Clean Diet What is neutropenia? If your neutrophil count is between 0.5 and 2.0 you are considered to be neutropenic. If it is lower than 0.5 it is classed as 'severe' neutropenia. What is a neutropenic diet? When you are neutropenic you are at a greater risk of infection from bacteria or fungus in foods. It may therefore be necessary for you to follow a 'neutropenic' or 'clean' diet. There are some foods that are considered to be 'high risk' and should be avoided by patients whose neutrophils are low. A clean diet eliminates these foods and suggests suitable alternatives. Poor appetite It is quite normal for you to find there are times when you cannot eat as much as usual and you may lose weight. However, eating well will help you avoid losing weight, help your body fight infection and cope with the side-effects of treatment. You can read about food safety below, or you can download our information leaflet that explains everything you need to know about a clean diet and poor appetite. The following information has been provided by the Haematology Sub Group of the British Dietetic Association’s Oncology Specialist Group. It is a guide and neither The AAT nor the BDA can advise on individual cases. You should therefore continue to be advised by your clinical team. Food safety advice during neutropenia - neutrophil count is below 2.0 x 109/L Avoid Alternatives All unpasteurised dairy products eg milk sold on local farms Any pasteurised, soya, Jersey or UHT milk Soft cheeses made with unpasteurised milk eg feta, parmesan; Homemade/deli paneer and labneh; Mould-ripened cheeses eg camembert, brie, goat’s cheese; Blue veined cheeses eg Danish blue and stilton Cheeses made with pasteurised milk, processed cheese eg Dairylea, Kraft, Philadelphia and halloumi; Pasteurised parmesan, mozzarella and goats cheese. Paneer made with pasteurised milk; Vacuum-packed pasteurised and hard cheeses eg cheddar and Edam Smoked salmon, raw sushi, caviar, oysters or lightly cooked shellfish Well cooked shellfish eg in a curry, risotto or stir-fry; Vacuum-packed fish eaten straight from a new packet. This includes smoked salmon Raw/undercooked meat, poultry or fish eg meat which is still pink; Smoked meats eg salami 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 Raw eggs or undercooked eggs eg homemade mayonnaise, homemade ice cream, mousse, egg-nog, meringue and hollandaise sauce and béarnaise sauce Hard boiled eggs; Scrambled or fried eggs but the white and the yolk must be solid; Shop bought mayonnaise and other products made with pasteurised egg Probiotic or ‘bio’ foods, drinks or supplements eg Yakult, Actimel, ProViva; Yoghurt which is described on the label as ‘bio’ or ‘probiotic’ Any yoghurt that does not describe itself as ‘bio’ or ‘probiotic’ including live, plain, Greek and fruit yoghurts Any type of unpasteurised meat or vegetable paté Pasteurised paté and paste in tins or jars that do not need to be refrigerated Food safety advice during severe neutropenia - neutrophil count is below 0.5 x 109/L Avoid Alternatives Raw unpeeled fruit or vegetables including salad items, stuffed vine leaves, fatoush and taboulleh; Raw dried fruit, products containing this eg muesli, Bombay mix and confectionary; Damaged or over-ripe fruit or vegetables; Unpasteurised or freshly squeezed fruit or vegetable juice or smoothies Good quality fruit and vegetables that are well cooked or peeled; Cooked dried fruit eg in fruitcake, flapjacks or cereal bars; Tinned fruit; Pasteurised smoothies; UHT or long-life fruit juices – in cartons or jars Fresh nuts, nuts in shells Cooked nuts, nuts in cans; Peanut butter, roasted nuts Uncooked herbs, spices and pepper Cooked herbs, spices and pepper Any cold smoked fish ie cold smoked salmon Cooked dishes containing smoked salmon Non-drinking water, bottled mineral or spring water, water from wells, water from coolers, domestic water filters and water fountains Freshly run tap water Please check with your hospital for guidance Ice when away from home eg in a restaurant or in Slush Puppies Ice made from appropriate water sources (see above) Ice cream from ice cream vans Ice cream from reputable sources in individual portions, wrapped or in small pots 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 eg olives, houmus, shawirma and baklava Ideally, packets should be individual portions eg butter, sweets, pickles General advice Shopping Avoid buying food with damaged or broken packaging Do not buy food from fridges or freezers that are overloaded as the food may not be cold enough Buy chilled and frozen foods last and get them home as quickly as possible. If it is not possible to get food home immediately, an insulated container or cool bag can help to keep food at the correct temperature Buy foods in small, individual packets. Avoid large packets that will be open longer and increase the chance of bacteria contaminating them Always check ‘best before’ or ‘use by’ dates on packaging Avoid shops where raw and cooked meats are stored in the same fridge or in a deli counter without a separating wall. Where possible buy pre-packed deli items. Storage Keep your fridge between 0 and 5 degrees Keep your freezer below -18 degrees. Always ensure that food is still frozen solid when it is removed from the freezer Store cooked food at the top of the fridge Raw or defrosting meat or fish should be stored at the bottom of the fridge in a covered container to prevent dripping or leaking into the fridge Do not overload your fridge or freezer as this will increase the temperature Always store eggs in the fridge Use and store food following the manufacturer’s instructions and within ‘best before’ or ‘use by’ dates Never refreeze thawed food. Food Preparation Always wash your hands with warm water and soap before preparing food Always wash your hands after going to the toilet, sneezing and after touching pets, hair, dirty washing, rubbish, ready-made or raw food Use a separate towel or use kitchen paper to dry your hands. Do not use a tea towel Cover any cuts and grazes with a waterproof plaster Keep pets away from work surfaces, food and your dishes Ensure any cloths or sponges are regularly bleached, disinfected or changed Avoid cross-contamination of food by changing or washing chopping boards and utensils between raw and cooked food. Ideally you should have three boards; one for raw meat, one for cooked meat and one for other foods. Kitchen Hygiene Disinfect work surfaces regularly Wash can tops before opening them Wash fruit and vegetables before eating Clean tap spouts regularly Wash the roof and the inside of your microwave regularly. Cooking Thaw meat and poultry in a fridge and not at room temperature as bacteria grow quickly at room temperature Cook all food thoroughly and ensure it is piping hot all the way through Cook meat until the juices are clear Pre-heat the oven to ensure food is cooked at the recommended temperature Always follow manufacturer’s guidelines and do not shorten cooking times. Reheating Food Eat rice as soon as it is cooked and do not reheat cooked rice as harmful bacteria can survive the heating process Microwave cookers can be used for defrosting and for heating prepared foods according to manufacturer’s instructions For home-cooked foods, cool food at room temperature within an hour after cooking and then refrigerate or freeze Eat reheated food within 24 hours of preparing or defrosting it Do not reheat food more than once Do not put hot food in your fridge as this will increase the temperature of all food in the fridge making it unsafe to eat Cover food and allow it to cool to room temperature before putting it in the fridge. Eating Out Ensure food is piping hot when served and cooked all the way through Choose freshly prepared foods from reputable outlets. Avoid salad bars, street vendors, market stalls, buffets, all-you-can-eat restaurants and ice cream vans Avoid foods which have been left out on display such as doner kebab meat Check restaurant hygiene ratings at www.ratings.food.gov.uk Talk to your doctor or healthcare team about eating out in restaurants or visiting crowded places.