Get Help Get Advice Eating a Healthy Diet by Monika Siemicka Senior Specialist Haematology and TYA Dietitian at Guys Hospital Tips on different food groups to eat well during treatment and beyond... 1. Protein Beans, pulses, fish, eggs, meat and other proteins This group provides us with lots of protein and iron. It includes red meat (such as lamb, beef, pork), poultry, fish, eggs, pulses, soya products, nuts and seeds. Why do we need protein? Proteins are often referred to as the ‘building blocks’ of life. They are needed for muscle growth, cell membrane structure, enzyme and hormone production. Proteins are chains made up of amino acids. There are 20 amino acids, 9 of which are essential (meaning they must be obtained from the diet) and the rest are either conditionally essential (can be made in the body as long as their pre-cursors are available) or non-essential (our body is able to make them). We need to make sure that our diet provides all the essential amino acids we need to be healthy. What are the different sources of protein? All the foods listed in this group, whether they are an animal or vegetable source, contain protein. Animal protein provides all the essential amino acids as do the vegetarian sources soya, quinoa and hemp. Other vegetarian sources, such as pulses (beans, peas and lentils), nuts and seeds will each provide some of the essential amino acids. Eating a range of these foods will ensure you get all the amino acids you need. What are the different sources of iron? Red meat provides a rich source of iron that is easily absorbed. Other sources include: breakfast cereals fortified with iron, dried fruit, pulses, leafy green vegetables, nuts and wholemeal bread and flour. Tip: If you are low on iron (anaemia), vitamin C helps your body absorb it, so try having some vegetables, fruit or a glass of fruit juice with your meal. Is red meat bad for you? Red meat is rich in iron, zinc and vitamin B12 but also contains saturated fat. A high intake of saturated fat increases the risk of heart disease, so we need to limit how much of it we eat. The World Cancer Research Fund recommends eating no more than 500g cooked red meat a week and to eat as little as possible, if any, processed meat (ham, bacon, some sausages). Try to choose lean cuts of meat and remove excess fat and skin before eating. Fish is a great alternative to meat and very good for you, too. Oily fish, like salmon, fresh tuna, mackerel and trout, is packed with omega-3s. However, they also contain some mercury so women who are pregnant, breastfeeding or planning on becoming pregnant should not have more than 2 portions a week; for everyone else it is safe to have up to 4 portions a week. Try to have 1 portion of white fish and 1 portion of oily fish a week. How much should I be eating? You should aim to have 2-3 portions from this group a day. A portion is: 80g cooked meat/poultry (palm of your hand) 140g cooked white/oily fish (whole hand) 120g soya/tofu/Quorn (snooker ball) 3-4 heaped tablespoons peas/beans/lentils (1 handful) 2 eggs A balanced diet containing the foods listed above will meet the protein needs of the general population, including those who exercise regularly. 2. Fats Oils and Spreads Fats are an essential part of the diet but are only needed in small amounts. They are needed for cell structure, hormone production, as a carrier of fat-soluble vitamins, and they form a layer under the skin providing insulation. Cholesterol and triglycerides are both fats, also known as lipids. If the level in our blood (sometimes called the plasma lipid profile) gets too high, it can be harmful, contributing to heart disease. Our diets provide different types of fat, the main three are: Saturated fats Monounsaturated fats Polyunsaturated fats. These three types of fat have a different effect on our plasma lipid profile. Cholesterol is carried in the blood as either low density lipoprotein (LDL) or high density lipoprotein (HDL). LDL cholesterol is associated with heart disease and stroke, whereas HDL cholesterol has a protective effect by removing cholesterol and transporting it to the liver for disposal. Atherosclerosis is the narrowing of our arteries due to the build-up of fatty deposits (plaque) causing coronary heart disease, which could eventually lead to a heart attack. LDL cholesterol contributes to this building up of fat whereas HDL cholesterol removes it. This is why eating a diet that helps lower your LDL cholesterol and increases your HDL cholesterol is so important. We know that reducing our intake of saturated fat and replacing it with polyunsaturated fat lowers serum cholesterol and risk of cardiovascular disease. Other factors that contribute to atherosclerosis are high blood pressure and smoking. Experts advise us to aim for the following cholesterol levels: Total cholesterol 4mmol/L HDL cholesterol 1mmol/L LDL cholesterol 2mmol/L Fasting triglyceride 1.7mmol/L What are the different types of fats? Saturated fats Saturated fats are associated with raising LDL cholesterol levels. Most are solid at room temperature and are mainly found in animal sources such as meat, butter and dairy. The exceptions to this are palm and coconut oil which are plant-based but high in saturated fat and liquid at room temperature. Saturated fat is also found in processed foods such as biscuits, cakes, chocolate and pastries. Men should have no more than 30g saturated fat per day and women no more than 20g per day. In the UK, the average adult exceeds the recommended level of saturated fat in their diet. Approximately 92% of the fat in coconut oil is saturated fat. To put it into perspective, butter contains 52% and rapeseed oil about 7%. Coconut oil has been very popular on social media and has been promoted as a ‘superfood.’ However, no clinical studies have been conducted on the health or treatment effects of coconut oil and it is not recommended that you include in your diet regularly. Foods high in saturated fat: Fatty meat Processed meat such as ham, bacon, some sausages and burgers Full fat dairy Coconut Butter, lard, ghee. Coconut oil and palm oil Pastries Monounsaturated fats Monounsaturated fats are good because they maintain the HDL level whilst lowering the LDL cholesterol. They are found in: olive oil rapeseed oil avocados nuts: almonds, cashews, hazelnuts, peanuts, pistachios and their spreads. Polyunsaturated fats These include omega-3 and omega-6 fats. They help lower the level of LDL cholesterol. Both are essential fats which means our body cannot make them and so we need to obtain them from our diet. Polyunsaturated fats are found in: oily fish sunflower seeds and oil corn oil safflower oil soya bean and oil sesame seeds and oil flaxseeds/linseeds and oil Pine nuts and walnuts Omega-3 fats The essential fatty acids eicosapentaenoic acid (EPA) and docosahexaneoic acid (DHA) are found in oily fish such as salmon, mackerel, trout, sardines and fresh tuna. The general population are advised to eat 1 portion of oily fish (140g when cooked) a week and no more than 4 portions a week. This is because oily fish contain a small amount of pollutants that can be harmful in larger amounts. Women who are planning to become pregnant or are pregnant should limit oily fish to 2 portions a week as the pollutant could affect the development of the baby. Alpha-linolenic acid (ALA) is an omega-3 fat from non-fish sources such as flaxseed and rapeseed oil and walnuts. The body converts some ALA to DHA and EPA but it is uncertain whether it has the same benefits as the omega-3s found in oily fish. Trans fats (partially hydrogenated fats) These are vegetable oils that have been processed making them less healthy. They can be found in pastries, biscuits, fried foods and cakes and are sometimes called ‘partially hydrogenated vegetables fats/oil.’ They act in the same way as saturated fats in that they raise the bad cholesterol. Triglycerides Triglycerides are fats that can also contribute to heart disease and so it’s best to aim for a level below 1.7mmol/L. Foods that can raise triglyceride levels include free sugars (such as biscuits, cakes and sweets), saturated fats and alcohol. So how much should I be eating? Overall, fat intake should contribute to 30% of total energy intake. Saturated fat should contribute to no more than 11% towards total energy intake, which equates to a maximum of 30g per day for men and 20g per day for women. It’s important to remember that fat, no matter what type, is the highest provider of energy at 9kcal/g. Protein and carbohydrate both provide 4kcal/g. So weight for weight, olive oil provides the same number of calories that lard does. This is why it’s still important to take into account how much you’re using, not just the type. 3. Carbohydrates Potatoes, bread, rice pasta and other starchy carbohydrates What are the different types of carbohydrate? All carbohydrates are chains made up of simple sugar units called monosaccharides. The main monosaccharides are glucose, fructose and galactose. After they are eaten, carbohydrates are broken down into these small units and absorbed from the gut. Carbohydrates are classified as either simple or complex depending on how many monosaccharide units they are made up of – complex carbohydrates contain more than simple carbohydrates. Simple carbohydrates Free sugars are sugars added to food and drink (like biscuits, cakes and soft drinks) as well as sugars naturally present in honey, syrups and unsweetened fruit juices. These simple sugars are absorbed very quickly and shouldn’t make up more than 5% of our total energy intake. This is equivalent to about 7 teaspoons a day. 330ml can cola 9tsp sugar 50g milk chocolate bar 7tsp sugar 150ml glass apple juice 3.5tsp sugar 2 milk chocolate digestives 2.5tsp sugar Free sugars provide lots of calories but little to no other nutritional value which we sometimes refer to as ‘empty calories.’ Sugars found in milk, fruit and veg are not considered to be free sugars as they provide other beneficial nutrients. Complex Carbohydrates Complex carbohydrates are found in foods such as bread, rice, potatoes cereals, yam, chapattis and naan. Refined versions of these carbohydrates are when the outer layers of the grain have been removed, like in white bread or rice. This process removes important protein and fibre which is why we should choose wholegrain or brown varieties. Complex carbohydrates are broken down and absorbed slowly into the blood stream. This group is vital to good health because it provides our body with the energy it needs to function; calcium; iron; B vitamins and fibre. Many fad diets recommend cutting out carbohydrates, but this can be harmful as it means cutting out important nutrients, not to mention a bit miserable. Carbohydrates have very little fat in them but if eaten in excess, like any other food, will be stored in the body as fat. As well as the portion size, what you add to them (such as cheese or butter) can push up calorie intake. Fibre Dietary fibre is carbohydrate not digested or absorbed in the small intestine. Eating more fibre is associated with a lower risk of heart disease and colorectal cancer. It helps lower total and LDL (bad) cholesterol levels and blood pressure. We should aim to have 30g/day which we can achieve by choosing wholegrain and brown varieties of carbohydrates, eating more pulses and fruit and vegetables. How much should I be eating? The thing to remember with this group is that portion size matters. Rather than cutting them out completely, be sensible about how much you’re having. The World Cancer Research Fund advises to eat 2 portions of carbohydrate at each main meal (about a fistful). For example: 4-6 tablespoons cooked pasta 4 egg sized potatoes/1 jacket potato/4 tablespoons mashed potato 4 heaped tablespoons boiled rice 2 medium slices bread 2 small chapattis 4. Fruit and vegetables Love them or hate them, this group is incredibly important. They provide many vitamins, minerals and fibre and may reduce the risk of some cancers, heart disease and obesity. They can be eaten by themselves as a snack, in a salad or as part of a meal - whatever works for you. The good news is that there are many types of fruit and veg, so it’s worth tasting different ones to find those you like and are happy to eat. Try to eat a variety or ‘a rainbow’ as the colours reflect the vitamins in the fruit/veg that will help nourish your body. How much should I be eating? The message ‘5 a day’ is well known but what we mean is eat at least 5 portions a day, a portion being 80g or roughly a handful. In the UK, only 30% of adults meet this recommendation. Examples of 1 portion: 1 medium-sized piece: apple/banana/tomato 2 small-sized pieces: plums/satsumas/kiwis 1 slice papaya/melon 30g/heaped tablespoon dried fruit 3 heaped tablespoons of cooked veg 2 broccoli spears 150ml glass of fruit juice/smoothie Frozen, tinned and fresh all count. If you are buying tinned ones then avoid anything in brine (salt) or syrup. Pulses count towards your 5 a day, but only as 1 portion (80g/3 tablespoons) regardless of how much you eat. This is because although they are a good source of fibre, they don’t provide as many vitamins and minerals as the other vegetables in this group. Potatoes don’t contribute to your 5 a day as they belong in the carbohydrate group. What about juicing? Juices are fine to have as part of your healthy diet, but they don’t replace eating fruit and veg in their whole state. Juicing breaks down a lot of the fibre content and some of the vitamins so we don’t get the same benefits. Fruit juices are high in sugar, even those with no sugar added. This is because fruit naturally contains small amounts of sugar but a glass may contain up to 4 portions of fruit so that sugar becomes condensed into a much smaller volume. As with pulses, fruit juices and smoothies count towards only 1 of your 5 a day, no matter how many glasses you drink. This is due to the sugar content and the loss of nutrients during processing. It’s best to limit these to 150ml a day to reduce sugar intake and limit tooth decay. Tips on getting more fruit and veg: Add a tablespoon of dried fruit to your cereal or chop a banana you’re your porridge Snack on carrot/celery sticks dipped in salsa or hummous Replace some of the red meat in a casserole or stew with pulses Have a side salad with your lunch Chop up veg into your pasta sauce Make sure you have a portion of veg with dinner 5. Dairy Dairy and alternatives This group includes milk, yoghurt and cheese as well as alternatives such as soya and nut milk and products. Why do we need dairy? Dairy products and calcium-fortified alternatives are a rich source of calcium which is needed for the healthy development of bones, blood vessel function, hormone secretion and muscle contraction. 99% of the calcium in our bodies is found in the bones and teeth. During childhood and adolescence calcium accumulates in the bone and we achieve our peak bone mass. During adulthood we maintain our bone mass but this becomes less dense in older adults, hence putting us at a higher risk of osteoporosis (bone thinning) and fractures. Post-menopausal women are particularly at risk as oestrogen deficiency leads to loss of bone density. Vitamin D Vitamin D, which we make when our skin is exposed to sunlight, helps us absorb calcium. However, in the UK the sun is only strong enough for us to make vitamin D from April to September (remember to be sun safe!). Those who do not spend time in the sun; cover up or are from ethnic minority groups with dark skin are more at risk of deficiency. Vitamin D is found is some foods including fish, eggs and fortified breakfast cereals/spreads but we can’t meet our vitamin D requirements through diet alone. The Scientific Advisory Committee on Nutrition (SACN) recommend that all adults should have an intake of 10micrograms vitamin D per day. In response to this, the government has advised that adults should consider taking a 10µg supplement of vitamin D during autumn and winter (October to March) and those with limited sun exposure during the summer months or people from minority ethnic groups with dark skin should consider taking one all year round. How much calcium do I need? The recommended calcium intake for adults is 700mg per day, but this rises in some populations such as breast-feeding mums (1200mg/day) and those with coeliac disease (at least 1000mg/day). As a rule of thumb, aiming for three portions a day in total of the following will help you meet your calcium requirements: 200ml glass of milk/milk alternative (240g calcium) 125g pot of yoghurt (200g calcium) 1 matchbox size of cheese (220g calcium) When buying your dairy products, choose the reduced fat and sugar options when possible. If you choose to buy organic products then it is worth remembering that they will not be fortified with calcium. Other foods containing calcium include sardines with bones (100g provides 490g calcium), spinach (80g provides 130g) and baked beans (½ tin provides 110g). Some foods are also fortified with calcium like bread, orange juice and cereal. Grains do not have a particularly high calcium content but because they are consumed frequently by most people, they do contribute to overall calcium intake.