Dietary recommendations for immunosuppressed patients of 17 hematopoietic stem cell transplantation centers in Brazil

ORIGINAL ARTICLE

Dietary recommendations for immunosuppressed patients of 17 hematopoietic stem cell transplantation centers in Brazil

Paola Pasini Vicenski^I; Paloma Alberti^II; Denise Johnsson Campos do Amaral^III

^IDepartment of Oncology Nutrition, Hospital Erasto Gaertner, Curitiba, PR, Brazil

^IIDepartment of Nutrition, Hospital Cajuru, Curitiba, PR, Brazil

^IIIBone Marrow Transplantation Service, Hospital das Clínicas da Universidade Federal do Paraná - UFPR, Curitiba, PR, Brazil

^{Corresponding author}

ABSTRACT

INTRODUCTION: Low-microbial diets are recommended to reduce the risk of foodborne infections when hematopoietic stem cell transplantation patients have neutropenia. However there is no pattern concerning the composition of such a diet.

OBJECTIVES: To collect information concerning the structure of nutrition departments and the diets recommended for immunosuppressed patients in transplant centers in Brazil.

METHODS: Questionnaires were sent to the 45 Bone Marrow Transplantation Centers listed by the Sociedade Brasileira de Transplante de Medula Óssea (SBTMO). Completed questionnaires were returned by 17 centers. The questions were related to the profile and the structure of the nutrition department, at what point a general diet is allowed after transplantation, and which food is allowed during the critical period of immunosuppression and soon after transplantation.

RESULTS: Of the 17 centers that participated, 82% have a professional nutritionist exclusively for the Transplant Department but only 41% have an area specifically for the preparation of diets for immunosuppressed patients. The patients are released from the low-microbial diet to general diets 90-100 days after allogeneic hematopoietic stem cell transplantation by 29% of the centers and only after suspension of immunosuppressive drugs in 24%. Most centers (88%) restrict the consumption of raw fruits, all restrict the consumption of raw vegetables and 88% forbid the consumption of yogurt in the critical period of immunosuppression. There was no consensus on forbidden foods soon after transplantation.

CONCLUSION: Major differences in diets recommended to hematopoietic stem cell transplantation patients were observed between the different centers.

Keywords: hematopoietic stem cells transplantation; immunosuppression; neutropenia; diet/standards

Introduction

Hematopoietic stem cell transplantation (HSCT) is the treatment procedure in which hematopoietic cells collected from the bone marrow, peripheral blood or umbilical cord are intravenously infused in patients with bone marrow failure with the aim of re-establishing hematopoiesis and the immune functions.^(1-4) This procedure requires an initial ablation of the bone marrow through cytoreductive chemotherapy and/or intensive radiation.^(1,5-8) Patients who undergo HSCT, especially those with complications such as Graft-versus-Host Disease (GVHD) may have anorexia, nausea and persistent vomiting, dysgeusia, mucositis, diarrhea and consequent insufficient oral intake of nutrients, with a worsening of their general and nutritional status.^(1,9-11) Additionally, fluid and electrolyte disorders (sodium, potassium, calcium, phosphorus and magnesium) are frequent and may further affect the intestinal motility.⁽¹²⁾

After the preparative regimen, during the neutropenia phase, the patient becomes susceptible to foodborne infections.⁽¹³⁾ Damage to the intestinal mucosa caused by chemotherapy and/or radiation may be a gateway for pathogens, a situation that may lead to bacteremia.^(13-16) Infections can be prevented by controlling the ingestion of potential pathogens found in various food sources. Studies have identified gram-negative organisms, such as Pseudomonas aeruginosa,Escherichia coli, Klebsiella and Proteus, in different foods.⁽¹⁴⁾

Low-microbial diets (LMDs) are recommended in order to reduce the risk of infections through decreasing potentially pathogenic microorganisms in foods,^(17,18) however there are no studies that show any reduction in the incidence of infections with the use of such diets.⁽¹⁹⁾ These diets, commonly called "cooked food diets" have been used in many HSCT centers in Brazil and consist of the exclusion of raw foods (raw fruits and vegetables, raw meats and eggs, and unpasteurized dairy products) and of foods considered a higher risk of contamination.^{(13,18,20,21)} The foods that have higher risk for patients submitted to HSCT are: raw eggs, unpasteurized dairy products (milk, cheese, butter, yogurt), raw tofu, matte tea, raw meat (including beef, chicken, pork, lamb), processed meats (sausage, bacon, baloney, and raw smoked meats), fruit juices and raw fruits, raw, unwashed and unpasteurized vegetables, unpasteurized honey, raw cereals, raw oleaginous fruits, tap water or water at high risk of contamination that is not boiled, ice made of tap water or water at risk of contamination, and meals from restaurants including fast-food.^(22-26) The aim of this study was to collect information with the application of a questionnaire in respect to the standardization of diets for immunosuppressed patients after HSCT and the structure of nutrition departments in HSCT centers in Brazil.

Methods

This was an observation and descriptive study carried out between June and October of 2009 and approved by the Ethics Research Committee of Hospital Erasto Gaertner in Curitiba (# 1881).

This paper was based on data collected using a questionnaire that was sent to HSCT centers and answered by the nutritionists in charge. The questionnaires were mailed in August 2009, together with an informed consent form, to the head nutritionist of each center, with the permission of the Head of Service of the Bone Marrow Transplantation Department.

The inclusion criteria for participation in this study were that centers had at least one nutritionist responsible for transplant patients and that the centers would return the completed questionnaire.

The study sample involved the 45 Bone Marrow Transplantation Centers in Brazil listed by the Sociedade Brasileira de Transplante de Medula Óssea (SBTMO).⁽²⁷⁾ Responses were returned by only 17 centers, which participated in this study; two centers from the State of Rio Grande do Sul, one from Santa Catarina, three from Paraná, three from São Paulo, two from Rio de Janeiro, three from Minas Gerais, one from Goias, one from Pernambuco and one from Rio Grande do Norte.

The questionnaire involved questions concerning information about the profile and the structure of the nutrition department, questions about the diet prescribed to HSCT patients, at what point the general diet is allowed after transplantation, and which food is allowed during the critical period of immunosuppression (CPI - from preparative regimen until engraftment or marrow recovery) and soon after transplantation (between being discharged from the hospital and 100 days after HSCT). These were objective multiple choice questions with different sections for beverages; bread, grains and cereals; dairy products; raw fruits and nuts; vegetables; beef, poultry, pork and fish; desserts; fats; and others. They were divided in: allowed and allowed under some condition (foods that can only be eaten after going through some specific process, for instance cooking, boiling, pasteurization, vacuum packaging). In the literature there is no definition or recommendation for which fruits should be considered thin-skinned or thick-skinned and so in this paper fruits such as grapes, strawberries, mulberries and jaboticaba were considered thin-skinned.

The deadline for returning the questionnaires along with the duly signed consent form was 20 days after having received them. Some questions were divided in allogeneic or autologous HSCT because of the difference in the time and the severity of the neutropenia.

The answers were analyzed, tabulated in Excel (Microsoft) and the results presented as graphs and tables.

Results

In relation to the number of beds, 6 (35%) centers have less than five beds, seven (41%) centers have between five and ten beds and three (18%) centers have more than ten beds. One center stated that they do not have beds specifically allocated for transplantation. All 17 (100%) centers perform autologous HSCT, 14 (82%) perform related allogeneic transplants and eight (47%) perform unrelated allogeneic transplants.

Two (12%) of the nutritionists interviewed graduated from college, 11 (65%) had post-graduations, three (18%) had master's degrees and one of the hospitals did not specify the professional training. Of the 17 centers analyzed, 14 (82%) have a professional nutritionist working exclusively in the Bone Marrow Transplantation Service and eight (47%) have trainees.

It was observed that only seven (41%) of the centers have an exclusive area for the preparation of food for immunosuppressed patients and only nine (53%) of the centers have employees who work exclusively in the preparation and distribution of the foods.

Fourteen (82%) centers reported using nutritional care protocols for patients undergoing HSCT and 13 (76%) have a protocol for indication and prescription of enteral and parenteral nutrition therapy.

In relation to the kind of diet prescribed to patients hospitalized for HSCT, one center (6%) prescribes a diet without raw fruits and vegetables and 16 (94%) prescribe LMDs.

There was a major difference as to the recommendation for when to discontinue the LMD (release to general diet) for patients submitted to allogeneic HSCT. Figure 1 shows that five (29%) of the centers release to general diet 90-100 days after HSCT, two (12%) recommend the release to general diet 120 after HSCT, one (6%) one year after HSCT, four (24%) only after discontinuing immunosuppressive medicines and one (6%) only releases for general diet after analyzing lab tests.

For patients undergoing autologous HSCT, two (12%) centers recommend releasing patients to general diet 15-20 days after HSCT, four (24%) recommend releasing to general diet 30-60 days after HSCT, seven (41%) 90-100 days after HSCT, one (6%) 120 days after HSCT and one (6%) recommends it only after analyzing lab tests.

One center did not specify the time to releasing to general diet after allogeneic HSCT and autologous HSCT and two of the centers did not give a specific time for releasing to general diet for autologous HSCT.

Table 1 shows the foods that are not allowed during the CPI. From these foods we see that some foods/drinks, such as alcoholic beverages, flax/sesame seed, raw thin-skinned fruits, raw vegetables, molasses and meals at fast food restaurants are not recommended during CPI by any of the participating centers.

Some foods, such as industrialized and homemade pies/cakes, seafood, sausages (baloney, salami, ham), oleaginous fruits (nuts, peanuts), fermented milk, yogurts, honey, frozen foods and raw thick-skinned fruits, although not completely forbidden, are restricted during CPI in most of the HSCT centers.

Table 2 shows the foods that are allowed at hospital discharge to 100 days after HSCT.

In comparison with the CPI, the diet becomes less restrictive. A major difference was found concerning the release time for the consumption of raw fruits and vegetables as 59% of the centers forbid the consumption of thin-skinned fruits (grapes, strawberries, mulberries and jaboticaba) and 35% forbid raw vegetables until 100 days after HSCT. Another major difference among the centers is the release time for the consumption of yogurts (59% centers forbid the consumption of yogurts and 71% forbid the consumption of fermented milk) and processed meats (47% of the centers forbid the consumption of cooked ham and 53% forbid the consumption of sausage).

Discussion

According to Justino,⁽¹³⁾ HSCT centers should adopt nutrition protocols in order to avoid that food, which costs very little in comparison with other procedures of the treatment, might be responsible for introducing microorganisms that are potentially pathogenic, into the gastrointestinal tract.

It is clear that the release time to a general diet recommended by professionals varies much between centers. How long the patient will have to remain on a special controlled diet depends on his immunosuppression and on the type of transplant involved.⁽¹³⁾ 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. However, other authors suggest that for allogeneic HSCT, the diet must continue until the end of all immunosuppressive therapy, and for autologous HSCT, the diet should continue until one month after the discontinuation of corticosteroids or three months after chemotherapy in the absence of gastrointestinal symptoms.^(1,9,13)

Although there is some reference for healthcare professionals on forbidden foods for the patient after HSCT, this study shows that there are still some differences among professionals concerning which foods are allowed, especially during CPI.

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%). Another food that raises doubts is chocolate, forbidden by 41% of the centers during CPI; however there are no guidelines that prohibit its consumption during CPI.

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. It was also observed that, because of the nonexistence of a standard diet for patients after HSCT, each participating center has its own nutrition protocol based on scarce published data and on professional experience.

During the research it was found that most centers recommended LMDs; there were, however, many different results concerning food recommendations. Many different opinions were found in relation to the release time to general diet and there was no consensus in this matter.

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. In this scenario, a national standard for the diet of such patients would be ideal as a tool to aid professional nutritionists.

References

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Submitted: 10/10/2011

Accepted: 1/31/2012

Conflict-of-interest disclosure: The authors declare no competing financial interest

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Publication Dates

• Publication in this collection
  11 May 2012
• Date of issue
  2012

History

• Received
  10 Oct 2011
• Accepted
  31 Jan 2012