dairy products

Camembert, Roquefort, Stilton, Gorgonzola, and blue cheese Mexican-style cheeses, such as queso blanco fresco, since they are often made with unpasteurized milk

Breads, cereal, rice, and pasta

Breads, bagels, muffins, rolls, cereals, crackers, noodles, pasta, potatoes, and rice are safe to eat as long as they are purchased as wrapped, pre-packaged items, not sold in selfservice bins. Raw vegetables and fruits and fresh herbs are safe to eat if washed carefully under running water and lightly scrubbed with a vegetable brush.

Bulk-bin sources of cereals, grains, and other foods

Fruits and vegetables

Fresh salsas and salad dressings found in the refrigerated section of the grocery store. Choose shelf-stable salsa and dressings instead. Any raw vegetable sprouts (including alfalfa, radish, broccoli, or mung bean sprouts)

Desserts and sweets

Fruit pies, cakes, and cookies, flavored gelatin; commercial ice cream, sherbet, sorbet, and popsicles; and sugar, commercially prepared and pasteurized jam, jelly, preserves, syrup, and molasses are safe to eat. Drink only water from city or municipal water services or commercially bottled water. Pasteurized fruit and vegetable juices, soda, coffee, and tea

Unrefrigerated, creamfilled pastry products Raw honey or honeycomb. Select a commercial, grade A, heat-treated honey instead.

Water and beverages

Water straight from lakes, rivers, streams, or springs Well water unless you check with your doctor first Unpasteurized fruit and vegetable juices

Sun tea. Make tea with boiling water, and use commercially prepared tea bags. Vitamin- or herbalsupplemented waters. These provide little, if any, health benefit.
+

Adapted from Grant BL, Bloch AS, Hamilton KK, Thomson CA. American Cancer Society Complete Guide to Nutrition for Cancer Survivors, 2nd Edition. Atlanta, GA: American Cancer Society; 2010.

How to cope with common eating problems

Cancer and cancer treatments can cause many different problems that affect how well you can eat and drink. Here are some of the more common problems and tips on how to deal with them. Always tell your doctor, nurse, or dietitian about any problems you have. There are often things that can be done to treat the problem or keep it from getting worse.

Appetite changes
Cancer and its treatment can cause changes in your eating habits and your desire to eat. Not eating can lead to weight loss, and this can cause weakness and fatigue. Eating as well as you can is an important part of taking care of yourself. Treatment-related side effects like pain, nausea, and constipation can also cause loss of appetite. Managing these problems may help you eat better.

What to do
Eat several frequent snacks throughout the day, rather than 3 large meals. Avoid liquids with meals, or take only small sips of liquids to keep from feeling full early (unless you need liquids to help swallow or for dry mouth). Drink most of your liquids between meals. Make eating more enjoyable by setting the table with pretty dishes and playing your favorite music, watching television, or eating with someone. Be as physically active as you can. Start off slowly, and increase your activity over time as you feel stronger. Sometimes a short walk an hour or so before meals can help you feel hungry. Keep high-calorie, high-protein snacks on hand. Try hard-cooked eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna or chicken, or trail mix. (See the table of high-protein foods under "Tips to increase calories and protein" in the section "Once treatment starts.")

 Review the tips on adding calories and protein to foods, and include these in meals and snacks throughout the day. Eat your favorite foods any time of the day; for example, if you like breakfast foods, eat them for dinner. Ask your doctor what can be done to help relieve constipation, nausea, pain, or any other side effects you have.

Constipation
Pain medicines, changes in your eating habits, and being less active can cause your bowels to move less often and stools to become harder to pass (constipation). If you are constipated, try eating high-fiber foods. Also drink plenty of fluids during the day, eat at regular times, and try to increase your physical activity, if possible.

What to do
Try to eat at the same times each day. Try to have a bowel movement at the same time each day. Drink 8 to 10 cups of liquid each day, if its OK with your doctor. Try water, prune juice, warm juices, teas, and hot lemonade. (A hot beverage may help to stimulate a bowel movement.) If you are prone to constipation, try to set up a regular bowel plan. This may include an over-the-counter stool softener or psyllium fiber. Talk to your doctor or nurse about what to use. Use laxatives only as directed by your doctor. Contact your doctor or nurse if you have not had a bowel movement for 3 days or longer. If its OK with your doctor, eat high-fiber and bulky foods, like whole-grain breads and cereals, fruits and vegetables (raw and cooked with skins and peels on), and dried beans. Add these slowly to your diet to avoid bloating and gas. Eat a breakfast that includes a hot drink and high-fiber foods. Ask your dietitian to recommend a high-calorie, high-protein, fiber-containing liquid supplement if you need more calories, protein, and fiber. Limit drinks and foods that cause gas if it becomes a problem. (See list below.) To lessen the amount of air you swallow while eating, try not to talk much at meals and do not use straws to drink. Avoid chewing gum and carbonated beverages.

Foods that might cause gas

Beans and peas, dried String beans Brussels sprouts Turnip greens Milk Mushrooms Cucumbers Peppers Pickles Strong cheese Kohlrabi Rutabaga Broccoli Cabbage Radishes Melons Beer Eggs Corn Onions, leeks, scallions Mustard Collards Avocado Nuts Sauerkraut Cauliflower Spinach Apples (raw), apple juice Fish Asparagus Sweet potatoes Spicy foods Lentils

Gas might also be caused by: Chewing gum Not taking in enough fluids Drinking carbonated or fizzy drinks Not getting exercise Chewing with your mouth open Having constipation Eating a lot of high-fiber foods Eating foods and candies, chewing gum, and having drinks with sugar alcohols such as maltitol, mannitol, and xylitol (These products are often labeled sugar free or no sugar added.)

High-fiber foods to choose more often* Breads and cereals Bran cereals

Serving size

Dietary fiber (in grams)

cup

3-13

Popcorn Brown rice Whole-wheat bread Whole-wheat pasta Wheat bran, raw Legumes Kidney beans Navy beans Nuts Vegetables Broccoli Brussels sprouts Carrots Corn Green peas Potato with skin Fruits Apple with peel Banana Blueberries Pear with skin Prunes Orange Raisins Strawberries

2 cups cup 1 slice cup cup

5 6 1-2 6 6

cup cup 1 ounce

8 9 3

cup cup cup cup cup 1 medium

4 3 2 5 3 3

1 medium 1 medium cup 1 medium 3 1 medium cup 1 cup

4 2 2 5 3 3 3 3

*Adapted from Eldridge B, and Hamilton KK, Editors, Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago, IL: American Dietetic Association; 2004.

Diarrhea
Cancer treatments and medicines can cause your bowels to move much more often and become very loose (diarrhea). Uncontrolled diarrhea can lead to fluid loss (dehydration), weight loss, poor appetite, and weakness. Avoid high-fiber foods, which might make diarrhea worse. These include nuts, seeds, whole grains, legumes (beans and peas), dried fruits, and raw fruits and vegetables. You should avoid high-fat foods, like fried and greasy foods, too, because they can also make diarrhea worse. After stomach or bowel surgery, some people may be sensitive to very sweet or high-carbohydrate foods as well. Stay away from gassy foods and carbonated drinks, too. Be sure to sip fluids during the day to prevent dehydration. Once the diarrhea has stopped, slowly start eating foods with fiber.

What to do
Drink plenty of mild, clear, non-carbonated liquids during the day. Drink liquids at room temperature. This may be easier to take than very hot or cold drinks. Eat small, frequent meals and snacks during the day. Avoid greasy, fried, spicy, or very sweet foods. Limit milk or milk products to 2 cups a day. Yogurt and buttermilk are OK. Avoid drinks and foods that cause gas, like carbonated drinks, gas-forming vegetables, and chewing gum. (A list of foods that cause gas is in the section on constipation.) Allow carbonated drinks to become slightly flat before drinking by pouring them into a glass and letting them sit at least 10 minutes; pouring them over ice may also help. Drink and eat high-sodium (salt) foods like broths, soups, sports drinks, crackers, and pretzels. Drink and eat high-potassium foods like fruit juices and nectars, sports drinks, potatoes with the skin, and bananas. Increase soluble-fiber foods like applesauce, bananas, canned peaches and pears, oatmeal, and white rice. Drink at least 1 cup of liquid after each loose bowel movement. Try water, sports drinks, or bouillon. Do not chew sugar-free gum or eat candies and desserts made with sugar alcohol (i.e., sorbitol, mannitol, or xylitol). Call your doctor if diarrhea continues or increases, or if your stools have an unusual odor or color. What to eat or not eat when you have diarrhea* Eat High protein Foods that may cause problems

Baked or broiled beef, pork, Fried meats, high-fat cuts of chicken, turkey, veal, fish meats, meats with gristle Eggs, buttermilk, cheese, yogurt Dairy products other than buttermilk or yogurt

Breads, cereals, rice, and pasta

Bread and rolls made from refined, white flour; pasta; converted or instant rice Refined cereals like farina, Cream of Wheat, Cream of Rice, oatmeal, cornflakes Pancakes, waffles, cornbread, muffins, graham crackers

Whole-grain breads and cereals like whole wheat, oat, and rye; bran Shredded wheat Granola Wild rice

Fruits and vegetables

Soups made with vegetables Fresh, unpeeled fruit; pears; listed here: cooked melon asparagus tips, beets, All other vegetables carrots, peeled zucchini, mushrooms, celery Tomato paste, tomato puree, tomato sauce Baked potato without skin Canned, frozen, or fresh fruit

Desserts with nuts Drinks, desserts, and other Butter, margarine foods Mayonnaise, salad dressing, Coconut, dried fruit vegetable oil Chocolate, licorice Cake, cookies, flavored Pickles gelatin desserts, sherbet Popcorn Decaffeinated beverages Foods with a lot of pepper, Salt, pepper, spices, and chili seasoning, or taco gravy as tolerated seasoning; hot sauces
*Adapted from Eldridge B, and Hamilton KK, Editors, Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago, IL: American Dietetic Association; 2004.

Fatigue
Fatigue is feeling very tired all of the time. It doesnt get better when you rest. It can be a problem for some people during cancer treatment, and is very common. If you are feeling tired or lack energy, talk to your doctor or nurse. Fatigue can have many causes, including cancer treatments, not eating enough food, lack of sleep, depression, low blood counts, and some medicines. When the cause of the fatigue is medical, your doctor may be able to treat the cause to help you feel better. Along with treatment, there are many nutrition steps you can take and other things you can try to help you cope with fatigue.

What to do
Talk to your doctor or nurse about your fatigue. If the fatigue has a medical cause, there may be treatment for it. Your doctor or nurse can help you figure out self-care measures that may help with the fatigue, too. Try to prioritize your activities. Do the most important ones when you have the most energy. Take short walks or get regular exercise, if you can. More and more research tells us that being moderately active can help decrease cancer-related fatigue. Drink plenty of fluids. Dehydration can make fatigue worse. Be sure to get at least 8 cups of fluid each day. If you are losing weight, be sure to include some fluids that have calories, like juices or milk. Make sure you get enough rest. Take 3 or 4 short naps or rest breaks during the day instead of 1 long rest. Plan your day to include rest breaks, and make rest time special with a good book in a comfortable chair or a favorite video with a friend. Try to balance rest and activity so that it does not interfere with nighttime sleep. Try easier or shorter versions of your usual activities. Dont push yourself to do more than you can manage. Ask for a referral to a dietitian who can work with you to choose the best diet for you. Do not eat sugary foods. These foods give you a quick energy boost, but it wears off and you will be even more tired afterward. Try eating some protein, fat, and/or fiber with each meal and snack. Protein, fat, and fiber can help keep blood sugar levels more stable. This will give you a more sustained feeling of energy from the food you eat. For example, instead of eating 2 pieces of fruit, try eating 1 piece plus a small handful of walnuts, almonds, peanuts, or other nuts. Or try fruit with cottage cheese. Be sure to meet your basic calorie needs. (See Tips to increase calories and protein in the "Once treatment starts" section.) Do not take large amounts of vitamins or minerals without first talking with your doctor or nurse. Some dietary supplements can interfere with your cancer treatment, and large doses of some supplements can have harmful effects. Stress can make fatigue worse. Ask your health care team about stress management.

Mouth dryness or thick saliva

Radiation therapy to the head and neck areas, some types of chemo, and certain other medicines can cause dry mouth or thick saliva. The glands that make saliva can become

irritated and make less saliva, or your saliva can become very thick and sticky. Dryness can be mild or severe. A dry mouth can increase your risk of cavities and mouth infection. If you smoke or chew tobacco or drink alcohol, the dryness can be worse. If you have either of these side effects, drink plenty of fluids throughout the day and eat moist foods as much as possible. Also brush your teeth and rinse your mouth often with the baking soda, salt, and water solution to help keep it clean and prevent infection (recipe below).

What to do
Drink 8 to 10 cups of liquid a day, and take a water bottle with you when you leave home. (Drinking lots of fluids helps thin mucus.) Take small bites, and chew your food well. Eat soft, moist foods that are cool or at room temperature. Try blenderized fruits and vegetables, soft-cooked chicken and fish, well-thinned cereals, popsicles, smoothies, and slushies. Avoid foods that stick to the roof of the mouth like peanut butter or soft bread. Moisten foods with broth, soup, sauces, gravy, yogurt, or creams. Suck on sugarless candy or chew sugarless gum to stimulate saliva. Lemon drops often work well. Keep your mouth clean. Rinse your mouth before and after meals with plain water or a mild mouth rinse (made with 1 quart water, 1 teaspoon salt, and 1 teaspoon baking soda shake well before using). Use a soft-bristle toothbrush. It is a good idea to gently brush your tongue, too. Ask your doctor if its OK to floss. Avoid commercial mouthwashes, alcoholic and acidic drinks, and tobacco. Limit drinks with caffeine, like coffee, tea, colas, and chocolate. Use a cool mist humidifier to moisten room air, especially at night. (Be sure to keep the humidifier clean to avoid spreading bacteria or mold in the air.) Fresh pineapple may help to thin saliva, but only try this if your mouth is not sore. Saliva substitutes are helpful if your salivary glands have been removed by surgery or damaged by radiation therapy. These products add moisture to your mouth. Nutritional supplements, like liquid meal replacements, may be helpful. Talk to your health care team about this.

What to eat or not eat when you have a dry mouth*

Eat Foods that may cause

problems High protein Meats, poultry, and fish in sauces and gravies Casseroles, soups, and stews Breads, cereals, rice, and pasta Bread, rolls Cooked and cold cereals, cereal with milk Dry breads, rolls Pasta, rice Dry meats, poultry, and fish without sauces

Pretzels, chips Rice soaked in gravy, sauce, Cereal broth, or milk Fruits and vegetables Canned and fresh fruits that Bananas, dried fruit have a lot of moisture, like Vegetables, unless in a oranges and peaches sauce or with a high Vegetables in sauce moisture content Cookies, cake, pie, unless soaked in milk

Drinks, desserts, and other Club soda, hot tea with lemon, fruit-ades, diluted foods juices, sports drinks Commercial liquid nutrition supplements Homemade milk shakes; ice cream, sherbet, pudding Butter, margarine Salad dressing Sour cream, half-and-half

*Adapted from Eldridge B, and Hamilton KK, Editors, Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago, IL: American Dietetic Association; 2004.

Mouth or throat pain or sores

Some people with cancer may have a sore mouth, mouth sores, or a sore throat. These problems are usually caused by certain chemo drugs and radiation to the head and neck area. If you have these problems, eating soft, bland foods and lukewarm or cool foods can be soothing. On the other hand, foods that are coarse, dry, or scratchy may make you feel worse. You may also find that tart, salty, or acidic fruits and juices; alcohol; and spicy foods are irritating. Rinse your mouth regularly with a salt and baking soda solution (1 teaspoon of baking soda and 1 teaspoon salt mixed in 1 quart water). This helps prevent infections and helps your sore mouth feel better. Gargle with the mixture to relieve a sore throat.