Nutrition During and After Colorectal Cancer Treatment, with Suzanne Dixon, MPH, MS, RDN, and Julie Lanford, MPH, RD, CSO, LDN

ASCO: You’re listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO, the world’s leading professional organization for doctors that care for people with cancer. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement. Cancer research discussed in this podcast is ongoing, so data described here may change as research progresses. In today's podcast, Suzanne Dixon and Julie Lanford discuss nutrition during and after treatment for colorectal cancer, including ways to manage side effects and guidelines for eating with a colostomy. Suzanne Dixon is a registered dietitian and epidemiologist in Portland, Oregon. Julie Lanford is a registered dietitian in Winston-Salem, North Carolina.  ASCO would like to thank Ms. Dixon and Ms. Lanford for discussing this topic. Suzanne Dixon: Hi. I'm Suzanne Dixon and I'm an epidemiologist and a registered dietitian, and I have a really long history of working in cancer care and I'm really passionate about making sure that people get good information that's based on facts and not fear. And I'm here with my friend and colleague, Julie Lanford. Julie Lanford: Hey, everyone. I'm Julie and I am also a registered dietitian. I've been an RD for about 13 years, and almost all of that time has been spent helping people facing cancer. I also have a master's in Public Health, and I'm a board-certified specialist on oncology nutrition. Suzanne Dixon: Well, thanks, Julie. I wanted to say thanks to ASCO, from both Julie and I. We're really excited to be here to discuss this topic of nutrition for people who are going through colorectal cancer treatment and also for colorectal cancer survivors who may be finished with treatment. So those are the topics we're going to tackle, and talking about how to help people eat well and get the nutrition they need to get through treatment. So I'll get started by talking a little bit of a brief overview about why good nutrition is so important for people with colorectal cancer who are going through treatment or perhaps after treatment. We know that cancer treatment, for a number of different types of cancer, but certainly, for a cancer like colorectal cancer that affects the digestive tract, that can diminish a person's ability to eat well. And there are other symptoms that might pop up that can even affect how the body digests food and uses nutrients. And we worry about something in the nutrition community called unintentional weight loss. In other words, losing weight without trying. And this is really different from when someone diets to lose weight intentionally. And unlike weight loss by choice, unintentional weight loss, or losing weight without trying, during colorectal cancer treatment can be harmful to your health. And I'm sure, Julie, you've probably heard this, too. And I've spoken with lots of colleagues who have worked with patients who want to put a positive spin on cancer-associated weight loss. Maybe they've been told they should lose weight by their doctor in the past for some other health issue, and they might even say something along the lines of, "Oh. Well, it's terrible I have cancer, but at least I'll lose a few pounds." And I think that really comes from the fact that a lot of the general public is dieting or trying to lose weight at any 1 time. And so a lot of people think any weight loss is good weight loss, and that includes even during cancer treatment. But unfortunately, that is not true. And what we do know is true is that, if you lose weight without trying during cancer treatment, meaning you're taking in less calories and protein than your body needs in order to maintain your current weight, it can make your treatment a little bit harder and sometimes even a little bit less effective. So you might think, "Okay. What's going on here? Why would that be the case?" And what happens is, with cancer, we know that the body doesn't necessarily respond to weight loss in a healthy way that it might do if you were, say, just dieting on any given day. And that's because stress of the treatment itself and stress of the cancer, that's very stressful on your body, can actually lead to the body not using fat for fuel. And so this is something that a lot of people don't realize. They might think, "Well, I have excess body fat, I'll just lose that weight. It'll be fine." But we know that the fact that the body can fail to use fat for fuel can be true even in people who are carrying excess body fat. And so I think it's really important for people to take away from this that, even if you have "extra body weight", it doesn't protect you as you're going through colorectal cancer treatment from the negative effects of unintentional weight loss. And that's because if you're not burning that fat for fuel, then that means you're burning lean tissue. And that's the healthy stuff, which is made up of muscle, bone, organs, red blood cells, white blood cells, platelets, other immune cells, all kinds of tissues. Those all are part of what we call lean tissue. And that explains why losing weight, if you're not trying to lose weight, during cancer treatment can be so harmful. For sure, you're going to feel a little bit weak and fatigued if you lose that muscle mass, but those very cells and tissues, that lean tissue that I mentioned? The red and white blood cells and all the other healthy tissues that you need to keep your immunity and your body strong through treatment can be depleted. And so this is where we worry about that unintentional weight loss maybe leading to more severe side effects from the treatment. And sometimes your physician might need to reduce the doses of your treatment or schedule breaks in your therapy, which makes recovery harder and makes it hard to reach your treatment goals. So that's kind of the baseline that we start from and lays the groundwork for why nutrition is such an important component of your care and why it's so important to make sure that that's something you think about as you're going through colorectal cancer treatment and as you're recovering even after treatment. So Julie, I'm going to turn it over to you for a minute here. And I wanted to hear a little bit about, what have you seen when you're working with patients in terms of symptoms that you feel are challenging and make eating difficult? Julie Lanford: Yeah. So it's definitely true, us oncology dietitians, we get very nervous when people lose weight, and it's not something that we want to necessarily see, especially during treatment. Every person is different. Their type of cancer, their type of treatment, how they tolerate it are all going to be different. The symptoms they may have during treatment can change with time, and so I actually find it helpful to start just by helping patients understand what the role of nutrition is during treatment. Since it's nota treatment for cancer, but it helps to support the healthy cells as much as possible. Treatment targets the tumor and then your nutrition plan helps to make sure that your body is well-nourished. So while we're looking at that, each person who's coming in, we're going to have to assess, "What are the challenges that they're facing individually?" and try to develop a plan based on that. Suzanne Dixon: Yeah, that's an excellent point, Julie, just the idea that everybody's different. And I think that's really important for anybody going through colorectal cancer therapy or any other type of cancers, that you might hear some ideas or things that people suggest that you do to help with your nutrition during treatment. And it's good to keep in mind exactly what you said about everybody's different and that we can't assume that what might be right for one person is right for another. So knowing that, say someone is coming in for the first time and they've received a colon or colorectal cancer diagnosis, and maybe they're getting started in treatment. What do you do when you first meet with them? Julie Lanford: Yeah. So once somebody comes in—oftentimes they're referred by their medical care team, and there's already an issue identified, but a lot of times I like to sort of start at the beginning and try to compare what their usual intake and their usual weight is to what they're currently looking at. So maybe somebody has lost weight, but they didn't realize it because it's possible that they lost a lot of weight before the cancer. Sometimes that's what's actually brings somebody into the doctor is that they say, "I'm losing weight and I'm not trying to," and then that's when they start looking at what the problems are. So rather than thinking, necessarily, just about, "Well, how much weight have you lost since treatment?" we want to look at, "How much weight have you lost over time from what is usual for you?" So we start with that, and then also looking at, "What are they able to eat? Are they able to eat a normal diet they usually eat? Are they not able to eat anything at all? Or are they having to sort of change the types of foods that they're eating?" And then we try to identify what kinds of symptoms might be causing their eating challenges, and that really is why you want to work 1-on-1 with an oncology dietitian because then you can start troubleshooting based specifically on what's going on. Suzanne Dixon: Yeah, that's a great point, just making sure that people understand that it's both about if they've lost weight in response to treatment but even coming into treatment. I think a lot of people do come in and they don't think about the fact that maybe they've lost 10, 20, 30 pounds even before they were diagnosed. So when someone walks into your office, what are some of the common side effects that you seem to find in those colorectal patients? Julie Lanford: So when I'm working with people, a lot of times the 2 top things that a lot of people are facing challenges with are not having much of an appetite and/or feeling tired or fatigued to the point where they either don't have the energy to prepare foods or they just don't feel like eating because they're so tired. And so those are pretty common. What I usually tell people is that actually, to help address both of those issues, we usually suggest eating five or six small meals a day in order to get nutrition without getting tired out by trying to eat a huge meal. A lot of people do feel overwhelmed by a large meal, but if they can eat small amounts throughout the day on a regular basis, that will still give them the calories their body needs. Also to keep high-calorie, high-protein snacks on hand is something that is always helpful. So having things like nuts, avocados, fruit, some kind of granola bar that's easy to eat, just something that's around all the time, that's easy to grab, so that you don't really have an excuse to not have something to eat. Some people will keep nutrition supplement drinks like Boost or Ensure in case they don't feel like having a meal, but they are willing to kind of take calories by liquid. And then when it comes to fatigue, what I tell people is try to rest when you're the most tired. And then when you're less tired, use that time to be physically active because physical activity has actually been proven to help increase energy, which sounds a little bit crazy, but that's how it works. Same thing with fatigue is to have meals and snacks available to you and making sure that you're eating several times a day because your body won't be able to have the energy it needs if you're not eating. So both of those things are kind of similar in their strategies for getting enough intake. So I was curious, Suzanne, though, what are some of the challenges and tips that you share with your patients about side effects? Suzanne Dixon: So as you said, everybody's individual, and I agree. I do see people with the poor appetite and the fatigue that you mentioned. But I've also seen a lot of patients over the years who have taste changes and mouth sores, which sometimes go together and sometimes don't. Sometimes you can have one or the other, or both at the same time, which can be a challenge. And I completely agree with your ideas around small, frequent meals and snacks, and kind of, as you said, more of what we call eating by the clock. Don't wait for a meal time per se because that appetite might never come. And especially if things don't taste right, or your mouth is sore, and that you have a lack of appetite, you're definitely not going to want to kind of let time go by and then think, "Oh, I need to eat lunch." Well, lunch might be too big, so you should be probably snacking throughout the whole morning. So I also encourage people to keep those high-protein, high-calorie foods readily available in the fridge, or on hand, as you said. Maybe something portable if they're leaving the house, not to leave without food, to keep some of those things with them in their purse or their bag. And I, at home, encourage things like eggs, chicken, fish, beans, nuts, lean beef, high-calorie liquids, smoothies, things like that. You could throw some fruit juice in a container, throw in a scoop of protein powder, shake it up, and drink it. That's the easiest kind of protein drink. Or you could make a straight-up smoothie where you throw some fruit, maybe some banana, and some other types of fruits that you might want to throw in there, or some frozen fruit like cherries, or those sorts of things. Peaches, maybe. And you blenderize them up with some juice or milk or whatever liquid that you might like. Throw in a protein powder, just a basic whey protein. Anything like that would be great. And just blenderize that all up, and you can kind of sip on it all day. I think for mouth sores, sometimes people feel challenged because it doesn't feel good to eat if your mouth hurts. And so I always encourage people to work with their medical team to make sure that their pain and their mouth sores are medically-addressed appropriately. And I encourage people to realize that just because a particular medication works for one patient doesn't mean it's going to work equally as well for you. And there are lots of options, so I always say, "If your mouth hurts so badly that you're just absolutely unable to eat, call your doctor or your nurse right away." There's all kinds of different pain medications available. Pills, patches, suspensions. There's oral mouth rinses that people can use to kind of numb the mouth a little bit, and you might want to time those so that you do that rinse, and then you eat when that pain control is at its absolute best. And we want to make sure that patients understand that, that if that pain control isn't good, communication is key. They need to let their doctor or nurse know because, typically, those folks are going to start with some standard medications for things like pain control or sore mouth. And if you don't tell them that, you're not getting good pain control, they're going to not know that and they're just going to assume they're fine. So I really do encourage people to keep up that dialogue with their physician and nurse, and to use some common sense tips about sore mouth type problems such as bland, soft, room-temperature foods, usually not hot or extremely cold. Maybe oatmeal, yogurt, casseroles with a lot of moisture in them, shredded chicken in broth, pasta with olive oil. The noodles can kind of slide past the mouth sores, that sort of thing. Applesauce, smoothies. And I always encourage, for the mouth sore part, any food that doesn't have seeds. You want to avoid the berries and the fruits with lots of seeds because those can get stuck in your mouth and irritate the mucous membranes a little bit. So you want to make sure that you kind of stick with those smooth fruits like the bananas, the peaches, those kinds of things, in your smoothie. And for the temperatures—I said room temp is good, but of course anything that requires cooking for food safety, so that would be things like the casseroles and the things with the meat and other types of foods in them that need to be cooked to be consumed, be sure to cook them thoroughly according to directions, and then you can let them cool down to room temp to avoid irritating your mouth. And of course, avoiding hard, crunchy things. If your taste is off, you can certainly do things like granola bars, and nuts, and those sorts of things. But if your mouth sores are really problematic, then you want to avoid those particular foods because they're crunchy, they're kind of poke-y, and they can make your mouth a little bit worse. There's some really unique taste changes that can happen for folks who are going through treatment. For example, a metallic taste in the mouth. Sometimes just using plastic utensils can diminish that a little bit. You don't want to stick a metal fork in your mouth if it already tastes a little bit metallic. Marinating meats, chicken, fish, lean beef, those kinds of things, in different types of flavors that you might not normally think of. Because those foods can taste kind of metallic in your mouth when you're going through certain types of chemotherapy. So fruit-based sauces, sometimes, something a little sweet on that, will take away that metallic. Some people even put a little jelly or jam on their meat to kind of kill that metallic aftertaste. And I just say experiment. If you are dealing with taste changes and you don't have mouth sores, you can experiment with things that are a little bit more acidic like lemon, or vinegar, lime. Those sorts of things can really pep up the taste and get rid of some of those nasty tastes that might come from the chemotherapy or radiation, those kinds of things. But I always say, don't use those acid foods if you have mouth sores. It's too irritating. But also look for other tips to keep yourself away from food smells, so staying out of the kitchen when food's prepared so that you don't kind of get that smell and that taste up in your nose and your mouth before you're ready to eat. A lot of people say things are overly sweet, so they might say, "Well, I don't really like a Boost or an Ensure, or one of those kind of liquid supplements. They just taste too sweet." You can take one of those and throw in something a little more tart, like frozen cranberries or a little bit of powdered coffee to one of those chocolate or vanilla types of supplements so that you get more of like a mocha flavor. It's not quite so sweet. So just asking yourself, "Do I feel like salty? Do I feel like sweet?" and just experimenting and trying whatever you feel like eating that day, I think that's really important for people to remember. There's no one right answer for everybody. And I wanted to turn a little bit and think about more—a little bit lower down in the digestive tract, so GI issues. And these are things I think a lot of people don't want to talk about. Sometimes patients are a little bit embarrassed to admit that their GI tract is doing weird things, things like constipation and diarrhea. That's not usually part of our polite conversation, but what you need to realize is embarrassment is definitely not going to get you the help you need. And the other thing is all of your healthcare providers deal with this type of stuff with their patients every single day, day in and day out, so there's nothing wrong with bringing up changes in your bowel habits, those kinds of things. So Julie, what do you see often if a patient comes in and they kind of hint around that maybe their GI tract isn't functioning quite so well? Julie Lanford: Yeah. You know, I think that GI issues are really common for people in cancer treatment in general, but especially for patients in colon cancer treatment. Diarrhea can be a significant issue, especially if you're having radiation. But a lot of the chemos, that's certainly a side effect. What I really recommend for people is to pay attention. You may need to track, because you might not realize how many bowel movements you're having a day. And one of the key things with diarrhea is making sure that you stay well-hydrated. So especially if you're on chemo, the last thing you need is to be dehydrated. And you lose a lot of fluids with diarrhea, so making sure that you increase your fluid intake to add any lost fluids back. If they're having constant diarrhea, finding sports drinks or a way to get electrolytes, even things like—Pedialyte is formulated for kids, but some way to get electrolytes back into your system, making sure to communicate with the medical team about that, avoiding caffeine and fizzy drinks. Usually, those can kind of irritate it a little bit more. Making sure to have small meals. I feel like I've already said that [laughter] couple of times so far today, but that really is a strategy that helps. Bland, salty foods, like pretzels, crackers, broths, soups, can help get some of those electrolytes while also replacing fluids. But yeah, Suzanne, what kind of tips do you have? Suzanne Dixon: Well, you touched on, a little bit, the importance of talking to your medical team. And I mentioned this too, but making sure you start that discussion with your physician if that medication isn't working the way it should. A lot of times, as you said, we expect that folks might suffer from a little bit of diarrhea or maybe a lot of diarrhea, and you may be given some medications to manage that. And again, keeping in mind that kind of what the standard medication is that maybe works for 80% of people with this particular problem, it may not work for you. So I think it's perfectly fine for you to perk up and tell your physician, "I know you gave me this medication for my diarrhea. I'm taking it just like you said, but I still have—" as you said, maybe you track it. "I still have eight watery bowel movements a day." That's not good. We don't want to see that, because it really can make it hard for you to stay well-hydrated, keep your electrolytes normal, and get the nutrition you need. So I think that's really important. And Julie, once that medical management is addressed, what do you do with helping people with their nutrition? Julie Lanford: Yeah. So hopefully, the medicine will actually kick in and make sure that people are digesting and absorbing nutrients during their treatments, and they can kind of get, at least, to a stable place with the diarrhea. And then what happens is sometimes they get the diarrhea under control and then their body tends to move towards constipation. And so it can be really challenging for people once they figure out, "Oh, I think I have a strategy that works," and then another issue comes up. So once it comes to constipation, again, being in touch with the medical team is really important, and making sure that if you are having constipation, just like diarrhea, you want to keep track of when your last bowel movement was, what's the consistency, is it painful, and then making sure to communicate and not wait too long. Because once somebody waits a long time, it's hard to get those bowels moving again. So it's really important to just keep that open communication with the medical team. With constipation, we really want to make sure people are eating food on a regular basis because your GI tract isn't going to work if you're not putting things into it, drinking plenty of fluids, so that's pretty consistent across the board. If it's possible, and you tolerate fiber, getting enough fiber will help. Being physically active. But if the constipation is a result of pain medication, a lot of times, our dietary strategies may or may not be effective, but you really need to be on some medical management for that. Suzanne, what kinds of things do you usually recommend for constipation? Suzanne Dixon: Well, I agree with what you said about pain-management. Some of those pain medications and anti-nausea medications can contribute to constipation. And sometimes our food recommendations can make a big difference with that, but for other people, they don't make as much of a difference. So if you are prescribed any kind of medication to help manage a side effect, like constipation, you want to make sure that you follow those instructions and do it as directed. And Julie, as you mentioned, I think it's really important to let your physician know that you're having this type of problem and if the medication isn't doing the trick for you because, as you said, once that problem gets really entrenched and you're really kind of backed up, so to speak, and you haven't had a bowel movement in several days, it's challenging to get that fixed. And so we don't want people to struggle to the point where they end up—what we call impaction, meaning they need to work with their physician to maybe have that stool mechanically removed, which nobody wants to go through that. And so we always encourage people, if you haven't had a bowel movement in a couple of days, make sure you let your physician know so they can up your medication or find other ways to control your pain that maybe aren't a medication that cause so much constipation, that sort of thing. And once that's all taken care of, as far as just using the diet in addition to those medical managements, fluid is really important. You mentioned that maybe sometimes people might take a fiber-containing product, or getting more fiber in their diet. Fiber only works if you get lots of fluids. I always tell patients, "Fluid, fluid, fluid. Get plenty of water or other liquids in your diet so that everything can kind of move through your digestive tract." And then the other piece is that I think it's helpful to know the different types of fiber in the diet and what they can do for you. So there's soluble and insoluble fiber. And soluble means it's dissolvable in water. It gets sticky or gooey when it gets wet. So oats are a great example of this. If you pour some liquid into your oatmeal, it actually thickens up and gets gooey. And that's soluble fiber. Now, insoluble fiber is just the opposite. It doesn't really absorb much water, and it doesn't really change much when you add a liquid to it. So I always think, "If you dropped a carrot stick or a celery stick into a glass of water, what would happen?" Not much. It just sits there because it's insoluble. It's a really different type of fiber. And so for constipation, we know that a combination of both soluble and insoluble fiber can help quite a bit. And for diarrhea, getting back to that topic, soluble fiber only is kind of where we head for people to go with their intake. So it's kind of interesting that fiber can be used at both ends of the GI spectrum, whether your GI tract is moving too slowly, with constipation, or too rapidly with diarrhea. Just remember soluble fiber only for diarrhea, and a combination of those two for constipation. And so some places you might a soluble fiber for food—and again, you want some of this for constipation, and only this for diarrhea. Oats in oatmeal, applesauce, lentils, pears, really finely ground flax seeds—not whole, because then it acts a little bit more like an insoluble fiber and it goes through too fast. Barley, really well-cooked barley, or white rice. If you cook it with a lot of extra water and you get this kind of stickiness to it, so you get this real, kind of globby, sticky white rice, that can really slow things down a little bit in the digestive tract. But insoluble fiber, again, what you're aiming to get some of this in for your constipation—and you would want to avoid this for diarrhea. But if you are going towards managing constipation, you add some insoluble fiber, which has things like whole wheat and wheat bran, rye-based breads or crackers, nuts and seeds, raw or lightly-steamed vegetables, berries. Those seeds that I mentioned earlier with the mouth sores? Those are good for constipation generally. Those berries have a little bit more fiber in them. And when you look at things like beans and peas, a lot of people think of beans as being very fibrous, and they are. They contain both soluble and insoluble fiber. And then in terms of kind of maybe picking a fiber product, like something like a Metamucil, or that sort of a product, you would want to work with your physician because there are some situations that could be worsened by adding in a fiber product. So you want to make sure that you're safe to add that in. If you have an infection or a small bowel obstruction, fiber will make that worse. So we want to make sure that you talk to your doctor before you do any of that stuff on your own. Julie Lanford: You know, if somebody wants to, or if they're told that they should take a fiber supplement, I think it is important that the medical team actually be specific about what type of fiber to look when you're purchasing a product, because there are some that claim, "You can add it to any liquid and it won't thicken up." But I find that the ones that don't thicken up aren't particularly beneficial, depending on [laughter] which issue you're dealing with. So you may want the gritty fiber supplement if you're trying to deal with constipation. But yeah, you definitely need to pump lots and lots of fluids if you're going to take those fiber supplements. So I feel like the progression on this since we're talking about all these bowel movements [laughter], is to talk some about colostomies because some people will have parts of their GI tract removed, and then they made have to use a colostomy. So just to explain a little bit about what a colostomy is, so essentially what happens is if somebody has to have surgery to either remove part of their GI tract, in order to eliminate stool from the GI tract, they may have to put in a temporary or a permanent exit for the stool to come out. And so the ostomy is where post-digested food would then exit the body, and then it's into a bag that's then emptied by the person who is having to use that device. And while it might be temporary for some people, for some people, it's actually permanent, but either way, there are some really great, I think, guidelines for eating after a colostomy. And most people kind of figure out what works for them and what doesn't, but especially in the beginning, as far as food goes, we really want to be cautious with adding something that might cause some discomfort or that the output would be difficult to handle. So we generally guide people to stay away from things like corn or popcorn, raw vegetables, the skins and peels of fruits and vegetables, because those can sometimes be the most difficult-to-digest pieces. And since part of the GI tract or the colon has been removed, it's extra-hard to digest, and you might not actually digest them at all, and that's why they show up in the bag as output. So we recommend kind of being really cautious with the foods that you start with, avoiding some of the gas-producing foods, broccoli, cauliflower, beans, peas. A lot of people know which foods tend to be more gas-producing. It's not to say that someone with an ostomy can never have those. It's just, especially when you get started and kind of try to figure things out, you want to err on the side of not having them. And then if you do want to add them eventually, you might start by blending or just having a tiny bit of it to test it out and see if it works for you. Suzanne, what do you tell people when it comes to colostomies? Suzanne Dixon: Yeah, I agree completely with those guidelines. Anything that you think of as kind of tough and fibrous, like all those raw fruits and vegetables, or corn, popcorn, peas, beans, all that sort of stuff, salad—you know, think about lettuce. Popular vegetable these days is either cauliflower or kale. Those are kind of 2 hot vegetables that people are always, "Oh, you need more cauliflower and kale." Those are tough to digest, so I really would encourage people to think about not having those for a while if they're first new to having a colostomy. And as you said, Julie, it doesn't mean you can never have it. If your colostomy's permanent, you can probably work your way up to some of that stuff, but you're going to want to do that slowly. Another piece of advice I think that most of us don't think about is to chew your food really thoroughly. And this takes a little bit of effort. I can admit myself that sometimes I sort of eat really rapidly and don't chew my food as much as I should. I know a lot of us, we're in a rush. We often just swallow our food without chewing it at all, and it's remarkable that our digestive tract, generally speaking, can handle that just fine, and that's because some of the action of digestion is due to enzymes, but some of it's due to kind of mechanical action called peristalsis, and your GI tracts squeezes and contracts and pushes food through, and that helps break it down, even if you haven't chewed it very well. However, if you're missing a piece of your GI tract, you're missing a piece of that digestive work that gets done, and so that means if you don't chew food thoroughly, it will show up in your ostomy bag as a piece of food. And I think the best example—and some people might think, "Oh, this is gross. Don't talk about this," but it really is true. Summer season comes. People eat corn on the cob and they joke about that—they look in the toilet after they've gone to the bathroom and there's corn pieces floating in there. That is exactly the type of food we're talking about that can be so difficult for someone with an ostomy. And so we really tell people to limit those things and to chew even the foods that are a little more easily digested. I can't even stress enough how much we need to chew our food more than we do, and especially if we have a colostomy, because that can go a long way towards breaking it down right there in your mouth and preventing some of those potential blockages of the bag. We don't want that to happen because then you can get leaks and other unpleasant things like that. And the gas-producing foods are good to limit, especially when you first have an ostomy bag, to see how your body responds because, of course, you don't want a lot of gas production. It can blow up the bag, make it harder to manage, so we really do encourage people to kind of go easy on their digestive tract and stick to some of those softer, blander foods, and to chew everything really thoroughly, meats, things like that, chicken, fish, beef. If you're having those kinds of foods, chew those pieces really well, cut them up small, and make sure that you kind of give your digestive tract that little advantage of letting your teeth do some of the work first. Julie Lanford: Right. I think we sometimes forget that just chewing is the first part of the process of digestion, and so that's why buying things that are blended or pureed ahead of time, or doing that yourself, kind of helps to make sure that, instead of eating peanuts, if you have peanut butter, it's already blended and kind of broken down before you even start to eat it. And so it can be just a little bit extra step to help your body digest it more effectively. Suzanne Dixon: Right. Yeah, I totally agree. I think we all forget about the fact that a big part of our digestion takes place in our mouth. So, I wanted to ask you a few questions, Julie, about long-term health. So we've got folks that have gone through treatment, and they're doing well, and they want to kind of transition back to their regular eating pattern. And so what do you do to guide people towards healthy, long-term dietary changes for their best, healthiest, cancer survivorship? Julie Lanford: Yeah. So especially with colon cancer, I think the challenges are that a lot of times, what we typically recommend for a healthy diet, especially after treatment is over, might not be something that people tolerate right away because of all these digestive issues. So I do just want to encourage those survivors out there who might be having digestive issues that we can tailor a diet to whatever challenges someone's facing. So while the current recommendation is that we want people to eat lots of fruits and vegetables and plant foods, I recognize that sometimes that's not possible. So I usually work with my client individually to figure out, "Well, what is kind of their best choice, given their challenges?" So for some people, they need to eat cooked vegetables. Some people need to always have blended vegetables. And in some cases, this is kind of the one time I might recommend that someone juice as opposed to blend their foods because, if they don't digest it very well, juicing is maybe the best option that they have. Suzanne Dixon: Yeah, that's a great point. We don't generally, as dietitians, promote a lot of juicing because you lose the fiber and other good components of the food. But of course, if you can't digest fiber, at least you can get those nutrients with some juicing without irritating your digestive tract. That's a great point. So as we're moving to the end here, Julie, do you want to kind of summarize some of the key takeaways? Julie Lanford: Yeah. What I would say is that since everybody has their own kind of individual issues, that I would just encourage people that you want to remember that your nutrition does matter. You want to stay well-nourished because that's going to improve your body's ability to tolerate and respond to treatment. There are so many dietary tips and tricks out there that you want to, as much as possible, kind of pick the ones that work for you, be in touch with your medical team, ask for a referral to an oncology dietitian, if you need that, and then once treatment is over, really try to work to find a nutrition plan that works for you. Suzanne Dixon: That's a great point. I like that. One-size-fits-all is not the approach. You definitely want to tailor things for your own needs. So it's really been great talking with you today, Julie, and I hope that a lot of patients can benefit from this information. Julie Lanford: Yeah, this was really fun. Suzanne Dixon: Thanks. ASCO: Thank you, Ms. Dixon and Ms. Lanford. Learn more about colorectal cancer at www.cancer.net/colorectal. And if this podcast was useful, please take a minute to subscribe, rate, and review the show on Apple Podcasts or Google Play. Cancer.Net is supported by ASCO’s Conquer Cancer Foundation, which funds breakthrough research for every type of cancer, helping patients everywhere. To help fund Cancer.Net and programs like it, donate at conquer.org/support.