Diet – Heads2gether

In the Exercise section, you looked at how exercise can help both your body and mind, increase your energy levels and improve your overall health. However, exercise is only one component in improving your wellbeing.
A balanced varied diet is important to maintain good health. Eating a variety of foods may your sense of wellbeing, reduce your risk from health conditions such as heart disease, stroke, some cancers, diabetes and osteoporosis (thin bones). Healthy eating may be difficult to manage after treatment for head and neck cancer and you may be adjusting to a new way of eating. This section on healthy eating hopes to give you some suggestions on how you could adapt your diet to help you make healthier choices.
If you are struggling with eating and/or drinking or having difficulties adapting your diet to make healthier choices, please ask for more specific advice from your Dietitian.

What is healthy eating?
Healthy eating is getting the ideal balance of fruit and vegetables, carbohydrates, protein, fats, sugary foods, salts, alcohol and fluids.

Fruit and vegetables.
Fruit and vegetables are an excellent source of vitamins, minerals, fibre and antioxidants. They should make up about a third of the food we eat every day and most of us don’t eat enough of them. Research suggests that diets high in fruit and vegetables may lower the risk of heart disease, stroke, high blood pressure, obesity and some types of cancer.

Try to eat at least 5 portions of fruit and vegetables day
Different fruits and vegetable contain different nutrients so try to eat a variety everyday to get maximum benefit
One portion is 80g (3oz) and they can be raw, cooked, canned, frozen or dried and fruit and vegetable juices and pulses are also included as a portion

One portion can be:

One banana, orange, pear or apple or similar sized fruit
Half large grapefruit or avocado
A slice of large fruit such as melon or pineapple
2 satsumas, plums or similar sized fruit
A handful of grapes, cherries or berries
1 heaped tablespoon of dried fruit
3 heaped tablespoons of fruit salad, tinned fruit, vegetables or pulses
1 dessert bowl of salad
1 glass (150ml) of fruit or vegetable juice or smoothie

If you have chewing and/or swallowing difficulties you may need to adapt how you eat fruit and vegetables and here are some tips that may help you increase your intake:

Softer fruits which may need the peel removed such as ripe pears, plums, peaches, nectarines, mangoes or melon
Tinned fruit such as pears, mandarins, peaches, strawberries, mango, fruit cocktail
Pureed or stewed fruit – you may need to sieve berries if you cannot manage the pips or seeds
Fruit or vegetable juices – these usually only count as one of your 5 a day but if you diet is restricted to liquids or pureed foods you will need to have more than one a day to increase your fruit and vegetable intake
Well-cooked vegetables that you can mash with a fork
You may need to avoid stringy vegetable such runner beans if these are difficult
Add vegetables and or pulses to soups and stews to help increase your intake
Tinned pulses
Less acidic tasting fruits if you still have problems with a sore or sensitive mouth and throat after treatment. Patients have reported that mango, melon, tinned fruit in syrup can be easier to tolerate

If you are still using a feeding tube your liquid prescribed nutrition includes vitamins and minerals so there is usually no need to take an additional multivitamin and mineral supplement. If you are transitioning from a feeding tube to oral diet and are concerned about fruit and vegetable intake, please speak with your Dietitian.

Starchy Foods.
Starchy foods provide your body with energy, fibre, B vitamins. They should also make up a third of what we eat each day. Aim to include one food from this food group at each meal time and try to choose wholegrain varieties where possible.

Pasta
Rice
Cous cous
Bread
Breakfast cereals

This food group is often quite difficult to eat, particularly if you have a dry mouth and throat following treatment. Patient often say that these foods are too sticky and difficult to swallow and here are some tips on how to make eating starchy foods easier:

Extra sauces or gravy to help reduce stickiness
Extra sips of water in between each mouthful to help with swallowing
Cook pasta, rice or cous cous for a little longer than normal to make it softer
Softer chips
Add rice or small pasta shapes to soups and stews
Risotto rice cooked for longer with extra cream/milk or stock to make it less sticky
Dunk bread or sandwiches in soup
Bread dipped into olive oil can help it slip down more easily
Breakfast cereals soaked in plenty of milk
Patients have reported that soda bread, brioche or toasted bread is sometimes easier to swallow as it is not as doughy or sticky
Wholegrain varieties may be difficult to manage and you may need to soak breakfast cereals or cook starchy foods for longer

Protein.
Protein helps to repair the body and growth of new body cells. Protein rich foods are also often a good source of vitamins and minerals, in particular iron, zinc and vitamin B12. You should try to have protein containing foods at least twice a day:

Meat (beef, lamb and pork)– limit consumption to no more than 3 portions a week. Three portions is the equivalent to about 350-500g cooked meat. less than 500g a week
Poultry – try to remove the skin
Fish – try to have at least 2 portions sustainably sourced fish a week and one should be oily such as mackerel, salmon, herring, pilchards, trout, kippers, sardines, fresh tuna
Eggs & dairy products like milk, cheese and yoghurts – try to choose low fat versions where you can
Pulses and lentils
Tofu, Quorn, Soya meat

Some patients find it difficult to eat meat or poultry after treatment as it is either too dry or chewy and can taste different.

Try slowed cooked recipes to help make the meat as soft as possible and have plenty of sauce or gravy to help reduce dryness
Lean, minced meat to reduce the amount of gristle with plenty of sauce or gravy
Some patients have reported that soya mince or Quorn mince is softer and gristle free and can be easier to chew and swallow. This is great source of protein, fibre and low in saturated fat
Choosing leg or thigh cuts of poultry rather than breast as they can be less dry
Fish in a bag or cooked in sauce

Fats.
Fats are an important part of a balanced diet as they provide the body with energy and some important fat soluble vitamins; A, E and D. They also contain essential fats which the body is unable to make itself. Too much fat can be unhealthy and it is important to get the balance right. There are different types of fats in the food we eat and some are better than others.

Saturated fats are hard fats like lard, butter, fats on meat and dairy foods
Trans fats are vegetarian oils which have been processed to make them hard. Some pastries, cakes and biscuits are made using these fats
Unsaturated fats/oil are found in plant foods such as seeds, grains, nuts, vegetables and fruit.
- Polyunsaturated fats are found in sunflower, soya, corn and sesame oils and
- Monounsaturated fats are found in rapeseed and olive oils. Evidence suggests that monounsaturated fats help promote a healthier type of cholesterol in the bloods. Almonds, hazelnuts, peanuts and avocadoes are good sources of monounsaturated fats.
- Omega-3 fats are sometimes also called “essential fatty acids” as the body cannot make sufficient amounts. These help prevent the blood from clotting and help to regulate heart rhythm. Oily fish such as pilchards, salmon, mackerel and sardines are goods sources of omega-3 and vitamin D. Plant foods can also provide omega-3 fats but in smaller amounts, e.g. rapeseed, soya, flax, linseed oil and walnuts.
Try to reduce saturated fats and replace with heathier unsaturated fats
Remove skin on poultry and choose leaner cuts of meat and trim off visible fat
Eat less fried food – bake, steam, poach food instead
Reduce processed foods high in fat
Choose low fat dairy foods (but watch out for added sugar)
Reduce snacks high in fat such as biscuits, crisps, pastries and cakes
Use unsaturated oils instead of saturated fats

Sugary Foods.
Sugary foods can be enjoyed as part of healthy diet but should limited and kept to a minimum. There is a lot of media attention on whether there is a link between sugar and cancer but the scientific evidence is very poor. Your dental hygiene is very important, particularly if you have had radiotherapy to the mouth area.

Drink water and unsweetened drinks such as tea or coffee
Fruit juices should not be consumed in large quantities
Try to avoid drinks with added sugar
Try to avoid adding sugar to foods and drinks
Ensure you have good dental hygiene and see your dentist or dental hygienist regularly

Fluids.
Fluids are essential to life and water is the main constituent of the body and has many functions including transporting nutrients and compounds in blood, removing waste products that are passed in urine and acting as a lubricant in joints. If you do not drink enough water you will become dehydrated. Your mouth will become more sticky and you will feel more thirsty. Tiredness, poor concentration, headaches and dizziness/lightheadedness can also affect you.

Aim to drink at least 8-10 cups a day (approximately 2000ml)
Drinks include any liquid; water, tea, coffee, milk, juice, soup etc.
Have regular drinks throughout the day
If it is hot or you are exercising you may need to drink more

Common household measures to help guide you on how much you are drinking.

1 medium glass 200ml
1 can of drink 330ml
1 mug 250ml
1 cup 200ml

You may need to drink more than the recommended amount to help with dry mouth and throat and to help make chewing and swallowing easier.

Salt.
Salt plays a vital role keep the body going but too much salt can be harmful and lead to an increased risk from high blood pressure, heart disease, stroke and kidney disease. The maximum recommended allowance for salt is 6g a day (about a teaspoon) but this is likely to reduce to 3g a day in the future. Ways to reduce your salt intake:

Reduce added salt to food
Use herbs and spices to flavour food instead of using salt
Marinate meat, fish and vegetables to add more flavour instead of using salt
Reduce your intake of processed foods such as cured meat, smoked fish and meat, savoury snacks, ready meals and soups, stock cubes etc.

Alcohol.
Alcohol has been linked with an increased risk of developing some types of cancer. The more alcohol someone drinks the greater their overall health risk. One unit is 10ml of pure alcohol. Different drinks and measures contain different amounts of alcohol and can be confusing. You should limit alcohol to a maximum of 14 units a week.

Half pint of lower strength (3-4%) beer, larger or cider = 1 unit
Half pint higher strength (5%) beer = 1.5 units
Standard glass of wine (175ml) = 2 units
A large glass of wine (250ml) = 3 units
A single measure (25ml) of 40% spirits = 1 unit
A bottle of alcopop (275ml) = 1.5 units

Cancer Prevention.
One question that is frequently asked is whether there are any specific foods that will help to prevent cancer. There is now certain some evidence that certain foods, particularly fruit and vegetables that can help protect us against developing some cancers. Also eating large quantities of certain foods has been linked to an increased risk of developing specific cancers. The World Cancer Research Fund (WCRF UK) recommends the following on food and cancer prevention:

Be a healthy weight – try to keep your weight within the healthy range and avoid weight gain in adult life
Move more – be physically active for at least 30 minutes every day and sit less
Eat a wide variety of wholegrains, vegetables, fruit, pulses and beans and make these a major part of your usual diet
Limit “fast foods” and other processed foods high in fat, starched or sugars
Limit red and processed meat – eat no more than moderate amounts of meat such as beef pork and lamb
Eat little if any processed meat
Limit sugar sweetened drinks and drink mostly water and unsweetened drinks
Limit alcohol – for cancer prevention it is best not to drink alcohol. If you do drink, limit alcoholic drinks to 14 units a week
Don’t rely on supplements – aim to meet nutritional needs through die88888t alone
Breastfeed your baby, if you can as it is good for both mother and baby
After a cancer diagnosis follow the above recommendations if you can

For more information on healthy eating and cancer prevention please go to:
British Dietetic Association www.bda.uk.com
World Cancer Research Fund www.wcrf-uk.org
Macmillan Cancer Support www.macmillan.org.uk
NHS Eat Well www.nhs.uk/live-well

Heads2gether are very grateful to Rupali Shah, Oncology Dietitian at the Churchill Hospital, Oxford, for providing the above guidance.