Burning Questions


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Food. We can’t live without it, but for many in the colorectal cancer community, it’s hard to live with it. Yet as doctors, nutritionists and research data all say: Diet and nutrition play an essential role in cancer prevention and treatment. Food is a topic we can’t ignore.  

Easier said than done.

“Why don’t we get ‘real’ answers about life after surgery or treatment?” asked Christina Haywood, a stage III rectal cancer survivor diagnosed at age 34. She voiced what many survivors and caregivers feel when it comes to diet and nutrition guidance. “We hear, ‘Wait and see,’ and ‘Everyone’s different,'’ or ‘At least you're alive’—but this doesn’t answer what we’re really wondering and what we really want to know.” 

Food pyramids, special diets and conflicting recommendations have caused great confusion in the cancer community, not to mention the spread of misinformation, particularly on social media. In fact, a recent study published in the Journal of the National Cancer Institute found that up to 30% of posts about cancer on social media are misleading or false. Patients need real answers—and fast.

To get to the bottom of the confusion, frustration and hanger (you know—when hungry meets anger), we reached out to several accredited experts who work in a variety of institutions. While opinions still vary on some topics, consistencies like the importance of a well-rounded, balanced diet full of plant foods and the benefits of working with a dietician or nutritionist remain.

At the end of the day, what you eat is your choice. Here is reliable, credited information to consider as you make the smartest choice for your health, lifestyle and preferences. 

Answers to your Burning Questions:

It feels like diet and nutrition are some of the least-discussed subjects with patients, but it’s something that affects us every day and in very tangible ways. Why doesn’t this come up more with patients during the treatment plan and into survivorship?

Despite the vast research establishing medical nutrition therapy’s beneficial impact on cancer patients, at multiple levels throughout the disease, it is also very common for patients to not receive it—especially at the early stages of disease. A cancer diagnosis is life changing for the patient, caregivers and loved ones. Usually, the main concerns involve the specifics about processing the cancer (like stage and treatment plan), communication to loved ones, economic issues, healthcare access, survivorship, among other serious issues. Clinicians are aware that individualized medical nutrition therapy plays an important role in a cancer patient’s life, even after no evidence of the disease is declared.

Medical nutrition therapy is important because it can help detect malnutrition, support muscle mass preservation, and monitor weight management. It should not be overlooked given the implications that it can have in the quality of life and patient’s prognosis. A more proactive approach that includes a tailored medical nutrition therapy should be promoted not only among the clinical interdisciplinary team but also among patients and caregivers. Patients, ask your doctors about this!

— Carrie Lynn Gibson, M.Ed and Wellness, RDN, LND, Clinical Supervisor Outpatient Unit Nutrition and Food Services, VA Caribbean Healthcare System- San Juan, Puerto Rico

It may come down to having more important things on your mind, or more pressing needs. Financial challenges, getting to treatment, having surgery, even facing the emotional realities of having cancer—nutrition is sometimes the least of patients’ worries. Approaching diet and nutrition when you’re ready is a valuable step. Having a medical team that supports the inclusion of nutrition as a necessary part of the treatment plan is helpful. Working with a dietitian can help patients feel more confident in their day-to-day choices, give them some sense of control, help manage side effects with and without medications, and give them a break from their diagnosis.

—Sarah Crowley, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

Some CRC patients can eat things I can’t, and vice versa, but we had the same diagnosis and the same treatment. Why is this, and what should I do if I’m struggling to find a diet that works for me?

Even if your treatment plan is the same as another patient, and you’re facing the same diagnosis, you are unique. Everyone’s systems react differently to treatment. Our genes, medical history, age, gender, and other factors determine our rate of digestion, absorption, and tolerance of foods. Your microbiome can change drastically during and after treatments, especially with radiation and chemotherapy, and this affects gut health—which ultimately decides which foods or combinations of foods your body can handle. Never compare yourself to someone else; we are all on different paths. Work with your doctor and a dietitian to understand why you may struggle to tolerate certain foods that others seem to enjoy without problems. Trial and error, along with journaling, can help you understand your body more. Focus on what makes you feel good, gives you energy, meets your specific nutritional needs, and satisfies your hunger—literally and physically.

—Sarah Crowley, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

You cannot “starve” cancer cells without starving healthy cells. Follow a well-balanced diet, and a well balanced diet includes all food groups: carbohydrates, proteins, and fats. During treatment, do not limit your food choices. It’s really hard out there. Food seems so complicated when actually it really doesn’t have to be. Work with a nutritionist so you can have the best possible outcome.

—Nichole Andrews, RDN, Oncology Dietitian, Nutrition with Nichole LLC, Seattle, Washington

Are there any foods, across the board, that a CRC patient should be eating? Is there a “magic bullet” that you’ve seen work for just about everyone? (Why or why not)?

Be very skeptical and discerning about "magic bullets" and "quick fixes." The ironic, quick answer is: Eat more real plant food. Research has shown that when a diet is high in fat and red meat, and low in complex carbs/fiber, this creates a gut flora environment toward dysbiosis and CRC. A diet high in fiber/complex carbs and low on fat and red meat creates an environment toward symbiosis and healthy gut cell lining. The amount of fiber we get from food has a direct and dramatic effect on our gut microbiome.

—Colin Zhu, DO, DipABLM, Chef, CEO of TheChefDoc™ & Host/Faculty Director of The THR5 Formula™ Masterclass Series

There is no, one-size-fits-all diet, the magic happens when it works for you. Many things need to be taken into consideration for a healthy diet to be successful: lifestyle, cancer stage, level of support, cancer treatment plan, side effects, economic status, likes and dislikes, and so much more. A tailored diet accounting for all of these factors is what will help you the most. Nutrition does play a major role in the prevention, treatment, post-treatment and survivorship of CRC patients. Avoiding foods that may cause harm to the individual may be more important, for example fried foods, processed foods, and alcohol should be limited as much as possible.

—Sarah Crowley, RD, CSO, Registered Dietitian, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

When browsing through a hospital menu, many choices seem less than healthy. Burgers and fries. Sugary desserts. Why do hospitals offer these choices when they’re considered unhealthy options by most nutrition guides? 

I trained in a Newark-based hospital with a popular fast food restaurant on the hospital grounds, directly next to the hospital cafeteria where most of the patients seen on the upper medical floors were sick and ill from various conditions including heart disease (the #1 killer in the U.S.). I asked myself this same question. What I learned: When in doubt, follow the money. According to the Journal of Public Health Management and Practice, when hospital cafeteria managers were asked why nutrition was not a top priority and why they were not following nutrition standards, they answered "…due to pressure on food service departments for cafeterias to generate profit." I hope this changes fast and soon.

—Colin Zhu, DO, DipABLM, Chef, CEO of TheChefDoc™ & Host/Faculty Director of The THR5 Formula™ Masterclass Series

Get recommendations and tips for adding more fiber into your diet.

What the Fiber?!

We are seeking the perfect poop: Not too hard. Not too soft. Just right. It sounds like a fairytale.

In all fairness, yes hospital menus need to offer more diverse and healthier options. In balance, they also need to make patients happy and comfortable. Seeing food choices that are common to them may give some patients peace of mind. When a menu is filled with only healthy options, some patients may be taken back. After all, food is comfort, and while burgers and fries are not the healthiest options, they can still fit into a healthy meal plan. Teaching and educating on better choices is where a menu with diverse options will help give the patient autonomy instead of forcing a choice. Also, it’s important to remember that not all patients who are in the hospital are cancer patients. Working with the hospital and kitchen staff to provide a menu with multiple options, healthy and not, with varying items from different cultures will accommodate the most people. Having the nutrition facts available would allow for more informed choices.

—Sarah Crowley, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

Non-GMOs, organic foods, there's a lot of things patients turn to when they have cancer. There's so much fear, especially around eating. Tips for how patients can cope and where to turn?

Do not fret, we live in a very toxic world unfortunately. Over the years, I researched and found some great consumer resources. I would recommend http://nutritionfacts.org/ for evidence-based food and nutritional resources. And best independent researched consumer guide for non-gmo and organic-related topics, go to: https://www.ewg.org/consumer-guides.

—Colin Zhu, DO, DipABLM, Chef, CEO of TheChefDoc™ & Host/Faculty Director of The THR5 Formula™ Masterclass Series

To date, there is not enough clinical evidence to support that avoiding Genetically Modified Organisms (GMOs) foods can increase risk for cancer. There is also not enough evidence to support that eating organic foods can decrease risk for cancer. The American Cancer Society (ACS) and the AICR (American Institute of Cancer Research) panels support these conclusions.

If you are concerned regarding the use of pesticides on fruits and vegetables, you can refer to the Dirty Dozen and Clean 15 lists that are released annually from the Environmental Working Group. These lists help guide consumers regarding organic vs. non-organic produce.

—Melissa Phelps, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

We are paying a lot more for our food to have labels on them. With organics, I would not buy them. They use pesticides. It doesn’t matter—synthetic or organic pesticides. There is a percentage of residue that is safe. Organics do not get tested often, so testing is not regular. When they have done tests, they have shown that organics have about the same amount of residue level as conventional/non-organic foods. There are no standards for that and no nutritional differences. Same with GMOs. Some foods do not even have a non-GMO option, like oranges for example. I would not buy them.

—Nichole Andrews, RDN, Oncology Dietitian, Nutrition with Nichole LLC, Seattle, Washington

Sugar feeds cancer cells—is this fact or crap? What is your recommendation on sugar to patients? 

Crap. Cancer metabolism is very complex. Cancer cells are not like normal cells. They divide quicker and spread quicker. Cancer cells also use fats and proteins as nutrients. The focus needs to be on supporting your healthy cells. No foods are off-limits during cancer treatment.

—Nichole Andrews, RDN, Oncology Dietitian, Nutrition with Nichole LLC, Seattle, Washington

Fact or Crap Food Guide

Sugar causes cancer. Never eat red meat. Cancer patients should take supplements. Is this fact... or crap?

According to the 2017 AICR Cancer Risk Awareness Survey, which included 1004 adult respondents in the U.S., 28% of Americans believe sugar directly feeds cancer. However, research shows that sugar is only indirectly linked to cancer since too much sugar in the diet can lead to excess body fat and unintended weight gain. Per the CDC, being overweight or obese increases the risk for 13 different cancers, including colon and rectal cancer. There are several reasons why excess body fat, particularly belly fat, can increase risk for cancer.

Keep reading about the biopsychology of sugar, cells, and cancer.

—Melissa Phelps, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutritibon, Capital Health Cancer Center, Pennington, NJ

I’m encouraged by health experts to drink a lot of water, but I can’t drink the recommended amount, especially after surgery. How important is hydration, and are there any other ways to get hydrated other than drinking water?

Remember to heed your regular physician's advice. We typically remember drinking 8 glasses of water a day as the norm, however, according to the U.S. National Academies of Sciences, Engineering,and Medicine, they recommend adequate daily fluid intake is:

  • About 15.5 cups (3.7 liters) of fluids a day for men
  • About 11.5 cups (2.7 liters) of fluids a day for women

This also covers water content from food! For example, a lot of food like watermelon and spinach are 100% water by weight. Other beverages contain water too like coffee, juice, and soda. But be careful of the other ingredients that our bodies don't need that come with those choices.

—Colin Zhu, DO, DipABLM, Chef, CEO of TheChefDoc™ & Host/Faculty Director of The THR5 Formula™ Masterclass Series

Up to 60% of the human adult body is water. Hydration is an essential component to ensuring our organs function efficiently. The general rule of thumb is to drink at least half your body weight in ounces. So, if you weigh 140 lbs., your goal would be at least 70 ounces of hydrating fluids each day.

What are hydrating fluids? They are fluids that do not contain caffeine, such as water, sport drinks, juice, herbal teas, soups, nutritional shakes and gelatin. You may need more if you have fluid losses, such as with increased perspiration or if you are experiencing diarrhea or vomiting. You may also need more fluids if you are receiving chemotherapy or have undergone a recent surgery. Increased intake of hydrating fluids can lessen the toxicity of chemotherapy and expedite surgical wound healing.

Many factors may affect your ability to stay properly hydrated, such as busy lifestyle or recently undergoing surgery. Also, as with age, your thirst or desire to drink fluids can decrease.

If you think you are not meeting your hydration needs, establish a plan to increase hydration with a plan personalized to address your barriers to getting adequate hydration. If water is unappealing, look to make it appealing, such as adding fresh fruit to your water. We eat with our eyes; why not drink with our eyes? Sometimes it is just a matter of changing out the container with which we are drinking fluids from, such as drinking out of a clear vs. opaque water bottle vs. a disposable water bottle. Or, purchasing a water jug that has times listed on the sides; this way if it is a certain time, like 10am, and you are still at the 8am mark, you know it is time to drink more fluids. If you enjoy fluids with caffeine and are not meeting your hydration goals, consider switching some of those fluids to caffeine-free varieties.

—Melissa Phelps, RD, CSO, Registered Dietitians, Certified Specialist in Oncology Nutrition, Capital Health Cancer Center, Pennington, NJ

This article originally appeared in the Fall 2021 Beyond Blue: The Food Issue. To get more diet and nutrition information, read the issue online.

Beyond Blue is a free magazine printed each fall and spring. Subscribe to get a FREE copy mailed to you.

4 thoughts on “Burning Questions

  1. Unfortunately most of what is discussed here will not work for rectal cancer survivors and LARS. Be careful what you tell all CRC survivors.

    1. Hi Donna,

      This issue of Beyond Blue is all about Food. We recognize the problems people who have had treatment and surgery had, have, and may continue with eating and digestion. While we understand there is no one-size-fit-all solution (believe us! We wish there were!), we hope you are able to find strategies that work for you in your life.

      The editor of Beyond Blue also has LARS (and she talks about this in her letter in this issue of Beyond Blue. You can order a paper copy (Click the button that says “Pre-Order your in-hand copy.). She is sensitive to offer information that will apply to a broad range of patients. There is a LARS Facebook group if you want to meet more people struggling with LARS.

      Have you read Eating with LARS Provider Perspective? We also have an article written by a dietitian who shares her personal GI surgery experience, as well as tips that have worked for her in Living and Eating After GI Surgery.

      Finally, this online issue of Beyond Blue contains additional content, which we hope you find helpful.

      We absolutely understand how frustrating and incapacitating living with LARS is. You are not alone, and Fight Colorectal Cancer’s goal is to provide help and hope through our online resources and website, as well as through Beyond Blue.

      Please reach out to us if you have any questions.

  2. I am a 5 year survivor, I had an extended right colectomy and I am a pharmacist. This article is so accurate, no one ever mentioned food or diet requirements after my surgery. Premier Protein shakes is a go to for me at work, even today. I have been so dehydrated that I have had ER visits for fluids. We live in a very humid part of the US and extremely hot summers. My list of vitamins I take every day include, Calcium, Magnesium and Zinc, Ferrous Gluconate, Vitamin C, B12 and aspirin chewable 81mg. Keep in mind the ascending colon is to absorb water and nutrients; many will need these types of supplements to avoid other health issues. The leg cramps were unbelievable before I found the combination that works for me.

    1. We appreciate your comment and agree with you that no one ever mentions food or diet requirements after surgery. This is exactly the reason we felt the need to have an entire Beyond Blue issue dedicated to food. We are happy that vitamins are working for you, and we talk about vitamins and supplements in our “Fact or Crap” guide. We hope you enjoy reading Beyond Blue!

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