Neutropenia Preventions - The Diet

Neutropenia is defined as a condition of  abnormally low number of neutrophils, as a  result of granulocyte disorder of that leads to Immunodeficiency with lower than normal  circulating white blood cells. Patients with neutropenia are susceptible to bacterial infections causes of neutropenic sepsis.
Neutropenia is either problems in the production of the cells by the bone marrow and destruction of the cells from somewhere else in the body, if  neutrophil count falls below 1,000 cells per microliter of blood.
Neutropenia can be classified into acute and chronic types, depending to the duration of the illness. Some researchers divided severity of the disease, depending to the absolute neutrophil count (ANC) and is described as follows(a).
1. Mild neutropenia, when the ANC falls below a lower limit of 1500 per mm3 (1.5 x 109 /1), but remains higher than 1000 per mm3 (1.0 x 109 /1).
2. Moderate neutropenia, when the ANC falls between 500 per mm3 and 1000 per mm3 (0.5 x 109 /1 - 1.0 x 109 /1)
3. Severe neutropenia, when the ANC falls below 500 per mm3 (0.5 x 109 /1)
Preventions
E.1. Diet to prevent Neutropenia
a. The Neutropenic diet, according to the article of The Neutropenic diet from Non Hopkin's lymphoma cyberfamily(36)

FOOD GROUPS	ALLOWED	NOT ALLOWED
Dairy	All pasteurized, grade "A" milk and milk products. Commercially-packaged cheese and cheese products made with pasteurized milk (i.e. mild and medium cheddar, mozzarella, parmesan, Swiss, etc.) Pasteurized yogurt Dry, refrigerated, and frozen pasteurized whipped topping Ice cream, frozen yogurt, sherbet, ice cream bars, homemade milkshakes Commercial nutritional supplements and baby formulas, liquid and powdered	Unpasteurized or raw milk, cheese, yogurt, and other milk products Cheeses from delicatessens Cheeses containing chili peppers or other uncooked vegetables Cheese with molds (i.e. blue, Stilton, Roquefort, gorgonzola) Sharp cheddar, brie, camembert, feta cheese, farmer's cheese
Vegetables	All cooked frozen or canned vegetables. All cooked herbs and spices (add at least 5 minutes before end of cooking)	Raw vegetables, salads Caesar Salads with Caesar dressing Pepper Garnishes Uncooked herbs and spices
Fruits and Nuts	Canned and frozen fruit and fruit juices Thick skinned fruits (oranges, bananas) Melons cut up and used immediately Canned or bottled roasted nuts Nuts in baked products Commercially packaged peanut butter	Dried fruits Raw fruit; foods containing raw fruits Unpasteurized fruit and vegetable juices Raw nuts Roasted nuts in the shell Precut fresh fruits
Bread, Grain, and Cereal Products	All breads, bagels, rolls, pan-cakes, sweet rolls, waffles, French toast Potato chips, corn chips, tortilla chips, pretzels, popcorn Cooked pasta, rice, and other grain All cereals, cooked and ready-to-eat	Raw grain products Bakery breads, cakes, donuts, muffins Potato/macaroni salad
Entrees, Soups	All cooked entrees and soups	All miso products (i.e. miso soup)
Meat and Meat Substitutes	All well-cooked or canned meats (beef, pork, lamb, poultry, fish, shellfish, game, ham, bacon, sausage, hot dogs) Well-cooked eggs (white cooked firm with thickened yolk acceptable, i.e. hard boiled, over hard) Pasteurized egg substitutes (i.e. Egg Beaters) Commercially-packaged salami, bologna, and other luncheon meats Canned and commercially-packaged hard smoked fish, refrigerated after opening Cooked tofu (which must be cut into 1" cubes or smaller and boiled a minimum of five minutes in water or broth before eating or using in recipes)	Raw or undercooked meat,, poultry, fish, game, tofu Meats and cold cuts from delicatessen Hard cured salami in natural wrap Cold smoked salmon, lox Pickled fish Tempe (tempeh) products Sushi Raw oysters/clams
Beverages	Tap water Commercial bottled distilled and natural waters All canned, bottled, powdered beverages Instant and brewed coffee, tea; cold brewed tea made with boiling water Brewed herbal teas using commercially-packaged tea bags Commercial nutritional supplements, liquid and powdered	Well water (unless tested yearly and found safe) Cold-brewed tea made with warm or cold water sun tea Egg nog Fresh apple cider  Homemade lemonade Spring water
Fats	Oil, shortening Refrigerated lard, margarine, butter Commercial shelf-stable mayonnaise and salad dressings (including cheese-based salad dressings, refrigerated after opening)	Fresh salad dressings containing aged cheese (i.e. blue, Roquefort) or raw eggs, stored in refrigerated case
Desserts	Refrigerated commercial and homemade cakes, pies, pastries, and pudding Refrigerated cream-filled pastries Homemade and commercial cookies Shelf-stable cream-filled cupcakes (i.e. Twinkies, Ding Dong), fruit pies (i.e. Poptarts, Hostess frit pies), and canned pudding	Unrefrigerated cream-filled pastry products (not shelf-stable) Cream or custard filled donuts
Other	Salt, granulated sugar, brown sugar Jam, jelly, syrups (refrigerated after opening) Commercially-packaged (pasteurized) honey  Catsup, mustard, BBQ sauce, soy sauce, other condiments (refrigerated after opening) Pickles, pickle relish, olives (refrigerated after opening)	Raw or unpasteurized honey Herbal and non-traditional (health food store) nutritional supplements, Chinese herbs Brewers yeast, if eaten uncooked

But according to the study by the New York University, despite improved survival of children with cancer, opportunistic infections remain a significant cause of morbidity and mortality in this population. Several interventions have been tried to decrease the incidence of infection by reducing patients' exposure to bacteria during neutropenia. The neutropenic diet is one such intervention that was intended to limit the introduction of bacteria into the host's gastrointestinal tract. The only studies evaluating this diet have used this strategy in combination with multiple other interventions, and the independent effect of this diet remains unknown(37). Other in the study to demonstrate a safe and feasible methodology to evaluate the infection rate in pediatric cancer patients randomized to the neutropenic diet or to Food and Drug Administration (FDA)-approved food safety guidelines with pediatric oncology patients receiving myelosuppressive chemotherapy randomized to the neutropenic diet or to FDA food safety guidelines and followed through one chemotherapy cycle found that four patients on each diet arm developed febrile neutropenia. The adherence rate was 94% for the neutropenic diet and 100% for the food safety guidelines. Although patients were able to tolerate both diets, there was more reported difficulty adhering to the neutropenic diet. Infection rates for children with cancer on the neutropenic diet were similar to those for patients following food safety guidelines(38).

b. Foods to enhance immune system
One of the most notable changes in the 2006 guidelines is that the level of risk when preventive use of blood cell growth factors is justified has been lowered. Previously, preventive use of blood cell growth factors was recommended for patients who had at least a 40% risk of developing febrile neutropenia. The 2006 guidelines recommend preventive use of blood cell growth factors for patients whose risk of febrile neutropenia is 20% or higher.
b.1. Green tea
Consuming green tea or its active ingredient, epigallocatechin-3-gallate (EGCG), has been shown consistently to benefit the healthy functioning of several body systems. In the immune system specifically, accumulating evidence has revealed an immunomodulating effect of green tea/EGCG. Several types of immune cells in both the innate and adaptive immune systems are known to be affected in varying degrees by green tea/EGCG. Among them, the dramatic effect on T cell functions has been repeatedly demonstrated, including T cell activation, proliferation, differentiation, and production of cytokines, according to the study by the Harvard Medical School(39).

b.2. Garlic
In the study to evaluate the immunostimulatory activities such as cell proliferation, tumor necrosis factor (TNF-α) and nitric oxides (NO) production of raw garlic and black garlic extracts on individual primary lymphocytes or macrophages isolated from the blood of 21 volunteers indicated that the immunostimulatory activities of RGE and BGE can be strongly correlated with the antioxidant and anticancer activities. Determination of immunostimulatory activities of different types of garlic using immune cells isolated from volunteers was dependent on the individual constituents due to changes in the composition of garlic during processing. Individual primary immune cells might be used as important tools to determine individual differences in all food ingredients for the development of personalized immunostimulatory active foods(40).

3. Turmeric and ginger
According to the study by the Assam University, polar fractions of C. longa and Z. officinale rhizomes boost the immune system by altering the cytokine milieu of the immunosuppressed macrophages, thus modulating their functional status. Therefore, it can be inferred that dietary intake of C. longa and Z. officinale potentiates the non-specific host defenses against opportunistic infections(41).

4.  Tomato
In the study to examine the effects of lycopene found abundantly in tomato, on the oxidative injury and immunity activities of N-methyl-N'-nitro-N-nitrosoguanidine (MNNG)-induced gastric cancer rats, showed that dministration of lycopene to gastric carcinoma-induced rats largely up-regulated the redox status and immunity activities to decrease the risk of cancer. up-regulation of antioxidants and immunity by lycopene treatment might be responsible for the anticancer effect in gastric carcinoma(42).
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Sources
(a) http://www.neutropenia.ca/about/what-is-neutropenia
(36) http://www.nhlcyberfamily.org/treatments/neutropenic.htm 
(37) http://www.ncbi.nlm.nih.gov/pubmed/12468911
(38) http://www.ncbi.nlm.nih.gov/pubmed/16679934  
(39) http://www.ncbi.nlm.nih.gov/pubmed/23835657 
(40) http://www.ncbi.nlm.nih.gov/pubmed/22260639 
(41) http://www.ncbi.nlm.nih.gov/pubmed/23295981
(42) http://www.ncbi.nlm.nih.gov/pubmed/21686188