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Nutrition and Physical Activity Guidelines
for Cancer Survivors
Cheryl L.Rock,PhD,RD1;Colleen Doyle,MS,RD2;Wendy Demark-Wahnefried,PhD,RD3;Jeffrey Meyerhardt,MD,MPH4;
Kerry S.Courneya,PhD5;Anna L.Schwartz,FNP,PhD,FAAN6;Elisa V.Bandera,MD,PhD7;
Kathryn K.Hamilton,MA,RD,CSO,CDN8;Barbara Grant,MS,RD,CSO,LD9;
Marji McCullough,ScD,RD10;Tim Byers,MD,MPH11;Ted Gansler,MD,MBA,MPH12
Cancer survivors are often highly motivated to seek information about food choices,physical activity,and dietary supplements to improve their treatment outcomes,quality of life,and overall survival.To address these concerns,the American Cancer Society (ACS)convened a group of experts in nutrition,physical activity,and cancer survivorship to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer.This report summarizes their findings and is intended to present health care providers with the best possible information with which to help cancer survivors and their families make informed choices related to nutrition and physical activity.The report discusses nutrition and physical ac-tivity guidelines during the continuum of cancer care,briefly highlighting important issues during cancer treatment and for patients with advanced cancer,but focusing largely on the needs of the population of individuals who are disease free or who have stable disease following their recovery from treatment.It also discusses select nutrition and physical activity issues such as body weight, food choices,food safety,and dietary supplements;issues related to selected cancer sites;and common questions about diet,
physical activity,and cancer survivorship.CA Cancer J Clin2012;62:242-274.V C2012American Cancer
Society.
To earn free CME credit or nursing contact hours for successfully completing the online quiz based on this article,go to
https://www.doczj.com/doc/683421037.html,/ce.
Introduction
A cancer survivor is de?ned as anyone who has been diagnosed with cancer,from the time of diagnosis through the rest of their life.1Given advances in early detection and treatment,the number of US cancer survivors is estimated to exceed12 million and is growing steadily,so that approximately one in every25Americans is now a cancer survivor.1,2Many cancer survivors are highly motivated to seek information about food choices,physical activity,dietary supplement use,and complementary nutritional therapies to improve their response to treatment,speed recovery,reduce their risk of recurrence, and improve their quality of life.3
The trajectory of cancer survivorship is marked by3general phases:1)active treatment and recovery;2)living after recovery,including survivors who are disease free or who have stable disease;and3)advanced cancer and end of life. Approximately68%of Americans diagnosed with cancer now live more than5years,4and their nutritional needs change over the course of survivorship.The need for informed lifestyle choices for cancer survivors becomes particularly important
as they look forward to the successful completion of therapy and seek self-care strategies to improve their long-term out-comes.For many long-term cancer survivors,healthy weight management,a healthful diet,and a physically active lifestyle aimed at preventing recurrence,second primary cancers,and other chronic diseases should be a priority.For other survivors, regaining health following a dif?cult treatment or managing nutritional needs and activity levels while living with advanced cancer becomes a particular challenge.
1Professor,Department of Family and Preventive Medicine,School of Medicine,University of California,San Diego,La Jolla,CA;2Director,Nutrition and Physical Activity,Cancer Control Science,American Cancer Society,Atlanta,GA;3Professor and Webb Endowed Chair of Nutrition Sciences,University of Alabama at Birmingham,Birmingham,AL;4Associate Professor of Medicine,Dana-Farber Cancer Institute,Harvard Medical School,Boston,MA;5Professor
and Canada Research Chair in Physical Activity and Cancer,University of Alberta,Edmonton,Alberta,Canada;6Affiliate Professor,University of Washington, Seattle,WA,Associate Professor,Idaho State University,Pocatello,ID;7Associate Professor,Department of Epidemiology,The Cancer Institute of New Jersey,New Brunswick,NJ;8Outpatient Oncology Dietitian,Carol G.Simon Cancer Center,Morristown Memorial Hospital,Morristown,NJ;9Oncology Nutritionist,Saint Alphonsus Regional Medical Center Cancer Care Center,Boise,ID;10Nutritional Epidemiologist,Epidemiology and Surveillance Research, American Cancer Society,Atlanta,GA;11Associate Dean for Public Health Practice,Colorado School of Public Health,Associate Director for Cancer Prevention and Control,University of Colorado Cancer Center,Aurora,CO;12Director,Medical Content,American Cancer Society,Atlanta,GA. Corresponding author:Colleen Doyle,MS,RD,American Cancer Society,250Williams St NW,Suite600,Atlanta,GA30303;colleen.doyle@https://www.doczj.com/doc/683421037.html,
DISCLOSURES:The authors report no conflicts of interest.
V C2012American Cancer Society,Inc.doi:10.3322/caac.21142.Available online at https://www.doczj.com/doc/683421037.html,
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After receiving a diagnosis of cancer,survivors soon?nd there are few clear answers to even the simplest questions, such as:Should I change what I eat?Should I exercise more? Should I gain or lose weight?Should I take dietary supple-ments?Cancer survivors receive a wide range of advice from many sources about foods they should eat,foods they should avoid,how they should exercise,and what types of supplements they should take,if any.Unfortunately,this advice is often inconsistent and not supported by data. Overview of the Report
The American Cancer Society(ACS)convened a group of experts in nutrition,physical activity,and cancer to evaluate and synthesize the scienti?c evidence and best clinical practices related to nutrition and physical activity after the diagnosis of cancer.This report summarizes their?ndings and updates the most recent report published in2006.5 Although this report is intended for health care providers caring for cancer survivors,it can also be used directly by highly motivated survivors and their families.The ACS also provides shorter and simpler summaries of the recom-mendations in this report,which are written speci?cally for survivors and caregivers.New scienti?c evidence has emerged since2006on the relationship between nutrition, physical activity,and issues of quality of life,comorbid conditions,cancer recurrence,the development of second primary cancers,and overall survival.Although this evidence is incomplete,reasonable conclusions and recom-mendations can be made on several issues that can guide choices about body weight,foods,physical activity,and dietary supplement use.
This report presents information in4sections.The?rst section addresses nutrition and physical activity across the phases of cancer survivorship;the second section addresses the guidelines for cancer survivors in speci?c areas of weight management,physical activity,food choices,alcohol intake, and food safety;the third section provides information regarding selected cancer sites;and the fourth section includes answers to common questions many survivors have. It is important that health care providers,cancer survivors, and caregivers consider the nutritional and physical activity issues discussed in this report within the context of the indi-vidual survivor’s overall medical and health situation.This report is not intended to imply that nutrition and physical activity are more important than other clinical or self-care approaches.For example,although we present dietary suggestions for persons with bowel changes and fatigue,we recognize that other medical interventions may be more effective in controlling those symptoms.Furthermore,just as standard treatment options vary by the type of cancer,nutri-tion and physical activity factors may impact some cancer types but not others.In writing these recommendations,we have assumed that survivors and their caregivers are receiving appropriate medical and supportive care and are seeking high-quality information on self-care strategies to provide further relief of symptoms and to enhance health. Physicians and other health care providers have a unique opportunity to guide cancer patients toward optimal lifestyle choices,and thus can favorably in?uence the survi-vorship trajectory regardless of the individual’s survivorship phase.The power of physician advice in facilitating preven-tive health behaviors has been consistently demonstrated.A study of450breast cancer survivors6showed that a simple recommendation from the oncologist to exercise resulted in signi?cant increases in physical activity.This is not to say that the physician needs to provide in-depth counseling to patients,but rather to at least plant an appropriate message and then either refer patients to registered dietitians or exercise trainers who are certi?ed within the area of cancer supportive care,or to provide user-friendly self-help brochures or other resources to support lifestyle changes. Nutrition and Physical Activity Across the Continuum of Cancer Survivorship
The continuum of cancer survivorship includes treatment and recovery;long-term disease-free living or living with stable disease;and,for some,living with advanced cancer. Survivors in each of these phases have different needs and challenges with respect to nutrition and physical activity.
Nutrition During Cancer Treatment and Recovery Prior to the identi?cation of effective cancer screening and treatment,many people were diagnosed with cancer in a late stage,when they may have already experienced the weight loss and cachexia that was common among patients with late-stage cancer.In addition,patients undergoing cancer treatment often experienced signi?cant untreated nausea and vomiting,which led to further weight loss. Because of these clinical experiences,cancer was considered to be a disease associated with weight loss,rather than obesity.However,many patients now being diagnosed have early stage disease and treatments are more effective. Therefore,with growing numbers of patients beginning the cancer treatment process already overweight or obese,7 additional weight gain is a frequent complication of treatment.8While highly variable depending on the type of cancer and stage at diagnosis,cancer can cause profound metabolic and physiological alterations that can affect the nutrient requirements for macro-and micronutrients.9 Symptoms such as anorexia,early satiety,changes in taste and smell,and disturbances of the bowel are common side effects of cancer and cancer treatment and can lead to inadequate nutrient intake and subsequent malnutrition. Substantial weight loss and poor nutritional status can still occur early in the course of some cancers,although the
Nutrition and Physical Activity Guidelines for Cancer Survivors 244CA:A Cancer Journal for Clinicians
prevalence of malnutrition and weight loss varies widely across cancer types and stage at diagnosis.10Consuming enough calories to prevent additional weight loss is therefore vital for survivors at risk of unintentional weight loss,such as those who are already malnourished or those who receive anticancer treatments affecting the gastrointestinal tract.10,11All of the major modalities of cancer treatment,includ-ing surgery,radiation,and chemotherapy,can signi?cantly affect nutritional needs;alter regular eating habits;and adversely affect how the body digests,absorbs,and uses food.9,12Nutritional assessment for survivors should there-fore begin as soon after diagnosis as possible and should take into consideration treatment goals (curative,control,or palliation)while focusing on both the current nutritional status and anticipated nutrition-related symptoms.12
During active cancer treatment,the overall goals of nutritional care for survivors should be to prevent or resolve nutrient de?ciencies,achieve or maintain a healthy weight,preserve lean body mass,minimize nutrition-related side effects,and maximize quality of life.Studies con?rm the bene?t of dietary counseling during cancer treatment for improving outcomes,such as fewer treatment-related symptoms,improved quality of life,and improved dietary intake.13-16Suggestions for ?nding an oncology nutrition expert to provide dietary counseling are provided in Table 1.Providing individualized nutritional advice can improve dietary intake and potentially decrease some of the toxicities associated with cancer treatments.9Examples of situations that may bene?t from seeking individualized advice include the following:
?For survivors experiencing anorexia or early satiety,and who are at risk of becoming underweight,consuming smaller,more frequent meals with minimal liquids con-sumed during meals can help to increase food intake.Liquids can and should be consumed in between meals to avoid dehydration.
?For survivors who cannot meet their nutritional needs through foods alone,forti?ed,commercially prepared or homemade nutrient-dense beverages or foods can improve the intake of energy and nutrients.
?For survivors who are unable to meet their nutritional needs through these measures and who are at risk of becoming malnourished,other means of nutritional
TABLE 1.Suggestions for Locating Specialized Nutrition Counseling
l Survivors should ask their health care provider for a referral to see an RD,preferably an RD who is also a CSO,if they experience nutrition-related challenges.l
If an oncology dietitian is not available in the medical or surgical practice or medical center where they receive their cancer treatment and care,an appointment with a dietitian associated with their primary care provider clinic may be arranged.
Survivors,caregivers,and providers can also consult the Academy of Nutrition and Dietetics to identify a private practice dietitian in their area.RD indicates registered dietitian;CSO certified specialist in oncology.
support may be needed,such as pharmacotherapy using appetite stimulants,enteral nutrition via tube feeding,or intravenous parenteral nutrition.
The use of vitamins,minerals,and other dietary supplements during cancer treatment remains controversial.For example,it may be counterproductive for survivors to take folate supplements or to eat forti?ed food products that contain high levels of folate when receiving antifolate therapies such as methotrexate.9Many dietary supplements contain levels that exceed the amount normally found in food and recommended in the Dietary Reference Intakes for optimal health.17-21Because of emerging evidence on detrimental effects from even the modest use of dietary supplements in the oncology population,many cancer experts continue to advise against taking supplements during and after treatment,or suggest limiting use to those dietary supplements needed to treat a de?ciency or promote another aspect of health.One reason for concern involves the theory that a subgroup of dietary supplements,antioxidants,could prevent the cellular oxidative damage to cancer cells that is required for treatments such as radiation therapy and chemotherapy to be effective.22In contrast,some clinicians have noted that the possible harm from antioxidants is only hypothetical and that there may be a net bene?t to helping protect normal cells from the collateral damage associated with these therapies.23,24With compelling evidence against the use of select supplements in certain oncology populations,health care professionals and survivors need to proceed with caution.25If interested in supplementation,individuals should ?rst assess whether they are nutrient de?cient,avoid ingesting supplements that exceed more than 100%of the Daily Value,and consider limiting dietary supplement use to therapeutic interventions for chronic conditions such as osteoporosis and macular degeneration,for which scienti?c evidence supports the likelihood of bene?ts and low risk of harm.
Exercise During Cancer Treatment
An increasing number of studies have examined the therapeutic value of exercise during primary cancer treat-ment.26,27Existing evidence strongly suggests that exercise
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is not only safe and feasible during cancer treatment,but that it can also improve physical functioning,fatigue,and multiple aspects of quality of life.28Some studies have also suggested that physical activity may even increase the rate of completion of chemotherapy.29Current evidence is unclear on the interaction of exercise and chemotherapy ef?cacy,but in at least one randomized controlled exercise study,there was no evidence of a negative exercise effect on response to chemotherapy in a cohort of lymphoma survi-vors.30One animal study also reported that exercise did not interfere with the ef?cacy of chemotherapy.31
The decision regarding when to initiate and how to maintain physical activity should be individualized to the
patient’s condition and personal preferences.Exercise during cancer treatment improves multiple posttreatment adverse effects on bone health,muscle strength,and other quality-of-life measures.32-36Persons receiving chemother-apy and/or radiation therapy who are already on an exercise program may need to exercise at a lower intensity and/or for a shorter duration during their treatment,but the principal goal should be to maintain activity as much as possible.Some clinicians advise certain survivors to wait to determine their extent of side effects with chemotherapy before beginning an exercise program.For those who were sedentary before diagnosis,low-intensity activities such as stretching and brief,slow walks should be adopted and slowly advanced.For older individuals and those with bone metastases or osteoporosis,or signi?cant impair-ments such as arthritis or peripheral neuropathy,careful attention should be given to balance and safety to reduce the risk of falls and injuries.The presence of a caregiver or exercise professional during exercise sessions can be helpful.If the disease or treatment necessitates periods of bed rest,then reduced?tness and strength,as well as loss of lean body mass,can be expected.Physical therapy during bed rest is therefore advisable to maintain strength and range of motion and can help to counteract fatigue and depression.
Recovery Immediately After Treatment
After cancer therapy has been completed,the next phase of cancer survivorship is recovery.In this phase,many symp-toms and side effects of treatment that have affected nutri-tional and physical well-being begin to resolve.Typically, survivors recover from the acute effects of their speci?c treatment within weeks or months after completing therapy,although in some instances,side effects of treat-ment persist.In addition,late-occurring or latent effects of treatment may appear long(months or years)after treat-ment has been completed.37-39Examples of continuing side effects or complications of cancer treatment relevant to nutritional status include persistent fatigue,peripheral neuropathy,changed sense of taste,dif?culty chewing and swallowing,dif?culty in replenishing lean body mass after the completion of therapy,and persistent bowel changes such as diarrhea or constipation.
Survivors may require ongoing nutritional assessment and guidance in this phase of survival.40-42For those who emerge from treatment underweight or with compromised nutritional status,continued supportive care,including nutritional counseling and pharmacotherapy to relieve symptoms and stimulate appetite,is helpful in the recovery process.13,43After treatment,a program of regular physical activity is essential to aid in the process of recovery and improve?tness.
Long-Term Disease-Free Living or Stable Disease During this phase,setting and achieving lifelong goals for weight management,a physically active lifestyle,and a healthy diet are important to promote overall health, quality of life,and longevity.44While cancer survivorship is a relatively new area of study and much needs to be learned regarding the optimal diet and physical activity practices for cancer survivors,current evidence supports recommendations in3basic areas:weight management, physical activity,and dietary patterns.These guidelines are featured in Table2.Because individuals who have been diagnosed with cancer are at a signi?cantly higher risk of developing second primary cancers,45and may also be at an increased risk of chronic diseases such as cardiovascular disease,diabetes,and osteoporosis,the guidelines established to prevent those diseases are especially important for cancer survivors.46-51Because family mem-bers of cancer survivors may also be at a higher risk of developing cancer,they should also be encouraged to follow the ACS nutrition and physical activity guidelines for cancer prevention.52
Convincing data exist that obesity is associated with an increased risk of breast cancer recurrence,53,54and similar evidence on obesity and prognosis is also accumulating for other cancers.55-57On the opposite end of the spectrum, TABLE2.American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Survivors
Achieve and maintain a healthy weight.
l If overweight or obese,limit consumption of high-calorie foods and
beverages and increase physical activity to promote weight loss.
Engage in regular physical activity.
l Avoid inactivity and return to normal daily activities as soon as possible
following diagnosis.
l Aim to exercise at least150minutes per week.
l Include strength training exercises at least2days per week.
Achieve a dietary pattern that is high in vegetables,fruits,and whole grains.
l Follow the American Cancer Society Guidelines on Nutrition and Physical
Activity for Cancer Prevention.
Nutrition and Physical Activity Guidelines for Cancer Survivors 246CA:A Cancer Journal for Clinicians
those with aerodigestive tumors such as head and neck, esophagus,or lung cancers may be malnourished and underweight at the point of diagnosis,and could therefore bene?t from increasing their body weight.58-61Therefore, achieving and maintaining a healthy weight,as well as consuming a nutrient-rich diet and maintaining a physically active lifestyle,are important to improve long-term health and well-being.
Extensive research has been conducted on the bene?ts of physical activity during recovery from cancer-related treat-ments,and an increasing number of studies have examined the impact of physical activity on cancer recurrence and long-term survival.28Exercise has been shown to improve cardiovascular?tness,muscle strength,body composition, fatigue,anxiety,depression,self-esteem,happiness,and several components of quality of life(physical,functional, and emotional)in cancer survivors.In addition,exercise studies have targeted certain symptoms particular to speci?c cancers and the adverse effects of speci?c therapies (eg,lymphedema in survivors of breast cancer)and shown bene?cial effects that are more cancer-speci?c.At least20 prospective observational studies have shown that physi-cally active cancer survivors have a lower risk of cancer recurrences and improved survival compared with those who are inactive,although studies remain limited to breast, colorectal,prostate,and ovarian cancer,and randomized clinical trials are still needed to better de?ne the impact of exercise on such outcomes.62-65
Living With Advanced Cancer
For individuals living with advanced cancer,a healthy diet and some physical activity may be important factors in establishing and maintaining a sense of well-being and enhancing their quality of life.Although advanced cancer is sometimes accompanied by substantial weight loss,it is not inevitable that individuals with cancer lose weight or experience malnutrition.9Many patients with advanced cancer need to adapt their food choices and meal patterns to meet nutritional needs and to manage cancer symptoms or treatment side effects such as fatigue,bowel changes,and a diminished sense of taste or appetite.For persons experienc-ing anorexia,negative changes in weight,or dif?culty in gain-ing weight,convincing evidence exists that some medications (eg,megestrol acetate)can help to enhance appetite.66 Additional nutritional supplementation such as nutrient-dense beverages and foods can be consumed by those who cannot eat or drink enough to maintain suf?cient energy intake. The use of enteral nutrition and parenteral nutrition sup-port should be individualized with recognition of overall treatment goals(control or palliation)and the associated risks of medical complications and/or ethical dilemmas. Both the American Society for Parenteral and Enteral Nutrition67and the Academy of Nutrition and Dietetics position papers recommend that nutrition support be used selectively and with clear purpose.68,69
Several systematic reviews have suggested that some level
of physical activity is feasible and may improve quality of life
and physical function in persons with advanced cancer, although this is likely speci?c to certain cancer types.70,71 Thus,the evidence of a bene?t from exercise for survivors of advanced cancer is insuf?cient to make general recommenda-tions.Recommendations for nutrition and physical activity
in those who are living with advanced cancer are best based
on individual nutrition needs and physical abilities.
Selected Issues in Nutrition and Physical
Activity for Cancer Survivors
Body Weight
In the United States,obesity is a problem of epidemic proportions72and is a well-established risk factor for some
of the most common cancers.52Overweight and obesity are clearly associated with an increased risk of developing many cancers,including cancers of the breast in postmenopausal women73;colon and rectum74;endometrium;and adeno-carcinoma of the esophagus,kidney,and pancreas.47,75 Obesity is also probably associated with an increased risk of cancer of the gallbladder,47and may also be associated with
an increased risk of cancers of the liver,cervix,and ovary,as
well as non-Hodgkin lymphoma,multiple myeloma,and aggressive forms of prostate cancer.52Thus,many cancer survivors are overweight or obese at the time of diagnosis. Increasing evidence indicates that being overweight increases the risk of recurrence and reduces the likelihood
of disease-free and overall survival among those diagnosed
with cancer.53,54,63,76-89Such data suggest that the avoid-ance of weight gain and weight maintenance throughout treatment may be important for survivors who are normal weight,overweight,or obese at the time of diagnosis,and
that intentional weight loss following treatment recovery among those who are overweight and obese may be associated
with health-related bene?ts.90
Although currently there is limited evidence to support
the hypothesis that intentional weight loss posttreatment in cancer survivors will result in improved prognosis and overall survival,53results of the Women’s Intervention Nutrition Study(WINS)found that a low-fat diet that resulted in a6-pound weight loss(approximately4%of initial weight)reduced the risk of recurrence among post-menopausal breast cancer survivors(especially those with estrogen receptor[ER]-negative tumors).91However,this
trial was not designed to speci?cally address weight loss,
and the results are confounded by the impact of a low-fat
diet that was the focus of the intervention.Nonetheless,it
is hypothesized that improvements in cancer-related
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outcomes are possible,and likely probable,through intentional weight reduction in overweight or obese cancer survivors.92Currently a National Cancer Institute-funded vanguard study is underway(Exercise and Nutrition to Enhance Recovery and Good Health for You[ENERGY]) (1R01CA148791-01)to test the feasibility and impact on quality of life of a diet and exercise weight management intervention in800overweight and obese breast cancer sur-vivors,as well as set the stage for a larger study examining the effects of weight loss on survival and other cancer out-comes.Evidence already exists that weight loss that results from intentional exercise and caloric restriction can improve the hormonal milieu93,94and quality of life and physical functioning among survivors who are obese or overweight.95 It may be dif?cult for individuals to pursue a host of new di-etary,exercise,and behavioral strategies to reduce body weight through reduced energy intake and increased energy expenditure while at the same time balancing the demands of daily life during initial treatments.96Thus,for many,active efforts toward intentional weight loss may be postponed until surgery,chemotherapy,and/or radiation treatment is com-plete.However,for cancer survivors who are overweight or obese and who choose to pursue weight loss,there appears to be no contraindication to modest weight loss(ie,a maximum of2pounds per week)97during treatment,as long as the treating oncologists approve,weight loss is monitored closely,and it does not interfere with treatment.Past studies showing deleterious associations with decreases in body weight after diagnosis have been unable to separate intentional from nonintentional weight loss.Safe weight loss should be achieved through a nutritious diet that is reduced in energy density and increased physical activity tailored to the speci?c needs of the patient.7,28,98
After cancer treatment,weight gain or loss should be managed with a combination of dietary,physical activity, and behavioral strategies.For some who need to gain weight,this means increasing energy intake to exceed energy expended and for others who need to lose weight, reducing caloric intake and increasing energy expenditure via increased physical activity to exceed energy intake. Reducing the energy density of the diet by emphasizing low-energy dense foods(eg,water-and?ber-rich vegetables and fruits)and limiting the intake of foods and beverages high in fat and added sugar promotes healthy weight control.99Limiting portion sizes of energy-dense foods is an important accompanying strategy.99Increased physical activity is also an important element to prevent weight gain,retain or regain muscle mass,promote weight loss, and promote the maintenance of weight loss in patients who are overweight or obese.For survivors who are severely obese and have more pressing health issues,more structured weight loss programs or pharmacologic or surgical means may be indicated.100It should be noted that among those who need to lose weight,even if ideal weight is not achieved,it is likely that any weight loss achieved by physi-cal activity and healthful eating is bene?cial,with weight losses of5%to10%still likely to have signi?cant health bene?ts.90,99,100Although most evidence related to these weight management strategies does not come from studies of cancer survivors per se,it is likely that these approaches can apply in the special circumstances of the cancer survivor.
Throughout the cancer continuum,therefore,individuals should strive to achieve and maintain a healthy weight,as de?ned by a body mass index(BMI)(Table3)between 18.5kg/m2and25kg/m2.Some cancer survivors can be malnourished and underweight at diagnosis or as a result of aggressive cancer treatments.101For these individuals, further weight loss can impair their quality of life,interfere with the completion of treatment,delay healing,and increase the risk of complications.In survivors with these dif?culties,dietary intake and factors affecting energy expenditure should be carefully assessed.13,58-60For those at risk of unintentional weight loss,multifaceted interventions should focus on increasing food intake to achieve a positive energy balance and therefore increase weight.13,58-60Physical activity may be useful to the underweight survivor when tailored to provide stress reduction and to increase strength and lean body mass,but exceptionally high levels of physical activity make weight gain more dif?cult.102
Physical Activity in Cancer Survivors
Since the2006update of these guidelines for cancer survivors, there has been a marked increase in the number of studies that have addressed the association between physical activity and a variety of outcomes in patients who have completed the initial phase of therapy for their cancer.27,63,76The outcomes of interest in this update include cancer recurrence,cancer-speci?c and overall survival,health-related?tness,patient-reported outcomes,lymphedema,and comorbid conditions.28 Prospective,observational studies have demonstrated that physical activity after cancer diagnosis is associated with a reduced risk of cancer recurrence and improved overall mortality among multiple cancer survivor groups,including breast,colorectal,prostate,and ovarian cancer.62,64,65,103-107 Among breast cancer survivors,physical activity after diagnosis has consistently been associated with reduced risk of breast cancer recurrence and breast cancer-speci?c mortality.A recent meta-analysis demonstrated that post-diagnosis exercise was associated with a34%lower risk of breast cancer deaths,a41%lower risk of all-cause mortality, and a24%lower risk of breast cancer recurrence.62Among survivors of colorectal cancer,at least4large cohort studies have found an inverse association between being physically active after diagnosis and recurrence,colorectal cancer-speci?c
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mortality and/or overall mortality,with improvements of up to50%for each outcome.104-107There is now a randomized, phase3trial underway comparing a physical activity program with health education in survivors of stage II and III colon cancer after standard chemotherapy.108
Exercise has been shown to improve health-related ?tness outcomes in several cancer survivor groups.As a result of both their cancer and treatment,cancer patients are often in a deconditioned state.Aerobic and resistance training consistently show a bene?t for cardiopulmonary ?tness,muscle strength,body composition,and balance.27 A substantial number of randomized controlled trials have tested the effects of physical activity after diagnosis on various patient-reported outcomes.In many studies,exercise improves quality of life,fatigue,psychosocial distress,depression,and self-esteem.For example,in one randomized study in men with prostate cancer who were undergoing androgen suppres-sion therapy,those assigned to a program of resistance and aerobic training had increases in lean mass,improved muscle strength,improved walk time,and improved balance,26and in a randomized controlled trial of breast cancer survivors,women assigned to moderate intensity resistance and impact training experienced improvements in bone mass and lean muscle mass.33
A recent meta-analysis of78exercise intervention trials showed that exercise interventions resulted in clinically mean-ingful improvements in quality of life that persisted after the completion of the intervention.109In another meta-analysis of44studies that included over3000participants with varying cancer types,cancer survivors randomized to an exercise intervention had signi?cantly reduced cancer-related fatigue levels,with evidence of a linear relationship to the intensity of resistance exercise.110
Historically,there were concerns that cancer survivors with upper extremity lymphedema should not engage in upper extremity resistance training or vigorous aerobic physical activity.There are now multiple trials that have demonstrated that such physical activity is not only safe,but actually reduces the incidence and severity of lymphedema.29,111,112
Many cancer survivors have an increased risk of comorbid conditions that can be reduced through increased physical activity.113,114The effects of physical activity on cardiovascular
TABLE3.Adult BMI Chart
BMI1920212223242526272829303132333435
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
BMI indicates body mass index.
Source:US Department of Health and Human Services,National Institutes of Health,National Health,Lung,and Blood Institute.the Clinical Guidelines on the Identification,Evaluation and Treatment of Overweight and Obesity in Adults:Evidence Report.NIH Pub.No.98-4083.Bethesda,MD:US Department of Health
and Human Services,National Institute of Health,National Health,Lung,and Blood Institute;1998.
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disease and diabetes have not been studied in cancer survivors, but it is reasonable to expect that the bene?cial effects of physical activity on such outcomes would not differ from those observed in the general population.
Despite the many bene?ts of exercise for cancer survivors, particular issues may affect the ability of survivors to exercise.Effects of treatment may also increase the risk of exercise-related injuries and adverse effects,and therefore speci?c precautions may be advisable,including:?Survivors with severe anemia should delay exercise, other than activities of daily living,until the anemia is improved.
?Survivors with compromised immune function should avoid public gyms and public pools until their white blood cell counts return to safe levels.Survivors who have completed a bone marrow transplant are usually advised to avoid such exposures for one year after transplantation.
?Survivors experiencing severe fatigue from their therapy may not feel up to an exercise program,and therefore they may be encouraged to do10minutes of light exercises daily.
?Survivors undergoing radiation should avoid chlorine exposure to irradiated skin(eg,from swimming pools).?Survivors with indwelling catheters or feeding tubes should be cautious or avoid pool,lake,or ocean water or other microbial exposures that may result in infections, as well as resistance training of muscles in the area of the catheter to avoid dislodgment.
?Survivors with multiple or uncontrolled comorbidities need to consider modi?cations to their exercise program in consultation with their physicians.
?Survivors with signi?cant peripheral neuropathies or ataxia may have a reduced ability to use the affected limbs because of weakness or loss of balance.They may do better with a stationary reclining bicycle,for example, than walking on a treadmill.
After consideration of these and other speci?c precautions, it is recommended that cancer survivors follow the survivor-speci?c guidelines written by an expert panel convened by the American College of Sports Medicine (ACSM).28The ACSM panel recommended that individu-als avoid inactivity and return to normal activity as soon as possible after diagnosis or treatment.For aerobic physical activity,the ACSM panel recommended that survivors follow the US Department of Health and Human Services 2008Physical Activity Guidelines for Americans.114Accord-ing to those guidelines,adults aged18to64years should engage in at least150minutes per week of moderate intensity or75minutes per week of vigorous intensity aerobic physical activity,or an equivalent combination of moderate and vigorous intensity aerobic physical activity(Table4). Some activity is better than none and exceeding the guidelines is likely to provide additional health bene?ts. Activity should be done in episodes of at least10minutes per session and preferably spread throughout the week.Further-more,adults should do muscle-strengthening activities involving all major muscle groups at least2days per week. Adults aged older than65years should also follow these recommendations if possible,but if chronic conditions limit activity,older adults should be as physically active as their abilities allow and avoid long periods of physical inactivity. Cancer type-speci?c recommendations will be discussed in the individual cancer sections below.
Supporting Exercise Behavior Change
Based on the current evidence,cancer care professionals can expect that fewer than10%of cancer survivors will be active during their primary treatments and only about20%to 30%will be active after they recover from treatments.115,116 Consequently,unless behavioral support interventions are provided,the majority of cancer survivors will not bene?t fully from regular physical activity.Behavioral support interventions to assist cancer survivors in adopting and maintaining a physically active lifestyle have been reviewed elsewhere.115-117Some successful strategies include short-term supervised exercise(eg,12weeks),support groups, telephone counseling,motivational interviewing,and cancer survivor-speci?c print materials.The key point for cancer care professionals is that cancer survivors have unique motives,barriers,and preferences for physical activity.Table4shows examples of moderate and vigorous intensity activities.118
Dietary and Food Choices
As summarized in recent reviews,results from observational studies suggest that diet and food choices may affect cancer progression,risk of recurrence,and overall survival in indi-viduals who have been treated for cancer.3,7,98,119Breast cancer survivors have been the focus of the majority of these studies,although a growing number of studies involving cohorts of colorectal and prostate cancer survivors have been conducted and published over the past decade.The majority of this research has focused on the effect of individual nutrients,bioactive food components,or speci?c foods.Disentangling the effects of these dietary constituents and related lifestyle factors and characteristics(eg,physical activity,obesity)that in?uence risk and progression of cancer has proved to be very challenging.Furthermore,people eat food,not nutrients,and even speci?c foods are generally consumed in a pattern that is characterized by several features and bioactive components that potentially in?uence cancer progression.Evaluating the relationship between survival and diet as a dietary pattern rather than by focusing only on speci?c foods may also be informative.
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For example,a dietary pattern high in fruits,vegetables, whole grains,poultry,and?sh was found to be associated with reduced mortality compared with a dietary pattern characterized by a high intake of re?ned grains,processed and red meats,desserts,high-fat dairy products,and French fries in women after breast cancer diagnosis and treat-ment.120Similarly,a43%reduction in overall mortality was observed in a study of breast cancer survivors in association with a dietary pattern characterized by the high intake of vegetables and whole grains.121Breast cancer survivors who reported eating at least5servings of vegetables and fruits each day and having weekly physical activity equiva-lent to30minutes of walking for6days per week were observed to have a higher survival rate,although a signi?-cant survival advantage was not observed for either of these behaviors alone.122In patients with colorectal cancer,one observational study of over1000survivors found that a diet characterized by a higher intake of red meat,processed meat,re?ned grains,and sugary desserts was associated with a statistically signi?cant increase in cancer recurrence and poorer overall survival.123
Diet Composition
Protein,carbohydrate,and fat all contribute energy to the diet,and each of these dietary constituents is available from a wide variety of foods.Because many cancer survivors are at high risk of other chronic diseases,such as heart disease, the recommended amounts and types of fat,protein,and carbohydrate to reduce cardiovascular disease risk are also appropriate for cancer survivors,particularly if they are at or above their recommended body weight.46,47,49,52
The Institute of Medicine and current Federal Guidelines, as well as the American Heart Association(AHA),recom-mend a spectrum of dietary composition for the adult population:fat:20%to35%of energy(AHA:25%-35%), carbohydrate:45%to65%of energy(AHA:50%-60%);and protein:10%to35%of energy(at least0.8g/kg).46,49,124 Several studies have examined the relationship between fat intake and survival after the diagnosis of breast cancer;evidence from these observational studies is mixed.Inverse associations have been found between fat intake and recurrence and/or survival in some of these studies, although these associations typically disappear with energy adjustment.98,125,126A U-shaped relationship between dietary fat intake and mortality following the diagnosis of breast cancer was identi?ed in one observational study,127 suggesting that extremes in fat intake may be associated with poorer outcomes.
Two large randomized controlled trials have tested whether a reduction in fat intake following the diagnosis of early stage breast cancer affects cancer outcomes.The WINS tested a low-fat diet(aiming for less than15%of energy)in 2437postmenopausal women with early stage breast cancer and found an effect on relapse-free survival that was of borderline statistical signi?cance.91On average,the women in the intervention arm decreased their fat intake to20%of energy at year one,and the intervention resulted in a24% reduction in new breast cancer events,with subset analyses suggesting that this effect was greater among women with ER-negative disease.Of note,as previously described,women assigned to the low-fat diet study arm lost an average of6 pounds over the course of the study,thus confounding whether the reduction in breast cancer events was due to dietary fat restriction or lower body weight.
The Women’s Healthy Eating and Living(WHEL) Study tested the effect of a diet low in fat(aiming for20% of energy intake)and very high in vegetables,fruits,and ?ber on cancer outcomes in3088pre-and postmenopausal breast cancer survivors who were followed for an average of 7.3years.122At4years,women in the intervention group reported a reduction in fat intake(from31.3%at enrollment to26.9%of energy intake),but recurrence-free survival did not differ between the2study arms.122Notably,women in the WHEL Study intervention group did not exhibit weight loss,in contrast to the low-fat diet intervention group in WINS.The WHEL Study intervention was observed to improve prognosis in women without hot?ashes when enrolled in the study,and who were therefore likely to have higher circulating estrogen concentrations,128suggesting that there may be survival bene?ts for this subgroup.
TABLE4.Examples of Moderate and Vigorous Activities118
MODERATE ACTIVITIES(I CAN TALK WHILE I DO THEM,BUT I CAN’T SING)VIGOROUS ACTIVITIES(I CAN ONLY SAY A FEW WORDS WITHOUT STOPPING TO CATCH MY BREATH)
l Ballroom and line dancing
l Biking on level ground or with few hills
l Canoeing
l General gardening(raking,trimming shrubs)
l Sports where you catch and throw(baseball,softball,volleyball) l Tennis(doubles)
l Using your manual wheelchair
l Using hand cyclers(also called ergometers)
l Walking briskly
l Water aerobics l Aerobic dance
l Biking faster than10miles per hour
l Fast dancing
l Heavy gardening(digging,hoeing)
l Hiking uphill
l Jumping rope
l Martial arts(such as karate)
l Race walking,jogging,or running
l Sports with a lot of running(basketball,hockey,soccer)
l Swimming fast or swimming laps
l Tennis(singles)
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A few observational follow-up studies of diet and survival after the diagnosis of prostate cancer have also been reported. In one of these studies,a higher saturated fat intake predicted shorter disease-speci?c survival and in another,greater monounsaturated fat intake predicted longer survival.129,130 Given that men with prostate cancer are at a signi?cant risk of death due to cardiovascular disease,these heart-healthy recommendations appear prudent not only for cancer prevention but also for competing causes of death.
Some studies have suggested that omega-3fatty acids may have speci?c bene?ts for cancer survivors,such as ameliorat-ing cachexia,improving quality of life,and perhaps enhancing the effects of some forms of treatment.131,132These?ndings are not entirely consistent,however,and more research is needed.133Regardless,including foods that are rich in omega-3fatty acids(eg,?sh,walnuts)in the diet should be encouraged,because this is associated with a lower risk of cardiovascular diseases and a lower overall mortality rate.46,49 Adequate protein intake is essential during all stages of cancer treatment,recovery,long-term survival,and living with advanced disease.The best choices to meet protein needs are foods that are also low in saturated fat(eg,?sh, lean meat,skinless poultry,eggs,nonfat and low-fat dairy products,nuts,seeds,and legumes).
Vegetarian diets can be healthy or unhealthy,depending on one’s food choices.Vegetarian diets differ with respect to the inclusion of dairy foods,?sh,and/or eggs,but avoiding red meat is a universal feature.Fish,dairy foods,or both contain a suf?cient quantity and quality of protein,and a vegetarian diet that contains these foods typically has a nu-trient content similar to an omnivorous diet.A vegan diet, which excludes all animal foods and animal products,can meet protein needs if nuts,seeds,legumes,and cereal-grain products are consumed in suf?cient quantities,although supplemental vitamin B12will be necessary to meet needs for that vitamin.As dietary vitamin D in the United States comes primarily from forti?ed dairy foods,a vegan diet may also need to include supplemental vitamin D if adequate ex-posure to the sun or ultraviolet light is not obtained.No direct evidence has helped to determine whether consuming a vegetarian diet has any additional bene?t for the prevention of cancer recurrence over an omnivorous diet high in vegeta-bles,fruits,and whole grains,and low in red meats. Healthy carbohydrate sources are foods that are rich in essential nutrients,phytochemicals,and?ber,such as vegetables,fruits,whole grains,and legumes.These foods should provide the majority of carbohydrate in the diet. Whole grains are rich in a variety of compounds(in addition to?ber)that have important biologic activity,including hormonal and antioxidant effects.For example,whole grains contain antioxidants,such as phenolic acids,?avo-noids,and tocopherols;compounds with weak hormonal effects such as lignans;and compounds that may in?uence lipid metabolism,such as phytosterols and unsaturated fatty acids.All of these compounds and their biologic effects have been hypothesized to reduce the risk and progression of cancer as well as cardiovascular disease.134Choosing whole grains and whole-grain food products as a source of?ber,rather than relying on?ber supplements,adds nutritional value to the diet. Re?ned grains have been milled,a process that removes the bran and germ.This results in levels of vitamins,minerals,and ?ber that are lower than those in the unre?ned,whole-grain counterpart.Examples of re?ned grain products include white ?our,degermed cornmeal,white bread,and white rice.In the United States,most re?ned grain products have been enriched,which means that micronutrients such as thiamin, ribo?avin,niacin,iron,and folate have been added back to the product after processing.Thus,they are not completely without nutritional value,but many of the potentially helpful constituents,such as?ber and biologically active phytochemicals,have not been added back.
High sugar intake has not been shown to increase the risk or progression of cancer.However,sugars(including honey, raw sugar,brown sugar,high-fructose corn syrup,and molasses)and beverages that are major sources of these sugars (such as soft drinks and many fruit-?avored drinks)add substantial amounts of calories to the diet and thus can promote weight gain.In addition,most foods that are high in added sugar do not contribute many nutrients to the diet and often replace more nutritious food choices.Therefore,limiting the consumption of products with added sugar is recommended. Vegetables and fruits contain numerous dietary constituents that potentially inhibit cancer progression,such as essential vitamins and minerals,biologically active phytochemicals,and ?ber.In addition,these are low–energy-dense foods that promote satiety,and thus may promote healthy weight management.135Whole fruit(instead of juice)adds more?ber and fewer calories to the diet.When fruit juice is chosen, 100%fruit juice is the best choice.
As noted above,results from more recent studies suggest that a dietary pattern that is rich in vegetables and fruits is associated with increased overall survival following cancer diagnosis and treatment.120In addition to being rich in vegetables and fruits,this dietary pattern is characterized as having more?sh and poultry rather than red meat and processed meat,low-fat rather than full-fat dairy products, whole grains rather than re?ned grain products,and tree nuts and olive oil rather than other sources of fat.A study of colon cancer survivors found that a Western diet charac-terized by high intakes of meat and added sugars,was associated not only with poorer cancer-speci?c survival,but a reduced likelihood of overall survival as well.123
In the observational studies that have examined the relationship between intakes of vegetables and fruits(or nutrients indicative of those foods)and the risk of breast
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cancer recurrence,the?ndings have been mixed.136The WHEL Study tested the effect of a diet very high in vegetables,fruits,and?ber on the risk of recurrence and overall survival in early stage breast cancer survivors who reported a high average intake of vegetables and fruits(7.3 servings/ay)at enrollment.At6years,the intervention group had increased to an average of9.2servings per day, whereas the control group averaged6.2servings per day, yet recurrence-free survival did not differ between the2 study arms.122However,serum estrogen levels at baseline were independently associated with poor prognosis,and a protective effect of the diet was observed in the subgroup of women who did not report hot?ashes at enrollment(an indication of higher estrogen levels).128These?ndings suggest that reproductive hormonal status may determine whether a diet high in vegetables,fruits,and?ber affects prognosis.In addition,longitudinal exposure to carotenoids was associated with breast cancer-free survival regardless of study group assignment.137Thus,diet prior to the diagnosis of cancer and over the long term may be more important than short-term dietary changes postdiagnosis.
A few studies have evaluated the association between diet and ovarian cancer survival.138A higher prediagnosis intake of vegetables,especially yellow and cruciferous vegetables,was associated with longer survival in these studies.139,140A single observational study of diet after diagnosis and risk of prostate cancer progression found those men who consumed more tomato sauce had longer survival.141The bene?ts of eating a variety of vegetables and fruits probably exceed the health-promoting effects of any individual constituents in these foods because the various vitamins,minerals,and other phytochemicals in these whole foods act in synergy.Current public health recommendations for adults are to eat at least 2to3cups of vegetables and1.5to2cups of fruits each day. Colorful choices such as dark green and orange vegetables are good sources of nutrients and potentially healthful phytochemicals.Fresh,frozen,canned,raw,cooked,or dried vegetables and fruits all contribute nutrients and other biologically active constituents to the diet.Cooking vegetables and fruits,especially with methods such as microwaving or steaming in preference to boiling in large amounts of water,preserves the bioavailability of water-soluble nutrients and can improve the absorption of others.For example, carotenoids are better absorbed from cooked vegetables than from raw vegetables.There is no evidence that organically grown vegetables and fruits are superior in their content of potential cancer-preventive constituents.
Dietary Supplements
According to the Dietary Supplement Health and Education Act(DSHEA)of1994,dietary supplements include vitamins; minerals;herbs/botanicals;amino acids;and a concentrate, metabolite,constituent extract,or combination of any of the aforementioned.Dietary supplement use is reported by 52%of US adults142and studies report ranges between64%
and81%among cancer survivors.98,143A recent systematic review indicates that14%to32%of cancer survivors initiate supplement use after their diagnosis.143Breast cancer survi-vors report the highest prevalence of supplement use,whereas prostate cancer survivors report the lowest.143Cancer survi-vors use supplements for a variety of reasons,including following the advice of health care providers or others,treat-
ing a symptom,to feel better,and/or as general insurance of adequate nutrient intake.144,145
Evidence from both observational studies and clinical trials suggests that dietary supplements are unlikely to improve prognosis or overall survival after the diagnosis of cancer,and may actually increase mortality.A2006meta-analysis found no association between antioxidant or vitamin A supplementation and all-cause mortality among cancer patients,although the authors noted that this report
was limited by the small number of trials,particularly those
of high quality.146The use of multivitamins or vitamins E
or C was not associated with protection from cancer death
in a cohort of77,719Washington state residents followed over a10-year period.147In2large observational studies,
the use of a full range of dietary supplements or multivita-mins in particular was not associated with breast cancer recurrence,breast cancer-speci?c mortality,or overall mortality among women diagnosed with early stage breast cancer.148,149A similar?nding was reported for multivita-
min use among colorectal cancer survivors.150In addition,
one trial suggests that beta-carotene supplements may increase the rate of colorectal adenoma recurrence in per-sons who smoke cigarettes,consume alcohol,or both.151A randomized clinical trial of540head and neck cancer patients receiving radiation therapy in which participants were randomized to either400IU/day of vitamin E or placebo found that supplement use was associated with sig-
ni?cantly higher cause-speci?c and all-cause mortality.152
In addition,the recent Selenium and Vitamin E Cancer Prevention Trial(SELECT)found that men who were assigned supplemental selenium or vitamin E had a higher incidence of diabetes and prostate cancer,respectively.153
Some observational studies have reported that breast cancer survivors have high rates of vitamin D insuf-
?ciency,154suggesting the need for vitamin D supplemen-tation.Although supplemental vitamin D may help to meet nutritional needs for this vitamin,circulating concentra-tions have not been shown to affect the risk of breast cancer recurrence.155Two observational studies have found that a higher circulating prediagnosis vitamin D or higher post-diagnosis vitamin D level is associated with signi?cant improvements in overall and/or colorectal cancer-speci?c mortality among colorectal cancer survivors.156,157A recent review,however,suggests that taking vitamin D
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supplements has not been proven to improve outcomes in cancer patients.158These?ndings underscore the need to ?rst assess whether nutrient status is indeed de?cient before initiating supplements,since individuals who are truly de?cient may derive some bene?t,whereas those who take additional supplements but who are already well-nourished are unlikely to bene?t and may incur harm.
Although the use of standard multiple vitamin and mineral supplements has previously been recommended during and after treatment as an‘‘insurance policy’’for obtaining adequate amounts of nutrients,this practice has recently come under scrutiny as more recent data suggest that multivitamin supplements may actually increase the risk of mortality among healthy individuals or,at the very least,may not be helpful.150,159-162The current body of evidence regarding supplement use by cancer survivors suggests that some general guidance should be considered:?Before supplements are prescribed or taken,all attempts should be made to obtain needed nutrients through dietary sources.
?Supplements should be considered only if a nutrient de?ciency is either biochemically(eg,low plasma vitamin D levels,B12de?ciency)or clinically(eg,low bone density)demonstrated.
?Supplements should be considered if nutrient intakes fall persistently below two-thirds of the recommended intake levels.Such a determination should be made by a registered dietitian,who is most quali?ed to assess the nutrient adequacy of the diet,especially in view of emerging data suggesting that higher nutrient intakes, especially through sources other than foods,may be harmful rather than helpful.
Open dialogue between patients and health care providers should occur regarding dietary supplementation to ensure there is no contraindication in relation to the prescribed cancer therapy or for longer term health effects.163,164In turn,health care providers should make an effort not only to provide time to review dietary supplement decisions with patients,but also to stay abreast of recent research in this area,particularly that related to potential drug interactions. It is most prudent to encourage cancer survivors to obtain the potentially bene?cial compounds from food.
Alcohol
Substantial observational evidence indicates that alcohol intake has both positive and negative health effects.47,165-167 Alcoholic drinks up to one or2drinks per day(for women and men,respectively)can lower the risk of heart disease, but higher levels do not offer additional bene?t and may increase the risk not only of complications of alcohol overuse,but also of speci?c cancers.168For this reason,it is important for the health care provider to tailor advice on alcohol consumption to the individual cancer survivor.The cancer type and stage of disease,treatment,treatment-related side effects,risk factors for recurrence or new primary cancers,and comorbid conditions should be considered in making recommendations.Many health care professionals ask individuals receiving chemotherapy or biological therapy to avoid alcohol consumption during treatment.This advice is also often given if receiving radiation therapy to the head, neck,or thoracic region.For example,during the time of active treatment,alcohol,even in the small amounts found in mouthwashes,can be irritating to survivors with oral mucositis and can exacerbate that condition.Therefore,it is reasonable to recommend that alcohol intake should be avoided or limited among survivors with mucositis and among those beginning head and neck radiation therapy or chemotherapeutic regimens that put them at risk for mucositis.Among cancer survivors,the prevalence of alcohol use generally mirrors that in the general population,although among some survivor groups(ie,survivors of prostate and head and neck cancers)it is higher.169
The link between alcohol intake and risk of some primary cancers has been established,including cancers of the mouth,pharynx,larynx,esophagus,liver,and breast and, for some forms of alcohol beverages,colon cancer.47,165,170 In individuals who have already received a diagnosis of cancer,alcohol intake could also increase their risk of new primary cancers of these sites171;moreover,a long-standing literature in patients with head and neck cancer suggests that continued alcohol consumption(as well as smoking) leads to lower survival rates,thus supporting the need to limit alcohol consumption in this population.168,172In breast cancer,the relationship with alcohol intake after diagnosis is less clear,although there is irrefutable evidence that alcohol intake is linearly associated with primary risk.52 Alcohol intake can increase the circulating levels of estrogens,which theoretically could increase the risk of recurrence of breast cancer.To date,a few studies have explored outcomes of breast cancer survivors by alcohol intake. The results are mixed,with some studies173-175suggesting that alcohol confers a protective effect on overall survival and subsequent ovarian cancer,and others176,177?nding an increased risk of contralateral disease and disease-speci?c and overall mortality.
Food Safety
Food safety is of special concern for cancer survivors, especially during episodes of treatment-related immuno-suppression that can occur with certain cancer treatment regimens.178Survivors can become susceptible to developing infections due to treatment-induced leukopenia and neutropenia.During any immunosuppressive cancer treat-ment,survivors should take extra precautions to prevent infection,and they should be particularly careful to avoid
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eating foods that may contain unsafe levels of pathogenic microorganisms.By following safe food practices,cancer survivors and their caregivers can reduce the risk of foodborne illness.General guidelines for food safety,as shown in Table5,should be followed.
Nutrition and Physical Activity Issues
by Selected Cancer Sites
Breast Cancer
For a woman diagnosed with breast cancer,achieving or maintaining a desirable weight may be one of the most important lifestyle pursuits.The majority of studies conducted over several decades indicate that overweight or obesity at the time of diagnosis is a poor prognostic factor and may be associated with less favorable lymph node status,as well as a variety of undesirable outcomes(eg, contralateral disease,recurrence,comorbid disease,and/or disease-speci?c or overall mortality,as well as treatment effects such as lymphedema).8,54,87,179-186Given that over-weight and obesity are well-established risk factors for worse prognosis,and many women are overweight when diagnosed with breast cancer,weight management is a concern for a substantial percentage of breast cancer survi-vors.A compounding problem is the fact that additional weight gain is frequently reported after diagnosis.187-189 Analyses conducted on a cohort of nonsmoking breast can-cer survivors within the Nurses’Health Study corroborated these?ndings.Women who increased their BMI by0.5to 2units were found to have a40%greater chance of recur-rence,and those who gained more than2BMI units had a 53%greater chance of recurrence compared with those who did not gain more than0.5BMI units.86In that study, survivors in whom weight decreased did not experience signi?cantly poorer outcomes.However,other recent studies have not found an effect of weight gain on prognosis.190 Although it must be considered that unexplained weight loss may be a symptom of recurrent disease and should be monitored closely,191there is a vast difference between weight loss that is intentional or purposeful versus that which is unexplained or a consequence of disease.Indeed, given accumulating data to suggest that overweight and obesity adversely in?uence not only cancer-speci?c out-comes but also overall health and quality of life,weight management is now considered a priority standard of care for overweight women diagnosed with early stage breast cancer.8,192A decade of previous research,193-196as well as more recent studies,also suggests that the weight gain experienced by women who have been treated with adju-vant chemotherapy or hormonal treatment seems to be the result of increased adipose tissue mass,with no change or a decrease in lean body mass.82,189,197,198This unfavorable shift in body composition suggests that interventions should be aimed at not only curbing weight gain during treatment but also at preserving or rebuilding muscle mass. Moderate physical activity(especially resistance training) during and after treatment may help survivors maintain lean muscle mass while avoiding excess body fat.188,199 Even if an ideal weight is not achieved,it has been estab-lished in the general population that a weight loss of5%to 10%over6to12months is suf?cient to reduce the levels of factors associated with chronic disease risk,such as elevated plasma lipids and fasting insulin levels.90Furthermore,a recent review of the scienti?c literature documented that intentional weight loss promotes favorable changes in breast cancer-relevant biomarkers,such as estrogens,sex hormone-binding globulin,and in?ammatory markers.200 There is substantial research on physical activity in breast cancer survivors and multiple systematic reviews focused on its role in these individuals.62,201In a meta-analysis of717 breast cancer survivors participating in14randomized controlled trials,physical activity led to statistically signi?-cant improvements in quality of life,physical functioning, and peak oxygen consumption,as well as a reduction in symptoms of fatigue.201Another meta-analysis of6prospec-tive cohort studies that included over12,000breast cancer survivors showed that postdiagnosis physical activity was associated with a24%and34%lower rate of breast cancer recurrence and mortality,respectively,and a41%lower rate of all-cause mortality.Despite these promising?ndings,
TABLE5.General Guidelines for Food Safety
l Wash hands with soap and water thoroughly before eating.
l Keep all aspects of food preparation clean,including washing hands before food preparation and washing fruits and vegetables thoroughly.
l Use special care in handling raw meats,fish,poultry,and eggs.
l Thoroughly clean all utensils,countertops,cutting boards,and sponges that have contact with raw meat;keep raw meats and ready-to-eat foods separate.
l Cook to proper temperatures;meats,poultry,and seafood should be thoroughly cooked and beverages(milk and juices)should be pasteurized.
Use a food thermometer to check internal temperatures of meats before serving.
l Store foods promptly at low temperatures(below40 F)to minimize bacterial growth.
l When eating in restaurants,avoid foods that may have potential bacterial contamination such as items from salad bars;sushi;or raw or undercooked meat, fish,shellfish,poultry,and eggs.
l Avoid raw honey,milk,and unpasteurized fruit juice,and choose pasteurized versions instead.
l If there is any question or concern about water purity(eg,well water),it can be checked for bacterial content by contacting your local public
health department.
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there remains a need for a randomized controlled trial to fur-ther test the bene?t of exercising in preventing cancer recur-rence and improving survival in women with breast cancer.62 Even with the increased use of sentinel lymph node dissection,lymphedema remains a concern among breast cancer survivors.However,aerobic physical activity and resistance training appear to be both safe and effective in reducing the incidence of lymphedema among survivors at high risk of this condition,and in improving the symptoms and severity of lymphedema for those in whom the condition was preexisting.111,112Progressive resistance training under the supervision of a trained exercise therapist and using appropriate compression garments is recommended.In addi-tion,because obesity is a major risk factor for lymphedema, weight loss is recommended among survivors who are overweight or obese.
Research is currently under way to evaluate various components of dietary patterns on cancer-speci?c outcomes, as well as overall health.An observational study found that dietary pattern was important for overall survival among breast cancer survivors,with those who ate a Western diet having poorer overall survival and those who ate a dietary pattern characterized by high amounts of fruits,vegetables, and whole grains having better overall survival;however, neither dietary pattern was associated with breast cancer recurrence speci?cally.120One factor that tends to separate these2dietary patterns is fat;however,to date,evidence that dietary fat intake could be associated with risk of recurrence or survival is not strongly or consistently supported,especially when total energy intake and the degree of obesity are considered.202,203
Two large clinical trials tested whether change in diet composition can reduce the risk of recurrence and increase overall survival in women who have been diagnosed with breast cancer.While the WINS low-fat dietary interven-tion group exhibited a borderline signi?cant24%reduction in risk of recurrence,the group also lost weight,so it is possible that the bene?ts were due to weight loss and not a reduction in fat intake.In the WHEL Study,a reduction in dietary fat was among the dietary goals,and an effect of the diet intervention(which was not associated with weight loss)was not observed.
Eating more vegetables is inconsistently related to reducing breast cancer risk,and the evidence that fruit intake is related to recurrence or survival is weak.204,205In the WHEL Study, the major intervention was increased vegetable and fruit intake,although women in the intervention group were also encouraged to reduce their fat and increase their?ber intakes.206Recurrence-free survival did not differ between the2study arms in that study,122although the fruit and vegetable intake of these women was already high,averaging greater than7servings per day at the beginning of the study.The WHEL Study intervention did improve prognosis in women without hot?ashes when enrolled in the study,128 suggesting that there may be survival bene?ts among women with higher circulating estrogen levels.Also,longitudinal exposure to carotenoids(a biologic marker of intake of deeply colored vegetables and fruits)was found to be associ-ated with longer recurrence-free survival,regardless of study group,suggesting that vegetable and fruit intake prior to the diagnosis of breast cancer may improve prognosis.137 Vegetables can reduce the total energy density in the diet, and both vegetables and?ber are associated with improved satiety.Data on breast cancer survivors participating in the Nurses’Health Study,who were followed for a mean period of nearly10years postdiagnosis,suggest that those who consume a healthy diet,with higher intakes of fruits, vegetables,and whole grains and lower intakes of added sugar,re?ned grains,and animal products,may not have had signi?cantly lower rates of recurrence or cancer-speci?c mortality,although women who report this eating pattern have signi?cantly lower rates of mortality from other diseases,such as heart disease,when compared with those who eat typical Western diets.120
Soy foods and?axseed are both rich sources of phytoestro-gens,biologically active compounds called iso?avones that can exhibit both antiestrogenic and estrogen-like properties. High circulating estrogen levels are a documented risk factor for breast cancer recurrence.207Because soy iso?avones have been shown to promote in vitro growth of breast cancer cells and mammary tumor growth in laboratory animals,there has been some concern about the potential adverse effect of soy consumption on prognosis in women who have been diag-nosed with breast cancer.However,3large epidemiological studies in the recent past have found no adverse effects of soy food intake on breast cancer recurrence or total mortality either alone or in combination with tamoxifen,and there is the potential for these foods to exert a positive synergistic effect with tamoxifen.208-210Two of these studies were focused on US samples and included iso?avone supplements in the data collection and analysis.Current evidence does not suggest that consuming soy foods is likely to have adverse effects on risk of recurrence or survival.Iso?avone supple-ment use was uncommon in the populations in these recent cohort studies,and therefore the evidence relating to the effects of these supplements is more limited.
Alcohol intake has been linked with an increase in the risk of primary breast cancer170;however,among cancer survivors,associations have been mixed,with protective effects found between alcohol intake and risk of subsequent ovarian cancer in one study,174increased risk of contralat-eral disease and recurrence and death found in2other studies,176,177and one study that showed neither risk nor protection for breast cancer recurrence with low to
Nutrition and Physical Activity Guidelines for Cancer Survivors 256CA:A Cancer Journal for Clinicians
moderate alcohol intake.175The discrepancy noted with regard to alcohol and overall survival may be due in part to the fact that alcohol intake is associated with a reduced risk of cardiovascular disease,a common comorbidity among breast cancer survivors,and also is usually inversely associ-ated with obesity.Theoretically,however,alcohol intake could affect the risk of a second primary breast cancer,for which all breast cancer survivors are at increased risk.Alco-hol is an unusual factor,however,because it presents both risks and bene?ts.In the general population,clear and con-sistent evidence links moderate alcohol intake(1-2drinks per day)with a lower risk of cardiovascular disease.166For breast cancer survivors,the decision to drink alcoholic beverages at moderate levels is complex because they must consider their levels of risk for recurrent or second primary breast cancer as well as cardiovascular disease.
It is important to remember that nutrition and physical activity recommendations to reduce the risks of a second primary breast cancer and heart disease are especially important for breast cancer survivors.49,52,211,212Diets should emphasize vegetables and fruits,have low amounts of saturated fats,and include suf?cient dietary?ber.124 Most importantly,breast cancer survivors should strive to achieve and maintain a healthy weight through eating a well-balanced diet and regular exercise.136In addition, regular physical activity should be maintained regardless of any weight concerns.
Colorectal Cancer
Epidemiologic,clinical,and laboratory research indicates that diet,adiposity,and physical activity have a signi?cant in?uence on the risk of developing colorectal cancer.213,214 Over the past decade,there has been an increasing number of studies that have examined the in?uence of these modi?-able host factors on physical well-being,quality of life,and cancer recurrences and survival.78
Several observational studies have shown that higher physical activity levels or meeting physical activity guidelines is associated with better patient-reported quality of life, physical functioning,and fatigue.215-220One randomized trial of an exercise intervention in colorectal cancer survivors demonstrated that participants whose aerobic?tness increased over the course of the intervention,regardless of group assignment,reported signi?cantly improved quality of life,physical functioning,and psychosocial distress compared with participants whose?tness decreased.221 Recently emerging,prospective,observational data have shown that colorectal cancer survivors who are physically active lower their risk of cancer recurrence,colorectal cancer-speci?c mortality,and/or overall mortality.104-107,222 These data have led to the initiation of the C olon H ealth a nd L ife-L ong E xercise Cha nge(CHALLENGE)trial,a randomized,controlled,multinational collaboration between Canada and Australia to determine the effects of a
3-year structured physical activity intervention on disease outcomes in survivors of high-risk stage II and III colon cancer who have completed adjuvant chemotherapy within
the previous2to6months.108
The impact of obesity on outcomes in colorectal cancer survival has been less certain.89,223-225Most prospective observational cohort studies have used a single measure-ment of weight and height at the time of diagnosis and have primarily demonstrated that only class II and III obesity(BMI 35mg/m2)may modestly worsen outcomes (approximately20%worse disease-free survival).89,225A recent study from the ACS Cancer Prevention Study II Nutrition Cohort reported that an obese BMI before the diagnosis of colorectal cancer(mean,7years prior to diagnosis)was associated with higher risks of death from
all causes,colorectal cancer-speci?c causes,and cardio-vascular disease,while the BMI reported after a diagnosis
of colorectal cancer was not associated with any of the mortality outcomes.226
Although diet has been extensively studied as a risk fac-
tor for developing colorectal cancer,there are very limited data concerning diet in colorectal cancer survivors as related
to survival outcomes.The largest prospective study to date included survivors of stage III colon cancer and demon-strated that a Western dietary pattern,resulted in a worse disease-free and overall survival.123In contrast,a diet characterized by high intakes of fruits and vegetables,poul-try,and?sh was not signi?cantly associated with cancer recurrence or mortality.Vitamin D status has been shown fairly consistently to in?uence the risk of developing colorectal cancer.227Emerging data suggest that vitamin D status may in?uence outcomes in colorectal cancer survivors
as well and this is an active area of research as both a secondary preventive and treatment strategy in colorectal cancer.156,157
Because most colorectal cancers arise from adenomatous polyps,the prevention of polyp recurrence has also been a focus of considerable clinical research.To date,trials have failed to show bene?ts in preventing new polyp growth during a3-year or4-year period from antioxidant vitamins,
?ber supplements,or modest dietary changes to increase
fruit and vegetable intake.228Folate has not been shown to reduce polyp recurrence in clinical trials229,230and was associated with an increased risk of having multiple adenomas.230Calcium supplements,however,provided a modest bene?t in preventing polyp recurrence.231
Colorectal cancer survivors should be advised to maintain
a healthy weight,participate in regular physical activity,
and eat a well-balanced diet consistent with guidelines for cancer and heart disease prevention.Colorectal cancer survivors with chronic bowel problems or surgery that
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affects normal nutrient absorption should be referred to a registered dietitian to modify their diets to accommodate these changes and maintain optimal health. Endometrial Cancer
Endometrial cancer is the most common gynecologic cancer and the fourth most common cancer in women.4The prognosis of endometrial cancer is related to the stage of disease at diagnosis,with a90%survival rate if diagnosed at stage I,232which is common because the main symptom, abnormal bleeding,is easy to detect and likely to cause women to seek medical attention.
Obesity is a strong risk factor for the development of endometrial cancer.Approximately70%to90%of women with type1endometrial cancer(the most common type)are obese.233However,there are few studies of the role of obesity in endometrial cancer prognosis.Prediagnosis obesity has been shown to be associated with a signi?cant increase in endometrial cancer mortality.234This may be related to common comorbidities among obese women, such as type2diabetes and hypertension,which may complicate cancer treatment.76In a study using data from participants in a Gynecologic Oncology Group trial of early stage endometrial cancer,obesity was associated with higher mortality from causes other than endometrial cancer but not with recurrence.235Obese women tend to develop less aggressive endometrial cancer236-238;however,decreased overall survival among obese endometrial cancer patients has been seen in some studies,235,239but not in others.236-238 No studies have reported on the role of dietary factors and physical activity in the prognosis of endometrial cancer.Although the role of obesity in endometrial cancer prognosis is not completely understood,studies have shown that a higher BMI and a sedentary lifestyle are associated with a poorer quality of life among endometrial cancer survivors.233,240,241
Ovarian Cancer
Ovarian cancer is the leading cause of death from gynecologic malignancies in the United States.4Symptoms tend be nonspeci?c,making early detection dif?cult.Consequently, most ovarian cancers are diagnosed at an advanced stage when the prognosis is poor,with an overall10-year survival rate of39%.4The role of lifestyle factors in ovarian cancer prognosis is largely unknown.138,242To our knowledge,only 3studies139,140,243have evaluated the role of dietary factors in ovarian cancer survival.These3studies were based on pro-spective follow-up of the cases participating in case-control studies and evaluated the association between prediagnosis dietary intake and mortality outcomes.One study,conducted in China,focused on the role of green tea and reported that a higher frequency and quantity of green tea intake after diagnosis was associated with better survival.243The other2 studies,conducted in Australia140and the United States,139 suggested that prediagnosis dietary intake may in?uence the survival experience of patients with ovarian cancer.Both studies tended to support the association of fruit and vegetable consumption with better survival.Dairy food intake was associated with poorer survival in one of the studies,140while in the other,only milk consumption and not total dairy food consumption was inversely associated with survival.139Meat consumption was associated with better survival in the Australian study,140and with lower survival in the study conducted in the United States.139 While these studies controlled for most relevant covariates, they did not include treatment information.In addition, these studies did not evaluate dietary intake after diagnosis. However,they do suggest that dietary intake may in?uence ovarian cancer survival and warrant further research in this area.
Only one study,also following cases in a case-control study for mortality,has evaluated the role of physical activity in ovarian cancer survival.244Prediagnosis physical activity was ascertained as hours per week for3life periods(childhood,between ages18-30years,and in recent years).The study also evaluated the role of changes in phys-ical activity over time.There was not much indication of an association with survival for any of these variables,except for physical activity at aged18to30years,which seemed to be associated with better survival for women with early stage ovarian cancer and with worse survival for women with an advanced stage of disease at diagnosis.245
The relationship between excess weight and ovarian cancer survival has been evaluated by relatively few studies. Obesity may affect ovarian cancer survival by having a neg-ative impact on optimal surgical and cytotoxic treatment and increasing the likelihood of postoperative complica-tions.246Overall,the literature evaluating the association between weight/BMI and ovarian cancer survival is limited and inconclusive.76,242Cohort studies evaluating the role of prediagnosis obesity obtained at baseline on ovarian cancer mortality have generally found elevated ovarian cancer mortality among obese women.234,247Other studies evaluating the role of prediagnosis BMI on ovarian cancer survival by following cases in a case-control study or clinical trial(using baseline data)have offered con?icting results.242 The role of postdiagnosis body size and weight changes on ovarian cancer survival is largely unknown.Only one study has reported on weight changes during chemotherapy and ovarian cancer survival and found that,among patients with advanced ovarian cancer,weight loss during chemotherapy was associated with worse prognosis;however,it is dif?cult to determine whether this weight loss was involuntary or intentional.248
Nutrition and Physical Activity Guidelines for Cancer Survivors 258CA:A Cancer Journal for Clinicians
In summary,while the current evidence is limited and inconclusive,it points to a possible role of dietary factors, physical activity,and body size and weight changes in modulating ovarian cancer survival,and for physical activity in improving the quality of life among ovarian cancer survivors.Further studies are needed before public health recommendations can be made.
Hematologic Cancers and Cancers Treated With Hematopoietic Stem Cell Transplantation
A possible relationship between dietary factors and outcomes of hematologic cancers has been examined in only a few studies to date.
Overweight or obesity appears to adversely affect prognosis for patients who undergo hematopoietic stem cell transplan-tation,although the evidence is limited.In a study that focused on clinical data from patients who underwent autologous stem cell transplantation,obesity had signi?cant adverse effects on treatment-related toxicity and mortality, overall survival,and disease-free survival.249 Observational research has shown that the physical activity levels of survivors of hematological cancer are low, with deleterious health consequences.Multiple interven-tion studies have tested the bene?t of exercise in both adult and pediatric survivors of hematological cancer.30,250,251 Systematic reviews of adult interventions have reported that physical activity can improve body composition, cardiorespiratory?tness,fatigue,muscle strength,physical functioning,and quality of life.250
The conditioning regimen of intensive chemotherapy, often in conjunction with total body irradiation,is associ-ated with several speci?c side effects that have signi?cant adverse nutritional consequences such as nausea,vomiting, diarrhea,oropharyngeal mucositis,and esophagitis.Total body irradiation damages the gastrointestinal mucosa,result-ing in malabsorption and diarrhea because these epithelial cells are highly susceptible to the effects of radiation. Nutritional problems also result from adverse effects of vari-ous drug therapies,such as oral immunosuppressive agents and antibiotics that may be necessary for posttransplant management.Finally,the common complication of graft versus host disease(in patients who receive an allogeneic transplant)results in abdominal pain,nausea,severe diarrhea, malabsorption,and substantial nitrogen losses.Patients who do not receive specialized nutritional support typically eat poorly for a prolonged period and are at high risk of poor nutritional status.252-254
As an infection prevention strategy,low-microbial diets are often prescribed for transplant recipients.A low-microbial or low-bacteria diet is primarily a cooked-food diet,because the major limitation imposed is on fresh or uncooked food items.255Because many food restrictions are imposed with this strategy,the nutrient adequacy of the actual food intake
of patients who are prescribed the low-microbial diet should
be monitored.Prevention of malnutrition and correction of energy and nutrient inadequacies has been incorporated into
the standardized posttransplant treatment at most transplant centers.In a recent review of the evidence regarding the relative effectiveness of enteral nutrition versus parenteral nutrition support,the issue could not be evaluated due to a
lack of evaluable data.256Recent trends include prescribing
less parenteral nutrition support and more enteral nutrition support,255which could reduce the risk of medical complications
and control costs.
Lung Cancer
Lung cancer treatment is often aggressive and causes adverse effects.Furthermore,many lung cancer survivors
are underweight and have low blood nutrient levels even before diagnosis as a result of the adverse effects of inadequate diets,smoking,or both on micronutrient status. During treatment and the immediate recovery period,lung cancer survivors may bene?t from eating foods that are energy-dense and easy to swallow.Small,frequent meals may be easier to manage than3large meals per day. Medications and nutritional support via energy-dense nutri-tional supplements or enteral nutrition may be helpful for those experiencing weight loss.257If nutrient de?ciencies are present or survivors cannot eat enough to adequately meet micronutrient needs,a multivitamin-mineral supplement is advisable,either in pill or liquid form.
Patients with lung cancer present with a complex variety
of symptoms that can limit physical function and lead to distress,including dyspnea,air hunger,anxiety,muscle weakness,fatigue,and limited cardiopulmonary function. Despite these issues,there have been several clinical trials
that have successfully demonstrated the feasibility of exercise interventions in select lung cancer patients.A recent systematic review of16studies inclusive of675lung cancer patients demonstrated that patients participating in
an exercise intervention prior to surgery reported improve-ments in exercise capacity but no change in health-related quality of life immediately after the intervention.258 Furthermore,other studies of exercise following standard lung cancer treatment demonstrated improvements in exercise capacity but had con?icting results with respect to
the impact on quality of life.More research is needed in
this cancer patient population.
The possible effect(either bene?cial or harmful)of nutritional supplements other than beta-carotene after the diagnosis of lung cancer has not been extensively studied. One clinical trial of selenium and skin cancer noted a reduced incidence of lung cancer in association with selenium supplementation.259While some researchers have
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found that individuals with early stage lung cancer who have better vitamin D status have improved survival,260 these?ndings need replication.
Few studies have examined the relation between dietary factors and lung cancer prognosis.Two small studies sought to determine whether dietary intervention with selected vegetables improved survival among those with advanced lung cancer.261,262Weight loss was less and survival was longer in the intervention groups in those studies,but these preliminary?ndings need to be con?rmed by larger studies. Three randomized clinical trials that included lung cancer survivors,among others,encouraged participants to increase their energy intake.263-265Although successful in increasing energy intake,none of the strategies used within these studies prevented weight loss. Recommendations for nutrition and physical activity for individuals who are living with lung cancer are best made based on individual needs.Striving toward a healthy weight by adjusting food intake and physical activity is a reasonable goal,as is ensuring that nutritional needs are met with a nutritious diet and a multivitamin-mineral supplement,if needed,to achieve adequate levels of intake.
Prostate Cancer
Most research on nutrition and prostate cancer has focused on prostate cancer incidence.266,267Because asymptomatic prostate cancer is very common in older men,the same lifestyle factors that are associated with a reduced prostate cancer incidence might also reduce the rate of prostate can-cer growth after diagnosis,thus preventing or slowing the progression of early stage prostate cancer.However,notable exceptions are body weight and obesity,which appear to be related to cancer progression and the more aggressive forms of prostate cancer,and not the latent or indolent disease that appears to be an artifact of aging.268In recent years,a few studies have tried to determine directly whether such dietary factors may prolong survival from prostate cancer or may in?uence biomarkers(eg,prostate-speci?c antigen[PSA]levels)that are associated with outcomes for men with prostate cancer.
A high intake of foods from animal sources,especially foods high in saturated fat,has been associated with an increased risk of prostate cancer.203,266Whether this increased risk is due to saturated fat per se or to the con-sumption of red meat and high-fat dairy products is unclear.The observation that fatty?sh intake may decrease prostate cancer mortality rates suggests that,if fat is important,the type of fat may play a key role.There are2 follow-up studies of dietary factors and survival in prostate cancer survivors.One found that saturated fat intake(but not total fat)is associated with worse survival,269and the other found that monounsaturated fat intake is associated with better survival.129Based on what we currently know and on the role of saturated fat in cardiovascular disease and its potential role in prostate and colon cancer incidence, decreasing saturated fat intake is likely very bene?cial in this population.47,49Recently,a secondary analysis of a trial of prostate cancer patients found that those who were assigned to the low-fat diet had signi?cantly decreased blood levels of in?ammatory markers that are linked to cancer progression.270Similar to the WINS study, however,it is unknown whether this response was due more to dietary fat restriction or to weight loss.
In one study in which the relationship between dietary intakes and risk of prostate cancer recurrence was examined, intakes of?sh and tomato sauce were observed to be associated with reduced risk.141Although bene?ts to prostate cancer risk and progression from vegetables and fruits are far from certain,a diet high in these foods has been found to reduce the risk of cardiovascular diseases.49Therefore,it is probably bene?cial for prostate cancer survivors to eat plenty of micronutrient-and phytochemical-rich vegetables and fruits.
Increased consumption of soy foods(eg,tofu and soy milk)is a common self-care strategy among prostate cancer survivors,under the assumption that the phytoestrogens may be bene?cial.Although some studies suggest that soy foods may decrease the risk of prostate cancer,no rigorous studies have been reported that examined the effects of soy or other phytoestrogens on the progression of prostate cancer after diagnosis.In a randomized controlled trial of161men,those assigned to consume30g of ground?axseed per day (a concentrated source of lignans,as well as omega-3fatty acids)were found to have signi?cantly lower prostate tumor proliferation rates compared with the control group.271 Prostate cancer survivors undergoing androgen deprivation therapy(ADT)are at a high risk of osteoporosis.In addi-tion,a recent study indicated that low25-hydroxyvitamin D(25(OH)D)levels(the major form of vitamin D in the circulation)were associated with lethal prostate cancer.272 It is not known if calcium or vitamin D supplements would be useful or detrimental in these cases,since high amounts of calcium,particularly through supplements,have been linked to more aggressive disease.273It would seem prudent for men to adopt a diet that provides at least600IU of vitamin D per day and to consume adequate,but not excessive,amounts of calcium(ie,exceeding1200mg/day), as well as to pursue active lifestyles that include routine weight-bearing exercises.The role of vitamin D and related compounds in the prevention of prostate cancer recurrence is currently being studied;2preliminary studies suggest that vitamin D,administered either separately or in conjunction with chemotherapy,may reduce PSA levels, although further research is needed to determine the longer term effects of vitamin D supplementation.274,275
Nutrition and Physical Activity Guidelines for Cancer Survivors 260CA:A Cancer Journal for Clinicians
Vitamin E supplementation in a large prevention trial intended to affect lung cancer was shown to be associated with a reduced risk of prostate cancer,but vitamin E had no effect on survival in the men in whom prostate cancer devel-oped in that study,276,277and results from a recently published randomized controlled trial indicated that men randomized to receive vitamin E were at a slightly greater risk of developing prostate cancer.153,278Likewise,although selenium supplements reduced prostate cancer incidence in a small trial intended to prevent skin cancers,259,279the same recently published trial (SELECT)found no protection from selenium in prostate cancer,and it actually predisposed men to diabetes.278
Two large cohort studies have found that obese men are at a much greater risk of prostate cancer mortality and pros-tate cancer speci?c mortality following diagnosis.234,280 Moreover,in a single-institution study,Freedland et al found that obesity was associated with a higher risk of bio-chemical failure in men treated with radical prostatectomy,56 and in another single-surgeon prostatectomy cohort,men who gained weight after diagnosis had almost twice the risk of recurrence(most being cases of biochemical failure)com-pared with men who maintained their weight after taking into account other prognostic factors.In this latter study, men who lost weight also appeared to have a lower risk of recurrence,although this observation was not statistically signi?cant.281
Many prostate cancer survivors are confronted with profound changes in body composition related to ADT,including bone loss,muscle loss,and fat gain.These changes lead to signi?cant deconditioning,muscle weakness,fatigue,and depression. Multiple trials have tested the impact of exercise,particularly resistance training,at different stages of the spectrum of treatment in men with prostate cancer.A systematic review of9studies on the effects of exercise on health outcomes demonstrated promising effects of physical activity on mus-cular?tness,physical functioning,fatigue,and health-related quality of life.282A recent randomized trial of121prostate cancer patients initiating radiation therapy with or without ADT randomly assigned to usual care,resistance training,or aerobic exercise demonstrated that resistance training improved short-and long-term fatigue,quality of life,aero-bic?tness,and upper and lower body strength,and prevented an increase in body fat.283Aerobic exercise improved short-term fatigue and?tness.
Recently,a prospective observational cohort of over2700 men with nonmetastatic prostate cancer found that physically active men had signi?cant improvements in all-cause and prostate cancer-speci?c mortality.65Men who engaged in at least3hours per week of vigorous activity had a nearly 50%reduction in all-cause mortality and a60%reduction in prostate cancer-speci?c deaths.
Men in whom prostate cancer has been diagnosed should strive to achieve and maintain a healthy weight,pursue a physically active lifestyle,and consume a diet that is rich in vegetables and fruits and low in saturated fat,with reliance
on dietary sources of calcium that are within moderate levels.Such dietary suggestions,however,need to be con-sidered within the context of an increased risk of fractures from antiandrogen therapy and physical activity patterns. Although the evidence relating these recommendations to prostate cancer recurrence is limited,there are likely substantial other bene?ts,most prominently decreasing cardiovascular disease risk,which is the major cause of death in prostate cancer survivors.
Upper Gastrointestinal and Head and
Neck Cancers
Few studies have considered whether dietary factors or physical activity in?uence prognosis in survivors with upper gastrointestinal or head and neck cancers.A clinical trial of
the effects of a beta-carotene supplement(vs placebo) among survivors with head and neck cancers found that those administered beta-carotene had rates of cancer recur-rence or survival that were similar to those in the control group.284In contrast,a clinical trial of vitamin E found an increased risk of recurrence compared with a placebo in this same patient population.152
Head and neck cancers can directly compromise food intake,and a high percentage of patients have lost weight
or are malnourished at the time of https://www.doczj.com/doc/683421037.html,prehen-
sive care of these survivors includes appropriate nutritional assessment and support,and physical activity and physical therapy to improve overall health before,during,and after treatment.Poor nutrient intake can stem from dif?culties
in biting,chewing,and swallowing at diagnosis or after sur-gery and from xerostomia,mucositis,and taste alterations resulting from radiation therapy or concurrent chemoradia-
tion therapy.Many long-term survivors of head and neck cancers will experience at least some degree of aspiration associated with substantial weight loss,diminished swallow-
ing ef?ciency,and lower quality-of-life scores.285During
and immediately after treatment,the texture,temperature, consistency,nutrient content,and frequency of oral feedings often need to be modi?ed.Acidic,salty,or spicy foods and foods at extreme temperatures may not be well tolerated. Sugar-free gums and mints as well as the use of commercial
oral rinses and gels and the consumption of water may provide limited relief of symptoms and enhance appetite. Pureed or blenderized foods may be better tolerated during treatment and recovery.Chemoradiation may have a signi?-cant effect on a patient’s ability to eat,which should improve by12months after treatment.286Health care providers may offer alternate approaches to meeting nutrient requirements if eating and drinking by mouth cannot support these needs.Gastrostomy tubes are commonly placed prophylactically to support the patient through
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清华考博辅导：清华大学体育学考博难度解析及经验分享根据教育部学位与研究生教育发展中心最新公布的第四轮学科评估结果可知全国45所开设体育学专业的大学参与了排名，其中排名第一的是北京体育大学，排名第二的是上海体育大学，排名第三的是华东师范大学。 作为清华大学实施国家“211工程”和“985工程”的重点学科，社会科学学院的体育学一级学科在历次全国学科评估中均名列第九。 下面是启道考博整理的关于清华大学体育学考博相关内容。 一、专业介绍 清华大学体育学是属于清华大学社会科学学院，清华体育的基本理念是育人至上、面向全员、追求卓越。清华大学的体育工作正是在这种氛围中适时地迈出自己的步伐，既继承几十年积淀和延续下来的优良的体育传统，又循着社会的发展及人们的思维定式和价值观的变化而融进新的思想、观点和方法，使得充盈清华园的"争取至少为祖国健康工作五十年"的理念化作清华人自觉的体育锻炼行为，将优良体育传统发扬光大.希望通过我们的努力使学校体育在体育教育、群体活动、竞技体育、体育科研、师资队伍、场馆设施六个方面跻身于国内普通大学一流行列，我们将以进取、创新、科学和务实的精神继承优良传统，跟上时代步伐，推动我校体育事业的全面发展，使学校体育不仅成为学校教育的重要组成部分，而且能够成为国家和社会体育的重要支持力量。 清华大学社会科学学院体育学专业在博士招生方面，划分为4个研究方向： 040300 体育学 博士研究方向： 01 体育人文社会学 02 运动人体科学 04 民族传统体育学 03 体育教育训练学 此专业实行申请考核制。 二、考试内容 清华大学管理体育学专业博士研究生招生为资格审查加综合考核形式，由笔试+专业面试+英语口语构成。其中，综合考核内容为: 综合考核形式为面试。每位考生约30分钟，满分100分。面试重点考查申请人在本
智慧树2018《健康生活预防癌症》章节测试答案
1 【单选题】(1分) 很多人吸烟饮酒，身体也很健康，说明吸烟饮酒也不一定会影响健康 A. 正确 B. 错误 正确 ?本题总得分：1分 本题的解析：点击查看 2 【单选题】(1分) 人体在受到外界致病因素的作用下，首先通过适应缓解作用压力，只有不能适应时，才会引起损伤。 A. 正确 B. 错误 正确 ?本题总得分：1分 本题的解析：点击查看 3 【单选题】(1分) 瘤的广泛性是指各种人种各种年龄都可发生肿瘤 A. 正确
B. 错误 正确 ?本题总得分：1分 本题的解析：点击查看 4 【多选题】(3分) 是否影响人身体健康，取决于以下因素： A. 影响因素的性质 B. 居住条件 C. 人的适应能力 D. 经济条件 正确 ?本题总得分：3分 本题的解析：点击查看 5 【多选题】(3分) 以下不良生活方式与肿瘤发生密切相关 A. 肥胖 B. 偶尔吸烟
C. 缺乏锻炼 D. 经常暴晒 E. 肝炎病毒感染 正确 ?本题总得分：3分 本题的解析：点击查看 1 【多选题】(3分) 癌症是世界上威胁人类健康的主要疾病之一，下列关于癌症的叙述错误的是( ) A. 癌细胞可不受机体的控制迅速生长，形成肿块B. 癌症就是绝症 C. 从癌细胞发展到癌症需要很长的时间 D. 癌症就是恶性肿瘤 正确
本题总得分：3分 本题的解析：点击查看 2 【多选题】(3分) 癌症转移的途径有哪些？（）A. 血道转移 B. 淋巴道转移 C. 种植性转移 D. 癌细胞浸润周围组织 正确 本题总得分：3分 本题的解析：点击查看 3 【多选题】(3分) 下列哪些是癌症的症状？（）
倡导健康生活，远离癌症病魔 一、癌症离我们有多远？——触目惊心的数据： 2007年城市居民主要疾病死亡率及构成中前10位：恶性肿瘤、脑血管病、心脏病、呼吸系统疾病、损伤和中毒、内分泌营养和代谢疾病、消化系统疾病、其他疾病、泌尿生殖系统疾病、传染病(不含呼吸道结核) 。 200８年城市居民主要疾病死亡率及构成中前10位:恶性肿瘤、心脏病、脑血管病、呼吸系病、损伤及中毒、内分泌营养和代谢疾病、消化系病、泌尿生殖系病、神经系病、精神障碍。 世界卫生组织最新的2012年《世界癌症报告》确定中国新诊断癌症病例为307万，占到全球总数的21%.8，年死亡人数220万，占到全球癌症年死亡人数的%。 估计到2015年,癌症患者达到1000万。我国80%以上的患者被诊断时,病情已经发展到中晚期; 70年代-90年代的20年间,死亡率上升%; 过去的30年，我国肺癌死亡率增加了5倍。 肝癌发病率占全球的55%。 过去的20年,我国中心城市乳癌发病率增长了109%。 ……
二、什么是癌症 1，癌症定义 癌症（cancer），医学术语亦称恶性肿瘤（malignant neoplasm），中医学中称岩，为由控制细胞生长增殖机制失常而引起的疾病。癌细胞除了生长失控外，还会局部侵入周遭正常组织甚至经由体内循环系统或淋巴系统转移到身体其他部分。 2，癌症是如何形成的： 接触致癌物质，致癌物质进入细胞,改变细胞遗传物质从而引发癌症起始。 促癌物质促使癌细胞增殖。 癌细胞由血液和淋巴向全身转移。 起始------增殖-------转移 当一个细胞变成癌细胞时，在它繁殖形成癌症之前免疫系统常常能消灭它。但免疫系统不是保险的，即使在它的功能正常时，癌症也能逃避免疫系统的保护监视作用,当免疫系统功能不正常时癌症更可能发生。 3，十大恶性肿瘤发病率排序 男性发病前十位（占86%）：肺癌、胃癌、肝癌、结肠/直肠癌、食管癌、膀胱癌、胰腺癌、白血病、淋巴癌、脑肿瘤 女性发病前十位（占82%）：乳腺癌、肺癌、结肠/直肠癌、胃癌、肝癌、卵巢癌、胰腺癌、食管癌、子宫癌、脑肿瘤 4，常见的癌症症状： （1）胃癌 突然出现原因不明的消化不良症状，而且比较顽固、进展快；突出的表现为食欲迅速下降、食后腹部饱胀感及不适感，同时体重明显降低；或过去没出有胃痛（“心窝痛”）的人，突然出现反复的胃痛；以前虽有胃痛，但近来疼痛的强度、性质、发作的时间突然改变，且原来治疗有效的药物变得无效或欠佳。 （2）大肠癌 凡30岁以上的人出现腹部不适、隐痛、腹胀、大便习惯发生改变，出现便秘、腹泻或者交替出现，有下坠感，且大使带血，继而出现贫血，疲乏无力，腹部摸到肿块，应考虑大肠癌的可能。其中沿结肠部位呈局限性、间歇性隐痛是结肠癌的第一个报警信号。下坠感明显伴大便带血，则是直肠癌的信号（大肠癌包括结肠癌和直肠癌）。 （3）鼻咽癌 鼻咽癌的早期征兆有一个共同特点，就是症状（和体征）多发生于单侧。单侧涕血（指擤出）、单侧鼻血、单侧耳鸣、单侧听力下降、单侧头痛、单侧颈淋巴结肿大。 （4）肺癌 咳嗽是肺癌的早期症状，其特点是以阵发性刺激性呛咳为主，有咳不净的感觉，一般无痰或只有少量白色泡沫痰，继发感染可出现脓痰。如经抗炎治疗2周后无改善，应警惕肺癌的可能。或在原有慢性咳嗽基础上出现咳嗽性质改变，甚至伴有“气管鸣”、“气短”应予注意。肺癌的另一警号是间断性反复少量血痰，或痰中带血丝。此外，还出现胸背痛、胸闷、发热等症状。 （5）乳腺癌 乳房发生异常性变化，如摸到拉厚或包块、胀感、出现微凹（“酒窝征”）皮肤变粗发红，乳头变形、回缩或有鳞屑等，疼痛或压痛，非哺乳期妇女突然出现单侧乳头流水（乳样、血样、水样液体）。 乳腺癌高危人群：父母或姐妹中有40岁之前得乳腺癌 不育或者35岁以后生育
SCCM/ASPEN重症患者营养指南(2016)精要 2016年1月15日，美国肠外肠内营养学会（ASPEN）和重症医学会（SCCM）联合发表了2016年版《成人重症患者营养支持疗法提供与评定指南》，分别刊登于2016年2月第2期的《肠外肠内营养杂志》（JPEN）和《重症医学》（CCM）。该指南面向医师、护士、营养师和药师，针对重症成人（18岁以上）患者，提供了最佳营养疗法的最新建议，协助医疗团队提供适当的营养疗法，可以减少并发症、缩短住院时间、降低疾病严重程度、改善患者结局。 2016年版指南的主要推荐意见包括： A.营养评估 A1.基于专家共识，我们建议对所有入住ICU的预计自主进食不足的患者评定其营养风险（NRS2002评分，NUTRIC评分）。营养风险高的患者是最可能从早期肠内营养获益的患者。 A2.基于专家共识，我们建议营养评估应包括共存疾病、胃肠功能和误吸风险。不建议将传统的营养指标（包括白蛋白、前白蛋白、转铁蛋白、视黄醇结合蛋白、人体测量等——译注）或替代指标用于营养评估，因其在重症患者的适用未得到确认。 A3a.如果条件允许，建议使用间接能量测定(IC)确定患者的能量需求，除非存在影响IC测量准确性的因素。A3b.基于专家共识，如果无法测定IC，我们建议使用各类预测公式或简化的基于体重的算法（25~30kcal/kg/d）计算能量需求。（肥胖患者参照Q） A4.基于专家共识，我们建议持续评估患者的蛋白补充是否充足。（重症患者较普通患者需更高比例的蛋白[1.2~2g/kg]，是否在普通肠内营养制剂的基础上添加蛋白组件依赖于对蛋白摄入是否充足的持续评估——译注） B.肠内营养的起始 B1.我们推荐不能进食的重症患者在24~48小时内开始早期肠内营养。 B2.我们建议需要营养支持治疗的重症患者首选肠内营养 B3.基于专家共识，我们建议对于大多数MICU和SICU的患者，虽然在肠内营养起始的时候应该评估胃肠道功能，但肠道收缩的明显标志（指肠鸣音和排气排便——译注）对于肠内营养的起始不是必须的。 B4a.我们推荐对于高误吸风险的患者（D4）或对胃内肠内营养不耐受的患者应降低营养输注速度。 B4b.基于专家共识，我们认为大部分重症患者可以通过胃内起始肠内营养。 B5.基于专家共识，我们建议血流动力学不稳定的患者应将肠内营养推迟至患者经充分的复苏或稳定后。已在减少血管活性药用量的患者可以小心起始/再次起始肠内营养。 C.肠内营养的用量 C1.基于专家共识，我们建议营养风险低、基础营养状况良好、疾病严重程度低（NRS2002<=3分，NUTRIC<=5分）的不能自主进食的患者，在入住ICU的第一周无需特别进行营养治疗。 C2.我们推荐ARDS/ALI以及预计机械通气时间>=72小时的患者适宜使用滋养性肠内营养（10-20kcal/h，不超过500kcal/d——译注）或足量肠内营养，两种营养策略在入住第一周的临床结局是相似的。 C3.基于专家共识，我们建议高营养风险的患者（NRS2002>=5分，NUTRIC>=5分[不包括IL-6]）或严重营养不良的患者应在24-48小时内尽快达到目标剂量，但同时应警惕再喂养综合征（指长期进食或严重营养不良患者不适当补糖时发生的电解质紊乱和大脑糖代谢障碍——译注）。在入住第一周，应该在48-72小时内达到预计的能量和蛋白需求量的80%以上才能获得肠内营养的临床获益。 C4.我们建议提供足量（高剂量）的蛋白。重症患者需要的蛋白大约在1.2-2.0g/kg实际体重，烧伤或多发伤患者可能需要更多(见M和P)。(还有肠瘘患者也可能需要更多！！——译注) D.关注肠内营养是否耐受和充足 D1.基于专家共识，我们建议每天监测肠内营养的耐受性。我们建议避免轻易中断肠内营养。我们建议诊断阶段的禁食禁水应该仅限于限制肠梗阻的蔓延并防止营养输注不足。 D2a.我们建议不必常规监测接受肠内营养治疗的ICU患者的胃残留量。 D2b.我们建议仍在监测胃残留量的单位，如果胃残留量<500ml且没有其他不耐受表现，应避免停用肠内营养。 D3a.我们推荐制定并实施肠内喂养预案，以增加营养用量。 D3b.基于专家共识，我们建议使用基于摄入量的喂养预案（即关注每日摄入量而非严控输注速度——译注）或自上而下的多重策略计划（基于用量、促动力药、幽门后喂养等——译注）。 D4.基于专家共识，我们建议使用肠内营养的患者应评估误吸风险并使用减低误吸风险和吸入性肺炎的措施。 D4a.我们推荐误吸风险高的患者使用幽门后营养通路进行喂养(同样适用B5）。D4b.基于专家共识，我们建议高风险患者以及对胃内推注式肠内营养不耐受的患者使用持续输注的方式给予肠内营养。 D4c.我们建议条件允许时对误吸高风险的患者可以使用促胃肠动力药（如胃复安、红霉素）。 D4d.基于专家共识，我们建议使用降低误吸风险和呼吸机相关肺炎的护理措施。所有插管的ICU患者在使用肠内营养时应
适量运动预防癌症 为了健康，安普先生建议大家在膳食均衡的同时，加入适量的运动，因为健康的饮食和规律的运动是保持身材和预防癌症的最佳组合。当然这样健康的生活方式同样可以降低罹患心脏病和糖尿病的风险。 世界癌症研究基金会认为：目前大约20%的癌症与身体肥胖、缺乏运动、过度饮酒或营养不良有关，由此，我们不难发现：适量的运动，可以在一定程度上降低罹患癌症风险。 在此安普先生介绍运动防癌的道理： 运动时肌肉会产生高热量，使体温暂时性升高，剧烈运动时体温甚至可上升至40℃，甚至更高，而癌细胞对热的耐受力很差，更容易死掉。同时运动会造成人体汗腺分泌大量汗液来降低体温，这样随着大量汗液的排出，也会及时将体内一些致癌物质（铅、锶和铍等）带离身体，很大程度上减少罹患癌症的风险。 运动时，人体吸氧量上升，肺部工作量加大，会把体内堆积的一些致癌物质排出体外，吸氧量的增大会使体内血液循环加快，血液循环加快，就会让体内出现的癌细胞无法长时间在某一特定位臵站稳脚跟、生长发育和转移扩散。对癌症预防有比较好的作用。 运动还可以增加免疫细胞和干扰素的产生，运动可刺激体内骨髓生成白细胞的速度，增加体内免疫能力，即使出现少量的癌细胞，自身免疫系统也可以消灭掉，干扰素在运动时会增加很多，可以起到很好的抗癌作用，避免真正发生癌症。 运动时，大脑会产生能引起人身心愉悦的物质，从而在一定程度上改善人的情绪，帮助人们抵制消极情绪的侵扰，而消极和抑郁这样悲观的情绪容易诱发癌
症的发生，同时运动也锤炼人的意志力，增强战胜癌症的信心。 安普先生认为，癌症预防更重要。 特别建议： 健康的年轻人，可以进行较大运动量的锻炼，而中老年人每周参加2、3次运动为宜，但运动量要适当，不疲劳为宜。对于不经常运动的人，需要循序渐进增加运动量，不能一开始就直接大量运动。 当然，安普先生坚决反对过度运动，过度锻炼对身体的伤害相当大，长时间高强度运动，非但不能帮助身体抵御疾病，反而会导致身体免疫力下降，当身体的负荷已经很沉重，极易感到疲倦，急需休息，恢复疲劳，如果再高强度地锻炼，只能加重病情，不利于身体恢复，故，坚决反对大强度运动，适量运动即可达到健身的目的，请各位读者切记，谢谢大家！
肠内营养治疗指南 肠内营养治疗指南 营养是治疗疾病和健康长寿的保证。对患者来说，合理、平衡、及时的临床营养治疗极为重要。营养治疗包括肠内营养（enteral nutrition ，EN）治疗和肠外营养（parenteral nutrition ，PN）治疗，而前者又分为饮食治疗和管喂营养治疗。危重病人的营养治疗非常重要，俗话说疾病三分治，七分养”，营养即在 其中。任何时候都应遵循，如果胃肠存在，就应首先考虑使用肠内营养。与肠外相比，肠内营养经济、安全、方便，符合生理过程。 肠内营养制剂按蛋白来源分为两大类：一类是氨基酸型和短肽型（要素型）制剂（冬泽力）；另一类是整蛋白型（非要素型）制剂（冬泽全）。每一类型的制剂中又可分为平衡型和疾病特异型。肠内营养制剂在国外还包括组件式肠内营养制剂。 为提高临床营养治疗效果，规范临床营养治疗程序，在参照国内外相关资料的基础上，结合冬泽特医专家的经验，制订营养治疗指南，供临床应用参考。 一、适应证 1、意识障碍、昏迷和某些神经系统疾病：如脑外伤、脑血管疾病、脑肿瘤、脑炎等所致的昏迷患者，老年痴呆不能经口进食或精神失常、严重抑郁症、神 经性厌食者等。 2、吞咽困难和失去咀嚼能力：如咽下困难、口咽部外伤及手术后、重症肌无力者等。
3、上消化管梗阻或手术：如食管炎症、化学性损伤等造成咀嚼困难或吞咽困难、食管狭窄梗阻、食管癌、幽门梗阻、吻合口水肿狭窄、胃瘫等。 4、高代谢状态：如严重创伤、大面积烧伤、严重感染等所致机体高代谢、负氮平衡者。 5、消化管痿：通常适用于低流量痿或痿的后期，如食管痿、胃痿、肠痿、胆痿、胰痿等。对低位小肠痿、结肠痿及空肠喂养的胃十二指肠痿效果最好。 6、术前准备和术后营养不良：如术前肠管准备期间、术中有额外营养素丢失者等。 7、炎性肠管疾病：如溃疡性结肠炎、Crohns病等。 8、短肠综合征：短肠综合征肠代偿阶段。
肠内营养指南（适应症，禁忌，常见并发症，注意事项） 欧阳光明（2021.03.07） 发表者：陈泽涛 3650人已访问 营养是治疗疾病和健康长寿的保证。对患者来说，合理、平衡、及时的临床营养治疗极为重要。营养治疗包括肠内营养(enteral nutrition ，EN) 治疗和肠外营养(parenteral nutrition ，PN) 治疗，而前者又分为饮食治疗和管喂营养治疗。危重病人的营养治疗非常重要，俗话说“疾病三分治，七分养”，营养即在其中。任何时候都应遵循，如果胃肠存在，就应首先考虑使用肠内营养。与肠外相比，肠内营养经济、安全、方便，符合生理过程。 为提高临床营养治疗效果，规范临床营养治疗程序，在参照国内外相关资料的基础上，结合我们的经验，制订营养治疗指南，供临床应用参考。 肠内营养指南 一、适应证 1、意识障碍、昏迷和某些神经系统疾病：如脑外伤、脑血管疾病、脑肿瘤、脑炎等所致的昏迷患者，老年痴呆不能经口进食或精神失常、严重抑郁症、神经性厌食者等； 2、吞咽困难和失去咀嚼能力：如咽下困难、口咽部外伤及手术后、重症肌无力者等；
3、上消化管梗阻或手术：如食管炎症、化学性损伤等造成咀嚼困难或吞咽困难、食管狭窄梗阻、食管癌、幽门梗阻、吻合口水肿狭窄、胃瘫等； 4、高代谢状态：如严重创伤、大面积烧伤、严重感染等所致机体高代谢、负氮平衡者； 5、消化管瘘：通常适用于低流量瘘或瘘的后期，如食管瘘、胃瘘、肠瘘、胆瘘、胰瘘等。对低位小肠瘘、结肠瘘及空肠喂养的胃十二指肠瘘效果最好； 6、术前准备和术后营养不良：如术前肠管准备期间、术中有额外营养素丢失者等； 7、炎性肠管疾病：如溃疡性结肠炎、Crohn s 病等； 8、短肠综合征：短肠综合征肠代偿阶段； 9、胰腺疾病：急性胰腺炎肠功能恢复后、慢性胰腺功能不全者。注意喂养管应插入近端空肠10cm 以上，营养制剂只能选用小分子低脂不需要消化即可吸收的要素膳，如维沃、爱伦多、大元素等；10、慢性营养不足：如恶性肿瘤、放疗、化疗患者及免疫缺陷疾病者等； 11、器官功能不全：如肝、肾、肺功能不全或多脏器功能衰竭者； 12、某些特殊疾病：急性放射病，各种脏器移植者，包括肾移植、肝移植、小肠移植、心脏移植、骨髓移植等； 13、肠外营养治疗不能满足要求时的补充或过渡。 二、禁忌证 1、完全性机械性肠梗阻、胃肠出血、严重腹腔感染；
2020智慧树，知到《健康生活预防癌症》 章节测试题完整答案 智慧树知到《健康生活预防癌症》章节测试答案 第1章单元测试 1、很多人吸烟饮酒，身体也很健康，说明吸烟饮酒也不一定会影响健康 答案：错误 2、人体在受到外界致病因素的作用下，首先通过适应缓解作用压力，只有不能适应时，才会引起损伤。 答案：正确 3、瘤的广泛性是指各种人种各种年龄都可发生肿瘤 答案：正确 4、是否影响人身体健康，取决于以下因素： 答案：影响因素的性质、人的适应能力 5、以下不良生活方式与肿瘤发生密切相关 答案：肥胖、缺乏锻炼、经常暴晒、肝炎病毒感染 第2章单元测试 1、癌症是世界上威胁人类健康的主要疾病之一，下列关于癌症的叙述错误的是 ( ) 答案：癌症就是绝症、从癌细胞发展到癌症需要很长的时间 2、癌症转移的途径有哪些?( ) 答案：血道转移、淋巴道转移、种植性转移
3、下列哪些是癌症的症状? 答案：异常肿块、疼痛 4、下列哪些是癌症的易患人群? 答案：家族有癌症患者的人群、中老年人群、职业易感人群、有癌前病变的患者 5、肿瘤发生率最高的是 ( ) 答案：增生最活跃的组织 6、致癌因素最容易作用于细胞周期的( ) 答案：S期、M期 7、增生是癌症发生的最重要的基础。( ) 答案：正确 8、只要一个细胞癌变，就是癌症。( ) 答案：错误 9、致癌剂作用于人体细胞主要是导致正常细胞快速生长 答案：错误 10、同样的生活环境下，有人患癌症最可能的原因 ( ) 答案：受到二次突变打击 11、基因突变是指 答案：基因的化学结构改变 12、细胞突变可发生在哪? 答案：生殖细胞、体细胞 13、肿瘤就是一种基因病。
癌症治疗费用一览表
癌症治疗费用一览表 癌症的治疗是一个慢性的过程,具体的费用是与不同种类的癌症和具体本身的体质是有一定的关系的。在日常生活中预防癌症是非常重要的。以下是我分享给大家的关于，一起来看看吧! 近年来，越来越多的癌症能够被有效地控制，甚至有很多癌症患者已经被治愈，无论如何，从癌症的阴霾中幸存下来，是值得庆贺的事情。在美国，截止2014年1月，约有1450万癌症的幸存者。随着治疗方法的改善，预计2024年幸存者将达到1900万人。 但是，最近一篇发表在Cancer杂志上的文章指出，目前每10位癌症幸存者里面就有3位面临经济困难问题，这会对癌症幸存者、患者的心理和生理产生长期影响。许多癌症患者和幸存者都有对高昂的癌症相关治疗费用的担心，从而不去或者推迟就医、错过随访。 随着医疗费用的不断增加，自费部分也在不断攀升，根据每个人的保险情况，平均每年癌症患者估计需要支付治疗相关费用为1730到4727美元。
虽然关于癌症治疗的研究发展很快，但鲜有研究关注癌症幸存者的沉重的经济负担。 21%的癌症患者都会担心大型医疗费用 Hrishikesh Kale和弗吉尼亚州联邦大学医学院里士满的其他同事分析了自2011年以来的1960万癌症幸存者的医疗支出数据。 经济负担：定义为该患者曾借钱、宣告破产、担忧大笔的医疗费用、无法负担医疗保健随访的费用，以及其他经济困境。 从结果来看，29%的癌症幸存者在癌症诊断、治疗或长期治疗后至少经历一次经济困难。调查结果来看，21%的人担心支付大笔医疗费用，11.5%的人无力支付医疗就诊费用，7.6%的人曾借钱欠债，1.5%的人宣布自己破产，8.6%的人遭遇了其他经济困境。 这些经济困难影响了他们的生活质量，对其心里和生理上的健康都造成了影响，与之而来的是抑郁症和心理疾病发生风险的升高。相比那些没有经济困难的癌症幸存者，他们更担心癌症的复发。而且，经济问题越严重，他们的生活质量受到的影响更大。 需要制定相关政策降低费用支出 合作者Norman Carroll博士表示可以通过制定相关政策法规最大限
成人围手术期营养支持指南 中华医学会肠外肠内营养学分会 自2006年中华医学会肠外肠内营养学分会制定《临床诊疗指南：肠内肠外营养 学分册》至今已有10年，为了更好地规范我国的临床营养实践，我们按照当今 国际上指南制定的标准流程，根据发表的文献，参考各国和国际性营养学会的相 关指南，综合专家意见和临床经验进行回顾和分析，并广泛征求意见，多次组织 讨论和修改，最终形成本指南。 指南制定方法学 本指南主要采用德国医学科学委员会、苏格兰学院指南协作网及牛津大学循证医 学中心所提供的分级系统，并根据GRADE系统对证据质量和推荐强度做出评定[1]。 证据级别主要由研究的数量和类型决定，用来评判相关证据的质量和效果的确定 性，等级从“高”到“极低”，最高证据质量来源于多项随机对照试验 (randomized controlled trial，RCT)所产生的一致结果和Meta分析结果(表 1)[2]。 表1《成人围手术期营养支持指南》采用的证据分级 证据级 别 定义研究类型 高我们非常确信真实的效应值接近效应估计无限制、一致性好、精确、可直接应用、无发表偏倚的 RCT；效应量很大的观察性研究 中对效应估计值我们有中等程度信心：真实值有可能接近估计值，但仍存在二者大不相同 的可能性有严重限制、结果严重不一致、精确度严重不足、部分不能直接应用、可能存在发表偏倚的RCT；有剂量反应、效应量大的观察性研究 低我们对效应估值的确信程度有限：真实值可有极其严重限制、结果极其严重不一致、精确度极其严
能与估计值大不相同重不足、大部分不能直接应用、很有可能存在发表偏倚 的RCT；观察性研究 极低我们对效应估计值几乎没有信心：真实值很可能与估计值大不相同有非常严重限制、结果非常严重不一致的RCT；结果不一致的观察性研究；非系统的观察性研究(病例系列研究、病例报告) 注：RCT为随机对照试验 根据PICO系统构建合适的临床问题，通过相应的关键词进行系统文献检索，文献搜索资源中，一级文献数据库包括MEDLINE、PubMed、EmBase、中国生物医学文献数据库，二级文献数据库包括 Cochrane Database of Systemic Reviews、 the National Guideline Clearinghouse，再利用Google学术搜索进行搜索(含电子出版物)，搜索时间截至2016年3月29日。所有文献由2～3名工作人员采用提取数据形式的方法进行数据验证和研究方法质量评估，每篇文献生成一个共识评估。采用Review Manager 5.2软件对数据进行处理，采用GRADE Pro 软件对分析后的数据就干预措施和其结果的证据主体质量进行评估并生成森林图。如就某个问题，观察性研究是唯一可用的证据时，采用GRADE系统进行证据质量评估；如无RCT或观察性研究能直接回答相关问题时，由相关专家对最佳临床实践意见进行协商，推荐意见归为“专家协商意见”。 确定推荐强度时，通过评价推荐意见的效益比、回顾支持性证据等方法进行综合协商，采用Delphi法进行群体决定和投票后达成一致；每个特定推荐需获得75%的参与专家同意方可成立。强烈推荐指确定针对特定群体或患者的临床决策或干
1很多人吸烟饮酒，身体也很健康，说 明吸烟饮酒也不一定会影响健康 A. 正确 B. 错误 2人体在受到外界致病因素的作用下，首先通过适应缓解作用压力，只有不能适应时，才会引起损伤。 A. 正确 B. 错误 3瘤的广泛性是指各种人种各种年龄都可发生肿瘤 A. 正确 B. 错误 4是否影响人身体健康，取决于以下因素： A. 影响因素的性质 B. 居住条件 C. 人的适应能力 D. 经济条件 5以下不良生活方式与肿瘤发生密切相关 A. 肥胖 B. 偶尔吸烟 C. 缺乏锻炼 D. 经常暴晒 E. 肝炎病毒感染 1癌症是世界上威胁人类健康的主要疾病之一，下列关于癌症的叙述错误的是 ( ) A. 癌细胞可不受机体的控制迅速生长，形成肿块 B. 癌症就是绝症 C. 从癌细胞发展到癌症需要很长的时间 D. 癌症就是恶性肿瘤 2癌症转移的途径有哪些？（） A. 血道转移 B. 淋巴道转移 C. 种植性转移 D. 癌细胞浸润周围组织 3下列哪些是癌症的症状？（） A. 异常肿块 B. 疼痛 C. 出现肺转移 D. 有出血坏死 4下列哪些是癌症的易患人群？ A. 家族有癌症患者的人群 B. 中老年人群 C. 职业易感人群 D. 有癌前病变的患者 5 肿瘤发生率最高的是（） A. 增生最活跃的组织 B. 增生不活跃的组织 C. 不增生的组织
D. 牙齿 6致癌因素最容易作用于细胞周期的：（） A. 致癌因素最容易作用于细胞周期的： G0期 B. G1期 C. S期 D. G2期 E. M期 7增生是癌症发生的最重要的基础。（） A. 正确 B. 错误 8只要一个细胞癌变，就是癌症。（） A. 正确 B. 错误 9致癌剂作用于人体细胞主要是导致正常细胞快速生长。（ ) A. 正确 B. 错误 10同样的生活环境下，有人患癌症最可能的原因（） A. 受到二次突变打击 B. 因为体质弱 C. 不吃早点 D. 肥胖 11基因突变是指（） A. DNA的化学结构发生改变 B. 染色体少了一条 C. 染色体多了一段 D. 原癌基因激活 E. 抑癌基因失活 12细胞突变可发生在那些水平 A. 生殖细胞 B. 蛋白质 C. 体细胞 D. 内分泌系统 E. 神经调节 13肿瘤就是一种基因病。（） A. 正确 B. 错误 14肿瘤发生的基因调控失常是指基因结构正常，基因表达的调节出现异常。 A. 正确 B. 错误 15因为基因内存在原癌基因，所以预防癌症最好地方式就是切除这些基因（） A. 正确 B. 错误 16癌症的发生就是原癌基因被激活，抑癌基因失活造成的（） A. 正确 B. 错误 17癌症发生的两阶段理论中，启动剂的作用主要是造成：
兰斯?阿姆斯特朗，依靠获得环卢森堡自行车赛冠军和环法公路车赛分赛段冠军，在25岁时候即成为世界最优秀的赛车手之。这时的兰斯?阿姆斯特朗似乎正处于不可战胜，前途片光明的时刻。紧接着他被确诊患有睾丸癌。此时摆在他面前的不再是自行车赛而是如何同癌症作斗争。睾丸癌这种癌症在15到35岁之间男子比较常见。如果治疗及时的话此种癌症的治愈率高达90％。可是，同其他精力旺盛的男士一样，兰斯对于早期的发病症状没有及早引起重视并且当时的他也绝对不会想到这种病情的严重性。由于兰斯早期设能及时治疗，癌细胞迅速扩散到了他的腹部，肺部与脑部。此时的兰斯治愈的希望很渺茫。 后来通过体育锻炼，医学治疗与强大的精神力量，兰斯始终同癌症作着不屈不挠的顽强斗争。兰斯宣称自己不是癌症牺牲者，而是名癌症幸存者，他积极主动地对待病情与治疗。凭着对医疗技术的信心与了解车王兰斯最终战胜了癌症。 切似乎命中注定早在兰斯治疗期间也就是当他的病情还没有康复的时候，兰斯就创办了兰斯-阿姆斯特朗基金会(此基金会旨在帮助全世界的癌症患者与幸存者并以提高社会对癌症关注为目的)。这标志着车王兰斯为癌症患者与幸存者积极奔走的开始并从此成为全球抗击癌症的代言人之一。 车王兰斯?阿姆斯特朗取得了胜利。这种胜利不仅是指车王兰斯在1999～2005的环法公路自行赛上连续获得七冠王，而且更是指抗癌斗争的胜利。抗癌胜利，不仅是指兰斯人而是指所有像兰斯样同癌症积极抗争的患者与幸存者，兰斯想要把这场全球的抗癌斗争继续坚持下去，并且兰斯希望你也能加入到抗击队
伍中来。这或许就是兰斯的抗癌宿命不过这同时也是UVESTRONG(含意，坚强活着)项目的由来。下面我们就来看一下，车王兰斯的LIVESTRONG系列的装备产品。
肠外肠内营养临床指南（2006 版）（草案） 第一部分总论 第二部分成人营养需要量 第三部分营养风险筛查（NRS） 第四部分肠外营养素 第五部分输注路径 第六部分疾病营养支持 一.术后糖电解质输液 二.围手术期肠外营养 三.围手术期肠内营养 四.危重病 五.成人烧伤 六.胰腺炎 七.短肠综合征与胃肠道瘘 八.炎性肠病 九.肝脏疾病与肝移植 十.心血管疾病 十一.神经性疾病 十二.糖尿病 Ⅱ.肠外肠内营养临床指南（2006 版）（草案） 第一部分总论 中华医学会肠外肠内营养学分会（Chinese Society of Parenteral and Enteral Nutrition, CSPEN）于2004年12月在京成立。作为一个多学科学术组织，CSPEN的愿景（vision）是倡导循证营养实践，促进我国肠外肠内营养的合理应用，为患者提供安全、有效和具有良好效价比的营养治疗。编写、制定与推广临床指南是实现上述目标的重要途径。指南定义为：按照循证医学原则，以当前最佳证据为依据，按照系统和规范方法，在多学科专家、大中规模医院的临床医师和护理人员合作下达成的共识。 本指南的宗旨是为临床医师、护理工作者、营养师和患者在特定临床条件下，制定和/或接受肠外肠内营养治疗方案提供帮助，并为卫生政策的制定者提供决策依据。 2005年，CSPEN组织我国临床营养、儿科、外科、内科等多学科专家成立了第一届《肠外肠内营养指南》编写委员会，于当年制定和公布了第一版《肠外肠内营养学临床―指南‖系列一：住院患者肠外营养支持的适应证》，先后在《中国临床营养杂志》、《中华医学杂志》和《中华外科杂志》登载。这是我国首个按照循证医学原则制定的肠外肠内营养指南，出版后受到国内同行的关注。 2006年版指南制订过程 在2005年版的基础上，2006年1月，CSPEN开始组织《肠外和肠内营养临床指南》修订工作。在广泛听取和收集国内同行意见和建议的基础上，2006年4月，召开了2006版指南第一次“共识工作会议”，讨论重
ESPEN指南：外科临床营养 早期经口喂养是手术患者营养的首选方式。营养疗法可避免大手术后喂养不足的风险。考虑到营养不良和喂养不足是术后并发症的风险因素，早期肠内喂养对于任何有营养风险的手术患者尤为重要，特别是那些进行上消化道手术的患者。 该指南的重点是涵盖术后加速康复外科（ERAS）概念和进行大手术患者的特殊营养需求，例如癌症，虽然提供最佳围手术期医疗，但是仍然出现严重并发症。 从代谢和营养角度而言，围手术期治疗重点包括： ?将营养整合入患者整体管理 ?避免长时间术前禁食 ?术后尽早重新建立经口喂养 ?一旦营养风险变得明显，早期开始营养疗法 ?代谢控制，例如血糖 ?减少加重应激相关分解代谢或影响胃肠功能的因素 ?缩短用于术后呼吸机管理的麻醉药物使用时间 ?早期活动以促进蛋白质合成和肌肉功能恢复 缩写 ?BM：生物医学终点 ?GPP：良好实践要点。根据指南制定小组临床经验推荐的最佳实践方法。 ?HE：医疗卫生经济终点 ?IE：整合传统终点与患者报告终点 ?QL：生活质量 ?TF：管饲 该指南共提出37项临床实践推荐意见：
1.对大多数患者从午夜开始术前禁食是不必要的。被认为无任何误吸风险的手术患 者在麻醉前两个小时应喝清流质。麻醉前六小时前应允许进食固体食物（BM、IE、QL）。推荐等级：A，高度共识（97%同意） 2.为了减少围术期不适症状包括焦虑，前一天晚上和术前两小时应给予经口进食碳 水化合物处理（而非夜间禁食）（B，QL）。为改善术后胰岛素抵抗和缩短住院时间，对大手术患者可考虑术前使用碳水化合物（0，BM、HE）。推荐等级：A/B，高度共识（100%同意）在完成过程中由工作小组根据最新荟萃分析下调等级（工作小组内成员100%同意） 3.一般情况下，术后经口营养摄入应持续不中断（BM、IE）。推荐等级：A，高 度共识（90%同意） 4.建议根据个人耐受性和实施的手术类型来调整经口摄入，特别关注老年患者。推 荐等级：GPP，高度共识（100%同意） 5.大多数患者应在术后数小时内开始经口进食清流质。推荐等级：A，高度共识（100% 同意） 6.建议在大手术前后评定营养状况。推荐等级：GPP，高度共识（100%同意） 7.营养不良患者和存在营养风险的患者有指征进行围手术期营养疗法。如果预计患 者在围手术期不能进食超过5天，也应启动围手术期营养疗法。预计患者经口摄入少，不能维持推荐摄入量的50%以上超过7天也是指征。在这些情况下，建议立即给予营养疗法（首选肠内途径ONS或TF）。推荐等级：GPP，高度共识（92%同意） 8.如果能量和营养需求不能仅通过经口和肠道摄入满足（＜能量需求的50%）超过 7天，建议肠内联合肠外营养（GPP）。如果有营养疗法指征，但有肠内营养禁
《运动营养学》课程教学大纲 一、课程说明 课程名称：运动营养学课程编号： 总学时：32学时总学分：2学分 学时分配：理论32学时 课程性质：专业必修课 先修课程：运动生理学适用专业：社会体育指导与管理 开课学期：第三学期 二、教学目标与要求 教学目标： 通过本课程教学，使学生了解运动营养的发展趋势，理解运动营养的作用与意义，掌握运动营养学基础理论、概念和方法，熟悉运动训练和体育锻炼中人体的营养特点及应用运动营养学的理论方法指导训练和体育锻炼，旨在培养学生严谨的作风，一丝不苟的态度，能针对性地分析和解决体育运动实践中的问题，并为学生日后从事体育教学训练和健身指导奠定基础。也为学生后续课程的顺利学习提供条件。 教学要求: 一、在保证该课程教学的科学性和系统性的前提下，着重突出运动营养学的实用性与应用性。有关本课程的基本概念、基本知识和基本技能，作为教学的重点内容，要求学生牢固掌握并熟练运用。 二、坚持理论密切联系实际，教学时，尽可能借助运动营养科研中的一些典型实例，深入浅出地阐明其基本思想，旨在拓开学生的思路，并积极引导学生将主要精力放在掌握运动营养方法的具体应用上。 三、课堂讲授实行启发式，力求做到少而精，突出重点，并注意将培养和提高学生的分析问题和解决问题的能力放在重要位置。 四、坚持课后练习是教好、学好本门课程的关键。在整个教学过程中，将根据正常教学进度布置一定量的课后作业，要求学生按时完成。 教学重点：运动营养在健身人群健身运动和运动员训练和比赛中的应用 教学难点：运动和营养相结合对延缓运动性疲劳的发生，促进疲劳的恢复和增进人体健康的作用 三、教学内容与目的 第一章运动营养基础 教学目的：1、了解营养素的概念和运动营养的基础，熟悉运动与宏量营养素、微量营养素、水和能量的关系；2、掌握糖类、脂肪、蛋白质、维生素、矿物质和水在运动中 的主要生物学作用和应用的基础原理。 教学重点：运动与宏量营养素、微量营养素、水和能量的基本关系。 教学难点：糖、脂肪、蛋白质、维生素、矿物质和水在运动中的生物学作用和应用的基本原理。 教学方法与手段：讲授式；探究式；任务驱动式 作业形式：课后作业
提示：下划线为答案 【单选题】(1分) 很多人吸烟饮酒，身体也很健康，说明吸烟饮酒也不一定会影响健康 答案：.错误 2 【单选题】(1分) 人体在受到外界致病因素的作用下，首先通过适应缓解作用压力，只有不能适应时，才会引起损伤。 答案：正确 3 【单选题】(1分) 瘤的广泛性是指各种人种各种年龄都可发生肿瘤 答案：正确 4 【多选题】(3分) 是否影响人身体健康，取决于以下因素： 答案; 人的适应能力 影响因素的性质 5 【多选题】(3分) 以下不良生活方式与肿瘤发生密切相关 答案： 缺乏锻炼 肥胖 经常暴晒 肝炎病毒感染 【多选题】(3分) 癌症是世界上威胁人类健康的主要疾病之一，下列关于癌症的叙述错误的是( )
B. 癌症就是绝症 C. 从癌细胞发展到癌症需要很长的时间 正确答案是:B,C 查看答案解析 2 【多选题】(3分) 癌症转移的途径有哪些？（）A、血道转移B、淋巴道转移C、种植性转移 D、癌细胞浸润周围组织 A. 血道转移 B. 淋巴道转移 C. 种植性转移 D. 癌细胞浸润周围组织 正确答案是:A,B,C 查看答案解析 3 【多选题】(3分) 下列哪些是癌症的症状？（） A. 异常肿块 B. 疼痛 C. 出现肺转移 D. 有出血坏死 正确答案是:A,B 查看答案解析 4 【多选题】(3分) 下列哪些是癌症的易患人群？
A. 家族有癌症患者的人群 B. 中老年人群 C. 职业易感人群 D. 有癌前病变的患者 正确答案是:A,B,C,D 查看答案解析 5 【单选题】(2分) 肿瘤发生率最高的是（） A. 增生最活跃的组织 B. 增生不活跃的组织 C. 不增生的组织 D. 牙齿 正确 查看答案解析 ? ?2分 6 【多选题】(3分) 致癌因素最容易作用于细胞周期的：（） A. 致癌因素最容易作用于细胞周期的：G0期 B. G1期 C. S期 D. G2期
成人危重症患者营养支持指南【2016】 2016年1月16日，美国肠外肠内营养学会与危重病医学学会联合发布新版《成人危重症患者营养支持治疗之提供与评估指南》，该指南将在2月份《肠外肠内营养杂志》与《CCM》杂志联合发表。该指南针对多种成人危重病提供了全方位的营养推荐意见。 A 营养评估 A1--根据专家共识，我们建议对所有入ICU的患者，如果预期自主摄食不足时，进行营养风险的评估（例如NRS-2002，NUTRIC评分）。营养风险高的患者从早期肠内营养治疗中获益的可能性最大。 A2--根据专家共识，我们建议营养评估包括对基础疾病，胃肠道功能，反流误吸风险的评估。我们建议不要使用传统的营养指标或者替代指标，因为这些指标在重症监护中没有得到验证。 A3a-我们建议在可能的情况下，以及没有其他变量影响的情况下，尽量使用间接测热法估计热量的需求。 A3b-根据专家共识，如果无法测定间接热需，我们建议使用发表的预测公式或者简单的基于体重的公式（25-30kcal/kg/天）来估计热量需求。 A4--根据专家共识，我们建议对蛋白的摄入量进行连续评估。 B 启动肠内营养 B1--我们推荐危重症患者如果无法保证自主摄入，于24-48h内启动肠内营养。 B2--对于需要营养支持治疗的危重症患者，相对肠外营养我们建议使用肠内营养。 B3--根据专家共识，我们建议对于大多数的内科危重症与外科危重症患者，尽管在启动肠内营养时，需要对胃肠道蠕动功能进行评估，但并不要求有明显的胃肠道收缩性。 B4a-对于反流误吸高风险患者或者对经胃肠内营养不耐受的患者，我们推荐营养管路尽量放置于下段胃肠道。 B4b-根据专家共识，对于大多数危重症患者，是可以接受经胃肠内营养的。 B5--根据专家共识，我们建议对于血流动力学受影响或者不稳定的患者，暂停肠内营养，直到患者充分复苏或者稳定。对于处于血管活性药物撤除过程中的危重症患者，启动或者再启动肠内营养需要谨慎。 C 肠内营养量 C1--根据专家共识，我们建议对于营养风险低，基础营养状态正常以及疾病严重程度轻（例如，NRS-2002≤3或者NUTRIC评分≤5），同时无法保证自主摄食的患者，在入住ICU7天以内不需要特殊的营养治疗。 C2--我们推荐对于急性呼吸窘迫综合征或者急性肺损伤的患者或者预计机械通气时间在 72h以上的患者，既可以通过肠内进行营养性喂养也可以进行全营养，因为两者在入院一周内对患者结局的影响是相同的。 C3--根据专家共识，我们建议对于营养高风险（NRS-2002>5或者NUTRIC评分≥5）或者严重营养不良的患者应在监测再喂养综合征与耐受的情况下，尽早在24-48h内达到预期量。在48-72h内到需要尽量到达目标热卡以及蛋白量的80%以上，这样才能在入院一周了实现肠内营养的临床效益。 C4--我们建议应该提供足够的蛋白摄入。蛋白需求可以根据1.2-2.0g/kg（实际体重）提供，对于烧伤或者多发伤患者可能还要更高。 D
运动营养师》教学 计划（精） 运动营养师》教学计划 一、教学目的掌握有关营养的一般基础知识，建立正确的营养与运动观念，为指导人群运动、健身训练服务。重点要求掌握营养素的概念、热能消耗及计算、运动健身者营养的一般要求、不同人群的营养供应特点与运动的合理选择方式，了解增脂、减肥的营养补充与运动方式、运动损伤的康复等。在重视基础理论的基础上，突出与实际的联系。 、学时分配 65学时（其中面授55学时、辅导及考试10学时） 三、教学内容及基本要求 第一章营养与健康（6课时）第一节健康与亚健康概述 一、健康理念 1、健康的概念 2、健康的标准 二、亚健康 1、亚健康的概念 2、亚健康的表现 3、亚健康形成的原因 4、如何改善亚健康第二节运动、营养与健康（重点） 一、运动与健康
1、“轻体育”的概念 2、运动的益处 二、营养与健康 1、合理营养的概念 2、如何做到合理营养 三、营养膳食的合理性 1、中国居民膳食指南（2007） 第二章营养对健身运动的影响（12课时）（重点）第一节营养素与运动（重点） 一、宏量营养素与运动 1、宏量营养素的概念 2、碳水化合物、脂肪、蛋白质的组成、分类、生理功能、对运动的影响、食物来源、 如何补充及合理摄入量 二、能量与运动 1、能量的概念及单位 2、生热系数 3、人体的能量消耗 三、微量营养素与运动 1、维生素的概念及分类 2、维生素B1、维生素B2、维生素B6、维生素C、维生素E对运动的影响、食物来源及合理补充 3、矿物质的概念和分类 4、钠、钾、镁、钙、铁、锌对运动的影响、食物来源及合理补充 四、其他营养素与运动 1、膳食纤维的概念 2、膳食纤维的生理功能 3、膳食纤维对运动的影响及适宜摄入量 4、水在人体的分布 5、水对运动的影响 6、水的生理功能 7、运动中的合理补水 第二节健身运动的膳食指导（重点） 一、平衡膳食营养指南 1、平衡膳食的概念 2、平衡膳食的要求 二、健身运动膳食的基本要求 三、合理膳食营养的意义 四、膳食营养计划的制定1、中国居民膳食宝塔的概念 2、中国居民膳食宝塔的说明 3、中国居民膳食宝塔的应用