Ask the Expert: Managing your weight after breast cancer

Managing your weight after a breast cancer diagnosis can be an ongoing challenge. During the month of January, Living Beyond Breast Cancer expert Suzanne Dixon, MPH, MS, RD, answered your questions about why breast cancer impacts your weight, why some people gain or lose weight, what you can do during treatment to help manage weight after treatment ends, and ways to get more exercise or find a fitness program to help your overall wellness.

What is the likelihood of weight gain with the chemotherapy combination ACT? What about with chemotherapy in general?

There is no good way to estimate exactly how likely any particular woman is to gain weight during chemotherapy, and weight gain is not listed among the specific side effects for these three medications (Adriamycin, Cytoxan, and Taxol). However, some women do gain weight after a breast cancer diagnosis. Beyond weight gain, there are a few things you can do to lessen the likelihood of all of the side effects of ACT. This includes:

• Increasing fluid intake, especially in the 24 hours after receiving Cytoxan
• Practicing good mouth care using alcohol-free mouth care products, and avoiding irritating foods, such as citrus, coffee and alcohol
• Avoiding sun exposure, and wearing protective clothing and sunscreen (at least SPF 15) if sun exposure is unavoidable

For reasons that aren’t entirely clear, about half of women undergoing breast cancer treatment gain weight. Often, this is just a few pounds, but some women can experience significant weight gain of 20, 30 or 40 pounds or more.

Even though health experts don’t fully understand why weight gain occurs during chemotherapy, there are some factors that seem to contribute to the likelihood of gaining weight.

• Physical activity. Many women report that their activity level hasn’t decreased during cancer treatment, but when activity levels are tracked, it becomes clear most women are less active. This isn’t surprising, given that fatigue is one of the main complaints of people in cancer treatment. It might seem counterintuitive, but regular physical activity is one of the best ways to manage and lessen treatment-related fatigue.Always check with your medical team before beginning any new activity, but once you have been given the go-ahead, you should do your best to incorporate regular physical activity into your day. You shouldn’t feel like you need to run a marathon, but regular walks, for example, can do several positive things for your body. Physical activity lessens fatigue, improves mood, helps preserve muscle mass, improves immunity and can help you sleep better.
• Loss of lean body mass. Treatments, the cancer itself, lack of activity and other factors can cause some women to lose a lot of lean body mass during treatment. Lean body mass includes your muscle tissue, and muscle tissue is what burns calories. When your muscle mass goes down, your calorie-burning ability goes down, and weight gain — especially fat gain — can follow.Researchers have found that if women engage in regular resistance training during and after cancer treatment, including activities such as push-ups, sit-ups, walking lunges, using stretchy bands to challenge your muscles, or lifting weights, they are much less likely to gain weight. Resistance training preserves your muscle tissue, and this in turn keeps your metabolism humming along.If you’ve never done any resistance training, ask your doctor for a referral to a cancer rehabilitation specialist or physical therapist. Also, if you’ve recently had surgery, be sure to get the OK from your doctor that you can begin some moderate resistance training. Fortunately, the latest research shows that women will not increase the risk of lymphedema by strength training.With just a few appointments, you can learn some basics about safely building your strength, get started and then continue the program on your own. There is even a speciality certification for trainers, which indicates that they have extra education in how to work with cancer patients. This is called a Certified Cancer Exercise Trainer, or CET. Learn more about this online.
• Emotional eating. Many women turn to food for comfort, which is not surprising. Receiving a cancer diagnosis is among the most stressful things a person can experience, and eating to soothe emotions is common. If you think that emotional eating is becoming a problem for you, make an appointment to see a registered dietitian. This person can help you identify triggers for emotional eating and give you practical steps for coping in healthier ways.If you feel depressed, hopeless or simply too overwhelmed to cope, it’s important to see a counselor or other mental health care provider. There’s no reason to suffer, and you should take care of yourself emotionally as well as physically.

Following chemo, what exercise can you do with joint pain, especially in the knees and ankle?

If you have joint pain, ask your doctor for a vitamin D blood test. Research shows that for women taking certain breast cancer treatments, having low vitamin D levels can worsen joint pain. Fortunately, if you are low in vitamin D, taking a vitamin D supplement can improve joint pain. Be sure to follow up with a blood test a few months after you begin taking vitamin D supplements, to make sure your body is responding and levels are coming up.

The best exercises for people with joint pain are those that don’t put a lot of stress or impact on the bones and joints. This includes swimming, biking, water aerobics, using a low-impact elliptical machine and walking on softer surfaces, such as a treadmill or a newly resurfaced track at your local high school, Y or college.

Can you advise on what is the most nutritious diet to follow?

According to available research, the healthiest diet for breast cancer survivors is to focus on eating mostly plant-based foods. Plant-based doesn’t have to be vegetarian. It simply means that most of your plate is covered by minimally processed, whole, healthy, plant foods. This includes vegetables, nuts, seeds, legumes, fruit and whole grains.

Think of your plate and try to have it appear as follows:

• Two-thirds to three-quarters should be covered by colorful vegetables and fruit.
• The remainder should be split between lean protein, such as beans, fish or chicken, and a small serving of whole grains.
• Add a sprinkling of nuts and seeds for healthy fat, fiber and a little more protein.

Also make sure you eat foods you enjoy. Don’t be a slave to the conventional wisdom that you must eat certain “cancer-fighting” foods. Sure, broccoli is healthy, but so are carrots, kale, peppers, cabbage, beets, collard greens and more.

There seems to be uncertainty about whether soy is safe to consume for those with estrogen-sensitive cancers. Should I, a woman who had ER+ breast cancer, stay away from all versions of soy (soy protein, soy lecithin, soy protein isolate, etc.)?

I believe one reason so many women have concerns about soy arises from the term “phytoestrogens.” Some soy nutrients — the isoflavones — have chemical structures that look a bit like the estrogen found in a woman’s body. This is where the term phytoestrogen originated. However, it’s important to note that phytoestrogens are not the same thing as female estrogens, and soy foods do not contain estrogen.

It’s unfortunate that people think of soy in relation to its so-called “estrogenic” effects. This gives the impression that soy’s impact on estrogen levels or estrogen receptors is the most important thing about this food, but this simply isn’t true.

Health experts who study soy note that it has many beneficial effects in the body. Soy contains antioxidants and can favorably alter cell behavior down to the molecular level. Soy nutrients seem to enhance a cell’s ability to withstand damage. Soy nutrients also can encourage damaged cells to die, in a process called apoptosis, before they can go on to become cancerous.

Soy can turn up the production of cell proteins that dampen cell growth, which may lead to lower cancer risk. Soy can turn down the production of proteins that spur cell growth, another way in which soy may lower cancer risk. Soy appears to have anti-inflammatory effects in the body, too. The list of soy’s potential beneficial effects is impressive indeed. None of these actions have anything to do with estrogen.

Human studies support soy’s safety

Even more reassuring is that several large, human studies — in which thousands of women have been followed for many years — consistently show that compared with women who do not eat soy, women who regularly consume soy foods have lower breast cancer risk. Several of these studies even show that women diagnosed with breast cancer who consume soy foods have a lower risk of breast cancer recurrence, compared with women who avoid soy after breast cancer.

These studies have been conducted in both Asian and U.S. populations. This is important, because soy has long been a part of many Asian cuisines, but it is a relatively new introduction to the American diet.

In the most recent studies of nutrition and breast cancer survival, women who regularly consume soy foods have up to 50 percent decreased risk of recurrence, compared with women who eat little to no soy. These studies are observational, which means researchers collect diet information from women and then follow them for many years to see who develops cancer. Researchers have looked at breast cancer in particular, and how soy foods are related to the risk of developing the disease.

In an observational study, it is always possible that the true connection with better breast health is not soy but something else that is related to eating soy. For example, suppose that women who eat soy foods also eat less fried food. Maybe they also happen to eat more vegetables, are thinner, don’t smoke and exercise more. Any of these factors could be the reason why soy-eating women have lower breast cancer risk.

This means that large, observational studies can’t conclusively prove that soy protects against breast cancer. However, these studies are reassuring in affirming that soy foods do not increase breast cancer risk. And they point toward a protective effect of soy on breast health, regardless of other lifestyle and diet choices.

Because these studies are observational, rather than controlled clinical trials, I don’t believe we should specifically recommend that all women with a history of breast cancer eat more soy. However, I am confident that soy foods are safe for breast cancer survivors.

Remember that soy foods are a healthy option, while soy supplements may not be. The research on soy and breast health has looked mainly at soy foods, not supplements.

The bottom line

If you are concerned about breast health, stick to healthy, whole soy foods such as tofu, tempeh, soy milk and edamame. Don’t rely on powders and pills. The occasional soy protein bar or snack food is fine, but as with all plant foods, less processed is better.

In the end, you should feel confident in whatever choice you make about soy foods. Eat these foods if you enjoy them, or skip them altogether if soy isn’t your cup of tea! And most importantly, give yourself permission to let go of the fear of soy.

Despite cutting back dramatically on carbs, making sure I get protein, drinking nothing but water and an occasional small juice, and exercising 5 days a week (cardio and weights), I am not losing any weight. What can I do? I am, incidentally, premenopausal and on tamoxifen.

Before you become too focused on weight, consider the big picture on nutrition, exercise and breast cancer recurrence.

The Women’s Healthy Eating and Living study tracked several thousand women of varying body weights before and after diagnosis. Researchers collected details about their health habits and followed them for several years to see who had a breast cancer recurrence.

Women were grouped as follows:

1. Low levels of physical activity and low intake of vegetables and fruit
2. High levels of physical activity and low intake of vegetables and fruit
3. Low levels of physical activity and high intake of vegetables and fruit
4. High levels of physical activity and high intake of vegetables and fruit

Regardless of weight, women who both exercised regularly and ate plenty of vegetables and fruit had about a 50 percent lower risk of breast cancer recurrence compared with women in the other groups!

In other words, even if the women did not lose a single pound or were obese — meaning significantly overweight, if they continued to exercise and eat well they were able to reduce their risk of recurrence. This tells us that health matters more than weight.

It can be very frustrating to put in a lot of effort and not see results on the scale, but  know that losing weight should not be the only marker of how well you are taking care of yourself.

We’d all like to maintain an “ideal body weight,” but if treatment has made it difficult to shed extra pounds, it may help ease your mind to know that exercising regularly and eating well seems to support a body resistant to getting breast cancer again.

How much exercise is enough? What about my diet?

In the WHEL study, the “high physical activity” group did activity equivalent to a 30-minute brisk walk, 6 days per week. The high vegetable and fruit group ate a minimum of five servings of vegetables and fruit per day.

This means that, at a minimum, you need to exercise for 30 minutes nearly every day of the week. More is great if you can fit it in. As well, you should eat at least three servings of vegetables and two servings of fruit per day — that’s 2 ½ cups of them, total. Again, if you can eat more of these foods, that’s even better.

The bottom line is that you can gain the “anti-cancer” benefits of healthy eating and getting regular physical activity by meeting these basic guidelines. For weight loss, as you’ve personally experienced, you may have to do more.

You may need to mix in different types of activity. Our bodies adapt to activity, so the only way to keep improving fitness levels and, hopefully, lose weight, is to keep the body guessing. For example, stead-state cardio, such as jogging at a set pace, needs to be mixed with what is called high-intensity interval training, or HIIT.

For HIIT, you would go “all out” — running, walking, moving on the elliptical machine, biking, swimming, etc. — for a short period of time, say 30 seconds to 1 minute. This would be interspersed with 2 or 3 minutes of more moderate activity, so you can “catch your breath.” Then you go back to 30 seconds or a minute of all-out effort, again followed by some slower activity to allow your body to recover.

You repeat this cycle a few times, and this is HIIT. Interval training is one of the most effective ways to rev up metabolism, which in turn may help you get the needle on the scale moving in the right direction again.

You may also need to mix up your weight training. For example, perhaps you do a weight training regimen in which you work on certain body parts on certain days of the week. You may want to do this for 6–8 weeks. Then, switch to circuit training.

For circuit training, you use slightly lower weights, and move through an entire “circuit” that hits all major muscle groups. You might do this circuit two or three times per session, and do it on 3 days of the week. After doing this type of weight training, you might go back to your original way of weight training.

Just like with cardio, the benefit comes from “mixing it up” in terms of how your train your muscles.

However, I want every woman to know that no matter how frustrating it is to do all the right things and not lose weight, it’s still important to keep going! Even if you do not shed one pound, you are reducing your risk of recurrence!

One final note on training: If you are new to any of these ways of working out, be sure to check with your doctor or physical therapist to get the OK for trying these new, more intense activities. You also may benefit from a few sessions with a knowledgeable trainer.

A trainer can walk you through these routines, and show you proper form so you can safely complete your workouts. Just be sure any trainer you work with is respectful of your health history and understands any limitations you may have due to cancer or previous injuries.

I have not changed my diet except for the better. Why have I gained weight since starting chemo? I have been taking letrozole (Femara) for the last few years and took tamoxifen previously.

About half of women who are treated for breast cancer will gain weight during or after treatment. Part of why this happens is because the body is going through a sort of “accelerated” aging, in terms of loss of lean body mass and slowing of metabolism.

All people slowly lose a bit of lean body mass every year that goes by, and every person’s metabolism slowly decreases with age. Normally, this happens slowly enough that we can adapt. We can move our bodies a little more, or eat a little less, and this will offset these trends.

Going through breast cancer treatment basically causes this trend to happen over a much shorter period of time. Because you don’t have any time to adapt to the “new you,” it’s easy to have pounds pile on very quickly.

However, researchers have found that if women engage in regular resistance training during and after cancer treatment, they are much less likely to gain weight. Resistance training activities include push-ups, sit-ups, walking lunges, using stretchy bands to challenge your muscles or lifting weights. Resistance training preserves your muscle tissue, and this in turn keeps your metabolism humming along.

If this resistance training is combined with regular cardio or aerobic activities, weight gain is even less likely to occur.

If you’ve never done any resistance training, ask your doctor for a referral to a cancer rehabilitation specialist or physical therapist. Also, if you’ve recently had surgery, be sure to get the OK from your doctor that you can begin some moderate training. Fortunately, the latest research shows the risk of lymphedema does not increase with strength training.

I was diagnosed with breast cancer in July 2012 and finished radiation therapy that November. I eat to hide feelings and gained 40 pounds in the past 15 months. What can I do to get better control of my emotional eating?

Receiving a cancer diagnosis is among the most stressful things a person can experience, and eating to soothe emotions is common. If you think emotional eating is a problem for you, consult a registered dietitian. This person can help you identify triggers for emotional eating and offer practical steps for coping in healthier ways.

In addition to this, one important thing you can do is to stop thinking about food as “black and white” or “all or nothing.” This is a very common issue for people who are trying to lose weight or gain control of binge eating.

Black and white thinking works like this: You eat healthfully for a meal, or a day, or even 2 or 3 days straight. Then you have one “slip up” and eat a “forbidden” food, such as cookies, cake, fried food, or whatever food you consider off-limits. In your mind you say, “Well now I’ve blown it, I might as well eat what I want for the rest of the day, the week, the month, etc.”

This type of thinking takes a single episode of eating a “forbidden food,” and turns it into a full-on binge.

Instead, what we need to do is allow ourselves to be human and to realize that nobody has a perfect diet. We all have our days when we don’t eat well, but that doesn’t make us bad people. It certainly doesn’t mean we are“weak-willed” or unable to commit to a healthy diet.

If we see occasional dietary “transgressions” as a reflection on our lack of willpower or as an excuse to eat everything else in sight, a lot of harm is done.

A study was just published that found how we eat Monday through Friday is the most important factor of whether we maintain a healthy body weight over time. It found that even people who eat more on weekends and enjoy some “forbidden” foods maintain a healthy body weight over time, and even lose weight, so long as they stick to their healthy eating pattern during the week.

Another helpful step is to read some well-written “self-help” books on how to establish healthy lifestyle habits. One of my favorites is The Willpower Instinct: How Self-Control Works, Why It Matters, and What You Can Do to Get More of It by Kelly McGonigal, PhD. This book offers insight into what “willpower” truly is and practical steps for tapping into yours. If you take a look at some of the online reviews of this book, you’ll see many people have found it helpful for all sorts of health challenges.

Finally, if you feel depressed, hopeless, or simply too overwhelmed to cope, it’s important to see a counselor or other mental healthcare provider. There’s no reason to suffer, and you should take care of yourself emotionally as well as physically.

I have what I would call a “sweet tooth” addiction. If I have a choice between an apple and cookies, I will pick cookies every time even though I know they are not healthy for me. I'm a 6-year survivor. I've heard sweets/sugar is like a drug addiction. What can I do?

Being a bit of a "sugar addict" myself, I can truly say I empathize with your challenge. The simple answer is don’t keep these foods around! If they are not available, you can’t eat them. That is a first step.

However, even that won’t keep you isolated from these foods 100 percent of the time. You have to address this from several angles to deal with those times when you are faced with the sugary foods, when the situation or setting is not within your control.

I’m not a big believer in “detoxing” or completely avoiding any of the so-called "bad" foods permanently. I believe in moderation and try to practice this in my life.

For some people, there are certain “trigger foods,” and sometimes it’s helpful to avoid these completely for a few days. The key is to know that you don’t have to never have your favorite foods again; you simply want to “take a break” from them for a few days.

Whether or not sugar is truly addictive is a matter of great debate, but I can say that when you don’t have these foods for a few days, cravings often do decrease. The first day or two can be very challenging, and again, this is where not having these foods around is important.

Once you’ve gone a few days without eating a lot of added sugar, you likely will find your cravings have diminished. Again, you don’t need to never eat these foods again, but you can help yourself regain a sense of control by avoiding them for a time.

In addition to this, you might consider working with a registered dietitian or therapist to address emotional eating issues. Or, try self-help books.

I've been cancer-free for 6 years now and my weight goes up and down. It’s very hard because I work out and eat right. Can you tell me what I can do to maintain a healthy weight?

One thing that can cause weight to fluctuate is unrealistic expectations of what an “ideal” weight is for ourselves. If we set this number too low, it’s easy to fall into a pattern where we reach the so-called “magic weight,” then we relax our vigilance on diet and exercise and the pounds creep back up.

We notice the gain, recommit to that “magic number” on the scale, and go back into dieting mode. Over time, weight goes up and down.

The good news? Current research does not show that so-called “yo-yo” dieting harms metabolism, physical health, or psychological wellbeing. It’s reassuring to know that despite what others may tell you, you have not done any permanent “damage” to your metabolism by losing and regaining the same few pounds.

However, even if losing and regaining weight isn’t slowing your metabolism, going up and down on the scale isn’t fun. To prevent the pattern from repeating, it’s important to figure out why this is happening.

Having an unrealistic goal can contribute to weight regain. If you only hit your "ideal" or lowest weight a couple of times per year, and the rest of the time you’re struggling to get back to it, you probably need to reassess whether this weight is right for you. Perhaps allowing yourself a “goal weight” that is a few pounds heavier will help you avoid the constant up and down.

Another thing to assess is whether or not you’re truly eating what you think you’re eating. For many of us, myself included, we have what is called “portion creep.” Over time, we tend to eat a little more here and a little more there. This can add up and contribute to a slowly increasing weight. When you notice your weight starting to creep up — and you don’t need the scale to tell you your clothes are a little snug — start writing down what you’re eating.

Nobody enjoys keeping a food diary, but even just a couple of days of writing down your food intake can help you notice if you’re eating more than you thought you were. This can help raise your awareness and get you back on track with your usual healthy eating habits.

What is the best way to manage fatigue and find the energy to exercise?

It may sound silly, but the best way to gain energy is to exercise. This is particularly true for fatigue related to cancer treatment. Researchers have found that the less active people are during and after cancer treatment, the more fatigued they feel.

Even if we know this is the case, getting up the energy to begin exercise is easier said than done. The following tips can help you tap into physical activity and feel more energetic.

• Rule out medical causes. First, talk with your doctor or nurse to rule out any medical causes of ongoing fatigue. If you have low red blood cell counts, for example, there may be medications or nutrients, such as iron, vitamin B12, and folate, that can help bring these counts back up.
• Start slow. If you haven’t been exercising, set some modest goals, such as taking a 15- to 20-minute walk every day, or every other day.
• Break it up. When you feel your energy beginning to flag, stand up, stretch, and take a 5-minute break to walk around your building (work), your house, or to take a quick trip around the block. Do this multiple times per day and you will have the beginnings of a very good exercise plan.
• Make a date. Find someone to meet for activity. If you’ve committed to meet someone for a walk, it’s harder to opt out. Tell friends, family, support group members, or anyone who has ever offered, “how can I help?” that they can help by meeting up with you for a 15-minute walk.
• Don’t nap. It may seem like a nap is what you need when you’re fatigued, but for some people regularly napping can lead to more fatigue. Napping can disrupt your normal sleeping patterns, which means you won’t sleep soundly through the night. There is an exception to this: If you’ve always been a napper and this is part of your normal routine, then napping may be helpful. Just keep naps short — 20 minutes is ideal — to avoid going into a deep sleep.
• Be kind to yourself. Know that cancer treatment is a big challenge, and it may take some time to get back to feeling more "normal," in terms of energy levels. Many women find that it takes up to a year or more to regain energy. With time, they do  report that energy does come back.
• Eat right. Many women reach for food to bolster energy, but this only works if you’re eating the right things. Try to have protein, healthy fat, and/or fiber with every snack and meal. This will slow glucose (carbohydrate) absorption from the gut into the body and will result in a more sustained energy supply over time. Try fruit and nuts or nut butter, vegetables and bean or hummus dip, or plain Greek yogurt with fruit.
• Try something fun. Exercise doesn’t have to be drudgery. Instead of saying, “I have to go walking or jogging” or “I must get to the gym,” try a new activity you’ve never done before. Maybe a dance or yoga class would inspire you. You could try spinning, jazzercise, zumba, or any of the other "newer" exercise options that are designed to be more fun and interesting than trudging away on the treadmill. Your local Y may even have exercise classes designed specifically for individuals affected by cancer.

I have a sit-down job. How can I get up and get some exercise?

When you feel your energy beginning to flag, stand up, stretch, and take a 5-minute break to walk around your office building , your house, or around the block.

If possible, ask your employer if a standing desk, or “sit-to-stand” desk can be installed in your office or cubicle. Sitting is one of the lowest energy states for the body (when awake!). Even standing for part of the day can burn significantly more calories, and reduce the risk of heart disease, diabetes, high blood pressure and stroke.

If you haven’t been exercising, set some modest goals, such as taking a 15- to 20-minute walk every day, or every other day. Find someone to meet for activity, too. If you’ve committed to meet someone for a walk, it’s harder to opt out.

When you’re not at work, make it a priority to avoid sitting around. Limit TV and computer time — the two biggest contributors to sitting at home — and make it a priority to move. This could include chores, walks, or anything that keeps your butt out of the chair.

How can I rev up my metabolism?

Do you exercise regularly? If not, this is the first thing you can do to rev up a sluggish metabolism. If you’re already engaged in regular, daily physical activity, you may need to mix it up a bit.

Our bodies adapt to activity, so the only way to keep improving fitness levels and keep our metabolism humming, is to keep the body guessing. For example, stead-state cardio, such as jogging at a set pace, needs to be mixed with what is called high-intensity interval training, or HIIT.

Interval training is one of the most effective ways to rev up metabolism. You don’t need to do hours of this type of training, just 15 or 20 minutes — as long as you are truly going “all out” during the high-intensity phase — a few times per week can greatly increase metabolism.

In addition to HIIT, you can benefit from adding some resistance or strength training to your regular activities. Muscles are what burn calories, so the more muscle you have, the higher your metabolic rate. Even something as simple as using your own body weight for resistance can be enough to build muscle mass.

Examples of “body weight” resistance training include push-ups, sit-ups, walking lunges and using stretchy bands to challenge your muscles.

If you already do regular strength training, you may benefit from trying new ways of challenging your muscles.

One final note on training: A trainer can walk you through these routines, and show you proper form so you can safely complete your workouts. Just be sure any trainer you work with is respectful of your health history and understands any limitations you may have due to cancer or previous injuries.

Could you please explain why it is so difficult to lose weight after being put into early, immediate menopause? I had to have a lumpectomy, radiation therapy, a hysterectomy and I am currently on letrozole (Femara). I can't keep the weight off and it seems to take an extraordinary amount of exercise to even lose a few pounds!

About half of women who are treated for breast cancer will gain weight during or after treatment.

There is some good news. Researchers have found that if women engage in regular resistance training during and after cancer treatment, including activities such as push ups, sit ups, walking lunges, using stretchy bands to challenge your muscles, or lifting weights, they are much less likely to gain weight. Resistance training preserves your muscle tissue, and this in turn keeps your metabolism higher.

If resistance training is combined with regular cardio or aerobic activities, weight gain is even less likely to occur. Combining regular weight training with regular aerobic activity also is key for losing weight.

If you’ve never done any resistance training, ask your doctor for a referral to a cancer rehabilitation specialist or physical therapist. Also, if you’ve recently had surgery, be sure to get the OK from your doctor that you can begin some moderate resistance training. Fortunately, the latest research shows that women will not increase the risk of lymphedema by strength training.

Does tamoxifen cause weight gain, especially around the midsection? And when I stop taking it, will I have an easier time losing the extra fat there? I have 10 months of the 5-year treatment left.

Tamoxifen is associated with weight gain, though not as much as many women believe. Health experts note that about 5 to 10 pounds of weight gain during and after breast cancer treatment may be due to tamoxifen. Certainly, 10 pounds is noticeable, and it’s not insignificant. However, tamoxifen alone isn’t the main reason why women gain 20, 30, or even 40 pounds after a breast cancer diagnosis.

Excessive weight gain is because the body is going through a sort of “accelerated” aging, in terms of loss of lean body mass and slowing of metabolism.

Regarding where the weight goes – your midsection vs. other areas of the body – tamoxifen may contribute to a thicker middle. Many women put on weight in their mid-section as they age, and this is generally attributed to decreasing estrogen levels. Since tamoxifen actively works to block the activity of estrogen in many tissues, it can contribute to weight gain around the belly.

There is no way to know if you will have an easier time losing weight in your mid-section after going off of tamoxifen. If you are postmenopausal, have received chemotherapy that caused your period to stop or are at an age at which it is very unlikely that your menstrual cycles will resume, you may not notice much difference in that “mid-section” weight. Again, this is because your estrogen levels are lower than when you were younger.

However, every woman is different. There’s no good way to know how your body will feel, or whether or not you’ll find weight loss easier, after you stop taking tamoxifen.

I am taking estrogen suppression medication as ongoing therapy. Since I had my chemical menopause, I find it very hard to lose even 5 pounds. I work out regularly. Can you suggest some dietary changes?

The single best way to improve diet is to add in more plant foods, especially vegetables and fruit. These foods have a low calorie density. This means you can eat more of them, without taking in a lot of calories.

For example, if you picture what 500 calories of apples or broccoli looks like, you would picture huge piles of food, much more than you could possibly eat in one sitting, and probably in one day! On the other hand, 500 calories of French fries or potato chips is a much smaller volume of food. It’s easier to overeat calorie-dense foods than it is to overeat vegetables and fruit.

In addition to this, try to have protein, healthy fat and/or fiber with every snack and meal. This will slow glucose (carbohydrate) absorption from the gut into the body, and will result in a more sustained energy supply over time. Try fruit and nuts or nut butter, vegetables and bean or hummus dip, or plain Greek yogurt with fruit.

It’s OK to have some calorie-dense foods, especially healthy ones, such as nuts and nut butters, but keep portions modest, and pair them with vegetables and fruit for the most balanced and healthy diet.