Dr. Cynthia Thomson is a Professor in the College of Public Health and holds joint appointments in the College of Agriculture and Life Sciences & the College of Medicine at the University of Arizona. Dr. Thomson received her Ph.D. from the Interdisciplinary Program in Nutritional Sciences, University of Arizona and completed NCI-sponsored post-doctoral training at the Arizona Cancer Center with a focus on diet and cancer prevention. Her research emphasis includes dietary intervention in breast and ovarian cancer survivors, as well as behavioral interventions for weight control and metabolic regulation. She was appointed as the Director of the Canyon Ranch Center of Prevention and Health Promotion at the Mel and Enid Zuckerman College of Public Health a center whose mission is to support a healthier Tucson community.
Caryn Hartglass: Hello everybody, I’m Caryn Hartglass and you’re listening to It’s All About Food. It’s December 16, 2014, and we have another great show lined up for you today talking about my favorite subject–food, and its relationship to one of my favorite diseases, cancer. And we’ll get into that in just a moment. I wanted to remind you, as I usually do, that my non-profit is Responsible Eating and Living, and I hope you visit our site responsibleeatingandliving.com. We have some fun things at this site; I will tell you a little bit more about that later. And any time you have a question regarding this show, anything related to food, please send me a message at email@example.com. I love to hear from you, I love your comments, and I haven’t invited you to message me recently so I thought I might remind you to do that. Great. Shall we get started? So, I want to bring on my guest, Dr. Cynthia Thompson, who is professor in the College of Public Health and holds joint appointments in the College of Agriculture and Life Sciences, and the College of Medicine at the University of Arizona. Dr. Thompson received her PhD from the interdisciplinary program in nutritional sciences at University of Arizona and completed NCI-sponsored post-doctoral training at the Arizona Cancer Center with a focus on diet and cancer prevention. Her research emphasis includes dietary intervention in breast and ovarian cancer survivors as well as behavioral interventions for weight control and metabolic regulation. She was appointed as the director of the Canyon Ranch Center of Prevention and Health Promotion at the Mel and Enid Zuckerman College of Public Health, a center whose mission is to support a healthier Tucson community.
Welcome to It’s All About Food, Dr. Thomson!
Dr. Thomson: Oh thank you very much, I’m glad to be here.
Caryn Hartglass: When I saw your recent research publication article in the Journal of National Cancer Institution on diet and ovarian cancer, I thought, “I need to talk to this person.” I was very excited to see that.
Dr. Thomson: Yeah, well there’s not much out there, and so you’re right, it is exciting to have an opportunity with the women’s health initiative to have enough information and enough cases to really start to tease this out and figure out what’s going on.
Caryn Hartglass: So important, I can’t underline how important this is. I know this intimately because I was diagnosed with ovarian cancer in 2006; here I am eight years later, thriving–
Dr. Thomson: Wonderful!
Caryn Hartglass: Yay me, I’m alive! And, it’s not by chance, and it’s not by luck. There were a lot of different things that contributed to my surviving and thriving, and a big piece of that is diet and nutrition. I’ve been immersed in health and diet for a long time so I had access to a lot of information when I was diagnosed. But still, it was so difficult to find information! So when I saw this study, I went, “Yay, let’s talk about this, let’s dig in, and see what you discovered.”
Dr. Thomson: Well, basically, with this analysis, what we did was–it’s not a trial, just to be clear–we looked at data from a large sample of 151,000 postmenopausal women who were in the women’s health initiative, and what was in that cohort, we looked at just 600 women who had developed ovarian cancer. We looked at what their diet quality was before they were diagnosed. So they had told us what they were eating a few times over the course of the observation, and we said “okay, if we look at the quality of that diet, does it predict survival?” And basically what we found was that the women who recorded higher-quality diets had a 27% lower mortality rate over the period of follow-up. So just about eight years, and we found a significant benefit from the diet.
Caryn Hartglass: So that’s a very significant number, and it comes from… I don’t want to say general data, but it’s not really fine-tuned because it wasn’t a specific test where you could really determine what you wanted to look at. You were just taking what you could from data that was already established.
Dr. Thomson: Yeah, so what happens with a lot of these large observational trials, people fill out what’s called a food frequency questionnaire. And these have about 100-150 line items where people tell us what they eat, when they eat it, and how frequently they eat it, and when they eat it, what’s their portion: small medium or large. Then from this, we developed a score: a diet quality score. And we applied what’s called the healthy eating index score. What it does is, it has 10 different factors that it evaluates and then people are given high or low scores depending on how much they eat. So, how much total vegetables, how much total grains, how much total saturated fat, how much total cholesterol, and that becomes a composite score. That composite score tells us the quality of your diet. The advantage of doing that over saying, “Oh was it broccoli or was it grapefruit or was it whole grain?” is, people eat whole diets with a variety of different foods, and while it’s interesting and maybe exciting for the cherry industry if we find that cherries are good, it really doesn’t help people because you can’t eat a diet that’s 100% cherries. So, the quality score really says that it’s all about getting healthy things in and fewer healthy things out and making sure that day in and day out, the quality of your overall diet is healthy.
Caryn Hartglass: So here’s what I like about that message. There are more pharmaceutical companies and supplement companies that want to sell us specific things, like a vitamin, or some concentrated nutrient from something that they say will improve our health or reduce our chance of cancer, or shrink our tumors. But, the message that we really need is that it’s our overall diet of a variety of all the right foods, less of the wrong foods, that’s going to make a difference in our health!
Dr. Thomson: Absolutely. And, it also gives people permission to say, “If I don’t want to eat broccoli today, I don’t have to eat broccoli today, but if I want to, I can” to really say, I can individualize how I get a quality diet.
Caryn Hartglass: Now, this was pretty general, and I know from my own experience that I honed in on some very specific foods because my understanding was they had tremendous power in fighting cancer and boosting my immune system, like cruciferous vegetables and mushrooms and things like that. So does a study like this encourage future studies so you can hone in on which of these foods do more good and which of these foods do less good?
Dr. Thomson: Well this study definitely supports the idea that we need to work with ovarian cancer survivors in trying to improve their diet. It also speaks to the fact that people should always think of a quality diet in terms of primary prevention, and understand that what you do today, tomorrow, when you’re in your 20s or 30s, matters when you’re 50 or 60. So I think it sends a few messages. In terms of finding magic foods, this analysis is not going to give us magic foods. In fact, I don’t think we’ll ever have the studies where we take a 100,000 women and put them on a high-mushroom diet for 20 years and go “okay, mushrooms matter, we have lower rates of ovarian cancer when people eat mushrooms.” And I doubt we’re going to have the studies where we take women diagnosed with ovarian cancer and give them mushrooms and look at outcomes, just for mushrooms. But I can tell you that we have a very large trial going on right now in ovarian cancer survivors, we call it the Live Trials: the Lifestyle Intervention for ovarian cancer and cancer survival. We’re really testing healthy habits and whether they make a difference in terms of prognosis after you’ve been treated for ovarian cancer.
Caryn Hartglass: Who’s participating in this study? I’m just asking because I’m a survivor and I don’t know about it.
Dr. Thomson: So this study is really recruiting people through what we call the gynecological oncology group and the NRG. So these are clinics throughout the nation who participate in clinical trials related to cancer. It’s one of the few that’s really focused on cancer and lifestyle. Many of the trials are trying new drug therapy and therapeutics, but this one is lifestyle. It is targeting women between 6 weeks and 6 months of finishing treatment. So we’re really trying to hit that window early, right after treatment, because that’s when we feel that women are ready to try something new, not totally overwhelmed, which can happen when you’re going through treatment, as you probably know. Yet, if we go too far out, what happens is we get kind of a biased sample of people who survived the disease and we can’t really tease out the effects of this healthy lifestyle. So we’re really targeting, and it’s very exciting that the ovarian cancer community has really stepped up. We’re probably just under 500 women that we’ve recruited in around two years and that is phenomenal for a national trial. Now, why a national trial? Because, the good news is, while ovarian cancer occurs way too much in too many women, it actually is one of the less common cancers, and any one side of the country would have a hard time recruiting over 1,000 women within a reasonable time period. So we hope to finish recruitment within three and a half years; we’re shooting for around 1,080 women. They’ll be randomized some on this trial, and we’re hoping we’ll have some answers within five years. But it takes time, unfortunately.
Caryn Hartglass: Yeah it takes time, it takes money, but I believe that for the most part, the information you’re going to find out will apply to not only ovarian cancer, but also other cancers, and other chronic diseases as well.
Dr. Thomson: That’s what we generally find, and we always tell people that yes, the message of healthy eating can be complex, but the good news is, pretty much across the board there are certain behaviors that hold true whether it’s cancer you’re trying to prevent, or diabetes, or cardiovascular diseases, or hypertension strokes. The message is pretty consistent and it starts out with getting to a healthy body weight, and try to maintain it. Do your best to be physically active while you eat healthy, and then start feeling that those eating habits to make sure you’re getting all those nutrient dense foods that you need.
Caryn Hartglass: Now a lot of people are confused about what a healthy diet really is, and I don’t even know that we would agree, but there are many things that most of us who promote a healthy diet, one way or another, will agree on. I think the majority of things that are important.
Dr. Thomson: I think you’re right, we all have our individual viewpoints on what constitutes a healthy diet, and these indexes, like the healthy eating index, guide us so we have some consistency in comparing with people across the world. But yes, I would say I have a bias towards vegetable more so than fruits, or I have a bias towards leafy vegetables more so than iceberg lettuce. Like you said, we don’t have a study, a lot of the basis for our feeling towards certain foods that are healthy come from smaller mechanistic research which says if you do this…
Caryn Hartglass: You’re getting a little fuzzy in the sound; I’m not sure if something’s changed in where you are or what you’re doing–
Dr. Thomson: I don’t think so, is that better?
Caryn Hartglass: That’s better!
Dr. Thomson: Okay, so I won’t move from here. But, I think that it’s important that we realize that foods have a variety of different compounds in them that can be health-promoting, and those compounds act in our bodies in a variety of ways to improve our health. So if you eat something like onions, it may reduce your rick of viral infections, it may promote immunity, it may also reduce inflammation; you have to remember that variety buys you not just a variety of nutrients and vital chemistry, but it also buys you a variety of kind of targets mechanistically that help you have a higher level of health.
Caryn Hartglass: Now when I was diagnosed, I consulted with a number of different, very reputable doctors, and I will never forget some of the responses I got from some of them that I really didn’t respect, and one of them really said that food had nothing to do with my outcome; he said it didn’t really matter what I ate, and I didn’t pursue or keep up with him after, because i knew differently. And I recently heard, I was speaking with a cancer doctor from Memorial Sloan Kettering recently on this show, and she was saying that many of her colleagues really rely on hard science. And that’s hard to come by!
Dr. Thomson: Yeah. Well, a couple of things. One is, if you’re looking for hard science, and by that meaning hard cancer outcomes, you’re talking trials that are hundreds of thousands of people; cancer is a rare disease, particularly ovarian cancer. So you just cannot fund, in a five-year cycle, trial after trial testing different food compounds. It’s not going to happen. And even when we try to do whole diet intervention, with or without physical activity, if you look at the number of trials that are funded that do these behavioral interventions, they can be few and far between in comparison to drug trials because the perception is the drug trial is going to give us a homerun, and the diet trial won’t. I always find it intriguing because, for example, a colleague of mine Rowan Chlebowski was at the San Antonio breast cancer conference last week and presented his data on women’s intervention nutrition study conducted over twenty years ago, low-fat diet, and what he’s finding is that 56% better survival all these years later in women who had triple negative breast cancer, who were on the low-fat diet. And they lost a modest amount of weight; we’re not talking a lot, you know, four to six kilos, not a huge weight loss, but that small amount of weight loss in a postmenopausal woman through a low-fat diet cuts the rate of recurrence in half. That’s pretty powerful drug therapy, in my opinion.
Caryn Hartglass: Has that been published, or was that just an observation?
Dr. Thomson: The original data was published about ten years ago, the shorter term; he just published this in abstract form at the meeting, but knowing Rowan, it will be out in literature within the next several months. So I think part of it is, we don’t have nutrition as a standard component in medical education. When it is there, it tends to get less attention because there’s a lot of things they need to learn and I respect that. But then what happens is, the assumption is if we didn’t learn it, it’s not important. That kind of concerns me, and I think somehow we need to convince the medical profession that diet is not to be all curative, that’s not what we’re talking about; what we’re talking about is the potential to extend life, quality of life, reduce recurrence rates–the evidence is certainly mounting for lifestyles in terms of diet and physical activity. And we at least need to be aware of where we are with that literature.
Caryn Hartglass: You used the word perception before when you were talking about pharmaceutical companies and drugs versus lifestyle research, and more of the funding goes toward the pharmaceutical because we perceive it will have a greater impact. I think that’s such an important concept because I don’t agree. I think that lifestyle is primary, and the diet is primary, and it starts even before we’re born.
Dr. Thomson: Oh absolutely. And I think increasingly we know that. But changing that perception is going to take evidence, and a larger and larger body of evidence to have a major paradigm shift in our approach.
Caryn Hartglass: Okay, so let’s talk a little bit about you and how you got into studying about ovarian cancer and nutritional science! How did you make the connection and realize that this was such an important topic?
Dr. Hartglass: You know, I think for me, I grew up in a home where we always had gardens and we ate healthy. My parents set a good precedent for me to be physically active and eat healthy. I actually contemplated medical school, and then realized–I was a registered dietician, I was working in the hospital setting back in the days when we first started doing bone marrow transplants, and one day I said, “You know this is tough, patients going through BMT suffer quite a bit during the process, and I would really like to prevent cancer.” And you know, to my benefit, and I guess maybe a bit fortuitous, the Arizona Cancer Center at the time had the leading cancer prevention researcher in the nation, Dr. Gabe Albert, running the cancer prevention control program. So I went and met with him and that was at the time when the Wins trial that I mentioned earlier as well as the women’s healthy eating and living trial, both of those, and breast cancer survivors’ diet interventions, were just getting off the ground and moving forward. And my skills as a dietician were obviously beneficial in terms of moving those trials forward at our university site. Once I started, I was… addicted, so to speak. I loved the opportunity to work with survivors, to help them make informed choices, to help them have an impact on their quality of life and their longevity, and I’ve never looked back. Now it’s just a matter of more and more reward as we develop this body of evidence, it’s going to be so important to changing how we treat survivors of cancer.
Caryn Hartglass: And what’s next for you? Are you working on some new research in this area?
Dr. Thomson: Well, the live trials that I mentioned is really a huge trial that we’re undertaking now. We’re about halfway through recruitment, have about 500 women across the country, and we’ll be recruiting up to 1,080, recently got funded to look at blood samples from those women to see what are the nutrients in those samples that may be protective, what impact are we having with diet and physical activity on inflammation, on insulin and glucose metabolism, body weight and adiposity. So we’re going to be looking at a number of different things to show what the mechanism is and how are these things working. Because that is something our research and medical colleagues want to know–how does it work. Even if we do get the magic bullet and find that we have a huge impact on progression pre-survival, there are still going to be those who want to know how do we do that. So we’ll be studying all of that.
Caryn Hartglass: The women who are involved in these trials, are they just reporting what they’re doing, or are you recommending that they follow certain guidelines?
Dr. Thomson: So half the women are given kind of the general guidelines on healthy eating and physical activity, sleep, and wellness, and the others are given a more intense telephone counseling to make specific behavioral changes. So it’s kind of a comparison group, there isn’t really a control group. It’s kind of, here’s what we tell people in the standard of care, and here’s the group where we’re going to rev it up a little bit higher and see if that makes a difference. So at the end of the day we can help people.
Caryn Hartglass: So without a control group, when you publish the study, are people going to respond well to it or criticize that you didn’t have a control group?
Dr. Thomson: Yeah, so you have to look at the change by group over time. And we think we’re going to have enough difference across the groups over time that it will be fine. The issue that you have to balance is, you have people who have been diagnosed with, as you know, a disease that does not generally have a great prognosis. So to tell a woman, “We’re having this healthy eating and physical activity study, and we don’t want you to do anything. Just sit on the couch and eat burgers and fries, whatever” is not really ethically the approach we want to take. so what we want to do is say, “Okay, this is the standard of care.” We tell people eat five a day, say 30 minutes of activity a day, you know, the standards that are out there. And then now with this group we’re going to see if it matters if you do more.
Caryn Hartglass: By five a day, that’s five fruits and vegetables?
Dr. Thomson: Yeah.
Caryn Hartglass: I do know a number of doctors who, over time, wanted to show that their approach really had an impact on one illness or another, and because of that fact where they had to have a control, they didn’t want to subject some of the people in their trials to doing something they knew wouldn’t be healthy for them.
Dr. Thomson: Yeah exactly. So we end up with comparison groups instead of two control groups.
Caryn Hartglass: All right, so I’m curious, what is the intensive version of this study?
Dr. Thomson: Well I don’t want to go into a lot of detail in terms of contaminating the comparison, but certainly it’s based on the current recommendations to being physically activity daily, making sure you get enough vegetables and fruit, making sure you monitor your fat intake and your fiber intake, and so all of those things are considered. Then it really is providing women with a higher level of support to motivational interviewing to really make those changes in the world that they live.
Caryn Hartglass: Well sometimes just knowing that there are people out there supporting you can make a tremendous difference in the outcome.
Dr. Thomson: Absolutely! And we’ll be looking at that, and we’ve pretty much designed this so there’s pretty equivalent support in terms of contact with patients and making sure that we care about them and we’re concerned about their welfare, so absolutely that’ll be something that we’ll be able to look at, the number of telephone calls women participated in, or the number of clinic visits they kept. Those sort of things we’ll track, to see if contact also may be influencing the overall outcome.
Caryn Hartglass: Has there been anything in your nutrition research that has surprised you in its outcome?
Dr. Thomson: I think not surprised me as much as frustrated me. A lot of times what happens in dietary trials is we get the healthiest people. So if I hang a shingle and say come be on my diet trail, whom do I get? I get the women who have probably tried to keep a healthy body weight and tried to stay active and tried to eat her vegetables or fruit. And in reality what I want is everyone. I want the burger king to be vegan. I want to get the variety of different approaches people take to their diet and their activity because that’s the real world I want to translate this information to. And so if anything I think my message would be, if you had an opportunity to participate in a lifestyle study, don’t rule yourself out because you think you might not eat very healthy, or you think you might not be very active. You are the exact participant that we want to support in making these changes.
Caryn Hartglass: I’ve never heard that before, but that’s actually a fascinating point, and I can see how people individually make that assumption, “I’m not right for this study because I’m doing all the wrong things.”
Dr. Thomson: Yeah, actually that’s the perfect candidate because more likely to improve their health over time.
Caryn Hartglass: Well, I’d love to participate in one of these lifestyle studies. Where do you find out about them?
Dr. Thomson: So the live trials is actually in the national cancer institute database and I know I’ve had a lot of women contact me by email over the last two years checking their eligibility, trying to find out more about the trial. We’ve been out talking to people at the National Ovarian Cancer Coalition meeting [30:29], we have it on websites. So we’ve been trying to promote it and it seems to be working because we’ve certainly had really favorable recruitments in a very short time period compared to a lot of other trials.
Caryn Hartglass: You know you mentioned wanting to get that broad spectrum of people who eat at Burger King to the vegans, and I’m a long term vegan, but even among vegans, there are unhealthy vegans and healthy vegans–there’s a wide range just in that tiny category. It’s so complicated.
Dr. Thomson: It is, and I always say, we do have our Twinkie vegans.
C: I’m just curious, what do they serve at some of these National Coalition meetings when it comes to food?
Dr. Thomson: You know, that’s another interesting hot topic. I go to a lot of different cancer meetings and it’s a gamut as you know. I will put in a plug–we have a group here at the integrative medicine center where Every year we put on a nutrition and health conference, and it’s one of the few conferences I’ve been to where we have used the break times and the mealtimes to educate. So one break could be like teas of the world, and drink different teas and the benefit of teas, and another might be the dark chocolate and cocoas of the world, and the lunch would be maybe serve up something like salmon with whole walnuts chopped over, glazed with kale, butternut squash, and lime juice. We really do everything in our power to send that message. I think that’s something that’s really important. I have another meeting I’m involved with for the Mediterranean diet and health, it’s going to be in January here in our nutritional sciences department, and again, the message is food matters and you need to use those break opportunities to train people up on how to eat healthy. But, anyone who’s done meeting logistics knows that it adds a level of complexities to what you’re trying to do, but I think people probably learn as much from these breaks at these meetings when you do it right, as they do from the meeting content itself.
Caryn Hartglass: Well, we’ve come a long way but we have such a long way to go because if you go to any kind of anti-smoking conference or lung association something or other, they’re not going to be serving cigarettes and cigars at that meeting. And yet we have so many cancer related or health-related conferences where they’re serving cancer-promoting foods, not health-promoting foods.
Dr. Thomson: I think it’s getting better, but–
Caryn Hartglass: Well I was just at the Head and Neck Cancer cancer conference keynote morning extravaganza event in New York City a few months ago, this was sponsored by the Memorial Sloan Kettering, they were celebrating their 100th year anniversary of the Head and Neck Cancer department, and the break time, I mean it was a disaster! It was white flower food, sugary foods, everything was white and flour, and cream cheese, and it was cancer food.
Dr. Thomson: I think a lot of times the meal times and breaks become an afterthought, and no one is really charged with looking at the nutritional benefit and the huge opportunity to send a health message. I mean, it’s just a huge opportunity! I went to the American Cancer Research, Oral Cancer Research fund meetings in DC in the end of October. they did a fabulous job making sure they were sending the message and walking the talk. So I think you’re right, it’s an important thing we need to evaluate and we need to do it more consistently. I’m just hopeful that the message is out there as I’m going to more and more conferences I’m starting to see that message now. The conferences I’m talking about are diet and cancer, and diet and health, so there’s probably a higher level of awareness than at more generic cancer meetings.
Caryn Hartglass: Sure, well if you’re including diet and cancer in the same sentence then I think that implies there’s a connection.
Dr. Thomson: Right, so you ought to do it right. But really everyone should be. Like you said, these are learning opportunities and we should take advantage of sending the right message.
Caryn Hartglass: Well, I’m very happy you got your research published, and when people Google diet and ovarian cancer they can easily get this summary that states healthy diets do make a difference in mortality and lowering the mortality risk in ovarian cancer. That’s such important and good news.
Dr. Thomson: Yes. Absolutely. And soon we’ll have a large trial that really evaluates this with a higher level of evidence, and I’m looking forward to those trial results.
Caryn Hartglass: Yeah me too! I’m looking forward to those results. So I’ll be looking out for them. Thank you so much for joining me Dr. Thompson on It’s All About Food, and I wish you very happy holidays!
Dr. Thomson: Thank you so much! I appreciate the opportunity to talk about something I love.
Caryn Hartglass: I do too.
Dr. Thomson: Take care!
Caryn Hartglass: Take care, bye bye. Okay, let’s take a quick break, shall we? I’m Caryn Hartglass and you’re listening to It’s All About Food, and we’ll be back in just a few minutes.
Transcribed by Julienne Wey, 1/11/2015