Nutrition & Breast Cancer


Good nutrition may reduce the incidence of breast cancer and the risk of breast cancer progression or recurrence. There are many studies in progress to help further understand how diet and cancer are related. We do know, however, that improved nutrition reduces risk of chronic diseases, such as diabetes, obesity, hypertension and heart disease, and also enhances overall quality of life. It is estimated that one third of cancer deaths in the U.S. can be attributed to diet in adulthood [1].

Here are comprehensive guidelines from Natalie Ledesma, MS, RD, CSO and Ida and Joseph Friend Cancer Resource Center, UCSF Helen Diller Family Comprehensive Cancer Center and the University of California, San Francisco.


Guidelines for a Healthy Diet

o Plenty of fruits and vegetables

o High fiber – whole grains and beans/legumes

• Low fat diet with emphasis on healthy fats

• Limit processed and refined grains/flours/sugars

• Drink plenty of fluids

• Be physically active to help achieve and maintain a healthy weight


Plant based diet

A lifelong commitment to a plant based diet may lower a woman’s risk of developing breast cancer

and may also reduce the risk of recurrent breast cancer. A plant based diet consists primarily of fruits,

vegetables, whole grains, beans/legumes, and other plant protein sources.

* All words noted with an asterisk ( * ) are defined in the glossary

SHINE ON:  Foods for Healthy, Glowing Skin

Fill your plate with approximately

50% vegetables, 25% protein,

and 25% whole grain.



Contain vitamins, minerals, fiber, and various cancer-fighting phytonutrients* (for example: carotenoids, lycopene, indoles, isoflavones, flavonols).

• Vibrant, intense COLOR is one indicator of phytonutrient* content.

• There is extensive and consistent evidence that diets high in fruits and vegetables are associated

with decreased risks of many cancers, and while results for breast cancer risk are not yet conclusive,

they are promising [2-12].

• In a study of about 3000 postmenopausal women, a protective effect for vegetables was observed [2].

SHINE ON:  Foods for Healthy, Glowing Skin

o Women who consumed 25 or more servings of vegetables weekly had a 37% lower risk of

breast cancer compared with women who consumed fewer than 9 vegetable servings weekly.


• An epidemiological study reported a significant protective effect of vegetables against breast cancer

when case-control* and cohort* studies were considered together [4].

• A meta-analysis* – looking at the data from 17 studies [13] revealed that high vs. low vegetable

consumption was associated with a 25% reduction in breast cancer risk, but these findings were not

confirmed by collected data from 8 studies [14].

• A recent case-control* study reported women who consumed more than 3.8 servings of fruits and

vegetables daily had a lower risk of breast cancer when compared with women who consumed

fewer than 2.3 daily servings [15].

• Japanese women following a prudent dietary pattern (high in fruits and vegetables, low in fat) had a

27% decreased risk of breast cancer [5].

• A Korean case-control study* reported that a high intake of certain fruits and vegetables resulted in

a significantly lower risk of breast cancer in premenopausal (tomatoes) and postmenopausal women

(grapes and green peppers) [6].

• While no effect was observed for vegetables, increasing total fruit intake significantly lowered the risk

of breast cancer when comparing those in the highest to lowest tertile [16].


o This effect was greater for those with estrogen-receptor positive (ER+) tumors.

• Eating a salad vegetable dietary pattern (high consumption of raw vegetables and olive oil) exerted a

significant protective effect against HER-2-positive cancers [10].

• A study assessing plasma or blood carotenoids as a marker for fruit and vegetable intake reported

that individuals in the top 1/4 had a 43% lower risk of breast cancer recurrence when compared to

those in the lowest 1/4 [17].

• However, no association was observed between fruit and vegetable consumption and breast cancer

recurrence when women consumed five servings daily vs. eight servings daily [18].

• Breast cancer survivors significantly reduced mortality by following a diet low in fat, high in

vegetables, high in fiber, and high in fruit [19].

• The combination of consuming five or more daily servings of vegetables and fruits, and accumulating

540+ metabolic equivalent tasks-min/wk (equivalent to walking 30 minutes 6 d/wk) decreased

mortality by nearly 50% [11].

o The effect was stronger in women who had hormone receptor-positive cancers.

• Vegetable intake has been inversely associated with serum insulin-like growth factor-I (IGF-I) levels [20].



• Beta-carotene is one of the 600 carotenoids that can be partially converted into vitamin A in the body.

• Carotenoids have a protective role for certain sites of cancer, including breast cancer [7, 21-24].

• Carotenoid intake was significantly associated with reduced mortality in breast cancer survivors [19].

• In various studies, serum beta-carotene levels were lower among breast cancer patients compared

to women without cancer [21,25-29].


o One of these studies reported the risk of breast cancer to be 221% greater for women in the

lowest quartile of serum beta-carotene compared to women in the highest quartile [29].

• A case-control* study reported that increased plasma levels of beta-carotene, retinol, and total

antioxidant* status were associated with about a 50% reduced risk of breast cancer [28].

• In vitro research indicates that carotenoids may inhibit the production of breast cancer cells [30-31].

o Beta-carotene may inhibit ER+ and estrogen-receptor negative (ER-) breast tumor development


• Beta-carotene may hinder the development of breast cancer cells by inducing apoptosis*, or

programmed cell death [32].

• Research indicates that dietary sources of beta-carotene are likely much more protective than

supplemental sources against the risk of cancer [33-35].

o Women who consumed higher amounts of dietary beta-carotene, lycopene, and betacryptoxanthin

were associated with a lower risk of breast cancer among Chinese women [23].

o Dietary alpha-carotene, beta-carotene, and lycopene were inversely associated with risk of

ER+PR+ breast cancer [24].

o Dietary beta-carotene intake was inversely associated with IGF-I levels in a large case-control

study [20].


Cruciferous Vegetables

• Some evidence suggests that the cruciferous vegetables, in particular, are associated with a

reduced risk of breast cancer [36-40].

• A Swedish study of postmenopausal women reported one to two daily servings of cruciferous

vegetables to reduce the risk of breast cancer, possibly by as much as 20-40% [37].

• Women who ate more turnips and Chinese Cabbage, in particular, significantly reduced the risk of

postmenopausal breast cancer [40].

• Consumption of cruciferous vegetables, particularly broccoli, was inversely, though not statistically

significant, associated with breast cancer risk in women [36].

• The U.S. component of the Polish Women’s Health Study found that women who consumed raw- or

short-cooked cabbage and sauerkraut 3 or more times weekly had a significantly reduced risk of

breast cancer [39].

o Cabbage that was cooked for a long time had no effect on breast cancer risk.

o Researchers suggested that glucosinolates, compounds in cabbage, may affect both the

initiation phase of carcinogenesis*, cell mutation*, and inhibit apoptosis*.

• Cruciferous vegetables appear to shift estrogen metabolism in a favorable manner; increasing

2-hydroxyestrone:16-a-hydroxyestrone [41-42]. Fowke and colleagues [42] concluded that

consuming more cruciferous vegetables across the population may very well have an impact on the

incidence of breast cancer.

• Several studies suggest that compounds found in these foods, isothiocyanates (sulforaphane), have

inhibitory effects on breast cancer cells in both cell studies and animal studies [38, 43, 44].

o One mechanism appears to be through potent inhibition of phase I and induction of phase II

detoxifying enzymes, such as glutathione-s-peroxidase [36,40,43].

o Furthermore, these compounds exhibited reduced cell proliferation and inhibited

cyclooxygenase-2 (COX-2) expression in breast cancer cells [45].

o Inhibited cell growth and induced apoptosis has also been observed [46].

• Indole-3-carbinol (I3C) is a compound found in cruciferous vegetables that has anticancer

properties and anti-proliferative effects on breast cancer cells [47].

o I3C may inhibit the growth of blood vessels that the tumor needs to grow (anti-angiogenesis)


• I3C and diindolylmethane (DIM) induce apoptosis*, or cell death, in breast cancer cells [41,49] for

both ER+ and ER- tumor cells [50].

• Furthermore, I3C and tamoxifen have been shown to act separately and/or cooperatively to inhibit

the growth of ER+ breast cancer cells [51].

• Dietary I3C may have effects that bolster immune function [52].

• Calcium-D-glucarate has been shown to inhibit beta-glucuronidase, an enzyme involved in phase

II liver detoxification. Elevated beta-glucuronidase activity is associated with an increased risk for

various cancers, particularly hormone-dependent cancers such as breast cancer [53].

Nutrient Dietary Sources Recommendation


Carrots, sweet potatoes, winter squash, cantaloupe, and mango.

Include these fruits and vegetables daily.


Cruciferous vegetables

Arugula, broccoli, Brussels sprouts,

cabbage, cauliflower, collard greens,

horseradish, kale, kohlrabi, mustard

greens, radishes, rutabaga, turnips

and turnip greens, and watercress

Include these vegetables daily.


Organic Produce

• Organic fruits and vegetables have fewer pesticides, lower levels of total pesticides, and less overall

pesticide toxicity than fruits and vegetables grown with chemicals. Although more research is

needed, recent evidence indicates a significant increase in antioxidants* in organic and sustainably

grown foods versus conventionally grown foods [54-58].

o Organic vegetables contained a greater concentration of phytonutrients* (phenolic acids) when

compared to conventionally grown vegetables [57,58].

• Consuming organic foods appears to increase salicylic acid, which may contribute to a lower risk of

cancer [57].

• Pesticides such as organochlorine compounds (OCC), known as environmental pollutants, have

been implicated in the etiology of estrogen-related disorders due to their potential estrogenic and

anti-estrogenic properties [59].

• Results of some studies [59-61], but not all [62] suggest that environmental exposure to

organochlorine pesticide residues or PCBs may contribute to multifactorial pathogenesis of breast



o In a study of women living on Long Island, New York, breast cancer risk was associated with

lifetime residential pesticide use [63].

o Organochlorine pesticide residues, including DDTs and HCHs, may increase women’s risk of

breast cancer, particularly in premenopausal women in China [60].

o Exposure to beta-HCH, an organochlorine pesticide residue, both accelerated the appearance

and incidence of breast cancer tumors when compared to control mice [61].

• The level of exposure may be integral in determining the effects of these OCC.

o One study found that when breast adipose tissue reached levels higher than 2600 ppb, women

with postmenopausal ERalpha-positive breast cancer exhibited high proliferation [64].

• Choosing organic produce will help you reduce your levels of pesticide exposure and will most likely

increase your phytonutrient* consumption.

o Although washing and peeling your non-organic fruits or vegetables may help to reduce

pesticide residues, it will not eliminate them.


• Listed below are produce with the most and least pesticide contamination, both in terms of number

of pesticides used and the level of pesticide concentration on an average sampling. Thus, for the

fruits and vegetables shown on the most contaminated list, it is wise to buy organic. Alternatively, if

organic choices are not available, you may want to consider substituting with produce that tends to

contain the least amount of pesticides.


Produce most contaminated by pesticides: Produce least contaminated by pesticides:

Peaches Onions

Apples Avocado

Bell peppers Sweet corn

Celery Pineapples

Nectarines Mango

Strawberries Sweet peas

Cherries Asparagus

Lettuce Kiwi

Grapes–imported Bananas

Pears Cabbage

Spinach Broccoli

Potatoes Eggplant

**Adapted from Environmental Working Group – A Shopper’s Guide to Pesticides in Produce


It is most important, however, to eat fruits and vegetables – organic or conventional. If the

availability or cost of organic produce is a barrier, you may wish to avoid those fruits and vegetables

that have the highest pesticide residue content.

Pomegranate (Punica granatum; Punicaceae)

• Various parts of the pomegranate fruit (for example: seed oil, juice, fermented juice and peel extract)

have expressed the suppressive effects on human breast cancer cells in laboratory research [65].

• Pomegranate seed oil and fermented juice block the cancer cells’ oxygen supply, slow cell growth,

and promote cell death [66].

• Fermented pomegranate juice polyphenols* appear to have twice the anti-proliferative effect as

fresh pomegranate juice polyphenols* [67].

• Furthermore, one study suggests that pomegranate seed oil may have the greatest preventive

activity (87% reduction in lesions) compared to fermented pomegranate juice (42% reduction) [68].


• A diet rich in natural fiber obtained from fruits, vegetables, legumes (for example: lentils, split peas,

black beans, pinto beans), and whole-grains may reduce cancer risk and/or reduce risk of cancer


• Fiber binds to toxic compounds and carcinogens, which are then later eliminated from the body [69].

• Various mechanisms have been proposed for the protective effects of dietary fiber against cancer.

These include:

o Increased fecal bulk and decreased intestinal transit time, which allow less opportunity for fecal

mutagens to interact with the intestinal epithelium [70].

o Binding to bile acids, which are thought to promote cell proliferation [71].

o Fermentation in the gut, producing short-chain fatty acids (SCFA). SCFA improve the gut

environment and may provide immune protection beyond the gut [70,71].

o Additionally, whole grains are rich in antioxidants*, including trace minerals and phenolic

compounds, which have been linked to disease prevention [71].

• Furthermore, a high fiber diet works to reduce hormone levels that may be involved in the

progression of breast cancer [70,72-75].

o A high-fiber, low-fat diet intervention found that fiber reduced serum estradiol* (estrogen breaks

down into estradiol* in the body) concentration in women diagnosed with breast cancer, the

majority of whom did not exhibit weight loss. Thus, increased fiber intake was independently

related to the reduction in serum estradiol* concentration [74].

o This decrease in estrogen levels in the blood thereby may potentially reduce the risk of

hormone-related cancers, such as breast cancer.

o Reduced levels of serum estrone* and estradiol* were observed in premenopausal women with

a greater intake of dietary fiber [73].

o Similarly, a high intake of dietary fiber was significantly associated with low serum levels of

estradiol in postmenopausal breast cancer survivors [75].

o Dietary fiber intake increases the amount of estrogen excreted in the stool [76].

• A high fiber diet is also associated with less obesity [72].

• Total dietary fiber intake, particularly from cereals and fruit, was found to significantly reduce the

risk of breast cancer in pre-menopausal, but not post-menopausal women [77].

• A recent cohort* study reported that high fiber intakes were associated with a 42% lower risk of

postmenopausal breast cancer, when comparing women in the highest quintile of fiber intake

compared to the lowest quintile [78].

An earlier prospective cohort* study, however, reported no protective effect of fiber against breast

cancer when comparing women who consumed fewer than 26 grams dietary fiber compared to

those who consumed even less [79]. This finding is not surprising given that the total grams of fiber

consumption was less than 30 grams.

o Similarly, another study that reported no significant findings compared women consuming less

than 25 grams fiber daily [80].

• Overall, case-control* studies have reported the greater the fiber intake, the lower the incidence of

breast cancer [8,81-84]. Data from prospective studies is mixed, reporting protective effects [78,85]

or no effect observed [79,80].

• Women who ate beans and lentils at least twice a week had a 24% lower risk of developing breast

cancer than women who ate them less than once a month [86].


High-Fiber Sources


Food Serving Size Fiber Grams/ Serving

Apple 1 medium 3.7

Banana 1 medium 2.8

Blackberries 1/2 cup 1.9

Blueberries 1 cup 1.3

Cantaloupe 1/2 cup 6.0

Figs (dried) 1/4 cup 6.0

Grapefruit 1 medium 3.4

Grapes 1 cup 1.6

Guava 1 medium 4.9

Kiwi 1 medium 2.6

Orange 1 medium 3.1

Pear 1 medium 4.0

Persimmon 1 medium 6.0

Prunes 1/4 cup 3.1



Food Serving Size Fiber Grams/ Serving

Amaranth 1/4 cup dry 7.4

Barley 1/2 cup cooked 3.0

Beans, black 1/2 cup cooked 8.3

Beans, red kidney 1/2 cup cooked 8.2

Beans, garbanzo 1/2 cup cooked 5.0

Bran cereals 3/4 cup Check labels (5.0-22.0)

Brown rice 1/2 cup cooked 1.4

Bulgur 1/2 cup cooked 4.0

Cream of wheat 1/2 cup cooked 0.5

Oatmeal 1/2 cup cooked 2.0

Peanuts 1/4 cup 2.9

Quinoa 1/4 cup dry 2.5

White rice 1/2 cup cooked 0.3



Food Serving Size Fiber Grams/ Serving

Artichokes 1 medium 6.9

Beets 1/2 cup cooked 1.7

Broccoli 1/2 cup cooked 2.3

Brussel sprouts 1/2 cup cooked 2.0

Carrots 1/2 cup cooked 2.6

Kale 1/2 cup cooked 1.3

Lima beans 1/2 cup cooked 4.5

Peas, green 1/2 cup cooked 4.4

Spinach 1/2 cup cooked 2.2

Squash, winter-type 1/2 cup cooked 3.4

Sweet potatoes (yams) 1/2 cup cooked 2.7



• High sugar foods are usually highly processed and refined, low in nutrient value, and also low in

dietary fiber. In addition, these foods appear to increase serum insulin* and serum IGF-I levels [87],

which appear to stimulate cancer cell growth.

o Overexpression, or high amounts, of IGF increases mammary tumors in mice [88].

o IGF’s may work by stimulating cell cycle progression & prevent cells from premature death [89-92].

o IGF-I may promote tumor growth via upregulation of ovarian steroid secretion [92,93].

o Research indicates a synergistic effect between IGF-I and estrogen [94] as well as IGF-I and

insulin* resistance [95] in breast cancer.

• A prospective cohort* study observed a significant 310% increased risk of breast cancer in

premenopausal women who had the highest quartile of IGF-I compared to women with the lowest

quartile [88].

o A weaker association was found with fasting insulin* levels where premenopausal women in the

two highest quartiles had a 70% greater risk for breast cancer.

o In premenopausal women, women in the highest quartile of serum glucose had a 280%

increased risk of breast cancer compared with women in the lowest quartile.

o In postmenopausal women, the associations of glucose, insulin*, and IGF-I were associated

with breast cancer risk in heavier subjects (BMI>26 1).

o Overall, these findings indicate that chronic change of glucose/ sugar metabolism is related to

breast cancer development.

• Other studies support a stronger link between IGF-I and breast cancer in premenopausal women


• Additionally, a case-control* study in China found that IGF-I significantly increased the risk of breast

cancer [95].

• Nonetheless, a recent meta-analysis* review of 18 studies reported no overall statistically significant

association between circulating IGF-I levels and risk of breast cancer although the levels were

greater in breast cancer patients than controls [90].

o However, IGF-I levels did appear to increase breast cancer risk in premenopausal women by

almost 40%.

• Similarly, a large prospective trial reported IGF-I significantly increased risk of breast cancer

in premenopausal women under the age of 50; no significant relationship was noted for

postmenopausal women [97].

• While not all studies [98] agree, a cohort* study reported that higher insulin* levels significantly

increased risk of breast cancer for both pre- and post-menopausal women [99].


• Recent studies indicate that high insulin* levels, increased concentration of IGF-I, and greater

abdominal fat are associated with increased risk for breast cancer [100].

• It has been suggested that decreasing IGF-I levels may be one factor that contributes to

tamoxifen’s anti-tumor activity in breast cancer therapy [101].

•Research is inconsistent regarding the association of IGF-I and disease-free survival or overall

survival [91].

• One study noted a direct association, though not statistically significant, between non-fasting serum

insulin* levels and 10-year mortality in postmenopausal breast cancer women [102].

• Among other factors, a diet low in fiber may favor the development of insulin* resistance and

hyperinsulinemia [89].

1BMI refers to body mass index, which is calculated by body weight (kg)/height2(m2).

• Hyperinsulinemia may contribute to the development of breast cancer in overweight or obese

women [103].

• Additionally, obesity and fasting hyperinsulinemia have been associated with a poorer prognosis in

women with established breast cancer [104].

• A recent case-control* study reported that carbohydrate intake significantly increased risk of breast

cancer; sucrose (table sugar) imparted the greatest risk [105]. This risk was lessened considerably

with a higher fiber intake.

• Furthermore, an Italian case-control* study found that women who consumed the highest tertile

of desserts and sugars had a 19% increased risk of breast cancer compared with women in the

lowest tertile [106].


• The consumption of sweet foods with a high glycemic index (GI) and glycemic load (GL) have been

implicated as a risk factor for breast cancer due to their effects on insulin and IGF-I [107-110].

o Women who consumed the greatest intake of desserts (including biscuits, brioches, cakes,

puffs and ice-cream) and sugars (including sugar, honey, jam, marmalade and chocolate) had a

19% increased risk of breast cancer compared with women who consumed the least desserts

and sugars [107].

• Adding credence to the idea that blood sugar levels may affect disease progression, women who

consumed a high GI and GL diet had a 57% and 253% increased risk of breast cancer, respectively


o This effect was most pronounced in premenopausal women and those women at a healthy

body weight.

• GI and GL were both associated with an increased risk of breast cancer among postmenopausal

overweight women; this effect was most pronounced for women with ER- breast cancer [109].

• This evidence was further supported by a meta-analysis that reported GI to modestly increase the

risk of breast cancer [110].


INSULIN HIGH TIDE. The observed link between obesity and cancer may be explained by the growthpromoting

activities of insulin and IGF-1. One theory posits that excess weight sets off a biochemical

cascade that increases insulin and, in turn, IGF-1 levels. Both hormones may activate IGF-1 receptors

on cells, which can spur cell growth and inhibit cell death pathways that usually protect against tumor


E. Roell/Source: Nature Reviews Cancer, 2004


Sugars & Insulin* – Bottom Line

• To help control your insulin* level:

o Eat a high-fiber diet with limited refined/processed foods

o Follow a low fat diet rich in omega-3 fatty acids

o Exercise

o Maintain a healthy body weight



Several studies have investigated the relationship of fat and the risk of breast cancer, but the results

remain inconsistent. However, two recent trials showed some promise in the area. The Women’s

Intervention Nutrition Study (WINS) found that a reduced fat intake improves relapse-free survival

by 24% in postmenopausal women with breast cancer compared with women following a standard

diet [111]. The risk of recurrence for women with ER- breast cancer decreased by 42%. Later, the

European Prospective Investigation into Nutrition and Cancer (EPIC) Study reported that eating a

higher fat diet significantly increased the risk of breast cancer; women who had a 35% and 39% fat

diet were at a greater risk than those eating a 31% fat diet [112]. While neither of these diets would

be considered low fat, a significant effect was still observed.


The potential elevated cancer risk may be, in part, due to the fact that a high fat diet stimulates

increased estrogen levels, which is associated with breast cancer growth. A study of adolescent

females found that modest reductions in fat intake during puberty resulted in significantly lower concentrations

of sex hormones (estradiol*, estrone*, progesterone) [113]. Further research is needed to

determine if in fact these lower levels lead to a reduced risk of breast cancer.

Additionally, a low fat, high carbohydrate diet may result in a significant reduction in breast density,

particularly in women going through menopause. Aim for close to 20% of your total calories from

fat, with less than 8% of total calories from saturated fat. Research indicates that the type of fat

may be of paramount importance.

Saturated Fats

• Several studies indicate a positive association between saturated fat intake from meat and

dairy products (animal sources) and cancer [114-117]. The breast cancer research, however, is


• Total saturated fatty acid intake was significantly associated with breast cancer risk in cohort*

studies in postmenopausal women, but not premenopausal women [118].

• Based on a seven-day diary for evaluating saturated fat intake, a high intake of saturated fat was

reported to increase the risk of breast cancer [116].

• A meta-analysis* observed a 19% increased risk of breast cancer with greater intake of saturated

fats [119].

• Other studies, however, have not found a significant association between saturated fats and breast

cancer [120-122].

Trans-Fatty Acids

• Preliminary research indicates that these fatty acids may be associated with an increased risk of

cancer [123-126].

• Minimal research exists on the relationship between trans-fatty acids and risk of breast cancer, thus,

more research is needed for conclusive evidence. However, some evidence points to a positive

association between these fats and breast cancer risk [125,127].

• These fats may disrupt hormonal systems that regulate healing, lead to the destruction of defective

membranes, and encourage the development of cancer.

• One study reported a 40% increased risk of breast cancer in postmenopausal women who had

higher tissue levels of trans-fatty acids [128].

• Women who consumed greater amounts of trans-fatty acids significantly increased their risk of

breast cancer [126].

o Women in the highest quintile of trans-fatty acid consumption had a 75% increased risk

compared with women in the lowest quintile.

Omega-9 Fatty Acids (Monounsaturated Fats)

• Most research at this time indicates a neutral relationship [120,126] or a slightly protective effect

[122,129-131] between these fats and risk of breast cancer.

• Several case-control* studies reported that olive oil consumption, rich in omega-9 fats, resulted in a

13-34% reduction in breast cancer risk [132-135].

o One study found that women who consumed ≥8.8 g/day of olive oil had a 73% lower risk of

breast cancer [131].

• Oleic acid, an omega-9 fatty acid found in olive oil, has been observed to synergistically enhance

the efficacy of trastuzumab (Herceptin) [136,137].

• A meta-analysis*, however, that included three cohort* studies reported total monounsaturated fatty

acids and oleic acid, a type of omega-9 fatty acid, to significantly increase breast cancer risk [118].

Essential Fatty Acids (EFA)

Essential fatty acids are necessary for the formation of healthy cell membranes, the proper

development and functioning of the brain and nervous system, and for the production of hormonelike

substances called eicosanoids* (thromboxanes, leukotrienes, prostaglandins). Among other body

functions, these chemicals regulate immune and inflammatory responses.

Eicosanoids* formed from the omega-6 fatty acids have the potential to increase blood pressure,

inflammation, platelet aggregation, allergic reactions and cell proliferation. Those formed from the

omega-3 fatty acids have opposing affects. Current research suggests that the levels of essential

fatty acids and the balance between them may play a critical role in the prevention and treatment of


Omega-3 Fatty Acids

• Research is growing supporting a protective relationship between omega-3 fatty acids [alpha

linolenic acid (ALA), eicosapentanoic acid (EPA), and docosahexanoic acid (DHA)] against the risk of

breast cancer [118,120,135-141].

• Studies show that omega-3 fatty acids inhibit breast cancer tumor growth and metastasis.

Additionally, these fats are immune enhancing.

• Mechanisms proposed for their protective effects include:

o Suppression of eicosanoid synthesis from arachidonic acid (omega-6 fatty acid), which

impedes immune function [139,142].

o Inhibit cell growth and differentiation via effects on gene expression and signal transduction

pathways [139,142].

o Alter estrogen metabolism, which reduces estrogen-stimulated cell growth [139,142].

o Effects on insulin* sensitivity and membrane fluidity [142].

• A prospective study reported that women who consumed 44 g or more of dietary marine sources of

omega-3 fatty acids reduced their risk of breast cancer by 26% when compared with women who

consumed 25 g or less [120].

• Women with the greatest EPA, DHA, and total omega-3 fatty acids in their red blood cell

membranes from fish had a 73%, 94%, and 89% lower risk of breast cancer, respectively [140].

• An inverse relationship was found between omega-3 fatty acids in breast tissue and the risk of

breast cancer [137].

o When comparing women in the highest tertile of ALA and DHA to the lowest tertile, cancer risk

was reduced by 61% and 69%, respectively.

• Preliminary research indicates that DHA may synergistically enhance taxane cytotoxicity [143]. More

research is needed, but these findings would indicate that DHA during taxane administration may

improve the effects of chemotherapy for breast cancer patients.

• Fish and plant-based foods, however, contain different types of omega-3 fatty acids.

o Fish contains EPA and DHA, two specific fatty acids that have shown promising results in the

research literature [135,140,144].

o Fish consumption in general has been associated with a protective effect against breast cancer


o The plant-based omega-3 fatty acid sources, such as flaxseed and others listed in the table

below, contain ALA. In an ideal environment, ALA is converted to EPA and DHA, however, this

process is inefficient [69,142,146]. On the positive side, the conversion process is enhanced by

following a diet that is low in saturated fats and low in omega-6 fatty acids [142,147].

Omega-6 Fatty Acids

• Recent studies indicate that a high intake of omega-6 fatty acids (linoleic acid, which can

be converted to arachidonic acid) promote breast tumor development and metastasis


• A meta-analysis* of 3 cohort* studies found palmitic acid, a type of omega-6 fatty acid, to be

significantly associated with an increased risk of breast cancer [118].

• Additionally, researchers reported that arachidonic acid, an omega-6 fatty acid almost exclusively

from meat, significantly increased oxidative damage as measured by urinary biomarkers [150].

• It is known that cyclooxygenase is the rate-limiting enzyme that catalyzes the conversion of

arachidonic acid to prostaglandins. Furthermore, COX-2 is known to be overexpressed in various

human cancers. In this breast cancer study, COX-2 overexpression was significantly correlated with

larger tumor size and advanced clinical stage, which indicates a poorer prognosis [149].

• A very interesting finding was reported in a prospective study that found no overall association

between omega-6 fatty acids and risk of breast cancer [120]. However, omega-6 fat consumption

increased risk by 87% in women who consumed 25 g or less of marine omega-3 fatty acids. This

effect was even greater for advanced breast cancer.

o Thus, the balance between omega-6 and omega-3 fatty acids may be of paramount

importance. This was further supported by other studies [137,138,151,152].

Fat – Bottom Line

• Less fat is better.

• Limit animal fats.

• Avoid hydrogenated fats.

• Extra-virgin olive oil, canola oil, macadamia nut oil or almond oil is preferred for salads

and cooking.

• Increase omega-3 fatty acids.

Fatty Acid Dietary Sources Recommendation

Saturated fatty acids Meats, poultry skin, baked goods,

and whole milk dairy products,

including butter, cheese, and ice


Reduce or eliminate meat and

whole milk dairy products.

Trans fatty acids Margarine, fried foods, commercial

peanut butter, salad dressings and

various processed foods including

breads, crackers, cereals, and


Avoid trans or hydrogenated


Products may be labeled “trans

fat free” if they contain less

than 0.5 mg per serving.

Omega-9 fatty acids Extra-virgin olive oil, almond oil,

canola oil, macadamia nut oil,

almonds, and avocados

Include these healthy fats daily.

Limit consumption of nuts to no

more than ¼ cup with meal

or snack to limit total fat and



Omega-3 fatty acids:



Cold-water fish (for example:

salmon, sardines, black cod, trout,

herring), breastmilk, and DHAenriched


Flaxseeds, chia seeds, walnuts,

hempseeds, and pumpkin seeds

Include these healthy fats

daily through diet and/or


It may be wise to consume

cold water fish or fish oil

supplements at least twice

weekly to obtain an adequate

amount of EPA and DHA.

If you choose to use a

supplement, opt for one that

is highest in EPA and DHA


Omega-6 fatty acids:

Arachidonic acid

Linoleic acid

Meats, butter, egg yolks, whole milk,

and whole milk dairy products

Common vegetable oils, such as

corn oil, safflower oil, sunflower

oil, and cottonseed oil, and

processed foods made with these


Reduce or eliminate meat and

whole milk dairy products.

Limit consumption of linoleic

acid-rich oils.

Substitute an omega-9 fatty

acid-rich oil for your current

cooking oil or fat.


• In a study of over 35,000 women, meat consumption significantly increased the risk of breast

cancer in both premenopausal and postmenopausal women [153].

o Women eating 1.75 ounces of processed meat daily increased the risk of breast cancer by

64% in postmenopausal women compared to women who did not eat meat.

• Consumption of red and fried meat quadrupled the risk of breast cancer in a case-control study in

Brazil [12].

• Meat consumption increased the risk of breast cancer risk by 56% for each additional 100 g (3.5

oz) daily of meat consumption in a French case-control study [135].

• Regular consumption of fatty red meat and pork fat increased the risk of breast cancer by 348%

and 632%, respectively in a small Brazilian study [154].

• A large case-control* study found that women who consumed very well-done meat for hamburger,

bacon, and steak had a 54%, 64%, and 221% increased risk for breast cancer, respectively [155].

o Frequent consumers of these well-done meats had a 462% greater risk of breast cancer.


Food Category Summary Recommendation

Fruits and vegetables One serving =

½ cup fruit or vegetable

1 cup raw leafy greens

¼ cup dried fruit or vegetable

6 oz fruit or vegetable juice

Eat 1 cup or more vegetables with

lunch and dinner.

At least 5, preferably 8-10 total

servings daily [156]

5 or more vegetable servings

3 fruit servings

Fiber Choose breads with 3 or more

grams of fiber per slice.

First ingredient on the label should

be whole or sprouted grain flour,

not white flour, unbleached white

flour, or enriched wheat flour.

Whole grains include, among

others, oats, barley, brown rice,

quinoa, amaranth, bulgur, millet,

buckwheat, spelt, wild rice, and


30-45 grams daily

This goal can be achieved

by meeting your fruit and

vegetable goal plus one

serving of legumes or at least

two servings of whole grains.

Refined carbohydrates and


Dietary sources include products

made with refined flours (for

example: white bread, white rice,

white pasta) or refined grains,

alcohol, sodas, drinks containing

added sugars, and desserts, such

as candy, cookies, cakes, and


Limit or avoid consumption.

Meat Dietary sources include beef, pork,

and lamb.

Reduce or eliminate meat


Avoid processed, grilled or fried


GENOTOXINS: Heterocyclic Amines (HCAs) & Polycyclic Aromatic Hydrocarbons (PAHs)

• Natural components in meat, such as amino acids, creatine*, and polysaccharide precursors,

are converted to HCAs during high-temperature cooking. HCAs are known to cause cancer in

laboratory animals [157,158].

• While human research is forthcoming, the majority of studies [155,157-162] although not all

[163,164] have observed a significant association between HCAs and breast cancer.

• Carcinogenic activity of HCA’s is affected by various dietary factors [165]:

o Factors that enhance carcinogenesis* when combined with HCAs include:

• High-fat diet

• Caffeine


o Factors that inhibit carcinogenesis* when combined with HCAs include:


• Conjugated linoleic acid (CLA)

• Isoflavones

• Diallyl Sulfides (found in the allium family, such as garlic, onions, leaks, and shallots)

• Green tea catechins*

• Indole-3 carbinol

• Probiotics

• Gamma-tocopherol

• The most important variables contributing to the formation of HCAs are:

o Cooking temperature (greater than 300°F)

o Cooking time (greater than 2 minutes)

o Cooking method (frying, oven grilling/broiling, barbecuing)

• Charring of food (charcoal-broiled or smoked foods) contribute to PAHs [166].

• Meat can potentially be made “safer” to eat by being cooked in a way that does not lead to HCA


o Choose lean, well-trimmed meats to grill.

o Using marinades significantly reduces the amount of HCAs.

o Brief microwave preheating substantially reduces HCA content of cooked meat.

o Small portions require less time on the grill.

• Additionally, the type of protein cooked can also affect the concentration of HCAs. It has been

reported, for example, that chicken has more than 100 times the number of HCAs than salmon [165].

London broiled steak had more than 600 times the amount of HCAs when compared to salmon.

• Grill vegetables or meat alternatives that do not lead to the formation of HCAs or PAHs.


• Regular consumption of alcohol may increase the risk for breast cancer [167-176].

o A recent review study reported that data from many well-designed studies consistently shows

a small rise in breast cancer risk with increasing consumption of alcohol [172].

• A recent study found that as little as a half a glass of wine a day raised a woman’s risk of

developing breast cancer by 6% (increased risk by 18% in postmenopausal women) [167].

o Furthermore, 1-2 drinks a day increased risk by 21% and 2 or more drinks a day increased risk

by 37%.

o The heightened risk was more pronounced for women with ER+ and progesterone-receptor

positive (PR+) tumor types.

•Women who drank two or more alcoholic drinks daily in the five years prior to diagnosis had an


82% increased risk of breast cancer compared to non drinkers [173].

•A pooled analysis of six prospective studies suggests that the risk of breast cancer increases

linearly by 9% with each 10 g /day (~ 1 drink) alcohol [177]. The risk increased to 41% when

comparing women who consumed 30-60 g/day (~2-5 drinks) to nondrinkers.

•A large meta-analysis* revealed that one drink daily increased breast cancer risk by 11% [178]. A

later meta-analysis* found similar findings [179].

•Since then, another meta-analysis* reported that breast cancer risk increased by 32% and 46% in

women who consumed 35-44 g alcohol (~3-4 drinks) daily and 45 g or more (~4.5 drinks or more)

daily, respectively [170].

o For each additional 10 g of alcohol (~1 drink) daily, risk increased by 7%.

•Other studies [168] claim that one glass of alcohol daily does not increase risk, but consuming 2-5

drinks daily increases the risk of breast cancer by 40% compared to non-drinkers [168].

o Greatest risk was among heavy drinkers who were also postmenopausal and had a history of

benign breast disease or who used hormone replacement therapy (HRT) [168].

•Similarly, a French study found that drinking 10-12 g wine (~ 1-1.5 drinks) daily lowered the risk of

breast cancer, but when intake increased above 12 g daily, the risk of breast cancer increased [180].

•Among ER+ postmenopausal women, those who consumed approximately 3 drinks or more daily

had a 76% increased risk of breast cancer when compared with women who did not consume

alcohol [181].

o The association between alcohol and ER- tumors was less clearly associated.

o Additionally, there was no clear association between alcohol and premenopausal risk of breast


•A recent cohort* study of postmenopausal women reported that alcohol consumption was

associated with an increased risk of breast cancer in ER+, but not ER- tumors [182].

•On a similar note, a recent meta-analysis reported that an increase in 10 g (~1 drink) alcohol daily

increased the risk of breast cancer, especially for women with ER+ breast cancers –ER+ (12%

risk), all ER- (7% risk), ER+PR+ (11% risk) ER+PR- (15% risk), ER-PR- (no effect) [174].

•Petri and colleagues [171] observed a stronger relationship between alcohol and breast cancer in

postmenopausal women compared to premenopausal women.

o Premenopausal women drinking more than 27 drinks per week had a 3.5% higher risk than

women who had one drink per week.

o Postmenopausal women drinking six or more alcoholic beverages per week had a 2.4% higher

risk than women who had one drink per week.

•On the contrary, women who drank about 1.5 drinks per week had a 40% greater likelihood of

developing breast cancer compared to non drinkers and this was most pronounced in women who

were premenopausal at diagnosis [175].

•Alcohol consumption (1 drink/day) during a woman’s fifties increased risk for postmenopausal

breast cancer by 12% in a large cohort* study, but statistical significance was not reached for

women in their twenties, thirties, or forties [169].

•These differing findings between pre- and postmenopausal women are likely related to the effect of

alcohol on estrogen levels. Alcohol appears to increase endogenous* estrogen levels [183-187].

•Folate, a B vitamin, may be of even greater significance with alcohol consumption. It has been

observed that women with low folate and high alcohol consumption had a 43% greater risk of


breast cancer when compared with nondrinkers with adequate folate intake [188].

Alcohol –Bottom Line

•It is best to limit or avoid alcohol.


The functions of water in the body include the following:

o Carries nutrients and waste products.

o Participates in chemical reactions.

o Acts as a lubricant and cushion around joints.

o Acts as a shock absorber in the eyes and spinal cord.

o Aids in the body’ temperature regulation.

o Maintains blood volume.

•Increased fluid intake is needed for a high fiber diet.

•Drink plenty of water daily to help meet fluid needs.


•The risk of breast cancer is much higher in industrial countries than in developing countries where

women are characterized by lower energy intake and higher energy expenditure.

•Modest caloric restriction has been shown to inhibit tumor growth in animal models decrease

oxidative DNA damage [189].

•Modest caloric restriction has been shown to decrease oxidative DNA damage.

•The mechanism involved may be related to the decrease in IGF-I observed when caloric intake is

restricted [190,191].

•Furthermore, evidence suggests that a high calorie diet may increase IGF-I levels [192].


•Epidemiologic evidence suggests a positive association between body mass and postmenopausal

breast cancer [193-196].

o Increasing BMI was associated with a 40% increased incidence and mortality of breast cancer

in postmenopausal women [197].

o Women with a BMI of ≥5 had a 58% increased risk of breast cancer [5].

o Obese postmenopausal women had 3.26-fold increased risk for breast cancer compared to

healthy weight women [198].

o In women with breast cancer, height and BMI were associated with postmenopausal breast

cancer [199].


•This effect was most pronounced in women with ER+ tumors.

o Obese postmenopausal women had a 50% increased risk for breast cancer [196].

•A recent case-control* study of 2000 women found that women who gain weight, particularly after

age 50, significantly increase their risk of breast cancer [200]. Conversely, women (young and

middle-aged) who lose weight may decrease the risk of breast cancer.

o This study suggests excess body fat increases estrogen levels, which may in turn increase the

risk for breast cancer.

o An earlier study reported similar findings with total weight gain serving as a strong predictor of

breast cancer risk, specifically among former and never HRT users [193].

•Increasing BMI was associated with a 40% increased incidence and mortality of breast cancer in

postmenopausal women [197].

•Results from a systematic review showed that, when adjusted for BMI, a larger waist size increased

risk of breast cancer among premenopausal women [202]. This study supports the idea that central

obesity is of greater concern than general obesity in regards to breast cancer risk.

o However, for postmenopausal women, a large trial found that, while general obesity was a

significant predictor of breast cancer risk, central obesity did not appear to be associated with

increased risk [203].

•Total body weight, BMI, and hip circumference were significantly associated with breast cancer risk

among HRT nonusers; obese women (BMI > 30) had a 31% greater risk compared to women with

BMI < 25 [203].

•Overweight or obesity is associated with poorer prognosis in the majority of the studies that have

examined body mass and breast cancer [204-210].

•Various studies report increased BMI or body weight to be a significant risk factor for recurrent

disease, survival, or both [204-210].

o May be related to increased estrogen [196,211,212] and elevated insulin* and IGF, which can

stimulate cell proliferation [101,204].

o Obese postmenopausal women (BMI >30) had 35% higher concentrations of estrone* and

130% higher concentrations of estradiol* compared with lighter-weight women (BMI < 22.0)

[211]. Additionally, free estradiol* and free testosterone were two to three times greater in

overweight and obese women compared with lighter-weight women.

o Recent findings indicated that oxidative damage, measured by urinary biomarkers, was

significantly greater in women with a higher BMI [150].

o Obesity among premenopausal women, however, may not be associated with increased risk

of breast cancer. Nonetheless, obesity during menstruating years is associated with obesity

throughout life and therefore to an eventual increased risk of breast cancer [132]. However,

other research suggests a stronger relationship between body weight and breast cancer in

premenopausal women [208,210].

o A cohort* study of 1300 women reported that breast cancer recurrence and death increased

with body weight in both premenopausal and postmenopausal women [158].

•Body weight prior to breast cancer diagnosis significantly increased risk of recurrence and death in

nonsmokers [208].

o Additionally, nonsmokers who gained weight after diagnosis had an elevated risk of breast cancer

death during follow-up (median, 9 years), compared with women who maintained their weight.


•Women with a BMI of ≥5 had a 58% increased risk of breast cancer [5].

•Research suggests a potential link between obesity, diabetes mellitus and breast cancer [214].

•Eating foods high in vitamin C, such as fruits and vegetables, may provide a protective effect from

breast cancer for overweight women (BMI>25) [215].


•Low levels of physical exercise appear to be associated with the risk of breast cancer [172,195,216-218].

•Lifetime total physical activity has been associated with a decreased risk of breast cancer


o Some studies indicate that physical activity has a more significant effect in reducing risk of

breast cancer in postmenopausal women [222].

o Exercise between the years of 14-20 appears to be the most beneficial in reducing risk of

breast cancer [219].

•A case-control* study reported significantly reduced breast cancer risk among women who

maintained, on average, 17.6 (MET)-hr of activity/week2 from menarche onward [195]. This

decreased risk with physical activity was limited to women without a family history of breast cancer

when adjusted for BMI.

•A cohort* study reported that postmenopausal women who were most physically active (> 42.0

MET-h/week)3 at baseline had a 29% lower incidence of breast cancer than active women with the

least activity (> 0-7.0 MET-h/week) 4 [218]. This difference was greatest for women who did not use

HRT at enrollment.

•Women who engaged in regular strenuous physical activity at age 35 had a 14% reduced risk of

breast cancer compared with less active women [217]. A similar trend was observed for regular

strenuous activity at age 18 and at age 50. These findings were consistent with women who did

and did not use HRT.

•Furthermore, a prospective observational study reported that physical activity after a breast cancer

diagnosis may reduce the risk of death from this disease [216]. The greatest benefit occurred in

women who performed the equivalent of walking 3 to 5 hours per week at an average pace. The

benefit of physical activity was particularly apparent among women with hormone-responsive


•As noted earlier, the combination of consuming five or more daily servings of vegetables and fruits,

and accumulating 540+ metabolic equivalent tasks-min/wk (equivalent to walking 30 minutes

6 d/wk) decreased mortality by nearly 50% [11].

o The effect was stronger in women who had ER+ cancers.

•Increased physical activity following breast cancer diagnosis significantly decreased the risk of

dying from breast cancer and improved overall survival when compared with women who exercised

<2.8 MET-h/wk [224].

•Survival may be enhanced by physical activity in those women who exercised the year prior to

diagnosis, especially women who were overweight or obese [225].

•Exercise was associated with improved quality of life among survivors [226,227].


•Physical activity can help ease cancer-related fatigue during and following cancer treatment


•Physical activity may reduce the risk of breast cancer through an influence on ovarian function and

a decrease in progesterone and estrogen concentrations via reduced body fat [217]. Furthermore,

exercise may increase sex hormone-binding globulin* (SHBG) levels and thereby reduce estradiol*.

•An increase in lean body mass (often achieved through physical activity) was associated with

a favorable change in 2-hydroxyestrone: 16-α-hydroxyestrone, a proposed biomarker of breast

cancer risk [230].

•Additionally, exercise reduces serum insulin levels [231], serum IGF-I levels [217,232], and improves

insulin* sensitivity [217].

•Greater physical activity in obese women was associated with significantly less mammographic

density, possibly suggesting another mechanism for the protective effect of physical activity [233].

•Healthy weight control is encouraged with an emphasis on exercise to preserve or increase lean

muscle mass.

2 This is equivalent to a 150lb individual burning 1257 kcals/week through physical activity.

3 This is equivalent to a 150lb individual burning about 3000 kcals/week through physical activity.

4 This is equivalent to a 150lb individual burning 500 kcals/week or less through physical activity.

Additional Nutritional and Lifestyle Factors for Breast Cancer Survivors

ANTIOXIDANTS* –Found in abundance in fruits and vegetables!

•Prevent oxidative damage in body cells.

o Research indicates a link between oxidant damage and breast carcinogenesis*.

•Examples of antioxidant* nutrients and non-nutrients include vitamins A, C, and E, selenium,

lycopene, and beta-carotene.

•Note that patients may be advised to NOT consume high-dose antioxidant* supplements during

chemotherapy or radiation therapy. Antioxidant* consumption via food sources and a basic

multivitamin supplement are very safe.


•Antioxidant* that scavenges free radicals and suppresses damage due to oxidation. Also is

essential for the immune system.

•Promising evidence indicates that selenium may decrease the risk of breast cancer [234-239].

o Inhibits cell proliferation and induces apoptosis* [238,239].

•Selenium may interfere and alter estrogen receptors decreasing mammary tumor incidence [236].

• Research shows that selenium reduces the incidence of malignant cells in animal models [237], and

enhances the effects of chemotherapeutic drugs, such as [235] taxol and adriamycin [235,239].

• Toenail selenium concentrations tended to be lower in postmenopausal breast cancer patients when

compared with healthy non-cancer patients, but the differences did not reach statistical significance [240].

o Interestingly, this study also found that plasma triiodothyronine (T3) (a thyroid hormone)

concentration was positively associated with toenail selenium in breast cancer patients and

controls. T3 concentration was significantly lower in breast cancer patients compared to

healthy non-cancer patients.

• A recent study suggested the combination of selenium and iodine, typical of a Japanese diet, act

synergistically in decreasing breast cancer risk [241]. It is known that iodine plays an important role in

thyroid function. Thus, selenium status may affect both thyroid hormone status and iodine availability.

• Selenium is a precursor to the glutathione* (GSH) antioxidant* system. GSH is the principal

protective mechanism of the cell and is a crucial factor in the development of the immune response

by the immune cells [242].

o Studies suggest the ratio of selenium to glutathione* is at lower levels in breast cancer patients

[234]. Research indicates that dietary selenium supplements correct abnormal glutathione*


Turmeric (Curcumin)

• Curcumin, the yellow pigment and active component of turmeric and many curries, is a potent

antioxidant*, that exhibits chemopreventive and growth inhibitory activity in several tumor cell lines


• Evidence suggests that curcumin may suppress tumor initiation, promotion and metastasis [245,247].

o This may occur through enhanced apoptosis* [243,245].

• Additionally, curcumin promotes detoxification in the liver and possesses anti-inflammatory activity,

possibly by inhibiting COX-2 activity [248,249].

Vitamin C

• Most research [250-255], although not all [7,19,256,257], has shown no protective relationship

between vitamin C and the risk of breast cancer.

o Vitamin C induces apoptotic effects on breast cancer cells [257].

• Low plasma levels of vitamin C have been associated with a greater risk of breast cancer [258].

• Dietary vitamin C has been significantly associated with reduced mortality in breast cancer

survivors [19].

• Furthermore, risk of recurrence and mortality was reduced in women who consumed vitamin C

supplements for more than three years [259].

Vitamin E

• Vitamin E acts as a cellular antioxidant* and an anti-proliferating agent. It consists of both

tocopherols and tocotrienols.


o Some research indicates that tocotrienols are the components of vitamin E responsible for

growth inhibition in human breast cancer cells [260].

• Research is inconsistent on the protective effects of vitamin E and breast cancer. Data from most

prospective studies have not revealed a protective relationship between vitamin E and risk of breast

cancer [250].

• Supplemental vitamin E does not consistently appear to offer protection against breast cancer [150]

although taking vitamin E for more than three years has been associated with a modest protective

effect [259]. Additionally, these researchers reported a decreased risk of recurrence and mortality

associated with long-term use of vitamin E supplements.

• However, low plasma levels of vitamin E have been associated with a greater risk of breast cancer [258].

• It was demonstrated recently that dietary vitamin E, unlike supplemental sources of vitamin E,

significantly reduced oxidative damage as measured by urinary biomarkers [150].

• Note that findings suggest that vitamin E supplements may interfere with the therapeutic effects of

tamoxifen [261].


• Resveratrol is a polyphenol found primarily in red grape skins with known antioxidant and antiinflammatory

properties, and is emerging as a potent chemopreventive and anticancer drug [262].

• Resveratrol has exhibited potential anticarcinogenic activities in several studies.

o Reduced tumor growth, decreased angiogenesis, and induced apoptosis in mice [263].

o Less tumors and longer tumor latency in a rat study [264].

o May inhibit IGF-I mediated cell migration in breast cancer cells [265].

o Induces apoptosis in breast cancer cells [262,263].

o Decreased levels of vascular endothelial growth factor (VEGF) in breast cancer cells [263].

o Inhibited cell growth and regulates IGF-II in breast cancer cells [266].

• Recent evidence indicates that resveratrol and glucans have significant synergistic effects on

immune function [267].

Nutrient/Phytonutrient Summary Recommendation

Selenium Dietary sources include Brazil nuts,

seafood, enriched brewer’s yeast,

and grains.

Selenium content depends

somewhat on the amount of

selenium in the soil in which the

products are grown.

200 mcg selenium daily through

diet and/or supplements

Two Brazil nuts provide 200

mcg selenium.

Turmeric (curcumin) A deep orange-yellow spice

commonly used in curries and

Indian cuisine.

Eat liberally.


Vitamin C Dietary sources include various fruits

and vegetables, including papaya,

citrus fruits, kiwi, cantaloupe,

mango, strawberries, bell peppers,

broccoli, and tomatoes.

Include these fruits and

vegetables daily.

Vitamin E Dietary sources include vegetable

oils, wheat germ, sweet potatoes,

nuts, seeds, and avocados.

Eat vitamin E-rich foods


More research is needed to

assess whether or not

supplements would be


Resveratrol Dietary sources include grapes,

grape products, peanuts, soy,

mulberries, and cranberries.

Eat resveratrol-rich foods


More research is needed

to assess whether or not

supplements would be



• Flax may also work to block tumor growth, inhibit angiogenesis*, and enhance the immune system [268].

• Consumption of 5 or 10 g flax for 7 weeks significantly decreased blood levels of estrone* and

estradiol* [269].

• Flax has been shown to enhance the effects of tamoxifen [270].

• Flaxseed is the greatest source of mammalian lignans* [271,272], phytoestrogens found in flax,

which appear to bind with estrogen and lower circulating levels of estrogen. This action may act as

one of the protective mechanisms of flax for breast cancer.

o Lignans* facilitate the removal of estrogens via increased retention within the gut, which are

later eliminated in the feces [273,274].

• Furthermore, lignans* positively influence estrogen metabolism by improving the ratio of 2:16a

hydroxyestrone [273,274].

• A recent study indicates that flaxseed (25 g daily) and its metabolites, such as lignans*, reduced

tumor growth in patients with breast cancer [271].

• Additionally, a recent pilot study observed lower breast density with a greater intake of dietary

lignans* [275]. Dense breasts are a risk factor for breast cancer.

• Flax has been shown in vitro and in human trials to decrease tumor proliferation of breast cancer

cells [271].

• An animal study reported that flaxseed inhibited established human breast cancer growth and

reduced incidence of metastasis by 45% [272].

• Tumor growth was reduced by 26% and 38%, respectively, when mice consumed a 5% flaxseed

diet and 10% flaxseed diet compared with those who ate no flaxseed [270].

o This effect may be partially due to its downregulation of IGF-I [270,272,276], decreased cell

proliferation [270], and increased apoptosis [270].



• Tea contains phytonutrients* known as polyphenols* (flavonoids) that provide antioxidant* and

anticancer properties [277].

o May block the formation of cancer-causing nitrosamines* [278].

o Prevents DNA damage [279].

o May inhibit tumor growth and induce apoptosis* [280-282].

o Increase immune response [281].

o Epigallocatechin gallate (EGCG) alters gene expresssion to lower the risk of breast cancer


• There is a significant amount of in vitro and in vivo evidence suggesting tea polyphenols* have

chemopreventive agents against various cancers [280,284,285]. More human data is needed.

o Green tea and its catechin* components inhibit breast cancer growth and angiogenesis* in both

in vitro and in vivo studies.

o Studies suggest green tea extract has been successful inhibiting cell proliferation and breast

cancer [277].

• Many studies indicate a lower risk of breast cancer with green tea consumption, but more research

is needed for conclusive evidence [286-289].

• EGCG has been shown in human studies to inhibit human breast cancer cell proliferation, reduce

tumor invasion and metastasis and prevent recurrence of breast cancer in early stage cases (stage I

& II) [290-292].

• A meta-analysis* reported that drinking green tea decreased the risk of breast cancer by 22% when

comparing women with the highest vs lowest intake [286].

• A case-control study* found that green tea consumption was associated with a significant reduction

in risk of breast cancer [289].

o Risk by 13% for women consuming 1-249 g of dried green tea leaves annually.

o Risk by 32% for women consuming 250-499 g of dried green tea leaves annually.

o Risk by 41% for women consuming 500-749 g of dried green tea leaves annually.

o Risk by 39% for women consuming ≥750 g of dried green tea leaves annually.

o Moreover, protection was greater with a longer duration of drinking green tea, a greater number

of cups consumed and the more new batches prepared daily.

• However, combined studies of 35000 Japanese women found that green tea did not affect risk of

breast cancer [293].

• Research suggests that while green tea did significantly decrease tumor mass, when green tea was

combined with soy phytonutrients*, the tumor mass decreased even further [294]. Further evidence

indicates a possible synergistic relationship between soy and green tea consumption [288].

• Similarly, a synergistic effect of green tea and Ganoderma lucidum extracts on the suppression of

growth and invasiveness of metastatic breast cancers was observed [295].

• Additionally, green tea increased the inhibitory effect of tamoxifen on the proliferation of ER + breast

cancer cells [296].

• Furthermore, some evidence suggests that the association of tea catechins* and breast cancer may

depend on specific genotypes [284].



• Associated with reduced rates of heart disease [297-299], protection against osteoporosis

[300,301], and certain types of cancer, including breast cancer [302,303].

• While there has been contention regarding soy and breast cancer, research findings are

predominantly neutral [304], if not protective [6,305,306].

o The majority of short-term soy intervention studies conducted in premenopausal women show

a reduction in endogenous* estrogen levels in association with soy intake, and thus, possibly

protecting from breast cancer.

o The conflicting data on the effects of soy isoflavones and breast tumor growth are based on in

vitro (test tube) studies.

• Recent human research has been more promising.

o A statistically significant inverse association between plasma genistein and breast cancer was

reported among Japanese women [305].

o A recent meta-analysis of well-controlled studies that included high-soy-consuming Asians

reported a significant trend of decreasing risk with increasing soy food intake. Risk was lowest

among those who consumed ≥20 mg isoflavones daily [306].

o High soybean intake in Korean women resulted in a significantly lower risk of breast cancer in

postmenopausal women [6].

• It’s becoming more apparent that the timing of soy exposure is critical. Consumption of soy foods

or an exposure to a soy isoflavone genistein during childhood and adolescence in women, and

before puberty onset in animals, appears to reduce the risk of breast cancer later in life [307].

• The type of soy consumed may provide some insight to the inconsistent findings. It has been

demonstrated that soy processing increases tumor growth in mice for postmenopausal ER+ breast

cancer [308].

o The difference in tumor growth observed may be related to isoflavone metabolism and

bioavailability, but more research is needed [309].

o Nonetheless, these studies suggest that WHOLE SOY FOODS appear to not have a

negative effect on postmenopausal ER+ breast cancer.

o A recent cohort* study of breast cancer patients found that soy foods had no negative impact

on breast cancer survival [310,311].

• An Asian-American study on soy found that women, pre- and postmenopausal, who consumed

tofu, had a 15% reduced risk of breast cancer with each additional serving per week [302].

• Moreover, a recent trial reported that women in the highest tertile intake of tofu had a 51% decrease

risk of premenopausal breast cancer when compared with women in the lowest tertile [303]. No

statistical significant association was observed between soy intake and breast cancer risk among

postmenopausal women.

• Soy consumption has been suggested to exert potential cancer-preventive effects in

premenopausal women, such as increased menstrual cycle length and SHBG* levels and reduced

estrogen levels.

o 40 mg/day soy isoflavones increased menstrual cycle length in Western women [312].

o Research also suggests that soy isoflavones may significantly improve the

2-hydroxyestrone:16-a-hydroxyestrone ratio [313].


o Additionally, soy intake increases time spent in the follicular cycles, when proliferation is at its

lowest [312].

• Furthermore, vegan protein sources, such as soy, appear to decrease circulating IGF-I activity,

which may impede cancer induction [298,314,315].

• Recent literature assessing the effects of soy and tamoxifen have yielded neutral [316] or beneficial

findings [317].

o In a study of Asian American breast cancer survivors on tamoxifen, soy intake had no effect on

levels of tamoxifen or its metabolites [316].

o The combination of tamoxifen and genistein inhibited the growth of ER+/HER2- human breast

cancer cells in a synergistic manner in vitro [317].

Source Amount of Soy

Protein (gm)

Amount of Soy

Isoflavones (mg)

Miso (1 tbsp) 2 7-10*

Soybeans, edamame (1/2 cup) 11 35*

Soymilk (8 fl oz) 10 23*

Soy nuts (1/4 cup) 19 40-50*

Tempeh (1/2 cup) 19.5 36*

Tofu (4 oz) 13 39*

* Isoflavone content varies by brand

Vitamin D

• Epidemiological studies suggest an inverse relationship between sun exposure, serum levels of

25(OH)-vitamin D, and vitamin D intake and the risk of developing and/or surviving cancer [318].

o Possible mechanisms that may explain the protective effects of vitamin D may be its role as

a nuclear transcription factor that regulates cell growth, differentiation, apoptosis and a wide

range of cellular mechanisms central to the development of cancer.

o Furthermore, breast density, a factor that may increase the risk of breast cancer, was inversely

associated with vitamin D intake [319].

• The women in the Nurses’ Health Study observed a 30% reduction in risk of breast cancer

comparing the highest with lowest quintiles of 25(OH)-vitamin D levels. [320].

•Post-menopausal breast cancer risk was significantly inversely associated with serum 25(OH)-

vitamin D levels [321].

o Risk decreased as women’s levels increased from 30 nM (12 ng/ml) to ≥75 nM (30 ng/ml).

•It is now believed that the recommended vitamin D dose should be between 800 and 2,000 IU per


o Research indicates that vitamin D3 (cholecaciferol) is better absorbed than vitamin D2

(ergocalciferol) [322].


Due to the likelihood of a biochemical deficiency without clinical symptoms or signs, a serum

25(OH)-vitamin D level is recommended.

o Optimal serum 25-hydroxy vitamin D levels have not been established though research

suggests 36-40 ng/ml may be ideal [323]. Some believe the normal level of vitamin D should be

50-60 ng/ml.

o While supplementation may be recommended, more appropriate dosing of vitamin D

supplementation can be made once a serum 25(OH)-vitamin D level has been established.

Food or Beverage Summary Recommendation

Flaxseed Good source of omega-3 fatty

acids and fiber, contains protein,

calcium, potassium, B vitamins,

iron, and boron.

Opt for ground flax seeds rather

than whole flax seeds, flax seed

oil, flax supplements to increase


Flax seeds may be ground in a

coffee grinder, blender, or food


2 Tbsp ground flaxseed daily

Flax can have a laxativelike

effect, thus, it is wise

to gradually increase


Sprinkle into various foods

and beverages, including

hot cereals, tomato sauces,

fruit smoothies, brown rice or

other grains.

Store flax in the refrigerator or


Green tea Green tea contains does contain

caffeine though much less than

coffee or black tea.

If opting for decaffeinated green

tea, opt for those naturally

decaffeinated with water as typical

caffeine extraction results in a

significant loss of phytonutrients.

1-4 cups daily

Soy Contains various nutrients, including

protein, fiber, calcium, and B


Rich in antioxidants*, known as

isoflavones, namely genistein and


Among others, dietary sources

include soybeans, edamame, tofu,

soymilk, tempeh, miso, and soy


Unless soy has been a part

of your diet for years,

postmenopausal individuals

with ER+ breast cancer

may be advised to limit soy

consumption to 1-3 daily


Soy supplements or

isoflavone extracts are not


Vitamin D A fat-soluble vitamin that we generate

through skin synthesis of sunlight

(ultraviolet rays).

Dietary sources include cold-water

fish, eggs, and fortified products,

such as milk, soy milk, and cereals.

400-2000 IU daily

Maintain serum 25 (OH)-vitamin

D >35 ng/mL.



• Melatonin is a hormone produced by the pineal gland. Its primary function involves the regulation of

the body’s circadian rhythm, endocrine secretions, and sleep patterns.

• Some research indicates that individuals with low levels of melatonin are at greater risk for breast


• The risk of breast cancer was reduced by 33% in postmenopausal women who slept 9+ hours

compared to those who slept ≤6 hours daily [324].

o Melatonin levels were 42% higher in those who slept 9+ hours vs ≤6 hours daily.

o Previous studies have reported an increased risk of breast cancer in night-shift workers who

are exposed to light at night [325-327].

• It may be that the length of time working night shifts makes a difference as

evidenced by this study where women who reported more than 20 years of rotating

night shift work faced an increased risk of breast cancer compared with women who

did not report any rotating night shift work [326].

o In vitro and animal research has supported the protective effect of melatonin against breast

cancer [328].

o A recent study found that women with higher urinary melatonin levels had a 30-41% reduced

risk of breast cancer [329].

• Melatonin may act by:

o Inhibiting cell proliferation [330,331].

o Inducing apoptosis* [332].

o Enhancing the immune system [330,333].

• May improve survival in cancer patients by protecting the immune system from

damage caused by chemotherapy [332].

o Reducing IGF-I [334,335].

o Decreasing the number and activity of estrogen receptors, thus reducing ways that the cancer

cell connects to estrogen [336].

• Various studies indicate that melatonin may inhibit breast cancer by interfering with estrogen

pathways, thus acting in an anti-estrogenic manner [331,333,337,338].

o Melatonin decreases the formation of estrogen from androgens by inhibiting aromatase activity


• Furthermore, the combination of melatonin and retinoids* [339] as well as the combination of melatonin

and vitamin D3 [340] appear to work synergistically to inhibit the growth of breast cancer cells.

• Melatonin does have blood thinning properties, thus it is recommended to not use supplemental

melatonin 7-10 days prior to surgery.


• Especially important for those with weakened or impaired immune systems and while on



• The following recommendations have been adapted from guidelines provided by the American

Cancer Society.

o Wash foods thoroughly before eating.

o Keep all aspects of food preparation meticulously clean.

o Use special care in handling raw meats, poultry, and eggs.

• Thoroughly clean all utensils, countertops, cutting boards, and sponges that

contacted raw meat.

• Thaw meats and fish in the refrigerator.

o Transfer large volumes of leftovers, such as soup, rice, or casseroles, to shallow containers and

place in refrigerator. This process ensures proper cooling.

o Do not eat perishable foods that have been left out of the refrigerator for more than two hours.

o Store foods at low temperatures (less than 40oF) to minimize bacterial growth.

o When eating in restaurants, avoid foods that may have bacterial contamination, including sushi,

salad bars, buffets, unpasteurized beverages or food products, and raw or undercooked meat,

poultry, fish, and eggs.


• Eat 8 to 10 colorful fruit and vegetable servings daily

o Two to three pieces of fruit

o One cup or more of vegetables with lunch and dinner

o 8 fl oz vegetable juice

• Consume 30 to 45 grams of fiber daily

o You will likely meet your fiber goal if you eat 8 to 10 servings of fruits and vegetables plus one

serving of beans/legumes or at least two servings of whole grains daily.

• Avoid processed and refined grains/flours/sugars

o Keep WHITE off your plate: bread, pasta, rice, cream sauces, cakes, and more.

• Limit meats and whole milk dairy products

• Include healthy fats like cold-water fish, flaxseed, walnuts, soybeans, olive oil, avocados

• Eat 2 Tbsp ground flax daily

• Limit alcohol consumption

• Drink 1 to 4 cups of green tea daily

• Maintain serum 25 (OH)-vitamin D levels above 35 ng/mL

• Drink plenty of fluids, water or non-caffeinated beverages, daily to help meet fluid needs

• Engage in daily physical activity to help achieve and maintain a healthy weight


Bone Health

• Pre- and postmenopausal survivors of breast cancer are at great risk for development of


o Thus, screening and preventive strategies for osteoporosis are imperative.

• Even small amounts of increased bone mass provide great risk reduction for fractures.

• Generally, humans reach peak bone mass around 30 years. After the age of 30, the goal is to

maintain or prevent loss of bone mass.

o On average, humans lose 0.3 – 0.5% bone mass yearly after 30 years.

• First signs of osteoporosis are seen in spine, hip, and wrist.

o Symptoms include back pain or tenderness, loss of height, and slight curving of upper back.

• Risks for osteoporosis include: female, Asian or white ethnicity, age, menopause, amenorrhea, low

testosterone levels in men, sedentary lifestyle, family history, diet low in calcium, diet low in vitamin

D, excessive alcohol and tobacco use, excessive caffeine use, diet high in sodium, diet excessive in

protein or very low in protein, certain medications (diuretics, steroids, thyroid meds), celiac disease

• Many nutrients have bone-building effects, including calcium, vitamin D, phosphorus, magnesium,

vitamin K, potassium, and boron (see table below).

• Exercise increases bone mass before menopause and slows bone loss after menopause.

o Include weight-bearing exercise, such as walking, jogging, skiing, stair climbing, aerobics, and


o Resistance training exercises are useful to strengthen muscles and bones.

• Recent research indicates diets high in fruits and vegetables have a positive effect on bone health.

o Good source of minerals (potassium, magnesium) that may have direct effects on bone cells.

o Counteract acid environment.

o Lower urinary calcium loss.

o Enhanced calcium bioavailability of most vegetables.

• Soy protein and/or soy isoflavones have been proposed to delay bone loss.

o May help to prevent urinary calcium loss.

o Soy contains phytosterols that mimic the actions of estrogen.

o May help to prevent rapid bone loss of menopause years.

o Studies report that soy may BMD.

• Calcium supplements

o Take 500 mg or less per meal to maximize absorption.

o Calcium citrate, lactate, or gluconate are recommended if you have iron deficiency.

• These do not decrease iron absorption like calcium carbonate.

o Calcium carbonate is least expensive, but may increase gas and bloating in some individuals.


• What about antacids with calcium?

o Trace minerals like zinc or iron may be less well-dissolved and absorbed with a lower stomach


o If you’re only taking enough antacid for the purpose of calcium needs, should not present a

major problem, but not ideal.

o May interact with thyroid medication.

• DEXA (dual-energy X-ray absorptiometry) instruments allow rapid, painless, noninvasive, and highly

reproducible measurements of bone density to be made [341].

o These measurements are used to diagnose osteoporosis, low bone density, and risk of fracture

and to determine rates of bone loss or the effectiveness of treatment over time [342,343].

Bone Health – Bottom Line

• Balanced diet – high in fruits and vegetables

• Calcium

o Aim for 3 rich sources daily.

o Include a supplement if necessary.

• Vitamin D

o Meet needs from sun, multivitamin, or other supplement.

o Consider serum vitamin D test.

• Exercise

o Weight-bearing exercise for at least 30 minutes on most days.

• Good posture

• Request to have a full body DEXA scan.


Bone Building Nutrients

Nutrient* Dietary Sources Function Recommendation

Calcium Dairy products, canned

fish with soft bones,

beans, leafy greens

(especially collard

greens, bok choy, and

kale), tofu, almonds,

fortified products, such

as soy milk, cereal, and

orange juice

calcium absorption

and bioavailability from

foods, especially plant


Vitamin D is essential for

calcium absorption.

1000-1200 mg


Vitamin K Dark leafy greens, liver,

tomatoes, soybeans,

and garbanzo beans

Also produced by

intestinal bacteria

Associated with bone

turnover and urinary

calcium excretion.

90 mcg daily

Phosphorus Meat, poultry, fish, eggs,

milk, products, legumes,

and nuts

Combines with calcium to

strengthen bones.

700 mg daily

Magnesium Whole grains, nuts, seeds,

spinach, and most fruits

and vegetables

Important in calcium and

potassium uptake.

320 mg daily

Potassium Bananas, strawberries,

tomatoes, prunes,

potatoes, spinach, and


Associated with

urinary calcium and

phosphorus excretion.

4700 mg daily

Boron Apples, avocados, beans,

milk, peanuts, peanut

butter, pecans, raisins,

prunes, and potatoes

Improves calcium


effects of vitamin D and

magnesium deficiency.

2 mg daily

Zinc Seafood, meats, tofu,

whole grains, blackeyed

peas, wheat bran

and germ

Important in calcium

uptake and immune


8-15 mg daily

* Vitamin D is listed in the previous table


Hot Flashes

• Hot flashes are a major cause of morbidity among postmenopausal women, including many

survivors of breast cancer.

• Approximately 75% of postmenopausal women who had breast cancer report experiencing hot

flashes [344].

o More than 90% of young survivors also experience hot flashes, which can be more severe and

long lasting, with iatrogenic ovarian ablation or antiestrogen therapy.

• Various non-hormonal therapies have been studied for improving hot flashes, including soy, black

cohosh, red clover, and vitamin E – none have shown much significant clinical value.

• Supplemental vitamin E at 400 IU/day [345] and 800 IU/day [346] has shown some limited efficacy

in improving hot flashes.

• Systematic reviews of randomized controlled trials have observed contradictory results, and

meta-analyses* demonstrate no statistically significant reduction of vasomotor symptoms for

phytoestrogens [347].

o Individual trials report significant reductions in vasomotor symptoms for red clover and soy


o The placebo effect in many of these studies was quite strong [348].

o Studies assessing black cohosh and red clover have had inconsistent results, with some trials

showing benefit and some no difference compared with placebo [349].

o In one study, women receiving black cohosh reported a mean decrease in hot flash score of

20% compared with a 27% decrease for patients on placebo [350].

• Mean hot flash frequency was reduced 17% on black cohosh and 26% on placebo.

o A previous study reported reduced hot flashes with soy isoflavones by 9 to 40% in some trials,

but most trials observed no effect when compared with placebo [349].

• Black cohosh extract had no effect on serum estrogenic markers [351].

• The use of black cohosh appears to be safe in breast cancer patients [352].

• Psychoeducational interventions, including relaxation, seem to alleviate hot flashes in menopausal

women and breast cancer survivors; however, the methodological quality of published research has

been considered to be fair or poor [353].


“Let food be your medicine and medicine be your food.”

– Hippocrates

For additional information or resources, please visit the Ida and Joseph Friend Cancer Resource

Center at 1600 Divisadero St. on the first floor, or call at (415) 885-3693. The information in this

publication is designed for educational purposes only and is not intended to replace the advice of

your physician or health care provider, as each patient’s circumstances are individual. We encourage

you to discuss with your physician any questions and concerns that you may have.


Three Day Menu Plan: 3 Meals + Snack

This menu is based on 1600 calories, calories can be adjusted by altering portion sizes. The menu

has been designed to merely serve as a guide in making healthy food choices. Experiment with

substitutions as desired.

Day 1 Day 2 Day 3

Oatmeal, cooked (1 cup)

Soy milk (1 cup)

Flaxseed, ground (2 tbsp)

Blueberries (1/2 cup)

Green tea (2 cups)

Bagel, whole grain (1 med)

Hummus (2 tbsp)

Tomato (6 slices)

Lemon pepper

Cantaloupe (1 cup)

Green tea (2 cups)

Tofu scramble

Tofu (4 oz)

Onions (1/4 cup)

Peppers (1/2 cup)

Mushrooms (1/2 cup)

Toast, whole grain (1 slice)

Jam (1 tbsp)

Turkey sandwich

Whole grain bread (2 slices)

Turkey (2 oz)

Lettuce (1/2 cup)

Tomato (4 slices)

Red peppers (1/4 cup)

Onions (2 tbsp)

Mustard (1 tsp)

Carrots (1/2 cup)

Snap peas (1/2 cup)

Vegetable Bean Soup (2 cups)

Corn tortilla (1 med)

Green salad (2 cups)

Oil/vinegar dressing (1 tbsp)


Spinach (3 cups)

Broccoli (1/2 cup)

Carrots (1/2 cup)

Tomato (1/2 cup)

Garbanzo beans (1 cup)

Barley, cooked (1/2 cup)

Avocado (4 slices)

Olive oil (1/2 tbsp)

Vinegar, balsamic (1 1/2 tbsp)

Roll, whole grain (1 med)

Orange (1 med)

Vegetable juice (12 oz)

Granola bar (1 each)

Fruit smoothie

Banana (1 med)

Berries (1 cup)

Flaxseed, ground (2 tbsp)

Yogurt, plain nonfat (1/2 cup)

Soy milk (1 cup)

Green tea (2 cups)

Popcorn, air-popped (3 cups)

Fish (3 oz)

Pasta, whole grain (1 1/2 cups)

Tomato sauce (1 cup)

Mushrooms (1/2 cup)

Olive oil (1/2 tbsp)

Broccoli (1 cup)

Mixed fruit (1 cup)

Chicken & vegetable stir-fry

Chicken breast (4 oz)

Mixed vegetables (2 cups)

Walnuts (2 tbsp) OR

Olive oil (1/2 tbsp)

Brown rice, cooked (1 cup)

Salmon (4 oz)

Quinoa, cooked (1 cup)

Asparagus (1 cup)

Fruit salad (1 cup)



Baked Tofu


• 1 pound tofu, firm, drained

• 3-4 tbsp marinade or sauce (personal favorite: Veri Veri Teriyaki by Soy Vay)

Chop drained firm tofu into 1” cubes. Place tofu cubes in glass dish for baking. Pour marinade or

sauce over tofu, stir well. Place tofu in oven at 350 F for 1 hour. Stir every 15-20 minutes.

Makes four 4-ounce servings.

Nutrition Information (per 4 oz serving):

Calories: 96 Dietary fiber: <1 gm

Protein: 8 gm Sodium: 318 mg

Fat: 5 gm Calcium: 155 mg

Saturated fat: <1 gm Iron: 1.4 mg

Recipe developed by Natalie Ledesma, MS, RD, CSO

Washington Insider Salad


• 1 can (15 oz) kidney beans, drained

• 1 can (15 oz) black eyed peas, drained

• 1 1/2 cups cooked barley

• 6 tbsp cilantro, chopped finely

• 1 can (11 oz) corn

• 1 1/2 cups tomatoes, diced

• 3 tbsp balsamic vinegar

• 2 tbsp olive oil

Prepare vegetables. Mix all ingredients together, and serve on a bed of dark green leafy lettuce. Add

salt and pepper to taste.

Makes 8 servings (1 cup each).

Nutrition Information (per serving):

Calories: 215

Protein: 10 gm

Fat: 4 gm

Dietary fiber: 9 gm

Recipe developed by Sous Chef Chris at the Occidental Grill, Washington D.C.

Spinach Spread


• 1 package (10.5 ounces) silken tofu

• 1 tbsp lemon juice


• 1/4 tsp garlic powder

• 3/4 tsp onion powder

• 1/2 tsp dried tarragon

• 1/4 tsp salt

• 1 box (10 ounce) frozen chopped spinach, thawed

• 1 cup coarsely shredded carrots

• 1/4 cup chopped green onion

Puree the tofu and lemon juice in blender until smooth. Whirl in the garlic and onion powders,

tarragon, and salt just to blend. Scrape into a mixing bowl. Squeeze the spinach as dry as possible.

Stir it into the tofu, along with the carrots and green onion. Mix well. Serve with crackers, pita

triangles, or vegetables.

Makes 8 servings (1/4 cup each).

Nutrition information (per serving):

Calories: 39 Sodium: 82 mg

Fat: 1 gm Calcium: 51 mg

Saturated fat: 0 gm Carbohydrate: 5 gm

Protein: 4 gm Dietary Fiber: 2 gm

Recipe from the U.S. Soyfoods Directory, 1998.

Tofuntastico – Tofu Sauce


• 1 package (12.3 ounce) silken tofu

• 1/2 cup water

• 3/4 cup fresh basil, chopped

• 4 tbsp nutritional yeast

• 3 tbsp Bragg’s liquid aminos (or tamari or soy sauce)

•1 tbsp lemon juice

•1 tsp garlic, minced

•3/4 tsp black pepper

•Alternative: Use lime/cilantro rather than lemon/basil

Blend all ingredients together in a blender or food processor. Serve over pasta, vegetables, baked

potato, or other.

Makes 6 servings (1/2 cup each).

Nutrition Information (per serving):

Calories: 47 Carbohydrate: 4 gm

Protein: 7 gm Dietary fiber: 2 gm

Fat: <1 gm

Recipe developed by Natalie Ledesma, MS, RD, CSO


Alaska Salmon Bake with Walnut Crunch Coating


• 1 pound salmon fillets, thawed if necessary

• 2 tbsp Dijon-style mustard

• 1-2 tbsp olive oil

• 4 tsp honey

• 1/4 cup bread crumbs

• 1/4 cup walnuts, finely chopped

• 2 tsp parsley, chopped

• Salt and pepper to taste

• Lemon wedges

Mix together mustard, olive oil, and honey in a small bowl; set aside. Mix together bread crumbs,

walnuts, and parsley in a small bowl; set aside. Season each salmon fillet with salt and pepper. Place

on a lightly greased baking sheet or broiling pan. Brush each fillet with mustard-honey mixture. Pat

top of each fillet with bread crumb mixture. Bake at 450 F for 10 minutes per inch of thickness or until

salmon just flakes when tested with a fork. Serve with lemon wedges.

Makes 4 servings (4 oz each).

Nutrition Information (per serving):

Calories: 228

Protein: 20 gm

Fat: 12 gm

Omega-3 fatty acids: 1.7 gm

Adapted from Alaska Seafood Marketing Institute.

Banana Bread


• 3/4 cup ground flax seed

• 1 cup mashed banana

• 1/4 cup apple juice concentrate

• 1/2 cup brown sugar

• 1/4 cup applesauce

• Egg replacer for 2 eggs or 2 eggs (Ener-G Egg Replacer is made from potato starch & tapioca

flour; works wonderfully in baked goods.)

• 1 1/2 cup whole wheat pastry flour

• 1 tsp baking soda

• 1/2 tsp salt

• Additional optional ingredients may include 1/2 cup walnuts, raisins, or chocolate chips.

Mix all ingredients together. Pour in a coated 8”x4” pan. Bake at 350 F for about 40-45 minutes.

Makes 10 servings.

Nutrition Information (per serving):


Calories: 168 Carbohydrate: 29 gm

Protein: 5 gm Dietary fiber: 5 gm

Fat: 4 gm Omega-3 fatty acids: 1.4 gm

Recipe developed by Natalie Ledesma, MS, RD, CSO

Dilled Salmon Salad with Peas


• 1 can (15 oz) salmon, drained

• 1 package (16 oz) frozen peas, thawed

• 1/4 cup lemon juice

• 1/4 cup fresh dill (or 1-2 tbsp dried dill)

• 2 tbsp Dijon-style mustard

• 2 shallots, sliced thinly (about 1/2 cup)

• 1 bunch radishes (about 11 medium), thinly sliced

• 6 cups red leaf lettuce

• Salt and pepper to taste

Drain salmon, place in a mixing bowl, and break into pieces. Prepare the lemon juice, shallots,

radishes, and lettuce. Add to the salmon the peas, lemon juice, dill, mustard, shallots, and radishes.

Mix together gently. Add salt and pepper to taste. Serve salmon mixture over lettuce.

Makes 6 servings (2 cups each).

Nutrition Information (per serving):

Calories: 160

Protein: 17 gm

Fat: 4 gm

Dietary fiber: 5 gm

Adapted from the Women’s Healthy Eating & Living Study (WHEL) at the University of California,

San Diego. Developed by Vicky Newman, MS, RD, WHEL nutrition coordinator.

Neat Loaf


• 2 cups cooked brown rice

• 1 cup walnuts, finely chopped

• 1 onion, finely chopped

• 1/2 medium bell pepper, finely chopped

• 2 medium carrots, shredded or finely chopped

• 1 cup wheat germ

• 1 cup quick-cooking rolled oats

• 1/2 tsp each: thyme, marjoram, sage


• 2 tbsp soy sauce

• 2 tbsp stone ground or Dijon mustard

• Barbecue sauce or ketchup

Preheat the oven to 350 F. Combine all the ingredients except the barbecue sauce or ketchup. Mix for

2 minutes with a large spoon. This will help bind it together. Pat into an oil-sprayed 5×9” load pan and

top with barbecue sauce or ketchup. Bake for 60 minutes. Let stand 10 minutes before serving.

Makes 8-10 servings.

Nutrition Information (per serving):

Calories: 204 Sodium: 248 mg

Protein: 9 gm Cholesterol: 0 mg

Fat: 9 gm

Carbohydrate: 19 gm

Recipe from The Peaceful Palate written by Jennifer Raymond (1996).

Chinese Cabbage and Radish Salad


• 4 cups Chinese cabbage, quartered and then thinly sliced

• 1/4 cup radishes

• 1/4 cup red onion, thinly sliced

• 2 tbsp white miso

• 2 tbsp brown rice vinegar

• 1 tsp maple syrup

• 1 tsp dill, dried

• 2 tbsp sunflower seeds, toasted

With a fork, mix the miso, vinegar, maple syrup, and dill. Mix the vegetables and press with a plate until

submerged in liquid for about 1 hour. Fluff the vegetables to serve and garnish with sunflower seeds.

Makes 4 servings.

Nutrition Information (per serving):

Calories: 64 Carbohydrate: 9 gm

Protein: 2 gm Cholesterol: 0 mg

Fat: 2 gm Sodium: 275 mg

Source anonymous.

Quinoa/Sweet Potato Patties


• 1 1/2 cups sweet potato, peeled and chopped

• 1 cup quinoa

• 2 tbsp parsley, fresh

• 1/2 tsp sea salt


• 2 tsp extra-virgin olive oil

Steam or bake sweet potatoes until done. Drain and mash potatoes. Wash the quinoa well and drain.

Dry toast the quinoa in a skillet until slightly browned. Meanwhile, bring a pot of water to a boil. Add

the toasted quinoa to the boiling water and cook, with lid off, for ~15 minutes. Drain well. Mix the

mashed potatoes and quinoa. Add the parsley and salt. Form 8 patties and place in a lightly oiled pan

over medium-high heat. Cook for about 5 minutes on each side and serve warm.

Makes 8 servings.

Nutrition Information (per serving):

Calories: 125 Sodium: 165 mg

Protein: 4 gm Cholesterol: 0 mg

Fat: 2 gm

Carbohydrate: 22 gm

Recipe adapted from the Vegetarian Resource Group (1997).

Nutrition Resources


How to Prevent & Treat Cancer with Natural Medicine – written by Michael Murray (2002)

The Color Code – written by James Joseph, Daniel Nadeau, & Anne Underwood (2002)

Ultra Metabolism – written by Mark Hyman (2006)


Cancer Lifeline Cookbook – written by Kimberly Mathai & Ginny Smith (2004)

Fat-Free and Easy: Great Meals in Minutes – written by Jennifer Raymond (vegetarian cookbook) (1997)

Lickety-Split Meals – written by Zonya Foco (1998)

One Bite at a Time – written by Rebecca Katz, Marsha Tomassi, & Mat Edelson (2004)

The Peaceful Palate – written by Jennifer Raymond (vegetarian cookbook) (1996)

12 Best Foods Cookbook: Over 200 Recipes Featuring the 12 Healthiest Foods – written by Dana

Jacobi (2005)


Cooking Light Fax: (205) 445-6600

Environmental Nutrition (800) 829-5384

Nutrition Action Health Letter Fax: (202) 265-4954


American Cancer Society (415) 394-7100

American Institute for Cancer Research (800) 843-8114


Caring4Cancer – Provides up-to-date & comprehensive information on the connection between

nutrition & cancer –

Center for Informed Food Choices – Offer cooking classes in the Bay Area that emphasize plantbased


Consumer Lab – Evaluates quality of over-the-counter supplements

Diana Dyer, MS, RD – Breast cancer survivor & dietitian

Ida & Joseph Friend Cancer Resource Center – UCSF Mt.Zion

(415) 885-3693

National Cancer Institute (800) 4-CANCER (800-422-6237)

Oncolink – Provides information regarding clinical trials, newsgroups, psychosocial support, & more.

San Francisco Vegetarian Society – Monthly restaurant outings & pot-luck dinners; call 415-273-5481.


The Vegetarian Resource Group – Provides vegetarian nutrition information & vegetarian recipes




Angiogenesis – The formation of new blood vessels.

Antioxidant – A substance that inhibits oxidation or inhibits reactions promoted by oxygen or peroxides.

Apoptosis – Programmed cell death.

Carcinogenesis – Beginning of cancer development.

Case-Control Studies – An epidemiological study in which a group of, say, cancer patients (cases)

is compared to a similar but cancer-free population (controls) to help establish whether the past or

recent history of a specific exposure such as smoking, alcohol consumption and dietary intake, etc.

are causally related the risk of disease.

Catechin – One of the tannic acids; phytonutrient, specifically, one of the flavonoids found in green tea.

Creatine – An amino acid that is formed in the muscle tissue of vertebrates; supplies energy for

muscle contraction.

Cohort Studies – Follow-up study of a (usually large) group of people, initially disease-free.

Differences in disease incidence within the cohort are calculated in relation to different levels of

exposure to specific factors, such as smoking, alcohol consumption, diet and exercise, that were

measured at the start of the study and, sometimes, at later times during the study.

Eicosanoids – Biologically active compounds that regulate blood pressure, blood clotting, and other

body functions. They include prostaglandins, thromboxanes, and leukotrienes.

Endogenous – Originating from within, as within the body.

Estradiol – A naturally occurring powerful estrogen secreted by the mammalian ovary.

Estrone – A naturally occurring weak estrogen secreted by the mammalian ovary.

Glutathione – A polypeptide produced primarily in the liver; involved in DNA synthesis and repair,

protein and prostaglandin synthesis, amino acid transport, metabolism of toxins and carcinogens,

immune system function, prevention of oxidative cell damage, and enzyme activation.

Insulin – Insulin is a hormone produced by the pancreas in the body that regulates the metabolism of

carbohydrates and fats, especially the conversion of glucose to glycogen, which lowers the body’s

blood sugar level.

Lignans – Phytoestrogens that have a similar chemical structure to estradiol and tamoxifen; appear

to offer protection against breast cancer.

Meta-analysis – The process of using statistical methods to combine the results of different studies.

Mutation – Abnormal cell development.

Nitrosamines – Derivatives of nitrites that may be formed in the stomach when nitrites combine with

amines; carcinogenic in animals.

Phytonutrients – Plant compounds that appear to have health-protecting properties.

Polyphenols – Phytonutrients that act as an antioxidant; compounds that protects the cells and body

chemicals against damage caused by free radicals, reactive atoms that contribute to tissue damage

in the body.

Retinoids – Chemically related compounds with biological activity similar to that of retinol; related to

vitamin A.

Sex hormone-binding globulin (SHBG) – A protein in the blood that acts as a carrier for androgens

and estradiol; inhibits the estradiol-induced proliferation of breast cancer cells.



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 Thank you


Healthy Father’s Day! by Maria Dorfner

Dad finds a Bocce court in Napa Valley and proceeds to give the boys from Pittsburgh a few tips.
Dad finds a Bocce court in Napa Valley and proceeds to give the boys from Pittsburgh a few tips.


Prior to Father’s Day, I like to reflect back to what my Dad was doing at my age. I am so grateful he was and still is involved in my life. Involved Dads make for smarter, happier kids.  I was definitely a happy kid.  I don’t know about smart.  I was a straight B+ student at Saint Ephrem’s. I only ever got an A in English, but I  wanted straight A’s like Grace, the smartest girl in class.  College had me getting a 4.0 only in English, Psych and Marketing.  Reminds me of the hilarious song in the Off-Broadway play Avenue Q called, “What Do You Do With a B.A. in English?”

Meantime, while I was busy trying but failing to get straight A’s, my Dad worked a bazillion hours, yet still managed to find time to spend with us.  Dad could have been the Tim Ferriss of Fathers and written “The 4-Hour Dad Week” because he was creative in terms of maximizing the minimum amount of time he had to spend with us.  He found time, even if it was a tad early.

I can still hear him yelling, “If you girls are ready at 3 a.m. I will drive you to college!!!  If you’re not ready, the car leaves without you!!!”  You girls were myself and my best friend, Rosemarie. We lived in Brooklyn and were starting Pace University in NYC, where our Dads worked in construction.  We still laugh at how we aced early bird Marketing because we had hours to kill studying.

Our Dads drove us each morning for four years, and even opened and closed the doors for us.  Chivalry was alive and well. Being earlybirds had benefits. We got to read the newspapers first and knew what was going on in the world before the rest of the world. Plus, no trains.

I’d been riding the subway since I was a kid.  I actually loved it, especially when the Big Apple came into view.  That faded when I had to learn to read people’s faces quickly or end up robbed or who knows what.  I grew up feeling safe until the infamous Son of Sam (David Berkowitz) terrorized our neighborhood by going on a brunette killing spree. The New York Post released a sketch of the suspect and it looked like everybody I knew.  Everybody.

So Dad, where were YOU last night at 0600 hours? Huh?

So, riding the subway suddenly meant sizing someone up quickly.  Roger Ailes who wrote my favorite book on Communication called, “You Are the Message” says you make your first impression within the first 5 seconds of meeting someone. Five seconds. 1…2…3…4…BAM. I got your number.  Our Dads already had this skill, and shared lots of stories while driving over the Brooklyn Bridge.

No need to talk first. In fact, Roger and my former agent who sadly passed away, Alfred Geller turn off the volume when they watch someone on-camera. Geller did that with my tape and exclaimed I belong in the #1 market before turning up the volume on the TV monitor in his seminar.  You see someone before you hear them. It’s not about what someone looks like –it’s about their energy. Ralph Waldo Emerson said who you are speaks louder than anything you say. Same on NYC subway. Back then, it assaulted all sense of sight, smell, touch and hearing. Taste too because if you ate anything, you’d feel nauseous.

So, Rosemarie and I were OVERJOYED to plan our entire college schedules around getting a luxury, stress-free, safe ride to school.

More importantly, it was quality time with the Dads. We never knew what they would ask us, and they took an interest in our classes. They’re both funny too.  After my Dad’s construction job he returned home, removed his dirty boots outside, showered and ran out to run a restaurant.  By this time, I’d be taking a train at City Hall to head over to my job as a sales associate at Sak’s Fifth Avenue or Barnes and Noble on Fifth Avenue.

When my entrepreneurial Dad wasn’t working two jobs, he did not go to the gym for fitness. He didn’t run. He did not play golf. My Dad loved a TV show called, “Bowling for Dollars.” It must have inspired him to take up the sport. He excelled at it. Strikes every time.

Recently, I notice three fingers on his right hand are dented as if he is still holding a bowling ball. It’s hilarious. I ask him about it and he says it’s from all those years bowling. I’ve never seen anything like that.  He had an amazing dance and spin he did like Fred Flinstone’s twinkle toes, only on steroids.  The ball spinned soooooo incredibly fast. I loved watching that.


He also played Bocce. Funny, it just hit me that’s bowling too. It’s bowling without pins. Dad’s favorite Bocce court was at Dyker Heights Golf Course. Lots of running from one side of the bocce court to the other, so that was his outdoor gym. After school, my cousin Josephine and I rode our bikes there to see our Dads play. If they were winning they gave us a dollar or two.

We loved Biking for Dollars. The apples do not fall far from the tree.

Our Dads always greeted us warmly. “Aaaay look who it is!!!” It was like the opening theme song to the TV Show “Cheers.” “…sometimes you wanna go where everybody knows your name…and they’re always glad you came…”

Subsequently, a study of Chinese parents finds warmth matters. It’s a father’s warmth toward his child that is the ultimate factor in predicting the child’s future academic success. Imagine that.

In fact, involving fathers from the start in children’s lives has a significant positive impact on their development, including the greater economic security of having more than one parent. They call it the “father effect.” Involved fathers are present, even when they can’t physically be there. Mothers play a role in letting kids know what their Dads are doing and when they can spend time together.

Moms can also be The Mole at times. If my Dad asked a question, I knew that he knew that I knew The Mole already told him the answer. The words, “Wait until your father gets home” were serious business. But discipline meant he was involved. And as mentioned previously, studies say “involved dads” make for smarter, happier kids.

Sunday dinners with Dad after church was when we each were excited (or scared!) to fill him in on what we were doing. It was also when he did his Rain Man thing of asking, “Quick! How much is 345 + 7890 – 4498 + 8768 – 2?”

I didn’t know he was preparing me to be a researcher on The McLaughlin Show. The host of the politically-oriented talk show, John McLaughlin would yell out, “Gut this encyclopedia and do it in two seconds!” By the time I was director of research for Roger Ailes, I was like a human Google search engine.

Turns out, I have Dad to thank for that because him being present during those dinners was healthy for my brain. Numerous studies find children growing up in a household with a father present show superior outcomes in intelligence tests. Although, I wonder if he cancelled that out with the beatings when we got home late. Ha!

Back to the IQ advantage. It’s attributed to the way fathers interact with their children. Outdoor activities and playing with kids outweigh language-based ones. So Dad showing me how to play bocce and then yelling at me to get off the court expanded my brain more than the Italian Savant quizzing me during Sunday dinners. Interesting.

According to a recent Canadian study from Concordia University finds girls whose fathers lived with them when they were age 6 to 10 demonstrate less anxiety when they are age 9 to 13. Being present is vital to having a positive impact and raising healthy kids.

Thank you to my Dad and to all the Dads out there who are and were present.  You’re loved and appreciated more than you know.

Healthy Father’s Day! I love you, Dad.

10 Healthy Start-up Tips from Pirates by Maria Dorfner



Ahoy!  I found a few metaphors for life in the Pirates of the Caribbean films, a la buried treasure:





WILL TURNER:  This is either madness…or brilliance.

JACK SPARROW:   It’s remarkable how often those traits coincide.




JACK SPARROW:  People aren’t cargo mate!




SWANN:  Even a good decision if made for the wrong reasons can be a wrong decision.





JACK SPARROW:  What a ship is…the black pearl really is…is FREEDOM.





WILL TURNER:  A craftsman is always proud to hear his work is appreciated.





GIBBS:  Not quite according to plan.

JACK SPARROW:  Complications arose, ensued, were overcome.





JACK SPARROW:  You look bloody awful, what are you doing here?

 NORRINGTON:  You hired me.  I can’t help it if your standards are lax.





WILL TURNER:  No cause is lost if there is but one fool left to fight for it.





JACK SPARROW:  We have a need to travel upriver.

GIBBS:  By “need,” do you mean a trifling need?  Fleeting?  As in, say a passing fancy?

JACK SPARROW:  NO, a resolute and unyielding need!!





JACK SPARROW:  Close your eyes and pretend it’s all a bad dream.  That’s how I get by.






JACK SPARROW:  You’ve seen it all, done it all.  Survived.  That’s the trick, isn’t it?  To survive?

CAPTAIN TEAGUE:  It’s not just about living forever, Jackie.  The trick is still living with yourself forever.







JACK SPARROW:  You can’t upright a ship if it’s not already capsized.










Hope these quotes help you navigate your vessel through any unexpected treacherous waters!   Stay healthy.  🙂



[Quote Sources: Pirates of the Caribbean:  Dead Man’s Chest (2006), Pirates of the Caribbean: At World’s End (2007), Pirates of the Caribbean: The Curse of the Black Pearl (2003); photos: Pirates of the Caribbean films; Jake and the Never Land Pirates (Disney TV cartoon 2011)]




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