Did You Wash Your Hands? The Neutropenic Diet and Other Food Safety Guidelines

Jun 09, 2023

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When it comes to protecting our health, our immune system is our trusty shield, defending us against invaders like harmful viruses and bacteria. However, individuals with compromised immune systems, like some cancer patients, face an increased risk of infection. Historically, the neutropenic diet has been prescribed to patients whose immune systems may be compromised as a way to prevent infection from pathogenic, meaning bad or harmful, bacteria found in foods. 

What is the neutropenic/low-microbial diet?

The neutropenic diet is a type of diet usually used for individuals with weakened immune systems, or those with an absolute neutrophil count (ANC) below 500. The classic or traditional neutropenic diet eliminates all raw foods like raw fruits and vegetables, raw dairy and cheese; soft cheeses like brie, feta, or farmer’s cheese; deli meats, take-out foods, and fermented foods like yogurt and sauerkraut. These foods are avoided due to their higher potential for pathogenic bacteria that could cause infection in those with compromised immune function.

The evidence for the neutropenic diet:

While the neutropenic diet is still prescribed to patients with impaired immunity, there has been some controversy about whether this diet is necessary. Most of the studies that support the use of the neutropenic diet date back to the 1960s and 1970s. These studies placed leukemia patients in isolated tents with restricted airflow, on sterile diets, and used oral nonabsorbable antibiotics to create an environment aimed at minimizing toxin exposure. Not only is this kind of environment not feasible for the average patient, but the results from these studies indicated that while a protected environment did help to prevent infection in those with compromised immune systems, it was unclear how much the sterilized diet actually contributed to the results of the study independently. 

A systematic review published in 2019 examined five randomized controlled trials, including 388 patients who primarily had acute myeloid leukemia, acute lymphoblastic leukemia, or sarcoma.  After examining the results from all 5 trials, the review reported that there was no significant difference in infection rate between the neutropenic diet group (53.7%) and the unrestricted diet group (50%). The review concluded that prescribing the neutropenic diet was not associated with a decreased infection rate in neutropenic cancer patients. 

When it comes to studying the effectiveness of the neutropenic diet, there are a few issues. The studies often involve only a small number of people, and it’s challenging to figure out which factors are actually causing infections in the participants. Because of these limitations, there isn’t enough evidence to say that the neutropenic diet can effectively prevent infections in people undergoing chemotherapy or with weakened immune systems. Additionally, there is no universal definition of the neutropenic diet across institutions and practitioners, making it difficult to discern which type of neutropenic diet may be affecting infection rates. Furthermore, there has been concern surrounding some very restrictive forms of the diet decreasing patient quality of life and potentially increasing incidences of malnutrition by removing many foods, including foods that have beneficial health effects, such as commercially prepared yogurts and fermented foods that may improve gastrointestinal health. 

Because of the lack of evidence to support prescribing the neutropenic diet, many major cancer centers, including Memorial Sloan Kettering and MD Anderson Cancer Center, as well as the Academy of Nutrition and Dietetics, have moved away from recommending a strict neutropenic diet in favor of targeted nutrition education around food safety. 

Therefore, it’s crucial to prioritize your safety by following basic food safety guidelines during chemotherapy or when your immune system is weak. This means taking precautions to avoid getting sick from potentially harmful bacteria in food. By being careful about food safety, you can reduce the risk of infections, even if the effectiveness of a classic neutropenic diet is still uncertain.

How to follow safe food practices:

When it comes to food safety, there are four key steps to remember: clean, separate, cook, and chill. By following these practices, you can significantly reduce the risk of foodborne illnesses.

Clean

Before handling or cooking any food, thoroughly wash your hands with soap and water for at least 20 seconds. Also, ensure that the surfaces you use for food preparation are clean and sanitized.

Separate

When shopping for groceries, try to keep raw meats, eggs, fish, and poultry away from your other produce and foods. If you are preparing both meats and ready-to-eat foods and produce, make sure to use a separate cutting board for your meats and your vegetables, bread, and other foods that need to be prepared. 

When marinating or defrosting meats and poultry in the refrigerator, make sure to store them on the bottom shelf away from your other foods so any juices from the raw meats do not contaminate your other ready-to-eat foods. Store your raw meats in sealed containers or wrap them tightly to ensure they do not leak in the refrigerator. 

One common practice that is actually not food-safe is washing raw chicken. Raw chicken is a ready-to-cook food and does not need to be washed in the sink prior to cooking.  Doing so could spread harmful bacteria to your sink area and potentially onto your other foods, which could make you sick. Cooking chicken to the appropriate temperature will kill any bacteria present.

Cook

To ensure food is cooked safely, use a food thermometer to check the internal temperature. Different meats have specific temperature requirements:

Whole cuts of beef, veal, lamb, and pork: 145°F

Fish with fins: 145°F or until the flesh is opaque and flakes easily

Ground meats (beef, pork): 160°F

All poultry (including ground chicken and turkey): 165°F

Leftovers and casseroles: 165°F

If using a microwave, follow recommended cooking and standing times. When reheating cooked foods, use a food thermometer to ensure the internal temperature reaches 165°F.

Chill

Bacteria multiply rapidly in the “Danger Zone” between 40°F and 140°F. When bacteria multiply and divide at a rapid pace, they can make you sick. To prevent this: 

• Keep your refrigerator at 40°F or below.
• Refrigerate perishable foods like raw meats, milk, cheese, cut fruit, and leftovers within 2 hours. If exposed to temperatures above 90°F, refrigerate within 1 hour.
• Thaw frozen foods in the refrigerator, in cold water, or in the microwave. Avoid thawing on the counter, as it exposes food to the Danger Zone for an extended period.

By following these simple steps, you can maintain food safety and reduce the risk of foodborne illnesses. For more information and specific questions on food safety, reach out to our registered dietitians at OncoPower.