Cancer and its treatment weaken the body's immune system by affecting the blood cells that protect us against disease and germs. As a result, your body cannot fight infection, foreign substances, and disease as well as a healthy person’s body can.

During your treatment for cancer, there will be times when your body will not be able to protect you as well. While your immune system is recovering, you may be told to try to avoid being exposed to possible infection-causing germs. For example, you may need to avoid some foods that are likely to have high levels of bacteria.

Nutrition suggestions for people with weakened immune systems

The following dietary suggestions, from the Fred Hutchinson Cancer Research Center in Seattle, Washington, were developed for patients with decreased immune function cause by chemotherapy and radiation therapy. Typically, these suggestions were used by their bone marrow transplant patients who had extremely weakened immune systems.

The purpose of these suggestions is to help you avoid specific foods that are more likely to contain germs that could cause infection while giving you healthy food choices. You may not need to follow this diet during your entire cancer treatment. Talk with your doctor or nurse about these suggestions and if and when you should follow this diet.

Foods to avoid

• raw and undercooked meat (includes game), fish, poultry, tofu, eggs, and egg substitutes
• cold smoked fish (salmon), lox, and pickled fish
• meats and cold cuts from a deli
• cured hard salami in a natural wrap
• unpasteurized milk and milk products, including cheese and yogurt
• cheeses with molds such as blue, Roquefort, gorgonzola, and Stilton
• cheeses containing chili pepper or other uncooked vegetables
• sharp cheddar, brie, camembert, feta cheese, and farmer’s cheeses
• fresh salad dressings (those stored in a refrigerated case) that contain aged cheese (such as blue or Roquefort) or raw eggs
• unwashed raw vegetables and fruits and those with mold that you can see
• all raw vegetable sprouts, such as alfalfa and mung beans
• unpasteurized commercial fruit and vegetable juices
• raw or non-heat treated honey and honey in the comb
• all miso products, tempeh, and maté tea
• all moldy and outdated food products
• unpasteurized beer
• raw, uncooked brewer's yeast
• well water, unless it is tested every year and found safe
• herbal preparations and nutrient supplements
• unroasted nuts and roasted nuts in the shell
• salads from delicatessens
• commercial salsas stored in the refrigerated case
• raw grain products
• cold brewed tea made with warm or cold water
• unrefrigerated, cream-filled pastry products (not shelf-stable*)

* "Shelf-stable" means unopened canned, bottled, or packaged food products that can be stored before opening at room temperature but require refrigeration after opening

Food safety considerations

When your immune system is weak, be especially careful when buying foods, preparing meals, and dining out. Following food safety guidelines reduces your risk of taking in germs that could multiply and cause a serious infection when your immune system is weak.

Food handling tips

• Wash your hands with warm soapy water for 20 seconds before and after preparing food and before eating.
• Refrigerate foods at or below 40° F.
• Keep hot foods hot (warmer than 140° F) and cold food cold (cooler than 40° F).
• Thaw meat, fish, or poultry in the microwave or refrigerator in a dish to catch drips. Do not thaw at room temperature.
• Use defrosted foods right away and do not refreeze them.
• Put perishable foods in the refrigerator within 2 hours of buying or preparing them. Egg dishes and cream- and mayonnaise-based foods should not be left unrefrigerated for more than 1 hour.
• Wash fruits and vegetables thoroughly under running water before peeling or cutting. Do not wash produce with soaps, detergents, or chlorine bleach solutions.
• Commercial produce rinses are not recommended. Using a clean vegetable scrubber, scrub produce that has a thick, rough skin or rind (cantaloupe, potatoes, etc.) or that has visible dirt on the surface.
• Rinse leaves of leafy vegetables one at a time under running water.
• Packaged salads, slaw mixes, and other prepared produce, even when marked pre-washed, should be rinsed again under running water; a colander can be used to make this easier.
• Do not eat raw vegetable sprouts.
• Throw away fruits and vegetables that are slimy or show mold.
• Do not buy produce that has been cut at the grocery store (such as melon or cabbage halves).
• Wash tops of canned foods with soap and water before opening.
• Use different utensils for stirring foods and tasting them while cooking. Do not taste the food (or allow others to taste it) with the same utensil used for stirring.
• Cook eggs until the whites are completely hard and the yolks begin to thicken. While the yolk should no longer be runny, it does not need to be hard.
• Throw away eggs with cracked shells.
• Boil tofu, in ½-inch cubes, for 5 to 10 minutes before using.
• Throw out foods that look or smell strange. Never taste them!

Do not cross-contaminate

• Use a clean knife to cut different foods.
• In the refrigerator, store raw meat sealed and away from ready-to-eat food.
• Keep foods separated on the countertops. Use a different cutting board for raw meats (see section, "Work surfaces and kitchen equipment.")
• Clean counters and cutting boards with hot soapy water, or you can use a fresh solution made of 1 part bleach and 10 parts water. Moist disinfecting wipes may be used if they are made for use around food.
• When grilling, always use a clean plate for the cooked meat.

Cook foods well

Insert a meat thermometer into the middle of the thickest part of the food to test for doneness. Test a thermometer’s accuracy by putting it into boiling water. It should read 212° F. Cook meat until it is no longer pink and the juices run clear. The only way to know for sure that the meat has been cooked to the right temperature is to use a food thermometer. Meats should be cooked to 160° F and poultry to 180° F. Even though they are already cooked, heat all hot dogs, luncheon meats, cold cuts, and other deli-type meats until steaming (165°F) before eating. Do not eat raw, lightly cooked, or soft-boiled eggs. Do not eat uncooked foods made with raw or undercooked eggs, such as raw cookie dough, cake batter, or salad dressings that contain raw or coddled eggs. Pasteurized eggs or liquid pasteurized egg products may be used in recipes for foods that will not be cooked and call for raw eggs.

Water safety

Water from your home faucet is considered safe if it is from a city water supply or municipal well serving a highly populated area.Well water is not safe to drink when your immune system is weak unless it is tested daily and found not to contain coliforms and Cryptosporidium organisms. If your water is not from a city water or municipal well, use boiled, distilled, or bottled water. (Bring tap water to a rolling boil for 1 minute.) Most water filters will not make the water safe if the water supply has not been chlorinated.

Microwave cooking

Rotate the dish a quarter turn once or twice during cooking if there is no turntable in the microwave oven. This helps prevent cold spots in food where bacteria can survive. Use a lid or vented plastic wrap to thoroughly heat leftovers. Stir several times during reheating.

Grocery Shopping

• Check "sell by" and "use by" dates. Pick only the freshest products.
• Check the packaging date on fresh meats, poultry, and seafood. Do not buy any products that are out of date.
• Reject damaged, swollen, rusted, or deeply dented cans. Be sure that packaged and boxed foods are properly sealed.
• Select unblemished fruits and vegetables.
• Avoid deli foods. In the bakery, avoid unrefrigerated cream- and custard-containing desserts and pastries.
• Avoid foods from self-serve or bulk containers.
• Avoid yogurt and ice cream products from soft-serve machines.
• Do not eat free food samples.
• Reject cracked or unrefrigerated eggs.
• Select frozen and refrigerated foods just before you check out at the grocery store, especially during the summer months.
• Refrigerate groceries right away and never leave food in a hot car.

Dining out

• Eat early to avoid crowds.
• Ask that food be prepared fresh in fast food restaurants.
• Request single-serving condiment packages and avoid self-serve bulk condiment containers.
• Avoid high-risk food sources including salad bars, delicatessens, buffets and smorgasbords, potlucks, and sidewalk vendors.
• Avoid raw fruits and vegetables when eating out.
• Ask if fruit juices are pasteurized.
• Be sure that utensils are set on a napkin or clean tablecloth or placemat, rather than directly on the table.
• If you want to keep your leftovers, ask for a container and put the food in it yourself rather than having the server take your food to the kitchen to do this.

What to Eat When Your White Blood Cell Count Is Low

	Recommended	Foods to avoid
High protein	well-cooked bacon, beef, chicken, fish, ham, hot dogs, lamb, pork, sausage, veal; canned fish; well-cooked pasteurized eggs or egg custard; cream, cottage, or processed cheeses; pasteurized yogurt; cooked homemade, canned, dehydrated, frozen soups	meat or fish salads with raw vegetables; raw fish and shellfish, such as sushi and oysters; raw or rare meats, such as steak tartare; raw or soft cooked eggs (includes "over easy," poached, soft boiled, and "sunny side up" eggs, as well as Caesar salad, home-made eggnog made with raw eggs, and raw cookie dough); fresh blue or Roquefort cheeses and salad dressings; Brie, Camembert, and other unpasteurized cheeses; cold, uncooked soups
Breads, cereals, rice, and pasta	all breads, bagels, muffins, rolls, and cereals without dried fruits, nuts, or seeds; crackers, French toast, noodles, pancakes, pasta, potatoes, and rice	macaroni or pasta salad or potato salad made with raw vegetables; breads or cereals with dried fruits, nuts, or seeds
Fruits and vegetables	peeled thick-skinned, unblemished fruit (banana, citrus fruit, melon), peeled apples, canned fruits, cooked dried fruits; well-cooked fresh, frozen, or canned vegetables	all other fresh or dried fruits; raw vegetables
Drinks, desserts, and Miscellaneous	Processed fruit juice, pasteurized milk, instant breakfast shakes, homemade milkshakes, non-dairy creamer, soda, coffee, tea, commercial liquid nutritional supplements Fruit pies; cakes and cookies without nuts; flavored gelatin; commercial ice cream, sherbet, popsicles; pretzels; chips Butter, margarine, cooked gravies, mayonnaise, salad dressing, vegetable oils Plain peanut butter Salt, pepper, herbs, spices, or honey (may be added to foods only during the cooking process) Sugar, jam, jelly, preserves, syrup, molasses, mustard, catsup; candy, chocolate; pickles, relish, olives	Non-commercial (home made) ice cream, sherbet, or popsicles; popcorn Raw or roasted nuts Salt, pepper, herbs, spices or honey added after cooking

Adapted from Eldridge B, and Hamilton KK, Editors, Management of Nutrition Impact Symptoms in Cancer and Educational Handouts. Chicago, Il: American Dietetic Association; 2004.

Guidelines to keep your home clean

Personal hygiene

Wash your hands with soap and warm, running water for 20 seconds before and after every step in food preparation.Wash your hands before eating and after using the restroom, handling garbage, or touching pets.Dry your hands with a paper towel or cloth hand towel that is changed daily.

Work surfaces and kitchen equipment

Plastic or glass surfaces should be used for cutting raw meat and poultry. Wooden boards are safe if they are used only for raw meat and poultry. Use a different cutting board for other food such as produce, cheese, and bread.Wash cutting boards after each use in hot, soapy water or in the dishwasher. Sanitize both wooden and plastic cutting boards with a solution of 1 part household bleach to 10 parts water. This should be done every time the board is used for raw meat, fish, or poultry. Sanitize boards used for other purposes every week. Allow the bleach solution to stand for at least 2 minutes, then rinse and air-dry or pat dry with fresh paper towels. Replace cutting boards with cracks or grooves.

Keep appliances free of food particles. Check the microwave oven, toaster, can openers, and blender and mixer blades. Remove blender blades and bottom when washing the jar. Use a bleach solution of 1 part household bleach to 10 parts water to sanitize these items.

Keep counter and kitchen surfaces free of food particles. Clean regularly with a solution of 1 part household bleach to 10 parts water.

Sink area

Keep soap nearby for hand washing and use paper towels to dry your hands.

Use fresh, clean dishcloths and dish towels every day.

If you use sponges, replace them at least once a week. Some experts suggest avoiding sponges entirely because they can hold germs and spread them around.

Soak dishcloths and sponges every day for 5 minutes in a solution of 1 part household bleach to 10 parts water (this sanitizes them). Or you may heat wet sponges in the microwave on high for 2 minutes (they will get very hot), or run them through the dishwasher.

Store food supplies away from the kitchen sink. Do not store chemicals and cleaning products near food supplies.

Use liquid dish soap and very warm water when hand-washing dishes, pans, and utensils. You may air-dry dishes instead of using a towel.

Refrigerator/freezer

Keep the refrigerator clean: Wipe spills up right away, check for food scraps, and sanitize shelves and doors regularly. Wipe the refrigerator once a week with a solution of 1 part household bleach to 10 parts water.

Keep the refrigerator temperature between 34° F and 40° F. Keep freezer temperature below 5° F.

Store all food in covered containers after cooling. First, cool hot foods, uncovered, in the refrigerator. Then, cover storage containers tightly after cooling. Freeze what you do not plan to use within the next 2 to 3 days. Throw out all prepared foods after 72 hours (3 days) in the refrigerator.

Throw out eggs with cracked shells. Throw out foods older than their "use by" expiration dates.

Throw out entire food packages or containers with any mold present, including yogurt, cheese, cottage cheese, fruit, vegetables, jelly, and bread and pastry products.

Throw out freezer-burned foods.

Cupboards/pantry

Keep food storage areas clean and check for signs of insects or rodents.

Throw out any can with signs of spoilage: bulges, leaks, cracks, or deep dents in the seam area. Do not taste these. Rotate food stock so older items are used first. Do not use foods older than their "use by" expiration dates.

Use home-canned foods within 1 year of canning, as chemical changes may take place. Before eating home-canned foods, review how it was processed to be sure the pH of food, size of bottle, and elevation above sea level was right. Look for mold and leaks. Check seals. If you think a home-canned food may not have been processed properly, if the lid bulges, or if the food has any bad odor or looks unusual after opening, throw it out.

Revised: 02/04/2008