In this second part of her series on lifestyle and cancer, medical oncologist Natalie Marshall, MD, offers evidence-based answers to common questions on diet, sleep, and other risk-related factors. Here’s how to help patients choose better carbs, try out intermittent fasting, address insomnia and recognize toxins in everyday products. Bonus: Glimpse the gut microbiome’s preventive potential.
mm. Let me see if I can get this to advance though. Okay, there we go. So this is just a review of part one. We talked about dietary influence on cancer, risk limiting sugary drinks, juice, processed foods, limiting processed meats and red meat because it's a class one carcinogen um limiting alcohol because alcohol increases the risk of getting cancer and then whole food, anti inflammatory diet. We looked over some data for vegetarian pesca terrian and their decreased risk of colorectal cancer. Um and then the diabetes, risk reducing diet. Um And then I also talked at our part one about exercise and strength training and how building muscle mass and not having sarka pina are very important for decreasing mortality, overall mortality and also um overall mortality in regards to having multiple cancers, this is independent of body mass index. So if anyone doesn't have the slides from my first talk, I'm happy to send them out. Um And and you guys can have those. So the topics for part two, I want to talk about carbs, which you know, everyone thinks carbs are the devil. And I just want to say that, you know, carbs can be the angel too. And there's there's ways in which you can have carbs where it's not bad for your body. Um In fact we need carbs for energy. And um there's certain ways that you can have carbs which won't um increase your glycemic um load and your glycemic index. Um There's I want to talk about intermittent fasting sleep. Uh endocrine disruptors and something called the extra biomom hoping to just kind of introduce that concept to people. And it's the role of the microbiome and estrogen metabolism which can influence cancer risk. So because you guys are primary doctors, you probably know a lot about glycemic index and glycemic load. I want to just re show this slide that I showed last time about different risk factors for uh risk factors and related deaths related to um different risk factors. And if you look at the light blue here, the neo plasm um there are dietary risk that caused me a plas ums there's tobacco use which everybody knows um there's a high body mass index, high fasting. Um blue plasma glucose. Um There is alcohol and drug use, alcohol being the biggest one for cancer risk. Um Air pollution, occupational risk. One of the occupational risk that I just want to mention is working the night shift which increases your risk of breast cancer. Um and that's because it interferes with the circadian rhythm and sleep and that that can cause you go dis regulation and then unsafe sex especially with HPV. I also want to just re show this slide um because it's going to be an intro to like looking at um carbs and intermittent fasting and why they're important in cancer prevention and cancer. Um and it's showing this complex biology of obesity and cancer but um there's a lot of um there's a lot of chemicals that fat cells make that are pro inflammatory and can interact with the cancer cell and the micro environment that talks to the cancer cell. And one of the pathways in which fat cells talk to the cancer micro environment and the cancer cell directly is through the insulin pathway and the glucose pathway. Another one is the estrogen pathway. And this applies to both men and women because obesity can cause um estrogen excess in men um as well as in women. So those two pathways, or I'm going to focus on today, the insulin pathway, glucose pathway and the estrogen pathway and how it relates to the micro environment and the cancer cell itself. So I want to just talk about carbs. Um So we I like to think about carbs in relation to the metabolic their metabolic fate. Um And so sometimes people think that complex carbs um are fine and sugars are not, but you know, some sugars are not worse than some complex carbs and causing an insulin and glycemic response. Um And and the metabolic fate of whatever you're eating. It should be used to classify the carbohydrate. Um The type of carbohydrates, I kind of classify them into slow and fast carbs. And people with diabetes and insulin resistance benefit from a lower carbohydrate intake and us primary care doctors probably know that better than me because you're talking to diabetic patients like all the time. Um and replacing processed carbohydrates with unrefined higher fiber carbohydrates would benefit human health in multiple ways and decrease chronic disease. So I'm looking at all of these diseases, cardiovascular disease, diabetes, um cancer, nash, insulin resistance, metabolic syndrome. Um These different things that people eat uh couldn't be replaced. So like refined grains, potatoes, sugar, sweetened beverages increased risk, but grey, whole grains, legumes and whole fruits are actually associated with a decreased risk of these diseases. Um And fruit is actually not evil. I just want to say that because my patients all the time say, oh, I can't eat any fruit, it has sugar. And I tell them well actually, if you eat fruit you eat fiber, you have a lower glycemic load, even if it has a glass of high glycemic index, you can have a lower glycemic load and eating fruit actually decreases your overall mortality rate. Um And fruit juice doesn't have that same benefit because it actually spikes your insulin level, spikes your sugar level. But eating fruit actually is not, doesn't give you that same response. And so I think that, you know, when we're limiting everything that people can eat, like telling them they can have no fruit is just not really a smart thing to do in my opinion. Um And I just want to kind of go over glycemic index and glycemic load. So everybody knows what glycemic index is most likely. And that's that standardized amount of available carbohydrate. And it measures the rise in blood glucose and insulin triggered by that specific food. And when compared to a control. Um and and these are the ranges of the glycemic index which are high, medium and low and then glycemic load, which I actually think is more important because it's actually looking at the glycemic index and multiplying at times the typical amount in a serving of carbohydrate, a typical amount of carbohydrates in a serving of that food And then dividing that by 100. And it predicts blood sugar response and thus insulin response better than a glycemic index alone. So I like to use watermelon is the example because people will say, oh watermelons high in sugar, it's got a high glycemic index. But if you look at how much you eat, it actually has a pretty low glycemic load. So it would be less likely to raise your blood sugar, potato, on the other hand, has a high glycemic index and glycemic load. That's that's probably something to avoid if you're trying to avoid um insulin response. Um you know, just pause for a moment and talk about, you know sugar. Everyone says all the patients will say sugar causes cancer to grow. It's actually not sugar, it's actually insulin. So insulin is the thing that we want to lower in the blood to lower the risk of cancer recurrence and lower the risk of getting cancer as well. Um So fiber and resistance starts to like to just talk about, you know how fiber and resistant starts can feed the microbiome and that does that does interact with our immune system and can modulate inflammation in the body. Um Short chain fatty acids are a food source for intestinal cells and influence hepatic insulin sensitivity. So eating more fiber and resistant starch can help help with insulin sensitivity but also can help with keeping inflammation down, which can help with inflammatory related diseases. Um there's soluble fiber and insoluble fiber. I have those definitions here. You probably already know this, but in case you don't um it's there for you. And uh you know like I like to talk to my patients about how do you identify a healthy carb food? Well, looking at the carbon fiber ratio and aiming for a 5-1 ratio is the way that I talk to patients about carbs. Um in a healthy ratio. Um if if you are eating something that has a higher ratio than 5-1, then it's you know, something that would be more likely to be too many carbs or it wouldn't necessarily be a healthy carb food. Um and I'd like to tell my patients to aim to 20 for 25-35 g of fiber for 2000 kilocalories diet. There's a mixture of insoluble and soluble fiber in food, trying to get both and these are some different things that you can use to get that in your diet. And if you can't get enough fiber in your diet from food, it's fine to take a supplement of fiber. So I'm looking um you know I did some like uh looking at this when I was in my cupboard um looking at Faro versus lentils so far as a whole grain, lentils are lagoon. And if you look at the ratio it's 32 g of carbohydrates to 10 g of fiber. So that's a 3.2 ratio. That would be considered a really good ratio. This is 33-5. So then it's not bad, there's at least 5g of fiber per serving still has a higher ratio. Now one thing I talk to patients about is uh adding fiber to their carbs. So if you're going to have Faro, but then you add a bunch of vegetables and You add fiber so that the total ratio of your dish of your whole meal, the fiber ratio is down below 5-1. Then you're that's going to probably be better as far as lowering your insulin response. And um raising your sugar. So you can think of it and your total fiber intake for that meal and that helps offset some of the the isolation that we can think about. Um when we're talking about carbs, like if you're eating carbs with fiber, it's better than if you're eating the car by itself, like a pastry by itself versus a Faro with a bunch of vegetables on it. So less than 5% of Americans get the recommended amount of fiber and these are some sources. And simple fiber recommendations. And I always want to talk to patients about increasing fiber or slowly so that they don't get a stomach upset and gas and bloating. And then there's certain drugs and supplements that shouldn't be taken with fiber as it interferes with absorption. So be aware of that. You know, if you're prescribing fiber for people, this is a little handout that you can give patients little so you can tell them. So the question I get a lot is should I go on a low carb diet? Um And that's a low carb diet definition is less than 45% of energy from carbs And less than 50 g of carbohydrate will prevent. We're sorry, greater than 50 g of carbohydrate will prevent ketosis and less than 50 will lead to ketosis. And everyone I'm sure is familiar with the Keto Diet. And um and looking at the you know the different the data for these. This is a very good review here. Um It's I have the reference at the bottom about um moderate low carb diet. Low carb diet are very low carb diet and and the different things that we see in the blood and patients that do this. Um And so as far as weight loss, there's really no difference between the groups. Um cholesterol. Um LDL cholesterol. It can go up in patients with very, very low carb diets. Um HDL goes up in all three types, triglycerides go down on all three types and there's no major difference in the insulin and glucose response and diastolic blood pressure seems to go down but not systolic blood pressure. And the thought about low carb diets is that there's a lower energy intake because of the satiating effect of fat and protein as well as appetite suppressing effective ketones. Okay so that's kind of the thoughts around that. Um And the data for low carbs is kind of mixed because um if you're cutting out carbs you have to compensate with something. So sometimes people eat more fat and protein and and that's expected. But some patients will actually way too much fat or way too much protein and they'll actually end up gaining weight even on their on a low carb diet. That seems to happen more in women than in men. But that is something that um I have seen in my patients um patients um lose weight undergoing weight loss treatment appeared they appeared to be able to lose way independent of the macro nutrient composition of their diet. So in cancer, specifically breast cancer specifically there have been low fat diets and low carb diets and the weight loss with those diets has been equal in patients. Um And I think really what's important is what can someone stick to what is someone able to do and not feel um stressed out and deprived from it. Um As far as the ketogenic diet, a lot of patients will want to do the ketogenic diet because they think it's going to be an anti cancer diet. Um And in patients with brain tumors. So glioblastoma multiform a bad brain tumors, it does decrease progression. It can it actually can really help with seizures. It's actually very effective in brain tumors and all of the other types of cancer. Um It's not necessarily better then if a person is exercising, gaining muscle mass and eating something with a moderate carb or low low carb diet but not ketogenic. So ketogenic is not necessarily better than other diets that help people control their weight plus using exercise. Um Long term adherence to very low carb diets is hard. Um And it also was associated with substantial reduced exercise performance and healthy subjects. Um Some patients also report, especially women report that they also can have some uh cognitive kind of cognitive changes where they don't feel as sharp as they did when they had a more a less restrictive carb intake. Um There's another study that showed improvement and waste deposit e body fat percentage triglycerides, insulin and low carb diets which further improved if the patients were also exercising doing hit exercise. So I think the message that I have about this is that it's not for everybody. It's sometimes hard to maintain, especially the really restrictive keto diets. Um and it's not right for every patient. So I think you have to it has to be an individualized decision with your patient if you're helping trying to help advise them on this. But especially in women it can sometimes be um it can be problematic sometimes. Um And actually some women will actually gain weight on keto and gain weight on low carbohydrate diets. Yeah so I wanted to go next to like the segue into intermittent fasting. And this has been studied extensively and different religious practices. Um It's very popular in the fitness culture. Um intermittent fasting can decrease inflammation. It can decrease fasting glucose, insulin hemoglobin a one C. And in some people it can cause weight loss. It's very different in men versus women. Um And it has been studied in obese subjects, diabetics, patients with cardiovascular disease, elite athletes and normal subjects And there's very results between these different subjects. There's varying results between men and women. Um There was a very very small fasting study And what I mean by small fasting study as it was only 12- 13 hours per day. Which And breast cancer patients with early breast cancer not metastatic breast cancer. And if they didn't eat for 12-13 hours per day they decrease their risk of recurrence by 36%. This was an estrogen positive breast cancer. So why caloric restriction? Um There's there's intermittent fasting is a way to do caloric restriction. But it's also a way to give the gi tract arrest um the G. I. Tract and the reset the insulin sensitivity. Um So caloric restriction can decrease a deposit e you can decrease blood sugar, it can decrease insulin and insulin growth factor which are directly related to cancer risk. It can decrease inflammation. And then there's other cellular adaptations that can happen with intermittent fasting and caloric restriction which help the body recycle organelles that are in cells that are damaged. And one other thing about intermittent fasting is that it also can synchronize with our circadian clocks. So when you think about circadian rhythm, which I'm going to talk about in a minute with the sleep part. Um The circadian rhythm is like you're sleeping when you sleep and also your temperature regulation of your body. But there's also circadian clocks for different organs. Like there's a circadian clock for your liver for instance, and your liver is very important in cholesterol metabolism, triglyceride metabolism glucose regulation. And and so when you're doing intermittent fasting and you're resting the gut, it changes your gut microbiome. It can change the circadian clock of the liver. Um And it can increase insulin sensitivity, decrease harmful lipids, increase satiety hormones and it can lower inflammation and all of these different things that it can do. Um And not equally among all patients. It's super complicated. Can affect chronic disease including obesity type two diabetes cardiovascular disease and cancer. Um So I think that intermittent fasting is a very it's a very interesting thing. Um I don't think we know exactly how to do intermittent fasting correctly In all patients. I have a patient of mine wants to try it. I do tell them to start off slowly with like 12 to 13 hours, see how they feel. Some people feel terrible when they fast, some people feel fine. Um I also if they're going to try to do like 14 hours of fasting or 16 hours of fasting and shorten their feeding window to to do it slowly and to make sure that they are paying attention to how they feel additionally And Super Elite athletes who did 16 8 intermittent fasting. These were weightlifters. These were people that were very in very good shape. What they showed is that if you do strength training when you exercise, I'm sorry, when you fast. Excuse me. If you do strength training when you do intermittent fasting, that you will not lose muscle mass. And in patients that were being studied at UCSF, they did a study using Uh in patients with cardiovascular disease doing 16, 8 intermittent fasting and they all lost weight. But they all lost lot of muscle mass. And that is really bad for people's metabolic health. And people that have sarko pina have a higher overall mortality rate for multiple reasons. So if you're going to be recommending in a minute fasting or if you're patient tells you that they're doing intermittent fasting. You want to make sure that they're exercising and that they you would be very good to recommend that they do strength training as well so that they don't lose muscle mass in in the and while they're doing it. So the other thing is immune system regeneration. Um And this is a uh a reference that I give you, which I like this because it shows in yeast and matt mice and in humans um periodic fasting or periodic fasting mimicking diet. There's different kinds of things. Fasting, mimicking diet is something that's kind of um And lifestyle medicine, we talked about it. Dr Ben English mentioned it to me before we got on today, but they're also studying it in cancer to see whether people that do periodic fasting mimicking diet can have a better response to their hormone blockers and breast cancer or to their therapy and colon cancer etcetera. We don't know the answer to that yet. We don't know if it's going to be better than just eating a normal diet. But there are ways in which it may be helpful and these are some of the different things that it can affect. I've mentioned these already but decreasing helping with glucose regulation which can decrease cancer growth is one of the important ways in which fasting or fasting mimicking diet can potentially help patients with cancer. And there's different ways too fast and I'm listening. These these are the ones that I could find in the literature. Um The different ways in which they have been studied. Um And that one at the top, the 12 to 13 hour one was the one with breast cancer patients. Early breast cancer patients. That lowered the risk of recurrence and the reason why they think it lowered the risk of recurrence schools, it lowered their fasting insulin insulin level. So that caveat I have at the bottom recommending strength training for anyone who is going to be doing fasting to decrease muscle mass loss. Okay, so we're going to go on over to sleep now. Um So healthy sleep habits can improve insulin sensitivity. Um I'm listing all the things that can happen to you if you don't sleep well, which I think you probably already know all of that. Um But the metabolic changes from chronic sleep deprivation are not always reversed upon the payment of sleep debt. That may be something that people don't know. So chronic sleep deprivation does not always. And then you start to sleep or you you pay your sleep dep on the weekend that doesn't reverse the metabolic changes that can happen, such as pre diabetes or diabetes or glucose a regulatory problems or high insulin level that can happen from sleep deprivation. The other thing I wanted to point out was the nighttime, light exposure, rotating, shift work and circadian disruption can promote or cause breast cancer. That is a known occupational hazard for getting breast cancer. So let's talk about cognitive behavioral therapy for chronic insomnia and I have three articles that I'm listening here for you guys to look up and read if you're interested, there were clinical trials looking at cognitive behavioral therapy for chronic insomnia and they compared it directly to taking sleeping pills such as Ambien and they found that cognitive behavioral therapy for insomnia was actually better and was able to maintain um better sleep long term in patients by teaching the patient how to sleep better. Um cognitive behavioral therapy is can be a one on one a thing with a with a sleep therapist, but it also there are group sessions for it that are done over five weeks. They do offer those at the Osher center in SAn Francisco. Um And Ashley Mason is runs those sleep groups and it's I sat in on those as part of my training and they were really, really interesting and they were really helpful um because patients were able to get off of their sleeping pills which can cause cognitive dysfunction long term if they take them, they were able to uh feel better, they were able to retrain their brain to sleep and not to worry in bed and have anxiety in bed. Um There were so many like positive things about it. I I really feel like it's an underutilized therapy that is available in the bay area. And so if you have a patient that has chronic insomnia and they're motivated to get better and maybe to not be on drugs that would be a really good therapy to recommend. So there's two more, these are meta analysis about CBT I and this is a study that was done looking at cognitive behavioral therapy versus tai chi for late life insomnia. And then there was also a control group that did a sleep seminar. And what they showed is that cognitive behavioral therapy was much better at helping with sleep problems, insomnia and maintaining a good sleep over time. The higher scores was worse sleep. The lower scores were better sleep. And so what is the prevalence of sleeping seven or fewer hours? So they say you should sleep 7 to 8 hours, all the sleep experts. Um, and for adults age greater than 18 years old in the US. This was in 2014. I haven't seen an update of this. Um, but this is actually pretty frightening if you ask me a lot of these these really dark squares, which is all over the east, especially in the south where we also have high levels of chronic disease such as diabetes and cardiovascular disease and cancer. You know, up to almost half anywhere from 40 to 50% of patients Are sleeping less than seven hours. So California is kind of moderate, not as bad as it could be, but not as not as good as it could be either. And this is just the normal circadian rhythm for the regulation of sleep. This is the biologic clock for humans unless they have some something messed up. And we are temperature is lowest in the morning around 4 to 5 in the morning and then it rises to the highest um around six o'clock, 5 to 6 at night and then it starts to go down again and then we go back to sleep. But this is our normal circadian rhythm for temperature. And I want to talk about this this concept of sleep pressure because sleep pressure is your your body building up sleepiness through the day. And this is the normal sleep pressure, buildings leave pressure through the day. And then this is if you take a nap. So for people that have chronic insomnia, taking a nap is actually a really bad idea because it lowers your sleep pressure and then when you're ready to go to bed usually pleasures down here rather than up here. So this is our, you know we are sleep pressure increases while we're awake. When we sleep it goes down and then it starts all over again. Um And something that can also interfere with our sleep pressure is caffeine because caffeine. One of the ways in which we we get sleep pressure. One of the ways in which we get sleepy is our dentist scene goes up throughout the day And if you take caffeine or take caffeinated beverages, especially like after 12 or 1:00. What happens is that those are a dentist, see blockers and so that will lower the ability to get to have sleep pressure. And this is just another, this is putting it together your circadian rhythm for temperature with your sleep pressure and it's kind of beautiful actually it's like a signed waiver co sign wave. And then what happens as we get older, our sleep changes. So are Stage one and 2 deep sleep or you know, non rem sleep are about the same. But what does happen is our very deep sleep goes down with time and as we age it gets smaller and smaller. Our rem sleep from middle age on stays about the same and our awakening after a sleep onset starts to go up as we get older. Now, maybe that's because people have to get up to the bathroom. Um You know, the prostate doesn't work as well as before, it's too big. People have overactive flatter, there might be various reasons why people wake up after sleep onset, but it does interrupt your sleep. Um the big the big thing though is that you get less stage four sleep. That's the big difference between being young and getting older and this is normal sleep architecture and what's important to note is that you do have some rem sleep in the first half of the night, but most of your rem sleep is in the second half of the night and most of your deep sleep is in the first half of the night. And unless you don't really have it at the end of the of the night. So when you drink this is your sleep architecture on alcohol. So alcohol suppresses your rim sleep in the first half of the night and it decreases the amount of time you need to go to sleep. So it's like because it's a sedative, you go to sleep okay and you don't have as much rem sleep and then you start waking up um sorry, I hope you can see this whole screen, alcohol increases wakefulness in the second part of the night and when you normally would wake up was would be when you're in rim, that's when your lightest in your sleep and when you drink alcohol it you have more awakenings um throughout the night and it also decreases your rem sleep. So alcohol, if you have sleep problems is not really that good of a substance for you, even though it might help you fall asleep, it's not good for your total type of sleep and the quality of your sleep. And you know, this is just like the evolution of insomnia. So you might have some predisposing factors for insomnia, but you're fine, you don't really have any problems, you have an acute event, someone dies, you move, you have a stressful job and you have this inciting event. Precipitating factors that gets you over the insomnia threshold and let's say this thing gets under control. But you have these perpetuating factors such as anxiety that you're napping, that you're worrying in bed that you have poor sleep hygiene. And that makes the insomnia stay around, which then it becomes a chronic problem. So these things we don't have control over our genetics, we don't have control over the things that happened to us, like if we have somebody die or a major life event, we oftentimes don't have control over that, but we do have control over these perpetuating factors. And so that's what cognitive based therapy tries to work on. And just like a stimulus control from Pavlov's dogs where you have a response to something you don't have a you have an unconditioned stimulus and unconditioned response. And then you start to associated with the thing that gave you the response in the first place. Then when you don't even have this food present, you'll still have the response. So this is what happens to people in bed. So stimulus control is important. And one of the things you can do is to not use your bed for anything but sleep or sex. Ah So television, laptops, you know, things that are that you do in bed reading in bed even uh not doing anything in bed with sleeping. Um and that helps you with your stimulus control to retrain your brain that when you're in bed you're to be sleeping. And when you're not in bed then you can not sleep. So it strengthens the bed as a cue for sleep and weakens the bed as a cue for activities that interfere with sleep and other factors that interfere with sleep are caffeine later night alcohol and drugs. Um By the way, sometimes there is evidence that marijuana, even though people use that for sleep can actually interfere with your your rem sleep. Um the sleep environment and that could be like light in the room or if you have an alarm clock that's really bright are eating too close to bedtime. Those are things that can interfere with your sleep or perpetuate sleep problems. And then I have for you guys to sleep hygiene checklist which you probably already know. Um keeping your bed cool, no electronics in bed, all those things. But there's other things too like early morning light. This is a big one. So if you're getting trying to get people to exercise, can try to see if they could exercise in the morning and get some more early morning light helping set reset the melatonin response. No exercising like right before bed um and not smoking, which you probably tell all your patients that anyway, so next I want to move on to hormone disruptors or endocrine disruptors and xeno estrogens. Um So um these are chemicals that can interfere with our normal hormone system. Um And they are um you can you can kind of see in this little cartoon, they can decrease or increase the normal amount of hormone they can mimic than body's natural hormones or they can alter the production of hormones. And so there's different ways in which chemicals that are endocrine disruptors or xeno estrogens can affect can affect the body. And there's a there's a website called the the Environmental Working Group. It's very good website E W G dot org And they have Like the dirty dozen in the clean 15 for food. Like what do you need to eat? That's organic and what can you eat? That's not organic because it's not really sprayed with anything terrible or anything at all. Um but it also has a dirty dozen for hormone disruptors. And um these are the dirty dozen. These are in toys there in food, they're in pesticides, they're in water, they're in flame retardants therein plasticizers. Um And these these substances are especially dangerous in the prenatal and the perinatal, the immediate post natal period while the child's brain and different organ systems are developing. So one thing that you can do as a primary care doctor is potentially to talk to patients about, you know, trying to avoid toxin exposure, especially during pregnancy. Um or when the child is young, I mean they had these pacifiers that had B. P. A. In them. And so people were little kids were you know using those they've taken ePA out of many things including the can can food where the lining has vespa in it. And there is now BPA free cans now that said what they're using to line that can we may just not know whether or not that's also dangerous or has the same effect it hasn't been proven to. But um there's a lot of toxin load in our world, in our food and things that we touch all the time um including like receipts they have BPH and them um So trying to avoid these things as much as possible. Um can you know, decrease their endocrine disrupting effects on the body. The other thing about these chemicals is that they can cause different kinds of cancer. There are associated with breast cancer and other kind of indifferent driven cancers like uterine cancer, prostate cancer. They also are associated with infertility, um obesity, early puberty, um early puberty and late menarche is associated with breast cancer. So that's affecting that could affect our girls when their women. Um And they did a study of VP a specifically and they found that 93% of americans have VP and their body. So it's it's a pretty it's a pretty um frightening thing to me because a lot of it is exposure that you don't know about or you don't feel feel it. And patients are really oftentimes not aware of it. So this is a good website to get information for for for that for patients. So these are toxic chemicals found in personal care products. And this is a cartoon from this campaign for safe cosmetics and A lot of things that women use on their face. And women use an average of about 12 products per day on their body. Um Have these different chemicals in them that are either toxic chemicals or endocrine disruptors. I love the lead in the lipstick. So you're just putting lead in your mouth. That's that's one that's really Terrible, a terrible one. Um And part of the problem is I'll go back here is that there's a lack of regulation of US in the US for personal care products. The EU has 1500 ingredients that are banned in the US only has 30. Um And many of these chemicals are hormone makers and can contribute to all of those different issues that I mentioned earlier. So hormone disruptors um work in breast cancer by working through the estrogen receptor beta and estrogen receptor alpha. And this has actually been worked out pretty well. Um And there's a a um a citation that I have at the bottom that shows how what we know about how dioxins plasticizers DDT A. D. S affect breast and endometrial cancer. Now Fido estrogen's are nonsteroidal phytochemicals that are similar to estrogen estrogen and that are found in females estradiol and you can see that the structure of of Fido estrogen's like this is an isoflavones what you would find like in soy. Um They're similar to um human estrogen and there's different classes of phyto estrogens. There's the flavonoids which isoflavones being the most common type. That's that's what we would find in soy. And then there's non flavonoids which are Liggins, congestions and still burns. Um There's a reference here about estrogen like phytochemicals. Now phyto estrogens do not act in the human body the same way that these endocrine disruptors do. And a lot of patients will say, well I'm not eating soy and I'm not eating flax seed and I'm not eating any lagoons. And and there's really no evidence that you have to give up whole foods soy or flax seeds or lagoons if you have breast cancer or if you want to decrease your risk of breast cancer. And in fact these compounds can be protective in different societies such as in japan, that which eat a lot of soy. Um Those societies eat a lot of soy, they have a lower risk of breast cancer than in America where we traditionally haven't eaten a lot of whole foods soy and these are different classes of the phyto estrogens, the isoflavones, Liggins and contestants in the different um food sources that people have and there's there's a really interesting um there's an interesting chemical called s equal and this is a secondary metabolite of isoflavones and when people um when people take isoflavones in their diet um they they will eat them absorbed in the nutrition through them as they go through the gut, the liver can congregate estrogen's and I'm gonna go over this in a minute more in more detail and the colonic bacteria can um changed the conjugated estrogen and their secondary metabolites that can come from that. One of them is called S equal now as equal is something that is they have differing abilities to make us equal depending on the microbiome. People have differing ability to make us equal. So in asian people There's about 50% of Asian people make as equal where they can detect it in the blood. And this actually um is a substance that can decrease um hot flashes can increase bone health and there's a decreased risk of menopause and hormonal dependent cancers and better central nervous system function and better cardiovascular function. So it acts kind of as a a positive type of estrogenic compound. But it is made by the colonic bacteria modifying the isoflavones in the gut and then resorting it. Um In caucasian population In America, 25% of patients have the types of bacteria that can do this and thus there as equal levels are lower and that maybe like some women who have very severe hot flashes and very severe menopause it maybe because of this different in as equal. Now this is something that's not been proven in a very large study but it's a very interesting, it's a very interesting um idea of how our microbiome can affect our hormone metabolism. So let's talk about the liver and detoxification of estrogen. So This is from medical school. I'm sure all of you remember everything about it. Um the Phase one and Phase two. conjugation pathways in the side of grumpy for 50 enzymes and how we remove fat soluble toxins are water soluble toxins, how our liver deals with it. Um and below at the bottom of the slide I have the nutrients that are needed to do Phase two or to do Phase one. So if you have nutrient deficiencies you may not be able to detoxify as well as if you didn't have nutrient deficiencies because they're these different vitamins are involved in these different pathways. So the one I want you to focus on is these conjugation pathways called glucose or glucose renovation. Okay because glue the renovation is how our body gets rid of estrogen excess estrogen in the body. So in the body when estrogens are circulating and this isn't men, men and women because men have high estrogen levels sometimes when they're obese um and are growing um breast tissue because they're obese. Um So this circulating estrogen in the blood goes through the liver circulation and gets conjugated and then it goes it's either excreted in the kidneys right here. I'm going to go get my pointer. So it gets excreted in the kidneys or more more of it gets goes into the intestinal tract through the bile and through the liver pathways and then from there depending on the company components of the microbiome you could just excrete it. Or certain bacteria will which have this enzyme called beta glue kirana days will d conjugated and then the body will resort bit into the bloodstream and so then you'll you won't get rid of the estrogen the way you're supposed to. So your body is supposed to use estrogen and then lose it and if you're not able to excreted through the intestinal track or the kidney, if your microbiome makes you able to resort bit then your levels of estrogen gets too high and that can increase your risk of cancer. And this is just a little cartoon about that. So if you have a healthy microbiome, your body sends the estrogen to deliver the gut excretes it and most of it exits the body. Maybe a little bit goes back into the body. But in an unhealthy microbiome, the opposite happens these bacteria that have been a good tirana Days will help the body re Zorba most of the estrogen back and then the the levels are too high and this is these are the different bacteria species that have been found to have high beta glue tirana days activity. So these top ones right here going down these have been a good you're on today's activity. So these are the ones that could d conjugate the estrogen and help that you resort bit these other ones don't have that. Now we're not quite ready for prime time where we to a microbiome sample and we decide what to do based on that. There are different companies trying to figure that out. There's one called via um that will give you your um supplements you should take and they tell you what your problems are and what you should eat based on your your makeup and your different diseases. And I think it's really interesting but I really don't think we have enough information but it's clear that the intestine and the microbiome do play a role in estrogen elimination and metabolism and that could influence cancer risk based especially cancers that are driven by estrogen. And this is just a kind of overall slide. Looking at that how the gut microbiome kind of can be affected by genetics, diet exposures. You know, it's something that perturb zit such as stress and than the enzymatic activity of the gut can change which estrogen's are delivered to the body in which biologically active forms and then Zeno estrogen's and and anti estrogens can also affect this as well. And xeno estrogens could could affect it in even a worse way. And that changes the hormonal milieu of the body and can in effect estrogen signaling. That could lead to initiation or progression of cancer. Um There's also the way in which the gut microbiome modulates inflammation and your immune system which could increase or decrease your cancer risk as well. So it's just it's a it's a very interesting thing to think about. It's not something that I was ever taught in medical school. I mean we didn't really know about the microbiome that long ago because I'm kind of old. But um it's it's I think there's beautiful and interesting evidence that um makes these very complex systems um affect disease risk and what's what's exciting to me and why I want to talk about this with doctors and patients is that there's some really simple things that you can do even if we haven't worked all this out, such as eating more fiber and helping your microbiome, eating more plant based diet unless things that cause inflammation and exercising and in building your muscle mass and helping your body be chemically and metabolically more healthy, getting enough sleep to help you with glucose regulation. Um all of these things that we can do that can actually make a really big difference in overall health and decrease the risk of cancer, which is what I'm most concerned about. But also decrease the risk of chronic disease, which is probably what you, as a primary care doctor are most concerned about because you see it every single day, diabetes, cardiovascular disease all the different things that you face every day and their chronic, but helping patients understand that they could make a very big difference in their health by sometimes these simple things that they can do
