mentioned this in my previous talk, but obesity increases the risk of MGUS. Once you have MGUS, obesity almost doubles the risk. So anything 1.9 to 2.6 is about two times more likely to progress to myeloma compared to somebody who has a normal BMI. Obesity is also increased risk to develop myeloma, increased risk for death once you have myeloma, and also myeloma with sustained BMI elevation compared to isolated elevated BMI. So if somebody has been obese for a long time versus if they're obese at any one time and then they go back to a normal weight. Also weight cycling, meaning gaining weight, losing weight, gaining weight, that's also not considered good and increases the risk. So as you can see, obesity is a known risk factor for myeloma. However, patients that unintentionally lose weight due to a myeloma diagnosis probably do worse, but that's because maybe their disease is overwhelming their body and they're losing weight from the disease. Obesity mechanisms, we published this last year where we looked at all the different mechanisms by which obesity might be leading to or increasing the risk for myeloma development. And I won't go into the details, but there are different molecules in the blood and the bone marrow that might be affecting it as well as hormones and insulin, and insulin-like growth factor. The next topic is diabetes. And how does diabetes increase the risk of cancer? This is not as straightforward as obesity and there's a little bit more confusion around this in the sense that is diabetes increasing the risk because it's a correlation that diabetes and cancer are happening in the same people because of the same risk factors, or is it that the diabetes is happening first and then the cancer is a result of the diabetes? And I think that answer is not fully put to rest in myeloma, but nonetheless, it's important to know that patients who have diabetes have higher risk of developing it based on some studies. So these are two studies, one from Israel and one from Canada showing that diabetes increases the risk of overall cancer and myeloma, blood cancers. We looked at this in a Swedish population and published it last year, where we showed that diabetes increases the risk of MGUS and myeloma within six months of diagnosis, but not after, meaning six months of diagnosis of diabetes and not long-term after. And so there may be some detection bias like I talked about in scenario one, but we have to, this is just a study looking at associations and it does improve causation. Diabetes was not associated in this study with the risk of progression of MGUS to myeloma, but in another study, metformin used for more than four years was associated with a reduced risk of progression from MGUS to myeloma. So there may be something around that, but I think studies need to look at it further. This is a study we did actually with the Myeloma Crowd and Health Tree Foundation. We surveyed patients through the Myeloma Crowd and 421 patients responded. And we asked them since their diagnosis, if they had questions around diet and nutrition, 82% said yes, 57% said their oncologist didn't really address it. 23% said they didn't address it despite asking. And then if a hematologist oncologist gave them advice, the majority were 94% said they actually were able to follow them or at least tried to follow them. The AICR or ACS guidelines, only a third of patients knew about them. And if they knew about them, about half of them tried to make changes to their diet. We then asked patients, are you interested in learning more about this? And you can see there's an overwhelming 90% interested in this. And we asked whether you would like your hematologist oncologist to make recommendations and many said they would. And they would be interested in changing their diet based on research available to date. So I think most patients are interested in this and it's nice to see. This is the AICR guidelines, which if you haven't seen before, I encourage you to go to their website and take a look. This is general cancer prevention survivorship guidelines, but it's very basic things showing you that food does matter, not just for myeloma, but even other cancer risks. We also asked the patients, did you make any changes since your diagnosis? And what we saw is actually patients make changes on their own. Maybe they read it online or they hear from somebody, but patients made healthier dietary changes that were statistically significant. And very few went from very unhealthy to even like, went from unhealthy to more unhealthy. Most patients actually moved in a positive direction post their diagnosis. So patients self-reported a significant increase in their consumption of plant-based foods and seafood and reduction in their consumption of junk foods and red meats. So what about dietary patterns and overall cancer risk? There are three big studies that were published in the world, basically one from France, one from the USA and one from UK. And actually, interestingly, all three studies are showing the same thing. So the France study showed that higher plant-based dietary scores, meaning they calculated a score for every patient and said those who had higher scores had 15% lower risk of all cancers. The USA study from the Adventist Health Group showed that they didn't make a score, but they looked at vegans, vegetarians, non-vegetarians, and they showed that the vegans had 60% less cancer than non-vegetarians. The UK study looked at vegans, vegetarians, seafood eaters and meat eaters and showed that the vegans had 19% less cancer than meat eaters and so did the vegetarians. There are two studies in myeloma and I've discussed this more in detail in the prior talks, but just briefly to show you that the Nurses Health study showed that pre-diagnosis dietary patterns, healthier patterns, meaning these patterns are actually the Mediterranean, DASH, and Prudent are pretty much plant-forward, meaning more plant-based diets. And then the Western diet or inflammatory diets are associated with a higher risk of myeloma death after diagnosis. And so this is quite a significant change. 15 to 24% lower myeloma deaths is quite significant. And the Epic Oxford study had actually the same study that I discussed here, looked at myeloma and they showed that the vegans and vegetarian had 77% less myeloma than meat eaters. Plant-based diets, for cancer, I showed you epidemiologic studies looking at the association, but there are two studies looking at this more just from the obesity and diabetes perspective. And these are randomized studies, so I wanted to show it to you, where patients who were obese were randomized half to the intervention group where they were given a plant-based diet and then the other half is the control group where they continued on their own diet. And what you can see is that six months, there's a significant reduction, again, a P less than 0.001 means it's significantly less, BMI reduction at six months compared to the control which had no change. Same thing with the hemoglobin A1C, which is a marker of diabetes and also with the cholesterol, which is LDL cholesterol reduced. This is the same thing seen in both studies, so it's consistent. So we know that plant-based diets are feasible and effective weight loss strategies, but patients who are a normal BMI are not gonna lose weight further if they're eating well on a plant-based diet. So this is good, it works for patients who have a high BMI, but not if you have a high BMI, normal BMI, it's not that you're gonna just keep losing weight. 10 to 15% reduction in BMI at six months were seen in these studies. So how could a plant-based diet work? And I think there are multiple ways that it could, the high fiber in the diet, the plant chemicals, they're called phytochemicals, the changes in weight, insulin growth factor levels are lower in those eating plant-based diets. The butyrate levels, we'll talk more of that, and inflammation. All of this may lead to cancer reduction. So what are plant-based diets? And I think there are many varieties. You could think about it as being vegan. Vegan is somebody who has zero animal products. Usually people who identify as vegan are doing this for ethical and environmental reasons. Dietary factors are one of the largest drivers of global warming, and also for ethical reasons where they don't want to be eating animals. But it doesn't always have to be healthy. They can eat a lot of junk food. French fries are vegan, maybe cakes are vegan sometimes. So it depends. A vegetarian diet includes some animal products, and this is also often for ethical or religious reasons, maybe environmental, but there is eggs and dairy is allowed. And again, it doesn't have to be healthy, though it could be. A whole food plant-based diet is basically focusing on whole foods and less processed foods and more of a plant-based diet. This diet is minimal animal products, and this is mainly for health reasons where there's a focus on whole foods, and mainly plants, and avoiding processed foods. So this is where a person can be vegan and unhealthy, or they can be vegan and healthy with their following mainly a whole food plant-based diet. So I think it's important to be whole food plant-based, whatever you identify as, focusing on the majority of your calories coming from plant-based foods. Some of the reasons, we'll talk about the microbiome a little bit. And this study shows you, I had discussed this study previously in my talk also, but briefly I wanted to show it again. We have five, these were only nine individuals, five days each on a diet. They were given a heavy plant-based diet and a heavy animal-based diet, and they provided the meals for them. And what you see is patients on the plant-based diet had obviously an increased fiber intake compared to when they were on the animal-based diet, where there was very little fiber intake. Because fiber only comes from plant foods, and you'll never get fiber in any animal food. And what they showed is changes in these stool metabolites. Metabolites are things that are made of factors or molecules made by the bacteria in the stool, and the microbiome. And what they showed is the butrate levels were higher in those on the plant-based diet, and so were the acetate levels. And so there are different molecules that are activated or synthesized by the bacteria based on the diet. And we do know that short-chain fatty acids, these are short-chain fatty acids, especially butrate is known to be an inhibitor of HDAC. HDAC is actually one of the, we have a drug in myeloma to treat called Panabinostat. It's an HDAC inhibitor. Also, this pathway is known to be activated in myeloma. So we know that this inhibits these pathways and maybe having anti-cancer and anti-inflammatory effects. This is also very important. And I think understanding that eating, even if you're eating a plant-based diet, you wanna have diversity in the plant-based diet you eat and not eating the same thing every day. There are some people who might just like, their favorite well, vegetable or grain. We tend to do this in the world where everybody eats a lot of wheat and everyone might eat potatoes or broccoli, but then we forget that there are hundreds of other types of vegetables and fruits and pushing yourself to go out of your comfort zone and picking something outside of that is good. So those that ate more than 30 plants and compared to those that ate less than 10 plants per week. So think about it for yourself and count on average what you do per week. And those who eat more plants, think about it as each plant is feeding different bacteria. So more plants you eat, you have a larger diversity or more types of bacteria in your stool and less antibiotic resistance and also increased conjugated linoleic acid abundance, which is a polyunsaturated fatty acid. So that's a good fat. So these are other studies looking at microbiome in myeloma. And what you see is that healthy individuals develop some microbial imbalances in MGUS and then further microbial imbalances in small ring myeloma and in newly diagnosed myeloma. And this is based on some small studies, but I think microbiome research is still in its early phases in myeloma. So these are the three studies. And the first one is just comparing you can see that where it's red here, it's blue in MGUS and it's blue in healthy. So there is a difference in the bacteria between the three groups. This study looked at myeloma and compared them to controls and showed that there was more diversity and more nitrogen recycling bacteria in myeloma. And these bacteria accelerate myeloma progression in mice. So I'll show you that in the next slide. And then the third thing is this study looked at changes in the different bacteria again in myeloma compared to the controls and showed that there's a change in diversity, decreased diversity in myeloma. So this study looked at nitrogen recycling bacteria and showed that they actually might be accelerating progression of myeloma in mice. Obviously, this is a mouse study. We still have to understand what happens in humans, but I think that's why the trials we're doing are important. In this study, what they did is they divided mice into three groups. They first gave them antibiotics. The antibiotics are given to kill all the bacteria that are present in the gut of the mouse. And then they gave them a transplant with a feces from a myeloma patient and then from a healthy control. And PBS is just saline, so this has no bacteria. And then they looked at how quickly was the rise in the myeloma markers in the blood. And what they showed is from the mouse that had the microbiome from the myeloma patient had a faster rise in the markers than a mouse which had a healthy control microbiome. So what it's showing you here is that the microbiome from a myeloma patient in a mouse might be accelerating progression in the mouse model. Then they looked at specific bacteria because they said, like, there is this bacteria that may be more predominant in the myeloma patient, and this is a good bacteria that we're seeing more in the control. And they showed that the patient, they did the same thing, gave antibiotics and then gave a specific bacteria to the mice and showed that those that had the bad bacteria, had a faster progression in the myeloma compared to those who did not. The same thing they looked at with giving ammonium or urea. So this is where the bad bacteria may be using more ammonium or urea because these are protein metabolism leads to these urea and ammonia formation. And what they showed is there is an increase again in the protein of the myeloma faster compared to a mouse with normal saline. These are three patient studies done at MSK. And what you can see here is in this study, patients on myeloma patients on maintenance therapy. So they had finished their initial chemotherapy and they were on maintenance. And it showed that there were some of these healthier bacteria were higher in the patients who are MRD negative. MRD negative means that they're in complete remission and there's no evidence of their myeloma. So a good bacteria was more in those who were in complete remission. Same thing here. This study looked at the good bacteria, the stool butrate producers, and they showed that patients who had more of them lived longer than those who had less of them. And then this study looked at this is not as relevant to myeloma, but this study is looking at if a patient had an allogeneic transplant, meaning cells from somebody else, not an autologous transplant, which is what we do mainly for myeloma. It showed that chronic graft versus host disease is a skin immune reaction when you have a transplant from another donor. And those who had higher butrate levels had less of graft versus host disease. So their immune system was able to have less inflammation and less of these issues around a transplant. So the common theme in these three studies were the butrate producers. This is a study that we recently did and we presented the preliminary findings at the IMW meeting last year. This is actually the same first study that I showed you here, but we did some more in-depth analysis with patients on this study. So what we did is these are patients with myeloma and lenalidomide maintenance. And we collected dietary and stool data. So we looked at what they're eating over the past year. So we just looked at dietary patterns. And what we did, we had about 30 patients who we were able to measure stool butrate levels and also look at the microbiome changes and then also had diet assessments. It was difficult to get everything on all patients just because doing trials in the prospective settings sometimes can be challenging to get patients to fill out things or drop off samples and some missed samples. What we looked at, we correlated diets. So in the diets, we looked at flavonoids. Flavonoids are plant chemicals that are associated with anti-cancer and anti-inflammatory properties. And we also looked at the healthy eating index. This is an index where the higher the score you have, the better your diet is in terms of healthy foods. And then we looked at the microbiome. I told you a more diverse microbiome is better generally. And we also looked at the abundance of butrate producers, meaning the good bacteria, how many are there. And then we looked at the levels of these metabolites or factors that were produced by these bacteria. And then we looked at the outcomes. How many of the patients are staying in remission? And is there an association with these diet and microbiome changes? And what you can see here is that patients who were, when you see yes, means they're in complete remission. And you can see higher levels of diversity, higher levels of butrate producers, and higher levels of stool butrate concentrations in patients who were MRD negative. We then looked at dietary associations and healthier plant proteins and plant chemicals were associated with higher butrate levels. And this is not a surprise given that I showed you that prior study not in myeloma, but there is an increased association. So dietary patterns with healthier plant proteins and more fiber lead to gut microbiome changes. And these may be the mechanisms by which they may lead to more myeloma control. Remember, this is a very small study. It's a preliminary study. So we can't really draw conclusions to say that this applies to everybody. But this is just showing us there are some patterns and there is something here to study further. So thinking about tilting the scale for myeloma development, we know that over 3% of the population over the age of 50 have MGUS or small ring myeloma. So this is a big population. We know that 70% of the US population is overweight or obese. 45% is pre-diabetic or diabetic. So this is a big population of patients who have metabolic risk factors. And we know that all of these risk factors are associated with increased risk for myeloma. And then we know that these are associated with a decreased risk. So what if we tried to alter these factors and see if we were able to make a difference to the natural progression of myeloma in patients and understand the microbiome changes as well. So basically, our hypothesis is looking at diet and supplement these plant foods and seeing whether changes in weight, inflammation, insulin resistance, microbiome, and immune changes may lead to a long-term change in myeloma proteins. Obviously, that is a hypothesis. It doesn't mean that that's true until we prove it or show. And it's very hard to prove because these are things that happen over years or decades. But I think if we are able to show that there are some biomarkers that are changing, that we know are associated with worse outcomes or better outcomes, then it helps lead credence to what we're suspecting. So that's what we're basically looking at with this study. So patients on the study will be getting 12 weeks of a plant-based diet and 24 weeks of nutrition counseling. We actually provide the meals for the patients in partnership with a company called Plantable. And patients are followed for a year. This study has been enrolling for the last six months. And we have actually met, enrolled about half of the study and will continue to be recruiting for patients over the next six months. These are the next two or three studies that are in development. And I wanted to share a little bit about them. So this study is going to happen through telehealth and through the Health Tree Foundation. This is a much less involved study. It's going to be just two weeks. Patients can be anywhere in the United States. And if you're interested with small ring myeloma, we'd love to have you on the study. The study is not yet open. I think it's going to take about six more months to open. But it would be good to know if patients, if you're interested in this study, you can let us know. And in this study, we are also going to understand the effect of supplements. Because I think patients ask these questions. And we want to see microbiome changes to understand what supplements are doing to the microbiome. And is this moving it towards healthier or better outcomes? We have this study that's also going to open in the next four months. This study will be at MSK and probably one or two other partner sites. But these are, again, patients with MGUS or small ring myeloma. This is a more involved study where patients would have 12 weeks, similar to the first study I showed you, where patients will have 12 weeks of the diet, 12 weeks of supplement or placebo. And every patient will get the diet eventually. At the next 12 weeks, eventually, the second two arms will. And we'll be providing the diet, the supplements, and the placebo for the patients. So this study is also going to be enrolling soon. And if you're interested in a more involved study, but you might have to come in for a few visits, then this could be a study for you. We're also going to be looking at now moving to the myeloma maintenance space. So I talked to you about three studies where we're looking at precursor myeloma, where it's small ring myeloma or MGUS. But this is a study looking at patients that we actually have the maintenance study open, where patients after the chemotherapy are going on either lenalidomide or daratumab maintenance. These are drugs for myeloma. And then we're going to offer 15 patients in each of these arms 12 weeks of the diet and see what happens while they're on a drug. So this study will also be open in the next few months. But if anybody's interested, they would have to first go on to the maintenance study. And then from the maintenance study, they would be able to consider opting into the dietary aspect of it. So the dietary part is completely patient driven. So if you're interested, if a patient's not interested, they'll go into the other arm. And this is not randomized. So if a patient wants the diet, they will get it on the study. So I just want to summarize a few points. I think it's important to focus on healthful nutrition habits and quality over quantity. I know a lot of people focus on calorie restriction and things like that. But I think it's more important to think about each food that you're eating and whether it is whole foods, unprocessed, and it's got a lot of plant foods in it. So some summaries around it. Carbohydrates, whole unrefined carbohydrates actually are associated with less cancer. Carbs are not bad. It's just that you need the whole grains. Refined carbs are not good. The unprocessed, the sugary drinks, all that you want to reduce. Fiber, fiber is extremely important. And a lot of patients do not meet this 30 grams. And fiber only comes from plant foods, like I said before. Protein, there are studies looking at whether plant protein is better or animal protein. And they've showed less cancer and less mortality or death with plant protein. So fiber, plant sources of protein, that could be beans, tofu, tempeh, and reduce processed and red meats. Same thing with fats, unsaturated fats, nuts, seeds, avocados, all of that is what you would prefer. And you want to reduce dairy, fried foods, and things like that. Other things to think about is I think calorie counting and calorie restriction are difficult to sustain long term. When you try to switch your diet, think about it more as a lifestyle and do it gradually. Don't think about it as a diet and this is a restriction. Don't focus on the things you can't have, but focus on the things you can when you're switching. And regular meal times is important, ensuring adequate hydration, learning to read ingredient lists and nutrition labels can be helpful. And gradual changes are usually more sustainable when patients just suddenly switch and then they suffer because they're like, I don't know what to eat, then they're hungry and then they feel like this is not sustainable for them. So the main thing is you don't want to go hungry when you're eating. So you might have heard of something called a fiber gap. And if you haven't, the recommended daily intake for fiber is 30 grams and only 67% of consumers, 67% of consumers believe they meet their fiber needs. So most of you must think that you get enough fiber, but in reality, only 5% of you do. So it's a really small number in the United States who are getting their fiber and fiber is your friend. So think about, this is another study where they looked at fiber rich diets and fiber free diets in a mouse model. And what they showed is that this pink layer is the mucus layer in the intestine. This is the gut or the colon lining. This is the intestine and these are all the bacteria in the intestine. And this mucosa is the healthy mucosa, the barrier that we need, this mucus layer barrier to protect our lining and prevent it. This lining tends to break down when there is no fiber because the bacteria end up eating this mucus because they have nothing else to eat. Bacteria eat fiber in general. So it's important to feed your bacteria with fiber. Another concept I think is important is understanding calorie density instead of calorie counting. I think a lot of people focus on the calories and with that, it's very difficult to sustain it because you're always focused on, oh, this is too many calories and I can't eat it. But if you look at this and you understand what calorie density is, these are all the same amount of calories, but fruits and vegetables will almost fill up your whole stomach with the same amount of 500 calories, whereas oil, just a few tablespoons are going to fill you up and it's 500 calories and not fill you up. So if you just eat more fiber and plant foods, you will be full more and you will not feel hungry and you will be able to eat. Another thing is reading ingredient lists. Not all bread is the same. So I just wanted to show an example here. Obviously there are many more examples, but this English muffin, Thomas English muffins, market themselves as 100% whole wheat. But when you look at their ingredients, you will see that there is sugar, there's salt, there's a lot of other things in it along with milk. It's not just a wheat bread. Whereas if you look at this bread, you see that there's nothing else other than just all the sprouted grains and yeast. And the order in which ingredients are written is literally how much of the ingredients are. So the one that's first, the most of it is there and then it goes down the list. So you can see that the sodium levels are high in this one. The fiber is not as high as this one. So you might want to pick a bread that has a high fiber content, has no sugar content. Like this one has zero sugars, this one has a gram. So this is just something to think about when you're buying your products. Same thing, this bread, probably not as healthy as this one, but still a very healthy option. If you look at the ingredient list, it's very clear that all of it is just whole wheat. It doesn't have to be organic. This bread does say that, but it doesn't have to be. I'm telling you more to focus on the whole. If you see wheat flour, it doesn't mean it's whole, but this means it's whole wheat flour. Another example, looking at yogurt and reading nutrition labels. So here you can see that these are all different yogurts and I've just like compared them just for you to understand what I mean. So non-fat doesn't mean it's better because it has more sodium, more carbohydrates, more sugar. And if you look at the whole milk one will have more cholesterol. So cholesterol only comes from animal foods. You will never find cholesterol in plant foods. So you can see that two plant-based yogurts have zero cholesterol and the others have cholesterol. So when they make non-fat yogurts and things like that, they have to still make it tasty because otherwise when they take the fat out, they add sugar and salt. So it doesn't mean that non-fat is always healthy. So it's important to look and think about these things. So a few things I just wanna conclude with. Obesity we know is a risk factor. Diabetes we know is associated with myeloma though we don't know whether it's causative or correlative. We know that nutrition matters for COVID, for cancer, for myeloma. And we would also know that microbiome matters but understanding how to manipulate and modulate it is something that's going to, we're gonna see more of it in the next few years. So with this, I'd like to thank all the sources of funding, my team at MSK and outside the collaborators. And if you are interested in participating in trials, if you have ideas for us of research that we could do, we'd be glad to hear it or any support you're interested in. So I think it's important to think about dietary habits. They affect comorbidities, they affect the microbiome, they affect your immunity and may affect plasma cell disorder outcomes. So it's nice to keep your fridge full with lot of options. So whenever you're hungry, you're not picking the fast food or ordering last minute because you planned ahead and you thought of what you might want and having a full fridge refrigerator is a good way to mitigate that. So with that, I'll end and... Thank you so much, Dr. Shah. And now we will turn the time over to William to share his story. Hello, everyone. I'm Will Wright. I'm 71 years old. I've been diagnosed with smothering myeloma, M. gus, for five years now. I had been very concerned about my ability to stave off full-blown myeloma and was interested in doing all I can to be able to mitigate any type of behaviors that I was doing at the time to be able to extend my life. Now, what makes this to me so important is that in 2010 was a very dark year for me. I was diagnosed in the same week having prostate cancer as well as renal cell carcinoma, kidney cancer. And the reason, the way I found it, those diseases was that it was July of that year. It was extremely hot. It was a record heat. I traveled in from Long Island to Manhattan, where I work. And this particular day, I stepped off the Long Island Railroad and going up the stairs at Hunter's Point Avenue, a street flight of stairs, a very steep station. And at the top of the stairs, I fainted. And I normally didn't feel as though there was anything particularly wrong at the time. But I went to work and I explained to my boss that I was running late. And just so happens that that week was Men's Health Week at my job. It was NBC Universal and it was Men's Health Week. And my boss said to me, you should go see if they can help you because it just so happens that they have urologists and men's health experts on site at the time. And also NBC Universal has a clinic. And so I should take advantage of the health benefit. Well, to my surprise, I visited the urologist there and the first thing they did was kind of check my red blood cell levels and I was hyperanemic. And next week I stepped in into the hospital for a battery of tests. And the first thing they found was that I had some nodes on my kidney. Which were cancerous. But they didn't stop there. They also noticed that there were nodes on my prostate which were cancerous. And it looked to me that I was doomed because a few years before that, I was diagnosed with being diabetic. So it seems that when you have these type of comorbidities that it would be a death sentence. That there was probably very little you can do. But fortunately for me, the doctors at Memorial Sloan Kettering didn't give up. They said, well, let's see what we could do about this. And so that year I had a partial nephrectomy which cut out all of the cancer of my kidneys. And I had my prostate removed which cut out all the cancer in my prostate. But they explained to me that just by sheer coincidence that incident that I had where I fainted was really important because it was that trigger that made me get myself checked out because both those diseases are fatal if they're allowed to continue unchecked. Especially prostate cancer, especially among men. So I then decided that I was gonna do all I can for whatever came up in my life to be able to do something about it. In the renal team at Memorial Sloan Kettering noticed that there were markers in my blood test that showed that I was pointed toward MGUS a smoldering myeloma. And they referred me to Dr. Alexei Shingarev who since then left Memorial Sloan Kettering and said but don't worry, I'm gonna put you in really good hands. And he pointed me toward Dr. Irvi Shaw. And I met Dr. Shaw and I told about all of my issues and I asked her, well, what can be done to prevent me from developing into a full blown myeloma patient? And she said, the first thing you should do is try to lose weight. Because at the time I was weighing 216 pounds, five nine, 216 pounds, that puts you in the obesity range. I think my body mass index was 36. It was pretty bad. And I was still struggling with diabetes. It was being obese, it was unchecked. I had to use tons of insulin to stay, to keep that in check. And my dietary habits were absolutely awful. And they were awful because I like to be the one in my household to cook. I cook for my family. I've always been that way. When I was in college, I cooked for my friends. When I was at home with my parents, I would follow my grandmother around the kitchen. She taught me how to cook. I am an amazing chef. And it's not necessarily the most healthy foods that you can have, but I can guarantee you it's the most tasty foods that you have. But the problem with that was I was obese. And anybody who hung around me was gonna get obese too because my dietary habits were awful. So I tried on my own to lose weight. And I managed in the eight months, the first eight months in which I met Dr. Shaw, I managed to get that 216 pounds down to 196. And not necessarily by doing any specific type of diet, but just pushing away from the table, eating less and exercising more and paying attention to portion control. And I thought I could never get any better. And Dr. Shaw would always coach me that my microbiome and the eating plant-based foods might be more beneficial to me. And she explained to me, and just as she spent the last 20, 25 minutes with us, going through the details on how it could be beneficial to you. And I am just so very fortunate that I was smart enough to pay attention to what she was telling me to listen to me. And then she said, we'll have a study that's coming up. And if you're interested in that study, I might be able to put you in. But you'll have to eat the food that we give you. It's gonna be plant-based. And the first thing I thought was, well, culturally that's an issue because being my family chef and African-American foods tend to be fatty and very meaty and extremely seasoned. I'm not sure if I'd be able to follow a vegan diet and if I can make it tasty. But I promised her that if you allow me into this study and give me the opportunity to improve my chances of surviving MGUS and not developing to myeloma, I promise you I will do everything I can to show you that A, I will pay attention to the diet. I will eat specifically what is given to me. And I will take all of the tests because I want you to see if there is any changes in my body, not only for me, but for also for African-American men who were very rarely part of these types of studies because of institutional distrust and also issues that we experienced in the past in terms of not feeling as though the medical community was operating in our best interest, but for things that was in their best interest. But my relationship with Dr. Shaw was something that was almost magical because I think that the success that I have at this point with memorial Sloan Kettering was that the medicine was important, but the trust that I had in the doctors were part of it. Then I really took an exercise regimen, my daughter in the mornings leads for the past year and a half was been leading my wife and me and a team of her friends and body pumps. So we've been doing exercise. So family diet, exercise and medicine became the cornerstone of my plan to survive this MGUS thing. So come August of this year, when the study started, I started getting food delivered to my house once a week from Plantable. They provided for me food for five days a week and it was for three months. And the two days that I didn't get Plantable foods, I was to follow a plant-based regimen to augment, to support what I was doing. And I think it was that way so I wouldn't go cold turkey, but as it turns out with the food that I got from Plantable, I started dropping pounds very quickly. And it wasn't because I was hungry, it wasn't because I was starving myself or because I was sick, it was because the impact of how Plantable viewed their dietary regimen was scientific. So if you, I'm not a scientist, I play one from time to time when I was writing articles, but one thing I did notice in looking at Dr. Shaw's presentation is that they're very specific markers, very specific chemical reactions that plant-based diets have for you, the way they react to you, the way they react in your gut, the way they supplement your body's immune system. And the food that was provided for me had the science behind it. So I recognized that if I really paid attention to this, that I would benefit greatly. And as it turns out that in August of 2021, I weighed 196 pounds and today I weigh 163 pounds. My body mass index is 24.1, so I'm officially no longer obese. And I was managed to, if you consider the fact that it was 53 pounds, weight differential from the time I really started on this journey to now. And my energy level is through the roof in terms of my physical strength and my moods, my happiness and my outlook for survival for the future. All of that has been buoyed by just paying attention to the diet. And did I ever think that veganism would be a thing for me? I could tell you, I have a lot of friends who are Mediterranean in their culture. And I would go out with them or I would go to their house and they would have their Mediterranean food and it would be vegetarian. And I would say, I'll be back. And I'd go out and have a hamburger because that was to me what was satisfying. And I never thought I would be able to get to this point. But I found that with the creativity of what I know about how to prepare food, there's, I look forward to preparing meals that are plant-based and relatively healthy. I get recipes from Plantable. I get recipes from Forks Over Knives. There are a lot of websites out there that are willing to help you and very generous with their ideas and with their information. And I've been very, I just feel so fortunate, so very lucky to have encountered this lifestyle. And I mentioned lifestyle because it is, it is a change in lifestyle for me. Even the times of days I eat, the fact that I now make sure that I log my food. And that's really important because Dr. Shaw's study requires you to log food. And the fun part was that I was logging food and I went to Dr. Shaw and I said, you know, I don't mind logging the food, but there's not enough room on this paper for what I'm doing and how I'm doing it. So I'll just take a second and show you, I'm no longer in the intervention part. It's the maintenance part of the study. But I wanted to show you what I do to... We'll also share about your diabetes experience. I think you didn't share about that. Oh, oh, yes, yes. Oh, well, before we get to that, then let me pop this. You can do that. No, let me, that's really important because I mentioned that I was diabetic and I took a lot of insulin prior to getting into the plant-based diet regimen. So you've been diabetic for over 10 years, right? For 15 years, for 15 years. I started off with metformin. I found that my diabetes was so out of control that pills were not working for me. So I went to injectables. I... Levamir and Novolog. Levamir to kind of get me through the day and Novolog for whenever I spiked. And I would literally chase my highs and lows. And it was more like a cat and mouse game. And then to keep my kidneys and my internal organs in check, I first started off using Bayetta. That stopped working. So then I was moved to Victoza and now I'm on Trilicity. But the point is I have not used a shot of insulin since August, not a single shot of insulin. And the interesting thing, I could even show you some interesting things about that. Let me do this. I will first show you my log. Well, we're talking diabetes, right? So let me... This is... I use clarity to kind of keep me whole in terms of where I'm at. And at this very moment, my blood glucose is 125. But you could see this is my range today, which is really interesting because this is 180 to 70. This is where I'm supposed to be and stay in that range. And you could see it's pretty steady. It's very remarkable. I wanted to add one thing, Will. Plant-based diets, you would think about as high carbohydrate diets because it's low protein, low fat. And despite being high in carbohydrates, your sugars are within the normal range. So complex carbohydrates aren't really bad if you're diabetic, if you're following like a whole food plant-based diet. So I just wanted to bring that out too. Yeah, and also, I used to love drinking Coca-Cola and I used to love drinking Cognac. All of that is behind me. I'll show you my food log. When I came off the intervention part of the study, I started maintaining my own log. And you could just see going from October, where I would log what my breakfast would be. Will, we can't see the food log. So you're gonna have to- You have to switch your screen, I think, or share. We can still see your blood sugars. Oh, got it, got it. Okay, let me, thanks for telling me. Let me see. Let me pull out for a second. Okay, let me go behind here and see what's going on. Okay, let me close the blood sugar. Got that, okay. Now, let's see. Sorry about that. Okay, let's see. Do you see it now? Yes. Okay, good. All right. So I put together, one of the things that was really important when I was, I'm retired now. I've been retired for over a year and a half. But when I was working, one of the things that we felt was really important in my line of work were metrics. That in order for you to make a change, to see how your blood sugar level and to see how you're doing, what the output is of your productivity is to log it. And I felt that the most important thing to keep me on track with my diet was to log my food. And if you log your food, you get a sense of where you're going or where you're at. For instance, back in October 16th, and I'll just go from the top all the way to the bottom very quickly. On this day, I weighed 168.6 pounds. My blood sugar was 103 on that day. That was my average. If we go all the way down to my very last day, Monday, well, let's go to, I didn't finish here, but let's go to Sunday where I log my food. I weighed 164.8 pounds. And I also logged my blood pressures and I also logged my glucose levels, which I showed you. And the thing is when you see all of this in one place, if you see how you're doing, it becomes not scientific, but it's almost, it's an epiphany in terms of how your body is helping you. And you're able to see how your body is helping you and what your body is doing for you. And so in summary, I could go on, I'm just so ecstatic about what has happened for me. I can go on for a while, but I just, I'm willing to, if anybody wants to do a follow-up with me, you can contact, well, you can contact me, willwilliam.right at fcc.edu. So contact me and I'll be very happy to share all of this information with you and all that I've done because I want to see everybody that's successful at this. And I was just so grateful to Dr. Shaw for just being my guardian angel. I was telling Audrey how fortunate I was. Not that I really enjoyed working with Dr. Shingerev, but he left and turned me over to Dr. Shaw and it was one of the best days of my life. Oh, Will, thank you so much for sharing your story with us. I really do appreciate you. And thank you, Dr. Shaw, for your comments. There's lots of questions here. I'll try to ask the most popular ones. And thank you again, both of you, for sharing your experiences and data with us. Yeah, thank you, Will. That was really nice of you to share your story. And it is really impressive how you've taken your own health into your hands. So very, very impressive story. Proud of you, Will. So one of the questions that's frequently asked here is what about coffee, tea, alcohol? What were your recommendations regarding these in terms of a whole food plant-based diet or healthier diet? Yeah, so I think green tea is good, coffee is good, but the issues that come with it is like the sugar that goes with the coffee or the tea. Sometimes if there's a lot of milk or things like that, that's what adds to the thing. But coffee in itself and green tea have actually been shown to have beneficial effects towards the microbiome and overall health. So I wouldn't say you have to cut out coffee or tea. You just wanna figure how you're having it and try to minimize the sugar especially and consider milk that's either a plant-based milk, if you would like to do that, or if you're doing regular milk, then do a little bit, not too much. Awesome, thank you for that. And then in terms of alcohol? So alcohol in general has been associated with an increased risk of multiple cancers. So alcohol consumption has an association which is quite strong. For myeloma, interestingly, there was one study that looked at this and showed that alcohol maybe has a decreased risk of myeloma, but it doesn't make a lot of sense because all the other studies are showing an increased risk for other cancers. And I think part of it could be that red wine has resverterol or these polyphenols as we call them, and they could have anti-cancer effects. But I don't think you need red wine to get those. You can just have grapes and get them or plant-based foods. So yes, if you want to have a little bit of red wine or alcohol, I wouldn't say like you have to cut it out, but it's good to do that in moderation and a little bit. It's very clearly linked to many cancers. Awesome, thank you. There's another question about intermittent fasting. Is that something that you recommend to your patients? So I'm not a proponent of trying to calorie restrict, fast, do all of those things because it just makes it very difficult and you are restricting yourself, which becomes hard to do long-term. If you find that intermittent fasting works well for you, there is some thought that there are beneficial effects on the metabolism and things where you have these brief periods where you're not eating. But I think part of why intermittent fasting may work is because overall you might just be eating less calories because you're eating for less time in the day. But if somebody is going to fast and then be so hungry that they eat a lot after, then I don't know that intermittent fasting is doing a lot. So there isn't a lot of data in myeloma. I know that there might be some studies from other centers looking at these things, but I would say if it works for you, there's nothing wrong with doing it. But I think it's more important the quality of the foods than trying to not eat at times. Definitely. Thank you for that. Another question is about probiotics. What are your opinions about taking these probiotics? And then there's follow-up questions to that, but let's just- Sure. So probiotics, I think is a complex issue. I would strongly recommend that patients focus on dietary changes, which are considered prebiotic because the fiber leads to changes in the gut bacteria. Probiotics, actually in one study recently published in Science by Spencer, it's from MD Anderson, this paper, they looked at melanoma and they looked at patients who were on immunotherapy with checkpoint inhibitors. So we don't really use them in myeloma. So this is not applicable exactly, but they show that those on probiotics actually did worse with the treatment than those who are not. So there may actually be something where in a probiotic, there are only very particular few strains of bacteria and you're not getting a diversity like with food that you eat. And so you're actually reducing diversity possibly with probiotics. But there are other studies showing that probiotics might increase the butrate producing bacteria or the good bacteria because these probiotic supplements try to enrich for the good bacteria that make these good molecules. So I think the jury is kind of not out on it. For myeloma, we don't know. That's why we're going to be studying it with a Neutrovention 2 study. It may not be right for with certain immune therapies and combination, like I said, but I think if you can do it with your diet, you don't really need the probiotic always. But for people who don't want to change their diet or things, maybe a probiotic could help. And I think that's what we'll be looking at. Thank you. Is there any vitamins that you recommend to your patients that they take consistently? So you can go back to the previous talks also, but vitamin D is one that I specifically recommend if it's less than 30. So I would like to see a vitamin D level over 30 for most patients if possible, or supplement. And then I'd say on plant-based diets, B12 is important to take once a week. And the reason for that is that B12 actually doesn't come from animal sources. It comes from actually the soil microbes. So if you eat dirt or soil, you will get B12, but we live in a very clean world. So we don't, even if we eat greens, we eat them triple washed and we're not eating the soil with it. And because of that, a plant-based diet is not getting enough B12, but animal-based diets get the B12 a little bit better than plant-based, not completely, but the way they get it is because in animal agriculture, the animals are injected with B12 or they are eating the dirt and then you're eating the animals. So you get some B12 through that, but it's not like meat inherently has B12 in it. Yeah. In terms of other supplements, since we're on the subject, do collagen peptide supplements pose as a danger for people with plasma cell disorders? There's no data, so I can't really say, but again, collagen, it's hard to know whether the high protein or whether collagen might be affecting the microbiome. I think these are the things we need to study and understand. No, that's great to know where we have to work on and what we know so far. I have several people wondering how they can either subscribe or register, what is that word that I'm forgetting? Join the study that is currently open or join the studies that are to come. So the studies that are currently open, like the new prevention pilot study, you can just reach out to me. There is, if you go to the clinicaltrials.gov, you will find a contact details there for the study, or you could even reach out to Audrey or something, or me, and then directly we can reach out to you with information about the study. For the other studies and your prevention too, we don't, it's not yet open, and probably in six months it will be, but I'm wondering if Audrey, like the Myeloma crowd, could create a way that you all are starting to collect a list of names for the new prevention too, because this is going to be through Health Tree, and if we are able to collect this list, then when the study opens, we can send out an email to all the patients who are interested. So that could be something we could do through Health Tree, maybe a form they fill out or something, and you get the contact details. Definitely. I see lots of questions here about tumeric or curcumin, and I just want you guys to know that next month in our Nutrition and Wellness for Myeloma chapter, we're going to be having somebody come and speak about supplements in general and how it affects cancers, so specifically precursor Myeloma. This is Dr. Terry. She's actually done some of the curcumin studies in Myeloma. In brief, there is very little data around this, and curcumin has been shown to have positive effects on the microbiome and things like that, so there may be a benefit, but it's not going to be a quick benefit, and it may be a long-term, and it may be in some populations, and that's part of the reason why we're studying it in the Nutrivention 2 and 3 study, because it's expensive to take these supplements, and we want to really understand what is it doing to the microbiome, is it helping patients. So if you're interested in doing the study, let us know. Awesome. Is there a difference between organic and non-organic? Go back to my talk from last year, I discussed that and bring up two, three studies around it. In brief, I would say, it's better to eat non-organic plant foods than not eat them at all, and there may be, some studies have shown no difference, then maybe some studies might show a slight improvement, but that may be because people who eat organic might just be choosing a healthier lifestyle, so we don't really know, and I would say it's better to eat plants than not eat plants, even if they're organic, and I have gone over some numbers and studies in that previous talk. Yeah, and she's mentioned those previous talks, there's two talks, like she talked about in the beginning, that she had previously given last year, and we will send recordings of those sessions out in the follow-up email that will include this recording as well, to your emails to everybody who registered, so if you're wondering what we're talking about, you will have access to those recordings. There was a question about the metformin dosage in the study, that study was looking at just patients who are already on it in a large population study, so it wasn't looking at the dosage, but there is a study looking at metformin that's from the Dana-Farber Cancer Institute, Dr. Catherine Maranac is running that one, so if you're interested in taking part in a MGUS small ring metformin study, you could reach out to their team. Awesome, thank you. There are some questions about, if there are similar studies for relapse multiple myeloma, like there are for MGUS. We would really like to do them, I think this is all, we've developed all these studies in the last few years, and with the support from patients like you and the enthusiasm, I think that would be our next step. We have a study in the myeloma maintenance setting, but not in the relapse setting, and I think once we gather a little bit of data in this, we could start doing more studies around it, but I definitely think we'd like to do that. And my, yeah, keep asking the questions, keep attending events like this, the more interest that we can show in this subject is going to get us more funding, is going to get us more clinical trials, is going to get us more answers, so keep doing what you're doing. I know it's frustrating not to have the answers you want, but this is where we start, and this is how we make changes. My son's trying to get into the room. So a couple other good questions, just as we finish up here, one of the attendees is wondering, their bone doctor is recommending yogurt and cheese for the calcium, but if they're plant-based, how can they get enough calcium? This is a common question, so I'd love for you to answer it. So if you just Google calcium-rich plant foods, I think kale is one of them, and things you can find a lot of them. I think another important thing is just make sure your vitamin D levels are good, because to get calcium from the food, you need to have good vitamin D, because that's what helps absorb it. And if you have low vitamin D, as much calcium as you eat, you're not going to really absorb the calcium from the foods. So I think those are some of the things. And then even fortified milks, like soy milk and things, a lot of them are fortified the same way as like, and have similar calcium content. Beans have calcium, there's a lot. So if you eat a really good whole food plant-based diet and think about a few calcium sources that you like by just Googling what are calcium plant-based sources and making sure you eat them regularly, making sure your vitamin D levels are good, I think overall you'd be fine if you feel like you really need more than a supplement could be okay as well, I think. Okay, awesome. Is the maintenance trial open right now, Dr. Shah? It will be, the trial for the drugs is open and the patients will go on the nutrition part of the study at one year on the trial for the maintenance. So it is open. And if you go on the study when you're like close, you have to be within six months of completing your chemotherapy or transplant or whatever it is. And once you go on the study, the nutrition part will start at 12 months of being on the study. So we're not doing it immediately as soon as you start on the study, but within the first year. So yes, if you're interested, you could join the study now and then it will be open in 12 months and then you would be able to go, it'll be open in few months, but you'll be able to go on it within the year. Okay, and I'll make sure that that's clear in our follow-up email that they can reach out to us if they're interested in any of those studies. So a couple more questions. Are vegan meats like Impossible Burgers, vegan sausage, et cetera, super processed or healthy? So they are very processed, but I would use them as an occasional when you're craving something or missing it, or use it as a way to transition, you know, when somebody's never eaten beans or soy or tofu and they're like, I don't like this, then maybe sometimes an occasional thing could be, you know, these are good transition things. There was a study called the Swap Meat Study, and I think again, I spoke about this in one of our last talks, but the Swap Meat Study compared eating basically all animal foods and then the plant-based version of those animal foods like chicken and then plant-based chicken, meat and a hamburger, Impossible Burger, and what they showed is the Beyond Meat Burger, and they showed that because even though these are plant-based foods, they have some fiber, because they're plant-based meats, they have some fiber in them. So there was actually a cholesterol improvement and things, not as much as if you eat beans, there was a little bit with that compared to eating the fully animal-based foods. What we don't know about it is obviously these are processed foods, so all the other chemicals or things that in the long-term may affect it. So I think it shouldn't be your staple diet, but if there's an occasional time somebody's really craving it or missing it, I don't think there's anything wrong with it. Awesome. And what has your experience been with those kinds of foods, William? As Dr. Schoetzer said, there are times when I do miss a hamburger, so I will do an Impossible Burger, but I've grown accustomed to really want just plants. Like a black bean burger or something. Yeah, yeah. But the Impossible Burger, also, sorry, one thing, the issue is that they have a lot of sodium in them sometimes, so you have to watch out for that if hypertension or things or heart failure is an issue. Yeah. Okay, awesome. And then... Somebody asked about fiber, and should we take a fiber supplement to get to 30 grams? I think, like I said, again, those are shortcuts, probiotics, fiber, everything, by taking a supplement, but a fiber supplement is, again, not the variety that your microbiome needs. It's, again, going to be one type of fiber, so I don't think it's the same thing, but it's better probably than not doing anything. Okay, awesome. And same with iron supplement. What's your opinion on that? I would only take it if you're iron deficient, otherwise you don't need it. And a lot of people who are anemic and not iron deficient end up taking iron supplements, and they shouldn't be, because iron overload is also a problem, and too much iron is not good. So only take it if you're iron deficient, otherwise there's no need for it. Okay, a couple of quick questions. Are egg whites and whole eggs, do they have the same health profile? Whole eggs have a lot of cholesterol. They have choline, and the yellow part of it has, the white has a little more protein, so there is a difference significant in terms of the nutrition value of a whole egg compared to this thing. But cholesterol from eggs is quite a bit, or there is going to be, if you're eating the yellow off it. So I would say that, yeah, occasional eggs are fine, but I wouldn't make that a daily staple. There is no study has shown that eggs reduce cancer or reduce, but they've shown maybe slight increase in sub-studies, maybe no difference. But if you're actually looking at foods that reduce risk, then the eggs don't fall into that. What were you gonna say, William? Well, I was gonna ask that to show you. I really missed eggs, and then I discovered something called just egg, which is mung beans, I believe. And it comes in two forms, it's frozen, and it's a paddy, and it's easy to cook, and then it comes in a liquid. The key is cook it low and slow, but it is so close to eggs that it's become my go-to breakfast. I make it sometimes too, and I rarely want to have the scrambled egg or something, but I don't miss it that much, so I don't. But my husband does, so I make it more because of him. That's awesome. Let's finish with this question. Actually, okay, sorry, two more questions. Barbara's wondering, with celiac disease, how she can get enough fiber? So, you know, we think about, celiac disease means you can't eat gluten, but there are so many different whole grains that are non-gluten whole grains, like there are millet, and there is quinoa, and there's buckwheat, and all of these things. So focusing on, and I would say this to even people who are non-celiac, what happens in the world just now is that you go out to eat a pizza, you go to eat pasta, you eat any bread, everything is wheat, and you just don't end up eating other grains. So you have to make it your mission to eat other grains, otherwise you'll never eat them. And I also, as a part of the same problem, where I would just automatically, we're so used to the taste of wheat for everything, like breads and all, that's what we pick. But now, I actually actively seek out different grains, and I'll say this wheat, and rice is the other one. We constantly eat rice with everything, white rice and wheat. Those are the two things everybody eats. I actually will make millet sometimes, or quinoa sometimes, or buckwheat, or different things to eat with the lentils that I make or something, so that I'm not eating rice every single day, or eating wheat. So it's good to switch it up, like I said already. And I think if you're celiac, then you just don't have the wheat, but there's so many other whole grains, if you look them up. Awesome, thank you. And then for the last question, and just so you two know, there are comment sections full of thank yous, and great jobs, and especially you, William, how inspiring your story is. So thank you again for taking the time to share with us tonight. Let's finish with Anita's question, because I think this is a common misconception. How can you lose weight, and get enough protein without gaining weight? So this is, I think I'd shown a slide around protein, and fiber in my last talk. That's why I didn't repeat it here, but actually a whole food plant-based diet, if you actually count the amount of protein in a day, and I had made an example of like plant-based foods, every food has carbohydrates, fat, and protein, because these are the three building blocks, so you can't take away, there's no food with zero protein, it would be very unusual. Most food have some, so if you're eating a whole food plant-based diet, even broccoli has protein, and things like that, so you will get enough, and I think we live in a world that's protein obsessed, but I think we should be living in a world that's fiber obsessed, and I think if you get enough fiber from your food, because you're eating whole foods, you will get your protein. We don't really need that much protein, so people on animal-based diets, who like a Western diet, probably get two times the amount of protein that's required on average, like we need about 0.8 grams per kilo, and they easily get two grams per kilo on a animal-based diet. On a plant-based diet, that's whole food, you will get over one and a half grams, or more than one gram per kilo, so you're already exceeding it with a plant-based diet, and with an animal-based diet, you're overexceeding it, and there are some studies showing kidney diseases associated with more animal-based foods and protein foods, so there is association where just more protein is not always healthy. Thank you for that, and I think William's just a testament to the fact that he was able to lose weight and feel better about himself. I mean, you already said it all, Will. Well, I noticed there's a question from Ellen about night eating. I used to do a lot of night eating, but being plant-based, I'm not hungry at night anymore, so that's not part of what I do. So I have three meals, and they're all plant-based and very nutritious, very filling, and I'm just enjoying it. If I get an urge to eat something at night, I'll take about 12 shell pecans or a few almonds, and that's it. Awesome, awesome. That's so inspiring. I'm like, I need to eat healthy. All right, thank you both so much for your participation. I'm just gonna end with a couple outro announcements, but thank you so much, and I hope to see you both again very soon. Thank you, Audrey. Thanks, Will. So, you can join us for our next meeting. We're gonna be meeting every other month as part of the MGUS Small Learning Chapter, and we're gonna be talking next time about MRD testing, or minimal residual disease testing, within precursor conditions. So MGUS Small Learning. Is it recommended to test for minimal residual disease as a precursor patient? Why or why not? And more details about this event will be coming shortly. You may be interested in other myeloma crowd community events we have coming up. On the 26th, we're gonna be talking about how to navigate neuropathy through nutrition. On the 27th, we're gonna be hosting our African-American myeloma community chapter. We're gonna be talking about fitness tips for your winter exercise reboot with fitness expert Vanya. And then the first is gonna be our budgeting workshop, and we're gonna be talking about how to pay for the costs of cancer through budgeting, getting our financial affairs in order. Willink, do sign up for any of those events. Excuse me, and even more events that I haven't mentioned is found at the bottom of the slide and will be sent out in the follow-up email along with the different recordings and resources that we've mentioned today. And feel free to reach out to me. I see some people asking about Dr. Shah's contact info, Will's contact info. I'll be the middleman for them. When we send out our email, respond to me saying, hey, I wanna be in contact with them, and I can make that connection for you. Once again, I thank you to our sponsors, Whistlemire Squibb, Takeda Oncology, CarioFarm Therapeutics, Adaptive Biotechnologies, Janssen Oncology, Abbe, Sanofi, Amgen Oncology, and Genentech. Thank you to each of you for spending the night, some of your night with us or day, depending on where you're located. And we're just really appreciative of the information that was shared here. We appreciate you. Hope that you have a great rest of your night. And thank you all so much. Take care.