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Produced 2010
Next revision due 2012

Nutrition and lymphoma

Finding that you have lymphoma does not mean you need to change your diet. If you are
eating well and feeling well you should continue to eat as normal. As always, of course,
you should eat a well-balanced diet, including a good variety of different foods.
Sometimes treatment produces side-effects which may make eating and drinking very
difficult. The lymphoma itself can do this too. If this happens you may want to discuss
making changes to your diet. There are some suggestions about this later in this article.
Everyones lymphoma is different. Therefore what works for you, in terms of what you eat
and drink, may not be what works for other people with lymphoma. Use this information
sheet as a guide but discuss any individual queries with your dietitian or medical team.

Why is a balanced diet important during treatment

for lymphoma?
Treatments for lymphoma, particularly chemotherapy, are easier to tolerate if you are well
nourished. So it is important that you continue to eat and drink well. You are likely to
be able to tolerate higher doses of chemotherapy with fewer delays and fewer infections
if you do. If you dont manage to eat a good diet during treatment you risk feeling both
emotionally and physically down.
Therefore if at any stage you start to struggle with eating and drinking it is important to let
your team know. They can quickly start to help you in finding ways to prevent weight loss
and depletion in your bodys stores. You should never feel this is not worth mentioning.
Ideally, you should aim to keep your weight steady throughout treatment, no matter how
much you weigh when you start. Remember that there is no specific diet for lymphoma
so the information here about a healthy diet applies to everyone, so long as they are fit
and well.

Energy (calories)
We eat calories to produce the energy we need to live our everyday lives. It is important
to eat enough calories each day. If your calorie intake becomes too low you will start to
lose weight. This can make you feel tired and lead to the slower recovery of blood counts
after chemo.
You may find that you need more calories than usual, particularly if you are having night
sweats and fever.

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You may also need more calories if you have an infection or raised temperature
during chemotherapy. If you are eating normally but are losing weight, discuss this
with your medical team or dietitian. You may need to discuss strategies for increasing
the energy in your diet. There is more detail about this later in this article.
Remember: if you can manage only small portions at mealtimes you will need to up the
calories you eat. So pile on the butter, cream or cheese which will give you the energy
you need. On the other hand, if your appetite is very good and you are eating large
portions, aim to fill up on foods such as fruit and vegetables or starchy foods which are
lower in calories. In this way you can take charge of your calorie intake depending on
your appetite at different stages in your treatment.

Protein
Protein is important in a balanced diet because of its role in building new cells and
repairing damaged cells. Without protein our muscles become weaker and our bodies
cannot function properly. During or after treatment you may need more protein,
particularly if your body needs additional healing.
Sometimes people worry about their protein intake during chemotherapy as good sources
of protein, such as red meat, can become difficult to eat. However, there are many other
good sources of protein. Fish, milk, cheese, eggs, nuts, seeds, beans and pulses are all
good sources of protein so if you are not eating your usual sources of protein try to
supplement with another from the list.

Vitamins and minerals

Vitamins, minerals and trace elements are all important for your body to work properly.
They each have a different role. The key to ensuring your diet provides the right amounts
of vitamins and minerals is variety.
We need a relatively small intake of vitamins and minerals so generally there is no need
to supplement your diet if you are not avoiding any particular food group or type.
Occasionally, if you are eating or drinking less or if you are unwell, it may become harder
to meet your daily vitamin and mineral needs. If you are concerned about this, you should
mention it to your doctor, pharmacist or dietitian rather than buy your own supplements.
This is important as some supplements can react with other medication and high doses
of some vitamins and minerals can even be dangerous. Only take individual supplements if
recommended to do so by your doctor.

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How will my treatment affect my eating

and drinking?
This is very individual and will depend on the type of lymphoma you have and your particular
treatment. Everyone will have different side effects and to different degrees even if they are
on the same treatment as other people. Table 1 highlights some of the more common side
effects of lymphoma treatments. It has some simple ideas to help if you are experiencing
these side effects. It is important to talk to your medical team if you are experiences difficulties.

Table 1 Problems that may affect food intake and some suggestions on overcoming such difficulties

Problem Likely cause Possible solution

Try to eat little and often

Chemotherapy
Try to have nutritious drinks
Poor appetite Radiotherapy
Have an alcoholic drink (check with your doctor first)
Other medication
Ask your doctor about appetite stimulant tablets
Take regular anti-sickness medication
Chemotherapy
Nausea and Try to eat dry plain foods
Radiotherapy
vomiting Have nutritious drinks
Other medication
Ginger drinks, ginger biscuits and fizzy drinks may help

Eat little and often

Chemotherapy
Feeling full Separate drinks from food (i.e have drinks 30 minutes
Lymphoma in the gut
quickly before or an hour after food)
Radiotherapy in the gut
Avoid filling up on bulky, low energy foods such as beans, salads

Have a soft/liquid diet

Chemotherapy Take nutritious drinks
Sore mouth/
sore throat Radiotherapy to the Avoid spicy and rough foods
mouth and throat area Ask for medication for mouth care and pain killers from
your doctor

Chemotherapy Brush your teeth regularly and use prescribed mouthwashes

Taste changes
Other medication Concentrate on foods that taste good
Ask your doctor for anti-diarrhoea medication
Chemotherapy Drink plenty of fluids to avoid dehydration
Diarrhoea
Radiotherapy in the gut If medication is not controlling your diarrhoea speak to
your doctor or dietitian for further details
Ask your doctor for laxatives
Pain killers
Make sure you are drinking plenty of fluids
Constipation Chemotherapy
Keep as active as possible
Anti-sickness medication
Try a high fibre diet

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What can I do to ensure I am eating and

drinking enough?
While the side effects from the lymphoma or from the treatment may affect your eating
or drinking, you may well have a good appetite throughout treatment and therefore there
will be no need to make any changes. If, however, you feel that you are not eating or
drinking enough it is sensible to make some simple changes to increase your daily intake.
Eat little and often, aiming to include small snacks between your meals.
Be positive about what you do eat. Remember that every mouthful counts.
Cut out diet, light, low fat or reduced sugar products as these are lower in calories.
Try adding extra butter, cream, cheese, honey or sugar to foods to increase the
calories you take in.
Add high fat dressings and sauces to meals wherever possible. Examples include
French dressing to salads, mayonnaise and butter to jacket potatoes, cheese sauce to
vegetables or ice cream and custard to desserts.
You may feel too tired to prepare meals especially at certain stages in your
treatment cycle. Ready made and convenience foods can be a useful standby. When
you do prepare meals, cook more than you need and freeze a portion for another day.
Eat more of the foods you do enjoy, whatever the time. For example, you may find the idea
of having a bowl of porridge or cereals easier to face in the evening than a cooked meal.
Make the most of your best times. You may find early mornings easier, so ensure you
have a good breakfast. Why not think about having a cooked breakfast in the morning if
it appeals to you?
You may find it easier to have your main meal in the middle of the day, rather
than in the evening when you may be feeling more tired.
If friends or family offer help with cooking or shopping, try to accept so that you can
save your energy for the things you enjoy. They will feel better if you do.

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Supplements
If you continue to lose weight even with some of the changes above, you may be advised
to take some food supplements. These come in a wide range of different formats and
types. You may need to try a few different ones before deciding on which suit you best.
A registered dietitian will help you decide which are best for you, the quantities you
should take and the best times of day to take them.
Some food supplements e.g. Build Up or Complan can be found in the supermarket and
you may like to try one or two of these to start with. They are available in a wide range
of types and flavours. Some are designed as a meal replacement. Others are designed to
fortify your regular food and drink, to increase the calorie or protein content and are
more like a drink which you have in addition to your usual meals. Some e.g. Ensure Plus
can be bought in chemists but are available on prescription from your doctor. They are
expensive to buy so it is well worth discussing this with your team.
There is also a range of supplements that are nutritionally complete. This means that
they can provide all the nutrients you need each day, if taken in sufficient quantity. Table 2
shows some of the more common supplements that you may be advised to try. This list is
not exhaustive and you should always discuss the most appropriate choices for you with
your doctor or dietitian.

Table 2 Nutritional Supplement

Type of supplement Examples of supplements available

Ensure Plus, Fresubin energy, Fortisip Bottle, Fortisip

Milky flavoured drink (without fibre)
Compact, Complan Shake, Calshake, Scandishake, Enshake

Milky flavoured drink (with fibre) Ensure Plus with Fibre, Fortisip Multi Fibre, Fresubin energy fibre

Juice/squash flavoured drinks Ensure plus juice style, Provide Xtra, Fortijuce

Yoghurt flavoured drinks Fortisip yoghurt style, Ensure Plus yoghurt style

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What happens if I am unable to maintain my

weight through eating and drinking alone?
If during the course of your treatment, either due to side effects of treatment or due
to the lymphoma itself, you develop swallowing difficulties or you are unable to manage
to eat and drink enough, you may need to consider an alternative method of nutritional
support. There would be several options for you if this happens and your medical team
and your dietitian will talk you through the details and advise you of the most appropriate
options. Generally, there are two kinds of nutritional support and which one is right for
you will largely depend on how your digestive system is functioning. Please contact the
helpline (0808 808 5555) if you would like further information about this.

Food safety
Food safety is always important as no one, however healthy, wants to get food poisoning.
However, following high dose chemotherapy or a stem cell transplant you may be
particularly vulnerable to infection from food borne bacteria. This is for two reasons:
Firstly, the white blood cells, that would usually fight bacteria, are at a low level. This is
called neutropaenia or immunosuppression.
Secondly, the gut lining acts as a barrier between bacteria and the blood stream.
Chemotherapy and radiotherapy damage the gut lining, making it easier for any
bacteria to cross this barrier. During this time you may be advised to follow a clean
or neutropaenic diet. You should contact your treatment centre for further details
on specific foods to avoid at this time. The information in Table 3 is a general guide for
all patients whose immune system is compromised in this way. If you become severely
neutropaenic it is likely that you will be given additional restrictions to follow.
Following any type of chemotherapy, care should be taken with the preparation and
handling of any food or drink. In addition to the preparation guidelines above, certain
foods should also be avoided if you are at risk of neutropaenia (see Table 4).

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Table 3 Food safety guidelines

Avoid buying food with damaged packaging

Shopping Avoid fridges and freezers that are overloaded
Buy chilled and frozen food last and take it home as soon a possible

Fridges should be kept between 0C and 5C

Freezers should be kept below -18C
Store cooked food at the top of the fridge and raw food at the bottom
Storage
Never refreeze thawed food
Defrost food in the bottom of the fridge
Always consume food according to manufacturers guidelines and before the best before date

Wash your hands with warm soapy water before preparing food and again after touching any
uncooked food, rubbish, pets, dirty washing or after sneezing or using the toilet
Do not dry your hands on the kitchen tea towel but use a separate to towel for hands
Preparation Cover any cuts or grazes
Ensure any clothes and towels are regularly bleached, disinfected or changes
Avoid cross contamination by washing chopping boards and utensils between raw and
cooked food

Cook all food thoroughly and ensure it is piping hot all the way through
Cook meat until the juices run clear
Pre-heat the oven to ensure food is cooked at the desired temperature
Cooking Always follow manufacturers guidelines never reheat cooked food
Do not put hot food in the fridge as this raises the temperature of all the food in the fridge
Only use a microwave for defrosting or heating prepared food according to the pack
instructions

Table 4 High risk food to be avoided by all immunocompromised patients

All unpasterurised dairy products i.e. farm fresh milk, Parmesan

Black peppercorns
Soft mould-ripened cheese i.e. Brie, Camembert, Goats cheese
Blue veined cheese i.e. Danish blue, Stilton
Raw or under cooked eggs i.e. home made mayonnaise, mousse, egg nog, meringue or hollandaise sauce
Raw or under cooked shellfish
Raw or under cooked meat, poultry or fish i.e. rare meat, sushi, smoked meats/fish e.g. parma ham, salmon
Pat and fish paste
Probiotics, live or bio products i.e. live yoghurts, probiotic containing supplements and drinks

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Conclusion
The information in this article is designed as a guide only. If you have any specific questions
about your diet and diagnosis, please contact your medical team or local dietitian who will
be able to provide you with individualised information.
As a general rule there is no special diet that you need to follow. Whenever possible try and
enjoy a wide variety of different foods and drinks. Aim to make mealtimes relaxed, making
the most of the times you feel at your best. If youre not able to manage a full meal, try
changing your meal pattern so you graze throughout the day, with small but regular snacks.

Further Information
Diet and Cancer & Eating Well After Cancer Treatment
Both booklets are published by Macmillan and are available free of charge from their
website: www.be.macmillan.org.uk

Eating well when you have cancer

Available from the Rehabilitation Secretary
The Royal Marsden NHS Trust
Fulham Road, London
SW3 6JJ
020 7808 2811
or through their website www.royalmarsden.org

After treatment a guide for cancer patients

Available from the Rehabilitation Secretary
The Royal Marsden NHS Trust
Fulham Road, London
SW3 6JJ
020 7808 2811
or through their website www.royalmarsden.org

Dietary advice for patients with neutropaenia

Published by Leukaemia & Lymphoma Research
43 Great Ormond Road, London
WC1N 3JJ
020 7405 0101
www.llresearch.org.uk

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Produced 2010
Next revision due 2012

Tips for coping with a loss of appetite

Loss of appetite or poor appetite is a common problem for those who are undergoing
treatment for lymphoma. A loss of appetite can be due to being ill, treatment itself,
a change in taste or the emotional stress of the whole experience.

Eating well will help to ensure that you get all the energy and nutrients you need to rebuild
damaged tissue, fight infection and cope with the possible side-effects of reatment. If your
appetite is poor and you are eating less than normal, choosing foods that are higher in
calories and eating smaller amounts more regularly throughout the day can help to meet
your bodys needs.
Below are some general tips on coping with a loss of appetite. However, we do suggest
asking at the hospital if there is a dietitian who can talk through any individual nutritional
needs or concerns.

Mealtimes
Where possible try to maintain your usual meal routine even if you are eating less than
you previously would have done.
Try to find somewhere comfortable and relaxing in which to eat. Turn the television
off if its distracting, or perhaps put a candle on the table.
Eating with friends or family can make mealtimes more enjoyable and you are likely to
eat more when you have company.
Try not to hurry meals, relax and take your time. You may need to rest before and
afterwards so that youre not too tired to eat.
Taking a gentle walk or getting some fresh air before your meal may help to stimulate
your appetite.
An aperitif (such as sherry or brandy) before dinner, or a glass of wine with a meal,
can boost the appetite. However, do check with the doctor first as this may not be
advisable for everyone.
Its important to drink plenty of fluids, preferably not just tea and coffee. However,
drinking large quantities at mealtimes can fill you up so it may be better to drink
between meals.

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If you have been advised to take nutritional supplement drinks, take these
in between meals rather than immediately before or during a meal as they are high in
energy and will fill you up.

Some thoughts on food and preparation

Smaller portions of food can be more appetizing. Perhaps use a smaller plate so that
your meal does not look overwhelming. If your portion sizes are smaller than usual,
eat six small meals or nourishing snacks spaced out throughout the day.
Sometimes the smell of food cooking can be off-putting, so if other people are able to
cook for you this might be helpful. Keep the kitchen door closed and maybe get some
fresh air while the meal is being prepared.
Food served cool or cold has less aroma and is just as nourishing.
Ensure you have food in your fridge or cupboard that is quick and easy to prepare such
as pasta with accompanying sauces or ready made puddings.
Accept offers from friends and family to help with cooking and shopping if you are
feeling too tired to prepare meals yourself. Alternatively, convenience foods can be a
useful standby and many supermarkets offer home delivery services if you dont feel up
to a trip to the shops.
Some people find it hard to be enthusiastic about preparing food and eating
it especially when feeling poorly. If you can, take time to make a meal look attractive
as this will help will help to tempt your appetite.
Vary the consistency and flavour of food from meal to meal by simply adding a sauce.
This can also add valuable calories too.
Try not to fill up on salads and vegetables which add bulk to your meal but provide few
calories unless you have been advised to do so.

Acknowledgements
We are grateful to Gayle Black, dietitian at the Royal Marsden hospital, London for writing
and reviewing this information sheet.

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About our publications:

The Lymphoma Association is committed to the provision of high quality information for people with lymphoma, their families
and friends. We produce our information in accordance with nationally recognised guidelines. These include the DISCERN tool for
information about treatments, the NHS Toolkit for producing patient information, and the Campaign for Plain English guidelines.
Our publications are written by experienced medical writers, in close collaboration with medical advisors with expertise in
the appropriate field. Textbooks and professional journals are consulted to ensure that information is as up to date as possible.
References are provided where they have been used. Some publications are written by professionals themselves, acting on guidance
provided by the Lymphoma Association. Our publications are reviewed every two years and updated as necessary.

Our publications are reviewed by a panel of volunteers with experience of lymphoma. Publications are also reviewed by members of
the Lymphoma Association helpline team, who have many years collective experience of supporting those with lymphoma.

In some instances, our publications are funded by educational grants from pharmaceutical companies. These sponsors do not have
any involvement in the content of a publication. They are not invited to see the content and have no editorial input.

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Views expressed in this publication are those of the contributors.
The Lymphoma Association does not necessarily agree with or endorse the comments included here.

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