An Overview of the Neutropenic Diet

Food Safety Practices During Chemotherapy

washing vegetables is important on a neutropenic diet
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The neutropenic diet, which involves special attention to food selection and safe food handling practices, is recommended for people with weakened immune systems to reduce the risk of infections. It is often advised during chemotherapy. Your neutrophils, the white blood cells that are the first responders in fighting infection, are strongly affected by most chemotherapy drugs, and low levels can make you prone to infections. Safe food handling practices as well as avoiding certain foods can reduce your risk of becoming ill while on chemotherapy.

While some researchers believe the very restrictive neutropenic diet recommended in the past is unnecessary and may increase the risk of malnutrition, safe food handling tips recommended by the Centers for Disease Control and Prevention (CDC) are imperative to lower the risks associated with chemotherapy-induced neutropenia.

General Recommendations

Recommendations from the CDC, as with most healthcare agencies and oncologists, begin with careful hand washing. Note that most people do not wash their hands properly, and hand sanitizers are not as effective at removing some bacteria. General recommendations include:

  • Wash your hands frequently, and before and after eating
  • Avoid raw meats and eggs—be sure to cook all the way through to kill any germs
  • Wash raw fruits and vegetables
  • Avoid sharing food with anyone
  • Do not share any personal eating utensils, like drinking cups or forks
  • Keep household surfaces clean, like the kitchen counter and table

Recommendations About Preparing and Storing Foods

The preparation and storage of foods is a common place for the introduction of harmful bacteria that could cause an infection. Recommendations for food preparation and storage include:

  • Keep hot foods hot (warmer than 140° F) and cold foods cold (cooler than 40° F).
  • Eat defrosted foods right away—do not refreeze them.
  • Refrigerate foods at or below 40° F.
  • Do not thaw meat, seafood, or chicken at room temperature—use the microwave, refrigerator, or water (but not for more than an hour).
  • After buying or making perishable foods, eat them within 2 hours. 
  • Eggs, cream, and mayonnaise-based foods should not be outside of the refrigerator for more than one hour—if so, throw them out.
  • Wash fruits and vegetables thoroughly—like the leaves of lettuce one at a time—with water before cutting or peeling.
  • Foods that will be peeled or sliced should be washed before cutting or peeling to avoid introducing bacteria into the foods from the skins.
  • Do not use chemical-based rinses.
  • Rinse "prewashed" food products like salads, even though the label may claim the product was thoroughly rinsed.
  • Avoid raw vegetable sprouts.
  • Toss fruits and vegetables or any foods that are slippery, slimy, moldy, or smell funny.
  • Avoid purchasing pre-cut veggies at the store (for example, precut watermelon or mango).
  • Use soap and water to wash the tops of canned foods before opening.
  • Use a different utensil for eating and tasting foods while cooking. 
  • Toss out eggs with cracked shells.
  • Do not use the same cutting board (or the same knife) for meat preparation as for vegetable and fruit preparation.
  • Use a meat thermometer to make sure meats are cooked to the proper temperature. If cooking in the microwave, make sure all areas are heated (as microwaves can heat food unevenly).

Some oncologists use the mnemonic picky (or actually "piccy" to help people remember safe food practices. The letters in "piccy" stand for:

  • P: Preventing infection by using foods that can be cooked or have been pasteurized
  • I: Inspecting foods before you cook them
  • C: Clean and scrub fruits, vegetables, and cooking surfaces
  • C: Cook all foods, both entrees and side dishes, thoroughly
  • Y: Yucky, moldy food should be tossed uneaten

Food Restrictions

Depending on your oncologist and the center where you are undergoing chemotherapy, you may be advised to avoid certain foods. Foods that should be avoided include:

  • Raw meats and seafood (save the sushi for when chemotherapy is done)
  • Raw nuts or fresh nut butter
  • Any foods that may contain raw eggs (such as Caesar salad dressing or Hollandaise sauce made from scratch). When cooking eggs, scrambled or hard-boiled make better choices than sunny-side-up or over-easy where the eggs may not be cooked through
  • Soft and aged cheeses especially if imported, such as Brie, Gorgonzola, Roquefort, Camembert, Feta, and Ricotta, as well as Mexican-style cheeses such as Queso and Fresco
  • Unpasteurized cheeses, milk, and fruit and vegetable juices
  • Bulk-bin sources of cereals and grains
  • Cream-filled pastries that are not refrigerated
  • Raw honey or honeycomb
  • Water straight from a water source (such as from a lake, spring, or stream). In some cases, well-water should be avoided as well
  • Vitamin-supplemented water (some vitamin and mineral supplements may interfere with chemotherapy)
  • Refrigerated salsas and salad dressings in the grocery store

Limitations/Risks of the Neutropenic Diet

Oncologists are now putting more of an emphasis on safe food handling techniques, as opposed to restricting foods. Chemotherapy already takes a huge hit on a person's body and their appetite. Further restricting foods may actually worsen any underlying nutritional deficiencies. While you may hear rumors that the neutropenic diet (as often used in the past), safe food handling and limiting the intake of certain foods is as important as ever in reducing illness, and potentially even mortality, while receiving chemotherapy.

Other Thoughts on Cooking and Eating During Chemotherapy

In addition to safe food handling, people going through chemotherapy often have other challenges as well. Some of these include:

  • Mouth sores: Painful sores in the mouth are common, but choosing foods that are less likely to irritate the mouth can do wonders. Avoiding citrus foods, sharp foods (such as toast), and more is often advised.
  • Taste changes: Some chemotherapy drugs can make everything you eat taste metallic and has been coined metal mouth. Choosing foods with strong flavors and eating with plastic utensils can be helpful, among other changes.
  • Nausea and vomiting: Nausea and vomiting certainly interfere with eating, but there are now many options to control these symptoms. Talk to your oncologist.
  • Loss of appetite: Even if you simply don't feel like eating, there are tips that can help you get adequate nutrition.
  • Cancer fatigue: Fatigue is one of the most annoying symptoms of cancer treatment, and is not uncommonly the reason why people don't eat as healthily as they should. Make sure to ask for help with cooking and cleaning up. (Keep in mind that loved ones of people with cancer often feel helpless, and asking for help is one thing you can do for them). You may also want to ask friends to stock up your pantry with easy-to-prepare foods such as canned soups, frozen entrees and vegetables, and packaged puddings.

If you are concerned about food handling or foods to eat while on chemotherapy, talk to your oncologist and ask if seeing an oncology nutritionist might be helpful.

Preventing Infections During Chemotherapy

In addition to safe food practices, there are many ways in which you can reduce your risk of developing an infection during chemotherapy, especially when your white blood cell count is low. We often think about friends who have a cough or a runny nose, but our pets can be a source of infection as well. Reptiles such as lizards, snakes, and turtles often carry Salmonella, as do birds. Avoiding crowded conditions is helpful, and you may wish to use a mask when in these situations or when flying. Learn more about how to lower your infection risk during chemotherapy.

For people who are at risk for severe neutropenia, such as those receiving "double-dose" chemotherapy or are receiving chemotherapy in preparation for a stem cell transplant, oncologists often prescribe the medications Neulasta or Neupogen. These medications, known as granulocyte-colony stimulating factors, increase the production and release of neutrophils from the bone marrow, and can significantly reduce the risk of infections.

A Word From Verywell

Practicing safe food handling techniques is important for you and your family whether or not you are receiving chemotherapy or otherwise immunosuppressed. While the neutropenic diet of the past (one that eliminated most fruits, vegetables, and meats) is unnecessary, safe food handling practices can reduce your risk of developing an infection, and the consequences of developing an infection during cancer treatment.

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