American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, June 19, 2013

Breast cancer and teen diets, what and when it's important

My onetime patient and student, Nicole Larizza*, earned her MS degree in nutrition studying the effects of nutrition in childhood on breast cancer risk in adulthood. Her important insights have led her to establish an organization dedicated to the early prevention of breast cancer, Nourish Our Girls.

I found the information Nicole shared with me important and provocative, and felt it deserved to be shared. My questions and her answers follow to that end.

1. Breast cancer typically presents during adulthood. Why is nutrition during childhood and adolescence important?

As women, we tend not to think about breast cancer until mid-life, our 40s, 50s, and beyond, when our friends, sisters, mothers, or coworkers are diagnosed with this dreaded disease. But adult breast health is largely determined much earlier in life, when the breast tissue is developing. During this time, the breast is most vulnerable and sensitive to nutritional and environmental stimuli. Research shows us that consumption of certain foods during the breast development process may actually change the physiology of the breast, thereby making it more or less susceptible to future cancer. One example of this is soy foods. Regular consumption of whole, traditional forms of soy during puberty is associated with the growth of fewer terminal ductal-lobular units (TDLUs) in the breast. These TDLUs are the end point of each mammary duct that extends out from the nipple, and are the site where the overwhelming majority of breast cancers originate. If we reduce the number of TDLUs in the fully-developed breast by altering a girl's pubertal diet, then we reduce the opportunity for cancer to occur there. This is just one of many examples about how diet during the breast development stage may affect physiology and influence risk as a result.

2. How does a girl's nutrition during childhood and adolescence affect her risk of breast cancer later in life?

The development of cancer is a multi-step process at the cellular level. Very simply, it begins with initiation when a single cell is damaged. This is followed by promotion as the damaged cell replicates and makes more damaged cells, and finally culminates with progression as masses of damaged cells spread throughout the body, infiltrate other tissues, and affect function. This process may take up to 35 years. With women being diagnosed at earlier ages now, in their 40s, 30s, and even some in their 20s, think about when that disease process may have started! The food a young girl eats may directly affect her risk of breast cancer by intervening at the earliest points along the cancer continuum. The presence of antioxidants and other nutrients may protect cells from becoming damaged in the first place, and may slow down or prevent the promotion of cell damage thereafter. Conversely, toxins and anti-nutrients like sugar and synthetic fats may actually cause cell damage or create a cellular environment in which cancer grows and thrives.

More indirectly, but just as important, certain dietary patterns and food intakes during childhood and adolescence are associated with the timing of menarche. Earlier menarche is an independent risk factor for adult breast cancer because it extends the window of exposure to estrogen. Estrogen has been implicated as a stimulus for cell division as well as a promoter of hormone-receptive breast tumors. As such, women with a higher lifetime exposure to estrogen have higher rates of breast cancer. Any behaviors we can modify to delay that first period, and shorten the window of estrogen exposure, may therefore result in decreased cancer risk. These behaviors include eating a lower-fat, lower-protein, higher-fiber diet, as well as being physically active and maintaining a lean body weight.

3. Which foods or dietary patterns during childhood/adolescence help to reduce risk of adult breast cancer?

Based upon available clinical evidence, there are essentially five dietary patterns that appear to be protective. The mechanisms of action are yet to be completely elucidated, but these patterns are associated with reduced risk of adult breast cancer and other breast cancer biomarkers. First, girls should aim to get more of their dietary fat from plant sources like nuts, seeds, avocado, and vegetable oils, and from cold-water fish like salmon, tuna, and halibut. They should limit dietary fat from meats, cheese, and dairy products. Second, girls should also try to get more of their protein from plant-based sources like legumes as opposed to relying on meat, poultry, eggs, and dairy products as their primary sources. Third, they should eat cruciferous vegetables such as broccoli, cabbages, kale, cauliflower, and Brussels sprouts at least a few times per week, ideally raw or lightly cooked to preserve their nutrients. These powerhouse vegetables contain cancer-fighting glucosinolate compounds that protect cells from initial damage and deter the proliferation of any further cell damage. Fourth, girls should also make whole, traditional soy foods like tofu, tempeh, and miso a regular part of their weekly menus. Similar to the broccoli family, these foods contain various compounds, indoles and isothiocyanates, in this case, that protect cells from damage and stimulate genes that suppress tumor formation. Lastly, girls should endeavor to eat a high-fiber diet, consisting of plentiful beans, lentils, nuts, seeds, fibrous vegetables and fruits, and unprocessed whole grains. Dietary fiber may help to decrease her exposure to high levels of estrogen, which in turn reduces her risk of breast cancer later in life.

4. Are there any foods that may increase risk and should therefore be avoided by young girls?

Especially for young girls, we should keep our focus on the positive, getting more of the good, health-supportive foods into her diet, rather than on the negative. If we persevere in our efforts, these nutrient-dense foods will ultimately crowd out some of the empty, nutrient-poor choices without creating an air of deprivation or food restriction. That said, there are, without question, certain dietary habits during childhood and adolescence that are associated with higher breast cancer risk later in life. High sugar intake, or a high-glycemic diet pattern, high animal protein consumption, low fiber intake, and any amount of alcohol consumption are all related to higher risk and should be avoided. Practically, girls need to learn to view sugary treats as just that, treats that are consumed occasionally rather than every day, or after every meal. They should be exposed to the endless possibilities for "meatless meals" and recognize that lunches and dinners don't need to be centered around animal protein. Vegetables and legumes shouldn't just be a side dish to their meal, they should be the meal! Girls should avoid refined and highly-processed grains like white breads, bagels, cereals, crackers, baked goods, and pastas. Instead, they should choose unrefined, minimally-processed whole grains and lots of vegetables and fruit in every meal to make sure they get enough fiber.

5. How can families apply this knowledge to their daughter's or granddaughter's diet in order to reduce her risk?

There are some really easy ways to change our girls' eating habits to reduce their breast cancer risk. Instead of butter, dress vegetables with extra-virgin olive oil. Instead of cream cheese on a bagel, serve natural peanut butter or almond butter on a whole-grain bagel. Replace the cheese on her sandwich with sliced avocado or a smear of flavored hummus. Make a few dinners each week "meatless meals" that are centered around beans, lentils, other legumes, and vegetables. Forget the ground beef and make vegetarian chili loaded with kidney beans, vegetables, and spices. Send broccoli or cauliflower florets with hummus as a snack in her lunchbox. Switch her pasta from traditional white pasta to a whole-grain or multi-grain blend that is higher in fiber. Throw away those packets of sugary instant oatmeal and make your own using old-fashioned or steel-cut oats, and flavor it with fruit, nuts/seeds, and a drizzle of maple syrup. Ditch the white rice and experiment with higher-fiber grains like wheatberries, farro, quinoa, barley, and wild rice instead. Throw a handful of kale leaves into her smoothie for great green color and dose of cruciferous vegetable at the same time. The possibilities are endless, and the health impact is immeasurable!

6. What is the take away message for anyone who has girls in their life who may be going through breast development?

Think of it this way: The breast is like a tree that grows from a seedling. If the seedling is exposed to health supportive nutrients, it is much more likely to develop a strong root system and grow into a mature tree that is able to withstand the storms Mother Nature may send its way. If that same seedling were starved of nutrients and exposed to toxins or anti-nutrients instead, it may still eventually grow into a full-sized tree. But without the foundation of a robust and healthy root system, that tree will likely be weaker and more susceptible to broken branches or uprooting when storms hit. Breast cancer is a very big, very complex storm. Admittedly, it cannot be eradicated through diet alone, regardless of when or how we structure it. But the evidence is compelling that nutrition during the breast development stage can influence the long-term health of this critical organ. Quite simply, we need to nurture our girls' seedlings the best we can now so they will grow to be strong, mature, healthy breasts for a lifetime.

*Nicole Larizza, MS is the Founder and Chief Nutrition Officer of Nourish Our Girls, an educational campaign to raise awareness about the role of childhood and adolescent diet in breast cancer risk reduction. She holds a Masters of Science in Human Nutrition from the University of Bridgeport. To learn more, contact her at or visit

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

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The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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