Nutritional Interventions for Reducing the Negative Side Effects of Chemotherapy

by Bill Misner, Ph.D.

Cancer patients typically experience "Break-Through" nausea, Neutropenia, and anemia as a result of the active pharmacology imposed by Intravenous Chemotherapy. Specific practical nutritional interventions, ones that do not interfere with chemotherapy's anti-cancer metabolic endpoints present a balanced nutritional protocol for replacing required substrates for normal cellular functions which result in significant reduction of negative systemic reactions. The purpose of this paper is to acquaint the chemotherapy patient with each intervention that has been observed to reduce symptoms in some cancer patients during intravenous chemotherapy. Not all interventions will result in decreasing symptoms or increasing blood lab values for every subject, leaving each intervention-trial test subject to determine its individual merit.

NAUSEA
Nausea inhibits nutrient adequacy for homeostatic repletion. If nausea is prolonged, white and red blood cell will be numerically depressed from nutrient deficiency, resulting in weight loss. Doctors prescribe drugs called antiemetics to control nausea and vomiting. Regulation of natural whole foods and/or concentrated supplemental substrates may reduce "Outbreak Nausea" from testing 3 interventions:

[1]-DO'S--->HELPFUL NAUSEA-REDUCING INTERVENTIONS;
[2]-DO NOT'S: HARMFUL NAUSEA-INDUCING DIETARY INTERVENTIONS TO AVOID
[3]-METHODS: DIETARY APPLICATIONS REDUCE NAUSEA

1. DO'S--->HELPFUL NAUSEA-REDUCING INTERVENTIONS-
[RANKED MOST TO LEAST EFFECTIVE]
- Try foods with minimal odor (scent of food may cause nausea)
- Eat dry cereal, toast, or crackers in the AM [low blood sugar in AM triggers nausea]
- Snack before bedtime, or even in the middle of the night [avoid an empty stomach]
- Hydrate frequently in small doses [sipping]; dehydration may cause nausea, clear liquids, Tea and Ginger Ale may decrease nausea, flat soda pop
- Eat a high protein diet. Try things like shrimp, eggs, tuna, milk, or peanut butter.
- If high protein doesn't work, try a high carbohydrate diet like pasta, rice, potatoes, bananas, toast, and dry cereal.
- Fruits & Vegetables: carrots, jello-peaches, cherries, and apricots
- Find foods you tolerate; add one food per day for variety
- Get plenty of rest
- Use a cold washcloth over your eyes when you feel nauseous
- Dill Pickles may alter the metallic taste sensation from chemotherapy drugs
- Yogurt
- Sherbet
- Pretzels [low fat or no-fat are preferred]
- Angel food cake
- Skinned chicken (baked or broiled, not fried)
- Ice chips
- Oatmeal
- Wrist wrap acupressure points "SEABANDS" for motion sickness [acupressure points on the wrist counteract nausea for some subjects]
- Drinking peppermint or raspberry-leaf warm or cool tea, or peppermint-flavored candy
- Take vitamin B6 (20-50mg per day)
- Ginger Root* or Ginger Capsules*

2. DO NOT'S: HARMFUL NAUSEA-INDUCING DIETARY INTERVENTIONS TO AVOID
- Fatty, greasy or fried foods
- Very sweet, such as candy, cookies or cake
- Spicy or hot
- With strong odors
- Avoid Iron supplements or try going without Vitamin multiples, except B-6
- Avoid NSAIDs, unless prescribed and/or enteric coated
- Avoid coffee or high acid hot drinks
- Avoid icy drinks, highly carbonated drinks, or very hot drinks

3. METHODS: DIETARY APPLICATIONS REDUCE NAUSEA
Eat small amounts often and slowly. Drink fewer liquids with meals. Drinking liquids can cause a full, bloated feeling. Drink or sip liquids throughout the day, except at mealtimes for adequate hydration. Dehydration induces nausea. Overhydration induces nausea. Using a straw may help. Eat foods at room temperature or cooler; hot foods may add to nausea. Don’t force yourself to eat favorite foods when nauseated as this may cause a permanent dislike of those foods. Avoid constipation; if bowels "back-up", nausea may result of worsen.

*-GINGER CONTRAINDICATIONS: Ginger is to be used only after consultation with a physician. Side Effects: Heartburn. Drug Interactions: European researchers concluded that ginger might enhance absorption of sulphaguanidine. Excessive consumption of ginger may interfere with cardiac, antidiabetic, or anticoagulant therapy. Patients with gallstones should not take ginger except on the advice of their physician.

Once nausea is effectively controlled resulting in active appetite substrate repletion, homeostatic normal reference ranges will be achieved. Once nausea is controlled for optimal nutrient repletion, specific dietary interventions may be further modified to include low white blood cell counts[Neutropenia].

NEUTROPENIC DIETARY PROTOCOL
Neutrophils are an important defense against infection, especially bacterial infection. Treatment and disease progression may compromise neutrophil counts. When neutrophil counts fall below 1000 (1.0 x 109/L), patients are in jeopardy of infections from bacteria found in everyday foods. If neutrophil counts drop to near or below 1000, patients should be on a neutropenic diet and should be in close touch with their Oncologists or Hematologists. These dietary protocols may be used when you are neutropenic. It is important to follow a low bacteria diet until your immune system returns to normal. You must prepare foods in such a way that you avoid risk of infection. As your neutrophils increase your doctor may liberalize your diet.

KEEP FOOD CLEAN
Check expiration dates on all products before you buy them. Be sure nothing you buy is past its expiration date. Wash with soap/citrus cleanser and hot water before and after touching food: counter tops, cutting boards (wash them in a dishwasher if you have one) all cooking utensils, all silverware, and all pots and pans. Food preparer should wash hands frequently with warm soapy water and dry with paper towels. This is especially important after touching raw meat, chicken, eggs, and fish. Wash dishes in hot soapy water or in dishwasher. Air-dries dishes--DO NOT use cloth towel. Keep perishable food very hot or very cold. DO NOT leave perishable items at room temperature for more than 10 to 15 minutes. All perishable foods should be cooked thoroughly. Yes, that means no rare meat. Thaw frozen foods in the refrigerator overnight or quickly in the microwave. DO NOT thaw food on the counter. Refrigerate leftovers promptly in airtight containers. Use leftovers only if they have been stored properly and have been around for no more than 24 hours.

NEUTROPENIC DIETS
Give your immune system a boost by including lots of yogurt that contains live active cultures of LACTOBACILLUS BULGARICUS & STREPOCOCCUS THERMOPHILUS. Some other specific foods to include are GARLIC, FOODS HIGH IN ZINC SUCH AS OYSTERS, POT ROAST, DARK MEAT TURKEY, PUMPKIN & SQUASH SEEDS (or make sure the multi-vitamin contains zinc), and shitake mushrooms. These mushrooms may not be appealing, so try pureeing them to add to spaghetti sauce, or chop them fine and add to a meat loaf. Other immune boosting foods are FRUITS & VEGETABLES. They may not increase white cell count, but they will make the white cells grow stronger. The best choices are the deep green and orange ones like spinach and carrots, melon and oranges. On the other hand, fish oil is an immune system enhancing agent. Serve a cup of yogurt with pureed strawberries for desert. Serve fresh salmon with some tender cooked broccoli florettes or spinach that has been steamed with fresh garlic and a little water; (garlic needs to cook longer than the spinach so give that a head start). A NEUTROPENIC DIET includes all well-cooked foods and eliminates foods that may contain potential disease-causing microorganisms (Oncology Nutrition Patient Education Materials by Walker and Masino, published by The American Dietetic Association, 1998). The restrictions on this diet vary from cancer center to cancer center.

GENERAL GUIDELINES
You could also take fresh or frozen fruits and vegetables, first wash them thoroughly under running water, microwave or steam them until well-done, cool covered in the refrigerator, and then use them in the shake. Some fresh produce even has better availability of nutrients and phytochemicals with cooking although other nutrients are also decreased with cooking. However, remember that this diet is only for short term use and try not to worry too much about the lost nutrients. Use the vacuum-packed (pasteurized) tofu to minimize bacterial counts. Change the storage water daily. Never buy tofu from open bins or barrels during this time of being immune-suppressed. [DO NOT USE the wheat germ, wheat bran, or flaxseeds stored in open bins.]

SPECIFIC FOODS RECOMMENDED BY THE ONCOLOGY NUTRITION PATIENT EDUCATION MATERIALS:
-Pasteurized yogurt
-Peeled thick-skinned, unblemished fresh fruit (banana, citrus, melon - be sure to wash the outside peels prior to cutting through the fruit with your knife)
-Peeled apples
-Cooked dried fruit
-Processed fruit juices - pasteurized milk (and soy milk)

SPECIFIC FOODS TO AVOID [ONCOLOGY NUTRITION PATIENT EDUCATION MATERIALS]
-Fresh-squeezed fruit juice
-Unpasteurized fruit juice
-Too much fat [polyunsaturated vegetables oils adversely effect immune system strength]

Be sure your blender and its cover, cutting board and utensils are clean, preferably by washing them all in the dishwasher. If you need to wash these items by hand, use warm soapy water, rinse well, and then wash again with a solution of 1-Tablespoon bleach in 4 cups of warm water. Let the solution stay on for at least 2 minutes and then rinse clean with hot clean water. PROBABLY MOST IMPORTANT OF ALL, THOROUGHLY WASH YOUR HANDS WITH SOAP AND WATER BEFORE HANDLING THE FOODS AND PREPARING THE SHAKE. [1]

NUTRITION-SPECIFIC COMPARISONS: THE PERMITTED VS NOT PERMITTED FOODS AND FLUIDS
PERMITTED: Distilled water, boiled well water, bottled spring water, and tap water
NOT PERMITTED: Raw, unpasteurized milk, eggnog or milk shakes made with raw eggs, fresh apple cider

PERMITTED: Shellfish well cooked, home prepared meat, and fish salads, pre-packaged sandwich meats
NOT PERMITTED: Raw or rare meat, fish, eggs, poultry commercially prepared meat and fish salads, sushi, and sandwich meats from the deli

PERMITTED: Pasteurized or Lactaid milk or yogurt
Pre-packaged ice cream or frozen yogurt, pre-packaged hard cheeses: cheddar, Colby, Monterey jack, Swiss, mozzarella pre-packaged soft cheeses: cottage cheese, cream cheese, ricotta
NOT PERMITTED: Soft serve ice cream or frozen yogurt hand-packed ice cream or frozen yogurt, feta, brie, camembert, blue, gorganzola, and quesco fresco cheeses any imported cheeses, and any cheese sliced at a deli

PERMITTED: Breads, cereals, rice, potatoes, pasta, all pre-packaged or homemade breads, muffins, cakes, rolls, donuts, cookies and crackers all boxed hot or cold cereals, except those with dried fruit or nuts, cooked potatoes, rice, noodles
NOT PERMITTED: Bakery breads, muffins, cakes, donuts, cream, or custard filled cakes, commercially prepared potato, or macaroni salad, popcorn (due to dental problems)

PERMITTED: All well washed and thoroughly cooked vegetables, all cooked or canned fruits, raw, thick-skinned, well-washed fruits (unbruised): oranges, grapefruits, melons, bananas, tangerines
NOT PERMITTED: Raw vegetables and salads, uncooked thin skinned fruits: apple, peaches, grapes, plums, nectarines, kiwi, strawberries, dried fruits

PERMITTED: Processed peanut butter, packaged roasted nuts, cooked nuts (in cookies, cakes, etc)
NOT PERMITTED: Raw nuts, uncooked nuts, unprocessed nuts

PERMITTED: All cooked fresh or canned spices (add at least 5 min. prior to end of cooking) ketchup, mustard, mayonnaise, served in separate containers with clean utensils, sugar, jelly, honey served from clean containers with clean utensils
NOT PERMITTED: Uncooked spices, raw honey, anything from a family container that isn't freshly washed
PERMITTED: Thoroughly cooked frozen dinners, thoroughly cooked frozen pizza, canned entrees, do not eat at restaurants for at least two months or use take out deli food even if it's behind the counter, avoid all salad bars for at least one year, avoid all self-serve buffets for at least one year.

SPECIFIC FOODS THAT SHOULD BE RESTRICTED ON A NEUTROPENIC DIET [2]:
-Raw nuts, vegetables, and salads
-Apples, peaches, grapes, plums, nectarines, kiwi, strawberries, and other uncooked thin-skinned fruits
-Self-serve buffets, salad bars, and deli foods
-Cheeses such as feta, Brie, Camembert, blue, etc.
-Raw or rare meats, fish, and poultry
-Commercially prepared potato or macaroni salad
-Raw, un-pasteurized milk and eggnog or milk shakes made with raw eggs
-Bakery breads, muffins, cake donuts, and cream or custard filled cakes
In addition to the selection of appropriate foods, extra care is important in food preparation. Food preparers must wash their hands frequently in warm soapy water, especially if handling raw meat, chicken, eggs, and fish. Counter tops, cutting boards, and cooking utensils should also be washed with hot soapy water after they have come in contact with food.

OTHER NUTRITIONAL CONSIDERATIONS
It is very important to maintain your weight during cancer treatments. If you have a scale weigh yourself weekly. If you notice a loss of five pounds or greater, contact your doctor. You may not wish to eat large amounts of food, so you are advised to maximize the calories you do eat.

EAT SMALL, FREQUENT MEALS OR SNACKS
Add margarine, butter, gravy, cheese, and non-fat milk powder to appropriate items. (If you're having dry mouth as a result of treatment you'll really appreciate these suggestions.)
Consume nutritional supplements like ice cream frappes made with enriched milk. To make enriched milk mix 1 quart of milk with 1 cup of dry milk powder. Stir well and keep refrigerated. This increases the protein, calorie and vitamin content of the milk.
Drink Instant breakfast, Ensure, Sustacal, or other commercially prepared supplements.
Some people may have trouble digesting milk products. Watch for symptoms of bloating, gas, cramps, or diarrhea after consuming milk products. You may want to switch to Lactaid Milk, or chew lactaid tablets when eating dairy products. Discuss this with your dietitian, nurse, or doctor.

IMPORTANT REMINDER: Check with your doctor after bloodwork is done, to determine when the low bacteria neutropenic-diet may be liberalized. Talk with the doctor or oncology nurse to keep your information up to the minute according to your blood counts.

NEUPOGEN INFORMATION [3]:
NEUPOGEN is a growth factor that primarily stimulates neutrophils. NEUPOGEN is indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a significant incidence of severe neutropenia with fever. A complete blood count (CBC) and platelet count should be obtained prior to chemotherapy, and twice per week during NEUPOGEN therapy to avoid leukocytosis and to monitor the neutrophil count. In phase 3 clinical studies, NEUPOGEN therapy was discontinued when the neutrophil count [ANC] was > 10,000/mm3 after the expected chemotherapy-induced nadir. NEUPOGEN therapy was adjusted to maintain the median ANC between 1500 and 10,000/mm3. Overall, the response to NEUPOGEN is observed in 1 to 2 weeks. NEUPOGEN therapy daily subcutaneous injections commence 2-4 days post chemotherapy and continue for 7-10 consecutive days. NEUPOGEN is contraindicated in patients with known hypersensitivity to E. coli-derived proteins, Filgrastim, or any component of the product. Drugs, which may potentiate the release of neutrophils, such as lithium, should be used with caution. In all phase 2 and 3 trials, medullary bone pain, reported in 24% of patients, was the only consistently observed adverse reaction attributed to NEUPOGEN therapy. This bone pain was generally reported to be of mild-to-moderate severity, and could be controlled in most patients with non-narcotic analgesics; infrequently, bone pain was severe enough to require narcotic analgesics. Bone pain was reported more frequently in patients treated with higher doses (20 to 100 mcg/kg/day) administered IV, and less frequently in patients treated with lower SC doses of NEUPOGEN (3 to 10 mcg/kg/day).

Shortly after white blood cell counts are compromised, red blood cell counts, hematocrit, hemoglobin, and red blood cell morphology may be depressed lower than normal reference range values. Dietary interventions may be further modified to support rebound red blood cell levels to healthy normal values.

DIETARY INTERVENTIONS FOR ANEMIA

COMMON CAUSES
The most common cause is iron-deficiency anemia in red blood cells which are smaller than usual and pale in color due to improper amounts of hemoglobin (the molecule in red blood cells that binds to oxygen and carries it in the blood). This lack of iron for the production of hemoglobin is due to:

-Loss of iron from the body due to blood loss
-Poor absorption of iron from one's diet
-Lack of dietary iron
-Radiotherapy or Chemotherapy
-Anti-cancer drugs
-Certain types of viral infections
-Genetic reasons
-A result of malaria
-AIDS
-A deficiency of vitamin B-12.
-A deficiency of folic acid.
-An imbalance between the ratio of B-12 & Folate

SYMPTOMS OF ANEMIA
[Note: There may be no symptoms if anemia is mild.]
1. Tiredness and weakness
2. Lethargy
3. Dizziness, shortness of breath, and palpitations (rapid heart rate)
4. Headaches
5. Pale complexion
6. Brittle nails (due to lack of iron)
7. Irritability
8. Sore tongue
9. Unusual food cravings (called pica)
10. Decreased appetite
11. Headache - frontal
12. Blue tinge to sclerae (whites of eyes)

MECHANISMS OF ANEMIA
Red blood cells that carry iron-rich hemoglobin live only 120 days or four months. Unless there is a continual supply of iron, vitamin B12, vitamin C and folacin from either food or supplements, anemia will result in poorly formed red blood cells that are ineffective carriers of oxygen. Iron deficiency anemia is the most common form of anemia. Approximately 20% of women, 50% of pregnant women, and 3% of men are iron deficient. Iron is an essential component of hemoglobin, the oxygen carrying pigment in the blood. Iron is normally obtained through the food in the diet and by the recycling of iron from old red blood cells. The causes of iron deficiency are too little iron in the diet, poor absorption of iron by the body, and loss of blood (including heavy menstrual bleeding). It may also be related to lead poisoning or chemotherapy. Anemia develops slowly after the normal stores of iron have been depleted in the body and in the bone marrow. Women, in general, have smaller stores of iron than men and have increased loss through menstruation, placing them at higher risk for anemia than men. In men and postmenopausal women, anemia is usually due to gastrointestinal blood loss associated with ulcers, the use of aspirin or nonsteroidal anti-inflammatory medications (NSAIDS), or colon cancer. High-risk groups include: women of child-bearing age who have blood loss through menstruation; pregnant or lactating women who have an increased requirement for iron; infants, children, and adolescents in rapid growth phases; and people with a poor dietary intake of iron through a diet of little or no meat or eggs for several years. Risk factors related to blood loss are peptic ulcer disease, long term aspirin use, colon cancer, or cancer-related chemotherapy treatment. Dietary sources of iron are red meat, liver, and egg yolks. Flour, bread, and some cereals are fortified with iron. If the diet is deficient in iron, iron should be taken orally monitored by a physician.

DIETARY INTERVENTIONS
Non-heme iron (ferric) is highly variable in its availability for absorption. Foods high in non-heme iron are grains, vegetables, fruits, eggs and some iron supplements. Absorption of non-heme iron increases in the stomach's acidic environment and the presence of vitamin C in foods. Also, the presence of red meat may increase absorption of non-heme iron four times. However, oxalates and phytates found in dark green leafy vegetables and whole cereal grains decreases the absorption of iron because they bind with iron in the gastrointestinal tract.
Heme iron (ferrous), found in red muscle meats of animals, is far more effectively absorbed. The absorption of heme iron is influenced by other foods in the diet such as foods containing vitamin C and an acid environment like the stomach. The Recommended Dietary Allowance (RDA) for iron is 10 milligrams for adult males and postmenopausal females. Males (ages 11 to 18) need 12 milligrams of iron per day. Females (ages 11 to 50 years) need 15 milligrams. The best food source of iron is liver and red meats. These foods contain heme iron, which is better absorbed than non-heme iron. Non-heme iron can be found in dark green, leafy vegetables (spinach, chard and kale) and whole cereal grains (bran and whole wheat bread). Include dark green, leafy vegetables and whole cereal grains in your daily diet. Oxalates and phytates found in dark green leafy vegetables and whole cereal grains decrease the absorption of iron because they bind with iron in the gastrointestinal tract. You should also look at iron fortified cereals to supplement iron in your diet. Also, if you are a menstruating woman, contact your doctor about having an annual blood workup. You may not develop anemia on a meat-free diet, but your iron stores may be low.

SUBSTRATE SUPPLEMENT CONSIDERATIONS [4]
- Acidophilus - 2-8 Billion Count, Good Bacteria
- Coenzyme Q10 - 100-150 mg daily
- Garlic capsules - 2 capsules 3 x daily
- Germanium - 200 mg daily
- Kelp - 100-225 micrograms/day
- Vitamin B6 - 50 mg 1-3 daily
- Vitamin B12 - 200-1,000 mcg
- Folic Acid - 800 mcg
- Proteolytic enzymes - Bromelain & Papain
- Selenium - 200 mcg daily
- Vitamin A - 15,000 IU daily or Beta Carotene - 25,000 IU daily
- Vitamin B Complex - 50-100 mg/day
- Vitamin C plus Bioflavonoids - 3000 mg daily divided doses
- Vitamin E - 400 IU daily
- Copper - 2 mg daily
- Zinc chelate or Picolinate- 50-80 mg daily ---->(Do not take zinc in amounts over 100 mg daily as it can impair the immune response.)

EPOETIN ALFA OR PROCRIT INFORMATION [5]:
Erythropoietin is a naturally occurring hormone that stimulates the production of red blood cells (RBCs). In the absence of erythropoietin, few RBCs are formed by the bone marrow. In normal adults, approximately 90% of human erythropoietin are produced in the kidney. [5, 6, 7] The level of tissue oxygenation normally regulates endogenous production of erythropoietin. A reduction in the delivery of oxygen to the kidney may occur when the hematocrit (Hct) is low, or as a result of changes in hemoglobin (Hb)-oxygen dissociation. Hypoxia and anemia generally increase the production of erythropoietin, which in turn stimulates erythropoiesis. Erythropoietin increases RBC production by stimulating the division and differentiation of committed erythroid progenitors in the bone marrow. [7] An important effect of erythropoietin is to stimulate the production of proerythroblasts from hematopoietic stem cells in the bone marrow. In addition, once the proerythroblasts are formed, erythropoietin causes these cells to pass through the different erythroblastic stages more rapidly; further accelerating the production of new RBCs. Overall, the regulation of erythropoiesis resembles a complete feedback loop. Erythropoietin, released primarily by the kidney in response to hypoxia, sends a highly specific signal prompting committed erythroid progenitor cells in the bone marrow to produce reticulocytes, which in turn mature into RBCs in the circulation. As a result, the oxygen-carrying capacity increases, the stimulus of hypoxia is alleviated, and the endogenous erythropoietin response is decreased. This feedback loop provides for the normal regulation of erythropoietin. The first evidence of a response to the weekly administration of PROCRIT is an increase in the reticulocyte count within 20-30 days, followed by gradual increase in the red cell count, hemoglobin, and hematocrit. Because of the length of time required for erythropoiesis -- several days for erythroid progenitors to mature and be released into the circulation -- a clinically significant increase in hematocrit is usually not observed in less than 2 weeks and may require up to 6 weeks in some patients. Once the hematocrit reaches the suggested target range (30-36%), that level can be sustained by PROCRIT therapy in the absence of iron deficiency and concurrent illnesses.

REFERENCES

[1]-Diana Dyer, MS, RD CNSD, [resource on World Wide Web]: Available from URL: http://www.cancerrd.com/FAQs/FAQ1.htm -cited 2-13-2002.

[2]-Dana Farber Cancer Institute Dietitians-cited 2-13-2002.

[3]-Neupogen [Filgrastim] Pharmacology Information-cited 2-13-2002: [resource on World Wide Web]: Available from URL: http://www.neupogen.com/patients/patientpi.html

[4]-As with any supplement, always confer with your physician or nutritionist as to the appropriate level or selection prior to use.

[5]-The "Science Behind" Procrit [resource on World Wide Web]-cited 2-13-2002. @: http://www.procrit.com/profonly/nephrology/what_is_procrit/the_science_behind_procrit.html

[6]-Guyton AC, Hall JE. Textbook of medical physiology. 9th ed. Philadelphia, PA: W. B. Saunders;1996.

[7]-Guyton AC, Hall JE. Human physiology and mechanisms of disease. 6th ed. Philadelphia, PA: W. B. Saunders;1997.

DISCLAIMER: This information is presented for educational purposes only. Please discuss this information with your personal physician or dietitian. If a medical or health concern is present, applications of this information are subject to the approval of your personal physician or licensed health care provider.

*Bill Misner Ph.D. is the director of Research & Product Development for E-CAPS INC., a manufacturer of micro- and macro- nutrients specifically formulated for endurance athletes. He is an Associate Editor, Metabolic Responses to Exercise for the Journal of Exercise Physiology-online, Editor of the Journal of Endurance, and author of "NUTRITION FOR ENDURANCE: FINDING ANOTHER GEAR" Dolezal & Associates Publishing, Livermore California, 1998. Misner is also a published author in the physician peer-reviewed Journal, CLINICAL PRACTICE OF ALTERNATIVE MEDICINE, and, has contributed to numerous sportscience articles to the world-wide web and magazines such as VOGUE, HEART & SOUL, RUNNERS WORLD, MOUNTAIN BIKE ACTION, & MUSCLE MEDIA, respectively. Misner’s most significant credential meriting consideration of this text is his wife, Celia, a Breast Cancer Survivor, who during remarkable treatment from the Rockwood Clinic in Spokane, Washington, defined the model “Heroine” providing inspiration that requires this information be shared with others.

Altering the intended context of this article requires the author's consent. You may contact Bill Misner Ph.D. This email address is being protected from spambots. You need JavaScript enabled to view it. or 1-800-336-1977.