Eating safely with neutropenia

Higher risk foods:

• mould-ripened soft cheeses with a white coating on the outside, such as brie, camembert and chèvre (unless cooked until steaming hot)
• soft blue cheeses such as Danish blue, gorgonzola and roquefort (unless cooked until steaming hot)
• unpasteurised or "raw" cow’s milk, goat’s milk or sheep’s milk or cream
• any foods made from unpasteurised milk, such as soft goats cheese and unpasteurised ice cream
• probiotic drinks and yoghurts like kefir, Yakult and Actimel.

What to have instead:

• any cheese from the avoid list as long as it's cooked until steaming hot before eating – this kills bacteria and reduces the risk of infection
• all hard pasteurised cheeses such as cheddar, edam, gruyere, stilton and parmesan
• soft pasteurised cheeses such as cottage cheese, mozzarella, feta, cream cheese, paneer, labneh, ricotta, halloumi, goat's cheese without a white coating on the outside (rind) and processed cheese spreads
• pasteurised milk, cream and ice cream – check the hygiene rating of the shop or van before before having soft ice cream
• plain, natural, fruit, Greek, bio and live yoghurt.

Higher risk foods:

• raw or runny eggs
• home-made foods made with raw eggs, such as home-made mayonnaise, mousse and ice cream.

What to have instead:

• well-cooked eggs
• shop-bought foods made with raw or undercooked eggs such as mayonnaise and ice cream, as these are likely to have been pasteurised to remove germs.

Higher risk foods:

• damaged or bruised fruit and vegetables
• uncooked sprouted seeds.

What to have instead:

• undamaged fruit and vegetables, including raw fruit, vegetables and salads.
• wash fruit and vegetables before eating, including pre-packed salad, even if it says ready washed
• sprouted seeds that have been cooked until they're steaming hot before eating.

Higher risk foods:

• smoked fish such as smoked salmon and trout (unless cooked until steaming hot)
• raw fish, including sushi made with raw fish
• raw shellfish.

What to have instead:

• cooked fish and seafood
• well-cooked shellfish (such as mussels, lobster, crab and prawns)
• sushi made with cooked fish or vegetables.

Higher risk foods:

• raw or undercooked meat and poultry
• unpasteurised paté, including vegetarian paté
• cured or smoked meats, such as salami, pepperoni, chorizo and prosciutto (unless cooked until steaming hot).

What to have instead:

• meat that has been well cooked with no trace of pink or blood – be especially careful with poultry, pork, sausages and burgers
• cold, pre-packed meats such as ham and corned beef
• cured or smoked meats that have been cooked until steaming hot
• pasteurised paté in a jar.

Higher risk foods:

• black pepper, dried herbs and spices bought loose from delis, farm shops or market stalls
• any foods from "refill stations" where people help themselves, for example cereals, nuts and dried fruits.

These are higher risk because they could have been handled by multiple people, so there’s a risk of contamination with germs.

What to have instead:

• pre-packed, sealed packages of black pepper, dried herbs, spices and other foods.

You might have heard the term “neutropenic diet". There’s no official definition of a neutropenic diet, but it has often meant avoiding a lot of different foods, and in some cases avoiding raw fruits and vegetables. The diet is sometimes called a clean diet or low bacteria diet.

In recent years, several research studies have found that a neutropenic diet does not reduce infections. It may even be harmful for some people, as it limits the range of foods you can eat, at a time when you may already be struggling to eat well due to the side effects of treatment. This could mean you don’t get enough nutrients.

Because of the lack of evidence to support it, many hospitals have stopped recommending a neutropenic diet. Instead, they encourage patients to eat a varied diet with as few restrictions as possible. Evidence does support avoiding some higher risk foods, but this is much less restrictive than it was in the past.

You do not need to peel fruit and vegetables. It’s safe to eat raw, unpeeled fruit and vegetables, as long as they are washed.

In the past, some neutropenic diet guidance recommended only having fruit and vegetables that were well cooked or peeled. But there’s no strong evidence that this reduces infection. Removing the skin could mean you don’t get important nutrients like fibre or antioxidants.

It’s safe to drink bottled water when you’re neutropenic.

Some older guidance said you should avoid drinking bottled water, but there’s not enough evidence that this reduces infection. Drinking bottled water can be a good way to stay hydrated, especially when you don’t have access to fresh tap water.

Most yoghurts you can buy in shops are safe to eat when you have neutropenia. Yoghurt is made using bacteria, but in most yoghurts the types of bacteria used are safe and do not cause infection. Fruit, Greek, natural, live and bio yoghurts are all safe to eat.

It’s best to avoid yoghurts or yoghurt drinks labelled ‘probiotic’ or ‘kefir’ if you’re neutropenic, unless your doctor or dietitian recommends them. These contain several different types of bacteria and yeasts that are promoted as having health benefits. At the moment there is not enough evidence to say if probiotic products are safe or beneficial for people with a weakened immune system.

You should also avoid home-made yoghurt made with raw milk, as this may contain harmful bacteria that could make you sick.

There’s no need to sterilise cutlery or crockery. Washing them with hot water and washing up liquid, or washing in a dishwasher, will keep them clean and free from germs.

Ask your hospital team about eating out and take aways. Their advice is likely to vary depending on your level or neutropenia. It’s best to stick to restaurants and take aways that have high standards of food hygiene. You can check their food hygiene rating on the Food Standards Agency website. 5 is the highest rating and means their hygiene standards have been rated very good.

It’s safest to avoid buffet restaurants and open salad bars, as food may have been sitting out for long periods of time and serving utensils may be handled by lots of people. This increases the risk of infection.

Your hospital team will be able to advise you on how long to follow these guidelines for, as this will vary from person to person. Even if you are no longer neutropenic, you might still need to avoid high risk foods because you might become neutropenic again, or your gut lining may still be damaged.