If you have experienced cancer-related fatigue (CRF), you will know that it is very different from the type of tiredness that you might have had before your cancer diagnosis. CRF is not caused by over-exerting yourself or by insufficient sleep, and getting more sleep or more rest does not improve the fatigue(1). If overdoing it and lack of sleep aren’t responsible for CRF, then what is?
There are a number of factors that relate to cancer itself and to cancer treatment that are recognised as contributing to CRF(2), (3). Looking at these can reveal strategies for minimising CRF using diet and lifestyle measures.
Inflammation
Both cancer itself and cancer treatments can cause increases in inflammatory signalling within the body. Even after treatment is finished, low grade inflammation and fatigue can persist.
An anti-inflammatory diet can contribute to reducing chronic inflammation, and has also been associated with improved cancer outcomes(4), (5), (6). If you look back through the blog, you will find a post from May 2023 all about the anti-inflammatory diet. Key components of it include:
A wide variety of vegetables of all colours – note too that deep colours tend to be more anti-inflammatory
Herbs and spices, such as turmeric, garlic, ginger and rosemary
Fruit, especially berries
Oily fish: salmon, mackerel, anchovies, sardines and herring
Green and black tea (as well as herbal teas)
Healthy fats such as extra virgin olive oil, avocados, nuts and seeds
Whole grains and pulses
Appropriate amounts of lean animal protein
Mitochondrial dysfunction
Mitochondria are organelles inside our cells. They are responsible for energy generation and are often called “the powerhouses of the cell”. We now know that changes to the functioning of mitochondria are associated with cancer(7), (8), and that cancer treatment can also cause damage to the mitochondria. Given their role in energy production, it is not too surprising that changes in the mitochondria have been associated with CRF(3).
There are several lifestyle factors that are known to either have a positive impact on mitochondrial functioning or that encourage more mitochondria to be produced.
Don’t overeat at a single sitting, nor graze constantly throughout the day.
Engage in moderate intensity physical activity.
Get adequate sleep.
Ensure that you are exposed to daylight every day, even when it’s cloudy.
Where possible, minimise your exposure to compounds that are toxic to the mitochondria: alcohol, cigarette smoke, plastics in food or water, environmental pollution.
The mitochondria need a steady supply of nutrients to use in producing energy. It’s wise to get these through food. Key nutrients include:
Magnesium: green leafy vegetables, legumes, nuts & seeds, whole grains, soy.
B vitamins: a diverse wholefood diet!
Essential fatty acids: oily fish, chia seeds, flaxseeds, walnuts.
Antioxidants: herbs, spices, black and green tea, brightly coloured plant foods.
Acetyl-L carnitine & CoQ10: meat, poultry, fish, soy, avocado.
You can see that there is quite an overlap with the foods found in an anti-inflammatory diet!
Physical deconditioning
Muscle cells have high numbers of mitochondria to power their movement, so it would make sense that mitochondrial dysfunction could result in muscle weakness. Chemotherapy can directly cause muscle wastage. By being in the Get Me Back membership, you are in the right place to train to stimulate muscle-building! However, you also need the building blocks to build muscles, in the form of protein.
Your individual protein needs will depend on factors such as where you are in relation to active treatment and the amount that you train. I would view a daily intake of 1g of protein for every kg of your healthy bodyweight as a minimum; higher amounts may well be needed. Very high protein diets, such as those that you may see being promoted on social media, may not be suitable for everyone who has had a cancer diagnosis.
It's impossible for me to generalise on the exact amount of protein that you need, but as a general rule, you should focus on eating a protein-rich food with every meal, including breakfast. Protein-rich foods include fish, meat/poultry, eggs, unprocessed soy, pulses and (to a lesser extent) nuts and seeds.
Blood sugar stability
This last point is not specific to CRF, but it impacts energy in everyone, whether they have had a cancer diagnosis or not.
Often when we feel tired, our instinct is to reach for a sweet treat, because we know that it will give us a rapid energy boost. Unfortunately, this is quickly followed by an energy slump, and if this is an ongoing cycle then it will only worsen fatigue. Simple carbohydrates such as white bread or white rice will have a similar effect to sugar.
Ensure that energy release from your food comes in a more sustained form by always choosing whole grains rather than white, and minimising added sugars including sugar-sweetened drinks. Eating protein and fibre (from vegetables!) at the same time as eating carbohydrates will also result in more sustained energy and fewer crashes. Even if you do this with meals, it’s important to do it with snacks as well.
The next time that you want to reach for a biscuit, consider having one of these snacks instead:
Oatcakes loaded with hummus
Greek yoghurt with seeds and berries
Apple slices spread with almond butter
The effect of a “fatigue reduction diet” on breast cancer survivors
We’ve discussed some of the factors underlying CRF and ways we could address these, but would these work in practice? Results of a clinical trial published in 2017(9) are certainly encouraging!
The study recruited 30 women who still had persistent fatigue at least 1 year after finishing active treatment for stage 0-3 breast cancer. The women could still have been having Herceptin or endocrine therapy. They were randomised to either a “fatigue reduction diet” (FRD) group or a control group which was given general health counselling but no dietary advice. The FRD consisted of:
5 daily servings of vegetables including 1 leafy green, 1 tomato, 1 yellow/orange vegetable
2 daily servings of fruit, including 1 high in vitamin C
1 daily serving oily fish
1 daily serving nuts/seeds rich in omega 3 fats (2 daily servings for vegetarians)
At least half of grains eaten as wholegrains
There are noticeable similarities with an anti-inflammatory diet. The fruits, vegetables, oily fish and nuts and seeds would also be expected to support mitochondrial functioning. This diet did not have to be overly complicated or require lots of energy to prepare; you could replicate it by including shortcuts such as ready-prepared vegetables, salad bags and tinned fish.
Although this was a small trial, the results were very promising. After 3 months, fatigue had reduced by 44% in the FRD group, compared with only 8% in the control group. Sleep quality improved by 50% in the diet intervention group, whereas it stayed the same or decreased slightly in the control group. As ever, we need more research, but this is certainly a good start.
Hopefully this has given you some ideas about some of the nutrition and lifestyle steps you can take to combat cancer-related fatigue. CRF can be challenging, but you may be able to have more impact on it than you think.
References
(1) Fabi, A., Bhargava, R., Fatigoni, S. et al. (2020). ‘Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment’, Annals of Oncology, 31(6), 713-723. Available at https://www.annalsofoncology.org/article/S0923-7534(20)36077-4/fulltext
(2) Bower, J.E. (2014). ‘Cancer-related fatigue: Mechanisms, risk factors, and treatments’, Nature Reviews Clinical Oncology, 11(10), 597-609. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC4664449/
(3) Yang, S., Chu, S., Gao, Y. et al. (2019). ‘A Narrative Review of Cancer-Related Fatigue (CRF) and Its Possible Pathogenesis’, Cells, 8(7), 738. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC6679212/#sec3-cells-08-00738
(4) Fowler, M.E. and Akinyemiju, T.F. (2017). ‘Meta-analysis of the association between dietary inflammatory index (DII) and cancer outcomes’, International Journal of Cancer, 141(11), pp2215-2227. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056732/
(5) Wang, K., Sun, J.-Z., Wu, Q.-X. et al. (2020). ‘Long-term anti-inflammatory diet in relation to improved breast cancer prognosis: a prospective cohort study’, NPJ Breast Cancer, 6: 36. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426822/
(6) Sasamoto, N., Wang, T., Townsend, M.K. et al. (2022). ‘Pre-diagnosis and post-diagnosis dietary patterns and survival in women with ovarian cancer’, British Journal of Cancer, 127(6), pp1097-1105. Available at https://pubmed.ncbi.nlm.nih.gov/35760897/
(7) Al-Faze, R., Ahmed, H.A., El-Atawy, M.A. et al. (2024). ‘Mitochondrial dysfunction route as a possible biomarker and therapy target for human cancer’, Biomedical Journal, 100714. Available at https://www.sciencedirect.com/science/article/pii/S2319417024000179
(8) Luo, Y., Jianjia, M. and Lu, W. (2020). ‘The Significance of Mitochondrial Dysfunction in Cancer’, International Journal of Molecular Sciences, 21(16), 5598. Available at https://www.mdpi.com/1422-0067/21/16/5598
(9) Zick, S.M., Colacino, J., Cornellier, M. et al. (2017). ‘Fatigue reduction diet in breast cancer survivors: a pilot randomized clinical trial’, Breast Cancer Research and Treatment, 161(2), 299-310. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC5480210/
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