Smilow Cancer Hospital Culinary Guide for Patients with Gastrointestinal Cancers

Smilow Cancer Hospital Culinary Guide for Patients with Gastrointestinal Cancers

INTRODUCTION Nourishing foods can have a powerful impact on your overall health, and maintaining good nutrition and a healthy weight is especially important when you are dealing with gastrointestinal (GI) cancer.

Cancers of the GI tract involve parts of your body that control your nutritional health. Depending upon your medical or surgical treatment, changes may occur in your body that disrupt how food is digested, and nutrients absorbed.

What you put on the end of your fork can enhance your overall wellness and improve symptoms you may be experiencing. There is no 'one size fits all' prescribed way of eating. You are an individual and the way your body reacts to food and eating habits will be specific to you.

Created by GI oncologists and dietitians at Smilow Cancer Hospital, this guide to cooking and eating is tailored to meet the special needs of patients with conditions like yours. We will advise you on foods to limit and avoid, and foods that will improve your health.

However, just because you may need to limit or avoid certain foods, that does not mean that your meals need to be boring and flavorless. We are hopeful that these tips and recipes will empower you with the tools to keep mealtimes FLAVORFUL and FUN.

Pamela L. Kunz, MD Director, Center for Gastrointestinal Cancers at Smilow Cancer Hospital and Yale Cancer Center Kiran Turaga, MD, MPH Chief of Surgical Oncology at Smilow Cancer Hospital and Yale Cancer Center Jeremy Kortmansky, MD Associate Chief Medical Officer, Smilow Cancer Hospital and Yale Cancer Center

Developed in collaboration with: Lora Silver, MS, RD, CDN, CNSC, CSO, Smilow Cancer Hospital Molly Stryker, RD, CDN, CSO, Smilow Cancer Hospital

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NUTRITION TIPS FOR PATIENTS WITH GI CANCERS Certain foods or eating habits are more likely to result in digestive symptoms such as diarrhea, gas, bloating, and abdominal pain. You only need to avoid particular foods if they cause you to have symptoms. Here are some helpful tips: Eat 4 to 6 smaller meals, instead of the typical 3 larger meals. Try not to wait until you’re hungry. Eat every 2 to 2.5 hours for constant energy. Pace yourself and eat slowly to feel satisfied.

Cooked vegetables may be better tolerated than eating raw vegetables. Try smooth pureed vegetables in a soup if you are not tolerating cooked whole vegetables. Choose frozen and canned vegetables with no salt added to eat healthy and save money.

Stay hydrated by drinking water and other sources, such as vegetables and soups. Sip fluids throughout the day.

Eat a variety of foods and you’ll get most of your vitamins and minerals from food. Try for a rainbow of fruits and vegetables every day. As you cook more, you will have leftover foods, such as cooked grains, dressings and soups. You can store some in the refrigerator and freeze some for later. You’ll soon have a supply of prepared foods. Stick with plants! Whenever plants are at the center of the plate -- and that includes herbs and spices -- you CANNOT lose.

Choose a diet higher in protein.

Reduce your fat intake. You may be advised to increase healthy plant-based fats like nuts, seeds, avocadoes, olives and vegetable oils to help increase calories if you are losing weight.

Limit or avoid highly processed foods. You'll automatically reduce many added sugars, unhealthy fats, additives and coloring.

You may need to take a supplemental multivitamin/mineral because of the effects of surgeries or other treatments. Work with your team to meet your unique nutritional needs.

Break up cooking into its parts: planning, shopping, prepping, cooking, and cleaning. Wash and cut vegetables when you get home. You'll be more likely to use them, if they're prepped beforehand and ready to go.

Ask family or friends to help with shopping, prepping, or cooking.

Cooking with friends and family makes it easier and more fun.

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NUTRITIONAL CONSIDERATIONS FOR DIFFERENT TYPES OF GI CANCER Esophageal or Stomach Surgery Following esophageal or stomach surgery, you will typically start on a liquid diet, progress to a soft diet, then reintroduce regular foods as tolerated after 6-8 weeks. Changes in the size or position of your postoperative stomach can lead to symptoms such as early satiety, reflux, or dumping syndrome—when incompletely digested food empties too quickly into your small intestine resulting in nausea, vomiting, abdominal cramping, bloating, and diarrhea. You may be at risk for weight loss due to reduced stomach volume.

Nutrition tips following esophageal or stomach surgery: Try to consume 6-8 small, frequent meals per day Eat slowly and chew your foods thoroughly Sit upright following meals. Avoid lying down for 2-3 hours after meals.

Consume liquids 30 minutes before or after meals, not during meals to prevent fullness.

To manage dumping syndrome, try limiting concentrated sweets, lactose, and fried/greasy foods. With each meal, eat a source of protein, fat and/or soluble fiber.

Discuss the need for vitamin supplementation with your team.

Smilow Dietitian-Approved Recipes to try: High Protein Tuna Salad (page 19) Creamy Mashed Potatoes (page 20) High Protein Eggs (page 21)

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NUTRITIONAL CONSIDERATIONS FOR DIFFERENT TYPES OF GI CANCER Pancreas Surgery Following pancreas surgery, you will typically start on a liquid diet, progress to a soft diet, then reintroduce regular foods as tolerated after 6-8 weeks. Changes in the size or position of your postoperative stomach can lead to symptoms such as early satiety, reflux, or dumping syndrome – when incompletely digested food empties too quickly into your small intestine resulting in nausea, vomiting, abdominal cramping, bloating, and diarrhea. After surgery, the remaining part of your pancreas may not be able to produce enough enzymes to aid digestion, and fat malabsorption may become an issue. This may result in diarrhea, bloating, gas and abdominal pain. You may also have more difficulty controlling your blood sugar after surgery due to reduced insulin production.

Nutrition tips following pancreatic surgery: Try to consume 6-8 small, frequent meals per day Eat slowly and chew your foods thoroughly Consume liquids 30 minutes before or after meals, not during meals to prevent fullness.

To manage dumping syndrome, try liming concentrated sweets, lactose, and fried/greasy foods. With each meal, eat a source of protein, fat and/or soluble fiber.

To manage blood sugar, limit refined carbohydrates (white breads, cereals, rice, pastas), consume meals at regular intervals, and include source of protein, fat, and/or fiber with meals. You may need medications to help manage your blood glucose.

Monitor for lactose intolerance. Try lactose-free or plant-based dairy alternatives.

Cultured dairy products such as yogurt or buttermilk may be tolerated.

Your team may prescribe pancreatic enzymes for you to take with all meals/snacks.

Discuss the need for vitamin supplementation with your team.

Smilow Dietitian-Approved Recipes to try: Congee Rice Porridge (page 22) Peanut Butter Spread with Crackers or Banana (page 23) Marinated Chicken (page 24)

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NUTRITIONAL CONSIDERATIONS FOR DIFFERENT TYPES OF GI CANCER Gallbladder Surgery After gallbladder removal, bile drains directly and more continuously into your small bowel, which can result in diarrhea. You may also require stent placement to open a blocked area of the bile duct or small intestines. A soft diet that is low in fiber and easy to chew and swallow will promote healing and protect the stent.

Nutrition tips following gallbladder surgery: Small frequent meals will be more comfortable and will help reduce gas and bloating Limit fried/greasy foods, full-fat dairy, cream sauces, and other high fat foods Eat slowly and chew your foods thoroughly Discuss the need for bile acid binders (such as cholestyramine), anti-diarrheal medications and vitamin supplementation with your team.

Smilow Dietitian-Approved Recipes to try: Sweet Potato Power (page 25) Cinnamon Yogurt Peach Smoothie (page 26) Soothing Lemon Soup (page 27)

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NUTRITIONAL CONSIDERATIONS FOR DIFFERENT TYPES OF GI CANCER Bowel Surgeries Surgery may involve removing or bypassing portions of the small bowel (or, small intestines). Remaining portions adapt to absorb nutrients, but it takes time. You will start with a low-fiber diet to avoid blockages and promote healing. The small bowel is the primary site of many, but not all, neuroendocrine tumors.

After colon and rectal surgeries in particular, diarrhea, and irregular bowel movements can be common. Right after surgery, a low-fiber diet will promote healing and make bowel movements more comfortable. Frequent and loose bowel movements may continue for several weeks after cytoreductive surgery (with or without heated intraperitoneal chemotherapy). Experiencing new gas, bloating, or diarrhea after consuming milk or other dairy products? This is common after surgery: try lactose-free dairy products instead.

Experiencing new diarrhea after consuming concentrated sugars in desserts or sugary drinks? This is also common after surgery: limit or avoid these foods until you have recovered and can work with a dietitian to test these foods again.

Nutrition Tips following bowel surgery: Small frequent meals will be more comfortable and will help reduce gas and bloating Try to eat bulking foods with each meal/snack, including applesauce, bananas, boiled white rice, cheese, creamy peanut butter, peeled potatoes, white bread/crackers/pretzels, and yogurt Avoid caffeine, sweets, sugary drinks, prunes, fried/greasy foods as they can aggravate diarrhea Stay well hydrated to reduce your risk of dehydration. Aim for at least 8 cups of fluids per day.

If you have had rectal surgery, discuss with your team whether a fiber supplement is right for you.

Discuss the need for anti-diarrheal medications and vitamin supplementation with your team.

Smilow Dietitian-Approved Recipes to try: Congee Rice Porridge (page 22) Outstanding Oatmeal (page 28) Clove Tea (page 29)

Watermelon Granita (page 30) Curried Sweet Potato Soup (pages 31-32) Coconut Macaroons (page 33)

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NUTRITIONAL CONSIDERATIONS FOR DIFFERENT TYPES OF GI CANCER Neuroendocrine Tumors with Carcinoid Syndrome Neuroendocrine Tumors (NETs) are rare cancers that begin in specialized neuroendocrine cells. Neuroendocrine cells have traits similar to both nerve cells and hormone-producing cells. Some Neuroendocrine tumors secrete hormones that are associated with symptoms of hormone excess; the classic example is carcinoid syndrome (CS) which is associated with serotonin production (often measured as urine 5HIAA). Serotonin is a chemical that transmits signals between nerves in the brain and throughout the body, also called a neurotransmitter. In CS, it functions as a hormone, and when elevated can cause symptoms such as diarrhea and flushing. These symptoms can often improve by modifying food choices and eating patterns.[1] Certain foods or eating habits can worsen flushing, diarrhea, gas, bloating, and abdominal pain related to carcinoid syndrome. Many patients with CS find specific foods that contain serotonin or amines can trigger their symptoms. By limiting or avoiding highly processed foods, you automatically reduce many amines, added sugars, and fats. [2] Nutrition tips for patients with CS: Keep a food diary to help monitor what might be triggering symptoms for you. You may not have to give up a favorite food entirely. Small portions may not trigger symptoms.

Most frequently reported trigger habits include: Eating larger meals Drinking large amount of any beverage with meals Eating high fat greasy, fried foods Eating spicy foods Work with your team to test your limits, and start with small portions of moderate and high amine foods like coffee or chocolate.

Low vitamin B3, niacin, is more common in patients with CS. Chicken, turkey, fish, beef, pork, brown rice, fortified breakfast cereals, and peanuts are good sources of niacin to include regularly in your diet.[3]

Smilow Dietitian-Approved Recipes to try: Egg Muffins (page 34) Pumpkin Soup (page 35) Citrus Water (page 37) Black Barley Cilantro Tabbouleh (when not experiencing diarrhea) (page 36)

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NEUROENDOCRINE TUMORS WITH CARCINOID SYNDROME Questions about the 5-HIAA test?

[4]

This is a blood or urine test that measures how much serotonin is in the body. It does this by measuring the substance (Hydroxyindoleacetic acid, also called 5-HIAA) left behind when the body breaks down serotonin. Did you know the foods you eat can change your blood and urine test results? Avoid these foods for 48 hours prior to and during testing: avocado, banana, cantaloupe, eggplant, pineapple, plum, tomato, hickory nut/pecan, plantain, kiwi, date, grapefruit, honeydew, and walnut.

Low Amine Diet for NET Symptom Management

[5, 6]

Foods that are naturally low in amines may help to reduce your symptoms. Even if this diet helps you to feel better, you may tolerate small portions of moderate or high amine foods. However, none of these foods are proven to worsen your cancer or negatively impact your treatment. This diet is for symptom management only.

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NEUROENDOCRINE TUMORS WITH CARCINOID SYNDROME Very High in Amines

Moderate in Amines

Low in Amines

Avoid - likely to trigger symptoms

Small portions likely to be tolerated in moderation

Eat freely, likely well-tolerated

Leftover foods older than 48 hours Aged and fermented cheeses – swiss, gouda, cheddar, parmesan, blue cheese, camembert, brick, roquefort, provolone, emmentaler

Un-aged cheeses – American, cottage cheese, ricotta, mozzarella, yogurt, cream cheese, milk

Smoked, salted, or pickled fish or meats – herring, bacon, salami, sausage, corned beef, bologna, pepperoni

Fresh fish, seafood, lean chicken and turkey

Broad beans, miso, soy sauce, tempeh

Alcohol – all types

Overripe bananas, pineapple, watermelon, dried fruit, canned fruit in heavy syrup

Tomatoes, tomato products, pickled or fermented vegetables, raw onions

Fermented foods and condiments: sauerkraut, shrimp paste, fish sauce

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Freshly cooked foods

Yeast extracts and “hydrolyzed” proteins: marmite, vegemite, brewer’s yeast, nutritional yeast

Low-fat dairy and lactose-free varieties may be better tolerated.

Eggs and egg substitutes

Tofu, fava beans, peanuts, coconut, some vegetarian meat substitutes, other beans and legumes

Soy milk, edamame, almonds, pistachios, cashews

Caffeinated coffees and sodas, chocolate, cocoa powder, fruit juices

Water, flavored waters, diluted fruit juices, diluted sports drinks

Raspberries, avocado, green and yellow bananas

Cruciferous vegetables – broccoli, cauliflower, cabbage, brussels sprouts

Peeled fruits: apple, pear, peach, nectarine, mango, papaya, cantaloupe, honeydew Blueberries, strawberries, blackberries, grapes Peeled cooked vegetables: carrots, all squashes, potatoes, parsnips, turnips, asparagus, string beans, peas, shallots, onions, green onions, bell peppers

Corn

Raw vegetables: leafy greens, celery (with ribbing peeled), cucumber (peeled and seedless)

Corn tortillas, whole grain bread products

Oatmeal, white rice, white bread, quinoa

Butter, shortening, coconut oil

Olive, canola, safflower, sunflower oils

NEUROENDOCRINE TUMORS WITH CARCINOID SYNDROME CS-Friendly Curry Powder

Store-bought curry powder often has cayenne pepper and mustard seed, but you can easily blend your own to use in recipes that call for it.

Double, triple, or quadruple this recipe as needed!

1 teaspoon tumeric 1/2 teaspoon cumin 1/4 teaspoon coriander 1/4 teaspoon ginger 1/8 teaspoon cinnamon 1/8 teaspoon ground black pepper

Spices, herbs, and aromatics are essential ingredients and the key to big flavor and nutrient density. Each is loaded with antioxidants and phytochemicals. When it comes to cooking, spices or dried herbs are added at the BEGINNING, and fresh herbs go in at the END.

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NEUROENDOCRINE TUMORS WITH CARCINOID SYNDROME Missing Your Favorite Foods? Food Substitution Ideas If you find yourself missing some of these CS trigger foods, here are a few substitution ideas.

Tomatoes A simple romesco sauce can be made with roasted red peppers, toasted almonds, olive oil and garlic. Or look for No-Mato sauce in stores or online: www.nomato.com.

Avocado Boiled eggs, hummus, or cashew cream, if tolerated, can add some of that creaminess avocados contribute.

Coffee Green tea or an herbal coffee such as Dandy Blend or Teecino.

Nuts Almonds, pistachios, and cashews are low in amines and are great if you aren't having any CS symptoms. However if you're not eating any nuts, then toasted sunflower or pumpkin seeds are an excellent substitution.

Vinegars or fermented foods Zest from a lemon or lime offers a bright burst of flavor and the juice adds the sour flavor or acidity. Zest with a microplane.

Aged cheeses Goat cheese or sheep feta add that umami and saltiness you're craving.

Sweets Baking or stewing fruit brings out the natural sweetness and concentrates the flavor. Try roasting fruit, a fruit crisp made with a nut or seed you can tolerate, or a little piece of chocolate, if tolerated.

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NEUROENDOCRINE TUMORS WITH CARCINOID SYNDROME Other Nutrition Resources: General https://www.aicr.org https://www.cookforyourlife.org https://www.oncologynutrition.org https://www.cancer.org/cancer/risk-prevention/diet-physicalactivity/eat-healthy/find-healthy-recipes.html Carcinoid syndrome: https://www.carcinoid.org/ https://netrf.org/for-patients/ https://www.foodyoulovebook.com https://www.oncolink.org/cancers/carcinoid-neuroendocrine-tumors

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DAILY NUTRITION FOR A PATIENT WITH GI CANCERS Enjoy balanced meals by following the New American Plate, developed by [7] the American Institute for Cancer Research. The same healthy eating guidelines to prevent cancer are supportive and protective for you during treatment and beyond. Discuss your specific calorie and protein needs with your dietitian.

Fill up to 1/3 of your plate with protein-rich foods including poultry, fish, meat, eggs, and dairy foods.

Fill the other 2/3 with a variety of plant-based foods: vegetables, fruits, beans, and whole grains. Make room for these foods to benefit from their cancer-fighting nutrients!

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DAILY NUTRITION FOR A PATIENT WITH GI CANCERS What is one serving of your favorite foods?

2 cups of raw salad greens 1 cup chopped vegetables (about the size of your fist) 1 medium piece of fruit ½ cup of dried fruit 1 slice of bread or 1 small tortilla 1 cup ready to eat cereal ½ cup cooked brown rice, oatmeal, or noodles (about the size of your cupped hand) 1 cup milk or yogurt 2 ounces of cheese 3 ounces of cooked meat, poultry or seafood (about the size of the palm of your hand) 1 egg or 2 egg whites ¼ cup cooked beans, peas, or lentils 1 tablespoon nut butter (about the size of your thumb) 2 tablespoons of nuts or seeds 1 tablespoon of oil, dressing, margarine, or butter

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DAILY NUTRITION FOR A PATIENT WITH GI CANCERS Translating Science to the Plate The size of your plate, bowl, and glass can make a difference.

Use smaller plates and bowls to compose your smaller meals. A larger plate may lead you to over serve and over eat. You may feel that the same portion of rice on a smaller plate will be just the right amount. The same applies to drinking glasses. If you have a larger glass, you may drink more.

8-inch plate

10-inch plate 4 ounces of salmon

8-ounce glass

16-ounce glass

6 ounces of water

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RECIPES HIGH PROTEIN TUNA SALAD

19

CREAMY MASHED POTATOES

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HIGH PROTEIN EGGS

21

CONGEE RICE PORRIDGE

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PEANUT BUTTER SPREAD

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MARINATED CHICKEN

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SWEET POTATO POWER

25

CINNAMON, YOGURT, PEACH SMOOTHIE

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SOOTHING LEMON SOUP

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OUTSTANDING OATMEAL

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RECIPES CLOVE TEA

WATERMELON GRANITA

29

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CURRIED SWEET POTATO SOUP WITH COCONUT MILK

31-32

COCONUT MACAROONS

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EGG MUFFINS

34

PUMPKIN SOUP

BLACK BARLEY CILANTRO TABBOULEH

CITRUS WATER

35

36 37

HIGH PROTEIN TUNA SALAD 2 SERVINGS

INGREDIENTS 1/2 cup 2% plain Greek yogurt

READY IN 15 MINUTES

DIRECTIONS 1. Mix everything together in a medium bowl until well

1 teaspoon Dijon mustard

combined. Enjoy, or refrigerate in airtight container for up to

Juice of 1/2 lemon

5 days.

1 tablespoon extra-virgin olive oil 1/8 teaspoon Kosher salt 1/8 teaspoon freshly ground black pepper

210 calories, 25 grams protein, and 0 grams fiber per serving

6 ounces solid white tuna in water (two 3-ounce pouches, for example) Optional: 1/2 ripe avocado, diced

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CREAMY MASHED POTATOES 3 SERVINGS

INGREDIENTS 1 pound peeled red potatoes, cubed

READY IN 30 MINUTES

DIRECTIONS 1. Cover cubed potatoes in a pot of water and boil 15-20 minutes until tender.

2 tablespoon olive oil

2. Drain and mash the potatoes.

2 tablespoons unsalted butter

3. Add remaining ingredients and stir until thoroughly

2 tablespoons prepared

combined.

broth/bouillon 6 tablespoons protein powder (bone broth for savory, plain whey protein isolate (?) for lactose-free, or pea protein for dairy-free) 1/2 teaspoon salt 1/2 teaspoon ground pepper

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350 calories, 23 grams protein, and 2.5 grams fiber per serving

HIGH PROTEIN EGGS 2 SERVINGS

INGREDIENTS

READY IN 10 MINUTES

DIRECTIONS

4 large eggs

1. Spray non-stick skillet and start medium heat.

1/2 cup low-fat cottage cheese

2. Whisk all ingredients in medium bowl with a fork, then pour

1/2 teaspoon salt 1/2 teaspoon ground pepper Non-stick cooking spray

eggs into the warm skillet.

3. Gently and slowly fold eggs using a rubber spatula for about 2 minutes until set.

4. Enjoy right away, or refrigerate leftovers in airtight container up to 5 days.

174 calories, 17 grams protein, and 0 grams fiber per serving

notes You will need a non-stick skillet.

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CONGEE RICE PORRIDGE 4 SERVINGS

INGREDIENTS

READY IN 1 HOUR 15 MINUTES

DIRECTIONS

3/4 cup long grain rice

1. In large pot, bring rice and water to a boil.

9 cups bone broth (or, use water

2. Once boiling, turn down to medium-low heat.

or prepared broth/bouillon)

3. Place the lid on the pot, tilting it to allow steam to escape.

1 teaspoon salt

4. Cook for about 1 hour until the rice breaks down and

Optional: Top with 1 teaspoon olive oil or sesame oil for flavor

becomes thick and creamy.

5. Add seasonings to taste and optional items.

6. Enjoy, or refrigerate in airtight container for up to 5 days.

Add shredded chicken or boiled egg for protein Add ground herbs and spices as tolerated

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274 calories, 18 grams protein, and 1 gram fiber per serving

PEANUT BUTTER SPREAD 6 SERVINGS

INGREDIENTS

READY IN 15 MINUTES

DIRECTIONS

5 tablespoons smooth peanut

1. Combine dry milk and water.

butter (try powdered peanut

2. Add honey and peanut butter, stirring slowly until liquid

butter prepared with water for

blends with peanut butter.

less fat if you are experiencing

3. Enjoy with crackers or banana.

diarrhea)

4. Can also roll into balls and eat chilled.

1 tablespoon non-fat dry milk powder 1 teaspoon water 1 tablespoon honey

104 calories, 5 grams protein, 1 gram fiber per serving

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MARINATED CHICKEN 4 SERVINGS

INGREDIENTS

READY IN 3 HOURS 15 MINUTES

DIRECTIONS

4 three-ounce boneless, skinless

1. Place chicken breasts in resealable plastic bag.

chicken breasts

2. In blender, combine all remaining ingredients until smooth

1 cup plain low-fat yogurt 1 medium shallot, minced 3 tablespoons olive oil 1 tablespoon lemon juice 1/2 teaspoon lemon zest

and add to the bag.

3. Marinate for at least 3 hours or up to overnight.

4. Cook on preheated grill on each side for at least 5 minutes until cooked through.

5. Enjoy or refrigerate in airtight container for up to 5 days.

1/2 teaspoon garam masala (or curry powder) 3 tablespoons chopped cilantro

228 calories, 24 grams protein, 0 grams fiber per serving

notes You will need a large resealable plastic bag, a blender, and a grill or grill pan.

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SWEET POTATO POWER 3 SERVINGS

INGREDIENTS

READY IN 30 MINUTES

DIRECTIONS

1 medium-sized sweet potato

1. Peel and cut sweet potato into ½-inch pieces.

1 1/2 cup apricot nectar*

2. Steam potato for 10-15 minutes until soft.

4 oz silken tofu (1/3 to 1/2 of

3. Transfer to mixing bowl.

package)

4. Add remaining ingredients and blend until smooth (use

2 tablespoons maple syrup or

immersion blender, hand mixer, or a blender).

honey

237 calories, 9 grams protein, and 2 grams fiber per serving

notes You will need an immersion blender, hand mixer, or a blender.

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CINNAMON, YOGURT, PEACH SMOOTHIE 1 SERVING

INGREDIENTS

READY IN 15 MINUTES

DIRECTIONS

1 cup diced peaches (fresh,

1. Clean, peel, and prepare the fruit and other solid ingredients.

frozen, or canned)

2. Place these ingredients in the blender.

1/2 cup low-fat plain yogurt

3. Add liquid ingredients to the blender.

1/2 cup milk, soy milk, rice milk,

4. Blend all of the ingredients together to your desired

Boost, Ensure, or a generic version of these products.

1 tablespoon honey

consistency.

5. Depending on the strength of your blender, you may need more or less liquid to make the mixture blend.

Cinnamon to taste (1/8 teaspoon is a good place to start) 244 calories, 15 grams protein, 2 grams fiber per serving

notes You will need a blender.

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SOOTHING LEMON SOUP 6 SERVINGS

INGREDIENTS

READY IN 20 MINUTES

DIRECTIONS

6 cups bone broth or chicken

1. Bring broth to boil in a large pot.

broth/stock

2. Stir in orzo and cook for about 7 minutes until just tender.

1 cup orzo pasta

3. Turn off heat.

3 eggs, slightly beaten

4. In a small bowl, whisk lemon juice into the beaten eggs.

1 large lemon, juiced

5. Whisk hot broth into the egg mixture now, adding 1 spoonful at a time and stirring continuously.

6. Do this for 3 spoonfuls until egg mixture is hot.

7. Add egg mixture to a large pot and stir everything together until well combined.

8. Enjoy right away or refrigerate in an airtight container for up to 5 days.

149 calories, 15 grams protein, 1 gram fiber per serving

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OUTSTANDING OATMEAL 1 SERVING

INGREDIENTS

READY IN 10 MINUTES

DIRECTIONS

1/2 cup rolled oats (or cream of

1. Slice fruit of choice.

wheat for less fiber)

2. Add rolled oats or cream of wheat into a bowl.

1 cup lactose-free milk

3. Add milk.

1/2 cup fruit (sliced banana,

4. Top with preferred toppings.

canned peaches, or peeled diced baked apples) Optional toppings: 2 teaspoons butter adds 90 calories; 2 tablespoons peanut butter adds 190 calories and 9 grams protein.

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149 calories, 15 grams protein, 1 gram fiber per serving

CLOVE TEA 1 SERVING

INGREDIENTS 5-7 whole cloves 8 ounces water 1 green tea bag

READY IN 15 MINUTES

DIRECTIONS 1. Simmer the whole cloves in 8 ounces of water until the volume is reduced by half.

2. Pour the hot liquid into a mug and remove the whole cloves.

3. Add 2 ounces cool water to mug.

4. Add green tea bag to mug and let steep for 2-3 minutes Recipe from caring4cancer.com

0 calories, 0 grams protein, 0 grams fiber per serving

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WATERMELON GRANITA 4 SERVINGS

READY IN 2 HOURS

INGREDIENTS

DIRECTIONS

2 cups seedless watermelon,

1. Puree the watermelon, lime juice and basil until smooth.

peeled and diced

2. Stir in sugar and taste for desired sweetness.

1/4 cup fresh lime juice

3. Pour the watermelon juice into a 9x9x2 inch glass baking pan

4 large basil leaves 1 to 2 tablespoons of sugar, to taste

and put into the freezer.

4. After 30 minutes, with a fork scrape to form flaky texture.

5. Continue to scrape the surface every 30 minutes until you have a fluffy snowy consistency.

6. Serve or keep in an airtight container in freezer, scraping every so often to keep a light texture.

50 calories, 1 gram protein, 0 grams fiber per serving

notes You will need a 9x9x2 inch glass baking pan.

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CURRIED SWEET POTATO SOUP WITH COCONUT MILK 6 SERVINGS

INGREDIENTS

READY IN 2 HOURS

DIRECTIONS

3 medium sweet potatoes,

1. Pre-heat the oven to 350F (180C).

peeled

2. Slice the sweet potatoes into 2-inch rounds.

4 tablespoons olive oil

3. Place potatoes in a baking tray and drizzle with 2 tablespoons of

1 onion, chopped

olive oil.

2 garlic cloves, finely chopped

4. Season with a little salt.

2 stalks of celery, chopped

5. Bake for 1 hour or until tender.

2 teaspoons cumin

6. Remove from oven and set aside to cool.

2 teaspoons curry powder 1 teaspoon sea salt 5 cups of bone broth 1 cup of coconut milk 1/2 cup of water Optional: crusty bread for dipping

7. Meanwhile, in a large saucepan, heat the remaining olive oil over a medium heat.

8. Add the onion and celery and fry, stirring often, for 5 minutes.

9. Add garlic and fry for 30 seconds.

10. Add garam masala and curry powder.

11. Fry, stirring constantly with a wooden spoon, for 30 seconds.

12. Remove the saucepan from the heat.

13. Scoop flesh out of sweet potatoes and discard the skins.

14. Place potatoes into the saucepan and stir well to coat in spices.

15. Add stock and bring to the boil.

16. Turn the heat down to medium-low and cover.

17. Simmer soup for 15 minutes.

18. Remove soup from heat and cool. (cont.’d next page)

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CURRIED SWEET POTATO SOUP WITH COCONUT MILK DIRECTIONS 19. Ladle soup into a blender or food processor and blend in batches until smooth and creamy.

20. Place soup back into saucepan on a medium heat.

21. Add coconut milk and water, and stir well to combine.

22. Simmer soup over a medium heat for 5 minutes.

23. Divide soup into bowls, and serve with a slice of crusty bread for dipping.

Adapted from www.tastebuddies.com

268 calories, 10 grams protein, 3 grams fiber per serving

notes You will need a blender or food processor.

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COCONUT MACAROONS 12 SERVINGS

INGREDIENTS

READY IN 45 MINUTES

DIRECTIONS

4 large egg whites

1. Preheat oven to 350 degrees F.

Pinch of salt

2. In a mixer fitted with a whip attachment. whip egg whites and

1/2 cup sugar

salt until they become white and begin to stiffen.

1 8-ounce package sweetened,

3. Add sugar in 3 parts.

shredded coconut, lightly

4. Continue to whip until the egg whites are very stiff.

toasted

5. Using a rubber spatula fold in toasted coconut.

6. On parchment lined cookie sheets, drop a teaspoon of the mixture leaving 1 to 2 inches around each cookie.

7. Place into the oven and bake for 15 to 20 minutes.

8. Bake until the outside becomes golden brown. The insides should still be moist.

164 calories, 3 grams protein, 3 grams fiber per serving

notes You will need a stand mixer with a whip attachment or a hand mixer, parchment paper, and a cookie sheet.

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EGG MUFFINS 12 SERVINGS

INGREDIENTS

READY IN 45 MINUTES

DIRECTIONS

Non-stick cooking spray

1. Prepare 12-cup muffin tin with non-stick spray.

1 bag frozen shredded hash

2. Preheat 350F oven.

browns, at least 12 ounces (try

3. Fill each muffin cup with about 1 ounce hash browns.

to get unsalted/unseasoned)

4. Bake about 15 minutes until brown.

1 cup lightly packed baby spinach, chopped 6 eggs 4 egg whites 4 slices low-fat American

5. Remove from oven, and while warm, use back of spoon to press potatoes against sides and bottoms to create a crust.

6. Whisk together remaining ingredients in medium bowl until combined.

7. Place even amounts of sliced cheese to each muffin cup, then layer egg mixture on top until almost filled.

cheese, cut

8. Bake about 20 minutes until eggs are fully set.

1/4 teaspoon salt

9. Let cool for 5 minutes, then remove from pan to enjoy, or let

1/4 teaspoon dried basil 1/4 teaspoon dried oregano

cool on wire rack.

10. Refrigerate in airtight container up to 3 days.

Optional: cooked ground turkey or cooked crumbled tempeh; finely chopped red pepper

notes You will need a 12-cup muffin tin.

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136 calories, 6 grams protein, 1 gram fiber per serving

PUMPKIN SOUP 8 SERVINGS

INGREDIENTS 2 tablespoons olive oil 4 carrots, peeled and sliced 1 onion, chopped 28 ounces canned 100%

READY IN 40 MINUTES

DIRECTIONS 1. Saute carrots and onions in olive oil over medium heat until they begin to brown.

2. Add pumpkin, broth, and beans, bringing to a boil then reducing heat to medium.

pumpkin puree

3. Cook on simmer about 20 minutes.

4 cups bone broth

4. Remove from heat and puree with immersion blender (or

2 cups any cooked white bean 1/4 cup fresh basil, chopped

transfer carefully to a blender in batches) until smooth.

5. Garnish with basil and enjoy.

129 calories, 8 grams protein, 5 grams fiber per serving

notes You will need an immersion blender or regular blender.

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BLACK BARLEY CILANTRO TABBOULEH 6 SERVINGS

INGREDIENTS

READY IN 40 MINUTES

DIRECTIONS

1/2 lb black barley, uncooked

1. Cook barley in simmering water for 30-40 min or until tender.

1 cup edamame, shelled

2. Drain and chill.

3/4 cup red bell peppers, diced

3. Place barley in a bowl and toss with remaining ingredients.

3/4 cup green bell peppers, diced

4. Refrigerate tabbouleh in a sealed container for at least 3

1/2 cup green scallions, diced 1/4 cup cilantro, chopped

hours to combine flavors.

5. Serve cold.

1/4 tsp salt 1/8 tsp ground black pepper 1/2 cup lemon juice 3 tablespoons extra virgin olive oil

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238 calories, 7 grams protein, 8 grams fiber per serving

CITRUS WATER 8 SERVINGS

INGREDIENTS

READY IN 30 MINUTES

DIRECTIONS

1/2 cup of cucumber slices

1. Wash all produce before slicing.

1/2 lemon, sliced

2. Place sliced produce in 2-quart pitcher and push down with

1/2 lime, sliced 1/2 orange, sliced 2 quarts of water

the back of a spoon to start releasing flavor.

3. Cover with water and refrigerate for up to 12 hours, then discard solids and enjoy.

Optional: Add True Lemon or Crystal Light Pure packets to taste.

0 calories, 0 grams protein, 0 grams fiber per serving

notes You will need a 2-quart pitcher.

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NOTES

[1] Clement DS, Tesselaar ME, van Leerdam ME, Srirajaskanthan R, Ramage JK. Nutritional and vitamin status in patients with neuroendocrine neoplasms. World J Gastroenterol. 2019 Mar 14;25(10):1171-1184. doi: 10.3748/wjg.v25.i10.1171.

[2] Warner ME. Nutritional concerns for the carcinoid patient: Developing nutrition guidelines for persons with carcinoid disease. Carcinoid Cancer Foundation, Inc., New York. 2000. Updated 2008. Accessed April 1, 2022. https://www.carcinoid.org/for-patients/generalinformation/nutrition/nutritional-concerns-for-the-carcinoid-patient-developing-nutrition-guidelines-for-persons-with-carcinoid-disease [3] Niacin Fact Sheet for Health Professionals. National Institutes of Health Office of Dietary Supplements. Updated March 26, 2021.

Accessed April 1, 2022. https://ods.od.nih.gov/factsheets/Niacin-HealthProfessional/#h2.

[4] National Comprehensive Cancer Network® (NCCN). NCCN Guidelines Neuroendocrine and Adrenal Tumors. (Version 1.2022) https://www.nccn.org/professionals/physician_gls/PDF/neuroendocrine.pdf. Accessed October 6, 2022.

[5] Eating Right with Neuroendocrine Tumors. Neuroendocrine Tumor Research Foundation. Accessed April 1, 2022. https://netrf.org/forpatients/living-with-nets/nutrition/ [6] Find Food You Love. Lexicon Pharmaceuticals. 2017. Accessed April 1, 2022. https://www.foodyoulovebook.com [7] New American Plate. American Institute for Cancer Research. Accessed April 1, 2022.

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