Science of Living Well

THE SCIENCE OF LIVING WELL, BEYOND CANCER
Relax Exercise Eat Real Food

1 in 9
Men will be diagnosed with prostate cancer.
1 in 8
Women will be diagnosed with breast cancer.
1 in 2 men and 1 in 3 women will be

diagnosed with some form of cancer in their lifetimes.
2
Who Should
Use This Guide?
Everyone.
This year, 1 in 9 men will be diagnosed with prostate cancer. 1 in 8 women will be
diagnosed with breast cancer. 1 in 2 men and 1 in 3 women will be diagnosed with
some form of cancer in their lifetimes. Everyone knows someone with cancer, but
we all wish we didn’t. An aging population, combined with poor lifestyle choices,
has contributed to an overall rise in chronic disease, including cancer, diabetes,
heart disease, autoimmune diseases, and depression.
Whether you are a cancer survivor or someone who just wants to prevent any
number of chronic diseases, this guide is for you.
At the Prostate Cancer Foundation, we care about your life and your livelihood.
We don’t just want men to survive prostate cancer—we want you and your whole
family to live well. We are also scientists, so this guide consolidates the latest
research, reviewed by experts in the field, on lifestyle trends that could have a
positive impact on your health. Because science changes constantly, this guide is
updated frequently as new evidence becomes available. For the latest updates,
please subscribe at pcf.org/livewell.
The most important thing to remember about your

lifestyle choices is that they are choices. You can be a
For the latest updates,
partner in your own health outcomes by making just a
please subscribe at
few of the simple changes found in this guide. pcf.org/livewell.
3
Contents
7 15
OVERVIEW RELAX
8 Is It Possible To Eat To Prevent Cancer? 17 Mental Health
8 Precision Nutrition 20 What Is Stress?
8 Precision Exercise 25 Sleep
9 Precision Rest 28 Yoga & Meditation
10 Own Your Health: Get Involved 29 Work
11 How To Read This Guide 31 Physical Touch
13 The Bottom Line 32 Community
ACKNOWLEDGEMENTS | We gratefully acknowledge the scholarly expertise and editorial contributions of:
June Chan, DSc (Professor, Epidemiology and Biostatistics, UCSF School of Medicine); Richard Mithen, PhD
(Professor of Nutrition, The Liggens Institute, University of Auckland); Lorelei Mucci, ScD, MPH (Associate
Professor of Epidemiology, Harvard T. H. Chan School of Public Health, Leader, Cancer Epidemiology, Dana
Farber/Harvard Cancer Center); Deborah Novak, MS, RDN (Associate Adjunct Professor of Nutrition, Santa
Monica College); Suzanne Conzen, MD (Professor, Department of Internal Medicine, UT-Southwestern and
Professor Emeritus, Ben May Department for Cancer Research, University of Chicago); Marc Brackett, PhD
(Director, Yale Center for Emotional Intelligence and Professor, Yale Child Study Center); Rob Knight, PhD
(Director, Center for Microbiome Innovation and Professor of Pediatrics and Computer Science & Engineering,
UCSD); Jonathan Simons, MD (President and CEO, Prostate Cancer Foundation); Howard Soule, PhD (EVP and
Chief Science Officer, Prostate Cancer Foundation); Rebecca Campbell, MD, MPH (Prostate Cancer Foundation);
Ruwanthi Ekanayake (Prostate Cancer Foundation), and Julie DiBiase, PhD, MFA (Prostate Cancer Foundation).
4
33 53
EXERCISE EAT REAL FOOD
35 The Basics Of Movement 55 What Is Real Food?
36 Body Mass Index 56 Cancer’s Worst Enemies: Food-Based
Antioxidant Anti-Inflammatory Compounds
38 Metabolism
59 The Microbiome
41 Vigorous Exercise
63 The Top 10 Foods To Eat To Prevent Cancer
48 Exercise During Treatment
68 The Relationship Between Inflammation
49 Exercise After Treatment
And Cancer
49 Exercise Suggestions For Seniors
71 How To Eat To Prevent Cancer
51 The Rise Of Complementary
76 How To Moderate Meat
Integrated Therapies
79 How To Moderate Sugar
83 What To Eat If You Have Cancer
85 Cancer Recovery Foods
86 Health And Wellness Suggestions For Parents
87 Smoking
88 Supplements
89 What To Drink (Or Not Drink) To
Prevent Cancer
91 How To Stay Current On What To Eat
5
Let food be thy
medicine and medicine
be thy food.
Attributed to HIPPOCRATES
6
OVERVIEW |
Overview
THE SCIENCE OF LIVING WELL

The idea of food as medicine is not new; it crosses centuries
and continents. The ancient Indians utilized turmeric for its
antiseptic properties, lentils served as a constipation rem-
edy in the Roman Empire, and the Aztecs used chocolate
drinks to relieve congestion.
In the Middle Ages, drugs and pharmaceuticals were natural remedies extracted
from plants. After the industrial revolution, pharmaceuticals transitioned from
extracts to synthesized chemicals. At this point, opinions began to polarize:
you either believed that food cured disease (quacks!) or medicine cured disease
(scientists). Now, the two points of view are merging again. Why?
One thing that has helped science catch up to

One thing that has the intuition that food can heal is “big data”:
helped science catch computers can now crunch large volumes of
up to the intuition data, allowing scientists to look for patterns
that food can heal is and trends that they could never see before.
“big data”: computers Here’s just one example: for a number of years,
drinking too much coffee was associated
can now crunch large
with poor health outcomes. But a 2018 study
volumes of data,
revealed that what was initially thought to be a
allowing scientists to
link between coffee and cancer turned out to
look for patterns and be a link between smoking and cancer. You see,
trends that they could many coffee drinkers smoke, and once there
never see before. was enough data and computer power, re-
searchers were able to see that the association
was not based on coffee at all. In fact, two studies have found that the antioxi-
dants in coffee may reduce risk of prostate cancer, and there is now ample data
to indicate that coffee may be associated with the prevention of certain types of
cancer, including liver and endometrial.
Thanks to global access to people, information, high-speed computing, and

time, we are beginning to understand the cause and effect (if any) of how certain
nutrition behaviors factor into health outcomes. The result is a shift in the way
food is being treated: the convergence of food as healing and nutrition as science.
7
Is It Possible To Eat To Prevent Cancer?
Is it possible to eat to slow down the growth of cancer, augment cancer therapy,
or remain healthy after treatment? As more and more large-scale research studies
are published, the answer seems to be, in most cases, yes. In one example,
researchers in Spain found that study participants who were randomly assigned
to a “Mediterranean diet”—including vegetables, beans, whole grains, fruits, fish,
extra virgin olive oil (EVOO), and nuts—vs. a reduced-fat diet (control) had lower
occurrence of cardiovascular disease and a lower risk of breast cancer.
However, it is also important to note that, as doctors, we see cases all the time
where a patient takes great care of themselves and seems in otherwise excellent
health…yet they still get cancer. Rest, exercise, and nutrition are three of the top
social determinants of health; they are not the only determinants of health.
Precision Nutrition Precision Exercise

Studies suggest that a diet supple- It’s a little easier to see how exercise
mented with extra virgin olive oil may works best when tailored to different
decrease risk of invasive breast can- people. For one guy, a walk up a steep
cer. However, we can’t always make hill may be challenging as well as
generalizations: for example, two health-promoting; for another gal,
breast cancer patients may respond running to the top of a mountain and
slightly differently to the same diet. back might feel easy. Research has
That’s because every person is unique, found some pretty clear associations
so every person needs a unique diet, between exercise and cancer pre-
optimized to meet their nutrition vention and recovery. Furthermore,
needs. If you are recovering from studies seem to indicate that exercise
cancer, your doctor will likely be able during treatment may be a boon for
to recommend a nutritionist to help long-term effectiveness and reduce
create a customized plan for you. side effects.
8
OVERVIEW |
What is Cancer?

Cancer is a collection of 187
If you are trying to eat to prevent diseases which are all due to
cancer, some of the information in
this document can be used as guiding uncontrolled cell growth.
principles—but it’s important to
remember that what works for
someone else may not work for
Cancer starts due to a genetic muta-
you. This is the concept of tion, generally in the form of damage
precision nutrition. to the DNA. Our cells divide many
times during our lives. At each division,
our genes—made up of DNA—need to
be replicated, and occasionally errors
occur. If the error, or mutation, is in a
gene that regulates cell division and it
is not fixed in time, this may result in
cancer. The majority of mutations that
cause cancer are the result of chance:
the more times cells divide, the more
chance an error will occur. This is why
cancer risk increases with age.
Cell division needs both energy and

Precision Rest building blocks to make new cells, and
What could be precise about rest? thus a cancer cell or a growing tumor
First, we have to answer the question needs plenty of glucose and amino
of what “rest” even means. Resting acids. Cancer cells ‘burn up’ glucose in a
your body can involve sleeping, different way than normal cells, re-
recovering or sitting; it can also sulting in a high level of glucose in the
refer to more active rest like yoga or cancer cells (this is one way in which
meditation. These activities, as well tumors can be detected). This differ-
as others described in the following ent type of metabolism, called the
section, can help ease chronic pain, Warburg effect, is not fully understood,
anxiety, and stress, resulting in all but it may help to fuel the growing
kinds of better outcomes for your tumor’s need for energy and building
immune system. blocks for new cells.
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Own Your Health: Get Involved
Whether you’re reading this guide as a cancer prevention tool or a cancer recovery
tool, the outcome could be in your hands. While 5%–10% of cancers, usually the
most aggressive, are due to factors like inherited genetic mutations, 42% of cancer
cases are thought to be preventable with the right lifestyle changes, including but
not limited to HPV vaccination, quitting smoking, and reducing obesity. It is never
too late to develop a personalized wellness plan.
It can be tough to figure out which changes

to make, though: the world is full of well-
meaning self-help gurus, people who have
been-there-done-that-spinach-smoothied
their way to remission, and even some old-
fashioned take-the-money-and-run shysters.
42%
You’ve heard this before, but we’ll say it again:
DO NOT believe everything you read on the
internet. Remember to look for science-based
of cancer cases are information, whether in this guide, at pcf.org,
thought to be prevent- or from other sites with a .gov, .edu, or
(in most cases) .org extension.
able with the right
lifestyle changes.
For those who are actively in treatment, espe-
cially treatments with side effects, there may
be recommendations that are extremely specific to your particular cancer therapy
protocol. Covering those is beyond the scope of this guide, but be proactive
about asking your oncologist or nurse what you can do to minimize side effects or
augment treatment efficacy with exercise and nutrition.
Lastly, although getting involved in your own health

is critical, getting involved in helping other people can
be even more uplifting. Without brave citizen scien-
Become a citizen scientist
tists coming forward to participate in clinical trials,
today—volunteer for a
much of the research used in this guide would not clinical study. Go to
exist. We hope you consider “paying it forward,” as clinicaltrials.gov
others have done; there are many open clinical trials for more info.
in exercise and nutrition that need your help.
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OVERVIEW |
How To Read This Guide

In this booklet, we have translated a lot of established and cutting-edge scientific
research into easy-to-read recommendations.
We put in a lot of science. If you want, you can download our references and read
the original source material. Either way, it is important to keep in mind that most
of the science today in the field of health and wellness is based on association,
not causation.
Association refers to two variables that seem to be related in some way. For
example, let’s say a scientist looks at the relationship between golden retriever
ownership and clinical depression diagnosis. Just based on survey data, it may
seem like owning a golden retriever corresponds with lower rates of depression.
DEPRESSION RATES AMONG GOLDEN RETRIEVER OWNERS
Depression Rates Among Golden Retriever Owners
45
40
35
Depression Rate (%)
30
25
20
But does this mean
15
10
owning more
5 golden retrievers
0 decreases your risk
0 1 2 of depression?
Number of Golden Retrievers
Not necessarily.
11
In order to determine
causation—not just
association between
the two variables—
you need to conduct But does this mean owning more golden
a randomized retrievers decreases your risk of depression?
controlled study. Not necessarily.
In order to determine causation—not just association—between the two variables

you need to conduct a randomized controlled trial. Randomly assigning subjects
into each group helps control for other possibly related variables, like age, person-
ality type, socioeconomic status, cancer stage, other disease interactions, etc. To
make any causal relationship more evident, you might consider selecting subjects
who are not currently depressed, and are generally healthy.
Maybe you give two golden retrievers to members of Group 1, one golden
retriever to Group 2, and no animals to Group 3. It might be a good idea to give
Groups 4 and 5 one and two Labrador retrievers, respectively, to make sure it’s
the golden retrievers themselves impacting depression, as opposed to the fact that
the subjects have dogs in general. To make your study really rigorous, you could
even give groups different kinds of pets—birds, hamsters, and fish, for example—to
make sure whatever results you get are based on owning a golden retriever, and
not just owning a pet.
Then, you might check in with every subject in two-year intervals for ten years to
determine whether or not they’ve been diagnosed with clinical depression. Let’s say
the results show that people with golden retrievers have a significantly lower rate
of depression diagnosis. Since the randomized assignment into groups helped you
control for a lot of other variables, you can safely conclude a probable causal rela-
tionship between owning a golden retriever and having lower rates of depression.
To review: randomized controlled studies over time help scientists to determine

causality. Does this mean that all other studies are inferior?
Not at all.
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OVERVIEW |
Epidemiological studies also use observational data; they may not control for as

many variables, but they look at population trends and hence have the advantage
of using much larger and more generalizable data sets than randomized con-
trolled trials. This is also useful information.
Here’s an example of one landmark observational study that examined associa-

tions between variables to make a life-saving health recommendation. In 1950,
Dr. Ernst L. Wynder published a retrospective study that found that a significantly
large percentage of lung cancer patients were also regular smokers. Even though
his results didn’t confirm a cause-and-effect relationship between smoking and
lung cancer, they were strong enough to help catalyze larger, long-term studies,
eventually leading to a US Surgeon General report that sparked a wave of
anti-tobacco initiatives. The percentage of Americans aged 18+ who smoke has
dropped by over 50% since the 1960s, and the percentage of deaths from lung
cancer, particularly in men, has also dropped significantly.
Today, we have cause and effect firmly in hand for smoking and cardiovascular
disease, lung cancer, bladder cancer, and more; back then we didn’t. But the
smoking gun (pun intended) of Wynder’s study was enough to recommend a
change in behavior even before the larger studies confirmed what we thought
we knew. And that change in behavior saved thousands of lives along the way.
The Bottom Line
We recommend your cancer avoidance journey focuses on three primary areas:

resting your body and mind, exercising vigorously to the best of your ability, and
eating a whole-food diet. The remainder of the guide focuses on the latest avail-
able scientific research in these three areas.
Relax Exercise Eat Real Food
13
Hallmarks of Human Cancer as Driven by Lifestyle Factors
By Obesity
By Inflammation By Inflammation
Sustaining Evading
Proliferative Growth
Signaling Suppressors
Deregulating Avoiding By Healthy

By Obesity Cellular Immune Microbiome
Energetics Destruction
Resisting Enabling By Good Sleep

Cell Replicative By Stress
Death Immortality By Inflammation
Genome Tumor-
By Charred Instability & Promoting By Bad Fat
Meats Mutation Inflammation
Inducing Activating
Angiogenesis Invasion & Metastasis
By Coffee By Inflammation Increased

By Green Tea Decreased
A 2011 landmark paper by Hanahan and Weinberg pub-

lished in Cell described six “hallmarks of cancer,” or biologic
capabilities common across all cancer types. Above are an
updated nine hallmarks, and some of the insights we now
have about how the lifestyle factors described in the rest of
this guide can affect cancer outcomes.
14
RELAX
15
Except our own
thoughts, there is
nothing absolutely
in our power.
RENÉ DESCARTES
16
RELAX |
Mental Health
Right now, you might be thinking to yourself: “I came

here for the latest info on cancer nutrition, and I’m getting
400-year-old advice. This is nonsense.” In fact, our ances-
tors were spot-on about a lot of things that we’ve now been
able to verify with modern research.
René Descartes famously explored the mind-body connection. While Descartes

mostly wrote about the mind’s ability to mechanically control the body, today’s
science shows that our mental states can affect our health as well.
Here’s one example: Prostate Cancer Foundation (PCF)-funded researcher

Suzanne Conzen studies the body’s stress hormone receptors. Her work, which
overlaps both breast and prostate cancer, indicates a strong relationship between
stress response and cancer. Our biggest hesitation in telling you that? That it will
stress you out. But fear not, there are many techniques for managing your mind,
and subsequently, the influence it has on your body.
In recent years, the value of something called emotional intelligence has been
on the rise. EQ (emotional quotient) refers to your ability to recognize and regulate
your emotions. In the “old days,” researchers used to think that IQ—intelligence
quotient—was a predictor of performance. We now know that your EQ is a far
more accurate predictor of success. On an intuitive level, that kind of makes sense,
right? You might be the smartest person in the class, but if you can’t modulate
your anxiety on test day, you’ll still get low grades.
Here’s some more good news: unlike IQ, EQ can

be trained and improved. The ability to identify
and regulate your emotions is critical if you’re
EQ
going through cancer diagnosis, treatment, or EQ refers to your
recovery. Even if you’re reading this as a preven- ability to recognize and
tion guide, the EQ toolbox is a good jumping-off regulate your emotions.
point for all your emotional management needs. It can be trained and
improved.
17
There are five 1 2
main components Self-Awareness Self-Regulation
of emotional It is important to have a line Once you’re aware of your
intelligence: on your own emotions and weak spots and tendencies,
thoughts: Are you anxious you can adapt to and redirect
in certain situations? Do your moods, often taking the
specific events trigger anger, time to think before you act.
sadness, or joy? If you are
going through cancer diag-
nosis or recovery, you may
experience the widest range
of emotions of your lifetime.
Self-awareness means know-
ing your emotional strengths
and weaknesses, without
beating yourself up for it.
It’s important to note that

Self-
all five components of Awareness
emotional intelligence
are interconnected: as
you work on one, you’re Social Self-
simultaneously improving Skills Regulation
your skills in another area. Emotional
For example, practicing Intelligence
positive self-talk to decrease
anxiety also might give you
confidence to try a more
Empathy Motivation
challenging workout routine
at the gym.
18
RELAX |
3 4 5

Motivation Empathy Social Skills
Find meaningful reasons to “You can’t help others until Your social skill set is the one
pursue your goals. Whether you help yourself.” Having that lets you connect easily
it’s altruistic in nature, a de- a firm handle on your own with people and build lasting
sire to showcase your skills, emotions allows you to react and supportive relationships.
a need for autonomy, or to to other people in a more For anyone going through
feel a sense of relatedness to understanding way. For cancer diagnosis, treatment,
others, having passion helps example, if you are helping recovery, survivorship,
to renew your energy and your dad through his cancer caregiving, and beyond,
optimism through ups and treatment—and he can’t nurturing your social network
downs, and helps you persist seem to stop snapping at and having the strength to
through to your goals. you—you might consider call upon those you love
that he is probably scared. will be a critical part of your
Instead of snapping back, journey.
take a deep breath and let
him know you understand
how hard it must be.
In his book Permission To Feel, Marc Brackett, PhD, Director of the Yale Center for
Emotional Intelligence, notes these tips for improving emotional intelligence:
1 Emotions are information! Historically, emotions were seen as disruptive -

information to be ignored. But the truth is, emotions provide valuable information.
Fear informs us: should I approach or avoid? Anger lets us know there has been an
injustice. Joy signals that things are safe.
2 Think like an “emotion scientist.” Be the learner, not the knower. Listen to
understand, not to build your own argument. Validate and show unconditional
support to yourself and others.
3 Managing your emotion skills is a lifelong journey! Think about it: none of
us are born with an advanced vocabulary to describe our inner lives. Work on
building your emotional vocabulary. Replace unhelpful strategies for regulating
emotions (negative self-talk) with positive strategies. Think about the advice you
would give a best friend or loved one and apply it to yourself.
19
What Is Stress?
“People are disturbed not by a thing, but by their perception of a thing.” –Epictetus
More and more, stress is a pervasive aspect of everyday life. Disease, parenting,
financial issues, relationships and work all seem more complex than they were
50 years ago. That means the things that relieve stress—mindfulness, community,
and laughter, to name a few—are in short supply compared with the stressors. The
perception that you are unable to “keep up with” or overcome multiple short-term
stresses can result in persistent long-term anxiety. Both long- and short-term stress
can impair cognitive processes, increase blood pressure, and cause headaches and
other physical effects, as well as increasing negativity and decreasing productivity.
But what IS stress? Because stress is something very personal, it can be tough to
imagine defining it. On a biological level, an individual person’s response to stress can
be measured by looking at increased levels of the hormone cortisol. Most cells in
the human body have receptors for cortisol called the glucocorticoid receptor, or GR
for short. This means that when you get frazzled (ie, have a big response to stress),
cortisol can affect almost every area in your body.
Have you ever felt “worried sick”? It’s not all in your head: stress responses have a
plethora of physiological effects, including links between stress and disease. Studies
have found that stress can trigger a physical reaction that appears to contribute to
and/or exacerbate conditions including asthma, arthritis, depression, cardiovascular
disease, chronic pain, HIV/AIDS, stroke, obesity, and certain types of cancers.
When it comes to cancer, it might be important to treat stress along with the
actual disease. Studies by PCF-funded researcher Suzanne Conzen found that high
expression of GR in tumor cells is related to decreased survival in ovarian cancer
patients. Her research also suggests that decreasing GR’s downstream effects in
tumor cells might delay cancer progression.
20
RELAX |
THE MECHANICS OF HOW STRESS AFFECTS CANCER GROWTH
Let’s say you’re frantically trying to meet a deadline. The mental angst is
connected to a release of the stress hormone cortisol into the bloodstream.
We’ll represent cortisol with a red square and GRs with dark blue wedges.
Cortisol can diffuse into your cells

(the large blue circle), and bind to
GRs—the dark blue wedge shapes.
This can provide an environment
Cell
for cancer to thrive.
Cell
Dr. Suzanne Conzen’s research
suggests that to enhance cancer
therapy, we should introduce
molecules that inhibit the activity
of GR: that is, they allow fewer
GR activated blue glucocorticoid
Cortisol
receptors.
GR
Cortisol
By blocking the places for cortisol to dock,
the effect is that cancer progression is reduced.
Instead of blocking the docking site,

there’s another option: use the tools
in this guide to decrease stress and
you’ll decrease cortisol secretion.
With fewer cortisol molecules
around, there’s a lower chance of
cortisol-GR binding, so again the
effect on disease progression is
reduced.
21
The takeaway from this research is that, believe it or not, we now have biological
evidence that high stress levels can fan the fire of cancer growth. Therefore, it is
important to keep your stress levels in check—that is easier said than done, espe-
cially if you are dealing with a cancer diagnosis.
The good news is that, as Epictetus said almost 2,000 years ago, you have the
ability to change how your body perceives stressful situations, events, and people.
Here are a few tips for keeping your stress response at bay. Even working on just
1-2 of these could have a substantial effect on your ability to manage stress.
1. Accept your stressors | Studies indicate that accepting stress

decreases negative emotions and protects against depression. This
doesn’t mean you hide from your stressors: it just means that you
acknowledge their presence, you do what you can to improve your
situation, and then try hard to let it go.
2. Spend time in person with friends | Research suggests that in

person socializing (vs. through social media) is important: limited
face-to-face contact may double your risk of depression, but making
the effort to have in-person conversations creates a more fulfilling
experience. Take time to meet a friend in person for coffee, or start a
monthly activity group with friends who share the same interests.
3. Give yoga a try | Despite what you might have seen on sitcom
TV, yoga practice isn’t about twisting yourself into a pretzel; the goal
is to connect your body and mind in a way that gives you peace,
power, and clarity. Research continues to find links between yoga
and decreased anxiety and depression, and better regulation of
your hypothalamic-pituitary-adrenal system, which controls cortisol
secretion. Check to see if your gym offers classes, take a free trial class
at your local studio, or look for online classes through your computer.
4. Jam out | Multiple studies provide evidence that listening to

music every day helps lower your stress levels. Research suggests
that listening to music for the express purpose of relaxation increases
the stress-reducing benefits of music, as opposed to using it as a
distraction from work or to stave off boredom.
22
RELAX |
5. Get physical | Not everyone’s a hugger, but research suggests that
both nonsexual physical affection and sexual activity itself may play
a role in improving mood and increased oxytocin secretion, which is
linked to antidepressive effects.
6. Laugh | Nothing feels better than a good belly laugh, and science
backs it up! Both mirthful laughter and anticipation of mirthful laugh-
ter decreases cortisol secretion (the stress hormone). Plus, just hearing
laughter helps your parasympathetic nervous system initiate a “rest
and relaxation” response, so consider taking in some local standup
comedy or start watching a TV show with a laugh track!
7. Get a pet | Research suggests that pet ownership alleviates

stress-related blood pressure increases, and especially helps reverse
depressive symptoms in the elderly. Dogs in particular are great
stress-reducing companions, but consider volunteering at an animal
shelter or visiting a dog park if you can’t own one yourself.
8. Exercise | This is an oldie but a

goodie: working up a sweat can release
endorphins, help your self confidence,
Working on just a
and improve mood-related disorders. few of these could
See page 44 for more on exercise. have a substantial
effect on your
9. Cry | While a lot of stress-reducing ability to manage
techniques focus on rerouting your neg- stress.
ative emotions, sometimes it’s good to
experience sadness and anxiety. Studies
suggest that crying improves mood for
both men and women, perhaps due See also, sleep
tips on pages
to parasympathetic nervous system
26-27.
activation, which helps your body calm
down from a stressful situation.
10. Get your sleep right | With jobs, commitments, and Candy Crush,
it’s easy to find yourself still awake at 4:00 a.m. with work the next day.
But your body needs time to rest and recover: lack of sleep can increase
your cortisol levels and may negatively impact your immune system.
23
In the following sections, we break down a few of the
stress management factors that have been studied in
relationship to cancer.
Headaches Worrying
Taut Muscles Muddled Thinking
Frequent Infections Impaired Judgment
Muscular Twitches Nightmares
Skin Irritations Hasty Decisions
BODY Breathlessness Negativity MIND
Fatigue Indecisions
STRESS
Loss of Confidence Smoking More
EMOTIONS Fussiness Restlessness BEHAVIOR
Irritability Insomnia
Anxiety Loss of Sex Drive
Alienation Drinking More
Depression Loss of Appetite
Apathy
Manifestations of Emotional Stress
24
RELAX |
Sleep
Sleep is the body’s chance to recover from everything that happened during the
day. During sleep, your muscles relax and receive increased blood flow, your
tissues grow and repair, and your brain cells get rid of waste so you’re bright and
fresh for a new day.
In terms of how many hours of dozing you need per night, the jury’s still out.
You’ve probably heard the 7-8 hours mantra, but there’s also new research to sug-
gest that 5-6 hours might be optimal for longevity. The National Sleep Foundation
also recommends paying attention to your quality of sleep, which includes falling
asleep in 30 minutes or less and waking up no more than once per night. Like
any other piece of advice we give in this guide, you have to figure out what works
for you: your coworker might be perky with 6 hours of sleep, and you might be a
zombie with any less than 8.
Note, however: There is evidence against too

much sleep. Studies suggest that oversleeping
(usually 9+ hours) is linked to mood disorders,
neurodegeneration, and inflammation.
Too little sleep also leads to similar issues.

One example indicates that sleep deprivation
may be correlated with increased cancer risk.
A 2008 study compared women who worked
the night shift (in other words, their circadian
30%
Researchers found that
rhythms were off) with those who worked
there was a 30% higher
a regular daytime schedule. Researchers
incidence of breast
found that there was a 30% higher incidence
cancer in the night shift
of breast cancer in the night shift subjects.
Shorter sleep duration has also more recently
been linked to higher risk of death from prostate cancer and other cancers,
particularly in patients who have other conditions such as cardiovascular disease.
Sleep, stress, and cancer can turn into a vicious cycle: a cancer diagnosis is under-
standably stressful; this can mess up your sleep cycle which makes you even more
stressed out, which could put you at an even higher risk of cancer progression.
25
How do you break the cycle?
Don’t despair. In addition to
the Tools for Managing
3
Ditch the device.
Stress in the previous section, There’s a bit of a catch-22 here: often
here are a few more tips people try to unwind on their phones
specifically on how to before bedtime, but smart devices
can make it more difficult to relax
improve your sleep quality. and are linked with worse quality of
sleep. Consider powering down at
least 30 minutes before bedtime,
and keeping your phone further than
an arm’s length from your pillow.
1
Have a regular bedtime routine.
This is especially helpful if you
suffer from insomnia: identify a
4
Keep your bedroom dark,
few practices that you find relaxing, quiet and cool.
and implement them before your Darkness allows your body’s mela-
head hits the pillow. This can include tonin levels to rise, which stabilizes
having a hot bath, dimming the lights your sleep/wake cycle. This goes
in your bedroom, listening to music, along with turning off all the tech in
or reading a few chapters of a book. the area: devices like smartphones,
TVs, and computer monitors emit
blue light, which is particularly
2
damaging to melatonin production.
Studies also find that low noise levels
(you might consider a white noise
Find the amount of sleep that is
machine or soft music if you live in a
right for you.
busy area) and a bedroom tempera-
Everyone is a little bit different, and
ture of around 66 degrees Fahrenheit
that includes the amount of sleep you
help create an ideal environment for
need to function optimally. While the
you to doze off.
“recommended range” is 7-9 hours
for adults (7-8 hours for those age
65+), you may need more or less.
26
RELAX |
5 8

Sleep in bedding made of natural Limit alcohol intake before bedtime.
temperature-regulating fibers. Ditch the nightcap—just because being
Studies suggest that bedding made tipsy makes you feel like you’re falling
of wool or cotton fibers may have a asleep faster doesn’t mean you’re ac-
regulating effect on skin temperature tually sleeping better. A glass of wine
and changes in humidity, allowing with dinner is fine, but anything more
your body to maintain an optimal than 2 servings can cause nighttime
temperature for sleep. waking and prevent REM sleep, which
is the most restorative stage of sleep.
6 9
Get active. Avoid over-the-counter sleep
Physical activity has been linked medications.
to improved sleep, especially in While prescriptions seem like a quick
insomnia patients. Regular exercise fix for sleeping problems, many
may even protect against the medications pose risks of addiction
negative cognitive impacts of sleep and daytime side effects, particularly
deprivation. Exercise is also associat- for the elderly. Consider drugs as a last
ed with better sleep quality. resort for improving your sleep, and be
sure to consult with your physician.
7 10
Limit caffeine intake in the Eat a balanced dinner, including
afternoon. healthy fats.
As tempting as it is to reach for Lean proteins, such as turkey and
a cup during that mid-afternoon fish, and healthy fats, such as the kind
slump, caffeine consumed up to 6 found in nuts, can boost serotonin
hours before bedtime can negatively levels and help you sleep. However,
impact your sleep quality. research has also linked eating too
close to bedtime with sleep distur-
bances, so try to finish dinner about
2-3 hours before you hit the hay.
27
Yoga & Meditation
Originating in ancient India, yoga is a practice

that links coordinated movements with con-
trolled breathing. It meshes both your physical
and mental well-being by combining exercise
with meditation. Millions of people practice
each year, and the original 8 forms of yoga
have exploded into many variations, including
“doga”: yoga you can do with your dog!
Studies suggest that a regular yoga practice may

have benefits for fighting cancer. For example, a
comprehensive review of studies involving yoga and health outcomes indicates that
yoga may play a role in improving health-related quality of life and reducing fatigue,
sleep disturbances, depression, and anxiety in breast cancer patients.
Another example comes from a PCF-funded study of men with prostate cancer,
jointly conducted in 2017 between researchers at the University of Pennsylvania
and Johns Hopkins University. Men in the control group (no yoga) reported wors-
ening cancer symptoms, while men in the yoga group self-reported stabilizing
symptoms over time. Because the study was self-reported by the men, it’s unclear
what caused the improvement. It could be due to the men unconsciously linking
yoga and health, so they perceived their symptoms to be lessening. Or it could
be that the yoga physically strengthened their core muscles and pelvic floor,
hence relieving symptoms of incontinence and erectile dysfunction. Either way,
researchers continue to investigate the physiological mechanisms behind yoga’s
effects on cancer—for now, scientists believe that there is evidence for a positive
connection.
If you’re just starting out, you might consider trying classes at a yoga studio, your
local gym, or the YMCA: group exercise has been shown to have physiological and
emotional benefits for cancer patients. If you are unable to practice yoga outside
the home, there are apps available for your phone, online courses, and free yoga
videos on YouTube. Take a look online and figure out what style might be right for
you. Because they all focus on breathing, you really can’t go wrong with any style,
but Hatha yoga offers a good starting point for beginners, because movements
tend to be slower.
28
RELAX |
What about meditation? Yoga and meditation are related in that focusing your
mind during yoga practice is as important, if not more so, than the movements
themselves. Some would say that the physical yoga practice is merely a prepa-
ration for the real work, which is calmness and mental focus. That’s why we have
categorized yoga under relaxation, and not the exercise section of this document.
In 2014, a Canadian study found that meditating altered the length of cancer
survivors’ telomeres. Telomeres are the caps at the end of our chromosomes, and
they shorten over time; this contributes to the process of cellular aging, and is
connected to cancer progression. Participants in this study who didn’t meditate
saw their telomeres shorten over the period of the three-month study; those
who meditated did not, which suggests that meditation can help prevent cancer
progression.
Meditation can be done with or without a physical yoga practice. There are many
apps that can help guide you through meditation at home. Research indicates that
even 10 minutes a day can help with pain tolerance and anxiety, thereby decreas-
ing stress and supporting cancer recovery.
Work
Modern-day work environments can be a

quadruple threat of stress, thanks to longer
hours, more responsibility, longer commutes,
and lower pay.
Perceived work stress is linked to higher risk of

prostate cancer in men under 65 as well
as higher risk of lung, colon, bladder, rectal, and
stomach cancer in all men. Chronic stress is
connected to more aggressive breast cancer.
Dan Buettner is the founder and CEO of the public health organization Blue
Zones. Buettner works with communities to emulate the conditions of unique
places around the world where people live unusually long and healthy lives—in-
cluding looking at diet, exercise, and workplace.
29
One important feature of Blue Zone regions is that their residents have a sense
of purpose. This “reason to get up in the morning” is baked into ancient cultural
norms: in Japan they call it ikigai and in Costa Rica, plan de vida. Buettner believes
that this sense of purpose is linked to reduced risk of Alzheimer’s disease, arthritis,
and stroke. A complementary study of 7,000 adults found that a stronger sense
of purpose is correlated with lower mortality from all causes, including cancer.
Likewise, as Buettner points out, sitting behind a desk simply isn’t what our bodies
were made to do.
How can you manage this? For some people, work is their reason to wake up in
the morning. For others, work is the polar opposite—instead, they prioritize family,
community, or friendships. One of the most valuable things you can do is to
identify your own personal ikigai, spend some time nurturing it, and learn not to
sweat the other things too much (see page 19 for emotional intelligence tips).
Even if work doesn’t show up on your ikigai list, most of us still

have to do it. Here are a few tips for weaving purpose into your
current job:
Add tasks you enjoy or that challenge you.

If you’re bored with the same old routine, ask around to see if there are new
and different job responsibilities you can take on.
Set small goals.

Not every day will be a groundbreaking victory, but you can focus on tackling
small projects. Keep a to-do list and take pride in crossing things out all day.
Work on relationships.
Building personal connections and finding shared interests with colleagues
helps make the workday more bearable. Ask someone different to lunch
every day, or arrange a group outing after work.
Remember the big picture.

In order to escape cog-in-a-machine syndrome, take time to reflect on how
the small contribution you make adds to a larger positive impact.
30
RELAX |
Physical Touch
In 2004, the National Bureau of Economic

Research reported that having sex once a
week instead of once a month is the happiness
equivalent of getting a $50,000 raise. Sex
releases oxytocin and endorphins, which boost
your mood and act as natural pain suppressors,
as well as stimulate your immune system.
Unfortunately, cancer diagnosis and treatment

can affect sexual drive and function. If you are
in a committed relationship, it is critical that
you maintain an open dialogue with your partner about any changes or worries
you are experiencing. It is not impossible to have a healthy, intimate relationship
with your partner during cancer treatment. Plus, if you are a man worried about
prostate cancer, we have some news you are going to like. There’s a growing body
of evidence that suggests that men who ejaculate more frequently have lower risk
for prostate cancer.
If you are a man who has been diagnosed with prostate cancer, you may have
many questions about erectile side effects from treatment. For a full review on
side effects, treatment, and the latest research, download the Prostate Cancer
Patient Guide at pcf.org/guides.
If cancer has affected your sex drive, there’s still
$50K
good news: the physical touch doesn’t have to
be sexual in nature to have beneficial effects.
Therapeutic touch and massage have been shown
to have a positive impact on cancer symptoms. Sex once a week
As we mentioned before, nonsexual touch helps
instead of once
with stress reduction, which is associated with
a month is the
lower cancer risk. Research also suggests that
happiness equivalent
a cancer diagnosis can actually increase needs
of getting a
for nonsexual touch and affection compared to
before the diagnosis. $50,000 raise.
31
Community
What would you cite as the best predictor

of risk of death? Common answers might be
cancer, heart disease, or behaviors like alcohol
abuse or drug addiction.
But a study published by the American Cancer

Society points in a different direction: social
isolation. Researchers found that compared to the least socially isolated in their
race-sex subgroup, the most socially isolated black men and women had more
than 100% increased mortality risk, and white men and women had 60% and
84% greater risks of death, respectively. While more research has yet to be done
on other demographics, this study provides some pretty compelling evidence for
the damaging effects of social isolation.
Social isolation, loneliness and lack of adequate support are distinct but related,
and are referred to as social determinants of health. Social isolation is physical
separation from other people. Loneliness refers to your perception of being alone
or separated from others. Social support refers to the overall overlap of your
actual support and your perceptions of being cared for or belonging.
Regarding the value of community for health, some of you may be thinking,
“I knew that!” while others of you may be thinking, “That’s just hippie stuff.”
Regardless of where you land on this continuum, the data are unwavering on
this topic: isolation, loneliness and lack of social support relate to adverse health
outcomes, especially for the elderly. Fortunately, there are many new organiza-
tions cropping up to address this problem. One program, Silver Sneakers, brings
older adults together to exercise, simultaneously helping to knock out both fitness
and loneliness issues in one swing.
This brings us full circle to Epictetus and the start of this chapter. Many of the
suggestions we’ve provided—strengthening your emotional intelligence, taking
yoga classes, or building relationships at work—are inherently tied to creating
strong networks to improve both your physical and emotional health. Research
indicates not only that positive thinking can improve outcomes, but that if you
perceive your situation to be lonely or stressful, regardless of whether it is, your
health can actually worsen. This is all the more reason to be a proactive participant
in your 360o wellness.
32

EXERCISE
33
Lack of activity
destroys the good con-
dition of every human
being, while movement
and methodical physical
exercise save it and
preserve it.
PLATO
34
EXERCISE |
The Basics Of Movement

Movement is the act of changing the physical position of
your body.
A lot of people think of walking as the most basic movement of the human body.
But let’s challenge that a little bit—think about the fact that babies cannot walk
when they are born. What can they do? They can grab, smile, roll over, crawl.
Over the course of an entire year, babies exercise a whole host of other natural
movements that help to build the strength and coordination they will eventually
need to walk.
So with that definition of movement, what is exercise? For this guide, we will
define exercise as intensity of movement with the intention to effect change. In
other words, exercise is anything you do where you 1) move your body rigorously
such that 2) the outcome is that you get better, stronger, or faster in motion.
Wait wait wait wait. You might be thinking to yourself, “I thought all I had to do
was walk briskly around the block for 30 minutes three times per week?” The
answer is that the amount and type of exercise you have to do to stay healthy
varies greatly with your body type and fitness level. Let’s imagine someone who
runs marathons for fun. Let’s say he runs a marathon in January and he has anoth-
er marathon planned for July. If he walks around the block for 30 minutes three
times per week until July, will he be able to do well in the second marathon?
Not likely. In comparison, for someone who spends most of their life at a desk
working on the computer, and is just starting out with exercise, the round-the-
block routine may drastically improve their fitness in that same 6-month period.
Your exercise routine needs to be tailored to maintain or improve your current

fitness. And in order to improve, you have to challenge your current fitness status:
you have to put in effort. For example, if you want to roll a ball up a hill, it takes
a certain amount of effort, and how much effort you exert determines how fast
you are able to push the ball up the hill. What happens if you get half-way up the
hill and you let go of the ball? It rolls backwards and you have to start again. Even
if you want to stay exactly as you are right now, you have to exert a little bit of
effort, consistently. This is the same song Plato was singing over 2,000 years ago.
This is exercise.
35
Find something you like to do, because
exercise is a lifetime healthy habit,
not a single sprint up the hill.
Start
over?!
If you stop effort, the ball
rolls down and you start
GETTING FIT from scratch.
To move the ball up, takes

some effort.
YOUR
FITNESS
LEVEL
I got
this!
YOUR
FITNESS
LEVEL
YOUR FITNESS PLAN
Body Mass Index
Body Mass Index (BMI) is often used in health and fitness as a measure of—to not
mince words—how overweight you are. BMI is an approximation, calculated by
dividing your weight (in kilograms) by your height2 (in meters). If you know your
weight in pounds and height in feet, you can use any number of online calculators
to get an approximation of how overweight you are (if at all).
BMI provides a crude but general way to measure obesity. Data indicates that as
your BMI increases beyond healthy ranges, so does your risk for many diseases.
One PCF-funded study found that obesity is associated with metabolic changes
that may promote prostate cancer progression. A high BMI is also linked with
36
EXERCISE |
MAINTAINING FIT

To keep the ball from
rolling down takes effort too!
It’s
worth it!
YOUR
FITNESS
LEVEL
Can I exercise when
I’m in treatment?
Every person, cancer, and cancer
treatment plan is different.
When you are in treatment, it is
recommended that you consult
with your health care practitioners
and not this guide. Your treatment
center will likely provide access to
or recommendations for alterna-
tive and complementary special-
ists (eg, a physical therapist) who
can help you during treatment.
increased risk of cardiovascular disease, hypertension, diabetes, and multiple

cancers including endometrial cancer and leukemia, as well as thyroid and colon
cancer in men.
Remember, this is a correlation, not a causation. In other words, being overweight

does not cause cancer, but it increases your risk both for getting cancer and having
worse outcomes if you do get diagnosed. For example, obese men diagnosed with
prostate cancer are nearly 30% more likely to die than those at a healthy BMI.
While data strongly suggests that obesity is correlated with cancer-related risk
and death, it’s important to point out that the full equation is more complicated.
Consider the famed village of Acciaroli in Italy. About one third of the people who
37
live there are over 100 years old; many are also overweight, and smokers. While
we absolutely do not advocate either of these lifestyle choices, it drives home the
point that the relationship between lifestyle factors and outcomes is complex.
For example, the folks in Acciaroli are also a part of a tight-knit community with
a low-stress culture. Could it be that this helps balance the other aspects of their
lifestyles? It’s unclear, and more research is needed. In the meantime, as we advise
in this guide, try to make small changes and improve upon all three aspects of your
health – relaxation, exercise, and eating well - to create a long, well-rounded life.
What is a normal BMI? That’s also a nuanced question. As already discussed,

every person is a little different. If we were to dig in, what is considered a “risky”
BMI may differ between diseases, e.g., heart disease vs. cancer. Likewise, BMI is
a generalization that can mis-estimate body mass in Asians, overestimate body
mass in athletes, and underestimate it in older people (because of differences in
bone density and muscle mass). According to the Centers for Disease Control and
Prevention, standard categories for BMI are as follows :
WHAT IS A NORMAL BMI?
18 or lower Underweight
18.5 to 24.9 Normal, healthy weight
25 to 29 Overweight
30 or higher Obese
If you are overweight, all is not lost. BMI is just one indicator of cancer risk.
Moreover, it is possible through a combination of healthy eating and exercise to
lower your BMI. The rest of this section will discuss how exercising can both drop
your BMI and have a marked effect on your cancer outcomes.
Metabolism
Metabolism is the process of converting food into energy, and occurs in every
living, breathing creature. Converting food to usable energy occurs in alternating
phases: 1) the food that you eat is converted to a form that your body can store,
and 2) the body breaks down the food that you stored (as calories) for energy.
38
EXERCISE |
How is food stored and used as energy?

There are three basic macronutrients in food that provide energy:
Carbohydrates Proteins Fats
The process of turning these foods Fat needs to be digested into fatty
into energy starts in the mouth. acids before it can be absorbed into
Enzymes in our saliva and then in our bodies. Once absorbed, the fatty
our digestive tract (or gut) break up acids can also be used for energy or
carbohydrates into individual glucose stored as fat.
molecules, which are transported
across the intestinal wall and into It is important to appreciate that
our bloodstream. these three basic building blocks—
glucose, amino acids, and fatty
Glucose molecules are subsequently acids—can all be interconverted to
reassembled into a type of carbo- each other inside the body.
hydrate called glycogen. When your
body stores glycogen, it starts with The chemicals derived from our foods
your muscles, then it fills up your have three fates: they can be used to
liver; and when your liver has no more repair our organs and tissues, they can
room left it is converted into fat. That be stored as either glycogen or fat (as
fat is stored as adipose tissue, either described above), or they can be ‘burnt
under our skin (“subcutaneous fat”) or up’ to produce energy in a process
around our organs (“visceral fat”). called respiration. It’s the equivalent of
stoking a fire: glucose, fatty acids and
Proteins are broken up into their indi- amino acids can all enter a metabolic
vidual amino acids which can then be process in which they are broken up to
absorbed and reassembled into the release energy and the “waste” carbon
various types of proteins our bodies is combined with oxygen (which we
need for various functions - including breathe in) to produce carbon dioxide
building muscle - but they can also be (which we breathe out), just like
converted into glucose and fat. burning fossil fuels.
39
BMR
Basal Metabolic Rate. So how are food, exercise, weight, and metab-
This refers to the olism related? You may have heard people say
amount of calories things like “Oh, she has a fast metabolism” or
you burn when you “He has a slow metabolism.” This implies that
are at rest. your metabolism is something that is unique to
you, that you were born with. That is only part of
the story.
How “fast” your metabolism runs is determined by your BMR, or your Basal
Metabolic Rate. This refers to the amount of calories you burn when you are at
rest. In other words, it’s the base amount of energy your body needs to keep your
heart pumping, your blood flowing, your cells regenerating, etc. It’s true that your
genetics are involved in determining your BMR, but it’s not 100% predestined.
Because maintaining muscle takes more energy than maintaining fat, it is possible
to raise your BMR by increasing your muscle mass (such as through weight train-
ing). Likewise, the reason that BMR often drops with age is because of loss of lean
muscle tissue.
Is it possible to calculate your BMR? Yes, but we think it is unnecessary. For the
purposes of eating and exercising for good health, avoiding obesity, and prevent-
ing cancer, this guide advises you to stick with the lifestyle changes and leave the
calculations behind.
40
EXERCISE |
Vigorous Exercise

You may have heard the suggestion that walking several times per week was all
that was required for good health. We now know, as we age, and especially if we
are aging with high cancer risk, more may be needed. Vigorous exercise—meaning
close to maximum effort, where your heart beats rapidly, you are sweating, and
you cannot carry on a conversation—is an important component of good health
and disease prevention. What vigorous means for you will depend on your fitness
level, but for most people, it equals more than just a walk around the block.
How Intense is Your Exercise? The Talk Test.
There are a number of personal fitness devices on the market today that can
calculate your heart rate and other exercise statistics. If that’s not your cup of tea
or your budget, here’s a classic test for determining intensity of exercise:
TALK SPEAK SING

If you can talk, If you can speak If you can sing while
but not sing, only a few words doing an activity,
during exercise, during exercise, it is then it’s movement
it’s moderate. considered vigorous. but not exercise.
41
Long-term exercise affects your energy
metabolism, lowers inflammation and
oxidative stress, and improves immune
response. In prostate cancer, several studies
conducted by PCF-funded researchers June
Chan and Stacey Kenfield have shown that
faster-paced walking or vigorous exercise
significantly reduced the risk of prostate
cancer recurrence or prostate cancer death
(respectively), compared with slower-paced or less intense exercise. Research also
suggests that regular exercise both reduces risk of breast cancer and helps allevi-
ate symptoms for breast cancer patients. Vigorous exercise in young adulthood
has been linked to lower risk of endometrial cancer later, suggesting that exercise
you do now could reduce risk of disease when you are older. As most cancers are
similar in what makes them tick, a healthy cancer-fighting choice for everyone
would be to exercise as vigorously and regularly as your personal fitness allows.
Exercise appears to be an effective adjunct therapy even in patients with ad-

vanced cancer. Across multiple studies, exercise interventions were associated
with improved quality of life, fatigue, psychosocial function and sleep quality, and
physical function. More targeted studies are required to determine the optimal
exercise “dose” to enhance outcomes for specific types of cancer.
Here’s just one example of what scientists are discovering, and how precise it can
get: PCF-funded researcher Lorelei Mucci and team studied a gene fusion called
TMPRSS2:ERG, which is a molecular alteration found in 30%–40% of prostate
cancer. This research suggested that long-term vigorous physical activity was as-
sociated with a lower risk of developing TMPRSS2:ERG-positive prostate cancers.
You don’t have to have a heart rate monitor or be a gym rat to exercise vigorously.
Here are just a few suggestions for how to easily get your heart rate up to vigorous
levels without having to get on a treadmill:
1 Walk or bike uphill

2 Run in place with your knees high
3 Put on some music and dance—make sure to move your feet, not just your hips!
4 Old fashioned “calisthenics”:—eg, jumping jacks!
42
EXERCISE |
Find your Baseline Fitness Level
Don’t belong to a gym or own a heart rate monitor?

Don’t worry. Here’s a great way to measure whether your
exercise routine is helping you improve fitness. In order to
record your baseline fitness and watch for improvements
over time, follow these 4 simple steps:
1 Find a hill in your neighborhood that is a minimum of 1 mile long (you

can use your car or an online map program to confirm the distance),
with a steadily rising upward slope. If you’re already in a decent physical
condition, then the steeper the better!
2
Get a good night’s sleep, eat a light breakfast (such as a piece of fruit
with peanut butter or a bowl of cereal), and get yourself to the bottom of
the hill.
3
Start the timer on your phone or your watch and walk (not run!) as fast
as you can for one mile uphill. Stop your timer. This is your baseline time.
Walk easily back to the start.
4
Repeat this workout as often as one time per week and record your time
to see your fitness improve. Try to keep your routine the same (#2 above)
and always start and stop your watch at the same locations.
Don’t worry if you get slower one week or even two weeks
in a row! It’s all about changes over time, and these are
not short-term fixes, but lifestyle changes. On the other
hand, if your other weekly workouts are effective and you Also: don’t forget to
feel yourself getting in better shape, you can choose a smile, you did it.
longer and/or steeper walk and start a new baseline.
Always consult a doctor or trainer before beginning any new exercise routine,
especially if you are new to exercise.
43
HIIT & Cancer
In recent years, High Intensity Interval Training (HIIT), has come into great pop-
ularity. But it is more than just a fitness fad. Interval training refers to alternated
periods of intense exercise and easy recovery, repeated over time. This includes
things like weightlifting sets and running sprints. Exercising in alternating phases
causes your body to metabolize energy beyond the workout itself. Ultimately,
HIIT is proven to lead to shorter and more satisfying workouts, more calories
burned, and improved cardiovascular health and vitality. Additionally, benefits of
HIIT during chemotherapy have been shown to continue a year into survivorship.
An example of a 1 1 Interval Training

1
MIN 1
MIN
Interval Training
10
single interval MIN MIN
1 1 Interval Training
MIN MIN
Jumping Jacks
Jumping Jacks
Jumping Jacks
Rest
Rest
Rest
10
Repeat that process
Repeat thattimes
multiple process
multiple times
Repeat that process
multiple times
1 1 20 Minutes Total
Anyone can participate 1
MIN 1
MIN
20 Minutes Total
10
MIN MIN
in interval training
1 1 20 Minutes Total
just by substituting MIN MIN
10
an activity that is
appropriate for their
level of physical fitness Dance Rest Total of 20 minutes
Dance Rest Total of 20 training
of interval minutes
in the “on” slot. of interval training
Dance Rest Total of 20 minutes
2 1 of interval
Harder training
Workout
2
MIN 1
MIN
Harder Workout
6
MIN MIN
You can also change the 2 1 Harder Workout

MIN MIN
6
duration of the rest or
active time.
Note that this is a significantly Run Walk Total of 18 minutes

Run Walk Total of 18 intervals
of running minutes
harder workout than the one of running intervals
above despite its total time Run Walk Total of 18 minutes
being shorter. of running intervals
44
EXERCISE |
The one thing you shouldn’t change effects of exercise do not happen
is the intensity. High intensity refers during exercise, but rather during
to how much effort you put into the rest in between workouts, when
your activity. If you were to dance your body rebuilds stressed-out cells.
vigorously for one minute, such that During exercise, your body breaks
you were out of breath at the end down muscle; during rest—whether it’s
of that minute, and could not hold a the time between intervals, the time
conversation, that would be consid- between workouts, or the time you
ered vigorous, or high intensity. On a are sleeping—is when all of the good
scale of 1 to 10, with 1 being easy and changes actually happen.
10 being as hard as you can possibly
go, high-intensity intervals should With regard to exercise and cancer,
be performed in the range of an one study of breast cancer patients
8-10. Change the activity, the activity showed that employing HIIT
length, or the rest time…but don’t during treatment resulted in less
change the intensity. post-treatment fatigue. In addition,
a meta-analysis suggested that HIIT
Why do intervals? Because of the could help improve health outcomes
short duration of the activity, you are for patients across cancer types, both
able to get your heart rate up quite a during and after treatment.
bit higher than you would for longer
exercise. When your heart is beating A word of caution about HIIT—it is
fast and you are pushing your body important that you consult a doctor
to close to maximum effort, many or fitness expert to ensure that exer-
positive metabolic changes take cising your body at near-maximum
place in your body both during and levels is safe for you. After cancer
after exercise. With HIIT, even more treatment, it may take your body a
so than with low-intensity exercise, while to recover normal function.
your body will continue to enjoy During early recovery, your doctor
many health benefits—such as higher may recommend a lower exercise
metabolism and improved cardiovas- intensity and volume to prevent inju-
cular health—well beyond the workout ry to bones and joints that may have
itself. been damaged during treatment.
Slow and steady increase in activity
As a matter of fact, this is a good time over time is always the wisest path to
to mention that most of the positive improved health.
45
The Science of Weight Loss
Obesity is associated with higher cancer risk, so if your BMI

is outside the healthy range, you might consider taking
steps to lose weight. Weight loss is about long-term behav-
ior changes, NOT short-term fad dieting or exercising. We’d
like to suggest that if you do these things for as little as one
month, you will start to feel the effects of a happier body.
1 Slowly build up to an exercise 5-6 meal instead sitting by the TV, take
days per week. Remember to adjust the stairs instead of the elevator, or
based on your base fitness level: do some gardening. Finding ways
a. Exercise vigorously 2 days per week to incorporate movement into your
for 30 minutes (can include one daily life will help keep your muscles
HIIT workout if your doctor allows), engaged even when you’re not
then stretch. “officially” working out.
b. Exercise moderately 2-3 days per
week for 40 minutes or more (this 3 Eat only whole foods that you
includes resistance training), then prepare. If it comes in a pre-wrapped
stretch. plastic package, box, bag, or a can,
double-check the ingredient list.
c. Exercise lightly 1 day per week
for 90 minutes or more (such as
walking), then stretch.
4 Be mindful about your
portion sizes. Research shows that
Note: if you’re a morning person, simply serving yourself a large
knocking this off before you even portion causes you to eat more than
hit your desk is a great strategy for you normally would, which leads
consistency. to weight gain over a long period of
time. “Standard” portion sizes have
2 Don’t sit when you can move! continued to rise in America, so it can
Work on crafting an active lifestyle be hard to determine how much is a
outside of official “workouts.” Put healthy serving size: check out some
on some music and move your hips guidelines on page 72.
while you cook, take a walk after a
46
EXERCISE |
5 Get 7-8 hours of sleep per night.
It may seem like the less you sleep,
the more calories you will burn. Not
true! Research in fact shows that
sleep disruption or chronic sleep
deprivation are linked to obesity and
increased cancer risk. In one study,
shorter sleep time was actually
associated with higher risk of fatal If you are not familiar with
prostate cancer in young men. what vigorous exercise means
for your body, consider
6 Don’t worry too much. Stress

consulting a fitness trainer
and getting a heart rate
causes your brain to trigger secretion monitor.
of the hormone cortisol, which is
linked to increased abdominal fat.
Plus, research suggests that cortisol
secretion contributes to stress eating Weight Bearing vs. Non-
cravings: so taking a few deep breaths Weight Bearing Exercise
may help you avoid reaching for the
chocolate cake. Exercises that force you to fight
against gravity are considered
7 Max out at 0-3 glasses of alcohol weight-bearing. They include things
per week, and never on the same day. like running, tennis, and dancing;
You’ve probably heard of studies that these exercises are great for main-
associate moderate drinking with taining bone density because when
increased longevity and cardiovas- your muscles contract and make
cular benefits. But it’s still not clear slight tugs on your bone, bones react
exactly what causes these benefits: with new growth.
whether it’s the drinking or some
other factor that moderate drinkers On the other hand, non-weight
have in common, like a strong social bearing exercises include things like
network. It’s worth it to cut yourself swimming, biking and rowing. They
off, though—higher levels of alcohol are great for people with injuries,
consumption are associated with mobility issues, and brittle bones.
risk factors for obesity and increased Consult your doctor before begin-
mortality. ning any new exercise routine.
47
Should You Eat Fat? What about stretching? Research indicates
that the primary benefit of flexibility
Cardio—good for your heart, exercises is improvement in joint range of
fat—bad for your heart, right? motion, and may improve postural stability
Maybe. For years, many studies and balance. For older adults, stretching and
seemed to confirm that saturated coordination exercises are recommended
fat and total fat intake were linked to maintain balance and avoid falls, which
to cardiovascular disease. Dean is also a major concern for those on cancer
Ornish famously published studies treatments. The American College of Sports
associating a low-fat diet with Medicine and American Academy of Family
lower prostate specific antigen Physicians both include regular flexibility
levels, among other things. Today, exercise in their recommendations for
we have a little more detail about healthy adults and older adults.
what’s good and what’s bad about
fat. U.S. government guidelines
now suggest optimizing the type Exercise During Treatment
of fat, vs. practicing a low- or
no-fat diet. Furthermore, even Recommendations for how to exercise
saturated fat is not linked to heart during treatment are beyond the scope of
disease in the absence of refined this guide, because each cancer and cancer
carbs and sugar. Saturated fats treatment affect individuals differently, with
can have inflammatory properties, different short- and long-term side effects.
and inflammation is being linked Consult with your doctor to determine
to cancer risk. Unsaturated fats, which exercise regimen might be right for
however, are a different story. you during treatment.
Studies have found that adding
nuts like walnuts to your diet, or Please note that many cancer treatments
EVOO — which are good sources cause fatigue to your body, and include side
of unsaturated fats - helped effects from anemia to kidney problems.
significantly decrease risk of a Although decreasing body fat is beneficial
cardiovascular event and risk of for most long-term cancer outcomes, it
breast cancer. is almost never ok to diet or exercise for
weight loss during cancer treatment, and
certainly without physician approval. Your
focus should be on eating enough calories,
and the proper type of calories in order to
minimize the side effects of treatment.
48
EXERCISE |
Exercise After Treatment

As we mentioned before, cancer treatment can include a plethora of side effects:
fatigue, pain, muscle loss are three of the most common. Other side effects in-
clude appetite loss, anemia, swelling, internal bleeding and bruising, and changes
to your bowel habits. It may seem counterintuitive to want to exercise with these
symptoms—after all, how can you exercise if you are tired, weak, and in pain?
However, if you can push through the initial discomfort, exercise, can actually help
relieve many post-treatment symptoms.
Numerous studies have supported the idea that exercise can help accelerate relief
from many of the side effects of cancer treatment. Consult with your doctor
to determine if you have any specific restrictions on what you can do with your
post-treatment exercise plan.
Exercise Suggestions For Seniors
It’s common to hear that, because of the

symptoms listed above, people feel as if their
bodies have aged beyond their actual age after
cancer treatment. For similar reasons, sometimes
seniors are afraid to exercise because they might
get hurt. Research indicates the opposite. A
study published by the NIH suggests that regular
physical activity is safe for older people with all
ranges of physical fitness, even those considered
“frail.” In fact, the risk of heart disease, obesity,
falling, cognitive loss, osteoporosis and muscle
weakness are all decreased by regular exercise.
So for seniors, we stick by our suggestion that exercise is exercise, but everyone
is different. What does this mean? It means that the same good habits of fitness
apply to all ages, but that each person has a different history, lifestyle, and genetic
footprint when it comes to exercise. For example, a 70-year-old man who runs
marathons could possibly employ a more intense fitness plan than a 40-year-
old man who is overweight and exercising for the first time as a result of doctor
recommendations after prostate cancer treatment.
49
Here are some tips to get the most out of your workout:
some of these may apply to you, and some may not,
depending on your level of fitness.
1 Don’t omit the strength training.

Muscle mass is lost at the rate of 3%–8%
per decade after age 30. Bone formation
also decreases with age. Weight training,
specifically high-intensity resistance
training, can prevent bone damage as
well as improve balance, strength and
muscle mass. This can have the won-
derful benefit of making everything you
do, from walking to dancing to bending
Principles of good
over, feel easier and more steady. It will fitness planning
also lower your risk of injury. That said, if
you have functional or cognitive im- Whether you are 17 or 70,
pairments that prevent you from being consider this:
able to perform some tasks or activities
safely, discuss with your doctor before Since everyone starts at a
beginning any weight training activity. different level, each exercise
plan should be personalized.
2 Watch for interference from injuries,
other non-cancer health concerns or Compare yourself to no one
medications. Even though you may be but yourself, last week.
through your cancer treatment and feel-
ing good on the other side, don’t forget Each week, make one small
to watch out for other disease states that positive change towards
can affect your ability to exercise. Heart better fitness.
conditions, diabetes, old fractures and
sprains, back or hip injury, medication Unless your doctor tells you
interactions, and asthma top the list specifically NOT to exercise,
of conditions that may interfere with there’s always something you
exercise, regardless of your age. Consult can do to move your body
with your doctor before beginning any towards better health.
exercise routine.
50
EXERCISE |
3

Get enough sleep. If our pro-sleep spiel sounds like a broken record, that’s just
because sleep is important to nearly every aspect of your health! Research indi-
cates that higher sleep quality is associated with higher levels of physical activity.
This makes sense: you’re not going to feel energized to work out and benefit from
all the gains that come with it if you’re exhausted. Because most changes to the
body happen during rest, it is critical that you give your body a chance to recover
day over day, and that means getting the proper amount of sleep (including
napping when you feel tired!). This coupled with eating a nutrient-dense diet sets
you up for exercise success.
4 Find an exercise partner. Everything is more fun when you have someone to
do it with! A training partner can help you pass the time, keep to your exercise
schedule, and provide support in the event of an injury. If you are single or if your
spouse is unable to join you, check with your local senior center to see if you can
be matched with a like-minded and like-abled exercise buddy.
The Rise Of Complementary Integrated Therapies
If it hasn’t become apparent so far, in addition to the theme of personalization

and precision, many of the recommendations herein are complementary. Taken
individually, they have some qualities that can improve your health outcomes.
Taken together, they can revolutionize your long-term health, the way you feel on
a day-to-day basis, and the way you live well beyond cancer.
The terms complementary, integrated, and alternative are sometimes used

interchangeably to refer to a class of strategies which can be used together with
traditional medicine to improve your quality of care. That includes exercise,
nutrition, yoga, meditation and other strategies in this guide. It also includes things
like massage, acupuncture, music therapy, hypnosis, cognitive behavioral therapy,
qigong and other strategies which may influence your ability to manage pain,
among other beneficial outcomes.
Please note that we are not including nutritional supplements in this category,
which are discussed in detail on page 88.
51
CAM
Complementary or
alternative medicine
The adoption of complementary or alternative
has been on the rise
medicine (CAM) or integrated treatments along-
for a few decades
side western medicine has been on the rise for
a few decades. In 2007, according to the CDC,
38% of adults used some kind of CAM. Today, the percentages of adults involved
in yoga, meditation, and chiropractic as specific CAM treatments have increased
even more. For example, CAM treatments are widespread in Americans aged 52
and older, particularly chiropractic treatments.
Are CAM treatments scientifically backed? The answer is: maybe. Many studies
have cited the health benefits of yoga, for example. On the other hand, many
CAM treatments still need much more testing to confirm benefits. The effects of
CAM therapies on cancer-related pain, for instance, look to be positive, but there
aren’t enough studies published to make a watertight case. However, no adverse
outcomes were related with these therapies, and this tends to be a trend with
evidence-based CAM investigations: we don’t know that they’re 100% effective,
but they’re usually non-harmful and could have positive mental and physical
effects.
As always, stick to the ideas that are contained in this guide or ask your doctor for
recommendations and never hesitate to do your own research. When researching,
make sure you stick to respectable studies from medical journals. There is a lot of
misleading information out there—for example, a PCF study found that there was
an inverse relationship between the number of views on YouTube videos about
prostate cancer and how legitimate the medical information was; this means that
just watching the most-viewed videos for your wellness information isn’t going
to cut it. There are, in fact, some snake oil salesmen out there who are looking
to capitalize on folks who are sick, desperate and at their weakest. Be a savvy
consumer.
52
EAT
REAL
FOOD
53
The word “diet” has
become laden with
meaning in modern
society. But it originates
from the Greek word
diaeta—which means
“way of life.”
54
EAT REAL FOOD |
What Is Real Food?

Real food has a single ingredient. It comes from a farm.
It is free of added chemicals or preservatives. It has been
minimally processed.
Why is it so important to eat real food? The answer is simple: real unprocessed
food, preferably freshly harvested from the ground, is higher in nutrient density.
Processing and transport (time from harvest to plate) can strip some of the nutri-
tional value from food. Also, because real food is minimally processed, it is usually
high in fiber. In an ideal world, which doesn’t always happen, we even know the
source of the food (the farmers’ market, our backyard garden, your local produce
aisle). More and more evidence seems to be indicating that the fiber in food, not
just the vitamins & minerals, are responsible for good health (more on that later).
If you are trying to eat to prevent cancer,

why is nutritional value important?
Take The Real Food Test Specific nutrient compounds in food
YES NO can prevent the kind of cell damage
Bacon that can lead to cancer. Phytochemical
Whole Grain Bread compounds, found in plant-based foods
such as fruits, vegetables, grains, nuts,
Watermelon seeds, and beans, work at the cellular
Protein Bar level, keeping your risk of cancer at bay.
You may have heard that vitamins like

A and C are considered antioxidants,
that is, compounds that prevent damage
to your body and your cells. But beyond
Go to pcf.org/realfood vitamins, the term antioxidant describes
to take the Real Food
a larger class of food-based compounds
Challenge and see
how you score. that can help ward off disease by sup-
pressing the division of cancer cells or
by upregulating our immune response
to cancer.
55
Cancer’s Worst Enemies:
Food-Based Antioxidant
Anti-Inflammatory Compounds
Even elemental foods, like the ones found in

the PCF periodic table on page 64, contain
a complex mixture of many thousands of
naturally occurring chemicals. Contrast this with a drug that your physician may
prescribe, which may contain only a single chemical, and you’ll see why nutrition
can be such a complex and often controversial subject.
Eating foods that contain the compounds listed below increases your body’s
ability to defend against oxidizing cell damage. That means less damage to your
DNA from lifestyle choices and environment.
Flavonoids | There are about 10,000 types of flavonoids, which are one of the
most-studied plant-based food compounds. Isoflavones are a class of flavonoid
found in soy, and early research suggests they help increase efficiency of cancer
treatments like chemotherapy and radiation. Other flavonoids, such as quercetin,
have been shown to promote apoptosis (ie, cancer cell death) while leaving alone
normal cells, and can be found in broccoli, apples, and strawberries.
Carotenoids | This class of phytochemicals gives foods yellow, orange, or red

color; dark-green leafy vegetables are also rich in carotenoids, but their color is
masked by chlorophyll. Lycopene is a red-hued carotenoid found in tomatoes,
watermelon, and grapefruit that has been linked with decreased risk of several
cancers. This is due to carotenoids’ antioxidant activity: they neutralize free
radicals, which are unstable molecules that contribute to cancer development.
Ellagic Acid | Ellagic acid is another naturally-occurring antioxidant found in

berries, grapes, and nuts. It has been shown to halt the cell cycle of bladder cancer
cells, preventing their replication, and trigger apoptosis of colon cancer cells.
Glucosinolates | Glucosinolates are found in many of the foods you were forced
to eat as a kid (but hopefully have grown to appreciate!): cabbage, broccoli, cau-
liflower, and Brussels sprouts. They have a variety of anti-cancer properties: they
promote cellular excretion of mutation-causing carcinogens, aid with antioxida-
tion activities, and arrest cancer cell growth.
56
EAT REAL FOOD |
Fresh Food is the Best Food

Per our suggestion to eat “real” food, here are 4 examples, with numbers, backed
by research, to show how each of these methods—freezing, canning, transport,
and pesticide-based farming—have the potential to affect nutritional value. Note
that effects of food preservation depend on the food and the specific vitamin—in
many cases, there is minimal loss of nutrition if storage temperatures are
well-maintained.
Vitamin C in fresh peas vs. Vitamin C in frozen peas | A study in

the UK found that several varieties of peas lost an average of 30%
of vitamin C content when frozen.
Vitamin A in fresh peaches vs. Vitamin A in canned peaches |

Researchers at The Ohio State University found a 50% decrease in
carotene once peaches were canned. Beta-carotene is converted in
the body to vitamin A.
Folate in spinach at harvest vs. Folate in spinach at 1 week | Folate

is a water-soluble B vitamin. A research team at Penn State found
that packaged spinach lost 47% of its folate after just 8 days at
39.2ºF, which is the temperature of the average refrigerator.
Organic tomatoes vs. Conventional tomatoes | One ten-year study

in California found that tomatoes grown with organic practices had
97% higher kaempferol content (a flavonoid known for its antioxidant
properties) than conventionally grown tomatoes. Does that mean that
all organic food has higher nutrient content? We just don’t know yet.
The organic vs. non-organic debate is a heated one. Each food needs
to be studied individually and that is a work in progress.
Life happens and a lot of meals end up on-the-run. If you

don’t have time to go to the local market to shoot the
breeze with the farmer who grew the organic carrots, don’t
despair. If it’s a choice between frozen veggies or nothing— Remember! Any
nutrient-rich vegetable
frozen it is! Even though freezing can alter a vegetable’s
from any source is bet-
appealing consistency, most of the healthy soluble and ter than no vegetable
insoluble fiber remains intact. Gently reheat and add a dash at all.
of olive oil and a squeeze of lemon for a healthy side dish.
57
Cancer-Fighting Trio
PHYTO-
How is it possible for CHEMICALS
food to act like medicine? Protect Against
The foods we eat make DNA Damage
biochemical changes to
our bodies at the cellular
level, either encouraging or
FOOD
discouraging the chemical AS
reactions that drive cancer MEDICINE
to grow and spread. NUTRIENTS FIBER
Sweep Free Feeds Your
Radicals & Keep Microbiome
Cells Safe
Should You Eat Organic?
You might think that because many pesticides are known carcinogens, eating food
without pesticides will help prevent cancer. And you may or may not be right—the
research on the differences between conventionally-grown foods compared with
organic practices is still ongoing. On one hand, conventional produce has been
found to have trace amounts of pesticides; on the other hand, those amounts are
small enough to currently be considered nontoxic. The FDA produces an annual
pesticide residue report as part of a monitoring program. Still, maybe you decide
you don’t want any pesticides in your food at all, and decide to opt for organic.
Even though researchers are still looking at the outcomes of organic vs. conven-
tional farming, research definitely favors eating plenty of brightly-colored fruits
and vegetables, regardless of whether you choose conventional, certified organic,
or pesticide-free foods.
58
EAT REAL FOOD |
The Microbiome

Did you know that at any given
time there are 30 trillion
microorganisms living in and on
you? Every day, more research
indicates that an improperly
balanced microbiome—the
collection of bacteria in your
body—may be the culprit in a lot
of modern health issues.
Many of the bacteria on your body were acquired at birth (through the birth canal)
and many of the bacteria in your gut are acquired through the food you eat.
Research seems to indicate that the more fiber-rich foods you eat, the more “good”
bacteria grow in your gut. Moreover, eating a healthy mix of different plant-based
foods can help foster the correct diversity of disease-fighting gut bacteria.
How does this work? Most nutrients are absorbed in the “upper gut.” However,
fiber passes into the lower gut or colon where millions of bacteria and some fungi
make up what is collectively referred to as the “gut microbiome.” Your microbiome
feeds and thrives on the undigested parts of food—a process known as fermenta-
tion. Some of the byproducts of this process, such as short-chain fatty acids, are
thought to be particularly good for health.
There are estimated to be nearly 5,000 species of microbes (bacteria!) making

up the human microbiome across different age groups, geographical locations,
and disease states; we might have several hundred of these species on our bodies
at any given time. The relationship of these microbes to you and to each other is
complicated.
For example, one crucial role of gut bacteria is to break down complex carbohy-
drates. The products of this process, in turn, feed other bacteria. This is good for
the bacterial host (you!). But, as anyone who’s ever taken antibiotics knows, this
relationship can be disrupted when too many “good” bacteria are killed off. When
it comes to gut bacteria, it’s all about having the right mix of players on your team:
if you have all quarterbacks or all wide receivers, you’ll never move the ball down
the field.
59
The Microbiome and Chronic Disease
The last 100 years has seen both the rise of many chronic
diseases as well as a decline in the amount of whole foods
eaten in the standard American diet. What we eat, our bac-
teria eat…and one thing we know for sure is that our bacteria
need the fiber from food to be healthy. The theory goes that
a decline in “good” bacteria may be responsible for many
modern diseases. On the opposite page, we list a few condi-
tions where researchers are making interesting observations
about the microbiome and disease. Most of these studies
have focused on fecal transplant (yup, that’s exactly what it
sounds like), but the hope is that some day, specific dietary
changes may be able to prevent or reverse these conditions
as well. Until then, a safe strategy is to eat fiber-rich,
nutrient-rich real food.
Bach, NEJM, 2002.
60
EAT REAL FOOD |
Diabetes Autism
The drug metformin is widely used A study published by researchers
in the treatment of Type 2 diabetes. at Arizona State University found
A 2017 study found that part of its that two years after a microbiota
therapeutic effect was due to how it transplant, children with autism
altered gut microbiota. demonstrated a 45% reduction in
core autism symptoms.
Obesity
Gut microbiota may play a significant Peanut Allergies
role in contributing to obesity: A 2018 study in mice linked lack of
research indicates that obese people specific gut bacteria with an allergic
have a different composition of gut reaction to peanuts, and a clinical
bacteria than leaner people. The the- trial is currently underway to test the
ory goes that this “obese microbiome” efficacy of microbiota transplants in
extracts more energy from food, protecting against peanut allergies.
thereby contributing to weight gain.
One current clinical trial is attempting Inflammatory Bowel Disease
to transplant a “lean microbiome” An ongoing phase 3 clinical trial
from leaner subjects to heavier ones, shows significant promise in treating
in an attempt to reverse or curtail IBD with fecal microbiota transplants.
obesity.
Asthma
Alzheimer’s Research has associated pediatric
A 2016 study found that elderly asthma cases with a lack of four types
Alzheimer’s patients given probiotic of gut bacteria, and a 2015 study
milk to supplement their gut microbi- found that inoculating newborn mice
ome showed improvements in their with these bacteria decreased severity
MMSE scores—a measure of cognitive of asthma symptoms in later life.
ability—compared with subjects who
were given a placebo (who showed Cardiovascular disease
cognitive decline consistent with A current clinical trial seeks to
disease progression). This suggests improve outcomes for heart failure
that altering gut bacteria composition patients using drugs targeting
could potentially reverse the effects microbiota.
of neurodegenerative diseases.
61
Why is this important? It allows us to confidently double down on our suggestion
that you eat real food. It doesn’t mean you can’t ever eat a piece of birthday cake
or a fried chicken sandwich. As a matter of fact, quite the opposite: microbiome
research indicates that the common denominator of gut health is the amount and
variety of vegetables, fruits, nuts whole grains, and beans that you eat (see pages
64-65 for a chart of fiber-rich and gut-friendly foods). That means if some of your
diet consists of meat or Pop-Tarts, as long as most of what you eat is fiber-rich
whole food—you’re in pretty good shape for good health. (But that’s overall good
health. For cancer, because it is often a disease that’s driven by inflammation,
we’re still telling you to eat less meat and Pop-Tarts!)
Manipulating the microbiome has specific implications for cancer. In 2018, several
studies found that patients with specific gut bacteria compositions showed
greater antitumor immunity. In addition, tests with mice suggested the possibility
of transplanting “good” microbiomes to patients who need them, which could
improve cancer outcomes. Similar results were found for prostate cancer patients.
62
EAT REAL FOOD |
Download our free
patient guides at
pcf.org/guides.
The Top 10 Foods

To Eat To Prevent Cancer
When we started writing this guide, this section was one of the first in our outline.
Because these kinds of lists are what everyone expects out of a cancer nutrition
guide, and because we want to make a point, we left it in. The issue of which
specific foods get a gold star is murky. So, instead of telling you what to eat, this
guide makes a point of telling you how to eat.
Hold on. We already told you that scholarly research on the relationship between
foods and disease has skyrocketed in the last 10 years. So why can’t we tell you
exactly what to eat? The answer is, we are just not there yet. New research is
constantly evolving. To give you a sense of how fast that evolution can be, and
how complicated the equation is around any particular food, on pages 66-67,
we’ve teased out the history of just one food (tomatoes) around one disease
(prostate cancer). For more on known dietary recommendations for prostate
cancer, download our dietary guide, created in collaboration with the University of
California, San Francisco, at pcf.org/guides. To join our monthly recipe club, go to
pcf.org/recipe.
63
Periodic Table of Microbiome-Friendly Foods
Ar Artichoke Sp Sweet Potato Pr Pear Sc Swiss Chard Wb White Beans

Cg Collard Greens M Mango Fg Fig Au Arugula Pb Pinto Beans
K Kale Pm Persimmon Da Dates Cs Chia Seeds Al Almonds
Dg Dandelion Greens Gu Guava Gb Green Banana Ln Lentils Sf Sunflower Seeds
Ag Asparagus Rb Raspberries Gp Green Peas Sp Split Peas Ps Pumpkin Seeds
Bs Brussels Sprouts Bb Blackberries Em Edamame Bp Black Eyed Peas Ss Sesame Seeds
Cr Carrot Sb Strawberries Sw Seaweed Gb Garbanzo Beans Fx Flax Seeds
Bt Beet Bl Blueberries Co Coconut Kb Kidney Beans Pe Peanuts
Br Broccoli Ap Apple Pu Prunes Bn Black Beans Pn Pine Nuts
Av Avocado Ba Banana Am Amaranth Lb Lima Beans Pa Parsnip
64
EAT REAL FOOD |
S Spinach Bm Button Mushroom Z Zucchini Ja Jerusalem Artichoke FERMENTED FOODS

As Acorn Squash P Portobello Mushroom Cl Celery Bi Brown Rice
Tp Tempeh
Bq Butternut Squash C Corn Ov Olive Q Quinoa
Ms Miso
Pm Pumpkin Pc Popcorn Lk Leek Bw Buckwheat
Kc Kimchi
Y Yam Fn Fennel On Onion Oa Oats
Sk Sauerkraut
Bg Beet Greens Eg Eggplant G Garlic By Barley
Pk Pickles
Nb Green Beans Cb Cabbage Sl Shallot Bu Bulgur
Yg Yogurt
Ok Okra Tm Tomato Br Bean Sprouts
Kf Kefir
Tn Turnip Po Potato Rd Radish
Km Kombucha
Sm Shiitake Mushroom Cf Cauliflower Jc Jicama
65
Is Pizza the Perfect Food?
In this guide, we have made many evidence-based recommendations for good

health. But research is constantly evolving and the relationship between food and
health is not simple. To illustrate this complexity, we’ll use pizza to discuss the
history of thinking around one food (tomatoes) and one disease (prostate cancer).
Who among us, at some point in time, has not enjoyed a drippy hot slice of pizza?
But is pizza healthy? You might remember the controversy in 2011 when Congress
supposedly declared pizza to be a vegetable. Let’s dig in…
Pizza is a part of the Mediterranean diet, an eating style that

dates back to ancient Roman times. However, pizza is a bit
newer: it can be traced to the 18th century when Neapolitans
started adding tomatoes to focaccia. The scientific community
started paying keen attention to the Mediterranean diet
in 1980 with the publication of Ancel Keys’ Seven Countries
Study, which associated lower risk of cardiovascular disease in
Southern European countries to lifestyle factors, including diet.
Tomatoes, such as those used in pizza and pasta sauce, have been proposed as
a beneficial food, possibly playing a role in, among other things, prostate cancer
prevention. Scientists have been studying vitamins A and C in tomatoes since at
least the 1940s. At that time, scientists didn’t know how important these nutrients
are for immunity and cell repair. But there’s more. Tomatoes also contain lyco-
pene, part of the class of carotenoid antioxidants that can protect cells from the
damage caused by chemicals called free radicals. This makes tomatoes potentially
a great food to fight cancer.
Subsequently, researchers uncovered another interesting fact about tomatoes:

cooking them increases the amount of available lycopene. This is because
molecules like lycopene are trapped in the cellular matrix, so crushing and cook-
ing releases them and enhances absorption. Scientists theorized that cooked
tomatoes and tomato paste would have a greater effect on reducing prostate
cancer risk than raw tomatoes, though so far results have been mixed. However,
lycopene supplements (vs. lycopene in tomatoes) have not been shown to
66
EAT REAL FOOD |
decrease prostate cancer risk or slow progression,
implying that there’s more to learn about what aspects
of tomatoes influence health (hint: it could be fiber).
What about food interactions? It turns out that lycopene is fat-soluble. So for
your body to use all the good stuff in tomatoes, you need to eat it with fat.
Mozzarella has fat, making tomatoes and cheese a (possibly) better combination
than tomatoes alone. Another check mark for pizza as the perfect food!
Not so fast…Mozzarella and other animal products increase inflammation, which

is in turn linked to cancer, as discussed in the following section. Good news,
though: for a healthier pizza, you can skip or reduce the cheese and make your
tomato sauce with olive oil—which has monounsaturated fatty acids and antiox-
idant, anti-inflammatory phenolic compounds—and sprinkle on the fresh garlic.
Garlic contains micronutrients similar to the sulforaphanes in broccoli, though in
much smaller quantities. Allicin, which is released when a clove of garlic is crushed,
is known for having a positive impact on your immune-boosting gut bacteria.
So is pizza the perfect food? Well, not exactly....if we knew of a perfect food, we
would have told you on page 1. Pizza provides a great example of how food as
medicine is an evolving art. Nevertheless, it’s hard to deny that the Neapolitans
were onto something.
We mentioned earlier that good health is about choices, and in the 21st century,
we certainly have our options when it comes to pizza. Do it like New Yorkers and
stick with a single slice for a (decently) healthy fast meal. Pass on the thick-crust
extra-cheese meat-lover’s pie and choose a thin whole-wheat crust with vegeta-
ble toppings—light on the cheese, please. You might even try a cauliflower crust!
While active research continues on the role of tomatoes, tomato products, and
lycopene in prostate cancer, data does suggest a relationship between brightly
colored vegetables and cancer prevention. So, if you like to eat your veggies on
pizza, to that, we say, “Mangia!”
67
The Relationship Between Inflammation And Cancer
The idea that inflammation causes cancer is not new. In fact, it dates back to the
1800s, when scientist Rudolf Virchow first observed that cancer originated at
sites of chronic inflammation. His theory was that the enhanced proliferation
of cells at sites of inflammation caused cancer to grow. While the mechanics of
Virchow’s theory were a bit oversimplified, we now know that what goes on in
the tumor microenvironment—that is, the collection of cells, molecules and blood
vessels that surround a tumor—is essential to a tumor’s overall survival, growth,
and migration to other sites in the body.
It is now widely accepted that chronic inflammation is a trigger for many diseases,
including some forms of cancer. Chronic inflammation can be caused by things
like poor dietary choices, stress, and smoking, which create a burden on your
immune system.
It is important to note that not all

inflammation is bad; for example, when
Bacteria, Inflammation, you are injured, inflammation at the
and Prostate Cancer injury site is your body’s way of signaling
your immune system to kick in gear, and
Bacterial infections support- send cellular soldiers out to help the
ed by poor dietary choices healing process. That is acute inflam-
cause small, slow-burning, mation; it is your body’s temporary and
asymptomatic damage at normal response to sudden distress.
the cellular level that end up
driving prostate cancer later The good news is that healthy life-
in life. Right now, we don’t style choices can reduce your risk of
know what dietary elements chronic inflammation-related diseases.
are the culprits, but dairy is Reversing the triggers mentioned
implicated. above—smoking, lack of exercise, and
a poor diet—will help your body flush
inflammation.
Remember, diet has the ability to affect health outcomes both negatively and
positively. What you put in your body affects your levels of C-Reactive Protein
(CRP), which is a protein that mediates your response to inflammation.
More CRP = more inflammation = bad, less CRP = less inflammation = good.
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EAT REAL FOOD |
Eating Choices that Cause Eating Choices that Reduce
Inflammation Inflammation
Artificial ingredients found in Fiber-rich foods: eg, vegetables, fruits,

processed, packaged, instant, and beans, and whole grains.
fast foods.
Healthy fats such as those found in
Processed meats: eg, bacon, hot dogs, avocado, extra-virgin olive oil, canola
sliced deli meat, pepperoni, sausage. oil, fatty fish like salmon, tuna, and
herring, seeds like flax, hemp, and chia,
Animal products: sadly, all animal and nuts such as walnuts and pecans.
products cause some inflammation,
including red meat, eggs, cheese, and Probiotics: eg, fermented foods such as
milk; If you do chose these products, sauerkraut, kimchi, other pickled vege-
choose those that are pasture-raised tables; kombucha, yogurt, miso soup.
and hormone-free, since everything the
animal eats is passed on to you.
Refined vegetable oils containing

omega-6 fatty acids: eg, corn, sunflow-
er, peanut, sesame, and soybean
oils found in processed and fried foods,
packaged cookies, and sweets.
Refined grains: eg, white bread, white

flour, white pasta, pastries.
69
Artificial vs. “Natural” vs. Like almost everything in this
Real Ingredients guide, everything you do is
connected. Another fantastic
For the purposes of this guide, a Real side effect of reduced inflam-
Ingredient is something that was cul- mation, in addition to reducing
tivated via farming and has not been risk of chronic disease, is that
significantly modified. As much as you will feel better. Chronic
possible, choose foods that are made inflammation can cause joint
from real ingredients. aches and pains, feelings of
overall lethargy, poor sleep,
Artificial Ingredients are man-made and and digestive distress. Reducing
chemically derived. Examples include inflammation can help you
artificial flavors and colors such as recover faster in between
aspartame (a sweetener), hydrogenated exercising, and sleep better.
vegetable oil (increases shelf life), Blue
#2 (color), butylated hydroxyanisole
(preservative), sodium nitrate (preser-
vative), potassium bromate (increases
bread volume). Many of these substanc-
es have been shown to have negative
effects in animal studies and some are
banned in Europe.
The term “natural” is the most ambig-

uous and ill-defined of these three.
Foods that are labeled “all natural” are
often assumed by the consumer to
be safe and free of artificial additives.
However, the U.S. FDA has no clear
definition of what constitutes “natural,”
so it’s important to read labels carefully. A healthy lifestyle includes
Food companies often use “natural” rest, exercise and nutrition.
as a marketing technique to get you to Together, these factors stim-
buy their food, so it’s up to you to be a ulate your immune system’s
smart consumer. One easy way to know ability to police your body
exactly what’s in the food you’re eating for cancer cells and prevent
is to buy real ingredients at the market them from growing out of
and prepare them yourself at home. control.
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EAT REAL FOOD |
EVERYTHING IS CONNECTED: THE HAPPY BODY FEEDBACK LOOP

EAT BETTER
Less inflammation
Better recovery
Feel better
EXERCISE EXERCISE
MORE SMARTER
Easier weight loss Less injury

More relaxed Less stress
More energy Less body fatigue
SLEEP BETTER
How To Eat To Prevent Cancer
A lot of the lifestyle changes presented in this guide can have a positive impact on
your overall health. However, as anyone who has opened up a newspaper, turned
on the evening news, or fired up an internet browser can tell you, there’s a LOT of
competing diet and nutrition advice out there.
The Prostate Cancer Foundation was one of the early advocates for precision
medicine: the idea that because every cancer and every cancer patient is unique,
treatment must be equally unique. The same is true of diet. For example, some
people see a spike in their blood sugar when they eat ice cream; others see a
greater spike when they eat brown rice. We can’t tell you exactly what to eat to
prevent yourself from getting cancer. But we can provide guidelines to help steer
your diet in a disease-fighting direction. Remember, 42% of cancer cases are
thought to be preventable with lifestyle choices.
71
Portion Sizes
Protein Animal / Meal
Examples that might
Government and doctor recommendations for por-
or
tion sizes have not increased over time, but anyone influence food volume:
who has eaten out at a restaurant knows that the Training for a 10K +
Protein Vegetable / Meal
amount of food you are served is often more than -
Trying to lower your BMI
1
you can eat. Opportunities to pay a fraction more
money to “supersize” your soda or get a bowlWhole
of Just finished treatment
Grains / Day
+
pasta the size of your head
CUP
are everywhere. -
Closed Fist Just turned 60
Lift weights 3x/week +
Vegetables
In this guide we’ve talked a lot about the quality / Breakfast
of the food you eat; this section is about quantity. / Lunch
½-₁/₃
Page 39 talks about what happens when you eat excess food – it triggers your
/ Dinner
body to convert calories to fat. Portion sizes are where the rubber meets the road:
CUP amounts of various healthy foods at each sitting.
it is important to eat appropriate
Open Palm Olive Oil &
/ Meal
Avocado
1 cup = 8 oz
1
HOW MUCH SHOULD YOU EAT? Fruits / Meal Get educated on
That’s where a little precision comes in. As we’ve emphasized before, each serving sizes.
TBSP
individual is different. We can’t tell you how much to eat—we can just give
Finger Nuts
you a few guidelines and some insight into the mechanisms of how your/ Day
body processes food. From there, it’s up to you to make good choices.
Category Size Frequency

Brightly-Colored Vegetables 6-8 cups Daily
Healthy Added Fats (eg. EVOO) 1-3 tbsp Daily
Fruit 3 cups/pieces Daily
Whole Grains (eg. Rice, Quinoa) ½ cup cooked Per meal
Nuts & Seeds 1 oz Daily
Breads, Pastas, Desserts 1 serving 3x per week
Protein 25 g* Per meal
*See box on p. 76
Why are Pasta and Bread with Dessert?

Most pastas and breads are made of refined grains. Highly refined grains (such
as white flour) behave similarly to sugar in your body. Read your labels, choose
carefully, and balance your daily choices (eg, if you have a sandwich at lunch, skip
the whole grains at that meal).
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EAT REAL FOOD |
How do our recommendations differ from what you may
already be eating?

• Brightly-colored vegetables should be the hub of your See infographic
eating wheel. We suggest 6-8 cups a day. That might be on page 75.
more than you’re used to!
• In addition to that, eat one serving of protein with each meal, alternating your
choices between beans, fish, tofu, and meat. Serving size? Rather than ounces
or cups, because volume varies widely between meat and vegetarian options,
we are suggesting 20-25 grams of high-quality protein per meal. See page 76
for examples.
• If you’re adding fat to your diet, focus on “good fats,” including avocado and
olive oil. Use 1-3 tablespoons per day, depending on your size. Note! Be smart.
If you’re already treating yourself to a marbled steak for dinner, skip the extra fat.
• Feel free to eat whole grains at every meal, but keep serving sizes small (about
½ cup cooked). Reduce grains on the meals where you eat bread or pasta.
• Whole-grain breads and pastas are okay a few times per week. Think of them
as a treat, like dessert. Keep portion sizes small. Check the label: in bread, use
higher fiber content and lower sugar to gauge quality.
• Speaking of dessert, focus on finishing your meal with fruits, nuts, and seeds
rather than treats with added sugar.
In addition to what you should eat, observe these “don’ts:”
• Whenever possible, don’t eat packaged food. Pack your lunch, make multiple
meals ahead of time, and focus on nuts, fruits, and vegetables for snacking.
• Don’t eat too much in a single sitting. Studies have linked body fat distribution—
such as having a lot of weight around your mid-section, with poor outcomes.
Controlling portion size is one of the few ways to help fend off the belly fat.
• Don’t eat too much added sugar: limit or eliminate.
• Don’t eat too much meat or dairy: moderation is key.
73
The Evolution of the Food Pyramid
1940s
In the 1940s, meats
and cheeses featured
prominently, with butter
and margarine having
a category of their own.
1990s
In 1992, bread, starches,
and grains were the
foundation of the pyramid.
74
EAT REAL FOOD |
Today
Today, at the Prostate Cancer Foundation, we recommend a diet whose
core is in brightly-colored, cancer-fighting vegetables.
H Y D R A
A R B O T E
C S
tables Frui
ege t
th er V
O
W
ho & P
olored Vege
ns
le
ai
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ly
ain
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Bre
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s, M s- F
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P R O
T E I N S
75
How To Moderate Meat
You might be disappointed to see on the previous chart that meat is listed in foods
to limit. Meat and meat products cause the body to respond with inflammation,
particularly red meat.
But meat is everywhere. It’s at that summer BBQ. It’s at that restaurant you love
and the wedding reception this fall. Burgers are cheap, easy, and tasty. So how in
the world is it possible to eat less of it? The first trick to cutting down on meat is to
stock low-cost, high-quality, easy and tasty sources of alternative proteins. Once
you do that, we are going to help you drop your consumption of meat products to
a maximum of one time per day.
How do you get the protein that your body needs?
The average-sized man or woman needs

Here is appoximately about 50-60 grams of protein per day.
25 grams of complete Those who exercise regularly, especially if
protein, 6 ways: you are doing weight training, require more
protein. If you exercise rigorously and often,
you may need as much as 2x the recom-
9 oz of Tofu
mended protein intake for a sedentary
5 oz of Salmon person. At each single meal, you should
4 Eggs try to eat no more than 20-25 grams of
2.5 cups of Lentils & Quinoa protein, so your protein intake must be
divided among your meals throughout the
2 cups of Low-Fat Yogurt
day. If you’re eating whole foods like we
3.5 oz of 90% Lean Grass-Fed suggest, you might find it easier to take in
Ground Beef protein than you think, because most whole
foods, like beans and grains, work together
to provide your body with complete protein. Complete proteins contain all nine
essential amino acids (the building blocks of protein) in the correct proportion.
Complete proteins that meet the standards in this guide include beans and grains
(which together make a complete protein), fish, and soy. Meat, eggs, and dairy are
also complete proteins, but we suggest eating them in moderation, if at all.
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EAT REAL FOOD |
As a strategy for replacing some of the meat in your diet, try varying your weekly
protein intake by choosing a few servings from each of the food families below.

Fish | Fish is a high-quality source of protein. Some white
meat fish are relatively low in fat compared with red meat
protein sources (although note that nowhere in this guide
have we advocated for a low-fat diet—just a low-bad-fat
diet). Other oily fish are high in omega-3 fatty acids, which
are the crème de la crème of cancer-fighting fats. This includes fish like wild
salmon, arctic char, Atlantic mackerel, sardines, anchovies, and albacore tuna.
Unfortunately, because of contamination from mercury, PCBs and other toxins
that fish absorb, fish consumption should be limited and fish sources should be
known and carefully monitored. For more information on which fish are safe to
eat and in what proportion, the Washington State Department of Health website
maintains an excellent resource.
Legumes | Beans, lentils, peas, and peanuts are all part

of a class of non-meat foods that are high in protein.
Unfortunately, they do not contain all of the essential amino
acids needed to make a complete protein. The good news
is that most grains (corn being the notable exception), when
combined with beans, form a complete protein. Beans and rice are eaten in many
countries around the world. You can combine different legumes with different
grains to make complete protein. Experts used to say that you had to eat beans
and rice in the same meal, but research now shows that your body harbors all the
amino acids from what you eat in a day to combine when needed; as long as you
are eating a variety of grains, beans and nuts throughout the day, your body can
make what it needs.
Soy | Soy products—such as edamame, tofu, and tem-

peh—have long been a staple of vegetarian and Asian diets.
Research has indicated that the isoflavones in soy may help
inhibit tumor growth in animal models. You may have heard
that soy was given a bad rap as potentially increasing the
risk of breast cancer, because isoflavones have a similar chemical composition to
estrogen. However, more recent studies have said quite the opposite—moderate
soy consumption can decrease the risk of breast cancer recurrence and we
recommend it as a regular part of any cancer-fighting lifestyle plan. A word of
77
caution: Soy is one of the most commonly genetically modified foods in the U.S.,
and GM soy has been found to have higher levels of the pesticide glyphosate. Buy
organic (hence non-GMO) if soy is a regular part of your diet. Like everything else
in this guide, stick to soy that is minimally processed, such as the products listed
above, and minimize fake “meats” made with soy derivatives.
Nuts | Nuts are a lovely way to supplement your protein

intake, but because they have a very high fat content,
they are not a good exclusive source of protein for a meal.
Instead, consider nuts an excellent high-protein snack that
can keep your blood sugar level and help you feel satisfied.
A piece of fruit plus a handful of nuts makes a great filler between meals, or even
to satisfy your “dessert” craving afterwards.
Meat Substitutes | If you like the taste, feel, and vibe of

meat, but want to avoid the health risks, try the occasional
plant-based protein substitutes. The market is now full of
a variety of engineered “burgers” made exclusively of plant
protein, designed to have the look, taste, and texture of
meat. Another caution: these products are new; although they have passed FDA
standards, they have not yet stood the test of time under any long-term study.
They are also highly processed in order to mimic meat’s qualities, which, as you
know, is against the recommendations in this guide. Consider meat substitutes to
be the occasional treat, eaten no more than two times per week, if that.
Still Love Your Red Meat? READ THIS
One (and only one of) the problems with red meat is that it contains large amounts
of omega-6 fatty acids, which cause inflammation. But there is good news for
meat lovers: while grain-fed beef contains high amounts of bad fats, grass-fed
beef contains high amounts of good fats. Grass-fed beef has less fat overall and
contains as much as five times the amount of omega-3s as traditional grain-fed.
PRO TIP: although you may love a good char on your steak, skip it. Grilling at high
temperatures results in the formation of two compounds—HCAs and PAHs—that
have been show to cause cancer in animals. Keep temperatures low to avoid the
formation of HCAs and PAHs, and remove charred pieces before eating.
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EAT REAL FOOD |
How To Moderate Sugar

Again, we are not going to mince words. There’s little left to debate about whether
too much sugar is bad for your overall health. It is.
Blood Glucose and Diabetes

The typical person has about 4 grams of glucose in their blood at any given
time. This level is carefully regulated by your body. When we eat food, our
blood glucose levels immediately increase, causing insulin to be released from
the pancreas. This helps our cells to absorb glucose and to store it as either fat
or glycogen, allowing our blood glucose to return to a healthy level. If we start
exercising, our muscles need more glucose to burn up to generate energy and
glucose is released back into the blood.
Having too much glucose in the blood can be devastating for our health—a
condition known as diabetes—and is a risk factor for many cancers (prostate
cancer being one notable exception). Type 1 diabetes is usually due to an auto-
immune reaction where the pancreas cannot make insulin. In Type 2 diabetes,
the cells of the body cannot respond to insulin and so glucose remains in the
bloodstream, resulting in hyperglycemia (high blood glucose levels).
How does the way something

tastes (sweetness) relate to
the way your body reacts to
it? Molecules like fructose and
sucrose are simple carbohy-
drates—monosaccharides and
disaccharides—and so can be
digested fairly quickly, leading
to spikes in blood sugar and
insulin secretion.
79
Does sugar cause cancer? Right now, there is no direct evidence that eating
sugar causes cancer. But we do know that eating a lot of sugar leads to weight
gain, body mass increase, increased fat in the mid-section, and diabetes. And we
know that all of those things are correlated (remember the difference between
causation and correlation?) with cancer.
Cancer aside, more and more research indicates that one of the characteristics of
the traditional Western diet that is at odds with good health may have to do with
high sugar intake.
We needn’t talk about whether to moderate sugar—it’s time to cut to the chase
and talk about how.
In 2014, the World Health Organization reduced its “free sugar” intake recom-
mendations (ie, added sugars, and sugars occurring naturally in fruit juices, and
honey) from 10% of your daily calorie intake to 5%. For a 150 lb middle-aged
adult, that’s about 25 grams of sugar, or 6-7 teaspoons per day. For reference, a
single soda, a single-serving low-fat flavored yogurt, and a single protein bar each
contain more than the WHO-recommended allowance.
To Eat Fruit or To Not Eat Fruit, That is the Question
Some of us have a sweet tooth. A 2017 study from the University of Copenhagen
found that, for some people who have a certain form of the gene FGF21, it might
be genetic. For others, it could be just a bad habit or way to cope with stress.
Fruit contains fructose, a sugar—that’s what makes it sweet. So should you skip
the fruit? The answer is, maybe. If you don’t have a sweet tooth, you don’t have
to add fruit to your diet, although whole fruit with skin on can be a nice way to
add fiber. On the other hand, if you are someone who just has to have that taste
of sweetness after dinner, swap your normal cookie, brownie, or ice cream for a
piece of fruit with nuts. Most fruit contains less total sugar than most desserts, and
the fiber and fat help keep your metabolism regulated. Skip juiced fruit, which has
a sweetness profile similar to sugared beverages and sodas.
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EAT REAL FOOD |
So the bottom line, in no uncertain terms, is that this guide recommends you
stick with the WHO guideline for added sugar intake. How do you calculate your
personal allowance of sugar? Take your current weight, and divide it by 6. That is a
reasonable approximation of the number of grams of sugar that you are allowed
to eat in a day. If you want to lose weight, we are sad to report that you would be
well-advised to eat even less.
Ugh. Depending on where you live and your lifestyle, this may be the hardest
thing we tell you in this guide. But it’s an important one. Tough love. Fortunately, if
you cut out the sweetened drinks (soda, pre-sweetened coffee and tea, and juice),
and fill up on a diet of home-cooked vegetables, whole grains, nuts and beans,
you’re off to a great start.
Read the label!
Beware of the Hidden Sugar

Here’s just a few of the foods that Salad dressings
have a higher sugar content than you
Marinades
might imagine. Read the label, com-
pare brands, and look for dressings Tomato sauce
that are naturally sweet vs. artificially
sweetened (from things like sugar Flavored yogurt
or, worse, high-fructose corn syrup).
Granola bars
Even better: make these items from
scratch at home so you know exactly Fruit smoothies/juices
what is in them.
Breakfast cereal
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How to Get Out of 7-11 Alive
We have all been in a situation, no matter how healthy we

are trying to be, where healthy choices are incredibly hard
to come by. One of those situations is travel.
These days, there are very few geographic locations where there are not a few
healthy choices to consider. Even McDonald’s has salad. Just as important as
having the right choices is making the right choices. Here are some tips for getting
through difficult health choices with grace:
In a restaurant Order a salad, ask if you can add plain grilled fish or meat, get
or at a truck a side of vegetables or soup, and skip the fruity cocktails and
stop. dessert; or, split one dessert with everyone at the table. If you
simply must have something sweet after your meal, see if you
can grab a piece of fresh fruit at a local grocery or restaurant.
Bring food Obviously you can’t do this at a wedding or a work event, but
from home. if it’s travel that has you worried, the options are limitless: pack
leftovers from home, sliced fruit and veggies, and nuts and
seeds to snack on. If you run out of food from home while on
your travels—tempting as it is to pull over to that rest stop and
grab a sugary drink and a bag of chips—think about choosing
water, unsweetened tea or coffee, a bag of nuts, dried fruit, or
even whole-grain crackers to keep you going.
Relax, and eat For real—if it’s just one meal or a day or even a week of meals
what you want. (vacation!)—you could be doing yourself more harm by worrying
than by just letting it go and enjoying yourself. Feel like having
that ice cream sundae for dessert? Do it. Good nutrition is a
marathon, not a sprint, and a few unhealthy meals are unlikely
to harm you, as long as it’s a blip in an otherwise healthy
lifestyle. For those days when you reach for the cake, ice cream,
and French fries, try to add lots of healthy vegetables to other
parts of your day. And if you can’t? Eh, fuggedaboutit.
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EAT REAL FOOD |
Ask your doctor for a
nutritionist who can help
develop a plan during
cancer therapy.
What To Eat If You Have Cancer
There are over 100 different cancer types based on organ sites (eg, lung, breast,
prostate), multiple subtypes of every one of these cancers, and endless amount
of nuance in how those subtypes are treated (type, dosage, frequency, duration).
Many of those drugs have side effects that can compromise taste buds and
appetite significantly; nausea and vomiting are both common side effects of
many cancer treatments.
During chemotherapy, many people find it hard to eat and keep down a sufficient
amount of calories. Eating a low-calorie diet with processed foods like low-sugar
or low-fat products is never advised, but that goes double for during treatment,
when you may be advised to pour on the olive oil and eat as much as you can
stomach to get the proper calories and nutrients needed to stay healthy.
As Hippocrates implied, food is medicine; therefore, food has the possibility to

interact with the drugs you are taking. For this reason, recommending what to eat
if you are in active treatment for cancer is beyond the scope of this guide. Please
consult your medical team to find out which foods are most appropriate and/or
banned during your specific treatment. Most facilities have associated nutritionists
who can help develop a plan that is right for you during cancer therapy.
83
How otherwise healthy foods can interact with
prescription drugs
Here are just two examples showing why it’s important to discuss diet with your
doctor, in conjunction with medication planning.
Example 1 Example 2
KALE GRAPEFRUIT
You may have marveled at the quick Oral chemotherapies have been
transition that kale has made in the shown to interact with foods and
past 5 years-—from inedible garnish other drugs. For example, a study
to cornerstone health food. There found that grapefruit consumption
is no doubt that kale is an antioxi- reduced efficacy of oral chemother-
dant-packed superfood. Just one cup apy for 19 different cancer drugs.
of chopped kale contains 100% more Grapefruit is also contraindicated
vitamin A and 40% more vitamin C when taking a statin because it
than you need in an entire day. It also interferes with your body’s ability to
contains trace minerals, compounds metabolize the drug, and can cause
that protect against inflammation, increased side effects.
heart disease, and cancer, as well as
7 times the RDA of vitamin K. And
here’s an example of where it gets
complicated. Vitamin K is critical
for blood clotting and medications
called anticoagulants inhibit the
formation of vitamin K-dependent
clotting factors. As such, if you were,
for example, recovering from a stroke
and taking an anticoagulant, you
should keep the amount of vitamin
K-containing foods (such as kale) that
you eat consistent to avoid affecting
the dosing you are provided.
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EAT REAL FOOD |
Cancer Recovery Foods

Eating to prevent cancer is very similar to eating to prevent cancer from reoc-
curring, but it is not exactly the same. Both immediately after treatment and
over time, many cancer therapies include a harrowing list of short and long-term
effects including: heart issues, hormonal irregularities, high blood pressure, loss of
muscle and bone density, lung problems, dental health issues, cognitive impair-
ment and many others. Because many cancer treatments harm normal as well as
cancer cells, they can systematically damage the body from top to bottom.
While developing more targeted drugs with lesser side effects is an active
high-priority area of research for the Prostate Cancer Foundation, in the immedi-
ate future we suggest the following:
1 Track your
symptoms.
If you are having treatment-related side effects, write
down when they occur and note intensity.
2 Follow up with
your oncology
team.
If your symptoms are new or intense, don’t hesitate to
get in with your doctor right away. Even if it’s years later,
and you’re not sure if it’s related, make the call.
3 Divide and
conquer.
Ask your doctor what your options are for managing side
effects with medication vs. complementary alternative
approaches vs. nutrition and exercise.
4 Share this
guide.
Let your medical team
know that you’d like to
eat healthy and exercise
and ask them to review
whether there’s anything To learn more about the
future of precision medicine,
in here that would be including the promise of
contraindicated during reduced side effects,
or after your particular visit pcf.org.
form of treatment.
85
Research shows
that what you do
to your body in
your 20s and 30s
has a profound
effect on how
Health And Wellness Suggestions
you age.
For Parents
You might wonder what this section is doing in a guide about cancer.
Good question! There are a few simple answers:
1 You love your kids, and you want them to be healthy at every age.
2 Your kids love you, and they want you to be around for a long time.
3 Here’s the kicker: research shows that what you do to your body in your 20s
and 30s has a profound effect on how you age, well or not so well. For exam-
ple, a 2016 study found that leanness (eg, those in the lowest BMI category)
enhanced the effects of healthy lifestyle choices on decreasing premature
mortality across 30 years.
Share this guide with your whole family, to help everyone live a long and
productive life.
What about if you are a new parent? You have to listen even more carefully.
Having a new baby can be the time in your life when you take the least care of
yourself…but not so fast! Now more than ever, because someone depends on you
100%, you have a reason to stay healthy.
86
EAT REAL FOOD |
A few pragmatic tips for new parents:
• Start your kids eating well as soon as they move from milk to solid food. Some

tastes have a genetic component, such as an aversion to bitterness. Other tastes
are acquired. Have you ever heard a parent say, “Oh, my kid would never eat
that!” To them, we say: sorry, but that’s your fault. In Chennai, India, children eat
fermented lentil dumplings with spicy tomato sauce for breakfast, something
most Western parents, much less children, would balk at. Teach your children’s
taste buds, right now, that vegetables are the core of their long life.
• Share this guide with grandparents. They, too, have a new stake in the game,
and you want them around for everything from the first day of kindergarten to
graduations to weddings.
• Take time to take care of yourself. It’s easy to fall into only taking care of some-
one else, because they need your help. But it’s important to take time to rest,
exercise and eat well, in order to ultimately make yourself the best parent you
can be. Tough (self) love!
Smoking
Smoking causes cancer.
So far, research has shown a link between smoking and at least 15 forms of cancer
(including lung and prostate) and heart disease. For every 15 cigarettes smoked,
there is a DNA change that could cause a cell in the body to become cancerous.
The good news is that it’s never too late to quit smoking, and the benefits start
immediately. Quitting smoking may reduce the risk of dying from prostate cancer,
and reduces the risk of dying from any cause. The health benefits from quitting
begin on the first day after smoking ceases. Recent evidence from a PCF study
further suggests that smoking is associated with more aggressive prostate cancer
at the time of diagnosis. Furthermore, smokers have a higher risk of prostate
cancer progression, including recurrence and metastasis, as well as an increased
likelihood of death. Importantly, PCF-funded researchers Stacey Kenfield and June
Chan found that when compared with current smokers, men who quit smoking
more than 10 years ago had prostate cancer mortality risk similar to those who
had never smoked.
87
According to the American Lung Association, most people who smoke know that
smoking is harmful to their health and to those around them. Most people have
already made at least one attempt to quit. As a matter of fact, one study reported
that on average it took a person about 2.7 attempts to quit. The advent of nico-
tine replacement therapies and apps to help provide support for quitting have
increased success rates. On the negative side, in 2018 the U.S. Surgeon General
issued a warning about rising rates of e-cigarette use among youth. In 2018, an
alarming 1 in 5 high school students and 1 in 20 middle school students were
e-cigarette users. Since 99% of smokers start before age 26, it is imperative to talk
to your family members about the risks of smoking and disease.
Supplements
Since we told you about all these good foods that

contain lots of vitamins, nutrients, and cancer-fight-
ing compounds, you might be inclined to think that
you’d be in really good shape if you just went out to Supplements cannot
replace the nutrient mix
the local health food store and bought some supple-
found in real food.
ments where these elements have been extracted
from real food into pill form. Not so.
It is generally accepted that the use of a regular multivitamin is safe and may be
beneficial. One large randomized controlled trial demonstrated a modest (8%)
reduction in overall cancer risk among men who regularly took a multivitamin
supplement. However, the general consensus is that there isn’t enough evidence
to support the use of any single supplement for protection against cancer.
Another risk of supplements is a false sense of security. It is not ok to

simply eat poorly, then take a vitamin. It is important to eat and live well.
Stick to a whole foods diet.
Simply because a product is derived from “natural” ingredients does not mean it
is safe. Remember, the supplement industry is regulated under a different set of
FDA standards than either food or medication: they are not required to be proven
88
EAT REAL FOOD |
safe to FDA satisfaction before they are marketed for
sale. It’s also important to note that some single-nutri-
ent supplements may be harmful, depending on your

particular situation. As just two examples, vitamin E
supplementation after surgery can increase unwanted
bleeding, and based on a PCF-funded study, selenium
supplementation after prostate cancer diagnosis may
actually increase the risk of dying from prostate cancer.
One potential exception is vitamin D. Vitamin D is not found in food, but rather is
produced in the body when the skin is exposed to sunlight. Because of the recent
proliferation of sun blockers, many people are now vitamin D deficient, especially
older people, those with less sun exposure or who live in northern latitudes, and
people with heavily pigmented (dark) skin.
It is recommended that you consult with your physician before beginning any
supplements, including vitamin D. Remember, more and more, research is indi-
cating that supplements cannot replace the complicated nutrient mix found in
real food.
What To Drink (Or Not Drink) To Prevent Cancer
So far in this section we’ve covered everything you put in your body—from food
to tobacco—that affects your cancer outcomes. Liquids have the power to tip the
needle in either a health-positive or health-negative direction. While we can’t
extensively cover every beverage on the planet, this guide would be incomplete
without a few do’s and don’ts from the common beverage cart.
Green Tea | Green tea has anti-angiogenic properties.

Angiogenesis is the process by which tumor cells recruit blood
vessels to grow. Green tea inhibits cellular ability to recruit new
blood vessels. Similar properties have been discovered in spices
like licorice, ginseng, cumin, and garlic. Green tea contains a
particular polyphenol called EGCG (epigallocatechin-3-gallate), which has been
show in mouse studies to interfere with cell replication. What about black tea? It
also contains polyphenols, but at levels about 50% lower than green tea.
89
Coffee | Coffee also contains various polyphenols, which were
shown in a University of South Carolina study to turn on a
tumor suppressor gene called RARB2. One study from research-
ers in Spain found that two compounds in coffee, kahweol
acetate and cefestol, both inhibited the growth of prostate
cancer cells in mice. Note that caffeine in coffee can interfere with sleep, which is
a critical part of good health. Lastly, try to limit or avoid cream and sugar.
Water | Drinking a lot of water to stay healthy is important for

good health, because it helps your body flush waste and keeps
your body temperature regulated. Maintaining adequate blood
volume in necessary to carry oxygen, water-soluble vitamins,
and other protective compounds around your body. How much
water you need can depend on your habits, but a good estimate is 12-16 cups per
day. If you’re eating a lot of fiber, as we suggest, you might want to add in a few
more cups. Alcohol, coffee, and tea are all diuretics that inhibit your body’s ability
to absorb water, so excessive consumption can lead to dehydration if water is not
replenished. A study from the Environmental Working Group found that a ma-
jority of water systems in the U.S. contained known or likely carcinogens at levels
above government health guidelines. We recommend that you add a water filter
at home to filter out contaminants. Other than during treatment, when you might
be dehydrated or short on calories and appetite, we recommend drinking water
when thirsty, as opposed to reaching for a juice or sweetened beverage.
Soda | Do not drink soda, sweetened with sugar or sugar

substitutes. One sugar-sweetened soda contains more sugar
than the WHO suggests for your daily sugar intake. “Diet” soda
containing artificial sweeteners has been show to send signals
to your brain similar to sugar, which has the accumulated effect
of disrupting your metabolism, as if you had consume sugar. Repeat: do not drink
soda. So how do you quit the habit? Try transitioning to fruit-sweetened seltzer.
90
EAT REAL FOOD |
Juices and Other Sweetened or Artificially Sweetened
Beverages | Ditto the previous. In short, and to repeat, do
not drink things that are sweet to the taste on a regular basis.

However, if you have to choose between sweetened beverages,
a vitamin-filled juice beats a soda anyday. That said, read the
labels. Many commercial juices have little nutritional value remaining. As with
food, stick with juice where you can I.D. the source of the fruit. Just remember:
sugar is sugar, whether it’s from fructose (fruit) or sucrose (table sugar).
Alcohol | Studies indicate an association between increased

alcohol consumption and increased risk for some types of
cancer. This includes all kinds of alcohol. The byproducts of
alcohol consumption can make it harder for your body to
control the normal growth of cells. You may have heard about a
compound called resveratrol, found in red wine, that is a strong anti-inflammato-
ry. Unfortunately, the amount of wine you would need to drink to get enough
resveratrol would be impractical. You may also have heard several association
studies that linked drinking with longevity. As we learned earlier, there may be
other factors at play here, like community-building and reduced stress that often
go hand in hand with alcohol consumption. This is also one of those times when
precision might come into your nutrition decision: alcohol intake has been consis-
tently linked to reduced risk of heart disease and diabetes…but elevated risks of
many types of cancer. A safe suggestion for those who enjoy a cocktail every now
and then is to limit to one drink per day maximum, drink it with friends, and make
sure to drink lots of water alongside your wine.
How To Stay Current On What To Eat
Nutrition research is a very swiftly evolving field. There

are thousands of articles published in each year on
nutrition and cancer and hundreds of active clinical
trials. Whether you’re a science geek who wants to stay Stay current on the
latest research: visit
current on the latest research or a healthy-ish eater
pcf.org/livewell.
who wants to make sure not to miss practice-changing
updates to this guide, go to pcf.org/livewell to subscribe
for updates.
91
Conclusion: There are no short cuts.
What if there was a pill you could take for cancer-fighting

good health? What if it didn’t matter if you exercise, sleep
or eat right… because this pill took care of everything?
Whether you are a cancer survivor, an elite athlete, or just
someone interested in good health, we’re here to tell you:
that pill does not exist. Good health requires long term,
sustained lifestyle changes. It does take some effort. But
the good news is, none of this has to be painful. Fruits and
vegetables are delicious, exercising outside is invigorating,
sleeping well boosts mood and makes us feel more resilient,
and reducing stress will open the door to a cascade of
positive people, places and things in your life.
92
Be Well.
1250 Fourth Street Santa Monica, CA 90401 | 1.800.757.CURE (2873) | www.pcf.org
© 2019 Prostate Cancer Foundation

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THE SCIENCE OF LIVING WELL, BEYOND CANCER

Relax Exercise Eat Real Food

1 in 2 men and 1 in 3 women will be

The most important thing to remember about your

THE SCIENCE OF LIVING WELL

One thing that has helped science catch up to

Thanks to global access to people, information, high-speed computing, and

Precision Nutrition Precision Exercise

THE SCIENCE OF LIVING WELL

Cell division needs both energy and

It can be tough to figure out which changes

Lastly, although getting involved in your own health

THE SCIENCE OF LIVING WELL

DEPRESSION RATES AMONG GOLDEN RETRIEVER OWNERS

Depression Rates Among Golden Retriever Owners

In order to determine causation—not just association—between the two variables

To review: randomized controlled studies over time help scientists to determine

THE SCIENCE OF LIVING WELL

Here’s an example of one landmark observational study that examined associa-

The Bottom Line

We recommend your cancer avoidance journey focuses on three primary areas:

Relax Exercise Eat Real Food

Deregulating Avoiding By Healthy

Resisting Enabling By Good Sleep

By Coffee By Inflammation Increased

A 2011 landmark paper by Hanahan and Weinberg pub-

Right now, you might be thinking to yourself: “I came

René Descartes famously explored the mind-body connection. While Descartes

Here’s one example: Prostate Cancer Foundation (PCF)-funded researcher

Here’s some more good news: unlike IQ, EQ can

It’s important to note that

THE SCIENCE OF LIVING WELL

1 Emotions are information! Historically, emotions were seen as disruptive -

Cortisol can diffuse into your cells

Instead of blocking the docking site,

1. Accept your stressors | Studies indicate that accepting stress

2. Spend time in person with friends | Research suggests that in

4. Jam out | Multiple studies provide evidence that listening to

7. Get a pet | Research suggests that pet ownership alleviates

8. Exercise | This is an oldie but a

Manifestations of Emotional Stress

Note, however: There is evidence against too

Too little sleep also leads to similar issues.

THE SCIENCE OF LIVING WELL

Originating in ancient India, yoga is a practice

Studies suggest that a regular yoga practice may

Modern-day work environments can be a

Perceived work stress is linked to higher risk of

Even if work doesn’t show up on your ikigai list, most of us still

Add tasks you enjoy or that challenge you.

Set small goals.

Remember the big picture.

In 2004, the National Bureau of Economic

Unfortunately, cancer diagnosis and treatment

If cancer has affected your sex drive, there’s still

What would you cite as the best predictor

But a study published by the American Cancer

THE SCIENCE OF LIVING WELL

Your exercise routine needs to be tailored to maintain or improve your current

• Don’t eat too much added sugar: limit or eliminate.

• Don’t eat too much meat or dairy: moderation is key.