What should I eat during chemotherapy?

By Michael McCulloch, LAc, MPH, PhD
Article Current as of December 20, 2020

Essential issues to address, and a critique of available books

“In many ways, reforming American agriculture depends on rebuilding a culture of routine home cooking. I’ve come to think that cooking is a ¹political act, with large consequences not only for ourselves but for the environment and agriculture as well… Cooking is probably the most important thing you can do to improve your diet. What matters most is not any particular nutrient, or even any particular food: it’s the act of cooking itself. People who cook eat a healthier diet without giving it a thought.”[1]

-Michael Pollan, author of The Omnivore’s Dilemma and In Defense of Food

The goal of this article is to present tools you can use – and the evidence supporting them – to protect body weight and strength during cancer chemotherapy. The intentions with this goal are improving long-term treatment outcomes, reducing toxicity, helping complete the planned course of treatment, and improving overall quality of life.

Immune health, and the starts in the gut. The quality and composition of meals shape the balance and function of the biome, the microbes in your gut. This in turn affects the innate and adaptive immune functions of the immune system,[2] and the integrity of the body’s muscle mass.[3] Although cancer chemotherapy can substantially impact nutritional quality of life, taking action with appealing and healthful foods early in the course of treatment is an important way to minimize that impact. And, by combining foods with exercise – addressed in another upcoming article – you can protect and maintain your body weight and functional strength,[4] which will improve long-term treatment success.[5]

In this article, we address questions frequently seen in clinical practice, and include evidence from recent research:

  • How can chemotherapy affect nutritional health?
  • How to know if you’re developing – or at risk for – malnutrition during cancer chemotherapy? And, what tools can you use in tracking the results of your action plan?
  • What evidence-based cancer nutrition guidelines are available to you and your oncologists?
  • What questions are important to ask of your oncology team?
  • What observations of your health are important to report to your oncology team?
  • What books are available to help learn what to eat during chemotherapy, and how to assess them for taste appeal and evidence-based nutrition standards?

Questions like these are essential, and are not always adequately addressed during the very busy workflow of cancer treatment, and the distress of having a new diagnosis. This can lead to cancer malnutrition being overlooked in its early – and more treatable – stages.[6]

How does chemotherapy affect nutritional health?
When food intake is reduced due to nausea, vomiting, stomach pain, diarrhea and/or constipation,[7] weight loss can quickly develop, leading to loss of muscle strength.[8] Early intervention to prevent weight loss during cancer chemotherapy is essential, as a drop in weight by over 5% total body weight can adversely affect survival.[8] This occurs more often in men than women, and is also more likely if protein intake is reduced, and if there are significant medical problems in addition to the cancer.[9] Depending on the type of cancer diagnosed, weight loss can be seen in anywhere between 40% and 92% of cases. But, using nutrition and exercise to prevent or reverse muscle loss leads to improved survival[5] and improved overall quality of life.[10]

How to know if you’re developing – or at risk for – malnutrition during cancer chemotherapy? And, what tools can you use in tracking the results of your action plan?
Given the crucial importance of protecting body weight during cancer chemotherapy, accurate ways to measure and track weight are essential. Muscle loss can be already present, even if a patient’s nutritional status is stable, or they are overweight.[11] And, many chemotherapy drugs have higher toxicity when malnutrition and muscle loss have occurred: 5FU, Irinotecan, oxaliplatin, FOLFOX, cisplatin, capecitabine, epirubicin, taxol, sorafenib, safeni, vandetanib, pemetrexed, gemcitabine, vinorelbine, ribuximab, cyclophosphamide, doxorubicin, vincristine, and R-CHOP.[11]

Tools you can measure yourself (listed in order from lowest to highest accuracy):

  • Body Mass Index (BMI): This long-used measure is reasonably good for general health, but has only a 29% sensitivity (ability to detect) malnutrition during cancer care, when compared with PG-SGA, described below.

  • The simple question: “Have you had unintentional weight loss in the last 3-6 months?” This question is often used in oncology centers, only has 56% sensitivity in detecting malnutrition, meaning that over half of the time it fails to detect malnutrition that has already begun.

  • PG-SGA: The gold standard against which other tools to identify malnutrition are compared, PG-SGA, is accurate and only slightly more complex to use. There is also a newly available iOS app called Pt-Global.

  • The Malnutrition Universal Screening Tool (MUST): this new test has perfect agreement with PG-SGA (Cohen’s Kappa=0.79), is more straightforward to use,[6] and has been validated for use both in oncology, and in most other health concerns.[12] Click here for an online version.

Tools your oncology team can provide:

  • If you have had a CT-scan at the level of the third lumbar vertebrae: this targeted scan allows an accurate and specific way of examining muscle mass.[11]

What evidence-based cancer nutrition guidelines are available to you and your oncologists?
Medical practice guidelines for care are intended to harmonize clinical decision-making, thereby ideally helping improve outcomes. These typically come in two types: those that are evidence-based (developed using published research) vs. consensus-based (developed by experts based on their experience and approach to medical care).[13]

How well do patient exercise/nutritional guidelines work?
Some guidelines are tested to see if they make a difference, making them clearly evidence- based. One example is the American Cancer Society’s “Nutrition and Physical Activity Guidelines for Cancer Survivors”. In a large trial, 992 people diagnosed with Stage III Colon cancer were recruited after surgery, and provided with guidance on how to use exercise and diet to maintain weight during chemotherapy. They were also given questionnaires mid-way during chemotherapy, and 6 months after completion. This 6-point scale assigned 2 points each to body weight, exercise and diet.

  • Body weight: to get a score of 2, maintain BMI between 18.5 to 25;

  • Exercise: to get a score of 2, each week exercise at least 2 1⁄2 hours, and strength training twice weekly. For example, an hour of fast walking, 30 minutes of light strength training, and 1 hour of jogging; and,

  • Diet: to get a score of 2, eat 5 or more fruit/veg servings/wk, and eat only whole grains[5]

Those patients who maintained a score of 5-6 on the ACS scale, were 1/3 less likely to have recurrence after 7 years, and more than twice as likely to still be alive after 7 years.

What questions are important to ask of your oncology team when preparing for – or already receiving – chemotherapy?
“Do you have a team-based nutritional intervention program?”

Team-based nutritional interventions can make a difference in helping maintain body weight and quality of life. Two recent studies make this point clearly:

  • Detecting muscle and weight loss: A Cancer Nutrition Program set up at a French university cancer center screened 3078 people being treated for cancer, and discovered that 70% (that’s 2 of every 3) had cachexia, a problematic type of malnutrition and muscle weight loss frequently occurring in people with cancer.[14]
  • Preventing weight loss with a team-based intervention: In a study of 110 colorectal cancer patients receiving chemotherapy were randomly divided into two groups of 55 each. In the control group, a normal diet was provided. In the intervention group, individualized recipes were designed by a team of nurses, doctors, dietician, family caregivers, and the patients themselves. After the intervention, although there was no difference in body weight between the two groups,[15] there were improved levels in the blood of albumin, a protein which can predict cancer survival.[16] This team-based approach, therefore, provided important immune system changes which can help improve a person’s longevity.

Books helpful for learn what to eat during chemotherapy:

Tools used in assessing nutritional health:

“Malnutrition Universal Screening Tool” from BAPEN (PDF)


1. Cooking: FAQ & Useful Links:

2. Kau AL, Ahern PP, Griffin NW, Goodman AL, Gordon JI: Human nutrition, the gutmicrobiome and the immune system. Nature 2011, 474(7351):327-336.

3. Mareschal J, Achamrah N, Norman K, Genton L: Clinical Value of Muscle Mass Assessment in Clinical Conditions Associated with Malnutrition. J Clin Med 2019, 8(7).

4. Naito T, Okayama T, Aoyama T, Ohashi T, Masuda Y, Kimura M, Shiozaki H, Murakami H, Kenmotsu H, Taira T et al: Skeletal muscle depletion during chemotherapy has a large impact on physical function in elderly Japanese patients with advanced non-small-cell lung cancer. BMC cancer 2017,17(1):571.

5. Van Blarigan EL, Fuchs CS, Niedzwiecki D, Zhang S, Saltz LB, Mayer RJ, Mowat RB, Whittom R, Hantel A, Benson A et al: Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial. JAMA Oncol 2018, 4(6):783-790.

6. Hettiarachchi J, Madubhashini P, Miller M: Agreement between the Malnutrition Universal Screening Tool and the Patient-Generated Subjective Global Assessment for Cancer Outpatients Receiving Chemotherapy: A Cross-Sectional Study. Nutrition and cancer 2018, 70(8):1275-1282.

7. Caillet P, Liuu E, Raynaud Simon A, Bonnefoy M, Guerin O, Berrut G, Lesourd B, Jeandel C, Ferry M, Rolland Y et al: Association between cachexia, chemotherapy and outcomes in older cancer patients: A systematic review. Clin Nutr 2017, 36(6):1473-1482.

8. Buskermolen S, Langius JA, Kruizenga HM, Ligthart-Melis GC, Heymans MW, Verheul HM: Weight loss of 5% or more predicts loss of fat-free mass during palliative chemotherapy in patients with advanced cancer: a pilot study. Nutrition and cancer 2012, 64(6):826-832.

9. Stobaus N, Muller MJ, Kupferling S, Schulzke JD, Norman K: Low Recent Protein Intake Predicts Cancer-Related Fatigue and Increased Mortality in Patients with Advanced Tumor Disease Undergoing Chemotherapy. Nutrition and cancer 2015, 67(5):818-824.

10. Mijwel S, Backman M, Bolam KA, Olofsson E, Norrbom J, Bergh J, Sundberg CJ, Wengstrom Y, Rundqvist H: Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial. Breast Cancer Res Treat 2018, 169(1):93-103.

11. Bozzetti F: Forcing the vicious circle: sarcopenia increases toxicity, decreases response to chemotherapy and worsens with chemotherapy. Ann Oncol 2017, 28(9):2107-2118.


12. Comparing Must and the NRI Tools in the Identification of Malnutrition in Heart Failure Patients DNP Projects. 36. []

13. Djulbegovic B, Guyatt G: Evidence vs Consensus in Clinical Practice Guidelines. JAMA 2019.

14. Senesse P, Isambert A, Janiszewski C, Fiore S, Flori N, Poujol S, Arroyo E, Courraud J, Guillaumon V, Mathieu-Daude H et al: Management of Cancer Cachexia and Guidelines Implementation in a Comprehensive Cancer Center: A Physician- Led Cancer Nutrition Program Adapted to the Practices of a Country. J Pain Symptom Manage 2017, 54(3):387-393 e383.

15. Lin JX, Chen XW, Chen ZH, Huang XY, Yang JJ, Xing YF, Yin LH, Li X, Wu XY: A multidisciplinary team approach for nutritional interventions conducted by specialist nurses in patients with advanced colorectal cancer undergoing chemotherapy: A clinical trial. Medicine (Baltimore) 2017, 96(26):e7373.

16. Gupta D, Lis CG: Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J 2010, 9:69.



Avenues – Autumn/Winter 2010

Avenues 31/32 - Autumn/Winter 2010From the Board

Our 2010 Accomplishments

Sleep: An Evolutionary Imperative. Are You Getting Enough?

Download the Autumn/Winter 2010 issue (2.2 MB): [PDF]


2010 Accomplishments

2010 has been a productive year for the Pine Street Foundation. We’ve published peer-reviewed research, presented papers at conferences, received lots of media coverage in the national press, and reached thousands of patients and doctors through our newsletter, Avenues.

Papers Published

Evidence for Cancer Biomarkers in Exhaled Breath. Published in Sensors Journal, this systematic review of all known evidence for cancer biomarkers in exhaled breath received a 5 out of 5 star rating by the prestigious World Wide Science group. Out of the 37 articles ranked, ours was the only one with a 5 star rating. Click here to read the full paper.

Canine Scent Detection of Human Cancers: A Review of Methods and Accuracy. Published in the Journal of Veterinary Behavior, this is a systematic review of all known published evidence in medical journals regarding dogs detecting cancer by scent. Click here to read the full paper.

Scent Identification in Criminal Investigations and Prosecutions. In this comprehensive summary of the use of canine scent lineups in the investigation of crimes, we review the proper procedures helping establish scent lineups can be valuable evidence for a jury to consider. Click here to read the full paper.

Papers Submitted

We’ve submitted for publication a landmark cancer survival study in collaboration with Kaiser Permanente, the Northern California Cancer Center, and the University of California at Berkeley. This research project encompasses a 10-year follow-up of patients with lung cancer and colon cancer, addressing the question of whether complementary and alternative medical therapy in combination with standard treatments can help extend survival. By using data about these patients gathered over a ten-year period, this study will explore the potential survival benefits associated with long-term use of an herbal-vitamin combination protocol. These two papers are now in the peer-review process.

Papers Presented

We’re presented our research results at two conferences:

  • The Annie Appleseed Foundation, in Florida
  • A conference for researchers in canine scent detection, in the Netherlands

Avenues Newsletter Distributed

In 2010, we physically distributed nearly 15,000 copies of our newsletter, Avenues, bringing our audience important information such as our comprehensive reviews on the benefits of vitamin D3 and uncovering some of the many issues surrounding the massive efforts directed against the swine flu outbreak. Additionally, thousands copies have been electronically downloaded from our website.

New Research Initiative Launched

We’ve launched a new research initiative, a systematic review and meta-analysis of all published randomized trials in which patients treated with Chinese herbal medicine combined with chemotherapy were compared to those treated with chemotherapy alone. Pine Street researchers will be looking for the impact of Chinese herbal medicine on both immediate results (do people using herbal medicine experience less damage to white blood cells or less drug toxicity?) and long-term results (do people using herbal medicine live longer after treatment and is their quality of life better?), as compared to treatment with chemotherapy alone. We will also be looking carefully at the quality of the published studies. Most of the studies we have located in our systematic search of the medical literature were published in China and one of our goals with this meta-analysis is to better understand the level of scientific quality of these studies; many researchers in the Western scientific community have criticized Chinese studies for their low quality of design and reporting. By analyzing these studies, we’ll determine what study quality problems are most significant and where improvement is needed. Pine Street has three primary aims in conducting this meta-analysis. First, we are using the results of this study as a basis for designing a double-blinded, randomized trial for patients with colon cancer. Second, by pointing out where improvements in study methodology are needed, we hope to contribute to the improvement in quality of clinical studies in China. Third, we want to educate readers outside of China on the vast quantity of research being conducted there, research that highlights the potential clinical benefits of integrative medical care.

A Selection of Media Clippings from 2010

Parade Magazine: Our work was prominently featured in the article “Cancer In America: Sniffing Out Disease.”

Huffington Post: In an op-ed in the Huffington Post, John Robbins wrote: “If you want to support an organization fighting breast cancer, you might want to know about the little known but extraordinary Pine Street Foundation.”

We were included in Cesar Milan’s new book, Cesar’s Rules: Your Way to Train a Well-Behaved Dog. Click here to read the chapter.

Avenues From the Board

From the Board (Avenues 31/32 – Autumn/Winter 2010)

Welcome to the last Avenues of 2010!


This past year has been a productive one for the Pine Street Foundation. We’ve published peer-reviewed research, presented papers at conferences, received lots of media coverage in the national press, and reached thousands of patients and doctors through our newsletter, Avenues. Click here for some of the highlights from our successful year.


Is there meaningful information contained within the breath that could lead to the early detection of ovarian cancer? In a collaboration with the University of Maine and the University of California at San Francisco, we are using dogs to find biomarkers in the breaths of women with ovarian cancer that could lead to earlier detection – and better treatment outcomes – for this disease.

So far, we’ve received breath samples from more than 100 wom- en and now just need:

» 12 More Women with Ovarian Cancer » 13 More Women with Endometriosis or PCOS

Visit to learn more about this project.

Recruiting patients for any research project is costly. But your donation – of any size – will directly help us locate enough eligible women and obtain samples of their breath to complete this important research.

Visit to show your support.


Whether you’ve known us since 1989 or have only recently dis- covered our work, it is important to note that the Pine Street Foundation is one of the most efficient and cost-effective research organizations of its kind in the country. And since the vast major- ity of all our funding comes from individual donors like you, your financial support truly helps us advance the field of integrative medicine and benefits those in need of better treatments.

As you consider your year-end charitable giving, please keep the Pine Street Foundation in mind. We really appreciate it!

Avenues Featured

Avenues – Spring/Summer 2010

Avenues 29/30 - Spring/Summer 2010From the Board

Vitamin D3: A Review of the Evidence for its Role in Human Health

Download the Spring/Summer 2010 issue (0.7 MB): [PDF]

Avenues Headline

Vitamin D3: A Review of the Evidence for its Role in Human Health

Vitamin D is crucial to our well-being. In this article, we discuss the history of its discovery, how we get it, and the evidence for its clinical effectiveness.

Avenues From the Board

From the Board (Avenues 29/30 – Spring/Summer 2010)

Welcome to latest issues of Avenues! 2010 is already off to an incredible start and this coming year promises to be our best yet, with new research projects and educational initiatives.


Swine Flu Vaccination, Treatment, and Prevention: A Common Sense Discussion and Review of the Evidence

Influenza, commonly called the flu, is a contagious respiratory illness caused by influenza viruses. In this article, we report emerging knowledge of the seasonal and swine flu epidemics, review the evidence on vaccinations, and introduce new evidence from research on common sense protective measures you can take.


From the Board (Avenues 27/28 – Autumn/Winter 2009)

Welcome to the last Avenues of 2009! In this issue, we turn our focus to H1N1, commonly referred to as “Swine Flu.”


Avenues – Autumn/Winter 2009

Avenues 27/28 - Autumn/Winter 2009
Avenues 27/28 - Autumn/Winter 2009

From the Board

Swine Flu Vaccination, Treatment, and Prevention: A Common Sense Discussion and Review of the Evidence

Download the Autumn/Winter 2009 issue (2.2 MB): [PDF]