Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week, Dr. Foss and Dr. Chagpar welcome Claire Criscuolo and Maura Harrigan.
Foss              We are here today to talk with our guests about healthy eating around the holidays, which I am sure is a subject we are all interested in hearing about.  Could you start off by introducing yourselves and telling us a little bit about yourselves, perhaps we could start with Claire?
Criscuolo      Thank you, this is going to be a great conversation.  My name is Claire Criscuolo and I am from Claire’s Corner Copia. It is a 37-year-old vegetarian restaurant across from old campus at Yale.  I am just a big fan of real food, good food, and fresh food and we prove every day that you can enjoy it and still have room for indulgences.
Foss              Maura, you are on the other side of things, which is helping us to learn how to eat properly.  Can you introduce yourself and tell us what you do?
Harrigan       Yes, thank you and thank you for having me here.  I am a registered dietitian and I am also board certified in oncology nutrition, so I deal with cancer survivors mostly, who are seeking out ways to eat in a healthy manner after their diagnosis.  I think Claire and I are very much on the same page with how to approach healthy eating and I have been a big fan of your store and menu Claire for many years and it shows that good eating and good business go hand-in-hand, and good food.
Chagpar        This is a big issue not only for cancer survivors, but for all of us. Maybe we could start Maura, with you telling us a little bit about cancer survivors.  Do they have particular nutritional needs and dietary restrictions that they need to be thinking about?
Harrigan       Good eating is a great tool to feeling better after cancer treatment and a lot of people come to the Survivorship Clinic seeking nutrition information, but oftentimes they come with a lot of misinformation, so clarifying where they get their nutrition information from is often job one, and often they come seeking out use of supplements, so over 90% of cancer survivors go to supplements for good nutrition.  My job is to get them to realize that they can get their full good nutrition through whole foods and I know that at Claire’s Corner Copia, she has all those foods which is wonderful.
Foss              Claire, can you tell us a little bit about what made you decide to open a vegetarian restaurant here in New Haven?
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Criscuolo      Actually I did not start out as a vegetarian restaurant.  I really wanted to have whole food, real food and food from everyone’s grandmother’s table, I think fearing that we were going to forget our heritage and forget our beautiful food histories, but then I gravitated back to a vegetarian diet on a personal level and that is when I started doing more reading about health and nutrition and prevention and I am fascinated by the possibilities, and that is why we eliminated meat and we eliminated smoking in the restaurant in 1976.  So, it sort of evolved from that.
Foss              Claire, you used to be a nurse, is that correct?
Criscuolo      Yes.
Foss              So, how did you go from being a registered nurse to opening your own restaurant?
Criscuolo      I am a big fan of prevention and my mother raised me always saying, why don’t you have a nice apple?  Eat this, it is good for you, and she always seemed to have a home remedy for things and later I learned how much sense they made, for instance,  squeezing lemon on your spinach, it helps metabolize the iron, and these are things that I think our parents and grandparents instinctively knew and again, it is a part of listening to your body, and I love it and I really fell in love with the prospect that we can get people to eat better, and still enjoy it and have a little fun.
Chagpar        Tell us a little bit about what choices we should be making?  And how we can make those choices?  Especially when we want to eat healthy but we also want to enjoy the season.
Harrigan       We always have to remember that food is meant to be enjoyed, particularly around the holidays. There are lots of traditions that need to be honored and celebrated.  So I always encourage people to manage their eating through the holidays first through moving more, moving your body more, getting out for walks, exercising, so that you can eat.  So keeping your activity going through the holidays is very important. Then the second tool, to use a dietitian term, portion control.  Have the foods, but be mindful of how much, enjoy it, and then go for a walk.
Chagpar        Claire, you had mentioned earlier that there were ways of not losing that indulgence, so how might we be able to indulge while still keeping in mind all of those healthy aspects that you were talking about?
Criscuolo      During the holiday time I think the biggest struggle is managing parties.  You are invited somewhere, so offer to bring something, offer to bring something like a huge salad, a gorgeous dip, something lovely like a really good roasted organic bell pepper hummus with organic corn chips, something that is high in iron and fiber, but something that is still delicious. Bring something festive like a punch, brew blueberry herb tea, and mix frozen blueberries and strawberries and maybe chop an apple in it, put a couple of cinnamon sticks in it, and then bring it in a jar along with a bottle of Pellegrino water and maybe a lemon and then put it together and you
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have a fabulous punch that is low in calories. You are getting your fruit in, you are working on eating healthy foods, or maybe if you want to bring a dessert, dried figs with dark chocolate chips and almonds, bake it in orange juice, that is just amazing and high in fiber and tastes like a total indulgence. You could also make a cake, but make it into cupcakes, make little cupcakes, like fairy cakes, and then someone could have one and you feel so satisfied especially if you use good ingredients.  If you are using organic eggs, good King Arthur unbleached flour, and making things from scratch from real food, I think you are more satisfied and you do not need as much of it and it does not hurt to have a huge glass of water before you leave the house to go to a party.
Foss              Claire, you are giving us some really great recipes here.  Can you talk to the average person out there say who has never been a vegetarian cook or who has not tried to be adventurous with their cooking? Can you give us some clues as to how we start, how does one actually begin being a vegetarian or cooking like a vegetarian with healthy foods?
Criscuolo      I think the easiest way is to transition, at the risk of using a totally non-vegetarian phrase, do not go cold turkey.  You really want to gradually introduce changes into your diet, so for instance, if you are going to a party and you know there is going to be a lot of cheese and crackers and you want to bring something that has some cheese in it, bring something that is lower sodium and lower fat like a nice ricotta cottage cheese surrounded with slices of organic apples and drizzle it with honey and sliced toasted almonds.  Also, when you are learning how to cook, go easy on yourself.  Master one recipe and make that one recipe every single week until you are so good at it that you barely have to look at the recipe. If I am making lets say a soup, or I am making a sauce, and I am not sure if I want to change the herbs in it, what we do at the restaurant, and what my mom used to do, is we take little cups and set them out on the counter and then put a pinch of each herb inside each cup and then taste it and then you could try a new herb and you might say, you know, I do like curry after all, that is a spice, but maybe you do like tarragon after all or rosemary, and then if you do not like it you can say that is not going to work and you do not feel like you have made a mistake.
Chagpar        Talking about all of these recipes and bringing these great dishes to your host’s home sounds fantastic, but all of us, around the holiday season in particular, but in life in general, we are really busy and I can imagine cancer survivors especially, people going through treatment, people who have just completed treatment, they have got a million other things that they are doing. How do you advise people to try to incorporate all of this great advice into what is otherwise a very chaotic and busy life?
Harrigan       That is one of the biggest obstacles, dealing with time management and it really starts with a good food shop and sitting down and taking the time to think about what you are eating, plan out some meals.  Write out a good food shopping list and we do that at the Survivorship Clinic.  We have food shopping lists that we share with people and encourage people to go into the grocery store, bring these healthy foods into their home and surround themselves and create a healthy food
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environment. Then it is easy to grab something on the go, because you are surrounded by healthy foods and I encourage them to create this healthy food environment in their home, in their car, as they are driving to work, in their office, so they have good food and healthy snacks in their drawer, so they always have it on hand and that way they are not skipping meals, which sets you up for overeating and for sugar cravings.  But when you back it all up, it all comes down to a good food shop and making the time for that and people come to that realization and they see the value of that.
Foss              How important is it for us to be shopping organic, to be buying organic meats or organic vegetables?
Criscuolo      I think it is very important.  We follow the guidelines of the Environmental Working Group at Claires, and of the Union for Concerned Scientists.  I think that less pesticides has to be better, less fungicides and herbicides has to be better, and I know they are expensive, believe me I struggle with that at the restaurant, but you could save money other ways.  Make your own yogurt.  If you eat two cups of yogurt a day and you make your own yogurt, you could save a thousand dollars at the end of the year.  So use that money towards it.  Make your own cleaning supplies.  I will give you the recipes; they are right on our website.  I give it away for free and that will save you money and then you can put that money towards it, but I think it is very important for children, for adults, for people who are well, for people who are trying to be well. 
Harrigan       I would just like to add to that the Environmental Working Group does put out a list called the ‘Dirty Dozen’ where buying organic makes a difference.  You do not have to buy organic across the board and for many people the cost of buying organic is prohibitive, and so rather than have them not eat fruits and vegetables because they feel they cannot afford organic, I do point out the ‘Dirty Dozen’ list, but also encourage them to practice good food safety with their produce, how to clean food, how to properly store it and that all decreases the risk of food borne illness.  So there are ways around it, but I agree with Claire, the more we can do it the better but the cost sometimes gets in the way.
Foss              We are in Connecticut where we have a lot of farming and there are farmer’s markets around as well, do you talk about those with patients and do you find patient’s gravitate in that direction?
Harrigan       Yes, in fact there is what is called the CSAs, they are Community Support Agriculture and they are these co-ops where you can buy shares and I encourage a lot of the women who come through the survivorship clinic and their families to join these and that opens up a whole new world of cooking and they will get a whole crop of greens that they have never even seen before and then they want to know, how do I cook this, what do I do with kale.  So that is a wonderful way to increase fruits and vegetable in a fun way.
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Foss              And sometimes, like in my town, you can actually volunteer to work on the farm as well for your share.
Harrigan       So you get your exercise too.
Chagpar        That is right.  We are going to take a break for a medical minute, but please stay tuned to learn more information about healthy eating with Claire and Maura.
Minute          Breast cancer is the most common cancer in women.  In Connecticut alone approximately 3000 women will be diagnosed with breast cancer this year, but there is new hope. Earlier detection, non-invasive treatments, and novel therapies provide more options for patients to fight breast cancer.  Women should schedule a baseline mammogram beginning at age 40 or earlier if they have risk factors associated with the disease.  With screening, early detection and a healthy lifestyle, breast cancer can be defeated.  Clinical trials are currently underway at federally designated comprehensive cancer centers such as Yale Cancer Center to make innovative new treatments available to patients.  A potential breakthrough in treating chemotherapy resistant breast cancer is now being studied at Yale combining BSI-101, a PARP inhibitor with the chemotherapy drug irinotecan.  This has been a medical minute brought to you as a public service by the Yale Cancer Center.  More information is available at yalecancercenter.org.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.
Chagpar        Welcome back to Yale Cancer Center Answers.  This is Dr. Anees Chagpar, and we are joined today by our guests Claire and Maura who are here to help us discuss healthy eating and cancer. Maura, before the break we were talking a little bit about your role in the Survivorship Clinic and how important healthy eating is. One of the questions that we always get asked is, as a cancer survivor, what should I be eating? Or as somebody who may be at high risk of developing cancer, is there anything that I should be eating that might help me prevent cancer? Or conversely, what foods that if I eat them will lead to cancer? Can you help us to sort out some of the facts and the fiction around diet and cancer?
Harrigan       Yes, you are talking about two different things, prevention and survivorship, but really the eating is the same and what we promote is predominantly a plant based way of eating.  Now, it does not have to be all the way vegetarian but we promote that if you are looking at your plate and think of your plate, you want 2/3 of your plate filled with foods that come from plants, fruits, vegetables, whole grains, legumes and you want 1/3 or less of your plate coming from animal sources.  So in that way I often say we use meat as a condiment, and we want our plate filled with colors, and colors is a short hand way of getting to the science, but if you are looking at all your fruits and vegetables and incorporating as many colors as you can, what you are capturing are all of the phytonutrients which are compounds that are only found in the plant kingdom and those are the
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compounds that impart the color.  So when you eat by color, you are actually capturing the healing power of food.  So that works for both cancer prevention and also as a survivor.
Foss              If you are going to eat meat, like a lot of folks in our audience do, can you instruct us more specifically, are there particular meats that we should and should not be eating and how much meat should we eat every day?
Harrigan       There are some people who think we should not eat any meat during the day.  You can eat without meat and receive your proper amount of protein from plant foods.  In fact, the typical American diet is too high in protein and often people receive nutrition misinformation where they are told to eat more protein as a way to the get in shape.  They are often told this misinformation in gyms by trainers and so people tend to consume a lot more protein than their body actually requires, so that is often a big change for people, to rein in the protein and make it a high quality protein.  My first choice would be plant based proteins, legumes, and in any one of Claire’s cookbooks, you have a recipe for every type of legume there is.  We promote fish, salmon for the omega 3 fatty acids, occasional chicken, skinless, and we really minimize the use of red meat.  It is really a preference.  If you really love it and have to have it, it is an occasional meat.
Chagpar        Claire, I know that you have been very involved with the cancer community in a variety of ways.  Tell us some other things that you do both in terms of education as well as starting to push on the research agenda and helping to get the word out about research.
Criscuolo      Over the years we have employed some young people who have had cancer.  So we have seen that cancer affects so many people we love and care about and we decided that we needed to more than try to make them healthy and teach them about eating well.  We needed to have more money for research because we see the numbers, we see how many people are alive today, and have battled cancer and have overcome cancer, and I know it is because of the research and I know that if we put enough money into research, we will find those cures that we are waiting for.  I feel confident of that and I am going to do as much as I can to help that.  We have something called ‘Coins for Causes’ at Claire’s.  Also what I have done this year is any money I get for any speaking engagements, I mean I already have a job, so I donate it to research and I am a big fan of Smilow, honestly because of Anne Worcester. After that I said, the gloves are off we are going to do everything we can.  I am never going let a day go by without talking about the need for more research for cancer.
Foss              You were also in the Fit Walk.  Can you talk about the Fit Walk Program?
Criscuolo      That is actually how I got to meet Anees, which was very nice.  Shannon Schneider started this.  It was one week and we had to walk 10,000 steps a day which is not easy, even for those of us who
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do a lot of walking, or think we do a lot of walking, because if you have to sit at a desk, if you have to write papers, it is really difficult to accomplish that, but we wore this Ultra Fitbit, and it monitored how many steps we took and then you had to report it on a computer.  So if you were inclined to cheat you could have, I had many staff who offered to wear it for me, but I could not do it, but it was a wonderful way of convincing the community and telling your friends and sharing the information that fitness matters and besides, if the five of us who were asked to wear this for one week finished it, the Fitbit people were going to present a 5,000 dollar check to Smilow.  So there was no way I was not finishing it.
Harrigan       I would like to add about the power of the pedometer, once you put one of those on it really makes you very aware of how little you actually move during the day and I am Project Director of the LEAN study which is Lifestyle, Exercise And Nutrition and one of the tools we have with the women in the study is the pedometer and the goal is 10, 000 steps a day and that is one of the biggest eye opening experiences and so many women say to me, I thought I was active until I put that pedometer on and to get to the 10,000 steps a day requires a lot of thought and thinking of how to maximize your movement during the day. We also have another goal which is 150 minutes a week of walking in addition to the 10,000 steps a day on the pedometer and those are two independent measures that we use because what is important for cancer survivors, and all of us, is weight management.  We can’t really talk about food without talking about the other side of the equation which is moving your body.  The two go hand in hand and pedometers are one way for everyone to get up and move more and take break from sitting at the computer.
Chagpar        Maura, it is fabulous that you mentioned the LEAN study and I think certainly exercise and diet are something that our School of Public Health is looking at in a variety of studies.  Can you tell us more about some of the other studies that cancer patients and cancer survivors can get involved in? And maybe a little bit more about what exactly the LEAN study is?
Harrigan       I will start with the LEAN study which is lifestyle, exercise and nutrition as I said, and it is a weight loss study for women who have completed treatment for breast cancer and want and need a way to lose weight and we do it through a combination of healthy eating and also moving your body more, as I said. With those simple goals of 150 minutes a week and the 10,000 steps a day on the pedometer, our goal is a 10% weight loss from the their starting weight and most women when you say that they will say, oh no, I want to lose more and I remind them that 10% really is a gift of health to your body.  If you lose that 10% and keep it off, you have reaped all the medical benefits from that weight loss, so it makes it very doable and we are getting great results and what the women say when they start eating a predominately plant-based way of eating, they eat less meat, they move their body more, the first thing they say is, I feel better and they love that and when you feel better you can deal with everything else better, you are stronger, and then they start to see the weight come off.  So, that it is very rewarding to work with women in the LEAN study and another study through the School of Public Health is called the HOPE study and that is for women who have been treated for breast cancer who are on a type of medication called aromatase inhibitors,
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and a side effect of the aromatase inhibitors is joint pain and muscle pain.  So, this HOPE study is deigned to use exercise as a way to manage the side effects of the aromatase inhibitors.  We are getting great results from that.  Many women who go on these inhibitors experience the side effect and it almost immobilizes them.  They describe it as having aged overnight and their inclination is to stop moving, and our study has them moving more and they find when they move more that it lessons the side effect in the medication and allows them to stay on the medication and reap the benefit because they ideally want to stay on the medication for at least five years.  So that is a long time to deal with joint pain.
Foss              Are there programs like that for other cancer survivor's, patients with lungs cancers and other solid tumors for instance who had surgical treatment and need to recover, or who finished chemotherapy? Are you recommending the same kind of exercise, walk 10,000 steps and eat a healthy diet?
Harrigan       Yes, there is another study for ovarian cancer survivors.  It is the Walk Study, but it is the same principle of eat smarter and move more as a way to achieve weight management because when your body is at a healthy weight your body works better.
Chagpar        The other thing too is that with the Survivorship Clinic, which I found most impressive, it is open to people with malignancies of any sort, and it is a truly multidisciplinary approach as I understand, with the physical therapist as well as yourself a dietitian, and a social worker and an oncologist who really work as a team to look at all of those aspects, how do we get patients to move more and eat better and get in touch with their life and have all of the medical benefits of the treatment plan going forward.
Harrigan       That is true, the beauty of the multidisciplinary team at the Survivorship Clinic is we have the opportunity to treat the whole patient in all aspects of their care and identify what their particular obstacles are to adopting healthier lifestyles and we see men and women with all cancer types and a particularly needy group in terms of cancer survivors, are those survivors of head and neck cancer because they often have to make modifications to the texture of their food.  They have difficulty chewing, swallowing, and there are some safety issues there.  So coming to the Survivorship Clinic allows them to be able to make adaptations to their diet and still get all their nutrients and again, feel better.
Foss              Claire, there are patients that we treat who are undergoing chemotherapy that lose weight and they need more protein.  You have given us some great recipes, can you advise on ways that we can help those patients? What can they be eating, what innovative things can we do with plant-based protein to help these folks?
Criscuolo      I think everyone loves soup, and I think it makes you feel good, it is warm, and it makes you feel nurtured.  I think starting with bean soups, whether it is a black bean soup or kidney bean soup,
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beans are just so healthy and they are so rich in protein, fiber and magnesium and they are very satisfying. I am not adverse to organic egg and having an olive oil, pan fried organic egg is just wonderful and you could have that with lots and lots of vegetables.  I think we need to look at food in a different way in terms of a meal; we do not need to start out with the salad, go to the soup, and go to the pasta dish or the meat entree.  Instead, maybe start with a half of a baked butternut squash, and if you pressed for time, put it in the microwave, it takes 2 minutes, cut side down, a little water on the bottom of the dish, flip it upside down when it is cooked and sprinkle some cinnamon on it.  That will at least make you feel satisfied while you are waiting for the meal.  But I think in terms of protein, I do not know if you recommend soy, I know there are some issues, but unprocessed soy, I am still a fan of tempeh, and you get that wonderful chewy texture and it is a source of protein, I am a big fan of organic tofu, you could change the texture by freezing it and then defrosting it and squeezing all the water out and then crumbling it almost like crumbled beef.  Looking at protein in a different way and looking at food in a different way, looking to make those vegetables choices whether you are eating at home or whether you are eating out, plan ahead, like you were saying Maura, be prepared, keep your freezer filled with things that you can eat, keeping you freezer filled with organic berries so that you can make a smoothie, and plain Greek yogurt is loaded with protein and you get those probiotics, it has calcium, it is so creamy and wonderful and you can get it fat free.  Some things like that but like you said being prepared and being open to try something new and I am thinking about how wonderful you are going to feel afterwards, even if you do not feel great when you first start.
Claire Criscuolo is the owner of Claire’s Corner Copia in New Haven and Maura Harrigan is a registered dietitian for the Adult Survivorship Clinic at Yale Cancer Center.  If you have questions or would like to add your comments, visit yalecancercenter.org where you can also get the podcast and find written transcripts of past programs. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.