05 Jan 2021

Summary

This document provides guidance for the provision of consistent advice on neutropenic dietary restrictions for haematology patients. It provides evidence/ best practice guidance for haematology patients undergoing chemotherapy as well as those with more profound neutropenia undergoing stem cell/ bone marrow transplantation. This is a guideline for those units who chose to continue to advise dietary restrictions during neutropenia.  It is not intended for people with neutropenia of a non- haematological cause.

Background

After chemotherapy and stem cell transplantation, patients are at a greater risk of infection from bacteria or fungus in food. This is for the following reasons:

  • The white blood cells (neutrophils) that would usually fight food poisoning bacteria are at a low level.  This is called neutropenia
  • The gut lining which acts as a barrier between bacteria and the bloodstream is damaged by chemotherapy and radiotherapy.  This makes it easier for bacteria to cross into the blood stream.

The ‘Neutropenic Diet’ has remained a controversial area across Haematology Units in the UK. The evidence for dietary restriction during immunosuppressive therapy and/ or neutropenia is still limited and some institutions have removed restrictions without any corresponding increase in infection rates (1). Due to concerns regarding inconsistent and inappropriate dietary advice during neutropenia, the Haematology Group of the British Dietetic Association established recommendations that were first published (2) and amended five years later.  Our group recognised that the evidence for this guidance needed to be re-visited, further up to date research and consultation has now led to updated recommendations. 

Purpose

The purpose of this statement is to:

  • To standardise dietary advice provided to haematology patients undergoing treatment throughout the United Kingdom using evidence/ best practice guidelines.
  • To enable dietitians working with haematology patients to confidently be able to advise about neutropenic dietary restrictions.

Recommendations - Food Safety

Following a literature search, which includes articles published in the last five years, we have gathered the following recommendations for our patient group. 

Food Safety

Evidence is emerging to support following food safety guidance, around food preparation, storage and good hygiene practices as well as being mindful of the way we cook our food. Below are some helpful tips for Food Safety, taken from The Royal Marsden ‘Food Safety information’ booklet (2019)

  • Avoid contamination of food by ensuring you washing and dry your hands before touching or eating anything.
  • Never touch your mouth or nose when preparing food.  Cover any cuts on your hands before preparing food.
  • Do not allow raw and uncooked foods to mix – use separate storage shelves and different chopping boards
  • Sanitise hands, chopping boards, knives, and utensils using hot water after touching raw meat, fish or vegetables.
  • Always cover food to be stored to prevent contamination.
  • Never overload your fridge or freezer - This can cause an increase in temperature, making food unsafe to eat.
  • Defrost food in the fridge, not at room temperature.
  • Be aware of shared utensils such as tongs at buffets, as these may have been handled by many people and may have contaminated food
  • When shopping, buy chilled and frozen foods last to limit the time it is kept at warmer temperatures.
  • Avoid bruised fruit and vegetables or damaged packages or tins.
  • Always check ‘use by dates’ and ‘best before dates’ before buying or eating food.
  • Always keep pets away from food preparation areas as they may carry bacteria even when well.
  • If storing cooked food, ensure it is cooled at room temperature before placing in fridge or freezer.
  • Never refreeze thawed food.
  • Avoid reheating rice and takeaway food as harmful bacteria can survive the heating process.
  • When eating out, check the food hygiene rating of restaurants and takeaways or access your relevant Food Standards website (3).

Food Safety Advice - Table 1

Avoid

Alternatives

All unpasteurised dairy products

e.g. milk sold on local farms

 

Any pasteurised milk, soya milk,

Jersey milk or UHT milk

 

Soft cheeses made with unpasteurised milk e.g. feta, parmesan

Homemade/deli paneer and labneh

Mould-ripened cheeses e.g. Camembert, Brie, goat’s cheese

Blue veined cheeses e.g. Danish blue, Blue Stilton

 

Cheeses made with pasteurised milk, processed cheese e.g. Dairylea, Kraft, Philadelphia, mesh and halloumi

White Stilton

Pasteurised parmesan, pasteurised mozzarella. Paneer made with pasteurised milk

Vacuum-packed pasteurised and hard cheeses e.g. cheddar and Edam

Stuffed vine leaves, Fattoush and tabouleh, alfalfa (sprouted seeds)

Damaged/ bruised/ over-ripe Fruit/vegetable

Freshly squeezed commercial or smoothies

 

Fresh fruit, vegetables and salad – including prepacked Salad and fruit. Ensure all above are well washed before eating

Raw dried fruit, products containing these e.g. muesli, Bombay mix, confectionary

UHT or long-life fruit juices – in cartons or jars

Pasteurised smoothies

Tinned or frozen fruit and vegetables

Cooked dried fruit e.g. in fruitcake, flapjacks or cereal bars

 

Fresh nuts, nuts in shells

 

Cooked nuts, nuts in cans

Peanut butter, roasted nuts

Raw or lightly cooked shellfish

Well-cooked shellfish e.g. prawn curry

Raw/undercooked meat, poultry or fish e.g. meat which is still pink, caviar and oysters

Smoked meats e.g. salami

Avoid smoked salmon unless eaten directly from a freshly opened packet

 

Well cooked meat, poultry and fish; tinned meat and fish

Vacuum-packed cold meats such as turkey and ham stored below 3°C and eaten following the manufacturer’s instructions

Vacuum packed fish eaten straight from a new packet. This includes smoked salmon.

Raw eggs or undercooked eggs e.g. homemade mayonnaise, homemade ice cream, mousse, egg-nog, meringue, hollandaise sauce, and béarnaise.

Any dressing containing raw eggs e.g. home/restaurant-made Caesar salad dressing

Hard boiled eggs; shop-bought mayonnaise and other products made with pasteurised egg

 

Probiotic foods, drinks or supplements e.g. Yakult, Actimel, ProViva

Yogurt which is described on the label as probiotic

Any yogurt that does not describe itself as probiotic including live, plain, Greek and fruit yogurts

Meat pate, vegetable pate

 

 

Pasteurised pate and paste in tins or jars that do not need to be refrigerated

Unpasteurised or ‘farm fresh’ honey and honeycomb

Pasteurised or heat-treated honey

Ideally try to use individual sachets or portions

Unnecessarily large packets of food items from pick and mix, universal jars

Deli counter foods e.g. olives, houmous, shawarma and baklava

Ideally, packets should be individual portions e.g. butter, sweets, pickles

Prepacked Houmous and olives

 

Ice when away from home e.g., in a restaurant and slush puppies

Ice made from appropriate water sources (see above)

Ice cream from ice cream vans

Ice cream from reputable sources, individual portions, wrapped, small pots

Non-drinking water, bottled mineral or spring water, water from wells, water from coolers, domestic water filters and water fountains

Freshly run tap, carbonated water

Please check with your hospital for guidance

Ice Cream

Ice Cream

Ice cream is used as a quick high calorie snack for many of our patients. There is inadequate research available to give evidence-based guidance; therefore, the recommendations are based on group consensus.  When considering the manufacturing process, it was felt that ice cream is unlikely to present a significant risk, provided it has been stored at the correct temperature, had not previously thawed, was individually wrapped and from a reputable source.  This excludes ice cream sold from mobile vans including ice cream from soft serve machines that may harbour unacceptable levels of bacteria.

Conclusion

Emerging evidence has increased the amount of food items our patients can consume during treatment; however, the lack of evidence still remains a problem when providing advice to neutropenic individuals.  However, it is felt by many that immunocompromised patients should avoid all unnecessary risk for potentially life-threatening infections. 

Ensuring a consistent and sensible approach to the dietary advice given during neutropenia should help minimise both the risk of food borne infection and worsening malnutrition at a time when nutritional intake can be severely compromised.

References

References 

  1. Sonbol M et al (2019) Neutropenic diets to prevent cancer infection: updated systematic review and meta- analysis. BMJ Supportive & Palliative Care 2019; 0: 1-9
  2. http://leukaemialymphomaresearch.org.uk/sites/default/files/Dietary%20Advice%20for%20Patients%20with%20Neutopenia%20(April%202011)_0.pdf. Leukaemia and Lymphoma Research. Dietary advice for patients with neutropenia. 2011. Accessed October 2011. Ref Type: Internet Communication
  3. https://www.food.gov.uk/safety-hygiene/food-hygiene-rating-scheme#differences-between-online-ratings-and-rating-sticker-displayed and https://www.foodstandards.gov.scot/business-and-industry/safety-and-regulation/fhis-info-for-businesses
  4. Arjun Gupta MD , Timothy J. Brown MD , Shruti Singh BS , Ahana Sen MD , Deepak Agrawal MD , Hsiao C. Li MD , Christopher Moriates MD , David H. Johnson MD , Navid Sadeghi MD , Applying the ÒCOSTÓ (Culture, Oversight, Systems Change, and Training) Framework to De-adopt the Neutropenic Diet , The American Journal of Medicine (2018), doi: https://doi.org/10.1016/j.amjmed.2018.08.009
  5. Borriello SP, Hammes WP, Holzapfel W, Marteau P, Schrezenmeir J, Vaara M et al. Safety of probiotics that contain lactobacilli or bifidobacteria. Clin Infect Dis 2003; 36(6):775-780
  6. https://www.ifst.org/news/new-advice-eating-runny-eggs-fsa-0
  7. Heng M et al (2018) Does a neutropenic diet reduce adverse outcomes in patients undergoing chemotherapy? Eur J Cancer Care. 2020;29: e13155