for Patients Who Are Immunosuppressed

Food Safety

DefinitionsIMMUNOSUPPRESSION 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 enoughneutrophils 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

This booklet provides a food safety guide for patients who are immunosuppressed. The purpose of the guide is to help protectyou from the harmful bacteria found in some foods. Your doctor

will let you know when the diet is no longer required. This booklet con-tains tips and suggestions about which foods you can safely eat, whilealso listing foods to avoid. It may come as a surprise that many of thefoods you already enjoy are safe to eat, providing that you follow the“Food Safety Tips” when preparing your meals.

It is important to maintain good nutrition during your recovery. Nutritionhelps your immune system become stronger. If you are having troubleeating for any reason, tell your doctor, nurse or dietitian. They will assistyou. Skipping meals is not a good option. “MyPlate,” recently developedby the United States Department of Agriculture (USDA) to replace whatwas known as “MyPyramid,” illustrates the different food groups that area part of a healthy diet. MyPlate is a model for healthy eating and servesas a simple tool to help you create a well-balanced diet. For more infor-mation go to ChooseMyPlate.gov. If necessary, your dietitian will give youspecific 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, maintainyour weight and improve your immune system.

TABLE OF CONTENTS

Why Is It Important to Follow theFood 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 abnor-mally low count of an infection-fighting white blood cell, called neutrophils, is knownas neutropenia. Low neutrophils or absolute neutrophil count (ANC) can be caused asa side effect of medications, chemotherapy, biotherapy, radiation and possibly by thecancer. With a low ANC, your immune system is not strong enough to fight off bacteriaand 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 untilyour doctor tells you that you no longer need this diet.

• For patients having an allogeneic transplant, follow the diet until you are off allimmuno suppressive therapy such as cyclosporine, prednisone, FK-506 ortacrolimus (Prograf®), mycophenolate mofetil or MMF (CellCept®) and thalidomide (Thalomid®).

• Prior to the end of these time periods, patients and their caregivers should discusswith their physician whether the diet or parts of the diet should be continued.

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Dietitian ServicesYou may find it helpful to speak with a dietitian. A dietitian can assist you even whenyou are finished with cancer treatment. The dietitian can help you return to healthyeating 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 easy-to-understand symbol about how to eat healthy, replacing the “MyPyramid” symbol previously used. MyPlate was introduced along with the 2010 Dietary Guidelines forAmericans, the federal government's evidence-based nutritional guidance to promotehealth, reduce the risk of chronic diseases, and reduce the prevalence of being over-weight 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, andpoultry) 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.

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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 andvegetables.

• 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.

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Temperature Chart*

*Cook foods to the minimum internal temperature

• Check dates on foods and do not buy or use food that is outdated. Throw awayfoods 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.

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STEAKS GROUND POULTRY PORK EGGS AND SEAFOOD CASSEROLESAND ROASTS MEAT AND HAM EGG DISHES AND LEFTOVERS

145°F 165°F 165°F 160°F 145°F 145°F 165°F

HandwashingProper handwashing is essential to help reduce the spread of illness, especially duringfood preparation.

To properly wash your hands, first thoroughly wet hands with warm water, then applyliquid 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 anddry. Keep in mind that it is the soap combined with the scrubbing that helps to dislodgeand remove germs and dirt. (www.nsf.org)

APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA

ALLOWED

• All pasteurized grade Amilk and milk products

• Commercially pack-aged cheese andcheese products madewith pasteurized milk(e.g., cheddar, moz-zarella, Parmesan,Swiss, etc.)

• Pasteurized and probiotic yogurt

• Refrigerated or frozenpasteurized whippedtopping

• Ice cream, frozen yogurt, sherbet, home-made milkshakes

• Commercial medicalnutrition supplementsand baby formulas, liquid and powdered

• Commercial eggnog

• Soy milk. Othernondairy milk or milkproducts, if pasteurized

AVOID

• Non-pasteurized dairy products

• Cheese from delicatessens

• Cheeses containing chili peppers or otheruncooked vegetables

• Cheeses with molds(e.g., blue, Stilton,Roquefort and Gorgonzola)

• Sharp cheddar, Brie, Camembert, feta and farmer’scheese

• Mexican soft cheeses, such as queso fresco and queso blanco

• Ice cream and milkshakes from self-serve machines

FOOD SAFETY TIPS

• Return refrigerateditems to the refrigeratorimmediately after use;do not allow them to remain out.

Dairy

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ALLOWED

• All well-done meats orpoultry

• Canned meats

• Cooked tofu

AVOID

• Raw or undercookedmeats

• Refrigerated pâté

• Tempe (tempeh) products

• All miso products suchas miso soup and misopaste

FOOD SAFETY TIPS

• Cook poultry to an internal temperature of 165°F.

• Cook ground meat to an internal temperature of 165°F.

• Cook roasts and steaks to an internal tempera-ture of 145°F.

Meat/Poultry/Meat Substitutes

ALLOWED

• Commercially pack-aged cold cuts and hot dogs, if heated until steaming hot (microwave, pan fry,grill or boil)

AVOID

• Raw or undercookedhot dogs unless heateduntil steaming hot

• Refrigerated, pre-madesalads (egg, ham,chicken, tuna orseafood salad)

• Meats and cold cutsfrom delicatessens

• Hard-cured salami innatural wrap

FOOD SAFETY TIPS

• Do not eat hot dogsfrom street carts or thatare left standing inwater baths or trays.

Hot Dogs/Deli Meats

ALLOWED

• All well-cooked fish and shellfish

• Canned fish and shellfish

AVOID

• Smoked fish (novastyle, lox, kippered,smoked or jerky), unless fully cooked,canned or commer-cially packaged

• Any raw or under-cooked fish (sushi,sashimi and ceviche)

FOOD SAFETY TIPS

• Cook seafood to an internal temperature of 145°F.

Fish/Shellfish

ALLOWED

• All eggs cooked well-done

• All pasteurized eggsand egg substitutes(egg beaters) cookedwell-done

AVOID

• Eggs with runny yolksuch as poached orover easy

FOOD SAFETY TIPS

• Cook eggs and eggdishes to an internal temperature of 145°F.

Eggs

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APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA

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ALLOWED

• All whole (un-cut) freshfruits and vegetablesthat have been thor-oughly rinsed underrunning water

• Cooked, canned, driedor frozen fruits and vegetables

• Bagged lettuce andbaby carrots if rinsedafter purchase

• Canned or bottled salsa

• Cooked or cannedbean sprouts

AVOID

• Unwashed fresh fruitsand vegetables

• Pre-cut fresh fruits andvegetables unless usedin cooking

• Fresh salsa from the grocery store or restaurant

• Raw sprouts of anykind (alfalfa or beansprouts)

• Foods from salad bars

FOOD SAFETY TIPS

FOOD SAFETY TIPS

• Use a separate cuttingboard that is used only for fruits and vegetables.

• Do not eat fresh berries or thin-skinnedfruits like strawberries,blueberries, raspberriesor grapes.

Fruits and Vegetables

ALLOWED

• All soft drinks

• Fountain drinks without ice that are not self-serve

• Pasteurized fruit and vegetable juices

• Smoothies and vegetable drinks made at home

• Coffee from coffeeshops; creamer mustbe provided by per-sonnel from behind the counter

• Brewed herbal teasusing commerciallypackaged tea bags

AVOID

• Self-serve fountain drinks

• Smoothies and vegetable drinks made in restaurants or juice bars

• Self-serve creamer from pitcher

• Self-serve water frompublic facility

• Cold-brewed tea madewith warm or cold water

• Wine, unpasteurizedbeer (alcoholic beverages should beconsumed only withphysician approval)

FOOD SAFETY TIPS

• Keep cold beveragescold and hot beverages hot.

• Avoid ice from restaurants and self-service.

Beverages

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APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA

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ALLOWED

• County and city water

• Bottled water fromNSF-approved sourcesor water that is purifiedwith reverse osmosis(Go to nsf.org for a listof current approvedbottled water)

• Some bottled waters, including Dasani®,Aquafina®, Publix®,Nestle®, Fiji®, CrystalSprings® andZephyrhills®

• Ice made at home

AVOID

AVOID

• Water from a well, unless chlorinated and tested

• Ice from restaurants or self-serve ice

FOOD SAFETY TIPS

• If you choose to use apitcher filter, you willhave to wash it daily.

• Remove the filter (place filter in a cleanbowl or cup) and washthe entire pitcher andall parts with warmsoapy water, then replace filter.

• Follow manufacturer instructions for when to change the filter.

Water

ALLOWED

• Those purchased for home use or individually packaged (catsup, mustard, BBQ sauce, soy sauce)Refrigerate after opening

• Commercial pasteur-ized Grade A honey

• Salt, granulated sugar,brown sugar

• Commercial jam, jellyand syrups

• Vinegar

• Pickles, pickle relishand olives Refrigerate after opening

AVOID

• All self-serve dispensersin restaurants (catsup,mustard, etc.)

• Herbal and nutrientsupplement prepara-tions

• Raw honey; honey inthe comb

• Adding spice or seasoning, includingpepper, after cooking

• Pickles from a picklebarrel

FOOD SAFETY TIPS

• Read all food labels.

• Check the expirationdates on all food itemsand circle the date forfuture reference.

• Prepare meals withspices and seasoning,but avoid adding seasoning after foodsare cooked.

Condiments

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APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA

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ALLOWED

• Nuts in baked products

• Shelled, roasted nuts

• Canned or bottled nuts

• Commercially packagedpeanut butter, almondbutter, soybean butter

AVOID

• Unroasted raw nutsand unroasted nuts inthe shell

FOOD SAFETY TIPS

• Do not eat nuts from a common bowl sharedby many other people.

Nuts

ALLOWED

• All breads, bagels, rolls, English muffins,muffins, pancakes,sweet rolls, waffles,French toast

• Potato chips, cornchips, tortilla chips,pretzels, popcorn

• Cooked grains andgrain products, includ-ing pasta and rice

• All cereals cooked andready to eat

AVOID

• Raw (not baked orcooked) grain products(such as raw oats)

• Breads, rolls, and pastries in self-serve bins

FOOD SAFETY TIPS

• Try apples, bananas,and walnuts in your cereal and avoidberries.

Bread/Grain and Cereal Products

ALLOWED

• Refrigerated, commer-cial and homemadecakes, pies, pastriesand pudding

• Refrigerated cream-filled pastries

• Cookies, both homemade and commercially prepared

• Shelf-stable cream-filled cupcakes and fruit pies (Twinkies®,Ding Dongs®, PopTarts®, Hostess®

fruit pies)

• Ices and popsicles

• Gum and candy

AVOID

• Unrefrigerated cream-filled pastries, not shelf-stable

• Self-serve candy FOOD

FOOD SAFETY TIPS

• Avoid sweets that are in containers or binswhere people are sharing food.

Desserts

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APPROPRIATE DIET FOR PATIENTS WITH NEUTROPENIA

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ALLOWED

• Vegetable oils andshortening

• Refrigerated lard, margarine and butter

• Commercial, shelf-stable mayonnaise and salad dressings, including blue cheeseand other cheese- based salad dressingsRefrigerate after opening

• Cooked gravy andsauces

AVOID

• Fresh salad dressings(stored in the grocer’scase) containing raweggs or cheeses listedas foods to avoid under“Dairy” on page 6

FOOD SAFETY TIPS

• Do not re-use oils andfats once they havebeen used to prepare a meal.

Fats

Disclaimer: If you are following a special diet for a medical condition, please consultwith your primary care physician or specialist before making any changes to your diet.

BibliographyAmerican Dietetic Association. (2010). Hematopoietic stem cell nutrition therapy. Retrieved May 19, 2010, fromhttp://www.nutritioncaremanual.org/vault/editor/Docs/HSCTNutritionTherapy_FINAL.pdf

Belfast Health and Social Care Trust. (2008, April 18). Good food. Retrieved May 19, 2010, http://www.belfasttrust.hscni.net/livewell/GoodFood.htm

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

Centers for Disease Control. (2000, October 20). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplantrecipients. Morbidity and Mortality Weekly Report. Retrieved April 27, 2010, from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4910a1.htm

DeMille, D., Deming, P., & Lupinacci, P. (2006). The effect of a neutropenic diet in the outpatient setting: a pilot study. Oncology Nursing Forum, 33, 337-343.

Mank, A., Davies, M., Langeveld, N., Van de Wetering, M. D., & Van de Lelie, H. (2008). Low bacterial diet to prevent infection in neutropenic patients. The Conchrane Collaboration, 1-9.

Mattson, J. (2006). Poor oral nutrition after allogeneic sct correlates significantly with severe gvhd. Bone Marrow Transplantation, 629-633.

Moody, K., Finlay, J., Mancuso, C., & Charlson, C. (2006). Feasibility and safety of a pilot randomized trial of infection rate: neutropenic dietversus standard food safety guidelines. Journal of Pediatric Hematology/Oncology, 126-133.

Nirenberg, A., Bush, A. P., Davis, A., Friese, C. R., Gillespie, T. W., & Rice, R. D. (2006). Neutropenia: state of the knowledge part II. Oncology Nursing Forum, 33, 1202-1208.

Restau, J., & Clark, A. P. (2008). The neutropenic diet: does the evidence support this intervention? Clinical Nurse Specialist, 22, 208-211.

Seattle Cancer Care Alliance. (2008, April 1) Diets and guidelines for specific needs. Retrieved April 20, 2010, fromhttp://www.seattlecca.org/nutrition-diets-and-guidelines.cfm

UPMC. (2008, May). Neutropenic diet. Retrieved April 20, 2010, from http://www.upmc.com/healthatoz/patienteducation/c/pages/neutropenic-diet.aspx

Wilson, B. J. (2002). Dietary recommendations for neutropenic patients. Seminars in Oncology Nursing, 18, 44-49.

Zitella, L. J., Friese, C. R., Hauser, J., Gobel, B. H., Woolery, M., O'Leary, C., et al. (2006). Putting evidence into practice: prevention of infection. Clinical Journal of Oncology Nursing, 739-750.

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