Neutropenic diet during high-dose therapy: a risk for patients

Peer reviewed / Opinions and position papers in Ernährungs Umschau, as in many other journals, are not subject to the peer review process because these texts have already been evaluated, discussed, and widely agreed upon by experts (peers).

Background

In the context of hematologic stem cell transplantation (HSCT), the immune system is severely weakened by chemotherapy [1]. Therefore, for more than three decades, patients undergoing HSCT have been significantly restricted in their food choices by a so-called neutropenic diet [1]. By avoiding numerous foods and special instructions for preparation, the risk of food infection is to be reduced by the immunosuppressed patients [2]. This seems rational at first, as infections are indeed associated with increased morbidity and mortality in affected individuals [3]. Nevertheless, there is a lack of scientific evidence as to whether adherence to a neutropenic diet prevents infections [1]. This is relevant because strict limitation of dietary options may affect quality of life and compromise body weight maintenance.

According to the definition of the Robert Koch Institute (RKI), a neutropenic diet is an "Explicit avoidance of any food that may cause infections in immunocompromised patients via contamination with and transmission of facultative pathogenic or opportunistic microorganisms." [4]
In practice, this is done in different ways. In 2006, Moody et al [5] defined a diet as "low-bacterial" (neutropenic diet) if it excluded raw fruits that cannot be peeled and if it did not include raw vegetables, aged cheese, cold cuts, fast food, or food prepared away from home. In their study published in 2018 [6], nuts and yogurt were additionally excluded for this dietary pattern. Van Thiel et al [7], in a clinical trial published in 2007, investigated a "low bacterial diet“ without raw vegetables, lettuce, soft cheeses, raw meats, fresh fruits, tap water, and spices that were not heated. In 2012, Trifilio et al [8] reported a "low bacterial" diet (neutropenic diet) that did not include fresh fruits or vegetables, black pepper, raw or undercooked meat, undercooked cheese products, cold-smoked fish, non-pasteurized dairy products, raw miso products, raw cereal products, or brewer's yeast. ...

Statement

• of the German Cancer Society, Working Group Prevention and Integrative Oncology (PRIO)
• the German Society for Hematology and Medical Oncology, Working Group Nutrition, Metabolism, Exercise;
• the German Association of Dietitians an the
• Professional Association of Oecotrophologists

Abstract

The neutropenic diet has been a dietary regimen prescribed in many centers to patients undergoing intensive chemotherapies and/or hematologic stem cell transplantation for decades. However, evaluation of the scientific data on the low-germ diet shows that this diet has no benefit but considerable risks for patients. Therefore, this form of nutrition is not indicated. The undersigned professional societies and working groups therefore call on all physicians, nurses, nutrition therapists and dieticians to provide comprehensive nutritional medical advice to patients undergoing and after intensive chemotherapy. This includes detailed information and training of patients and relatives on hygiene measures in the kitchen and when consuming food.

Key words: neutropenic diet, chemotherapy, hematologic stem cell transplantation, immunosuppression, malnutrition, hygiene training, cancer, nutritional medicine, nutritional therapy

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