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This section will give you practical tips and advice on how to cope with eating and digestion challenges during treatment.

But first of all there are five very clear benefits to eating healthily before, during and after treatment:

* a balanced and healthy diet before treatment gives you a store of nutrients to help you keep up your strength, prevent excess tissue breakdown, assist  with tissue repair and help defend against infection
* there is evidence that people who eat healthily before and during treatment are better able to cope with side effects
* some treatments are actually more effective if the person with cancer is well-nourished and getting enough calories and protein
* you may be able to tolerate higher doses of treatment
* well-nourished people tend to recover from treatment more quickly

Not everyone experiences side effects during cancer treatment. It can’t really be predicted how treatment will affect you, and until you begin treatment, you don’t know how you will feel. Because of the variability in people’s response to treatment, and indeed to their diagnosis, it is important, from a nutritional point of view, to listen to your body. You must not feel pressurised by yourself or any one else to eat textbook-definition ‘healthy food’ if you aren’t up to it.  Do what you can and what your body tells you to do. If that means sipping soup and build- up drinks for a while, so be it. Many people find that their energy and digestion is improved with the ‘little and often’ approach – with whatever food they eat.

Although there aren’t any ‘rules’ as such on how to eat during treatment, the optimal diet during treatment and recovery is, ideally, one high in variety and in nourishment. Some people may continue to have a good appetite and eat as normal throughout their treatment. Others may have days, and sometimes longer, of either not wanting to eat at all or experiencing physical difficulties in eating. For many people, side effects will come and go with the rhythms of treatment. Adjusting your diet is a key way of handling your body’s changing responses and needs.

If you are able to, planning ahead can really help. Time and energy-savers such as supermarket delivery, stocking your freezer and larder (for variety and to minimise shopping later) and getting others to shop and cook for you, are often invaluable when you are in the midst of treatment. Take the time to make a list of what would be most helpful for you to do yourself beforehand, and also of what others can do for you. Update this list as you go through treatment.

Factors affecting eating and nutrition during treatment

• The cancer itself
• Mood changes; state of mind
• Hospital environment (and the unappetising food that may be offered)
• Surgery, Chemotherapy, Radiotherapy, Immunotherapy and Hormone Therapy

Potential unwanted side-effects

• Loss of appetite/weight loss: due to cancer itself, drug side effects and/or psychological state
• Feeling full quickly 
• Abdominal pain and discomfort (bloating and wind)
• General or site-specific pain (e.g. from surgery or radiotherapy)
• Nausea/vomiting
• Diarrhoea
• Constipation
• Food malabsorption (eating enough but still losing weight)
• Taste changes (known as ‘mouth blindness’) that result in decreased appetite/weight
• Dry mouth
• Tiredness
• Physical problems with eating: difficulty swallowing; sore mouth; dry mouth; mouth ulcers
• Weight gain (e.g. because steroids increase appetite)


This may sound like quite a long list. Different treatments can cause different side-effects. Some effects will only be very temporary while others may linger a bit. Although it isn’t necessarily helpful to anticipate experiencing every side-effect going, it is probably wise to expect one or two and have strategies to best manage them. 


CHALLENGES TO EATING 

The tips detailed below are to help you get through any discomfort and worry about eating. If problems persist beyond what you can reasonably tolerate or if you are losing a lot of weight (more than five per cent of your norm in one month) you should speak to your treatment team or your doctor.

Preventing and Treating Nausea and Vomiting
Nausea and vomiting are probably the most familiar – and most dreaded – side effects of cancer treatment. They can be experienced by those undergoing chemotherapy or radiotherapy, or as a perfectly normal stress reaction to the diagnosis and treatment of cancer. Usually the experience is mild and short-lived. If, however, it is prolonged or extreme, anti-emetic (anti-nausea) drugs can be prescribed to lessen this symptom. 
Before Treatment:
• Ask your doctor or treatment team about the likelihood of your treatment causing nausea or vomiting. These symptoms are decreased if anti-emetic (anti-sickness) drugs are taken just prior to treatment. Take the medication as recommended – don’t wait until you are feeling sick.
• If you are up to it, prepare single-serving portions of soups, stews and other meals for heating up later. Better yet, get someone else to cook for you. Friends and family are often glad of the chance to help. 
• Refrain from eating or drinking for two hours before or after treatment.
On treatment days: 
• Avoid eating your favourite foods on treatment days. Doing so may result in a ‘learned aversion’ to these foods. For example, don’t tuck into a grilled chicken salad if that is your favourite meal, as you may associate any nausea experienced after treatment with this particular meal, and that would be a shame. If you are trying to give up chocolate this might be a good time to eat some!
Nausea prevention 
• Have a small starchy snack followed by a room temperature drink (less of a shock to the stomach) two hours after treatment ends. Even if you don’t feel much like eating do try and drink little and often.
• Eat small, frequent, snack-size meals. This will help restore your energy and cause less stimulation to your digestive system.
• Eat sitting up. This may sound a bit like something your granny might say but it will help food and stomach acids from backing up into the oesophagus.
• Steer clear of cooking odours, tobacco smoke and strong perfumes. Pressure and steam cookers reduce cooking smells, while cold or room-temperature foods tend to be less smelly. Sandwiches are a good, odour-free option.
• Eat lower-fat foods. Fat keeps food in the stomach longer, increasing the opportunity for nausea to develop. 
• Go for bland foods until you know you will not be nauseous. Strong odours and flavours as well as extremes (e.g. very salty, very sweet, very squishy) can be off-putting.
• Eat easily digested foods, such as savoury biscuits, dry toast or pretzels. This is highly recommended as a first bite two hours after treatment. If this is well-tolerated, move on to something low in fat and high in protein, like poached white fish or skinless chicken breast, lentil soup or scrambled egg/scrambled tofu. 
• Eat in a stress-free environment. Relax in a seated position after eating. Resist the temptation to immediately tidy up the dishes.
• Wear an acupressure wristband. These bands, available from chemists in the travel section, can be a very useful, drug-free way of preventing or minimising nausea. Ginger is good too (see below).
• Uncontrolled nausea can result in vomiting. Motion, food, strong odours, treatment and unpleasant environments can cause vomiting. Certain odours associated with the hospital environment are particularly provocative. Minimise these intrusions as best you can: sniff a fresh-smelling hankie, keep an eye on the horizon line when in a car. If you do vomit, avoid eating and drinking (you probably won’t want to anyway). After vomiting, sip a clear liquid or a fizzy drink (preferably one that has gone a litte flat) every 15 minutes or so. Gradually go onto a full-liquid diet (e.g. soups, milky cereals) and then onto a regular diet.
Nausea Relief:

• Sip a room temperature or cool non-acidic drink; suck on some chipped ice or a fruit ice lolly. Ginger tea (a few slices of fresh ginger in mug of boiled water) and peppermint tea are also helpful in relieving nausea. Some people find that fizzy drinks such as soda water or ginger-ale/non-alcoholic ginger beer help too. If these ease ‘normal’ nausea for you they will probably do so now. Other helpful drinks are Japanese miso soup (delicious and available in small sachets – just add hot water), broth or consommé; iced black, green or herbal tea. Coffee is best avoided.

• Many people find that nibbling on crystallised stem ginger or sucking on a mint gives some relief. Dry toast or crackers is a standard remedy. Stem ginger biscuits are good, too.
• Drink between meals rather than with meals.• Eat little and often, avoiding anything that you know will make things worse. The biggest culprits are fatty, creamy foods. 
• Fresh air, ‘yoga’ breathing, tip-top oral hygiene, a cool gel pack on the back of the neck – these are other suggestions that some people find helpful in relieving nausea.
• Listen to your body. If you don’t feel like eating – don’t. Just wait for the nausea to pass. Do however try and drink plenty of fluids (again, little and often so as not to overwhelm your stomach). You must tell your doctor or treatment team if you cannot even tolerate water or rehydration liquids: you may need IV fluids.
Dry Mouth and Difficulty Swallowing
Surgery and radiotherapy to the head and neck area can decrease saliva production while some chemotherapy drugs cause temporary mouth dryness and soreness. Anti-sickness drugs can also cause this sensation. Good oral hygiene will make your mouth feel a bit better, as well as reduce the risk of infection by localised tissue damage. Saliva substitutes and other lubricating agents, as well as sugar-free gum and sweets, can be helpful. Ask your doctor or chemist for advice.
Other ideas:
• Eat foods prepared with moist heat, for instance soups, eggs, quiches, pasta, rice, steamed soft vegetables.
• Add gravy, sauce, mayonnaise, ‘silken’ tofu, butter, olive or seed oils to foods to help them slip down more easily.
• Sip drinks and smooth soups through a straw. 
• Tea (green and black), coffee, alcohol and smoking are very drying to the mouth. Avoid. 
• Hold off on spicy, salty, bitter, crispy, or rough foods – for obvious reasons. If you can tolerate them, then tart tastes, such as lemon juice (added to a glass of water) or sour boiled sweets, can stimulate salivary flow. Try this a quarter of an hour before meals. Vinegar added to meals also has a stimulating effect: cider vinegar in a glass of water; vinaigrette on some salad or cooked vegetables.
• Meal replacement drinks can help you keep up your calorie intake if chewing and swallowing are too challenging. You can get these on prescription and from the chemist.
• Mashed and puréed foods are soothing. Try organic baby foods – especially the fruit ones (tastiest).
• Try not to rely too much on soup and ice cream as they can get a bit boring. Experiment with softening up your normal diet. For example, add extra liquid and gravy to meat dishes that you have minced up. Trim the crust from bread and make tuna pâté sandwiches. Whiz up a stew or casserole in a blender and top with fresh mashed potato and a bit of melted cheese. Fruit-based smoothies with added protein powder, nut butter or ‘silken’ tofu make a complete meal that can be easy to swallow.
• Well-cooked mashed vegetables and fruits are more easily swallowed than raw. Steam vegetables to retain the most vitamins.
• Cold foods and drinks are often soothing, especially if you have mouth ulcers.
• Always have a drink handy, especially when eating and by your bedside. Carry a bottle of water with you.
• If swallowing liquids proves tricky, ask your treatment team or doctor about a beverage thickener. These help you to have more control over liquids in the mouth and reduce the chance of them going down the windpipe.
Taste Changes
This is an annoying side effect that can make eating less pleasurable. These changes may also result in a diminished appetite or a restricted, nutritionally limp diet. Chemotherapy, oral surgery, radiotherapy and mouth infection can damage taste buds or alter taste. Some chemotherapy drugs cause a bitter or metallic taste. It is important therefore to make sure that you make each bite count; replace any nutritious foods you are avoiding with alternatives.
Before and during treatment:
• If you are to have chemotherapy do not be tempted to eat your favourite food directly beforehand. Taste changes may cause you to develop an aversion to this food. Crackers, toast or pretzels are recommended. You may also like to have some ‘nippy’ sweets like lemon or sour plum drops (some people swear by sherbet dib dabs), or peppermints to take away any unpleasant tastes caused by chemotherapy.
After treatment or surgery:
Altered taste
• Experiment with flavourings such as salt, herbs and spices. You may also find that while you go off some foods, other foods – ‘opposite’ foods – become more interesting. For instance if you have always had a sweet tooth, pretzels, crisps and salted nuts may be preferred.
• ‘No-salt-added’ foods can have a metallic taste. Avoid unless you have high blood pressure.
• Cold, cool or room temperature foods are often more palatable than hot ones.  Frozen smoothies, grapes, melon, citrus and pineapple can sometimes cut through changed tastes.
• Lemon, grapefruit, lime, gooseberry and rhubarb are often well tolerated. Lemon sorbet is a nice treat and appetite enhancer.
• Spices such as cinnamon and ginger can help decrease sweetness in puddings. Lemon tones down sweetness in other foods and in drinks.
• Avoid obviously salty things like crisps, sauces and packet soups. If food tastes too salty, add a pinch of sugar.
• Drink bottled or filtered water if you are bothered by the taste of tap water. Use water to dilute sweet-tasting drinks. 
• Try plastic cutlery if things taste metallic. This really can help.
• Keep teeth and tongue well brushed and rinsed to minimise unpleasant tastes. Rinse the mouth with salt water (if no ulcers or cuts), or water with added bicarbonate of soda, before meals.
• Use sugar-free mints, sweets and gums to take metallic and bad tastes away.
• Pineapple ‘cleans’ the tastebuds and is very refreshing.
• Meat often tastes metallic. Try eating chicken, tofu, fish, nuts, pulses or low fat dairy.
Loss of taste
• Food isn’t just about taste. Seventy percent of taste comes from smell. Stimulate your senses and appetite by cooking with garlic and spices, using colourful fruits and vegetables, stir-frying (the popping, sizzling sounds can be appetite stimulants) and including a variety of textures. 
• Make your plate look as appetising as possible: use a teacup to mould food into small portions; garnish with herbs; eat colourfully if possible.
• Choose flavour-packed foods such as sharp cheese, Marmite on toast, a small portion of something spicy like chilli con carne. Don’t worry too much about whether your choices are healthy; eat whatever appeals.
• Marinate foods to add flavour.
*  Texture is linked in the brain to taste and smell. Changing textures of food may help you taste them.
Loss of Appetite
This side effect has numerous causes, all of which usually result in some loss of weight. The catch all term ‘anorexia’ is sometimes used but is different from the eating disorder, anorexia nervosa. Loss of appetite, early satiety (feeling full before you have eaten enough), bloating and cachexia (loss of weight, fat and muscle mass while eating normally) are usually caused by the side effects of treatment (such as nausea), effects of the cancer itself, surgery to the gastrointestinal tract, unrelieved pain or emotional state. Regardless of the cause, cancer-caused anorexia may be limited with some meal planning and a bit of creative thinking.
Meal planning: 
• Eat what you want, when you want it. Don’t worry about whether it is healthy or not, just get the calories in you.
• Some people find that setting an alarm for every three hours reminds them that they should eat something. Clock-watching isn’t normally recommended but if you don’t have an appetite it is easy to ‘forget’ to eat – and you need to.
• As with nausea (which may be causing appetite loss), eat little and often, reserving drinks for between meals. Have mini meals and snacks rather than a ‘proper’ meal, or nibble on nuts, yogurts, bananas, filled rolls and the like between meals.
• If you are up to it, a walk or other light exercise before mealtime can sometimes stimulate the appetite.
• Carry snacks with you to eat whenever you feel peckish. Good bets include nuts and seeds, protein bars, dark chocolate, dried fruit and bananas. 
• For in-house snacks keep soft and/or easy-to-eat, high-calorie foods on hand: little pots of fromage frais, rice pudding, custard, yogurts and little pots of dairy-type desserts that children like. Alpro make a soya dessert that doesn’t need refrigeration and comes in great flavours. Other ideas include hard-boiled eggs, muesli bars, peanut butter crackers, cheese, ice cream.
• Because you know best what you may want to eat (and this may change from day to day) try and plan your own meals but perhaps gets others to shop for you.
• Try and avoid cooking odours.
• Eat in as pleasant an environment as possible, with fresh air if possible.
• Use a small plate and don’t overload it. A big mound of food can kill what appetite you have mustered. Keep serving spoons away from well-meaning relatives.
• Try and make sure the food you eat is attractively served. Press food like rice or shepherd’s pie into a dinky ramekin dish or teacup; upend on the plate and garnish.
When you eat:
• Start with the most nutrient-dense food –  the meat, fish or most calorific food – in the event that you cannot manage to eat much.
• Don’t put pressure on yourself –or be pressurised by others – to eat if you really don’t feel like it. Over-the-counter and prescription nutritional supplements will give adequate nutrition and calories if your diet is very limited. See your GP or dietitian for the types that are right for you. 
• Make your liquids count as food. Instead of tea, coffee and fizzy drinks which have no energy content other than caffeine, try smoothies, milk or ice cream shakes. Stir in malt extract (available at chemists and health food stores) to milky drinks for extra nutrients.
• Because of their fibre and water content, fruits and vegetables can be quite filling. Cook them down and mix in with higher calorie foods. Choose fruit and vegetable juices and purees if you can’t manage the intact version; this will give you a good nutrient boost when the rest of the diet is limited.
• Meat is often off-putting when you lack appetite or feel nauseous. It can also taste ‘metallic’. Chicken is often a more-tolerated animal protein, as are eggs. Select soya milk, whole milk or blend UHT packed silken tofu into smoothies or soups for a great protein boost. Coconut milk, almond and cashew ‘milks’ and ‘butters’ provide protein as well as needed fats.
• Fortified wines stimulate the appetite of some people. Have a small glass of sherry or brandy half an hour before meals, or a small glass of wine with meals. Other stimulants are very sweet and very tart foods. A squeeze of lemon or a tot of cider vinegar in a glass of water may perk up your taste buds and get your saliva flowing.
• Use flavourful sauces like sweet and sour or even curry (if the smell doesn’t bother you) to nudge your appetite. Supermarkets have whole shelves full of interesting sauces that can be poured over your choice of protein – beans, beef, chicken, tofu, fish, and even eggs. Calorific peanut satay sauce makes a great dip for a snack meal. 
• If you can only make room for a tiny bit of food at a time, make it something protein-rich, like cheese, avocado, chicken, fish, eggs, nut butters or tofu. These are easy to digest and will cause minimal upset compared with red and processed meats. Some people find they cannot tolerate milk but this is a ‘good’ liquid if food is not on the agenda. Most supermarkets stock lactose-free milk with the ‘normal’ milk. Add skimmed milk powder to organic whole milk for more protein and calories.
• Take advantage of days when you feel like eating. Make such days as pleasant as possible for yourself so that you have positive associations with food. If the weather is fair, go on a picnic with a friend, or get a table at your favourite restaurant. But don’t feel guilty if all you fancy is a burger and chips or a bowl of soup. Eat what sounds good and not necessarily what you think you should eat.
Diarrhoea, Wind and Cramps 
Chemotherapy, radiation to the intestinal tract, change in diet and emotional upset are all implicated in digestive disturbances. These can be treated in the same way as normal. Lots of liquids and a bland diet are the key weapons. If you can, eat a little toast or mashed banana to keep the intestinal tract going – disuse causes atrophy and continuation of digestive problems, as well as weight loss and fatigue.
 • If diarrhoea is severe or frequent (3 + episodes per day) use re-hydration powder mixed with water to replace lost electrolyte nutrients. Try a clear liquid diet that includes some salty beverages like miso and broth– a stock cube will do. Coconut water (an additive- and- fibre-free kind such as Vita Coco) tastes really good and is an excellent electrolyte replacement drink. Anything with caffeine is dehydrating.
• If you have more than 6-8 episodes of diarrhoea in 24 hours, have abdominal pain lasting more than two days, or no improvement in your situation despite dietary changes contact your doctor immediately for alleviating medication and possible IV fluids.
• Certain drugs and radiation treatments can cause lactose intolerance-induced diarrhoea. If this happens, eliminate dairy from your diet or buy lactose-free milk, which can be found in the chill cabinet with the milks or with the UHT milks. Because the lactose in them is broken down during processing, cheese and bio-yogurt are usually well tolerated. Replace missing dairy with these calcium-rich foods: leafy green vegetables, nuts and seeds, tinned salmon and sardines (the bones are a rich source of calcium), dried figs, cooked beans, calcium-fortified orange juice, calcium-fortified soy, rice or almond drinks, tahini paste, kelp powder.
Foods that help: 
• Drink or eat starchy liquids like rice or porridge oats, mashed bananas and potatoes (not together, of course), dry white toast (no butter), low-fibre cereals like cornflakes, and oatcakes (not more than two at a time as their roughage may irritate) 
• Soy protein may protect against chemo-induced diarrhoea – powdered form may be best in this situation (get this from the chemist or health food store). Caution for those with estrogen+ breast cancer.
• Soups made with peeled vegetables
• Interesting fact: freshly grated nutmeg reduces gut motility. Sprinkle this aromatic spice onto yogurt, or mashed banana on toast.
• Apple sauce and bananas contain binding pectin.
Foods to avoid: 
• Hot foods and spicy foods 
• Fibre-rich food and drinks like prunes, figs, apple and pear juices (these have a laxative effect), unpeeled raw fruits and vegetables, wholegrains and wholemeal bread (including bran)
• Sugar, chocolate and caffeine (including energy drinks) as they stimulate the bowel
• Gas-producing foods like beans, pulses, cabbages and eggs (you will know best which foods normally cause you discomfort) 
• Drinking while eating can make bloating worse
• Sweets and drinks sweetened with mannitol or Xylitol (they can cause diarrhoea)
Constipation
If you experience reduced appetite you may also experience constipation. Nausea, vomiting, sore throat, dry mouth, and difficulty swallowing can all have a knock-on effect in the digestive tract. Reduced intakes of fibrous foods cause constipation as do some drugs used to treat the side-effects of your treatment. Pain-killing opiates are also notorious for bringing things to a halt, as are some anti-sickness drugs. Stress, lack of activity/being bedridden, and loss of colon muscle tone through radiation and surgery are also culprits. 
How to get food ‘moving along’:
• Rice and oat bran – found in health food shops – will be of great help (wheat bran can be an irritant in some people). These foods are very concentrated forms of insoluble fibre – the substance that increases the bulk (by holding water) and frequency of bowel movements. Try different ones to see which one works best for you and whose taste you find most agreeable. Use as directed on the container.
• Other dietary fibres are good too. Add ground linseeds/flaxseeds to your daily diet (try 1tbsp sprinkled over porridge, cereal or yogurt); eat wholemeal bread, brown rice and other whole grains for their bulk and bran; increase your intake of fruit and vegetables too. Variety is important here as each food has its own goodness and benefits. But don’t go overboard – keep it balanced.
• Fill up a two-litre bottle with water each evening and keep in the fridge to sip on during the following day. Try one of those ‘fancy’ overpriced waters for a change – you’ll be surprised how different all of them taste. Water is especially important if you use any of the brans or linseeds suggested above. 
• Try a hot (but not mouth-burning hot) drink in the morning –tea or coffee are fine – to stimulate your digestion.
• Ask your GP or dietitian to recommend a high-calorie, high-protein, fibre-containing liquid supplement if you need more calories, protein and fibre.
• To lessen the amount of air swallowed while eating try not to talk much at meals, drink without a straw and avoid chewing gum.
• Try and have at least some modest daily exercise, such as walking around the house, bending and stretching, going for a walk or swimming. Anything that gets you moving. If bed-bound, try bending your legs and twisting your arms from side to side. If you are up to it, a careful bounce on your kids’ trampoline may help!
• Don’t use over-the-counter laxatives except as instructed by your doctor. This is especially important if your white blood cell count or platelet count is low.
• Phone the doctor about any of the following symptoms: 
o no bowel movement in three days (if you normally go daily)
o blood in or around the anal area or in the stool
o no bowel movement within two days of taking a laxative
o persistent cramps or vomiting

Low-fibre diets – See separate entry under  Nutrition and Cancer

Recommended Reading: American Institute for Cancer Research “Living with Cancer” online flipbook – for during treatment and post-treatment guidance


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