"I Expect My Patients to Be Outliers": Applying Nutrition to Improve Cancer Outcomes

 

Nalini ChilkovNalini Chilkov, OMD, Founder American Institute of Ingegrative Oncology “I expect my patients to be outliers, to defy the statistics, to defy the odds,” says Nalini Chilkov, LAc, OMD, a practitioner of oriental medicine and nutrition counseling, who specializes in working with cancer patients.

Over a career spanning more than 30 years, Dr. Chilkov has treated thousands of people with diverse forms of cancer. She’s witnessed first-hand the positive impact that thoughtful, carefully-tailored diets and supplementation protocols can have.

She has also seen the bewildering confusion many patients--and physicians—face when considering nutritional strategies. There are dozens of contentious arguments over which diets and specific foods promote or inhibit cancer, how various phytochemicals impact tumors, which nutraceuticals are appropriate, and which are to be avoided.

In an in-depth webinar sponsored by Holistic Primary Care last year, Dr. Chilkov—founder of the American Institute of Integrative Oncology--dispelled much of the confusion, as she shared a host of practical tips, research reviews, and hard-won wisdom drawn from her own clinical practice.

“What if every cancer patient had a health plan, and not just a disease care plan?” Beyond simply removing or reducing tumors, cancer care needs to include modalities aimed at reducing oxidative stress, controlling inflammation, inhibiting angiogenesis while promoting apoptosis, strengthening immunity, enhancing detoxification, and controlling blood sugar.

Cancer is a Metabolic Disease

First and foremost, Chilkov urges clinicians to recognize that cancer is fundamentally a metabolic disease. The process is systemic, not localized, though it manifests as a tumor in a particular anatomic site. At the same time, the tumor microenvironment is a key area of focus, because it determines nearly every aspect of the ultimate outcome. Change the microenvironment, and you change the course of the disease.

Dietary factors play a major role in the development of at least one-third of all forms of cancer, and they greatly influence the tumor microenvironment.

“You want to use nutritional strategies to help the oncologist fight the tumors, while modulating the biological “terrain” so it becomes unfavorable for cancer growth. At the same time, you want to nourish and strengthen the patient.”

There is no simple “one-size-fits-all” nutritional support in cancer care. “People need different protocols at different stages, and it all needs to be individualized.”

That said, there are some core principles that apply for most, if not all, cancer patients.

Quelling “Onco-Inflammation”

Neoplasia is intimately connected with chronic inflammation, and survival is inversely correlated with degree of inflammation, Dr. Chilkov said, coining the term “onco-inflammation” to describe the relationship.

Inflammation promotes angiogenesis, proliferation, and metastasis. It is also the primary cause of debilitating cancer-related fatigue, experienced by roughly 80% of all patients.

“You want to do all that you can to minimize chronic systemic inflammation. An anti-inflammatory diet is key.”

Chilkov shared her “A-List” of anti-inflammatory foods and supplements. It includes:

“All of these are multi-taskers” she stressed. Among their various effects, they: Inhibit oncogenes while promoting expression of tumor suppressor genes; Inhibit mRNA translation in tumor tissue; Inhibit DNA methyl transferase (a necessary enzyme in tumor proliferation); Downregulate inflammation while stimulating the immune system.

Green Tea & EGCG: Chilkov finds that 2-4 cups of green tea per day is very healthy for cancer patients. In addition to its tumor suppressing effects, it also reduces insulin and leptin, both of which drive tumor progression.

EGCG (epigallocatechin gallate)—a polyphenol derived from tea that may have anti-cancer properties (Johnson R, et al. Maturitas. 2012)—is, in Dr. Chilkov’s experience,

“good for some patients but not all. Some will have liver problems with it. But this will show up quickly as an increase in liver enzymes. If you see that enzyme surge, stop the EGCG and green tea.”

Coffee: Dr. Chilkov generally advises patients not to drink a lot of coffee, not because it is inherently risky, but because coffee is one of the most heavily sprayed crops. “A cup of coffee is also a cup of herbicides.” This probably isn’t a problem for healthy people. But for cancer patients whose livers are already working overtime, it only increases the toxin load. “One cup a day is okay, if a patient enjoys it. It can help as a laxative.”

Ganoderma (aka Reishi): These mushrooms, a staple in traditional Asian medicine, contain immunostimulatory and anti-cancer compounds. Though a 2016 Cochrane metanalysis indicated that Ganoderma gives only marginal ancillary benefits, Dr. Chilkov finds that it does provide good adjunctive support, especially in reducing leaky gut, which is common among cancer patients.

Omega-3 Fatty Acids: Dr. Chilkov recommends measuring omega-3 and omega-6 levels in cancer patients. “I like to see a 4:1 ratio between omega-6 and 3, but most patients are like 12:1. So try to get as much omega-3 into them as possible.”

L-Glutamine: This amino acid is great for healing myositis and mucositis, both of which are common following chemotherapy. The pain and discomfort can make it difficult for patients to eat, which not only raises the risk of malnutrition and cachexia, but also deprives patients of simple culinary and social pleasures.

N-Acetyl Cysteine (NAC): This glutathione precursor can help support hepatic detoxification, but it will likely interact with many drugs. “You need to be careful with it,” Chilkov says.  She generally withholds strong antioxidants—and this includes herbs like Milk Thistle and phytochemicals like sulforaphane—during days 1-5 of chemotherapy infusion cycles. Give things like NAC, glutathione, and other liver support supplements after a round of chemotherapy, not during.

Supplements can and do play an important role in Chilkov’s patient care protocols, but she stressed that they are not stand-alone fixes. Nor are they essential.

“You can still do a lot with ordinary food. So even if you have a patient who cannot afford a lot of supplements or herbs, or if you are dealing with an oncologist who is very rigid and won’t allow herbs and supplements, you can still do a lot to help your patients.”

Glycemic Control

When working with cancer patients, it is essential to control glucose and insulin tightly. “You want to keep the blood glucose in the lowest quartile.  Cancers thrive in a high-glycemic environment. So, it is crucial to control glycemia.”

Insulin itself may be tumor-promoting. “Not only does it drive glucose into cancer cells, it has direct tumor-promoting activity. So obviously, we want to do whatever we can to optimize insulin sensitivity and minimize excessive insulin. That means major reductions in carbs.”

For this reason, Dr. Chilkov questioned the proposed benefits of juicing.The problem with juicing is that it eliminates most of the fiber from fruits and vegetables, but concentrates the sugars. “I don’t want those glycemic surges.” Even something generally healthy like carrot juice can be very high-glycemic.

“If a patient wants to juice, I recommend they do green juices. And get a Vitamix machine, as these tend to keep a lot more of the fiber in.”

She added that patients need to be aware that grapefruit juice can accelerate drug metabolism, a significant consideration when someone is undergoing chemotherapy.

Speaking of glucose control, some practitioners—most prominently integrative oncologist Dwight McKee, MD--have advocated off-label use of metformin as an anti-cancer agent. There are some studies suggesting that metformin can attenuate the progression and promote survival in breast, prostate, and ovarian cancers. “The insulin-driven cancers will respond best to metformin, but it can be problematic for people who are poor methylators,” Chilkov says.

She prefers to use berberine, rather than metformin. This herbal extract is an anti-cancer multi-tasker that does what metformin does in terms of increasing insulin sensitivity and exerting anti-cancer effects, but without the side effects. It has the added benefit of helping to foster the growth of beneficial bacteria in the gut microbiome.

Ketosis is Key—But Not Too Strict

Owing to mitochondrial abnormalities, most cancer cells cannot metabolize ketones. Therefore, ketosis stresses them and renders them vulnerable to destruction by the immune system. Thomas Seyfried and colleagues from Boston College outlined the basis for ketosis as a cancer care strategy in their landmark--though controversial-- 2014 paper.


 

Chilkov fastingAccording to Dr. Chilkov, “keto” has advantages and downsides. “You have to manage these patients very, very carefully. Cancer patients should not try to do keto regimens on their own.” Done properly, ketogenic diets impede tumor growth, reduce angiogenesis, quell inflammation, and increase apoptosis. But strict keto or “paleo” diets tend to make cancer patients nauseous, and often induce diarrhea, owing to their very high fat content. 

Most of the popular keto protocols call for 60-85% of total calories from fat, with 10-30% as protein, and only 2-10% carbohydrates. Cancer patients who do try ketogenic or paleo protocols will likely need pancreatic enzymes, and/or ox bile, to aid in fat digestion.

“Strict keto is not a healthy long-term diet for cancer patients. It is a therapeutic diet to achieve a particular goal.” Long periods on keto or paleo diets can lead to significant microbiome changes, and not always for the good. People on these diets long-term often show weird variances in the ratios between different microbial species, as well as . higher susceptibility to leaky gut.

The reality is, it is difficult for most people to stay with strict keto over the long term.

“You can get a lot of benefits with a modified keto diet: low glycemic, carb-restricted, with moderate protein can give a lot of the benefits in terms of changing the tumor microenvironment, without a lot of the downsides of the strict keto approach.

If you reduce carbs to 10-20% of total dietary intake, you do slow tumor growth,” Dr. Chilkov says, citing a 2011 paper by Ho and colleagues at the University of British Columbia.

The OutSmart Cancer Diet

“The main thing is, you need diets that people can stay on.”

With that in mind, she developed a basic diet protocol she calls the Outsmart Cancer diet. It is a mostly plant-based, moderate-protein, low-carb whole foods diet that stresses the following:

Limited dairy and animal-derived proteins and fats; Reduced glycemic load; Increased intake of colorful phytonutrients, cruciferous vegetables, and sulfur-containing foods (garlic, onions); Daily consumption of fermented vegetables; Liberal use of monounsaturated fats and oils; Increased spices and herbs, High fluid intake; Elimination of pro-inflammatory foods; Limited alcohol intake, and as much organic unprocessed unrefined food as possible.

On this diet, roughly 25-40% of total intake is protein, with 30-45% being fat, and 10-25% as carbs. It is higher in protein and lower in fat than most ketogenic diets.

“I go for around 60g protein per day. If a patient is sarcopenic, however, he or she will need more. Preferably vegan protein. Too much animal protein drives cancer growth.”

Do all cancer patients need to go full-on vegan? Not necessarily.

There’s ample evidence that plant-based diets benefit cancer survivors. Chilkov says she does recommend vegetarian and vegan diets, but doesn’t push them. Chilkov anti cancer dietThe main thing is to encourage patients to eat as many vegetables and fruits as they can.

“Once you get up to 40-50% of someone’s daily intake as plant-based foods, you start to see reduced occurrence and recurrence of cancer.”

Be aware that patients who do go vegetarian or vegan will likely need to supplement with Omega-3s and B vitamins. Also keep in mind that vegetarian diets can be very high-glycemic. “These patients need to be on low-carb vegetable-based diets”

She likes to see all her patients getting a lot of fiber—ideally in the range of 25-35 g/d. Most Americans typically get only 15. The caveat is that some cancer patients may be at risk for bowel obstructions. In these cases, it is wise to limit fiber.

Cancer patients should be careful to limit iron and copper intake. If someone has true iron deficiency anemia, he or she will need repletion. But for many cancer patients, excessive iron and copper can be detrimental. Both minerals may play a role in promoting cancer. This means not too much in the way of nuts and seeds.

Dr. Chilkov’s OutSmart Cancer diet generally eliminates lard, which is advocated by some keto/paleo enthusiasts. She prefers olive oil, avocado oil, or grass-fed butter.

Though her recommendations are largely veg-based, Dr. Chilkov is a big fan of bone broth, especially for patients who have mucositis, gastritis, nausea or reduced appetite. “Bone broth is very nutritious, contains lots of collagen, minerals, and electrolytes. For some patients, 4-6 cups per day is great.” The caveat is that it needs to be made from high quality organic, and ideally grass-fed, meats.

That’s because environmental toxins concentrate in fat and bone. Cancer patients definitely do not need any further toxic strains.

Eggs are another animal-derived food that some patients may want to include. “So long as a patient does not have any allergies to eggs or sensitivities to albumin, and not a vegan, eggs are an excellent source of protein. If patients do want to eat them, she advises them to seek high quality, high omega-3 fortified eggs.

Fasting & Fast-Mimicking Diets

This approach is getting a lot of media attention these days, thanks to the work of Valter Longo, PhD, the University of Southern California-Davis cell biologist/gerontologist who is one of the most outspoken scientific advocates for fasting. Longo’s popular book, The Longevity Diet, his TED talks, and his widely publicized early-stage clinical trials, have amplified the notion of fast-mimicking in the media.

According to Dr. Chilkov, Longo’s recommendations make for a very sound cancer-fighting, health promoting diet.  However, she acknowledged that beyond anecdote, clinical experience, and some very early clinical data, there is little definitive human research on these approaches. So they’re not yet truly “evidence-based.”

Cancer patients who do want to try intermittent fasting need to be careful. “If they’re relatively young and relatively healthy, they can safely fast for 48 hours. But patients who are fragile shouldn’t fast at all.” She added that, “my feeling is that cancer patients need a lot of nourishment.”

Raw Food Diets

Though raw food diets are promoted as “healthy” and “cancer fighting,” for their high phytonutrient and fiber content, many cancer patients cannot handle a lot of raw vegetables, nuts, and fruits. While it is good to include some, the approach should not be extreme. She advises cancer patients not to eat raw meat and fish, because they increase exposure to bacteria and molds. That may not be problematic for healthy people, but it can be for cancer patients with compromised immune systems.

Also, be aware that some phytochemicals—lycopene in tomatoes, sulforaphane in broccoli, for example—are only released when the vegetables are lightly cooked. They are liberated by heat. This is one reason why steaming is a preferred method for cooking vegetables.

Soy

“Soy is so controversial and so misunderstood,” said Dr. Chilkov. Yes, it is a source of isoflavones which are plant estrogens. But traditional fermented soy products are seldom problematic and often beneficial for people with cancer.

A 2008 analysis of 8 separate studies showed that women with the highest soy intake (including soy milk, tofu, and similar soy foods) had a 29% lower lifetime risk of breast cancer compared with women who did not eat soy. A 2014 review of 35 studies put that risk reduction at 41%. And a 2012 analysis of over 9,500 breast cancer survivors showed a 30% reduction in recurrence among the women who ate the most soy. 

It is true that some people do not tolerate soy very well, but most will benefit from fermented soy foods. And there’s little risk if they are eating traditional fermented soy foods (miso, tofu, tempeh, natto).

The problems come with modern unfermented soy products and isolates. She strongly advises against products made from genetically-modified soy—which, unfortunately, means many of the mainstream mass-market soy products.

Citing a comprehensive 2013 review paper by Don Abrams and Mary Hardy, Dr. Chilkov insisted that it is high time for clinicians to reconsider their biases against soy.

Gluten

Some thought leaders within the functional medicine world contend that there is a direct link between gluten and cancer, but this is very far from solidly evidence-based, said Dr. Chilkov. That said, gluten can trigger systemic inflammation in some patients, and that is cancer-promoting. So, it is probably a good idea for cancer patients to eliminate—or at least minimize--their gluten intake.

Her Outsmart Cancer diet is largely gluten-free. “Eliminate the refined carbs, and you will eliminate a lot of the gluten.” But she only pushes a strict gluten-free diet if a patient has brain fog, depression and signs of autoimmune disease, and/or colorectal cancer.

Hydration & Shakes

Hydration is vital, especially for cancer patients during chemotherapy. Plain water is a must, and vegetable broths and/or bone broths are also very nourishing and hydrating.

The reality is, many cancer patients have limited appetites or, owing to myositis and mucositis, they experience a lot of pain when trying to eat solid food.

For them, protein rich shakes and smoothies are ideal. She recommends a ketogenic shake recipe containing 30-40 grams of whey or collagen protein (pea or rice protein for vegetarians), medium chain fatty acids, concentrated red and green powders, pumpkin seeds, a whole lemon and a host of other ingredients (see sidebar).

“One or two of these shakes can get cancer patients through a full day, if they’re having difficulty eating solid food,” she said.

Exercise

If a patient has the strength to exercise, encourage participation in whatever forms of reasonable non-strenuous activity he or she enjoys. The benefits are many. She noted that she regularly collaborates with an oncologist who has patients running on treadmills while getting their chemotherapy infusions. “They’re not necessarily invalids,” she stressed.

Practical Implementation

Dr. Chilkov is the first to admit that it can be very challenging to do nutritional counseling for cancer care in a medical context. First, it requires a fair amount of knowledge. To this end she has compiled an intensive online clinician training course called Foundations of Integrative Oncology.

It also takes a fair amount of counseling skill and patience. Lifestyle changes are never easy, even with very motivated patients. Physicians are not always ideally trained to do this sort of work. Nutritionists and health coaches are.

In her practice, she has two nutritionists that work directly with the patients to help make the recommended lifestyle shifts.

To do this work well, it is equally important to develop strong collegial relationships with oncologists in your area. That means recognizing the limitations of natural medicine, and the value of conventional modalities. You want to work with each patient’s oncology team, and avoid adversarial stances. The worst thing you can do is put a patient in the middle of a contention between yourself and her specialists.

“I’m not anti- standard of care, and I’m careful not to interfere with the oncologists,” she said. “I’m a consummate ‘middle of the road’ practitioner. I don’t do a lot of really radical things.”

Conventional oncologists and cancer treatment centers vary widely in their stances on supplements, diet therapies, and other “alternative” strategies. Some centers, like Memorial Sloan Kettering and City of Hope have strict institutional policies against patients using herbs and supplements while undergoing treatment there. At others, like Cancer Treatment Centers of America, nutraceuticals, herbs and a host of naturopathic therapies are an integral part of the care protocols.

The important thing is cultivating mutual respect with conventional medical colleagues. “What I say to oncologists is, ‘You be the disease expert. Let me become the health expert. Many of my patient referrals actually come from the oncologists.”

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