- Email: [email protected]
Alternative Nutrition Therapies in Cancer Patients
173
Seminars in Oncology Nursing, Vol 21, No 3 (August), 2005: pp 173-176
OBJECTIVES: To review diet guidelines on selected alternative nutrition therapies, and the origins, limitations, and implication of these recommendations.
DATA SOURCES: Clinical research articles on alternative nutrition therapy.
CONCLUSION: Alternative nutrition therapy will continue to receive increasing scrutiny as research in science and technology develops. Individual needs vary widely; there is not one perfect diet for everyone. However, nutrition/diet plays a major role in cancer care and patients need to be educated about safe alternative nutrition therapy.
IMPLICATIONS PRACTICE:
FOR
NURSING
Whatever decision patients make regarding alternative nutrition therapies, support should be provided so that communication is increased between the patient and the health care team.
From the Memorial Hospital Cancer Resource Center, Chattanooga, TN; The Saint Vincent’s Comprehensive Cancer, New York, NY; and the University of Wisconsin Hospital and Clinics, Madison, WI. Canlas Maritess, RD, LDN: Clinical/Oncology Dietitian, Memorial Hospital Cancer Resource Center, Chattanooga, TN. Shayne Small, RD: Nutrition Services Coordinator, The Saint Vincent’s Comprehensive Cancer, New York, NY. Megan Waltz-Hill MS, RD, CD: Clinical Nutrition Services, University of Wisconsin Hospital and Clinics, Madison, WI. Address correspondence to Maritess Canlas, RD, LDN, 6220 Shallowford Road, Suite 211, Chattanooga, TN 37421; e-mail: [email protected]
© 2005 Elsevier Inc. All rights reserved. 0749-2081/05/2103-$30.00/0 doi:10.1016/j.soncn.2005.04.005
ALTERNATIVE NUTRITION THERAPIES IN CANCER PATIENTS CANLAS MARITESS, SHAYNE SMALL, MEGAN WALTZ-HILL
AND
O
NCOLOGY has always coexisted with therapies that are not part of conventional cancer treatments. Many of these therapies have focused on altered nutrient intake that may help to “heal” or “detoxify” the body from cancer and/or conventional cancer treatments. Therefore, food, diet, and medicine play a major role in determining the quality of life during a patient’s cancer journey. Information is a vital concern to patients in managing their care. Health care professionals can provide necessary tools for responsible education. Some of the alternative nutritional therapies are based on theories not found in biomedicine and have been described as “unproven” because of a lack of controlled clinical trials leaving the actual therapeutic value of these treatments unknown. However, many alternative diet treatments have been investigated in clinical trials and have been shown to be ineffective. This article reviews the diet guidelines for three popular nutritional approaches: the Macrobiotic Diet, Gerson Therapy, and the American Institute of Cancer Research.
MACROBIOTIC THERAPY
T
he macrobiotic lifestyle was developed by a Japanese philosopher, George Ohsawa, who believed healthy food was a step toward world peace and harmony, and popularized in the mid 1960s in the United States by his student, Michio Kushi, who promoted health as a key to peace.1–5 The macrobiotic eating plan is a philosophical approach to well-being and just one part of a macrobiotic lifestyle that encourages other healthy behaviors such as exercise, meditation, stress reduction, and
174
MARITESS, SMALL, AND WALTZ-HILL
limited exposure to pesticides.6 It is a common misconception that macrobiotics is an approach to treating cancer.1 Macrobiotic Recommendations Each individual macrobiotic eating plan considers the patient’s age, sex, activity level, environment, traditional diet, cultural food patterns, environment, and food availability. The content of the diet is high in complex carbohydrates and low in fat and animal protein. Organically grown and minimally processed foods are recommended. Forty to 60% of the foods are cereal grains (eg, buckwheat, brown rice, barley, millet, oats), 20% to 30% are vegetables, and 5% to 10% are beans (chickpea, lentils and bean products such as tofu). Daily consumption of sea vegetables is encouraged and white-meat fish, seeds, nuts and fruit are allowed a few times per week. Meat, poultry, animal fats, dairy, eggs, refined sugars, and foods that contain artificial sweeteners are eliminated.6,7 Potential Problems Following a macrobiotic lifestyle can empower patients by giving them a sense of contributing to their healing. However, many patients find the eating plan difficult to maintain because of the lack of food availability and the side effects of cancer treatment. Individuals on the plan need to consume large quantities of food to meet nutrient needs, as many of the specified foods are not calorically dense. This can prove difficult for a patient with an already reduced appetite as a consequence of cancer treatment. Time-intensive food preparation and the relatively high cost of organic foods add to the challenge of adhering to the diet plan. Preliminary research fails to establish a rationale for further investigation of macrobiotics as an effective cancer therapy.1 There have been individual published reports of patients following macrobiotic lifestyles who have recovered from cancer2–5; however, these publications reflect primarily the individual’s beliefs and are inadequate for determining its effectiveness of this in cancer treatment. A clinical trial sponsored by the National Center for Complementary and Alternative Medicine (NCCAM) and conducted at Columbia University in New York is currently studying the macrobiotic eating plan to determine whether following it would promote favorable effects on biological parameters that are related to the risk factors of the major diseases of aging.8
Review A well-planned liberal macrobiotic eating plan may be able to meet the nutrition needs of a healthy person with a high caloric intake.9 However the macrobiotic eating plan can easily be deficient in protein, vitamin B12, calcium, and fluid.7 Nutrient deficiencies result from the combination of extreme dietary restriction and multiple side effects from the disease and or treatment that create barriers to eating. The extreme restrictions and labor-intensive demands of this eating plan may not be appropriate for cancer patients undergoing treatment because of their increased protein, energy, and fluid needs.
GERSON THERAPY Max Gerson, MD developed Gerson Therapy in the 1940s as a dietary approach to treat tuberculosis.10 Gerson later used his diet therapy to treat cancer and other degenerative diseases by focusing on the role of minerals, enzymes, hormones, and other dietary factors to restore health and well-being, to “reverse” the conditions thought to sustain growth of malignant cells, and to eliminate toxins from the body. Gerson believed that to be “healed,” the body needed to be “detoxified” with sodium and fat restrictions, potassium supplementation, and a raw food vegetarian diet.11 The scientific evidence and efficacy of Gerson Therapy remain highly questionable, and reviews by both the National Cancer Institute and the American Cancer Society have found it to be ineffective.12–16 Despite this information, Centro Hospitalario Internacional del Pacifico in Mexico still offers the Gerson Therapy at a cost of about $4,000 per week plus $200 or more per week for laboratory testing. The center also recommends that a companion accompany the patient, costing an additional $330 per week.17,18 Gerson Therapy Recommendations The program recommends a raw vegetarian diet, with patients drinking 13 glasses of freshly prepared vegetable and fruit juices made from organic fruits and vegetables (ingested one every hour during the day).19 Various supplements are given, including an iodine solution, vitamin B12, potassium, thyroid hormone, an injectable crude liver extract, and pancreatic enzymes.20
ALTERNATIVE NUTRITION THERAPIES
Coffee, chamomile, or castor oil enemas are encouraged daily to manage pain and to stimulate the bowel and liver enzymes to increase the release of toxins. Salt, oil, nuts, berries, drinking water, and all bottled, canned, refined, preserved, and processed foods are forbidden.19 Aluminum cookware or utensils are not used when preparing food. Potential Problems Patients may suffer flu-like feelings, loss of appetite, perspiration with strong odor, weakness, dizziness, cold sores, and fever blisters during treatment.19 Tumor masses may become painful, and patients may experience high fever, intestinal cramping, diarrhea, and vomiting.20 Some patients have suffered from serious infections and death from electrolyte imbalances caused by daily enemas.12 Thyroid supplementation has been thought to be the cause of severe bleeding in some patients with liver metastases.13 Review Nutritionally, the adherence to some of the dietary principles, such as a vegetarian diet with fresh fruits and vegetables and high-quality protein sources, is possible with well-planned meals and snacks to provide adequate nutrient intake. However, the Gerson Therapy diet plan is very low in fat content and the features of daily enemas and hourly consumption of organic fresh fruit and vegetable juices makes this eating plan undesirable in a population such as cancer patients that is already prone to the many side effects of the disease and conventional treatment including decreased appetite. The associated monetary costs may make it impractical for many patients.
AMERICAN INSTITUTE FOR CANCER RESEARCH (AICR) DIET THERAPY
175
yellow, and purple. In 1997, the World Cancer Research Fund and AICR jointly published a report titled “Food, Nutrition and the Prevention of Cancer: A Global Perspective”22 to educate professionals and the public about nutrition and cancer. In 2001, the World Cancer Research Fund commissioned a second part of the study to be published in 2006, reporting further evidence and developments related to cancer and diet therapy. AICR Recommendations AICR research into diet, nutrition, and cancer provides guidelines for educational programs to help create changes to lower cancer risk and promote awareness. Education is a very powerful weapon to prevent cancer and improve quality of life for those who have been diagnosed with the disease. AICR’s education program and recommendations are based on current research in diet and cancer from around the world and are summarized as follows: 1. Choose a diet rich in a variety of plant-based foods. 2. Eat plenty of vegetables and fruits. 3. Maintain a healthy weight and be physically active. 4. Drink alcohol only in moderation, if at all. 5. Select foods low in fat and salt. 6. Prepare and store foods safely. Review AICR’s guidelines are derived from ongoing scientific research. Cancer patients and their families have benefited with practical and easy guidelines and tips on diet and overall wellbeing. The AICR guidelines are designed to be holistic, taking into account other diseases that are linked to diet, and are designed to be updated as new evidence accumulates.23,24 Following these recommendations makes a positive impact on our dietary habits.25
CONCLUSION
T
he American Institute for Cancer Research (AICR) was founded in 1982 and focuses on evidenced-based research related to diet and cancer prevention.21 The diet emphasizes plantbased foods, focusing on fruits and vegetables with dominant, bright colors such as red, green,
T
here is increasing evidence that nutrient intake may play a role in the development of cancer and outcomes of cancer treatment. Patients should be encouraged to follow evidenced-based guidelines on diet therapy.
176
MARITESS, SMALL, AND WALTZ-HILL
REFERENCES 1. Kushi KH, Cunningham JE, Herbert JR, et al: The macrobiotic diet and cancer. J Nutr 131(supp1) 2001;3056S-3064S. 2. Brown V, Stayman S. Macrobiotic Miracle: How a Vermont Family Overcame Cancer. New York, NY; Japan Publications; 1984. 3. Faulkner H. Physician, Heal Thyself. Becket, MA; One Peaceful World Press; 1993. 4. Nussbaum E. Recovery from Cancer. Garden City Park, NY; Avery Publishing; 1992. 5. Fawcett A, Smith C. Cancer-Free: 30 Who Triumphed Over Cancer Naturally. New York, NY; Japan Publications; 1991. 6. Kushi M, Jack A. The Macrobiotic Path to Total Health: A Complete Guide to Preventing and Relieving over 200 Chronic Conditions and Disorders. New York NY; Random House; 2004. 7. Anonymous. Questionable methods of cancer management: ’Nutritional’ therapies. CA Cancer J Clin 1993; 43:309-319. 8. National Cancer Institute. Clinical trials. Available at http://www.clinicaltrials.gov/show/NCT00010829 (accessed January 20, 2005). 9. WeitzmanS. Alternative nutritional cancer therapies. Int J Cancer 1998;11(suppl 1) 69-72. 10. Lowell JA. The Gerson clinic: Nutr Forum 1986;39-12. 11. Hesse CC. The Gerson Primer. Tijuana, Mexico; Curtis C. Hesse; 1982. 12. Centers for Disease Control. Campylobacter sepsis associated with “nutritional therapy”: California. MMWR Morbid Mortal Wkly Rep 1981;30:294-295. 13. US Congress. Office of Technology Assessment: Unconventional Cancer Treatments, OTA-H-405. Washington, DC; US Government Printing Office; September 1990.
14. Lerner M. Choices in Healing. Cambridge, MA; MIT Press; 1994. 15. Anonymous. Questionable methods of cancer management: “nutritional therapies.” Cancer 1993;43:309-319. 16. National Cancer Institute. Cancer Facts, Gerson Therapy. Reviewed December 7, 1999. Available at http://cis.nci. nih.gov/fact/9_7.htm (accessed January 20, 2005). 17. Fritz N. Gerson Institute, Progress Report. Letter to members. Bonita, CA; August 1983. 18. Ontario Breast Cancer Information Exchange Project. Guide to unconventional cancer therapies. Toronto, Ontario; Breast Cancer Information Exchange Project; 1994. 19. Lerner IJ, Kennedy BJ. The prevalence of questionable methods of cancer treatment in the United States. Cancer 1992;42:181-191. 20. American Cancer Society. Unproven methods of cancer management: Gerson Method. Cancer 1990;40:252-256. 21. American Institute for Cancer Research. Published Educational Booklet. Available at http://www.aicr.org/brochure.ns. htm (accessed January 2005). 22. World Cancer Research fund and American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC; American Institute for Cancer Research; 1997. 23. American Institute for Cancer Research. Simple Steps to Prevent Cancer: Healthy Living and Lower Cancer Risk. Washington, DC; American Institute for Cancer Research; 2000. 24. Dwyer J. Nutrition Guidelines and Education of the Public. J Nutr 2001;131:3074S-3077S(Suppl 11). 25. Kritchevsky D. Diet and cancer: What’s next. J Nutr 2003;133:3827-3829.
Seminars in Oncology Nursing, Vol 21, No 3 (August), 2005: pp 173-176
OBJECTIVES: To review diet guidelines on selected alternative nutrition therapies, and the origins, limitations, and implication of these recommendations.
DATA SOURCES: Clinical research articles on alternative nutrition therapy.
CONCLUSION: Alternative nutrition therapy will continue to receive increasing scrutiny as research in science and technology develops. Individual needs vary widely; there is not one perfect diet for everyone. However, nutrition/diet plays a major role in cancer care and patients need to be educated about safe alternative nutrition therapy.
IMPLICATIONS PRACTICE:
FOR
NURSING
Whatever decision patients make regarding alternative nutrition therapies, support should be provided so that communication is increased between the patient and the health care team.
From the Memorial Hospital Cancer Resource Center, Chattanooga, TN; The Saint Vincent’s Comprehensive Cancer, New York, NY; and the University of Wisconsin Hospital and Clinics, Madison, WI. Canlas Maritess, RD, LDN: Clinical/Oncology Dietitian, Memorial Hospital Cancer Resource Center, Chattanooga, TN. Shayne Small, RD: Nutrition Services Coordinator, The Saint Vincent’s Comprehensive Cancer, New York, NY. Megan Waltz-Hill MS, RD, CD: Clinical Nutrition Services, University of Wisconsin Hospital and Clinics, Madison, WI. Address correspondence to Maritess Canlas, RD, LDN, 6220 Shallowford Road, Suite 211, Chattanooga, TN 37421; e-mail: [email protected]
© 2005 Elsevier Inc. All rights reserved. 0749-2081/05/2103-$30.00/0 doi:10.1016/j.soncn.2005.04.005
ALTERNATIVE NUTRITION THERAPIES IN CANCER PATIENTS CANLAS MARITESS, SHAYNE SMALL, MEGAN WALTZ-HILL
AND
O
NCOLOGY has always coexisted with therapies that are not part of conventional cancer treatments. Many of these therapies have focused on altered nutrient intake that may help to “heal” or “detoxify” the body from cancer and/or conventional cancer treatments. Therefore, food, diet, and medicine play a major role in determining the quality of life during a patient’s cancer journey. Information is a vital concern to patients in managing their care. Health care professionals can provide necessary tools for responsible education. Some of the alternative nutritional therapies are based on theories not found in biomedicine and have been described as “unproven” because of a lack of controlled clinical trials leaving the actual therapeutic value of these treatments unknown. However, many alternative diet treatments have been investigated in clinical trials and have been shown to be ineffective. This article reviews the diet guidelines for three popular nutritional approaches: the Macrobiotic Diet, Gerson Therapy, and the American Institute of Cancer Research.
MACROBIOTIC THERAPY
T
he macrobiotic lifestyle was developed by a Japanese philosopher, George Ohsawa, who believed healthy food was a step toward world peace and harmony, and popularized in the mid 1960s in the United States by his student, Michio Kushi, who promoted health as a key to peace.1–5 The macrobiotic eating plan is a philosophical approach to well-being and just one part of a macrobiotic lifestyle that encourages other healthy behaviors such as exercise, meditation, stress reduction, and
174
MARITESS, SMALL, AND WALTZ-HILL
limited exposure to pesticides.6 It is a common misconception that macrobiotics is an approach to treating cancer.1 Macrobiotic Recommendations Each individual macrobiotic eating plan considers the patient’s age, sex, activity level, environment, traditional diet, cultural food patterns, environment, and food availability. The content of the diet is high in complex carbohydrates and low in fat and animal protein. Organically grown and minimally processed foods are recommended. Forty to 60% of the foods are cereal grains (eg, buckwheat, brown rice, barley, millet, oats), 20% to 30% are vegetables, and 5% to 10% are beans (chickpea, lentils and bean products such as tofu). Daily consumption of sea vegetables is encouraged and white-meat fish, seeds, nuts and fruit are allowed a few times per week. Meat, poultry, animal fats, dairy, eggs, refined sugars, and foods that contain artificial sweeteners are eliminated.6,7 Potential Problems Following a macrobiotic lifestyle can empower patients by giving them a sense of contributing to their healing. However, many patients find the eating plan difficult to maintain because of the lack of food availability and the side effects of cancer treatment. Individuals on the plan need to consume large quantities of food to meet nutrient needs, as many of the specified foods are not calorically dense. This can prove difficult for a patient with an already reduced appetite as a consequence of cancer treatment. Time-intensive food preparation and the relatively high cost of organic foods add to the challenge of adhering to the diet plan. Preliminary research fails to establish a rationale for further investigation of macrobiotics as an effective cancer therapy.1 There have been individual published reports of patients following macrobiotic lifestyles who have recovered from cancer2–5; however, these publications reflect primarily the individual’s beliefs and are inadequate for determining its effectiveness of this in cancer treatment. A clinical trial sponsored by the National Center for Complementary and Alternative Medicine (NCCAM) and conducted at Columbia University in New York is currently studying the macrobiotic eating plan to determine whether following it would promote favorable effects on biological parameters that are related to the risk factors of the major diseases of aging.8
Review A well-planned liberal macrobiotic eating plan may be able to meet the nutrition needs of a healthy person with a high caloric intake.9 However the macrobiotic eating plan can easily be deficient in protein, vitamin B12, calcium, and fluid.7 Nutrient deficiencies result from the combination of extreme dietary restriction and multiple side effects from the disease and or treatment that create barriers to eating. The extreme restrictions and labor-intensive demands of this eating plan may not be appropriate for cancer patients undergoing treatment because of their increased protein, energy, and fluid needs.
GERSON THERAPY Max Gerson, MD developed Gerson Therapy in the 1940s as a dietary approach to treat tuberculosis.10 Gerson later used his diet therapy to treat cancer and other degenerative diseases by focusing on the role of minerals, enzymes, hormones, and other dietary factors to restore health and well-being, to “reverse” the conditions thought to sustain growth of malignant cells, and to eliminate toxins from the body. Gerson believed that to be “healed,” the body needed to be “detoxified” with sodium and fat restrictions, potassium supplementation, and a raw food vegetarian diet.11 The scientific evidence and efficacy of Gerson Therapy remain highly questionable, and reviews by both the National Cancer Institute and the American Cancer Society have found it to be ineffective.12–16 Despite this information, Centro Hospitalario Internacional del Pacifico in Mexico still offers the Gerson Therapy at a cost of about $4,000 per week plus $200 or more per week for laboratory testing. The center also recommends that a companion accompany the patient, costing an additional $330 per week.17,18 Gerson Therapy Recommendations The program recommends a raw vegetarian diet, with patients drinking 13 glasses of freshly prepared vegetable and fruit juices made from organic fruits and vegetables (ingested one every hour during the day).19 Various supplements are given, including an iodine solution, vitamin B12, potassium, thyroid hormone, an injectable crude liver extract, and pancreatic enzymes.20
ALTERNATIVE NUTRITION THERAPIES
Coffee, chamomile, or castor oil enemas are encouraged daily to manage pain and to stimulate the bowel and liver enzymes to increase the release of toxins. Salt, oil, nuts, berries, drinking water, and all bottled, canned, refined, preserved, and processed foods are forbidden.19 Aluminum cookware or utensils are not used when preparing food. Potential Problems Patients may suffer flu-like feelings, loss of appetite, perspiration with strong odor, weakness, dizziness, cold sores, and fever blisters during treatment.19 Tumor masses may become painful, and patients may experience high fever, intestinal cramping, diarrhea, and vomiting.20 Some patients have suffered from serious infections and death from electrolyte imbalances caused by daily enemas.12 Thyroid supplementation has been thought to be the cause of severe bleeding in some patients with liver metastases.13 Review Nutritionally, the adherence to some of the dietary principles, such as a vegetarian diet with fresh fruits and vegetables and high-quality protein sources, is possible with well-planned meals and snacks to provide adequate nutrient intake. However, the Gerson Therapy diet plan is very low in fat content and the features of daily enemas and hourly consumption of organic fresh fruit and vegetable juices makes this eating plan undesirable in a population such as cancer patients that is already prone to the many side effects of the disease and conventional treatment including decreased appetite. The associated monetary costs may make it impractical for many patients.
AMERICAN INSTITUTE FOR CANCER RESEARCH (AICR) DIET THERAPY
175
yellow, and purple. In 1997, the World Cancer Research Fund and AICR jointly published a report titled “Food, Nutrition and the Prevention of Cancer: A Global Perspective”22 to educate professionals and the public about nutrition and cancer. In 2001, the World Cancer Research Fund commissioned a second part of the study to be published in 2006, reporting further evidence and developments related to cancer and diet therapy. AICR Recommendations AICR research into diet, nutrition, and cancer provides guidelines for educational programs to help create changes to lower cancer risk and promote awareness. Education is a very powerful weapon to prevent cancer and improve quality of life for those who have been diagnosed with the disease. AICR’s education program and recommendations are based on current research in diet and cancer from around the world and are summarized as follows: 1. Choose a diet rich in a variety of plant-based foods. 2. Eat plenty of vegetables and fruits. 3. Maintain a healthy weight and be physically active. 4. Drink alcohol only in moderation, if at all. 5. Select foods low in fat and salt. 6. Prepare and store foods safely. Review AICR’s guidelines are derived from ongoing scientific research. Cancer patients and their families have benefited with practical and easy guidelines and tips on diet and overall wellbeing. The AICR guidelines are designed to be holistic, taking into account other diseases that are linked to diet, and are designed to be updated as new evidence accumulates.23,24 Following these recommendations makes a positive impact on our dietary habits.25
CONCLUSION
T
he American Institute for Cancer Research (AICR) was founded in 1982 and focuses on evidenced-based research related to diet and cancer prevention.21 The diet emphasizes plantbased foods, focusing on fruits and vegetables with dominant, bright colors such as red, green,
T
here is increasing evidence that nutrient intake may play a role in the development of cancer and outcomes of cancer treatment. Patients should be encouraged to follow evidenced-based guidelines on diet therapy.
176
MARITESS, SMALL, AND WALTZ-HILL
REFERENCES 1. Kushi KH, Cunningham JE, Herbert JR, et al: The macrobiotic diet and cancer. J Nutr 131(supp1) 2001;3056S-3064S. 2. Brown V, Stayman S. Macrobiotic Miracle: How a Vermont Family Overcame Cancer. New York, NY; Japan Publications; 1984. 3. Faulkner H. Physician, Heal Thyself. Becket, MA; One Peaceful World Press; 1993. 4. Nussbaum E. Recovery from Cancer. Garden City Park, NY; Avery Publishing; 1992. 5. Fawcett A, Smith C. Cancer-Free: 30 Who Triumphed Over Cancer Naturally. New York, NY; Japan Publications; 1991. 6. Kushi M, Jack A. The Macrobiotic Path to Total Health: A Complete Guide to Preventing and Relieving over 200 Chronic Conditions and Disorders. New York NY; Random House; 2004. 7. Anonymous. Questionable methods of cancer management: ’Nutritional’ therapies. CA Cancer J Clin 1993; 43:309-319. 8. National Cancer Institute. Clinical trials. Available at http://www.clinicaltrials.gov/show/NCT00010829 (accessed January 20, 2005). 9. WeitzmanS. Alternative nutritional cancer therapies. Int J Cancer 1998;11(suppl 1) 69-72. 10. Lowell JA. The Gerson clinic: Nutr Forum 1986;39-12. 11. Hesse CC. The Gerson Primer. Tijuana, Mexico; Curtis C. Hesse; 1982. 12. Centers for Disease Control. Campylobacter sepsis associated with “nutritional therapy”: California. MMWR Morbid Mortal Wkly Rep 1981;30:294-295. 13. US Congress. Office of Technology Assessment: Unconventional Cancer Treatments, OTA-H-405. Washington, DC; US Government Printing Office; September 1990.
14. Lerner M. Choices in Healing. Cambridge, MA; MIT Press; 1994. 15. Anonymous. Questionable methods of cancer management: “nutritional therapies.” Cancer 1993;43:309-319. 16. National Cancer Institute. Cancer Facts, Gerson Therapy. Reviewed December 7, 1999. Available at http://cis.nci. nih.gov/fact/9_7.htm (accessed January 20, 2005). 17. Fritz N. Gerson Institute, Progress Report. Letter to members. Bonita, CA; August 1983. 18. Ontario Breast Cancer Information Exchange Project. Guide to unconventional cancer therapies. Toronto, Ontario; Breast Cancer Information Exchange Project; 1994. 19. Lerner IJ, Kennedy BJ. The prevalence of questionable methods of cancer treatment in the United States. Cancer 1992;42:181-191. 20. American Cancer Society. Unproven methods of cancer management: Gerson Method. Cancer 1990;40:252-256. 21. American Institute for Cancer Research. Published Educational Booklet. Available at http://www.aicr.org/brochure.ns. htm (accessed January 2005). 22. World Cancer Research fund and American Institute for Cancer Research. Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington, DC; American Institute for Cancer Research; 1997. 23. American Institute for Cancer Research. Simple Steps to Prevent Cancer: Healthy Living and Lower Cancer Risk. Washington, DC; American Institute for Cancer Research; 2000. 24. Dwyer J. Nutrition Guidelines and Education of the Public. J Nutr 2001;131:3074S-3077S(Suppl 11). 25. Kritchevsky D. Diet and cancer: What’s next. J Nutr 2003;133:3827-3829.