When facing a weakened immune system, especially during treatments like chemotherapy for breast cancer, dietary choices become crucial. A compromised immune system increases the risk of food poisoning, making it essential to understand which foods to avoid and which are safer to consume. This article provides a comprehensive guide to navigating dietary needs for immunocompromised patients, drawing on expert insights and evidence-based recommendations.
Understanding the Immunocompromised State
Breast cancer treatments, such as chemotherapy or the removal of lymph nodes, can weaken the immune system. While the immune system is resilient, these treatments can impair its ability to function optimally. When the immune system is weak, the body becomes more susceptible to bacteria and other organisms that can cause illness. Therefore, dietary adjustments are necessary to minimize the risk of infection and support the body's defenses.
The Importance of Nutrition
Maintaining a strong immune system requires adequate nutrition. Getting enough protein is particularly important. Good sources include:
- Lean meat, thoroughly cooked. Always check the internal temperature with a thermometer to ensure it's at the proper temperature to kill any bacteria.
- Fish, well-cooked.
- Eggs, well-cooked.
- Pasteurized tofu, well-cooked.
In addition to protein, a multivitamin may be beneficial to supplement any nutritional gaps.
Foods to Avoid
Certain foods carry a higher risk of harboring bacteria and should be avoided by immunocompromised individuals:
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- Raw vegetable sprouts (alfalfa, radish, broccoli, mung bean, etc.) due to the high risk of Salmonella and E. coli contamination.
- Salad bars, delis, buffets, sidewalk vendors, and potluck gatherings, where food handling and hygiene may be questionable.
- Undercooked meat and eggs.
- Unpasteurized milk and milk products.
- Refrigerated smoked seafood (except in a cooked dish).
Water Safety
It may be essential to have tap water tested, especially if the water source is a private or small community well. City water supplies and municipal wells serving large populations are regularly tested for contamination, whereas private and small community wells are not.
Adapting to Nutritional Challenges
Oncology patients often face multiple nutritional challenges, including:
- Appetite changes, such as anorexia.
- Nausea and vomiting.
- Changes in taste.
- Neutropenia (low white blood cell count).
These challenges can make it difficult to meet increased nutritional needs. In the past, healthcare providers often eliminated foods like fresh fruit and raw vegetables from the diet due to the risk of bacterial introduction. However, this approach can lead to a less diverse and appealing diet, potentially exacerbating nutritional deficiencies.
Innovative Approaches: The Moffitt Cancer Center Experience
The H. Lee Moffitt Cancer Center in Tampa has implemented new practices that allow immunocompromised patients to enjoy fresh fruits and vegetables safely. Linda Rice, RN, OCN, RN III, staff nurse at Moffitt’s Medical Oncology/Hematology unit, presented these practices at the 26th Annual Conference of the Oncology Nursing Society.
The Moffitt Cancer Center staff conducted a literature review and consulted with other oncology centers to gather information on best practices. They then presented their findings to the Infectious Disease Department and bone marrow transplant (BMT) physicians. The primary concern was how to wash fruits and vegetables effectively without leaving a bad taste. The decision was made to use plain running water to rinse raw vegetables and fruits. The key is to use running water, not a tub or bath, to ensure that any bacteria are rinsed away.
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To ensure accountability, the center uses immunosuppressed diet production worksheets that food service workers sign to verify that special preparation methods are used, 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.
Exceptions to the program include mushrooms (as they are a fungus) and garnishes. Since implementing these new practices, the Moffitt Cancer Center has reported no increase in infection rates. This approach has expanded nutritional opportunities for patients, enabling them to increase their nutritional intake and better meet their nutritional needs while providing a more appealing diet.
Moffitt Diet Guidelines for BMT Patients with Decreased Immune Systems
- All meats, including chicken, fish, and eggs, should be thoroughly cooked. Avoid raw or undercooked meats or eggs.
- Fresh raw fruits and vegetables must be washed for 30 to 60 seconds under running water before eating, including thick-skinned fruits like bananas and oranges.
- Avoid sprouts of any kind.
- Do not eat garnishes such as parsley or lettuce on the plate.
- Avoid ordering salads when dining out, as they may not be properly washed.
- Avoid aged cheeses such as bleu cheese, Brie, feta, Roquefort, Camembert, sharp cheddar, Stilton, Mexican-style pepper cheese, or farmer’s cheese.
- Avoid yerba mate 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.
- Use only pasteurized milk and milk products, including cheese and yogurt.
- Use only pasteurized honey without honeycomb.
- Do not drink well water unless tested yearly for bacteria and found to be safe.
- Do not use herbal or other supplements unless approved by your doctor or dietitian.
- Avoid fast food restaurants, salad bars, delis, buffets, ice cream parlors, and sidewalk vendors unless approved by your doctor.
- Wash hands well prior to and during food preparation and handling.
- Store foods properly. Cooked foods should not be left at room temperature for more than 1 hour to prevent bacterial growth. Refrigerate or freeze food in small portions within 1 hour of cooking.
- Throw away leftovers in the refrigerator after 2 days.
- Diet discontinuation guidelines: Standard priming chemotherapy patients start this diet 5 days after discharge and stop when WBC > 1,000 (as indicated by CBC blood draws). Autologous BMT patients may discontinue guidelines 3 months post-transplant. Allogeneic BMT patients may discontinue guidelines when all immunosuppressive therapy has been stopped.
Expert Insights on Boosting Immune Health
Nicole Parker, LD, RD, a registered dietitian at Dartmouth Cancer Center, emphasizes a balanced approach to diet and lifestyle for maintaining a healthy immune system. She highlights that no single food or nutrient can offer complete protection. Instead, a diverse and colorful diet is the most effective strategy.
Key Foods for Immune Support
- Yogurt: A great source of probiotics, which are healthy bacteria that live in the digestive tracts.
- Lentils and beef: Excellent sources of zinc, a mineral vital for immune function.
- Red bell peppers, spinach, oranges, and strawberries: Packed with vitamin C, a powerful antioxidant.
- Walnuts and almonds: Good sources of vitamins A and E, which also play a role in supporting the immune system.
- Mushrooms: One of the few foods that are a good natural source of vitamin D. Other sources include egg yolks, tuna, and fatty fish like salmon and herring.
The Gut-Immune Connection
The digestive system is home to trillions of microbes, or healthy bacteria, that make up the gut microbiome. These microbes help ward off bad bacteria and are closely linked to the immune system. Incorporating probiotics and prebiotics into the diet can support this vital connection.
- Probiotics: Live healthy bacteria found in fermented foods like yogurt, kefir, sauerkraut, pickles, and kombucha.
- Prebiotics: Food for those healthy bacteria. Good sources include beans, whole grains, garlic, bananas, onions, and asparagus.
A symbiotic snack, like Greek yogurt topped with sliced bananas, combines both probiotics and prebiotics.
Read also: Weight Loss with Low-FODMAP
The Truth About Supplements
Unless there is a documented deficiency, supplements may not provide a benefit and can even be harmful. High doses of antioxidants like CoQ10 or turmeric in supplement form can interfere with the effectiveness of chemotherapy. It's essential to consult with a medical team-provider, dietitian, or pharmacist-before starting any new supplement.
Holistic Approach to Immune Health
Nourishing the immune system goes beyond diet. A holistic approach includes:
- Hydration: Water is essential for carrying oxygen to the cells and supporting lymphatic fluid, which transports white blood cells throughout the body.
- Sleep: Chronic lack of sleep can weaken the immune system. Aim for seven to nine hours of sleep per night.
- Physical activity: Regular exercise strengthens the immune system by reducing inflammation and encouraging immune cell regeneration. The American Cancer Society recommends 150-300 minutes of moderate activity each week.
- Stress management: Chronic stress can suppress the immune system. Find effective ways to decompress, such as yoga, meditation, gardening, or reading.
Low-Microbial Diets in Hematopoietic Stem Cell Transplantation (HSCT)
Low-microbial diets are often recommended to reduce the risk of foodborne infections in hematopoietic stem cell transplantation patients with neutropenia. A study involving 17 Bone Marrow Transplantation Centers in Brazil revealed significant variations in dietary recommendations.
Most centers (88%) restrict the consumption of raw fruits, all restrict the consumption of raw vegetables, and 88% forbid the consumption of yogurt during the critical period of immunosuppression (CPI). The CPI extends from the preparative regimen until engraftment or marrow recovery.
After the preparative regimen, patients are highly susceptible to foodborne infections. Damage to the intestinal mucosa caused by chemotherapy and/or radiation can create a gateway for pathogens, potentially leading to bacteremia.
Key Findings from the Brazilian Study
- 82% of centers have a professional nutritionist exclusively for the Transplant Department.
- Only 41% have an area specifically for the preparation of diets for immunosuppressed patients.
- 29% release patients from the low-microbial diet to general diets 90-100 days after allogeneic hematopoietic stem cell transplantation.
- 24% release patients only after the suspension of immunosuppressive drugs.
Table 1 shows the foods that are not allowed during the CPI.
| Food Category | Restriction |
|---|---|
| Fruits | Raw fruits (especially thin-skinned fruits like grapes, strawberries, mulberries, and jaboticaba) are often restricted due to the potential for harboring bacteria on their surfaces. |
| Vegetables | Raw vegetables are universally restricted due to the risk of contamination with soil-borne pathogens and the difficulty in ensuring thorough cleaning. |
| Dairy | Yogurt is frequently restricted due to the potential for containing live cultures that may pose a risk to immunocompromised individuals. Pasteurized milk and milk products are generally preferred. |
| Meats | Processed meats like cooked ham and sausage are often restricted due to the risk of Listeria contamination and the potential for inadequate cooking or handling. |
| Beverages | Unpasteurized juices and beverages are restricted due to the risk of bacterial contamination. |
| Other | Foods from salad bars, buffets, and street vendors are generally restricted due to the potential for inadequate hygiene and cross-contamination. Honeycomb honey is often avoided due to the risk of containing bacteria or other contaminants. Herbal supplements and remedies are restricted due to the potential for interactions with medications or adverse effects on the immune system. Well water is restricted unless tested and confirmed to be free of contaminants. Sprouts are restricted due to the high risk of Salmonella and E. coli contamination. Aged cheeses are restricted due to the potential for Listeria contamination. |
Variations in Dietary Recommendations
The study revealed major differences in the recommendation for when to discontinue the low-microbial diet (LMD) for patients submitted to allogeneic HSCT. In comparison with the CPI, the diet becomes less restrictive. However, significant differences were found concerning the release time for the consumption of raw fruits and vegetables, yogurts, and processed meats.
Some Brazilian authors recommend that LMDs should be extended to up to 100 days for patients undergoing autologous HSCT and during immunosuppression for those submitted to allogeneic HSCT, i.e., up to 60 days after the procedure.
In the international literature, some foods, such as yogurt and cheese, are allowed during CPI as long as they have been pasteurized. However, in most of the participating centers (88%), the consumption of these foods is not allowed. The same is true for thin-skinned fruits, which are allowed during CPI according to literature as long as they have been properly washed before consumption; however, most of these centers forbid them (88%).
Implications for Practice
This survey shows that most HSCT centers do not have an area exclusively for the preparation of food for immunosuppressed patients, and many of them do not have employees working exclusively in the preparation and distribution of the meals. During the research, it was found that most centers recommended LMDs; however, there were many different results concerning food recommendations.
Therefore, although there are some publications concerning this subject, data to support the professionals who work in this area are still very scarce, making it unsafe to recommend foods that can be ingested by patients after HSCT.
Addressing Vague Information and Improving Food Safety
Recognizing the lack of clear and specific food safety resources for cancer patients, researchers like Dr. Mark and Carly Gomez have been working to improve the information available. Current resources often provide general guidelines that are not specific enough for immunocompromised individuals.
Gomez's research includes experiments to model the risk associated with consuming certain foods and to develop patient education materials in collaboration with dietitians like Meteyer. The goal is to balance the risk of infection with the loss of nutrition that results from restrictive diets.
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