Moffitt’s Diet Guidelines for Immunocompromised Patients

SAN DIEGO--The staff at the H. Lee Moffitt Cancer Center in Tampa has initiated new practices that allow immunocompromised patients to eat fresh fruits and vegetables without worrying about bacterial infection, said Linda Rice, RN, OCN, RN III, staff nurse at Moffitt’s Medical Oncology/Hematology unit.

Ms. Rice explained the program and procedures in her podium presentation, "Fresh Fruit for Neutropenics: A Diet With ‘A Peel’," at the 26th Annual Conference of the Oncology Nursing Society (abstract 40).

Multiple Nutritional Challenges

"Oncology patients encounter multiple nutritional challenges," she said. "Therefore, our patients often have difficulty meeting their increased nutritional needs. They have appetite changes, which can include anorexia, nausea, and vomiting, as well as a change in taste, and, of course, neutropenia is often present."

In the past, food that might be a major source of bacterial introduction, such as fresh fruit and raw vegetables, was eliminated from the diet. The risk, Ms. Rice said, was that enterococcus, E coli, pseudomonas, and aspergillus could reside in the food and infect already immunocompromised patients.

"We reviewed our previous practice because the patients continued to tell us they wanted fresh fruit and vegetables, and we wanted to give them a more diverse selection of food, considering their known difficulty meeting nutritional requirements," Ms. Rice said.

A literature review was done, and other oncology centers were contacted for information on their practices. The staff then compiled the information and presented it to the Infectious Disease Department and the bone marrow transplant (BMT) physicians.

The issue of how to wash the fruit and vegetables raised concerns about using products that would leave a bad taste on the food. Thus, a decision was made to use plain water to wash the raw vegetables and fruit. The key, however, is to use running water, not a tub or bath, so that any bacteria will be rinsed away.

To ensure accountability, the Center now uses immunosuppressed diet production worksheets that food service workers sign to verify that special preparation methods are used as outlined, including wearing gloves. All food is fresh and tagged to identify its age. Salads are made fresh daily, no foods are used more than 3 days after they were prepared, and all items are wrapped individually.

The program, which was initiated 2 years ago, has some exceptions. "Mushrooms, being a fungus, are not allowed," Ms. Rice said. "Neither are garnishes."

Ms. Rice said that a complete list of diet guidelines are available for patients and their caregivers (see below). There has been no increase in infection rates reported after the introduction of the new immunosuppressed diet, either from the Bone Marrow Transplant Program or the Infectious Disease Department, and, she said, it has opened up nutritional opportunities for patients.

"With our diet expansion, we have enabled our immunocompromised patients to increase their nutritional intake and better meet their nutritional needs," Ms. Rice said, "while providing a more appealing diet in comparison to our previous neutropenic dietary restrictions. We’ve achieved our greatest goal, patient satisfaction." 

Moffitt Diet Guidelines for the BMT Patient With a Decreased Immune System

1. All meats should be thoroughly cooked, including chicken or fish and eggs. No raw or undercooked meats or eggs!

2. Fresh raw fruits and vegetables must be washed for 30 to 60 seconds under running water before eating them. This includes thick-skinned fruits like bananas and oranges.

3. Do not eat sprouts of any kind.

4. Do not eat garnishes such as parsley or lettuce on the plate.

5. Do not order salads when dining out as they may not be properly washed.

6. Avoid aged cheeses such as bleu cheese, Brie, feta, Roquefort, Camembert, sharp cheddar, Stilton, Mexican style pepper cheese, or farmer’s cheese.

7. Avoid yerba mat tea (Paraguay tea), miso (soy condiment), and tempeh (fermented soybean cake). Tofu is allowed if cut in 1 inch cubes and boiled for 5 minutes in water or broth before adding it to a recipe.

8. Use only pasteurized milk and milk products, including cheese and yogurt.

9. Use only pasteurized honey without honeycomb.

10. Do not drink well water unless tested yearly for bacteria and found to be safe.

11. Do not use herbal or other supplements unless approved by your doctor or dietitian.

12. Avoid fast food restaurants, salad bars, delis, buffets, ice cream parlors, and sidewalk vendors unless approved by your doctor.

13. Wash hands well prior to and during food preparation and handling.

14. Store foods properly. Cooked foods should not be left at room temperature for more than 1 hour to prevent bacterial growth. Within 1 hour of cooking, food should be refrigerated or frozen in small portions.

15. Throw away leftovers in refrigerator after 2 days.

16. Diet will be discontinued as follows: 

Standard priming chemotherapy patients will start this diet 5 days after discharge. Stop diet when WBC > 1,000. You’ll know from CBC blood draws done M-W-F.

Autologous BMT patients may discontinue guidelines 3 months post-transplant.

Allogeneic BMT patients may discontinue guidelines when all immunosuppressive therapy has been stopped.