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‘Futile’ neutropenic diets should be abandoned for individuals with cancer
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Routine use of the neutropenic diet for patients with cancer should be abandoned, according to a paper published in Journal of Hospital Medicine.
Neutropenic diets are intended to eliminate foods that may harbor pathogenic microbes in an attempt to reduce infection risk. However, there is minimal uniformity among health systems about what constitutes a neutropenic diet.
In addition, fresh fruits and vegetables — along with dairy and meat products — are eliminated. This compromises nutritional intake for individuals with cancer, who already are at high risk for malnutrition, Arjun Gupta, MD, chief resident for quality, safety and value within the department of internal medicine at University of Texas Southwestern Medical Center, and colleagues concluded.
Gupta and colleagues reviewed evidence from previous clinical trials and determined restrictive neutropenic diets may be equivalent — or potentially inferior — to more well-rounded dietary approaches.
“We actually did not report new data in our paper. We simply compiled what was known with a hope that it raises awareness about the futility of these diets and how we are unknowingly causing patient harm,” Gupta told HemOnc Today.
In addition, evidence suggests adherence to FDA-issued safe food-handling guidelines — which all hospital kitchens are required to follow — provide adequate protection against food-borne infection. This precludes the need for neutropenic diets, Gupta and colleagues wrote in their paper, published as part of the journal’s “Things We Do for No Reason” series.
HemOnc Today spoke with Gupta about the heterogeneity of the neutropenic diet, the challenges associated with eliminating this diet, and what should constitute proper nutrition for individuals with cancer.
Question: Can you provide an overview of the neutropenic diet for patients with cancer?
Answer: A neutropenic diet is an umbrella term for restrictive diets that have been used for the past 50 years with the intention to reduce infection rates among patients with cancer who develop neutropenia due to the cancer itself or due to therapy. In the 1960s and 1970s, clinicians noticed that patients undergoing chemotherapy or bone marrow transplantations were getting infections. We started looking for interventions to reduce these infections. Theoretically, it made sense that the gastrointestinal tract is a natural place for pathogens to enter the body. We concluded that reducing the intake of potentially pathogenic microbes would reduce infection rates. It sounds very logical, but multiple randomized clinical trials show that these restrictive neutropenic diets do not reduce infection rates compared with more standard, liberal diets.
Also, there is no standardization between or even within institutions regarding what constitutes a neutropenic diet. Data from across the world have demonstrated the heterogeneity of the content of these diets. Institutions restrict tap water, dried or fresh fruits, vegetables, cooked eggs, meats and alcohol inconsistently and without logic. There also are variations in the threshold of neutropenia to start these diets, whether it’s just during chemotherapy or after, and whether it is at a neutrophil count or 500, 1,000, or 1,500 per microliter of blood. No one seems to know the answers to these questions, and everyone is doing their own thing.
These restrictive diets are not benign or free of harm. Patients with cancer-associated neutropenia often have mucositis, nausea, vomiting, diarrhea, taste changes and poor appetites, all of which result in malnutrition and reduced quality of life. These patients are not eating or drinking as well at baseline, so restricting certain food and drink items worsens their nutritional status and quality of life.
Q: How prevalent are these diets?
A: There have been multiple surveys across the globe showing that the majority of cancer centers propagate their use in some form. Across the United States, there is no specific guideline about what constitutes a neutropenic diet. However, we looked at the websites of the top 20 cancer centers in the United States and found that 16 of them either did not address this question or provided incorrect information to patients about the neutropenic diet. This level of heterogeneity in recommendations for patients with cancer is unacceptable.
Q: Can you elaborate on the inconsistencies with which these diets are prescribed or followed?
A: It is hard to know what different cancer centers are doing because there are no uniform guidelines, but we do know patients are getting inconsistent messages. When we spoke to the kitchen staff at our hospital, even they didn’t know exactly what the neutropenic diet involved. We received a number of different answers about exclusion of fresh fruits and vegetables, and some said there should be no tap water. Another important point is patient ease for following these diets. Studies show patients are unable to fully comply with these diets, even in the short term.
Q: If patients are not following these diets, does that skew data that show they do not effectively prevent infections?
A: That’s a good point. The data sets showing that patients don’t follow these diets have largely been done in the outpatient setting. However, a majority of the randomized controlled studies that demonstrated the ineffectiveness of the neutropenic diet were performed with patients admitted to the hospital, where diets are provided by the hospital and the study team has control over the food exposures.
Q: These studies from the inpatient setting show the diets are not working?
A: Absolutely. Multiple randomized controlled trials have proved they do not work. Pooling these data in meta-analyses show they do not work. There is no higher level of data needed.
People argue that the monetary cost of these diets is not that much. Value in health care is defined by patient value or experience divided by the cost of the intervention. The cost of eliminating an apple from a patient’s diet is almost zero, but you have to measure how the removal of that apple is affecting the patient experience, which we know has been terrible.
Q: You are suggesting that this diet be eliminated . Can you explain the rationale? Is there any place in the health system for this diet?
A: Our final recommendation is to encourage de-adoption of the neutropenic diet. We want it abolished. This is a strong statement and we recognize that. We managed to successfully de-adopt the diet from our hospitals. We hope other hospitals and institutions also follow. In an upcoming paper, we discuss how we went about this process and engaged all the stakeholders in supporting the demise of the neutropenic diet.. The caveat is that we recognize neutropenic patients are at an extraordinarily high risk for infection. By abolishing the neutropenic diet, we do not mean that patients should eat unsanitary or unsafe food. The FDA has easy-to-understand, easy-to-follow safe food-handling guidelines that have been shown to be safe. These focus more on food procurement, preparation and storage rather than restricting food items completely. All hospitals are required to adhere to these FDA guidelines. Our aim is to have people focus more on preparation than restriction. For example, we don’t say, ‘Don’t eat meat.’ We recommend purchasing fresh meat from a reliable source, keeping raw meat separate from cooked or ready-to-eat foods, cooking it thoroughly, refrigerating it, and thawing safely if freezing it.
Q: What response have you received to your paper?
A : The responses have change based on the conversations we have had with people about it. When we first brought this up to our hospital committee, people were amazed that the neutropenic diets didn’t work. This has been dogma for 40 years, but people respond to data. We showed the abundant data proving our point — that the diet did not work and, in fact, harmed people. Part of this consensus-building effort is to present data that are there already, which we have done. Next, we will come to the most important but difficult part of it, which is changing behavior. – by Rob Volansky
Reference:
Wolfe HR, et al. J Hosp Med. 2018; doi:10.12788/jhm.2985.
For more information:
Arjun Gupta, MD, can be reached at University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8852; email: guptaarjun90@gmail.com.
Disclosure: Gupta reports no relevant financial disclosures.