Before recommending the ideal breast cancer diet and lifestyle program, perhaps health concerns need to be triaged or probability based. Reviewing the most common causes of morbidity and mortality allow for an easier understanding of dietary changes that should be recommended for patients in general. These recommendations need to be simple, logical, and practical for the patient as well as the clinician. Thus, reviewing common causes of mortality are paramount to construing all other recommendations in this manuscript.

Cardiovascular disease (CVD) is the number 1 overall cause of mortality in the USA and in other industrialized countries [1, 2]. CVD is currently the number 1 cause of death worldwide, and is the number one cause of death in virtually every region of the world. Cancer is the second leading cause of death in the USA and in most developed countries, and it expected to potentially mirror the number of deaths from CVD in the next decade in various regions of the world. Regardless, CVD has been the number one cause of death in the USA every single year for the last 100 years, with the exception of 1918, which was the year of the influenza pandemic.

If cancer becomes the primary cause of mortality, the majority of what is known concerning lifestyle and dietary change for CVD prevention applies to cancer prevention [3]. Heart healthy changes are tantamount to overall health improvements regardless of the part of the human anatomy that is receiving attention, including the bladder, brain, breast, colon, kidney, liver, ovaries, pancreas, penis, or prostate. Heart healthy changes need to be advocated in cancer clinics because it places probability and the sum of the research into perspective. Triaging preventive medicine for breast health is providing probability based advice via evidence-based medicine.

The largest US and worldwide pharmaceutical-based breast cancer primary prevention trials exemplify the urgent need for a more proper and balanced perspective. For example, the P-1 trial for tamoxifen (breast cancer) chemoprevention was a landmark trial because it represented the first drug ever approved by the Food and Drug Administration (FDA) for the prevention of any major specific cancer [4]. Participants (premenopausal and postmenopausal) in this trial had a higher risk (Gail Score >1.66) of being diagnosed with breast cancer, but despite this drug reducing the risk of breast cancer by approximately 50 % few individuals and media outlets realized that four times as many heart disease deaths occurred in the drug and placebo arms of the trial versus breast cancer deaths (25 versus 6). This was arguably similar in multiple ways to the P-2 STAR (Study of Tamoxifen and Raloxifene) prevention trial [5], which allowed raloxifene to also receive FDA approval for breast cancer prevention. Approximately 20,000 postmenopausal women from nearly 200 clinical centers with 327 invasive breast cancer diagnosed found raloxifene to be as effective as tamoxifen. However, there were over 430 total cases of ischemic heart disease, stroke, and transient ischemic attack that occurred during the trial! However, there were 93 deaths from cancer, 30 from lung cancer, and six from breast cancer and there were 42 causes of death from cardiovascular disease (14 from ischemic heart disease). The updated analysis or 81-month median follow-up revealed a continuation of this trend [6]. In other words, the primary risk or concern for women at high-risk of breast cancer is lung cancer, cardiovascular disease, and then other cancers. In other words, reducing the risk of cardiovascular disease is of paramount importance to simply reduce all-cause morbidity and mortality whether this includes tobacco cessation or weight reduction.

Interestingly, research from both the P-1 and P-2 trial found a slight nonsignificant increased risk of invasive breast cancer with increased weight. In fact, compared with women with a BMI less than 25, the risk for premenopausal women was 59 % higher for BMI 25–29.9 and 70 % greater for BMI 30 or more [7]. Obviously, like tobacco, obesity is a risk factor for CVD and cancer. Heart health is again tantamount to breast and overall health.

Interestingly, when perceiving the landscape outside of breast cancer, especially the largest pharmaceutical clinical trials ever conducted, the results are no different. For example, the results of the Prostate Cancer Prevention Trial (PCPT) seem to have garnered attention plus co ntroversy regarding the use of the drug finasteride daily versus placebo to reduce the risk of prostate cancer [8–10]. The discussion over the advantages and disadvantages of finasteride will continue, but one observation from this important trial has not received adequate exposure and debate in the medical literature. Over 18,000 men were included in this randomized trial, and five men died from prostate cancer in the finasteride and in the placebo arm, but 1123 men in total died during this primary prevention trial [8]. Thus, prostate cancer was responsible for approximately less than 1 % of the deaths, while the majority of the overall causes of mortality deaths were from CVD and other non-prostate cancer causes. Randomized trials tend to accurately provide a snap shot of day-to-day morbidity and mortality in this regard. This finding places the overall risk of morbidity and mortality in a more proper perspective. Men and women inquiring about the advantages and disadvantages of finasteride or dutasteride for prostate cancer or tamoxifen or raloxifene for prevention need to be reminded that the number 1 risk to them in general is CVD, and then the potential cancer risk-specific consult should occur after this first more relevant point is discussed, emphasized, reiterated, and in some cases even documented in the chart. Regardless, CVD prevention in terms of lifestyle changes mirrors cancer prevention.

Arguably, one of the largest dietary supplement studies con ducted in women globally was the US Women’s Health Initiative (WHI) , a double-blind, placebo-controlled trial randomly assigned 36,282 postmenopausal women to 1000 mg calcium carbonate per day and 400 IU vitamin D per day (OsCal^®, GSK Pharma US Consumer Division) or placebo with an average intervention of 7.0 years [11]. The study was designed to determine if these supplements would primarily reduce the risk of hip fractures and secondarily total fracture and colorectal cancer risk. When the overall results of the trial itself and post-interventional follow-up were completed the controversy over supplementation initiated, but the overall morbidity and mortality numbers, a reflection of what happens in real life, did not seem to garner attention. Invasive breast cancer occurred in 1667 women and myocardial infarction or stroke occurred in 2645 women and CVD death occurred in 1074 women and approximately one of three deaths were due to a CVD cause [12–14]. A total of 46 deaths occurred from breast cancer. Interestingly, the mean age at baseline was 62 years and the mean BMI was 29 (overweight), but there were more obese women compared to overweight and normal BMI women. Again, larger randomized clinical trials generally reflect the overall health status of that same population being studied.

The largest dietary supplement trial ever conducted in healthy men (essentially the mirror of the WHI) once again reiterates that risk needs to be placed in its proper perspective. The largest dietary supplement clinical trial to prevent prostate cancer was the selenium and vitamin E supplementation randomized trial (SELECT) [15]. It was terminated approximately 7 years early because of a lack of efficacy, and even a potential negative impact with these supplements at these specific dosages. CVD represented the primary cause of mortality overall in this study with over 500 deaths occurring from this cause compared to the one death from prostate cancer in just 5 years follow-up. Heart healthy programs simply need to receive more emphasis throughout medicine.

The lifestyle recommendations proffered in this chapter essentially serve to impact CVD and breast and overall health simultaneously. Patients can now be offered lifestyle changes that can potentially impact all-cause morbidity and mortality rather than just disease-specific morbidity and mortality.

Know and always try to improve on the 4 low cost and proven heart healthy parameters:

The lack of general health knowledge exhibited by some patients and even future health care professionals can be concerning. For example, surveys of the general population indicate that a majority of individuals do not know their cholesterol values, or most risk factors for CVD and this finding is consistent regardless of age, race, and even gender [16–20].

In my experience when the dual concern of CVD and overall breast cancer prevention/recurrence risk is emphasized and promoted, patients tend to become familiar with all of their clinical values, numbers, and overall risks. It is of interest that at least in the USA the prevalence of cardiovascular disease is still high. For example, almost 15 % of men and 10 % of women have cardiovascular disease between the ages of 20–39, and that number increases to approximately 40 % from the ages of 40–59 years, and over 70 % from 60 to 79 years, and over 80 % from 80+ years of age [21]. These prevalence numbers are quite surprising for some patients, but again it places disease risk in perspective.

Approximately 150,000 individuals die annually of a cardiovascular event in the USA before the age of 65, and 15,000 women die yearly of CVD before the age of 55. One in two women die from heart disease or stroke compared to one in 25 women who will die of breast cancer [22], and since 1984, the number of CVD deaths for women has surpassed those for men [23]. I often remind women concerned about breast cancer that CVD was a “super epidemic” and now it is simply just an “epidemic.” Thus, a woman or man attending a breast cancer awareness or screening would appear to be at risk of ending up with a myopic health and disease perspective unless other screenings, such as blood pressure, cholesterol, weight, and/or glucose were also proffered or at least emphasized equally.

Patients should be edu cated regularly on the normal values of a cholesterol panel, which are updated by expert guideline groups such as the National Cholesterol Education Program (NCEP) [24, 25]. Patients need multiple resources, apart from the generally over burdened primary care practitioners, to emphasize and review basic optimal lipid and general health values. Table 3.1 is a modified quick review for patients and health care professionals of past cholesterol guidelines that are in flux but this at least gives some proper perspective [24, 25]. Despite the potentially ongoing changes in lipid and heart parameters the generally “less is more to a point” philosophy is still evidence-based and also plays a role in preventing all-cause morbidity and mortality (see Chap. 4). Additionally, the evolving recommendation on lipids and women’s health is amply reviewed in Chap. 4 of this book, and Chap. 5 of this book also provides adequate review and perspective.

The NCEP suggests a first cholesterol screen at an age of 20 [24, 25], which is approximately at least 20–30 years before a suggested mammography screen or colonoscopy, but few if individuals in my experience have had a lipid test at this early age. Clinicians can assist patients in adhering to this early screening age. For example, women and men with a family history of breast or prostate cancer or an early diagnosis of most diseases often inquire about what their children or other family members should do, first and foremost, to prevent this condition from happening to the next generation. A common suggestion that I reiterate for children or adolescents is to just have an initial blood pressure, cholesterol, and glucose screening tests and to maintain a healthy weight and have their weight and waist size monitored. In my experience, this tends to surprise and simplify patient concerns because this is an unexpected suggestion. The time is now more appropriate than ever for this approach because of the past and ongoing concern in abnormal lipid levels among adolescents screened in the USA, which is approximately 20–43 % based on a variety of factors, especially weight status (normal, overweight, or obese) [26]. Other novel cardiovascular markers such as high-sensitivity C-reactive protein (hs-CRP), or traditional ancillary markers such as hemoglobin A1c (arguably a better reflection of long-term glucose control even in non-diabetics), and evidence of subclinical atherosclerotic disease could also be discussed for example with the patient [3, 27]. All of these items tend to garner less attention than a novel genetic test for example in cancer, which is why lifestyle and these numerical parameters associated with them matter even more today.

Other tangible advantages may occur for the patient and clinician that continue to follow these overall cardiovascular markers. For example, cholesterol levels are an adequate indicator of how well a patient may be adopting lifestyle changes or even medication compliance following breast cancer screening or after some definitive therapy. If these numbers improve it appears more likely that the patient is following a breast health lifestyle program. High-density lipoprotein (HDL) provides a good indicator of the commitment to aerobic exercise and is, in a sense, the “truth serum” as to how much physical activity has recently occurred. HDL tends to rise, and at times substantially and acutely with a greater amount of aerobic physical activity [28]. Triglycerides are an indicator of changes in belly (visceral) fat because this compound is generally stored in this anatomic location with increasing blood levels. In addition, a large drop in triglycerides can reflect adequate dietary changes and/or weight loss. Although table one suggests a triglyceride level of below 150 mg/dl is ideal, personally when a patient carries a level less than 100 mg/dl, my experience suggests a serious commitment to dietary change or a reflection of profound changes during that period of time. One other point needs emphasis, which is the obsession some clinicians and patients have beyond basic lipids such as lipid particle sizes and a variety of other costly lipid parameters. In general, the vast majority of these esoteric parameters normalize when a patient reaches the ideal basic lipid values. Simplicity negates the need for complexity and anxiety.

Hypertension is becom ing the leading cause of CVD mortality in wom en and it should receive more of an emphasis. Thus, blood pressure monitoring should also be emphasized as much as any other value. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure adequately and regularly defines a healthy blood pressure [29, 30]. Individuals and their partners should be informed that normal blood pressure is less than 120/80 mmHg and individuals with a systolic blood pressure of 120–139 mmHg or diastolic blood pressure of 80–89 mmHg are actually considered to be “prehypertensive,” and lifestyle changes should be advocated in these individuals (see Table 3.2) [29, 30].

Blood pressure can be reduced with a healthier lifestyle [31], and again is a good indicator of lifestyle adherence or compliance. Interestingly, one of the more subtle but prevalent etiologies of high blood pressure may be excessive alcohol consumption [1], and this should be discussed with patients as much as sodium (or sugar) restriction, and moderate to excessive alcohol intake, regardless of the beverage source, is a risk factor for breast cancer [32].

Hypertension is also an earlier ma rker of a high-risk type II diabetes patient or “pre-diabetic.” Regardless, patients that adopt healthy lifestyle and behavioral changes should always be given encouragement to continue these changes because of the other potential profound impact these behaviors may have on overall and mental health [33, 34]. Due to the phenomenon of “white coat hypertension” it seems critical to encourage some patients to invest some money in a at home blood pressure measurement device [35]. These devices have become cost-effective and potentially more accurate of the patient’s blood pressure status compared to 1 or 2 values derived annually for example from a medical office. And patients should also be given a review of the potential behaviors that can lead to minor and major temporary false elevations in blood pressure. A review of some of these behaviors that can elevate blood pressure dramatically, especially a distended or full bladder (up to 10–15 mmHg) for example, is provided in Table 3.3 [36].

Fasting blood glucose is as imp ortant as any other parameter for your patients. Abnormally high blood glucose and diabetes is considered such a high-risk cardiovascular situation that these patients are treated as if already having established cardiovascular disease in terms of lipid control. Diabetes also appears to be a risk factor for breast cancer from past meta-analyses [37], and even pre-diabetes may soon become an established risk factor [38]. The relationship between glucose intolerance and sexual dysfunction is already well established in women and men [39, 40]. Patients appear more motivated to continue healthy lifestyle changes when there is some tangible healthy outcome with the behavioral change, and this becomes more probable when all numbers are utilized in the consult including cholesterol, blood pressure and glucose for example as opposed to just other single or disease specific values or images. Please see Chap. 6 for more unique information of the glucose and breast cancer relationship.

The negative impact of being overweight or obese on overall morbidity and mortality is also well known. Body mass index (BMI) is a moderately re liable as an isolated anthropometric measurement, but at least it is a rapid method to determine who may be overweight or obese [41]. BMI is defined as the weight (in kilograms) divided by the square of the height in meters (kilograms per square meter). Another method to calculate the BMI is to take weight in pounds and divide it by the height in inches squared and to multiply this number by 704 (pounds/in. × 704). A BMI < 25 is considered normal by the Word Health Organization (WHO), whereas 25–29 is overweight, and >30 is defined as obese, and 35 or more is considered morbidly obese. BMI does not fully account for changes in lean muscle mass, which is why it is often criticized (for example a lean extremely muscular women or man could be easily considered overweight with a BMI measurement), but again this is just one ancillary measurement to be used with others to access adipose status.

Several of the largest and most recent preventive medicine randomized trials of women or men have demonstrated that most individuals in these studies are indeed overweight at baseline, and this includes trials to prevent specific health abnormalities with prescriptions, supplements, or just dietary change [15, 42]. Thus, it has become so common for participants of the major cli nical trials to be overweight or obese that only a small percentage of individuals in these studies have a BMI in the healthy range (a mirror reflection of the prevalence of this condition in the USA and other populations).

Waist-to-hip ratio (WHR) may be another rapid measurement to determine obesity [41]. An individual must stand during the entire me asurement of WHR. WHR more precisely measures abdominal adipose circumference or tissue and fat distribution. The waist is defined as the abdominal circumference midway between the costal margin and the iliac crest. The hip is defined as the largest circumference just below the iliac crest. However, it requires more time and detail, which is why waist circumference (WC) alone is perhaps the easiest and fastest method to currently access obesity, and is my preference together with pant size (waist size).

“Belly fat” (visceral adipose tissue) seems to have one of the best predictive values of CVD and potential all-cause mortality risk among all the other weight parameters from some of the largest prospective studies in the world [43–45]. However, the combination of WC with a BMI measurement may have added predictability. Still, WC is also one of the best predictors of heart unhealthy changes and/or future cardiovascular events, regardless of the age group and ethnic group studied [46, 47].

WC is also one of the five specific criteria of the metabolic syndrome. WC has a tangible advantage over BMI, which can be appreciated after an individual com mits to resistance exercise. An increase in muscle mass from resistance activities such as weight lifting can actually again cause an increase in BMI, which could be frustrating to the patient and clinician [41]. However, this does not generally occur when additionally utilizing the WHR or especially the more simplistic WC measurement. Informing patients of their official WC and asking pant size allows these parameters to not only be documented in the chart, but allows for the patient to identify a goal of maintaining or reducing these numbers by the time of the subsequent clinical visit. Thus, reducing the emphasis on just the weight scale or trying to compete with a national standard. A patient with a BMI of 35 and a WC of 40 in. is not as concerning compared to an individual with similar measurements and a lack of aerobic fitness and some modicum of caloric control, or not being able to reduce their WC value slightly over time is more of an issue. A summary of the basic interpretation of the BMI and WC value are found in Table 3.4 [41].

The list of medical conditions increased or exacerbated by adipose tissue or weight gain is remarkable and could occupy a full-text. For example, kidney stones and renal cell carcinoma (RCC) may have a strong relationship with obesity [48–51]. A table of a more comprehensive list of conditions exacerbated by weight gain is remarkable and found later in this chapter.

Clinicians should begin to carry and utilize tape measures that can measure WC or some weight parameter, and I often argue that this is as critical as the stethoscope. Clinicians should also refer patients on a consistent basis to ancillary diverse weight management services such as: nutritionists, therapists, social workers, a variety of professional and even surgical weight-loss programs if needed, and recent weight loss consumer publications. Simply becoming familiar with local weight loss resources is an initial step in the appropriate direction for the patient and clinician. For example, inviting a medical director of a local weight loss program to give grand rounds on what kind of treatment plans they proffer to the community demonstrates commitment in my opinion to this cause.

Another method that may provide positive teaching experience is to discuss or at least remind patients about the importance of a healthy weight by mentioning the gastric bypass or surgical weight loss data. The intent is obviously not to advocate the use of gastric bypass or any type of surgery for every patient, but to demonstrate how weight loss clearly and at times quickly impacts health. For example, researchers in the USA and Sweden found in separate studies that obese individuals that had gastric bypass surgery had a 30–40 % lower risk of dying 7–10 years after having the surgery compared to those that did not have the surgery [52–54]. The Swedish study was one of the longest studies ever published at that time with long-term health outcomes [53]. Researchers at the Goteborg University compared 4047 individuals with a body mass index (BMI) of over 34, who received one of three types of surgery (banding, vertical-banded gastroplasty, or gastric bypass) or some dietary advice (control group). Some of the basic characteristics of these patients before the study started were the following:

In the US study (funded by a US government grant, or branch of the National Institutes of Health), which was retrospective and not prospective like the first study mentioned above, researchers (University of Utah and other centers) looked at 7925 severely obese individuals who had gastric bypass [52]. These patients were matched to 7925 control individuals with identical weights and height. About 84 % of the patients were women and the average age was 39 years, and the average BMI was 45–47. After an average of follow-up of 7 years there were 213 deaths in the surgery group versus 321 deaths in the non-surgical group. A total of 136 lives were saved per 10,000 gastric bypass surgeries after an average of 7.1 years following the actual procedure. The following interesting and significant results were found:

An examination of more recent surgical series should continue to impress the health care professional and patients. In the Swedish Obese Subjects (SOS) study, an on going review of outcomes from 25 public surgical departments and 480 primary health centers in Sweden, a total of 2010 obese patients matched to controls found a 53 % reduction in the number of cardiovascular deaths (p = 0.002), and the total of first time cardiovascular events were reduced by 33 % (p < 0.001) [55]. Gastric bypass and other surgical weight loss randomized controlled data for obese type 2 diabetics from the Cleveland Clinic also continued to demonstrate the profound and immediate changes with weight loss [56]. A significant reduction in the utilization of medications to lower glucose, lipid, and blood pressure occurred within 12 months of their study on 150 patients, which in some cases occurred before the patients were discharged from the hospital! In a similar study from Italy the complete remission rates of type 2 diabetics approached 75–95 % within 2 years [57].

Again, the profound health changes in individuals that lose weight from surgery is an adequate teaching tool for patients to understand the devastating consequences of abnormal weight gain of any type on the human body. Adipose tissue is not inert and secretes a variety of compounds (not just increased aromatase and estrogen) and other inflammatory signals to the rest of the body that essentially causes even innate immune responses to occur against self. In other words, I often tell patients that greater accumulation of adipose tissue is somewhat tantamount to an autoimmune condition.

Lung cancer is the nu mber 1 cancer killer of women and men in the USA, killing more women each year than breast, ovarian, and uterine cancers combined [58]. Women with breast cancer who smoke appear to have a lower chance of both overall and breast cancer-specific survival [59]. A meta-analysis found a significant 33 % increased risk of death from breast cancer in women who were smokers at diagnosis compared to never smokers.

The challenge in smoking cessation is not just the issue of addiction but one of metabolism. Tobacco provides one with a metabolic advantage, which is why substantial weight gain (over 10 pounds in first year and 15 or more pounds overall) is common after cessation [60]. Thus, addressing this frustration before cessation and the need for caloric control and exercise … should also be emphasized in my opinion as much as the method suggested for smoking cessation.

Rarely discussed is the accumulating data to support second hand smoke (SHS) exposure with an increased risk of breast cancer [61]. A summary of three meta-analyses reported a 65 % increase in premenopausal breast cancer risk among never smokers that were impacted by SHS. An expert panel from Canada and breast cancer risk concluded that SHS is indeed a risk factor utilizing the most current data.

Exercise is one of the only con sistent findings in the literature, apart from maintaining a healthy weight, to lower breast cancer risk, recurrence and mortality [62, 63]. Yet it may be the ancillary benefits of aerobic and resistance exercise that can also motivate patients, such as a reduction in bone loss [64], or even an improvement in fitness without exacerbating lymphedema [65], which use to be a perpetuated theory without clinical evidence that might have and still deter many individuals from engaging in exercise.

More recently, a 1-year randomized trial (n = 121) of aerobic (150 min per week) and resistance exercise (supervised resistance activity twice a week) versus usual care in women on aromatase inhibitors (AI) demonstrated a reduction of 29 % in worst joint pain scores versus control group (p < 0.001), and pain and interference along with arthritic and disability scores also significantly (p < 0.001) and favorably changed versus controls [66]. This is a remarkable initial finding considering arthralgia can occur in 50 % of breast cancer patients on these medications and it is the primary cause of reduced compliance.

One of the best past reviews on physical activity and cardiovascular disease found ample evidence for exercise to favorably impact markers of heart disease including triglycerides, apolipoprotein B reduction, HDL, LDL particle size, and a reduction in coronary calcium [67]. Thus, aerobic and resistance activity need to be emphasized equally because of the documented synergism. Weight training can increase fat free mass, lean body weight, reduces sarcopenia, increases resting metabolic rate, and potentially reduce the risk of abdominal adipose deposition [68, 69]. Weight training or resistance training also appears to improve glucose parameters, including insulin sensitivity, and may slightly improve lipid levels, educe hypertension, and reduce bone loss [69, 70]. Muscle tissue like the rest of the body exists in a “use it or lose it” state and the only consistent method found to maintain or improve lean muscle mass is the actual regular stimulation or exercise of the tissue itself.

The mental health improvements with increased exercise appear to be just as notable as the physical health benefits [71, 72]. For example, one often referenced trial published over a decade ago included 156 adult volunteers with major depressive disorder (MDD) randomly assigned a 4-month course of aerobic exercise (30 min three times/week), sertraline therapy (one of the biggest selling antidepressants in US history), or a combination of exercise and sertraline [73, 74]. After 4 months patients in all three groups demonstrated significant mental health improvements; however, after 10 months, individuals in the exercise group had significantly lower recurrence rates compared to individuals in the medication group of the study. Exercising during the follow-up period was associated with a 51 % reduction in the risk of a diagnosis of depression at the end of the investigation.

Remarkably, the overall effects of exercise in clinical trials of depression for example are not generally interpreted in a manner suitable for impact in a clinician or patient patient’s discussion. Recently, experts have come to an interpretive rescue so to speak by mentioning that most prescription antidepressants demonstrated a 2- to 3-point benefit over placebo on depression rating scales, but a majority of exercise studies (13 of 16) have found a 5-point improvement on the depression scale [75]!

Novel studies of MRI utilization have demonstrated the prevention of temporal lobe hippocampal atrophy with physical activity at a variety of ages because the hippocampus is a primary area of memory storage and retrieval [76], and many patients inquire about preventing memory loss. Even recent randomized studies of patients with significant comorbidities such as heart failure have significant improvements in physical and mental health with regular exercise [77]. It is important to explain to patients that if the overall results from exercise studies were viewed similar to a specific pharmacologic intervention than it probably would have already garnered attention worthy of a Nobel Prize in arguably multiple categories of medicine. And the ability of exercise to work synergistically with medication is also notable.

Still, despite the plethora of positive research, are health care professionals excited about recommending exercise to their patients? The National Health Interview Survey (NHIS) data are recorded throughout the year from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) by interviewers from the US Census Bureau [78]. It is a household-derived survey, and interviews are usually conducted in the respondent’s homes. Questions were asked in 2000, 2005 and 2010 with over 20,000 in each of these years sampled that visited with a physician or other health care professional within the past 12 months. In most recent year of data gathering which was 2010, about 32 % of adults that had visited with a physician or other health care professional had been recommended to begin or continue exercise or some form of physical activity. Between the years of 2000 and 2010, the percentage of adults given exercise advice increased by approximately 10 %, and women were more likely that men to have been advised to exercise, and one-third of patients with cancer were also recommended exercise. Thus, only one in three adults who had seen a physician or health care professional in the past 12 months had been told to begin or continue exercise/physical activity. You have the ability to improve these numbers everyday in your practice and I would encourage you to take advantage of this situation.

One final motivational incentive should be provided to patients before they leave your office. When the diversity of the potential benefits of exercise is distributed to your patients on a handout I believe the potential for effectiveness is heightened. Exercise tends to be discussed in terms of singular benefits (reduces heart disease, breast cancer, colon cancer risk, …), and Table 3.5 provides just a partial list of the diverse overall benefits [79, 80]. In fact, a basic Medline search on the word “exercise” provides almost 30,000 citations! Again, it has to be emphasized that after countless decades of research, exercise is one of the only known lifestyle changes to potentially reduce the risk of breast cancer or recurrence.

The NCEP recommends that saturat ed fat be reduced to less than 7 % of total calories to reduce the risk of CVD [24]. In reality this is simply an indirect method to achieve partial caloric reduction in my opinion [79, 80]. Many foods that contain high levels of saturated fat also contained (in the past) the highest levels of trans fat (“partially hydrogenated fat”), cholesterol, and more importantly total calories. For example, there are almost twice as many calories in 8 ounces of whole milk (5 g of saturated fat) compared to skim, or soymilk (0 g of saturated fat each), and there are almost four times as many calories in whole milk compared to almond or cashew milks. Thus, identifying two similar products, such as milk, meats, dairy, chips, and choosing the item lower in saturated in general allows for a profound (at times) reduction in total caloric intake, which is critical to helping maintain or reach an appropriate weight or waist size and improving overall heart health.

Yet simply reducing all saturated fat in an in dividual’s diet is not necessarily a practical and healthy dietary lifestyle change because some saturated fats in the diet may promote healthy parameters and encourage satiation [79, 80]. The cardiovascular goal of obtaining less than 7 % of calories from saturated fat seems ideal, but ingesting minimal to no calories from saturated fat is also excessive, and it actually appears to reduce levels of HDL (“good cholesterol”) from past CVD and other health promoting clinical trials [81, 82]. Aggressively reducing saturated fat consumption also implies that this type of fat, in and of itself, is heart unhealthy, which is not accurate from the largest recent meta-analysis of prospective studies [83]. And in some countries around the world where overall caloric intake is very low compared to the USA, saturated fat may have some tangible cardiovascular benefits, but this also needs to be placed in perspective [79]. For example in some regions of the world, such as Japan, a closer look at healthy individuals with the largest intakes of saturated fat in this country would actually be suddenly placed in the lowest category of saturated fat intake in the USA if they were to immediately migrate to the USA [84]. Regardless, one potential positive impact of reducing saturated fat, in my opinion, is that it may reduce overall caloric intake and reduce weight and waist gains in some individuals (again in others it might encourage satiation). Another benefit of reducing saturated fat is that it allows for the opportunity to reduce dietary cholesterol intake and increase the consumption of other monounsaturated and polyunsaturated fats that have shown a greater reduction in CVD from past clinical trials and epidemiologic research [85, 86]. If the patient has normal weight, exercise and other heart healthy parameters then the concern over saturated fat intake should not be as acute because caloric restriction or caloric control in some form by these individuals is not as beneficial. A summary of the different types of dietary fat, food sources, and impacts on specific lipids are found in Table 3.6 [79].

The Women’s Intervention Nutrition Study (WINS) was one of the most unique lifestyle clinical trials in breast cancer research history [87]. A total of 2437 women were involved in a randomized, prospective, multicenter clinical to determine the effect of dietary fat red uction in women with resected, early-stage breast cancer receiving conventional treatment. An interim analysis was conducted after a median follow-up of 5 years when funding for the trial ended. The reduction of relapse events in the low-fat group was 24 % lower compared to the control group and was significant (p = 0.034). In reality, despite all the discussion of a lower fat intake there was a clear significant reduction in overall daily calories at 5-years (−167 calories per day; p < 0.0001) and weight (−6 pounds; p = 0.005) versus the control group, which could be argued was the true reason for the benefit. Table 3.7 is a summary of the primary dietary parameters and changes that occurred at baseline, during and at the end of this trial [87].

However, another landmark randomized trial of over 3000 women of five vegetable servings plus 16 ounces of vegetable juice, three fruit servings, 30 g of fiber, and 15–20 % of energy from fat compared to a comparison group (print materials describing “5-A-Day” diet guidelines) was also conducted [88]. This trial was known as WHEL (Women’s Healthy Eating and Living) trial and tried to determine if increasing vegetable, fruits and fiber and reducing fat in take can impact breast cancer recur rence or survival. And after 7.3 years of follow-up these modifications in diet did not reduce breast cancer events or mortality. Why? In my opinion, when looking closer at the more heart healthy changes between the groups in terms of endpoints there was minimal to no difference. In other words, as stated in the results section of the publication: “Study groups differed by less than 80 kcal/day in energy intake and by less than 1 kg in body weight at any study point.” Interestingly, an ancillary study of the inflammatory marker CRP (C-Reactive Protein), a marker of acute inflammatory response, demonstrated a reduced survival in WHEL when CRP was 10 mg/L or higher [89].

It is of interest that heart healthy changes including exercise and weight reduction can reduce CRP. For example, recent evidence from the LEAN (Lifestyle, exercise, and nutrition) study demonstrated significant improvements in cardiovascular risk and some can cer markers in breast cancer patients in only 6 months [90]. This study incl uded a total of 97 overweight or obese breast cancer survivors identified from the Yale Hospital Tumor registry and randomized to a usual care group (n = 33) or weight loss instruction (n = 64) from a registered dietician. On average, the group assigned to the dietician lost 6 % of body weight and the comparison group 2 %. However, the women in the intervention group experienced reductions in insulin, glucose, and even CRP was reduced by 30 % compared to 1 % in the usual care group, but they also had increases in IGF-1. It is also interesting that IGF-1 increased and this use to be thought of as a cancer marker, but I believe that exercise slightly increases growth hormone that allows this value to increase slightly. In other words, I think it is another indication that the human body responds very well and very quickly to caloric reduction, exercise and weight loss and slight increases in IGF-1 after achieving these benefits is an indication of a more optimal physiologic state that is attempting to increase lean muscle mass and repair muscle tissue after exercise.

After 30 years of working in the diet and lifestyle milieu I simply allow the fad diet to fit the patient’s personality. It appears the end may justify the means, and whatever appears necessary to reduce caloric intake and improve activity and reduce weight seems appropriate. A recent non-industry funded review from Stanford and the University of Toronto may have provided further impetus for this novel approach [91]. Researchers utilized a total of six electronic databases and overweight or obese adults randomized to a named (aka “fad”) diet for 3-months or longer were included (primarily analyzing weight loss and BMI changes at 6- and 12-months). Two reviewers independently procured this data and the analyses were adjusted for behavioral support and exercise. A total of 48 randomized trials including over 7200 individuals were included. The results of this analysis found that weight loss differences between fad diets were “small.” And the conclusion was noteworthy: “This supports the practice of recommending any diet that a patient will adhere to in order to lose weight.” This is a particularly relevant finding since a recent a comprehensive global report concluded that over the past 33 years not a single country has experienced success against the obesity epidemic [92]. This also relates to why the next patient recommendation/step number 5 also revolves around caloric restriction.

In conclusion as long as a patient can fulfill five Dr. Moyad criteria on any fad diet I am a personal advocate of it. These criteria include:

The above parameters appear to be similar to the Step 1 recommendation in this chapter, which is also not a coincidence. Regardless, there is one final critical point that must be demonstrated to health care professionals and patients in terms of weight/waist gain and obesity. This medical condition (obesity) is now responsible for a striking number of diseases either in terms of increasing risk and/or exacerbating the risk of recurrence or severity or even death from almost countless medical conditions. This list of diseases, found in Table 3.8 [80], has increased so dramatically that I like to provide and overview during my lectures or discussions with individuals in the public, patients, and health care workers (everyone).

Media attention and research appears to focus on one fruit or vegetable with each passing year. Why? In my opinion it is because of good marketing and knee-jerk responses without the careful evaluation of the publication [80]. Clinicians need to be able to remain somewhat objective and explain to patients that these media reports do not necessarily represent a ny major research breakthrough, but rather supports the ongoing and past research that consuming a diversity of low-cost fruits and especially vegetables is just one practical and logical approach to improving heart health. Several examples of this controversy exist including the past attention garnered toward the compound lycopene and tomatoes in preventing cancer based on numerous epidemiologic studies and a notable meta-analysis [93]. However, this meta-analysis concluded by reminding readers that this is just further evidence that a diversity of fruits and vegetables were important for a healthy diet, but this appeared to be misconstrued. Tomatoes were never the only or necessarily the primary source of lycopene. A variety of other healthy products contain this compound such as: apricots, guava, and pink grapefruit [94–97]. Watermelon is also an outstanding source of lycopene, and is the largest source per gram compared to any other nutritional source, including tomato products. Regardless, lycopene has minimal overall beneficial data to solve various health issues, but at least the compound and products that contain this compound are generally safe or even heart healthy [98–100].

The ongoing pomegranate juice and supplement research has experienced a somewhat similar story, but with a slightly different message for clinicians. Although this is a story that is rooted in prostate cancer, it is a paradigm or lesson as to why other cancers including breast cancer should not succumb to preliminary data without more heart healthy studies to suggest it is a situ ation of “first do no harm.” The first attention gathering study did not include a placebo group or another group of men that consumed another type of healthy juice product [101], and other studies have questionable methodology and results [102]. Yet this should not be construed as a lack of efficacy and some of these companies should be lauded for at least investing in research, but an objective overview of the preliminary research and the caloric contribution of these and other juices are necessary. Many brands of these novel juices contain at least 140 calories per 8 ounce serving, which is a similar caloric contribution than most commercial regular soft drinks and alcoholic drinks (approximately 100–150 calories) [79, 80]. A quick glance at the internet and commercialized products now demonstrates that many fruit juices have as much or more sugar per ounce than a can of cola! Thus, fad diets that also dramatically reduce sugar intake (ketogenic or high fat, high protein, …) also appear to provide favorable results for those that can comply with them over the short- or long-term.

Further, again in partial defense of some of these companies it is also laudable that some lower caloric exotic juice options from these same manufactu rers are now becoming commercially available. Still, many of these juices are expensive in comparison to cheaper nutritious and lower calorie products. Additionally, drug and juice interactions are still being researched, which is important since grapefruit juice studies has provided a paradigm of medication interactions [103], but novel juices may also cause some potential concern with medications metabolized by CYP3A4 [104, 105]. In reality, if a patient believes in pomegranate juice or another product I often recommend lower calorie or a no calorie option and utilize weight and other heart healthy changes (Moyad 5 parameters above for an effective fad diet) as the primary driving force or whether or not to continue or advocate for or against this patient driven regimen. I am not optimistic that any “exotic” or fruit juice high in calories and sugar will be found to reduce cancer incidence, progression or survival. And I also find it interesting that there are no consistent examples of these juices in the literature assisting patients with cholesterol, blood pressure, blood sugar or weight/waist reduction. Although past preliminary laboratory data has now accrued for pomegranate juice and breast cancer [106], clinicians need to be cautious about making any claims in the area without some future heart healthy data. Again, I am not optimistic.

Patients should try and think of the “natural” or “processed” debate as particularly applying to fruits and vegetables. Fruits or vegetables in their natural state are generally associated with less cost, less calories, less sugar, and more fiber [79, 80]. An ap ple is better than apple juice or applesauce, and an orange is better than orange juice. It is interesting that it takes multiple oranges to produce one cup of orange juice and the extra sugar and minimal to no fiber also is carried into glass of what I call “liquid sugar.” In terms of fullness and potentially helping to lower weight, fruit and especially vegetables can be of assistance and they also play a role in lowering blood pressure with their high potassium and low sodium content. Overall, the specific evidence for fruit and vegetable intake and heart health is moderately consistent but in the area of breast cancer prevention or to reduce recurrence the evidence is inconclusive or weak [107, 108].

Fruits and vegetables have unique and shared anticancer and anti-heart disease compounds that may contribute to improved overall health. Again, the overall data curre ntly supports a slightly greater potential reduction in CVD risk and mortality [109], perhaps through assisting in weight loss or via another heart healthy compound(s) such as natural salicylates (aka aspirin derivatives) or other natural compounds in these products (please also refer to Chap. 5 in this book for more on the subject of food salicylates) [110]. Clinicians should recommend fruit and vegetable consumption for better overall and heart health, but not for cancer prevention where large-scale data appears to be less impressive [111]. There are also certain high risk factors for breast cancer (obesity, alcohol, genetics, lack of exercise, tobacco, …) that cannot be simply fully eliminated or erased by im proving one aspect of lifestyle such as increased fruit and vegetable consumption. In other words, triaging lifestyle changes or recommendations from most-to-least important is critical to a patient’s success.

Another point is critical for your patients, because it appears that the public is inundated by “experts” espousing the regular consumption of the most colorful or diverse or a variety of fruits and vegetables with the most antioxidants for a greater potential benefit on health. However, this is not evidence-based and has a not proven when analyzing past research on heart health. It is difficult eno ugh to consume regular quantities of fruits and vegetables and I do not advocate creating a lifestyle recommendation simply because it appears to make sense when it fact it is not supported by research. For example, in one of the largest epidemiologic studies to date to examine the issue of fruits and veggies and heart disease, a higher intake of fruits and veggies was associated with a lower risk of heart disease (only about 17 %—not dramatic but modest) [112]. However, there was no added advantage over consuming a diversity or variety of fruits and vegetables. Over 71,000 women from the Nurses’ Health Study and over 42,100 men from the Health Professionals Follow-Up-Study were followed for over 20 years and over 6000 cases of heart disease cases were diagnosed in this study (largest to date). It was also interesting that this study documented the effect of a threshold for fruits and veggies whereby up to five servings a day provided more protection and beyond five servings the impact was the same. Interestingly only 1 other study has looked at fruit and veggie variety and heart disease and again no difference was found for diversity or variety [113].

Again, it is difficult enough to consume several servings of fruits and veggies a day and this is reflected in the national average or just 2–3 servings! What happened to avocado, celery, cucumber, or kale? They might not be brightly colored but they have a lot to offer, so I si mply tell patients to consume the ones they like to consume first and foremost. Pushing fruits or vegetables only because they are brightly color in my experience has also caused some patients to seek out exotic or novel juices from a variety of sources that are “high in antioxidants” such as mangosteen or acai or goji and they spend a lot of money and time doing this which reinforces quick-fix without hard clinical effects or endpoints behavior. In other words, these creates a great deal of disappointment and noncompliance versus boring or dull products or fruits and veggies which harbor more evidence, less cost, and greater overall benefit and mental health for patients. I think the latter increases compliance and reduces stress.

In order to further exhaust the point that marketing or what tends to feel good can drive dietary or fruit and vegetable recommendation, I will take a moment to impress the reader when it comes to this author’s personal marketing skills. It could be argued that since 50,000 or more overall medical publications occur each month there are enough studies to espouse any position in medicine today if subjectively reviewing the data. I argue often that medicine is a courtroom with the preponderance of the evidence that provid es the highest probability of the truth. However, if someone wanted to slant the truth when the subject of fruits and vegetables is discussed I have decided to provide a review in Table 3.9 of how any fruit or vegetable could be construed as life changing based on preliminary data of some the compounds in them and basic research [79, 80]. In this table (see Table 3.9) are only a small percentage of the compounds found in these products that tend to receive some form of health promotion (imagine if I decided to publish the comprehensive list).

Additionally, health care professionals and patients ask if fruits and vegetables in a capsule are healthy and similar to ingesting fruits and veg etables in terms of antioxidants. And although some research exists from these companies to support preliminary blood marker benefits, there are no clinical endpoints in general that are exciting for me (especially in terms of cardiovascular disease prevention). And the idea of promoting more pills rather than the real product has always been concerning and I discourage it. Healthy behaviors promote more healthy behaviors like a pendulum that continues to swing in just one direction. I want to see all the vitamins, minerals, and especially fiber that are derived from real fruits and vegetables that are not capable of being placed in a capsule. In my experience, when someone relies just on a capsule for their fruits and vegetables, apart from paying an enormous financial cost they pay an enormous health cost by promoting their own pill seeking behavior and then their pendulum can swing in the opposite direction.

I am also often asked about “organic” versus “non-organic” fruits and vegetables and this is one of many examples where I let the economic pressure of our time determine the outcome. Similar to the trans-fat debate many years over time it became economically problematic if food products continued to harbor them so many companies began to remo ve them. Similarly, it hurts the economic viability long-term of a company not to offer a more “organic” option, so in time I believe prices will continue to drop on organic fruits and vegetables, especially as all of the leading food chains have begun to offer them [80]. Currently, since compliance on fruits and vegetables is low and since organic for the most part is still costly I cannot ethically espouse their use in most patients especially ones that are economically disadvantaged, and there is no consistent evidence as of yet they personally provide a healthier clinical endpoint or outcome. I believe organic will be a better future choice for environmental and perhaps other health reasons, but there is only so much energy to expend in a day and I am allowing the passage of time and economic pressure to ultimately solve this issue. I am comfortable that soon an organic box of many fruits and vegetables will be the price of the non-organic option.

Consume more (soluble and insoluble) dietary fiber (20–30 g/day, or 14 g per 1000 calories consumed), especially from food sources. “Fiber is nature’s internal Botox for the human body” and both soluble and insoluble fiber have unique and synergistic benefits when found together (as in most healthy dietary sources [80].

General and num erous health benefits are derived from consuming dietary fiber that have been well documented and include reductions in the following [114–117]:

For example, a pooled analysis of past cohort studies of dietary fiber for the reduction of CHD (coronary heart disease) included research fr om ten international studies and included the USA [118]. Over a period of 6–10 years of follow-up, and after multivariate adjustment it was revealed that each 10 g/day increase of calorie-adjusted total dietary fiber was correlated with a 14 % reduction in the risk of total coronary events and a 27 % reduction in risk of coronary death. These findings were similar for both genders, and the inverse associations occurred for both soluble (“viscous”) and insoluble fiber.

Past studies have not observed a consistent benefit with one class of fiber over the other [119, 120]. Recent large US and other international studies have even found more striking overall potential benefits for consuming more dietary fiber. For example, the NIH-AARP US prospective cohort found not only a lower risk of dying from cardiovascular, respiratory and infectious disease with greater intakes but a significantly lower risk of dying younger (“total death”) in men and women [121]. This study may represent a major shift into the research behind fiber intake because now the potential health impact may be so much larger than first realized since reductions in the death rates of some of the largest causes of mortality may occur with greater fiber intakes [121, 122].

Even minor additions of fiber can positively impact medication dosages. A total of 15 g of psyllium husk supplementati on daily with a 10 mg statin (simvastatin) was demonstrated to be as effective as 20 mg of this statin by itself in reducing cholesterol in a preliminary placebo-controlled study of 68 patients over 12-weeks [123]. Although adding soluble fiber from commercial products appears to be safe and synergistic with cholesterol lowering medications [124], the first choice of increasing fiber intake should be food sources based on cost-effectiveness and simplicity.

A meta-analysis of 24 randomized placebo-controlled trials of fiber supplementation found a consistent impact on blood pres sure reduction [125]. Supplementation with a mean dose of only 11.5 g/day of fiber reduced systolic blood pressure by –1.13 mmHg and diastolic pressure by –1.26 mmHg. The reductions were actually greater in older and more hypertensive individuals compared to younger and normotensive participants. Recent international studies continue to support the modest reduction or control in blood pressure with greater intakes of dietary fiber [126].

How much fiber should patients be consuming daily? Daily intakes of total fiber in the USA and many other Western countries is approximately 10–15 g/day, which is approximately only half or even less than half of the total amount consistently reco mmended by the American Heart Association (AHA) and American Dietetic Association (20–30 g/day) for adequate overall health [116, 117, 127]. Another perspective on recommended fiber intake for children and adults is that for every 1000 calories of food and beverage consumed there should be at least 14 g of fiber consumed.

Dietary fiber from food is easily achieved by low cost sources of soluble and insoluble fiber. For example, I often tell patients to just consume a third of a cup of a bran cereal such as All-Bran Buds^® several times a week, which is approximately only the size of 1–2 liquor shot glasses, with flaxseed and some fruit, and before they leave the door in the morning approximately 20 g of fiber will have already been ingested toward the 25–30 g goal [79, 80]! Low-cost fiber sources such as flaxseed can provide potentially numerous heart healthy and overall healthy benefits and ou tcomes [128, 129]. Perhaps the low-cost and non-commercialization of this product on a large-scale has led to the lack of adequate education that I have observed on this product. Flaxseed is also one of the highest plant sources of heart healthy omega-3 fatty acids [129], and chia seed is arguably the largest plant source of fiber and omega-3 [130], and both of these additions to the overall diet would be ideal.

Interestingly, the preliminary clinical trial data on ground flaxseed (average of 30 g or three rounded tablespoons per day) in other hormone m ediated cancers such as prostate disease and prostate cancer has been as or more impressive (reduced proliferation rates or Ki-67) versus a low-fat dietary intake [131–134]. Thus, it should not be a surprise that preliminary data of flaxseed in breast cancer is also impressive and similar to some of the prostate cancer observations. For example, human studies of 25 g/day of flaxseed for 4 weeks downregulated Ki-67 by 34 %, increased apoptosis by 30 %, and decreased HER2 neu by 71 % in breast cancer [135].

Flaxseed contains a high conc entration of lignans, which are also considered phytoestrogens, which are structurally related to endogenous estrogens and tamoxifen [79, 136]. The primary circulating lignan is known as “enterolactone,” a weak estrogen compared to estradiol. Flaxseed may favorably alter hormone pathways, growth factors, aromatase and inhibit cell growth in estrogen positive and negative cell lines. Flaxseed oil also has preliminary data against breast cancer [137], but this and other oils are a large source of calories (120–130 calories/tablespoon) and contain no fiber so rarely have I recommended them over low cost flaxseed powder (similar to the real whole non-processed fruit versus the fruit juice debate mentioned earlier).

Overall dietary fiber intake (again not pills or powders) continues to garner evidence as a method of breast cancer prevention. One of the largest meta-analyses reviewed 16 prospective studies found a lower risk primarily among studies with a large range of intakes or high levels of fiber consumption, which equated to 25 g or more per day [138]. Another meta-analysis of 10 prospective studies involving over 16,800 cases, and also found a significant reduction in risk with greater intake [139]. This correlation did not differ by geographic area, menopausal status, or follow-up length. And for every 10 g/day increase in dietary fiber consumption there was a significant 7 % reduction in breast cancer risk. Multiple mechanisms are potentially involved with this fiber benefit including:

Still, fiber itself appears to have become overtly commercialized, and in my experience some patients are turning primarily toward powders and pills to solve their fiber deficit, and this is not only costly, but it also provides primarily small amounts of soluble fiber that make it difficult to reach their total fiber goal utilizing only these sources. For example, I often ask audiences and students how many fiber capsules/pills are needed to be consumed daily to obtain just 20–30 g of fiber, and the answer always seems to provide adequate shockvalue (the answer is 30–50 pills a day or more depending on the commercial source) [80]! A bolus of only soluble fiber without insoluble fiber can also create exce ssive bloating and other gastrointestinal issues because soluble fiber is utilized by gut bacteria and then subsequently converted to gaseous compounds.

Processed soluble fibers abound today in protein bars and cookies and these items need to be avoided not only for a lack of evidence but again gastrointestin al discomfort with moderate to high intakes [80]. Research continues to support the overall and heart healthy health benefits of fiber, especially when it is primarily derived from food sources [116], because these sources also provide a unique and optimal balance of soluble and insoluble fiber. Another comprehensive list of dietary fiber benefits are found in Table 3.10 and this is why I often tell patients that “nature’s greatest internal Botox” has to be dietary fiber! The plethora of internal antiaging effects it provides is noteworthy, from preventing cholesterol and glucose changes to preventing hemorrhoids, and it is easy to forget that humans do not just age externally but internally with time. Botox for cosmetic antiaging is attention grabbing but why isn’t fiber just as notable for preventing internal aging? Table 3.10 can help level this playing field so to speak [79, 80].