Neutropenic Diet Questions

Recently, I was asked about the use of neutropenic diets for individuals with low white blood cell counts due to cancer treatment. This health care provider asked, “Is there any evidence-based literature [research] to support the neutropenic diet? What materials are useful for educating patients on neutropenic diets?”

Medical Options

One important thing to know is that there are several medical options for managing low blood counts. If you have low white blood cell counts, you should talk to your doctor about these options. As well, you can learn more about blood counts by reading our information on Diagnosis & Testing Complete Blood Count (CBC).

The Neutropenic Diet

A diet that limits certain types of food in order to limit exposure to bacteria is referred to as a neutropenic diet. Neutropenic diets are designed to reduce the risk of food-borne illness (food poisoning) in individuals whose immunity is low due to low white blood cell counts.

Most food contains some bacteria, but under normal circumstances our immune systems quickly kill the bacteria so this food does not make us sick. For people who have low white blood cell counts due to cancer treatment, certain foods may contain too much bacteria. These foods may need to be avoided until white blood cell counts improve.

Evidence for Neutropenic Diets

Neutropenic diets often are used in cancer care clinics and hospitals, although the research on them is limited (1-3). Over the years, numerous approaches to food safety for patients with low white blood cell counts have been adopted and discarded by different institutions, but none have been well studied in a controlled, systematic way to determine if they really are necessary or effective.

Furthermore, the small studies that have been conducted on this topic suggests that extensively limiting certain foods is no more effective than general food safety practices for minimizing risk of food-borne illness in patients with low white blood cell counts (4-6).

Most health care providers who faithfully follow their institution’s neutropenic diet guidelines probably aren’t aware that for the most part, there is no research evidence to support these recommendations. However, this does not mean that all neutropenic diet guidelines should be abandoned.

One problem with doing a large controlled trial is that it would involve randomizing some people to receive no special guidelines for food safety. The fear of infection is high among most healthcare providers. Many simply aren’t willing to risk not following any particular guidelines for patients with very low white blood cell counts, even for the purposes of a controlled trial, which makes sense.

Typically, health care providers have concluded that following neutropenic diet guidelines makes sense intuitively, isn’t going to cause harm, and may protect the patient from unnecessary infection risk, so there are no reasons not to do it.

Common Sense Neutropenic Guidelines

With this in mind, many institutions are going toward a more “common sense” approach to food safety for neutropenic patients. This means trying to do the things that make the most sense from an infection risk perspective, but avoiding unnecessarily limiting dietary intake. Given that some patients struggle to eat adequate calories and protein, it seems wise to avoid limiting foods people may enjoy if these foods are believed to be safe.

To get started with some basic guidelines, you can view our information Food Safety During Cancer Treatment.

These guidelines are not strictly evidence-based, because unfortunately, there isn’t any clear cut evidence on this topic. But these guidelines are in line with the general consensus of ways to reduce infection risk without limiting the diet beyond what is necessary. Remember that the goal is to use common sense to lower patients’ infection risk, but also give them enough flexibility to eat as well as they can.

Along with following common sense food safety guidelines, one of the single most important ways to minimize infection risk is to wash hands well and frequently. Hand washing is a time-tested and effective way to reduce infection risk both in general and among those with white blood cell counts.

Reassuring Support for Common Sense Approach

Finally, there is an unrelated study that provides reassurance that this “common sense” approach to food safety is appropriate for most patients with low white blood cell counts (7). This study compared home care versus hospital care for patients who had received an allogeneic (unrelated donor) stem cell transplant.

Home care was superior in many aspects, including that home care patients had fewer days on total parenteral nutrition, less acute graft-versus-host disease (grades II-IV), lower transplantation-related mortality rates, and lower costs compared with the control patients treated in the hospital. The 2-year survival rates were significantly higher in the home care group versus the patients managed in the hospital as well.

Even though this study did not examine food safety specifically, it is reassuring. It suggests that basic food safety guidelines that can be used in the home setting are an acceptable way to manage food-borne infection risk in patients with low white blood cell counts.

References

1. Moody K, Charlson ME, Finlay J. The neutropenic diet: what's the evidence? J Pediatr Hematol Oncol. 2002;24(9):717-21.
2. Wilson BJ. Dietary recommendations for neutropenic patients. Semin Oncol Nurs. 2002;18(1):44-49.
3. Smith LH, Besser SG. Dietary restrictions for patients with neutropenia: a survey of institutional practices. Oncol Nurs Forum. 2000;27(3):515-20.
4. Moody K, Finlay J, Mancuso C, Charlson M. Feasibility and safety of a pilot randomized trial of infection rate: neutropenic diet versus standard food safety guidelines. J Pediatr Hematol Oncol. 2006;28(3):126-33.
5. DeMille D, Deming P, Lupinacci P, Jacobs LA. The effect of the neutropenic diet in the outpatient setting: a pilot study. Oncol Nurs Forum. 2006;33(2):337-43.
6. Larson E, Nirenberg A. Evidence-based nursing practice to prevent infection in hospitalized neutropenic patients with cancer. Oncol Nurs Forum. 2004;31(4):717-25.
7. Svahn BM, Remberger M, Myrbäck KE, Holmberg K, Eriksson B, Hentschke P, Aschan J, Barkholt L, Ringdén O. Home care during the pancytopenic phase after allogeneic hematopoietic stem cell transplantation is advantageous compared with hospital care. Blood. 2002;100(13):4317-24.