Food Safety for Patients Who Are Immunosuppressed

Food Safety
for Patients Who Are
Immunosuppressed
Definitions
IMMUNOSUPPRESSION is a decreased ability of the immune system to fight
infection or other diseases.
• The suppression of the normal immune response can occur as a result of disease
or drugs, such as some drugs used to treat cancer.
• Immunosuppression may also be deliberately induced with drugs, as in
preparation for bone marrow or other organ transplantation to prevent the
rejection of the transplant.
NEUTROPENIA is an abnormal decrease in a certain type of white blood cell,
called a neutrophil, that is made in the soft tissue center (marrow) of most bones.
• Neutrophils play an essential role in fighting bacterial and fungal infections
by surrounding and destroying invading organisms.
• Neutropenia most often occurs when the bone marrow does not make enough
neutrophils or when neutrophils are destroyed rapidly.
• This condition can happen quickly as the result of disease or drugs, or
neutropenia can develop slowly over time.
• Neutropenia puts a person at risk for infections.
ABSOLUTE NEUTROPHIL COUNT An absolute neutrophil count (ANC) measures
the percentage of neutrophils in your white blood count.
• A normal ANC is over 1,500.
• An ANC of 500 to 1,000 is considered neutropenic.
• A person whose ANC is less than 500 has severe neutropenia.
Food Safety for Patients
Who Are Immunosuppressed
his booklet provides a food safety guide for patients who are
immunosuppressed. The purpose of the guide is to help protect
you from the harmful bacteria found in some foods. Your doctor
will let you know when the diet is no longer required. This booklet contains tips and suggestions about which foods you can safely eat, while
also listing foods to avoid. It may come as a surprise that many of the
foods you already enjoy are safe to eat, providing that you follow the
“Food Safety Tips” when preparing your meals.
T
It is important to maintain good nutrition during your recovery. Nutrition
helps your immune system become stronger. If you are having trouble
eating for any reason, tell your doctor, nurse or dietitian. They will assist
you. Skipping meals is not a good option. “MyPlate,” recently developed
by the United States Department of Agriculture (USDA) to replace what
was known as “MyPyramid,” illustrates the different food groups that are
a part of a healthy diet. MyPlate is a model for healthy eating and serves
as a simple tool to help you create a well-balanced diet. For more information go to ChooseMyPlate.gov. If necessary, your dietitian will give you
specific information about your diet plan and how it fits within the
guidelines of the USDA’s food plate tool.
REMEMBER: During your treatment and recovery, it is very important
to eat well and fuel your body. Food helps you build strength, maintain
your weight and improve your immune system.
TABLE OF CONTENTS
Why Is It Important
to Follow the
Food Safety Tips?
2
Food Preparation and
Kitchen Safety Tips
4
Handwashing
5
Appropriate Diet
for Patients with
Neutropenia
6
Bibliography
16
Why Is It Important to Follow the Food Safety Tips?
Food-borne illnesses are a real danger when you are immunosuppressed. An abnormally low count of an infection-fighting white blood cell, called neutrophils, is known
as neutropenia. Low neutrophils or absolute neutrophil count (ANC) can be caused as
a side effect of medications, chemotherapy, biotherapy, radiation and possibly by the
cancer. With a low ANC, your immune system is not strong enough to fight off bacteria
and you may get infections. When this happens, you are considered to be neutropenic.
PATIENTS WHO MAY NEED TO FOLLOW THIS DIET INCLUDE:
• Any patient with an absolute neutrophil count below 1,000
• Any patient with an autologous transplant undergoing chemotherapy
• Any patient with an allogeneic transplant who is on immunosuppressive medication
• Any patient with a solid organ transplant who is on immunosuppressive medication
• Any patient with medication-induced neutropenia
Special Note for Patients Having Bone
Marrow Transplantation
• For patients having an autologous transplant and undergoing chemotherapy only,
follow the diet during the first few months after chemotherapy or transplant, or until
your doctor tells you that you no longer need this diet.
• For patients having an allogeneic transplant, follow the diet until you are off all
immunosuppressive therapy such as cyclosporine, prednisone, FK-506 or
tacrolimus (Prograf®), mycophenolate mofetil or MMF (CellCept®) and
thalidomide (Thalomid®).
• Prior to the end of these time periods, patients and their caregivers should discuss
with their physician whether the diet or parts of the diet should be continued.
2
Dietitian Services
You may find it helpful to speak with a dietitian. A dietitian can assist you even when
you are finished with cancer treatment. The dietitian can help you return to healthy
eating habits or discuss ways to manage any lasting eating problems.
For Nutritional Services in the Hospital, call (631) 444-1433.
For the Cancer Center, call (631) 638-1000.
“MyPlate”
In June 2011, the U.S. Department of Agriculture introduced “MyPlate” as an easyto-understand symbol about how to eat healthy, replacing the “MyPyramid” symbol
previously used. MyPlate was introduced along with the 2010 Dietary Guidelines for
Americans, the federal government's evidence-based nutritional guidance to promote
health, reduce the risk of chronic diseases, and reduce the prevalence of being overweight and obese through improved nutrition and physical activity.
• MyPlate is a new icon to serve as a reminder to help consumers make
healthier food choices.
• MyPlate is not intended to provide specific messages or a rigid prescription,
but rather is a general guide to help you choose a healthful diet that is right
for you.
• MyPlate promotes fruits and vegetables, grains, proteins (such as meat, fish, and
poultry) and dairy so that you get the nutrients you need and, at the same time,
the right amount of calories to maintain healthy weight.
Go to ChooseMyPlate.gov for practical information about building healthy diets.
3
Food Preparation and Kitchen Safety Tips
• Wash your hands, utensils and countertops before and after you prepare food.
This is most important when preparing raw meat, poultry or fish.
• Prepare your raw meats separate from fruits and vegetables.
• Use one cutting board for meat and a different board for fruits and vegetables.
Some cooks find it helpful to have different colored cutting boards for meat and
vegetables.
• Wash your hands, utensils and countertops between the handling of raw meat,
poultry, fish and vegetables to avoid bacterial transfer.
• Scrub all raw fruits and vegetables before you eat them.
• Do not eat foods (like raspberries) that cannot be washed well. You should
scrub fruits and vegetables that have rough surfaces, such as melons, before
you cut them.
• Thaw frozen food in the refrigerator or defrost them in the microwave. Do not
leave them sitting out.
• Cook meat, poultry and eggs thoroughly. Meats should not have any pink inside.
Eggs should be hard, not runny. (See temperature chart.)
• Do not keep refrigerated leftovers for more than three days.
• Keep hot foods hot (more than 140 degrees Fahrenheit) and cold foods cold
(less than 40 degrees Fahrenheit). Put leftovers in the refrigerator as soon as
you are done eating.
• Avoid canned foods that are swollen, dented or damaged.
• Wash the top of canned foods before opening. Clean the can opener before
and after use.
4
• Check dates on foods and do not buy or use food that is outdated. Throw away
foods with mold.
• Buy food in small amounts so they will be fresh when eaten.
• Choose snack-sized or single-serving packages. These may help you measure
portions and not waste food.
• Do not eat from salad bars and buffets when eating out.
• Do not use a sponge. When hand washing dishes, use a disposable cloth or
launder after each use. Let dishes air dry. If possible, use a dishwasher.
Temperature Chart*
STEAKS
AND ROASTS
GROUND
MEAT
POULTRY
PORK
AND HAM
EGGS AND
EGG DISHES
SEAFOOD
CASSEROLES
AND LEFTOVERS
145°F
165°F
165°F
160°F
145°F
145°F
165°F
*Cook foods to the minimum internal temperature
Handwashing
Proper handwashing is essential to help reduce the spread of illness, especially during
food preparation.
To properly wash your hands, first thoroughly wet hands with warm water, then apply
liquid or clean bar soap. Rub your hands vigorously together for at least 20 seconds,
scrubbing all surfaces including between fingers and under nails. Then rinse well and
dry. Keep in mind that it is the soap combined with the scrubbing that helps to dislodge
and remove germs and dirt. (www.nsf.org)
5
APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA
Dairy
ALLOWED
AVOID
FOOD SAFETY TIPS
• All pasteurized grade A
milk and milk products
• Non-pasteurized
dairy products
• Commercially packaged cheese and
cheese products made
with pasteurized milk
(e.g., cheddar, mozzarella, Parmesan,
Swiss, etc.)
• Cheese from
delicatessens
• Return refrigerated
items to the refrigerator
immediately after use;
do not allow them to
remain out.
• Pasteurized and
probiotic yogurt
• Refrigerated or frozen
pasteurized whipped
topping
• Ice cream, frozen
yogurt, sherbet, homemade milkshakes
• Commercial medical
nutrition supplements
and baby formulas,
liquid and powdered
• Commercial eggnog
• Soy milk. Other
nondairy milk or milk
products, if pasteurized
6
• Cheeses containing
chili peppers or other
uncooked vegetables
• Cheeses with molds
(e.g., blue, Stilton,
Roquefort and
Gorgonzola)
• Sharp cheddar,
Brie, Camembert,
feta and farmer’s
cheese
• Mexican soft
cheeses, such as
queso fresco and
queso blanco
• Ice cream and
milkshakes from
self-serve machines
Meat/Poultry/Meat Substitutes
ALLOWED
AVOID
FOOD SAFETY TIPS
• All well-done meats or
poultry
• Raw or undercooked
meats
• Canned meats
• Refrigerated pâté
• Cook poultry to an
internal temperature
of 165°F.
• Cooked tofu
• Tempe (tempeh)
products
• All miso products such
as miso soup and miso
paste
• Cook ground meat to
an internal temperature
of 165°F.
• Cook roasts and steaks
to an internal temperature of 145°F.
Hot Dogs/Deli Meats
ALLOWED
AVOID
FOOD SAFETY TIPS
• Commercially packaged cold cuts and
hot dogs, if heated
until steaming hot
(microwave, pan fry,
grill or boil)
• Raw or undercooked
hot dogs unless heated
until steaming hot
• Do not eat hot dogs
from street carts or that
are left standing in
water baths or trays.
• Refrigerated, pre-made
salads (egg, ham,
chicken, tuna or
seafood salad)
• Meats and cold cuts
from delicatessens
• Hard-cured salami in
natural wrap
7
APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA
Fish/Shellfish
ALLOWED
AVOID
FOOD SAFETY TIPS
• All well-cooked fish
and shellfish
• Smoked fish (nova
style, lox, kippered,
smoked or jerky),
unless fully cooked,
canned or commercially packaged
• Cook seafood to an
internal temperature
of 145°F.
• Canned fish and
shellfish
• Any raw or undercooked fish (sushi,
sashimi and ceviche)
Eggs
ALLOWED
AVOID
FOOD SAFETY TIPS
• All eggs cooked
well-done
• Eggs with runny yolk
such as poached or
over easy
• Cook eggs and egg
dishes to an internal
temperature of 145°F.
• All pasteurized eggs
and egg substitutes
(egg beaters) cooked
well-done
8
Fruits and Vegetables
ALLOWED
AVOID
FOOD SAFETY TIPS
• All whole (un-cut) fresh
fruits and vegetables
that have been thoroughly rinsed under
running water
• Unwashed fresh fruits
and vegetables
• Use a separate cutting
board that is used
only for fruits and
vegetables.
• Cooked, canned, dried
or frozen fruits and
vegetables
• Bagged lettuce and
baby carrots if rinsed
after purchase
• Canned or bottled salsa
• Cooked or canned
bean sprouts
• Pre-cut fresh fruits and
vegetables unless used
in cooking
• Fresh salsa from
the grocery store or
restaurant
• Do not eat fresh
berries or thin-skinned
fruits like strawberries,
blueberries, raspberries
or grapes.
• Raw sprouts of any
kind (alfalfa or bean
sprouts)
• Foods from salad bars
FOOD SAFETY TIPS
9
APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA
Beverages
ALLOWED
AVOID
FOOD SAFETY TIPS
• All soft drinks
• Self-serve fountain
drinks
• Keep cold beverages
cold and hot
beverages hot.
• Fountain drinks
without ice that are
not self-serve
• Pasteurized fruit
and vegetable juices
• Smoothies and
vegetable drinks
made at home
• Coffee from coffee
shops; creamer must
be provided by personnel from behind
the counter
• Brewed herbal teas
using commercially
packaged tea bags
10
• Smoothies and
vegetable drinks
made in restaurants
or juice bars
• Self-serve creamer
from pitcher
• Self-serve water from
public facility
• Cold-brewed tea made
with warm or cold water
• Wine, unpasteurized
beer (alcoholic
beverages should be
consumed only with
physician approval)
• Avoid ice from
restaurants and
self-service.
Water
ALLOWED
AVOID
FOOD SAFETY TIPS
• County and city water
• Water from a well,
unless chlorinated
and tested
• If you choose to use a
pitcher filter, you will
have to wash it daily.
• Ice from restaurants
or self-serve ice
• Remove the filter
(place filter in a clean
bowl or cup) and wash
the entire pitcher and
all parts with warm
soapy water, then
replace filter.
• Bottled water from
NSF-approved sources
or water that is purified
with reverse osmosis
(Go to nsf.org for a list
of current approved
bottled water)
• Some bottled waters,
including Dasani®,
Aquafina®, Publix®,
Nestle®, Fiji®, Crystal
Springs® and
Zephyrhills®
• Follow manufacturer
instructions for when
to change the filter.
• Ice made at home
AVOID
11
APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA
Condiments
ALLOWED
AVOID
FOOD SAFETY TIPS
• Those purchased
for home use or
individually packaged
(catsup, mustard,
BBQ sauce, soy sauce)
Refrigerate after
opening
• All self-serve dispensers
in restaurants (catsup,
mustard, etc.)
• Read all food labels.
• Commercial pasteurized Grade A honey
• Salt, granulated sugar,
brown sugar
• Commercial jam, jelly
and syrups
• Vinegar
• Pickles, pickle relish
and olives
Refrigerate after
opening
12
• Herbal and nutrient
supplement preparations
• Raw honey; honey in
the comb
• Adding spice or
seasoning, including
pepper, after cooking
• Pickles from a pickle
barrel
• Check the expiration
dates on all food items
and circle the date for
future reference.
• Prepare meals with
spices and seasoning,
but avoid adding
seasoning after foods
are cooked.
Nuts
ALLOWED
AVOID
FOOD SAFETY TIPS
• Nuts in baked products
• Unroasted raw nuts
and unroasted nuts in
the shell
• Do not eat nuts from
a common bowl shared
by many other people.
• Shelled, roasted nuts
• Canned or bottled nuts
• Commercially packaged
peanut butter, almond
butter, soybean butter
Bread/Grain and Cereal Products
ALLOWED
AVOID
FOOD SAFETY TIPS
• All breads, bagels,
rolls, English muffins,
muffins, pancakes,
sweet rolls, waffles,
French toast
• Raw (not baked or
cooked) grain products
(such as raw oats)
• Try apples, bananas,
and walnuts in your
cereal and avoid
berries.
• Potato chips, corn
chips, tortilla chips,
pretzels, popcorn
• Breads, rolls,
and pastries in
self-serve bins
• Cooked grains and
grain products, including pasta and rice
• All cereals cooked and
ready to eat
13
APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA
Desserts
ALLOWED
AVOID
FOOD SAFETY TIPS
• Refrigerated, commercial and homemade
cakes, pies, pastries
and pudding
• Unrefrigerated creamfilled pastries, not
shelf-stable
• Avoid sweets that are
in containers or bins
where people are
sharing food.
• Refrigerated creamfilled pastries
• Cookies, both
homemade and
commercially prepared
• Shelf-stable creamfilled cupcakes and
fruit pies (Twinkies®,
Ding Dongs®, Pop
Tarts®, Hostess®
fruit pies)
• Ices and popsicles
• Gum and candy
14
• Self-serve candy FOOD
Fats
ALLOWED
AVOID
FOOD SAFETY TIPS
• Vegetable oils and
shortening
• Fresh salad dressings
(stored in the grocer’s
case) containing raw
eggs or cheeses listed
as foods to avoid under
“Dairy” on page 6
• Do not re-use oils and
fats once they have
been used to prepare
a meal.
• Refrigerated lard,
margarine and butter
• Commercial, shelfstable mayonnaise
and salad dressings,
including blue cheese
and other cheesebased salad dressings
Refrigerate after
opening
• Cooked gravy and
sauces
Disclaimer: If you are following a special diet for a medical condition, please consult
with your primary care physician or specialist before making any changes to your diet.
15
Bibliography
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Caring 4 Cancer. (2010). Food safety during cancer treatment. Retrieved May 19, 2010, from
http://www.caring4cancer.com/go/cancer/nutrition/eatingwell/food-safety-during-cancer-treatment.htm
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Moody, K., Finlay, J., Mancuso, C., & Charlson, C. (2006). Feasibility and safety of a pilot randomized trial of infection rate: neutropenic diet
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Restau, J., & Clark, A. P. (2008). The neutropenic diet: does the evidence support this intervention? Clinical Nurse Specialist, 22, 208-211.
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http://www.seattlecca.org/nutrition-diets-and-guidelines.cfm
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neutropenic-diet.aspx
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Notes
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