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VCU Health System

By Theodore Johnson,2014-07-11 19:16
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VCU Health System

    DIET GUIDELINES FOR IMMUNOSUPPRESSED PATIENTS

    Persons with decreased immune function due to chemotherapy and radiation are at increased risk of developing a food-related infection. The purpose of this diet is to help you avoid specific food choices. Choose foods from the ―Approved‖ column. Do not eat foods in the ―Not Allowed‖ column. You may want to discuss the safety of these or other foods with your dietitian.

    This diet should be followed before and after all conditioning (chemotherapy and/or radiation) therapy. Your doctor and dietitian will provide guidelines as to when the diet is no longer required. In general, we are recommending that chemotherapy only patients and autologous transplant patients follow the diet during the first three months after chemotherapy or transplant. Allogeneic transplant patients should follow the diet until off all immunosuppressive therapy (e.g., cyclosporine, tacrolimus, sirolimus, prednisone, cellcept, thalidomide, etc.). Prior to the end of these time periods, patients and their caregivers should discuss with their referring physician whether or not the diet or parts of the diet should be continued.

    Immunosuppressed Patient Diet

Food Groups Allowed Not Allowed

    All pasteurized, grade ―A‖ milk and Unpasteurized or raw milk, cheese,

    milk products yogurt, and other milk products Commercially packaged cheese and Cheeses from delicatessens cheese products made with pasteurized

     milk (e.g., mild and medium cheddar, Cheeses containing chili peppers or

     mozzarella, parmesan, swiss, etc.) other uncooked vegetables

    Pasteurized yogurt Cheeses with molds (e.g., blue, stilton, Roquefort, gorgonzola, etc.) Dairy Dry, refrigerated, and frozen pasteurized whipped topping Sharp cheddar, brie, camembert, feta

     cheese, farmer’s cheese

    Ice cream, frozen yogurt, sherbet, ice

    cream bars, homemade milkshakes Soft serve ice cream or yogurt

    Commercial nutritional supplements and

    baby formulas, liquid and powder

    Commercial pasteurized eggnog

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    Food Groups Allowed Not Allowed

    All well cooked or canned meats (beef, Raw or undercooked meat, poultry,

    pork, lamb, poultry, fish, shellfish, fish, game, tofu game, ham, bacon, sausage, hot dogs) Raw or undercooked eggs and egg Well cooked eggs substitutes

     Well cooked pasteurized egg substitutes Meats and cold cuts from

    (e.g., Egg Beaters?) delicatessens Meat and Meat i Substitutes Commercially packaged salami, Hard cured salami in natural wrap bologna, and other luncheon meats

     Cold smoked salmon (fish); lox

    Canned and commercially packaged

    hard-smoked fish; refrigerated after Pickled fish

    opening

     Tempe (Tempeh) products

    Cooked tofu

    All cooked entrees and soups All miso products (e.g., miso soup) Entrees, Soups

    Canned and frozen fruit and fruit juices Unwashed raw fruits

     Well washed raw fruit; foods containing Unroasted raw nuts well washed raw fruits Roasted nuts in the shell

     Dried fruits

    Fruits and Nuts Unpasteurized fruit and vegetable

    Canned or bottled roasted nuts juices

    Nuts in baked products

    Commercially packaged peanut butter

    All cooked frozen, canned, or fresh Unwashed raw vegetables or herbs

    vegetables and potatoes All raw vegetable sprouts (alfalfa, Well washed raw vegetables radish, cauliflower, broccoli, mung bean, all others)

     Fresh, well washed herbs and dried

    Vegetables herbs and spices (added to raw or Salads from delicatessens

    cooked foods)

    Commercial salsas stored in

    refrigerated case

    Raw mushrooms

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    Food Groups Allowed Not Allowed

    Tap water and ice made from tap water Well water (unless tested frequently

     and found to be free of coliforms) Commercial bottled distilled, spring, and natural waters Cold-brewed tea made with warm or cold water

     All canned, bottled, powdered beverages

     Unpasteurized commercial fruit and iiInstant and brewed coffee, tea; cold vegetable juices Beverages

    brewed tea made with boiling water

     Mate tea

    Brewed herbal teas using commercially

    packaged tea bags Alcohol

    Commercial nutritional supplements,

    liquid and powdered

    Refrigerated commercial and homemade Unrefrigerated, cream filled pastry

    cakes, pies, pastries, and pudding products (not shelf stable) Refrigerated, cream filled pastries

     Homemade and commercial cookies iiiDesserts

    Shelf stable cream filled cupcakes (e.g.,

    Twinkies?, Ding Dongs?, etc.), fruit

    pies (e.g., Pop Tarts?, Hostess Fruit

    Pies?), and canned pudding

    Ices, popsicle-like products

    All breads, bagels, rolls, muffins, Raw grain products

    pancakes, sweet rolls, waffles, French toast Bread, Grain, and Cereal Potato chips, corn chips, tortilla chips, ivProducts pretzels, popcorn

    Cooked pasta, rice, and other grains

    All cereals, cooked and ready-to-eat

    Oil, shortening Fresh salad dressings containing aged

     cheese (e.g., blue, Roquefort) or raw Refrigerated lard, margarine, butter eggs, stored in refrigerated cases Fats

    Cooked gravy and sauces

     (Continued next page)

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    Food Groups Allowed Not Allowed

    Commercial, shelf stable mayonnaise

    and salad dressings (including cheese Fats based salad dressings; refrigerated after

    opening)

    Salt, sugar, brown sugar Raw or non-heat treated honey; honey

     in the comb Jam, jelly syrups; refrigerated after opening Herbal and nutrient supplement preparations

     Commercial (heat treated and/or

     pasteurized) honey Brewers yeast, if eaten uncooked v Other

    Catsup, mustard, barbeque sauce, soy Pepper added to food after cooking

    sauce, other condiments (refrigerated

    after opening) Any raw uncooked spices such as

     cinnamon, ginger, nutmeg, etc.

    Pickles, pickle relish, olives

    (refrigerated after opening)

    Candy, gum

     i Tofu must be cut into 1 inch cubes, or smaller, and boiled a minimum of five minutes in water or broth before eating or using

     in recipes ii If using water service other than city water service recommend using distilled or bottled water. iii ―Shelf stable‖ refers to unopened canned, bottled, or packaged food products that can be stored, before opening, at room

     temperature; container may require refrigeration after opening. iv Recommend patients themselves not make (mix, knead) any bread product containing yeast. v No honey products allowed for children less than one year old and all children with SCIDS until nine months post transplant.

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    FOOD SAFETY GUIDELINES FOR TRANSPLANT PATIENTS

    Food-borne illness is occurring with increasing frequency. Sources of food poisoning may be the handler, the environment (such as a contaminated work surface), or the food itself.

    Bacteria and other organisms exist in most common foods. Most of these organisms are of little risk to the average healthy person. However, infection is of major concern to persons undergoing chemotherapy, radiation, or a marrow or stem cell transplant. The food these persons eat must be safe.

    These food safety guidelines are intended to supplement immunosuppressed patient diet guidelines, which identify higher risk foods. By following safe food practices, patients and caregivers can reduce the risk of food-borne illness. If you have any other questions regarding food safety and diet guidelines, talk to your dietitian.

    All handling, cleaning, and preparing of meats and produce should be performed by someone other than the immunosuppressed patient.

Safe Food Handling

    1. Purchase a food thermometer. They are available at most kitchen stores and have either a dial

     read or a digital read.

    2. Caregivers preparing food should wash hands frequently- before, during, and after food preparation.

     Use plenty of hot water and soap and wash for at least 20 seconds (you can sing the ―Happy Birthday‖

     song twice.

3. Hold food at safe temperatures: hot food above 140?F and cold food below 40?F.

    4. Cook meat until well done and measure the final temperature with a thermometer. Red

     meat should reach an internal temperature of 165?F and poultry to 180?F.

    5. Thaw meat, fish, or poultry in the refrigerator away from raw fruits and vegetables. Place on a dish

     to catch drips. Cook defrosted meat right away; do not refreeze. If you are in a hurry, you can thaw in

     the microwave- but you must cook the meat immediately and thoroughly clean the microwave in case

     of contamination.

6. Never leave perishable food out of the refrigerator for over two hours.

    7. Wash fruits and vegetables thoroughly under running cold water before peeling and/or cutting. Ask

     your dietitian or nutritionist for details on handling and preparation of fruits and vegetables.

    8. Wash the tops of canned foods before opening. Clean the can opener before and after use. 11/08 Reviewed 4/11 37

    9. During food preparation, do not taste the food with the same utensil used for stirring.

10. Cook eggs until the whites and yolks are completely hard cooked.

11. NEVER TASTE FOOD THAT LOOKS OR SMELLS STRANGE!

Microwave Cooking

    1. Microwave cooking can leave cold spots in food where bacteria can survive. Rotate the dish a

    quarter turn once or twice during cooking if there is no turntable in the appliance.

    2. When heating leftovers, use a loose-fitting lid or vented plastic wrap to cover. Stir several times

    during reheating. When heated thoroughly (to at least 165?F), cover and let sit for 2 minutes.

Outdoor Grilling

    1. When cooking meat on the grill, be sure the meat is cooked well done and measure the final

    temperature with a thermometer. Red meat should reach an internal temperature of 165?F and

    poultry to 180?F.

    2. Eat your grilled food indoors to avoid outdoor contaminates (e.g., air-borne bacteria, insects).

Grocery Shopping

1. Check ―sell by‖ and ―use by‖ dates. Select only the freshest food product.

    2. Check packaging date on fresh meats, poultry, and seafood. Do not purchase if they have passed

    the ―sell by‖ or ―use by‖ date.

    3. Reject damaged, swollen, rusted, or deeply dented cans. Check that packaged and boxed foods are

    properly sealed.

    4. Select unblemished fruits and vegetables. Fresh fruits and vegetables should look and smell fresh.

    Wilted salad greens may be an indication that the product is old and not properly handled. Your

    caregiver should wash all fruits and vegetables (including bagged pre-washed salad greens) before

    using.

5. Reject foods with any mold present.

    6. Avoid foods from delicatessens, including prepared salads and sliced meats and cheeses. In the

    bakery, avoid unrefrigerated cream and custard containing desserts and pastries.

7. Avoid foods from self-serve bulk containers or bins.

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8. Avoid yogurt and ice cream products dispensed from soft serve machines.

9. Avoid tasting free food samples.

    10. Avoid cracked and unrefrigerated eggs. Liquid pasteurized egg products may be used instead of eggs

    in the shell.

    11. Purchase frozen and refrigerated foods last, especially during the summer months.

    12. Store groceries promptly after purchase. Never leave perishable food in the car.

    Dining Out…Is It Safe? (Please check with your physicians to see when this is appropriate to start)

    1. Eat early to avoid crowds.

    2. Due to the uncertainty of the cleanliness of the handler and produce preparation,

    consumption of raw fruits and vegetables when dining out is not allowed.

    3. Request single serving condiment packages to avoid public self serve condiment containers.

    4. Avoid high-risk food sources: salad bars, delicatessens, buffets, smorgasbords, potlucks, fast food

    restaurants, and sidewalk vendors.

    5. Check the general condition of the restaurant environment. Are the plates, glasses, and utensils

    clean? Are the restrooms clean and stocked with soap and paper towels? How the manager and

    employees maintain the restaurant may be an indication of the amount of pride they take in

    preparing the food.

    HOME SANITATION GUIDELINES

     **Directions for preparing bleach solution: Mix 1 part household bleach to 10 parts water.**

Personal Hygiene

    1. Wash hands with soap and warm, running water for 20 seconds before and after every step in food

    preparation.

    2. Wash hands before eating, after using the rest room, handling garbage, touching pets, etc.

Work Surfaces and Kitchen Equipment

    1. Use separate cutting boards (plastic or wooden) for cooked foods and raw foods. 11/08 Reviewed 4/11 39

    2. Wash cutting boards after each use in hot, soapy water, or in the dishwasher. Sanitize boards

    weekly using a dilute bleach solution. **Let the boards air dry.

    3. Keep appliances free of food particles. Check the microwave oven, toaster, can opener, blender,

    and mixer blades. Blender blades and bottom ring should always be removed when washing the

    jar. Wash can openers before and after use. Sanitize these items with a dilute bleach solution. **

    4. Keep counter and kitchen surfaces free of food particles. Sanitize using a dilute bleach solution. **

Sink Area

1. Have soap available for hand washing.

2. Use paper towels for drying hands.

3. Replace dishcloths and dishtowels daily.

4. Replace sponges at least weekly.

    5. Sanitize sponges daily in a dilute bleach solution** or run through the dishwasher.

    6. Do not store food supplies under the sink. Do not store chemicals and cleaning solutions near or

    over food supplies.

7. Use liquid dish soap when hand washing dishes, pans, and utensils by hand.

Refrigerator and Freezer

    1. Keep the refrigerator clean. Clean spills immediately. Sanitize shelves and doors weekly using a

    dilute bleach solution. **

2. Maintain refrigerator temperature between 35?F to 40?F.

3. Maintain freezer temperature below 5?F.

    4. Store all food in covered containers after cooling. First, cool hot foods uncovered in the refrigerator.

    Then cover storage containers after cooling. Make sure that covers seal tightly. Freeze what will not

    be used within the next 2 to 3 days. Discard all refrigerated prepared foods after 72 hours.

5. Discard eggs with cracked shells.

6. Discard foods older than their ―use by‖ or expiration dates.

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    7. Discard entire food packages or containers with any mold present, including yogurt, cheese, cottage

    cheese, fruits (especially berries), vegetables, jelly, bread, and pastry products.

8. Discard freezer burned foods.

Cupboards and Pantry

1. Make sure food storage areas remain clean.

    2. Discard without tasting or opening all bulging, leaking, cracked, or deeply dented cans.

    3. Rotate food stock so older items are used first. Monitor expiration dates. Do not use foods past the

    expiration dates.

    4. Do not consume any home canned foods with bulging lids, broken seals, or any food that has a bad

    odor or any unusual characteristics after opening. Home canned foods need to be used within one

    year of canning.

    GUIDELINES FOR FRESH FRUIT AND VEGETABLE CONSUMPTION

    Consumption of fresh produce is allowed even during periods of neutropenia.

    Use the following guidelines for proper handling.

Produce Handling and Storage

Preparation and Washing:

    1. A caregiver, not the patient, should do all preparation and washing of produce.

    2. Wash hands thoroughly before handling fresh produce. Always use clean cutting surfaces. Use a

    clean knife.

3. Rinse produce thoroughly under clean, running cold water just before use.

    4. Using a clean vegetable scrubber, scrub produce that has thick skins or rinds (such as melons,

    potatoes) to remove excess soil.

    5. Wash the outside of all fruits and vegetables (such as oranges, melons, bananas) even if the

    produce is to be skinned or peeled. Bacteria on the outer surface can be transferred to the inside of

    fruits and vegetables when cutting with a knife.

    6. Rinse leaves of leafy vegetables (such as lettuce, cabbage) individually under clean, cold running

    water.

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    7. Packaged salads and other prepared produce, even when marked pre-washed, should be rinsed

    under clean, cold running water again. Check for ―used by‖ dates.

    8. All raw vegetable sprouts are prohibited due to high risk of Salmonella and E. Coli contamination.

    9. Do not wash fruits and vegetables with produce rinses, soaps, detergents, or chlorine bleach

    solutions. Produce can absorb these cleaning agents.

Storage

    1. Refrigeration slows and even suppresses the growth of bacteria. Refrigerate produce promptly.

    The refrigerator must be clean and cold. (40?F or colder).

    2. Discard fruits and vegetables that have been stored too long. Discard fruits and vegetables that are

    slimy or show mold.

Commercial Products for Cleaning Fruits and Vegetables

    Manufacturers of some commercial produce rinses claim that their products are ―100% natural,‖ ―300% more effective in removing pesticides,‖ and ―made of natural vegetable-based ingredients taken from

    foods eaten daily.‖ However, there have been no recent studies proving that these products are more effective for cleaning bacteria off the produce. The danger with using these products is that they may remain on the produce if not well rinsed with water following use, and may also be absorbed in the produce. There is no information available as to the safety of the chemicals used in these solutions.

Use of Organic Produce

    The term ―organic‖ or ―natural‖ refers to growing without the use of chemical fertilizers or pesticides, and has no relationship to the cleanliness of the produce. Bacterial contamination can occur in the fields, either from the use of natural fertilizers (such as animal manure) to human contact during produce harvesting and distribution to the market. As a result, all produce may carry dangerous bacteria, such as E. Coli, Salmonella, and Listeria. These bacteria have been linked to food borne disease outbreaks. Use above recommendations for handling both mainstream and organically grown produce.

    WATER SAFETY GUIDELINES

    Public water quality and treatment varies throughout the United States. Always check with the local health department and water utility regarding the water source as well as the safety of tap water and ice use by immunosuppressed persons.

Tap Water

    Water from your home faucet is considered safe if your water is from a city water supply or from a municipal well serving highly populated areas.

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