Nutrition Essentials | How Diet Can Affect Breast Cancer Risk with Michela Palma, RD

Podcast Transcript

John Horton:

Hello, and welcome to another episode of Nutrition Essentials, a side dish that pairs nicely with our regular Health Essentials Podcast. I'm John Horton, your co-host, with registered dietitian Julia Zumpano.

Julia Zumpano:

Hey, John, I don't know about you, if it's just me getting older, but I'm noticing more and more people getting diagnosed with cancer, specifically women getting diagnosed with breast cancer.

John Horton:

Julia, that is so true. And I know the statistics I've read, it says 1 in 8 women will eventually have to deal with breast cancer, and I think we've all maybe felt it, experienced it with a family member or a friend, and it's devastating when it happens.

Julia Zumpano:

Absolutely. And one thing I must say that's a positive is we're getting better at screening. So I think there's earlier detection and better treatment, so I think the outcome's always going to be a little better in that case. But I think it's definitely a discussion worth talking about, diving deep into, because we're all faced with it day-to-day.

John Horton:

And that is what we're here to talk about today, because there are things that people can do proactively to improve their odds and reduce that risk of having that breast cancer diagnosis.

Julia Zumpano:

Absolutely, there are. And that is why we brought on registered dietitian Michela Palma, who works with the oncology team at the Cleveland Clinic.

John Horton:

Well, Julia, let's see what she has to say and how we can give people the help they need.

Michela, welcome to the podcast. We're so happy you had some time to come and hang out with us today.

Michela Palma:

Thank you so much for having me. I'm excited to be here.

John Horton:

Well, we like to know a little bit about our guests when they arrive, so if you could tell us a little bit about what attracted you to oncology care and what sent you down that road?

Michela Palma:

Yeah, of course. So I initially started my career as a dietitian in the inpatient setting. I was seeing people when they were admitted to the hospital, and the one thing that I noticed was very common was that many of my patients had multiple existing health conditions, and many of them suffered from some form of cancer.

At some point in their cancer journey, they ended up losing their love for food, whether it be due to side effects or even, say, fear of certain foods. So that sparked my desire to go ahead and make my way into the outpatient world and work with cancer patients to help them figure out what they can eat and how to enjoy food again.

John Horton:

Wow. Well, we definitely don't want people to lose their joy of food because it is so important to everything we do, and we also don't want people to have to see you for cancer care. That's part of why you're here today, so we can talk about how diet can maybe affect your risk of getting breast cancer. And even saying that, I want to throw an asterisk on there right away because as we all know, there are a lot of different factors that go into whether or not somebody ends up getting breast cancer.

Julia Zumpano:

Absolutely, John, there's so many risk factors. So what we can do, the best we can do, is just take steps to change our lifestyle and the choices we make to help reduce our risk.

So nothing's guaranteed in any way when it comes to diet and lifestyle, but we can only just do the best we can. And we know there are certain things that are really helpful for reducing your risk. And then we know there are things that are harmful toward increasing your risk. That doesn't mean that it's 100% on either side. It's just general guidelines that we know of when it comes to nutrition and lifestyle that can really help you take ownership of your health and help you be more in the driver's seat and your risk factors.

John Horton:

And I know they talk a lot about non-modifiable factors and modifiable factors, and I know those non-modifiable factors are family history, age, breast density, things like that. But what are some of those modifiable factors?

Julia Zumpano:

Sure. So some of the modifiable factors include your physical activity, your stress level, sleep, your diet and your nutrition, and what you choose to feed yourself and nourish yourself with every day. And then also, some of the exposures of certain chemicals and environmental toxins and things that are just in our environment that we can slowly try to reduce and be more aware of.

John Horton:

Yeah, I read one study that said they estimate that up to 30% of breast cancer cases can be connected to those modifiable risk factors.

Michela, is that something that you've seen as you talk to people and really start to assess how they ended up, I guess, seeing you for cancer?

Michela Palma:

Yes. Yes, of course. And it's unfortunate that it's caught in that moment, which is why trying to control those risk factors prior to getting to that point is so important, which is why nutrition in your diet plays such a huge role.

John Horton:

Now, Julia, I know we were talking ahead of time and you have just a very powerful story about these external factors that play a role and really how it's shaped you. So if you'd share that, that would be fabulous.

Julia Zumpano:

Sure. Yeah, so I was adopted, and my parents who adopted me, my mother actually died of a brain tumor in her 50s, and my father also died of lymphoma later in life.

And then, as I grew and had children, I decided to dig deeper and find my biological parents. And I found that my biological mother died of breast cancer in her 50s. So I'm no stranger to cancer; I've been exposed to it my whole life, unfortunately.

And in my late 30s, I decided to take a lot of extra steps to make sure I reduce my risk. So I went to the breast cancer center at the Cleveland Clinic, and I get screenings twice a year. So that has really helped.

So I do have dense breasts, so that is a risk factor. So I do get an MRI and a mammogram every year. I'm seen once a year. And then, I took personal steps as well. So I've significantly reduced my alcohol intake, and it's not that I don't drink at all, but I just keep it socially. I'm very aware of how much alcohol I consume. I try to make it more of a special occasion type thing.

I've definitely changed my skin care and personal care products. So I found the Environmental Working Group is a great resource. They have a phenomenal app that you can look up certain skin care products and cleaning products, and they'll rate it.

So there's a lot of other steps I've taken, too, from a nutrition standpoint that we can speak toward further. But there are a lot of lifestyle changes you can make. I favor physical activity, so I'm very active — I enjoy physical activity, so it's another great excuse to get out there and keep moving. I prioritize sleep. So just basic things that we know that are super important for us from an overall health standpoint, but just looking at it and taking it one step further and trying to keep as consistent as you can.

John Horton:

Yeah. I would imagine that there's a lot of empowerment in that because when you think about breast cancer or you start wrestling with that topic, it just seems so random and that there's nothing you can do about it. But the truth is that there are some factors we can control, and it seems like you really tapped into that just to make yourself healthier and just to feel better about your chances of avoiding that disease.

Julia Zumpano:

Absolutely. And I also did genetic testing. So I was lucky enough to be at a phenomenal facility where we have so many great resources at the Cleveland Clinic to use, so I was able to get genetic testing. Luckily, I do not carry either of the genes that make me more predisposed to having breast cancer. I am at a slightly higher risk than the normal population due to my family history, but it's just important to know. And for me, that doesn't mean I'm not going to get breast cancer, but I know that for sure I've done what I can to help prevent it. And if I do ever have breast cancer or any other kind of cancer, I have built my body up to hopefully be able to fight it off.

John Horton:

Yeah. Well, and today, we're going to focus on ways that people can protect themselves and specifically through diet. So Michela, let's talk about how you guide people as they come in, as to what foods they should gravitate toward to reduce their breast cancer risk.

Michela Palma:

Yeah. So the first thing I'd just like to start off by saying is everybody is different and also, everyone has, say, different possible preexisting health conditions. So it's very important to go ahead more closely with your doctor, with a registered dietitian. There is no type of diet, one type of diet or type of food that can, say, cure cancer or completely eliminate your risk of cancer.

John Horton:

If only there were. We're all looking for that. They got to find that in some jungle somewhere, that piece of fruit that can do it.

Julia Zumpano:

That would be amazing, wouldn't it?

Michela Palma:

It really would. And the nice thing, though, is that there are foods and things that we can do to at least reduce our risks. So the Mediterranean diet has much popularity, and part of that is due to the fact that it helps to ensure that you're getting everything you need to reduce your risk.

So the first component of the Mediterranean diet that I start by talking through with my patients is protein and fat. So specifically, with protein itself, we recommend that people focus on lean sources of protein. You can get protein from things like low-fat dairy products, your chicken, your fish, nuts and seeds, and then, say, other plant-based sources.

Now, this ties a little bit into fat in our diet. So fat itself, if we have a high-fat diet, that increases our risk of breast cancer itself. Part of this depends on the quantity of fat that we consume, and then also, too, on the type of fat we consume, which I'll just start with, the quantity of fat can increase your risk of obesity. And for those who suffer from obesity and have extra adipose tissue, that fat tissue aromatase enzymes that actually help to create estrogen live in those tissues, which is why a high-fat diet could put us more at risk.

John Horton:

Saturated fats are bad, and we've covered that on this podcast a ton. It's bad, bad, bad.

Michela Palma:

Yes.

Julia Zumpano:

Well, we also want to avoid trans fats, obviously. We all know that. The hydrogenated or partially hydrogenated oils.

Michela Palma:

Yeah. And that goes into just the types of fats in our diet, which is nice about the Mediterranean diet because it focuses more so on what those are, they're called the heart-healthy fats, if you will.

So things like your omega-3 fatty acids, which you get from some of those lean protein sources that we talked about. And then also, things like your polyunsaturated fatty acids, which you can get from certain plant-based oils. Those fats help to have an anti-inflammatory effect in the body and can actually improve your overall immune health itself.

John Horton:

Now, I noticed the one thing you didn't mention in all that was red meat. So steaks, burgers, things like that. And I know, Julia, we were talking ahead of time, just how red meat is a huge risk factor when you're talking breast cancer.

Julia Zumpano:

Specifically, processed red meat. So we really want to avoid all processed forms of red meat. So that's things like hot dogs and bacon, salami, pepperoni, bologna, those types of things. Lean cuts of grass-fed red meat can be consumed on occasion. That shouldn't be our primary source. It's safe in moderation, but really, the processed red meat should be completely avoided.

Traditional lean cuts of grass-fed or well-raised red meat can be consumed, like I said, once or twice a week. But we really want to emphasize the omega-3 fatty fish, plant-based sources of protein, and leaner cuts like poultry and eggs.

So really, trying to really limit red meat, but avoiding processed red meat.

John Horton:

Now, you mentioned grass-fed beef, and for both of you, I want to know, is it really that much of a difference when you hear something like grass-fed or organic or things like that? Is the food that much better for you if you go that route?

Michela Palma:

Julia, do you want to take this?

Julia Zumpano:

Sure. So I would say we don't have good data on whether it's better or not. We do note there are hormones and different additives, antibiotics in some of the meats that we are being provided at the grocery store.

So when you think of grass-fed meat that doesn't have any of that exposure, we just associate that that can help reduce our risk. Now, again, we don't have really good clinical trials that prove that, but if you have the ability to afford it and you have the access to a local farmer and you're able to choose it, I would go ahead and do so.

But I wouldn't be fearful about it if you can't, if you can just choose conventional red meat. I would be more cautious on the fat and the processing of the meat way more than whether it's being grass-fed or not.

John Horton:

Yeah. Is there a percentage that you recommend staying at? When you look at that, you'll see the 80/20, the 90/10, 93/7. Where should you try to hit on that?

Michela Palma:

Well, one thing that, too, I would just like to say is we typically advise our patients no more than 12 to 18 ounces of red meat per week. So that's the equivalent to, say, if you were to have a 6-ounce steak. As far as with that overall fat percentage, Julia, I am going to give that over to you.

Julia Zumpano:

Yeah, so I usually say 85% being the highest, I'm sorry, the highest percent of fat, right? You're at 15% fat and 85% lean. That's what it means when you have that percentage. So we're always looking for a higher percentage of lean and lower percentage of fat. I'd say between 85 to 90% is what I advise.

John Horton:

So we've talked about the proteins in the Mediterranean-style diet and how you want to stick with those lean proteins, lean fats, fish, the omega-3s, all that. Obviously, a lot of the Mediterranean diet is also based on plants, plant-based foods. So Michela, where do you guide people there as far as what they should look for and how they should fill their plates?

Michela Palma:

Sure. So the Mediterranean diet places a huge emphasis on ensuring adequate intake of fruits, vegetables and overall whole grain consumption, specifically hoping to get three servings of fruit, three servings of vegetables daily. And a lot of that has to deal with the fiber composition of our food and then also, some of the other things that the fruits and vegetables have themselves.

I'd like to go ahead and just start by talking about fiber a little bit. Fiber plays such a crucial role in our health, primarily starting even, too, from a weight management perspective. If we can control our weight, that can be helpful with reducing our risk of breast cancer.

And then, just other components of having a high-fiber diet, fiber acts as something called a prebiotic. A prebiotic is basically a type of... it's a food that can help with growing your gut bacteria, and we actually house a portion of our immune system in our gut itself. So ensuring that we have enough fiber in our diet, it can help to improve our immune response itself.

John Horton:

And then, that ends up with a protective effect against cancers and things like that. The stronger your immune system is, you're just maybe able to fight it off a little more.

Michela Palma:

Yeah, of course. And the other thing, too, that's really great about fiber is that fiber itself, when you get enough of it, it actually can help with lowering your cholesterol. And cholesterol actually is a precursor to estrogen, meaning it's like a building block to the estrogen itself.

Julia Zumpano:

Yeah, so there have been studies that show that fiber can reduce circulating estrogen levels in the body, and that's kind of that mechanism there.

Also, fiber helps manage blood sugars, which blood sugar management can help control so many things, but specifically your weight and your metabolic health. So it's really important to have a very high-fiber diet and abundant in, obviously, as Michela said, plant-based foods, and soy being one of those essential foods. Because soy can act as a source of fiber, as well as a source of protein in the plant-based form. Soy also has some omega-3. So it's really a very packed, nutrient-dense food when it comes to overall health, but specifically when it comes to breast cancer risk.

Michela, can you tell us a little bit more about soy?

Michela Palma:

Yeah, so a lot of people come to me and they have great fear around soy. They've been told that soy can be very harmful in terms of their breast cancer, that it can increase their estrogen levels, and that's not necessarily the case.

There's a lot of research out there that shows that having a diet where you're consuming soy can actually help with reducing your risk. And part of that is due to the fact that soy itself, and I should say this is whole soy products, not more so your processed soy products.

Julia Zumpano:

So an example would be tofu, edamame, soy milk.

Michela Palma:

Yes, soybeans, too. And soy has something called phytoestrogens. So phytoestrogens, they're not estrogen. Phytoestrogens are basically the plant form of estrogen in plants themselves. They are structurally different, but they actually bind to the same receptor sites as estrogen, which can help with lowering the amount of estrogen in our bodies itself.

And Julia already pointed out that there are great anti-inflammatory effects of soy products themselves. But the other thing, too, is that those phytoestrogens actually exhibit a very weak estrogenic effect itself. I actually encourage my patients to consume soy products in their diet as a source of protein if they wish to.

Julia Zumpano:

And Michela, flaxseed is another phytoestrogen, which is another, in my opinion, power food. So flaxseeds are a seed that are very high in fiber, good source of protein and also contain the plant-based source of omega-3.

John Horton:

Now, I know another thing that comes up all the time that you hear are talks about, you want food with antioxidants because they help fight free radicals. Those are terms that I feel like all of us hear all the time, but we don't really have a good grasp as to what they are. So can you guys break down what antioxidants are, what free radicals are and how they fit into this non-development of cancer?

Michela Palma:

Yeah, sure. So antioxidants themselves, which are found in our fruits, our vegetables, our soy products, too, they are basically, I'll call them the good guys. They help to go ahead and fight against the free radicals and help to prevent cell damage themselves.

Now, free radicals, on the other hand, are the bad guys in a way. The free radicals are typically found in a lot of our processed foods or, say, our fried or fatty foods. Now, they are more on the unstable side and actually can cause cellular damage themselves, which is why typically we advise to eat those processed foods, or I should say more so ultra-processed foods, in moderation themselves.

Julia, I don't know if there's anything you would like to add to that before I talk a bit about the antioxidants more.

Julia Zumpano:

No, I would completely agree with everything you mentioned. I think antioxidants are very protective from an overall body standpoint. It's very protective from a heart perspective, from a weight perspective. We know foods and a diet rich in antioxidants are definitely the way to go.

Michela Palma:

Yeah, and certain foods that have those antioxidants that I like to tell people about are vitamin C-containing foods, those that have vitamin A, vitamin D and zinc. And like I said, we can get these from our fruits and vegetables.

Vitamin C and vitamin A specifically, they actually can help, they serve multiple purposes, but they actually help with our body's first line of defense, which is our skin. Our skin ourself protects us from environmental toxins. So if we have a diet that's high in vitamin C and high in vitamin A, this can help with skin cell regeneration. It can also help fight off things like those free radicals in themselves.

The other food component, vitamin D, which is typically found in foods like our fortified orange juice, our fatty fish, helps with cell signaling and can greatly improve our immune health itself.

And then, Julia, you look like you're ready to add something.

Julia Zumpano:

Well, I was going to say that olive oil, extra virgin olive oil, we've covered before, is also very rich in antioxidants. Specifically, an antioxidant called oleocanthal, which has been actually compared to a weaker form of ibuprofen. So it can have very anti-inflammatory benefits.

John Horton:

So it has ibuprofenous qualities to it?

Julia Zumpano:

It's just been shown to have inflammation-reducing properties. So it's been compared to that. In studies that give you a dosage amount, that would provide you some of that anti-inflammatory benefit.

John Horton:

I've never heard that before. I love that little factor. Julia, you have so much information in there, so I love when you drop these things on us.

Michela Palma:

Yeah, and the one thing, too, that I always like to tell my patients, especially since there's such a focus with those heart-healthy oils on the Mediterranean diet — and Julia, I'm sure you've talked about this with your patients, too — while we love to see that our patients are having things like the extra virgin olive oil, olive oil in itself, there are other really great oils out there.

And really, if you only have access to things that are, say, another source of plant-based oils, that's completely fine, too. Sunflower oil, canola oil, whatever you have access to is OK to have in your diet.

What matters is the form of cooking that you are using, especially since certain oils have a certain heat and smoke point. So we typically try to make sure that patients aren't doing a high amount of, say, pan-frying, that can result in converting some of those fats to the more bad fats, those hydrogenated fats in themselves.

Julia Zumpano:

And avoiding deep-frying, of course.

John Horton:

Deep-frying never seems to be the answer to anything on here.

Michela, when we were talking the other day, you mentioned that one of the big questions that you get from people involves sugars and whether or not that could actually help cause cancer. So I guess that would be sugary foods, maybe even high-carb sort of things. What do you tell people on that?

Michela Palma:

So sugar and cancer is a very tricky relationship because our body's No. 1 energy source is carbohydrates. And basically, there are certain foods that can put you at a higher predisposed risk if you eat them in excess. So those are things like our ultra-processed sweets, say, our sugary beverages. And basically, over time, if we eat those foods in excess, that can lead to things like possibly obesity and increasing our risk of breast cancer. Now, there are certain really great sources of carbohydrates, so I advise my patients to try and focus on those, which come from fresh fruits and vegetables, your whole grains, and then eating more of those ultra-processed sweets in moderation.

So they should not be afraid of, say, carbohydrates and sugar.

Julia Zumpano:

I couldn't agree more. I completely agree that carbohydrates are essential, and they're also a great way to get fiber in. So whole-grain bread or whole-wheat pasta or brown or wild rice, et cetera. But we want to separate the two. So carbohydrates are a macronutrient; sugar is an additive. Sugar is something we add to our foods. So the carbohydrates are what we are encouraging. The sugar is what we're not encouraging.

That doesn't mean you can't have a cookie on occasion, but a high sugar intake has been shown to increase your risk of pretty much every disease, including diabetes, obesity, heart disease and cancer. So if you want to consume some sugar, what I typically recommend to my patients is try to make baked goods at home. You're going to save money, you're going to be able to control the sugar and you know all of the ingredients that are inside. So just try to bake at home as much as you can. Choose simple forms of sugar.

So if you're going to have a hot tea or hot coffee, just use a spoonful of sugar versus buying sugar-laden drinks that have an excessive amount of sugar. And I don't like when people take that to the other stuff because then they're like, "Oh, well, sugar's not good for us. Let's just get everything diet." So we also don't want to go on the other end in choosing just all the sugary versions of foods in the diet form, which are artificial sweeteners. So we know those aren't good for us in excess either.

So it's all in moderation. But when you really focus on whole foods, it simplifies the picture.

John Horton:

And Julia, that seems to get, too, into the idea of additives and preservatives, which I know are something that you talked about with us the other day as being a big risk factor when it comes to foods and cancer.

Julia Zumpano:

Absolutely. So we know that there are certain preservatives that can increase our risk. Again, it's the excess amount of them, so just being more aware. So when we talked about processed meats, we know some of those ingredients, the nitrates, and nitrites and other preservatives in processed meats are what are the cause for the increased risk. That's why it's still safe to eat some red meat that's not processed.

We know these artificial dyes in our foods, these artificial preservatives and gums and sweeteners, again, they're wreaking havoc on our system. And they can affect your hormone production, they can inhibit your hormone production. So we really want to focus on whole foods as much as we can, reading labels, and trying to minimize any of these food dyes or preservatives or additives.

And again, moderation is the key. It doesn't mean elimination; it just means moderation.

Michela Palma:

I'd like to piggyback off that because, Julia, I'm sure you get this question as much as I do. I have people ask me, "What's moderation?" And typically, I tell people less than three times per week would technically be moderation.

Julia Zumpano:

I would agree. I would say about two to three servings a week. But that is a serving. So a serving is a scoop of ice cream. It's not three scoops. So if you have three scoops of ice cream, that's three servings. That's your [inaudible 00:30:42].

John Horton:

You're telling me that little pint container's not one serving?

Julia Zumpano:

Right. That's your three servings for the week. So that was a great, great addition there, Michela. I get that all the time. And I always say special occasions, too, like birthdays are going to come up, holidays, we're going to go out with friends and celebrate, especially this time of year, with graduation parties during the winter season, with the holidays.

So special occasions are going to come up, so that's where I usually tell people, try to do your day-to-day routine, minimize them so then when they come up with these special occasions, you can just enjoy, indulge and not worry.

John Horton:

Yeah. Moderation is also something that comes up all the time when we talk about alcohol and obviously, it's popular because we see it all over the place when we're at gatherings, when we're out with friends. What would be moderate drinking? And if you're worried about breast cancer risk, where should you try to draw the line?

Michela Palma:

Sure. So I'll take this one. So with alcohol and breast cancer, since there's more so a lot of observational studies, it really is going to be dependent on the person. With those groups that are especially at higher risk, they should take greater precautions.

But I typically tell my patients no more than one to two times per week. And we have to be mindful of what a serving actually is. Going back to even, say, the example that was given even with the ice cream. Five ounces of a glass of wine, this is for women, a bottle of beer or, say, one ounce of a spirit. And for men, it would mean two times that serving one to two times per week.

Julia Zumpano:

Yeah, I would agree. I would agree with that recommendation. I also try to look at, of course, risk factors and other factors that come into play. But I'd say a lot of people drink habitually, so I think it's a matter of breaking the habit.

So if you don't have to drink, I usually say, tell people, don't. And enjoy the times that you do want to drink and have a drink and save that beverage for those times, like maybe when you're out with friends or at a barbecue. But if you're drinking every night at home, try to minimize and start there, looking at alternatives. Because we do know the higher intake of alcohol can increase your risk. So minimizing and limiting. And if you don't drink, don't start.

John Horton:

Always good advice there. Michela, you mentioned, too, that people have a lot of questions about dairy and breast cancer risk. So what's the story there?

Michela Palma:

Yeah. So dairy with breast cancer, there is a fear that the hormones, say, in dairy, could possibly increase your risk of breast cancer. There's not really enough clinical evidence to actually support that.

And really, the biggest recommendation I have for my patients is, especially, depending on what stage you're at, if you're in the prevention stage or even, say, if you're in the survivorship stage, meaning you've been treated, just ensuring that you're getting out adequate calcium intake in your diet. You don't even have to do this with dairy itself, but if you do consume dairy, just trying to focus more so on those low-fat dairy products.

Julia Zumpano:

Yeah, I agree. There's a lot of great plant-based sources of calcium as well, non-dairy sources. So a lot of our non-dairy milk alternatives are calcium-fortified, leafy greens have calcium, almonds. So you can certainly get calcium from plant-based sources. So trying to really increase those foods as well if you are concerned with dairy or trying to limit it.

John Horton:

As we've talked about all these different food things, I think the one thing we all understand is, we have a complicated relationship with food. And I know there can be issues where people are so worried about weight gain or what they're eating that all of a sudden, they go too restrictive or they try a fad diet, and that causes problems. Talk about how those link in with breast cancer risk.

Michela Palma:

Sure. So it really is going to be dependent on the diet that people are trying. But the fad diets that are out there, depending on what they're promoting that you eat, certain diets are a little bit, say, higher in fat than others or are so restrictive to where you're not getting enough of the essential vitamins and minerals that you need.

So I just try to remind people, with any information out there, it's so important to work with your healthcare provider and your dietitian to create a plan that's right for you, and also something that is supported by evidence.

Julia Zumpano:

Yeah, I couldn't agree more. There's a lot of fad diets out there, but they're just fads. They'll ebb and flow, and some of them will cause an immediate source of weight loss. But most of the time, they're so restricted that the weight will be regained, and it's very unhealthy to have that yo-yo effect in our body, increasing your weight drastically or decreasing it.

We really want to focus on maintainable changes that are science based, that we know will reduce our disease risk, as well as help us lose weight. And that just comes back to all the factors we've already talked about today.

John Horton:

Yeah. And I know, Julia, we've talked about it before on this podcast, the whole problem with the concern about malnutrition. If you just deplete your body of the nutrients and vitamins and resources it needs, the outcomes just aren't great.

Julia Zumpano:

Right. And it can lead to a condition called orthorexia. Orthorexia is the fear of eating certain foods because they may have negative health effects. So we certainly don't want to go that route. We certainly don't want to create fear in anyone. What the goal here is empowering you to make better choices in your day-to-day food choices and beverage choices and lifestyle factors so you can reduce your risk on your own account.

John Horton:

And one of the fascinating things I know that we were talking about before, Julia, was it's not just the food you're eating, it's even how that food is packaged. And this is something I don't think we think about when we're at the store and you're grabbing products that are in Styrofoam™ or wrapped up in plastic, but it sounds like that's something we should be cognizant of when we're looking at our health and cancer risk.

Julia Zumpano:

Absolutely. We do want to be very aware of the packaging and plastics and synthetic materials that our foods are being stored in. So if you can minimize plastics, that would be great, starting with simple things that you can control, such as plastic storage containers — so trying to avoid using plastic storage containers, definitely avoid heating them. So if you're going to store it cold and that's all you have, that's fine, but really avoiding heating them because the heating can really seep that plastic into our foods.

Using glass containers, or even if you don't have glass, I usually have people use just their normal eating bowls because they're usually ceramic or some form of safer material and just putting a cover on it so you're not necessarily storing the food in plastic, but maybe a bowl or some kind of glass container that you may have for cooking or eating.

So anything you could do to minimize plastics — plastic water bottles are a big problem or drinking bottles of any whatever beverage or drinking that are in plastic or cans. So trying to minimize that, pouring them into a glass, trying to have a reusable water bottle. So anything you can minimize there because that's a huge consumption in America. We use a lot of plastic products there.

When you're getting takeout, if the food's in a Styrofoam container, not heating it in that Styrofoam. So putting it on a safe microwave plate and heating it that way or even reheating it in a pan versus the microwave.

So little simple steps that you can take day-to-day to start to minimize what you store your food in and what you buy your food in, and how you buy and store your beverages as well, can really make a big difference.

John Horton:

And it sounds like we should also talk about how you prepare or clean the food that you get because we focus so much on eating fruits and vegetables, which we know are good for you, but the reality is there's also some bad stuff that might be on them from when they were grown and harvested and all that stuff. Julia, I think you called it, there's a list called the “Dirty Dozen,” as far as foods that you need to be concerned about?

Julia Zumpano:

Yeah, I mentioned the Environmental Working Group. I love that organization. They put out the Dirty Dozen each year and the Clean 15. So what that means is-

John Horton:

…such great names.

Julia Zumpano:

…I know, right? You can't forget them.

The Dirty Dozen are the dozen foods that have the highest pesticide content. So if you're looking to purchase organic, the Dirty Dozen is the way to go. Choose those foods organic.

And then the Clean 15 have the lowest pesticide exposure. So those are safe to buy conventionally, not organic. So it just does help you understand a little bit more of where you should have a concern or not.

Michela, you made a good point of how to visually think of that. Can you share that with us?

Michela Palma:

Yeah, sure. So with some of those foods on the Dirty Dozen, I'll use the example of a berry. You can't scrub a berry or you can't scrub something like a blackberry.

So just saying if you can't get in the nooks and crannies of your fruit or vegetable, then odds are, it's at a higher risk of having more of the herbicides and pesticides themselves.

The one thing that I typically tell people, because I get the question of, "So what is a good cleaner, say, for my fruits and vegetables?" And we typically advise people, you could do two parts water, one part vinegar as a natural cleaning solution to wash your fruits and vegetables.

Julia Zumpano:

Yeah, that's great. I also use baking soda and you can also use vinegar. So those are some great household items you can get. And there are fruit and vegetable washes if you ever wanted to go that route. I don't think those are necessary when you have great resources in your kitchen already.

Another thing to add there, the Dirty Dozen, there are some outliers, too, that you may not be able to scrub. So apples are on the Dirty Dozen list, hot or bell peppers, green beans.

The lettuces aren't surprising there because it's really hard to get into those little fibers, but just being able to take particular attention to those foods. And if you can't buy them organic or they're not available in your area, which is very common, just making extra steps to clean them properly.

And then, the Clean 15 are, again, more tougher skin. So that same concept, you'll get things like an avocado or a banana or an orange, something with more of an outer protection.

John Horton:

OK, so we've covered a ton of ground here, and it seems like there are foods you can definitely gravitate toward that can reduce your risk, but as we said at the start, there are no 100% guarantees. So what steps do you two recommend taking to reduce that risk and start tilting the odds in your favor?

Michela Palma:

Sure. So the one thing that I feel is really important is just starting practicing these preventive measures as early as you can. The other factors, as you know, Julia's mentioned, leading a healthy lifestyle is so important in combination with your diet, being very physically active.

And then, just a couple other things that I tell my patients, trying to get as much of your nutrition from your food as possible is so important. There's not a lot of great data to support the safety of use of things like vitamin and mineral supplements, especially, unfortunately, when you're at the stage of having breast cancer itself, or even just in general for reducing your risk. So trying to get your nutrition through your food.

Julia, I don't know if there's anything you would like to add.

Julia Zumpano:

Yeah, I think one important thing would be knowing your risk. So if you are concerned or you know have some form of family history, really seeking out medical attention or medical help, just to know your risk factors and to be able to be more aware of them, and then that can also help guide your lifestyle changes. But we know any of the lifestyle changes we talked about today reduces your risk for any disease. So they're all very, very beneficial.

John Horton:

Julia, I think that's an important point because even if you are higher risk, you can still lower that higher risk if you take some of these protective steps.

Julia Zumpano:

Yeah, genetics aren't ... I always tell people, just because you're genetically predisposed to something does not mean you're going to get that. So you can turn on or off those genetic switches by your lifestyle choices and the changes you make day-to-day.

Michela Palma:

The one thing I would like to add to that, too, in terms of your diet, is just recognizing that, again, all of our bodies are different, and a lot of us have different existing health conditions, so it can be normal that, at times, your dietary needs may change. However, a lot of the recommendations talked about today can encompass a variety of health conditions and reduce your overall risk.

John Horton:

Now, if you want help getting an eating plan in order, how hard is it to get an appointment with a dietitian? Or is this something you can talk with your doctor about and maybe get something set up?

Michela Palma:

Sure. So in my setting currently, I typically see people who are actively being treated themselves. It's something that the patient can request the appointment, and I feel that the patient is their best advocate themselves. So I always encourage people, speak up, vocalize your needs. The doctor can go ahead and request it for you or a nurse. But other than that, we have a really great scheduling team with the clinic. So an appointment can be requested at any time with a registered dietitian.

Julia Zumpano:

Yeah, we have over 40 outpatient dietitians, they're all at different family health centers. So within the Cleveland Clinic health system, you have access to a dietitian, and you do not need a referral to see a dietitian — unless your insurance requires you to have a referral, then you would. But even locally, eatright.org is the Academy for Nutrition and Dietetics, and you can find a dietitian on their website locally by just putting in your ZIP code. So I would definitely seek out the nutrition professionals, the registered dietitians to help you along your way.

John Horton:

So when it comes to using nutrition to maybe guard against breast cancer, if there's one thing you want people to take away, what would it be? Michela, why don't you get us started there?

Michela Palma:

I think the biggest thing is just realizing that it is OK to eat certain foods in moderation. I feel that that will help to make some of these lifestyle changes more lasting in the long run. And then, really, just trying to utilize resources that are created by healthcare professionals themselves, since there is so much misinformation out there, just to ensure you're receiving the best information possible.

Julia Zumpano:

Yeah, that's great. Great advice. Mine would be that you have the power and you have the power to change your health outcome by the choices you make. So if anything resonated with you today, pick one thing and start there. And you do have the power to make a big positive change in your health.

John Horton:

Well, both of you have given people a lot of opportunity to grab that power. So I want to thank you for just sharing everything that you have today and just for just a great conversation that should really help a lot of people.

Michela Palma:

Yeah, no, thank you guys so much for having me today.

Julia Zumpano:

Thanks, Michela, for joining us.

John Horton:

So Julia, we learned so much during that conversation, whether it's how you prepare your food or wash your food, the whole Dirty Dozen thing, how you store your food and then of course, everything that you should be eating to reduce your breast cancer risk.

Julia Zumpano:

Absolutely. I think the good takeaway here is, we have little steps that everyone can take, depending on where they're at, to reduce their risk. And again, take it one step at a time.

John Horton:

Well, and Julia, I got to say, I really loved the personal story that you shared because you realize how you can look at what's happening in your life and within your own family and maybe make some decisions that could really be monumental and protective.

Julia Zumpano:

Yeah, it's very close to home for me and it's something that I've pretty much lived my life in preventing diseases, and that's where my passion comes toward nutrition and overall empowerment to make your own health decisions and be able to control those risk factors as best you can.

John Horton:

Well, you did a great job of explaining that today.

So if you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.