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Cranberry, the alt-med zombie

If there’s a characteristic that’s common among proponents of alternative medicine, it’s tenacity. The willingness to stick with an idea, no matter the evidence, must give one a certain clarity. The naturalistic fallacy is often the foundation. Natural is good, synthetic is bad, no matter the evidence. In some cases, in spite of the evidence. How one deals with contradictory evidence is an effective tool to differentiate between medicine and alternative medicine – given sufficient convincing evidence, medicine changes its practices. The same can’t be said for alternative medicine, where few treatments are ever discarded. Otherwise practices like homeopathy, acupuncture, reiki, and chiropractic would have disappeared long ago. It’s also why disproven products continue to have occasional resurgences in interest. Cranberry is one. It has been touted as a treatment and a preventative for urinary tract infections for years.  And it doesn’t seem to work – not well, and not reliably, if you look at all the trials. And that’s being generous, considering the poor quality of the evidence with its inherent biases. I know a dead parrot when I see one. Yet its advocates, mainly manufacturers (is there a Big Cran?) keep insisting it’s alive, supported by the occasional positive report that appears. With a new systematic review and meta-analysis that declares it’s effective, it’s time to update our review.

Mark Crislip did a nice overview of cranberry juice back in 2011. It’s most commonly used as a supplement (as juice, extract, or capsules) to prevent and treat urinary tract infections (“acute cystitis”). These infections are generally very responsive to antibiotic treatment. If untreated, it can worsen and move up into the kidneys and beyond. Some women (UTIs are uncommon in men) have repeated UTIs, and there are a number of non-drug strategies that can be used to reduce them. Cranberry juice has been a popular folk treatment for years. A decent reason why cranberry might prevent or treat urinary tract infections is still lacking despite five decades of study. An ingredient in cranberry, proanthocyanidins, is thought to block some variants of E. coli bacteria from adhering to bladder cells, which might reduce the risk of infection. But these “fimbriated” bacteria are uncommon in species isolated from urinary tract infections. So even if the theoretical mechanism of action is correct (which remains unproven), the real-world effect, based on this assumption, should be minimal. And that’s largely what the evidence shows, when you account for the poor research quality. But we don’t need to know how it works, if it works. And there is no good evidence that cranberry is an effective treatment for UTIs. The data are less clear with prevention. There are lots of trials and the results are mixed. The best reviews of clinical evidence are systematic in nature, and happily Cochrane has a perspective. A 2012 review noted the following:

Cranberries (usually as cranberry juice) have been used to prevent urinary tract infections (UTIs). Cranberries contain a substance that can prevent bacteria from sticking on the walls of the bladder. This may help prevent bladder and other UTIs. This review identified 24 studies (4473 participants) comparing cranberry products with control or alternative treatments. There was a small trend towards fewer UTIs in people taking cranberry product compared to placebo or no treatment but this was not a significant finding. Many people in the studies stopped drinking the juice, suggesting it may not be a acceptable intervention. Cranberry juice does not appear to have a significant benefit in preventing UTIs and may be unacceptable to consume in the long term. Cranberry products (such as tablets or capsules) were also ineffective (although had the same effect as taking antibiotics), possibly due to lack of potency of the ‘active ingredient’.

The Cochrane review included both juice and capsules of cranberry. Most trials were about 6 months in duration, which is probably the minimum time period in which a difference could be identified. Of the 24 trials Cochrane identified, 13 could be combined in a meta-analysis. The meta-analysis found no significant difference in the rates of recurrent urinary tract infections. There was a suggestion of benefit, with a relative risk of 0.86 but a confidence interval of 0.71 to 1.04. Trials that could not be included in the meta-analysis were also studied, with the majority finding no benefit. Is there any reason to be optimistic? Probably not, given the overall quality of the research.  There was little follow-up and lots of patient dropouts, likely a result of the difficulty in taking the juice daily. Perhaps not surprisingly, cranberry manufacturers and their affiliated scientists insist cranberry is effective, despite the evidence, and blamed poor quality products and poor quality trials for hiding what they felt was a benefit. One researcher, Amy Howell, even dismissed the idea that cranberry could be evaluated in a Cochrane review:

“At Cochrane they typically review pharmaceutical drug studies and their prevention of disease. They do not have anyone on their staff that specializes in supplements and functional food products.  This is not their strong point,” Howell said. A European commentary in 2005 had already cited problems with Cochrane review of nutrition studies.  That review, Howell said, found that, “you really cannot really use drug criteria to review these types of foods. It just doesn’t work.  You can’t look at just one thing.” Howell quoted the European review as saying: “It’s hard to even imagine a human clinical trial in which one half  of a large group of middle age people agreed to avoid vegetables for five years and then agreed to be followed up to see how many developed of them developed cancer.”

Handwaving and a straw man argument.  Studies required the consumption of a specific supplement for about 6 months – not unlike any other clinical trial of an intervention. If cranberry works, we should be able to measure its effects when we test it. Now I’m in agreement with the other contributors to this blog that Cochrane can get CAM wrong. But it’s because they don’t consider prior plausibility – not because the the technique of a systematic review isn’t applicable. If anything, Cochrane’s methodology is somewhat biased towards accepting implausible treatments, not against them. (Consider this evaluation of a homeopathic remedy, for example.)

Now there’s another systematic review of cranberry with a different conclusion. This one is by Wang and colleagues, and it’s entitled, Cranberry-containing products for prevention of urinary tract infections in susceptible populations. It, like Cochrane, is also systematic review and a meta-analysis. This study also identified 13 trials (mainly juice, some capsules) and included 1616 subjects in its dataset. The authors looked at the risk of bias in each trial, and all but two were rated “High Risk” in at least one category.

Their conclusion: a relative risk of 0.62 (with a confidence interval of 0.49-0.80). Just better enough to achieve statistical significance. How did this occur? Some statistical sleight-of-hand. The authors put all the trials into a Galbraith plot, a test to measure statistical heterogeneity (non-uniformity). One is strongly positive (A) and one is strongly negative (B). The authors declare that the negative trial by Babosa-Cesnick is too heterogeneous to be included, so the exclude it. Yet the positive trial by Ferrara, which is also heterogeneous, is included. Guess what happens to the result?

Wang_Figure_2

Dropping the negative trial makes the overall benefit from cranberry look positive. So the authors announce that cranberry “seemed to be effective in prevention of UTIs”. The authors then go on to illustrate how questionable the cranberry data set really is. They look at the statistical significance of the combined by removing other trials, one by one. You can see how excluding the negative Babosa-Cesnik data slides the risk ratio to the left (see the bottom line), making the result look much more compelling:

Wang_Figure_3

Perhaps not surprisingly, the cranberry producers and their scientists like this study a lot more. The same researcher, Amy Howell, who dismissed the Cochrane methodology seems to find this one a lot better:

Commenting independently on the review’s conclusions, Amy Howell, PhD, from the Marucci Center for Blueberry Cranberry Research at Rutgers University told NutraIngredients-USA:  “The results of this latest meta-analysis of clinical trials in a highly regarded journal provide further convincing support for the use of cranberry in the prevention of recurrent UTI in susceptible populations.  Results indicate that despite the challenges of utilizing cranberry in different formulations, dosages, and target populations, overall positive outcomes were obtained in many cases.”

In other words, this meta-analysis supports my confirmation bias, so it’s a good paper.

My personal take is that if there is an effect from consuming cranberries, it’s so slight that the clinical trials so far haven’t been large enough to pick it up. Whether it’s an attractive approach, despite the evidence, depends on a a consideration of consequences, alternatives, and costs. The excellent Therapeutics Education podcast did a clinical review of the evidence and included a brief dietary and economic analysis. They estimated that even if we accept the positive data, we need to consider the following:

  • You need to consume about 500mL of cranberry cocktail to obtain the studied amount of the pure juice. This costs $0.45-$0.66 per day and could provide 120-150 calories.
  • Over 6 months, in order for a 1 in 12 chance of avoiding a UTI (that’s the efficacy), you’d spend about $180 and consume about 45,000 calories which (holding everything else equal) could cause a weight gain of several pounds.

I calculated 61 grams of sugar per day in two cups of Ocean Spray cocktail, which means 24 lbs of sugar consumption over 6 months. So while it’s “natural”, and may not have many acute side effects, it’s not without the potential for unwanted effects.

Finally, let’s look at the alternatives to the alternative. Antibiotics taken for the prevention of UTIs are very effective, reducing the risk of an infection by up to 95%. You only need to treat two people for one year to prevent 1 recurrence. An NNT of 2 is pretty impressive, anywhere you see it in medicine. It’s not a panacea, though. There are justifiable concerns about the risk of antibiotic resistance developing, and there are drug-related side effects, including more yeast infections. However, long-term antibiotics appear to be far more useful as a strategy for those experiencing many infections per year. Some choose just to take antibiotics when infections recur – managing the infection effectively while minimizing overall exposure to these drugs.

Conclusion

Medicine isn’t unlike any other aspect of our lives. We see what we want to see.  These two systematic reviews, and their interpretation, illustrate this nicely. Methods matter if we want to minimize bias. Cochrane has the most rigorous approach to data collection, synthesis and analysis. Their conclusion is a reasonable analysis of the evidence base. There is no persuasive evidence that cranberry can prevent or treat urinary tract infections. In comparison, the Wang paper looks more like an exercise in data-dredging, where the analysis was manipulated until a positive result could be identified. This post-study rationalization is akin to throwing darts at the wall, drawing the target around the darts afterwards, and then declaring victory – or in this case, clinical effectiveness. Even taking the analysis at face value, cranberry is only modestly effective, expensive, and may come at a high dietary cost. And, it’s substantially less effective than conventional treatments. So is this the final word on cranberry? It probably should be, but that’s unlikely. It’s a zombie, and it will be back.

References

Jepson R.G., Williams G. & Craig J.C. (2012). Cranberries for preventing urinary tract infections., Cochrane database of systematic reviews (Online), PMID:

Wang C.H. (2012). Cranberry-Containing Products for Prevention of Urinary Tract Infections in Susceptible PopulationsA Systematic Review and Meta-analysis of Randomized Controlled Trials, Archives of Internal Medicine, 172 (13) 988. DOI:

Posted in: Clinical Trials, Herbs & Supplements

Leave a Comment (38) ↓

38 thoughts on “Cranberry, the alt-med zombie

  1. elburto says:

    Volunteering in sexual health meant I saw this ridiculous myth propagated all the time. Even worse than that was that it was typically touted as a cure for UTIs.

    In places without free/cheap or easily accessible medicine it is rooted especially strongly, as women desperately want to believe that $2 of juice will do the same as a course of abx. To them a doctor’s appt and prescription fees are as out of reach as the bill they’ll get for presenting at the ER with a kidney infection that may well affect their health for years.

    Oh, and at the risk of being Comrade Question, how in the name of the Dark Oblivion is this a thing:

    Marucci Center for Blueberry Cranberry Research at Rutgers University

    Anyone? Bueller?

  2. DugganSC says:

    This quote from the Cochrane review confused me:
    “Cranberry products (such as tablets or capsules) were also ineffective (although had the same effect as taking antibiotics), possibly due to lack of potency of the ‘active ingredient’.”

    So are they saying that taking antibiotics is ineffective? Personally, I fell for this one for several years (I inherited a tendency toward UTIs from my maternal grandfather as best I can tell. He gets them too). I wouldn’t be horribly surprised if the focus on drinking cranberry juice results in people drinking more liquids overall, both because they’re focusing on drinking something and also because cranberry, with its tartness, tends to result in me also drinking something else a bit later to cleanse my palate.

  3. WilliamLawrenceUtridge says:

    @elburto

    Sounds delicious though, doesn’t it? Like some sort of fruit-stuffed pastry you would buy in Rome.

    @DugganSC

    If you expand the abstract, you get this information:

    The effectiveness of cranberry was not significantly different to antibiotics for women (RR 1.31, 95% CI 0.85, 2.02) and children (RR 0.69 95% CI 0.32 to 1.51).

    Cranberry products were not significantly different to antibiotics for preventing UTIs in three small studies.

    Suggesting that antibiotics may be good as treatment, but crap as prevention. Which contradicts Scott’s link above to a 2004 review about prophylactic antibiotics. It might be due to the specific comparison of cranberry products to antibiotics within a small number of studies; looking at the 2004 review, it includes a larger number of studies with more than 1100 subjects, so it’s possible those results allow a clearer indication of the issues. But I’m guessing.

  4. windriven says:

    @elburto

    Hose down your righteous indignation. The Marucci Center is part of Rutgers’ agriculture program. Philip Marucci was an expert in blueberry and cranberry cultivation. The primary programs are plant breeding, entomology and plant pathology. There is also a program studying the health benefits of the berries. If that strikes you as inappropriate, it would be interesting to know why.

    The health benefits work is directed by Amy Howell whose doctorate is in plant pathology. She did post doc work in phytochemistry and in ‘nutraceutical’ studies at Rutgers. Some of her work is financed by Big Cranberry and some by NCCAM.

    I have nothing to say about the quality of her research – it is far outside my area of expertise. But she has published in major peer-reviewed publications including JAMA and New England Journal of Medicine.

    Is it your contention that cranberries and blueberries can have no biological effects and therefore research should be forbidden? Or is it that private industry should have no role in funding research? Or is it that cranberries have been hyped and therefore cranberry research is inherently flawed?

    The object of research is to expand human knowledge. Some is good, some is bad. Ultimately, the method separates the wheat from the chaff. That has always been part of the march of science.

  5. mattyp says:

    Cranberry goes great with a nip of vodka, ice & a lime wedge.

  6. BKsea says:

    SBM may bear some of the blame if this is a zombie idea. Dr. Novella wrote in August of last year:

    “It is true that cranberries likely have some benefit in preventing UTI, but the clinical studies have been problematic”

    Dr. Hall noted in her positive review of the Mayo Clinic Book of Home Remedies that cranberry could be useful for prevention of UTIs (with some caveats).

    Up to this point, I would have given SBM’s position on this as not a glowing endorsement, but an acknowledgement that taking cranberry to prevent UTIs is not unreasonable.

  7. windriven says:

    @mattyp

    “Cranberry goes great with a nip of vodka, ice & a lime wedge.”

    If the vodka is kept in the freezer (as it should be) and the cranberry juice in the refrigerator, then the ice does nothing except take up space ;-)

  8. mousethatroared says:

    Me loves me some cranberries and blueberries…but I’ve never had a problem with UTIs (knock on wood). They’ve gotta be good for something, vitamin C? Fiber? at least an excellent complement to turkey, sparkling water and cereal.

  9. elburto says:

    Windriven – Calm down. I hadn’t realised that blueberries and cranberries saved your childhood puppy from ravenous bald eagles.

    Now, if you’ve sipped some delicious Teamazepam alongside your delicious, flaky, berry Marucci*, all I was basically amused by was such a specific and commercial sounding name, like it’s a branded product, rather than a research centre.

    Are other bacciferous plants verboten? Do they research team get into feuds with Big Grape? Do they have a rival Ocean Spray research division? Are employees subjected to urine tests for goji and elderberry compounds, rather than opiates? Oh and finally, do they viciously snark people who refer to aggregate and accessory fruits as ‘berries’?

    I will forever, and always, reserve the right to mercilessly take the p¡ss** out of any person/company/organisation that promotes dangerous pseudoscience. That’s especially true when they do so under the umbrella of respected research institutions, or using wealth/power to do so.

    “cranberries cure/prevent UTIs”^+limited access to healthcare= catastrophic consequences. Ever had a kidney infection, especially one for which you were unable to seek treatment? If someone was too poor to seek timely treatment before their situation became grave, hospital bills plus lack of income is only going to push them further down the spiral

    Woo maims and kills, and one of the horrible ironies is that it’s more likely to take hold in the places where it has the potential to do the most damage. if you don’t think that’s worth getting p¡ssed off about then you might not be paying enough attention. That’s why groups like SBM and the Nightingale Collaboration, and blogs such as Dr Gorski’s NSSSOB and Dr Jen Gunter’s blog are so important.

    Flags need to be raised about this rubbish getting a stranglehold on lives, and about otherwise legitimate institutions allowing utter bollocks (like the cranberry nonsense) to be promoted in their names, as it automatically grants it an air of credibility.

    *Thanks WLU! Although I’m craving pastries now

    ** Pun very much intended

    ^The sad thing is that so many women trying this approach admitted to using “cranberry flavoured juice drink”, as the real deal was unpalatable and expensive. If every penny counts then even a fiver can mess up your budget.

    The “juice drink” was essentially sugar (and HFCS in the US), water, and flavour compounds. The nearest it had been to an actual cranberry was the picture on the carton.

    Not only would it do nothing for their UTI, but the sugar load was awful. I frequently sent $40 via PayPal so that the affected person could swing by a doc-in-a-box place after work with a view to getting herself a urine test and cheap abx. At the time that was only about £20, worth it to stop my evil, righteous, European lefty guilt at having access to healthcare from plaguing me.

  10. windriven says:

    Ah elburto, those with whom you think you might disagree are all dirtbags. What a way to live.

    “I will forever, and always, reserve the right to mercilessly take the p¡ss** out of any person/company/organisation that promotes dangerous pseudoscience.”

    Ummm … are you suggesting that Howell or Rutgers does?

    You seem quite adept at throwing crap at the wall but not in supporting it with facts. Has Dr. Howell’s work “promoted dangerous pseudoscience”?

    There is a substantial difference between quacks promoting cranberry or acai as a therapeutic agent and a credentialed professional conducting legitimate research. Some of that research is funded by BigBerry and some by the idiotic NCCAM, but those facts aren’t hidden by Dr. Howell or by Rutgers so that those reviewing the work can take this into account. But if Dr. Howell is spewing propaganda unsupported by the available science, you would have a legitimate argument. Unfortunately, you have yet to mount it.

  11. mousethatroared says:

    Someone really must insert a remark that incorporates “pissing contest” into the thread.

    -and I’m just the one for the job. ^

  12. windriven says:

    @mouse

    “Someone really must insert a remark that incorporates “pissing contest” into the thread.”

    “Since the 1940s [pissing contest] has been used as a slang idiomatic phrase describing contests that are “futile or purposeless”, especially if waged in a “conspicuously aggressive manner”.*

    While the descriptive phrase may not be often used in these pages, the practice is widespread :-)

    *Oxford English Dictionary by way of University of Google, advanced semantics seminar

  13. annappaa says:

    I have enjoyed writing about cranberry myths over at the Planned Parenthood AZ blog, and appreciate learning about these new reviews. I especially appreciate the criticism of the latest review’s statistical weaknesses — I hope to become much more savvy in interpreting that stuff over the next year, as I continue my education beyond the level of my dusty bachelor’s degree.

    One of the pervasive myths about cranberry juice and UTIs is that it MUST be 100%, unsweetened cranberry juice. There is a streak of masochism among some of those devoted to good health — the whole “no pain, no gain” mentality. I mean, have you ever tried swigging pure cranberry juice, unadulterated by sugar or a medley of more pleasant-tasting fruit juices? It is awful enough to make you gag! If you’re me, you will literally gag!

  14. mousethatroared says:

    Hey annappa! I just happened to be over at the PPAZ blog on this topic. I was googling because I was curious what the typical user would get searching for “cranberry juice UTI treatment” (do I have too much time on my hands? hey it’s better than watching paint dry).

    I thought your blog piece was excellent! Nice that it was informative even beyond the issue of UTI and cranberry juice, discussing possible mechanisms, how anecdotal evidence can be deceiving and the kinds of studies that give the most reliable evidence.

    Sad that the poor WebMD article is the first Google listing, but glad your link was on the first page.

  15. mousethatroared says:

    windriven – too true. I’ve got more – “pissing into the wind”

    Strange, having two kids, I usually keep my language proper but the crude idioms just keeping popping into my head today.

  16. goodnightirene says:

    @windriven

    I think you’re being too touchy about what elburto said, especially after her explanatory second comment. She wasn’t attacking Howell personally, just being (as she explained) amused (as was I) by the name of the institute–I appreciated your follow up in the sense that you had detailed information that contributed to understanding the work that is done there, but I share elburto’s skepticism that anyone getting funding from Ocean Spray AND NCCAM is, well…deserving of skepticism, especially when you add in the comments this woman make about research that were included in the post. Harvard is generally a very prestigious place, but they get my eyebrows arched just as high when they open a department of woo.

    I also share elburto’s concern for people who do not have access to health care and often turn to things like cranberry in desperation (if not true belief) when they actually have serious infections. This has led many a shruggie down the path of woo and I know (knew) at least three (poor and uninsured) people quite dead from treating their cancer with woo–not necessarily because they believed (or doubted)–but because they had no options and being science neutral (illiterate) they “hoped for the best”.

    So, we already know that berries are good for us–what’s in it for “Big Cran” and NCCAM except to try to adulterate them and market them as “medicine”, or waste more money endlessly studying them for treatment of URI? I think it’s great to study berries and breed them for their benefits in the context of a balanced diet, but I’m sad to see Rutgers getting in bed with NCCAM. It’s possible Ocean Spray has somewhat respectable motives I suppose.

  17. mousethatroared says:

    “The Philip E. Marucci Center for Blueberry and Cranberry Research and Extension is a substation of the New Jersey Agricultural Experiment Station (NJAES) of Rutgers University located in Chatsworth, NJ (Burlington County). The Center’s goals are to:

    Ensure the continued production and availability of high-quality blueberries and cranberries through basic and applied research;

    Minimize the use of pesticides in the culture of these two crops;

    Maintain research programs on the identification of natural products in cranberries and blueberries with beneficial health properties;

    Investigate causes and controls of diseases that affect blueberries and cranberries.”

    http://pemaruccicenter.rutgers.edu

    This is like the Agricultural Research and Extension centers that you see all around the country supporting….shocking, agricultural research and education on different topics. In Michigan, we have apples, cherries, probably sugar beets and beans. It seems that region has an interest in cranberries and blueberries. It seems to me that we really should be able to have a civil disagreement with people researching agricultural products without first resorting to unsupported accusations of “promoted dangerous pseudoscience”.

  18. hippiehunter says:

    Mouse are you taking the piss?

    I work in aged care where cranberry and aromatherapy are sadly ubiquitous.

  19. Narad says:

    I’m surprised at the dropout rate, but then again, I’m fond of straight (well, concentrate plus water) cranberry juice. At $8 for 32 fluid ounces (Knudsen; 8.75 calories per ounce), it’s kind of pricey, though.

  20. Rick_Hallpike says:

    Regarding the 1 in 12 chance of avoiding UTI in 6 months, does that mean the NNT is 12 over a six month period? Another way to look at it would be that it would take 6 years of drinking 500mL of cranberry juice a day to prevent 1 UTI.

    All things being equal, assuming 500mL juice = 120 calories, and that an additional 3500 calories/week equates to 1 pound/week (it’s actually 1-2 lbs), you would need to drink enough cranberry juice to gain ~75 lbs over 6 years to prevent 1 UTI.

    That’s assuming the only change is the additional juice in someone with stable weight. Correct me if I am wrong.

  21. windriven says:

    @goodnightirene

    It is, I think, important to keep the idea of science rather than emotion at the heart of these pages.

    @Rick_Hallpike

    The grail I suppose, would be determining the compounds responsible, isolating them and synthesizing them. That would be the only way to assure dosage. Of course, this presumes that there is actually something there worth synthesizing.

  22. mousethatroared says:

    @ hippiehunter – I don’t know much about aged care. My parent’s and Grandparents were pretty much healthy until they got cancer (or had a stroke) and had hospice care before passing away. Correct me if I’m wrong…but don’t people often lose their sense of smell as they age? Aromatherapy does not seem like a natural fit.

    Not that I have anything against smells. There’s a few scents that I rely on to lift my spirits when I’m stressed or blue, but that’s like…what do they call it in the Dialect Behavior Therapy world? – Self soothing or distraction. It does seem that in an emotionally healthy environment, people would have access to some of their preferred pleasurable distractions, but the tendency to medicalize these things seems to miss the point.

    My mom enjoyed watching the chipmunks in the yard when she was in home hospice care. A daily dosage of 1/2 hour watching a prescribed chipmunk videotape at 4:00PM would probably not have the same benefit and it would be wrong to pretend that it would do anything beyond bring a moment of enjoyment or distraction into a difficult time.

    Why do people have to take something that is essentially pleasant and fine as it is and turn it into some sort of mystical medicine? Isn’t a lovely summer’s day good enough as it is…does it have to cure cancer to boot?

    And as a complete non-sequitor and in no way directed at anyone…but the next urinary idiom would be “go piss up a rope.”

  23. ConspicuousCarl says:

    Cranberry juice is gross. My theory on the persistence of the belief in cranberry juice as a biological cleanser is that it tastes like something you would use to clean your bathroom. Pretty convincing, actually.

    And these two common statements are completely contradictory:

    “It doesn’t matter how it works, as long as the end user says it works.”
    “That negative research doesn’t count because the researchers are not specialists in [insert nonsense].”

    If it doesn’t matter how it works, why do the people evaluating it have to be masters of the rhetoric? Why is a random idiot off the street qualified to determine that their pain is gone, but not when an educated doctor asks them… unless that doctor has studied unproven nonsense? And why is that doctor qualified to determine the presence of e. coli, but not qualified to determine the presence of the same e. coli after some CAM garbage was applied? Does the CAM treatment create some fake benign form of e. coli which tricks doctors?

  24. dinseattle says:

    I am someone subject to UTIs. Years ago I participated in a clinical trial to determine how long the antibiotics needed to be given to clear one up. At the time, standard practice was 7 days. I believe it is now just three days (or less?) and perhaps the trial I participated in helped that. I know I was in the three day dose category and my infection cleared up.

    At the time the researcher explained that some women’s vaginal secretions had properties that acted like an e coli magnet (sorry, I know that’s not the proper medical term) so no matter how good the hygiene, intercourse was likely to push some e coli into the urethra. So peeing after sex was the standard preventative technique, and for the most part, it worked for years. I have no idea if the explanation is still considered valid, this was 25 years ago.

    Perimenopause and the changes to hormones and tissue composition brought back the specter of UTIs (at least that was the explanation of my doctor). But not often, more like once every 18 to 24 months. (so a 6 month study would not be enough for me.) My doctor poo-pooed cranberries. She said (based on her husband the urologist’s advice) that taking vitamin C right before intercourse (along with still peeing shortly afterward) would probably do the trick. The idea was that the extra C in the urine would acidify it and help combact the e coli. She said that if that doesn’t do the trick, then prophylactic antibiotics would be the next step. I am under the impression that that would mean not daily, but only related to intercourse.

    So is this acidifying the urine at all science-based? I am also very curious about that line suggesting that antibiotics prophylactically are not considered effective? “Cranberry products (such as tablets or capsules) were also ineffective (although had the same effect as taking antibiotics)”

    As for the cranberry myth, I have to sympathise with young women subject to UTIs who would try it out of desperation. A UTI really hurts. (now the pain relief is also OTC though.) Sometimes getting treatment is very inconvenient, even with good health care. My first vacation with my then boyfriend (now husband of 22 years) involved driving 150 miles to the nearest doc-in-a-box, then two days later doing the same thing for a yeast infection (I don’t ordinarily get one). Thank goodness that’s now OTC! My doctor nowadays trusts that I know the symptoms well enough to allow for refills so I can have some on hand for trips or holiday weekends or simply an ordinary time if I get a recurrence. There’s a sense of stigma as well. Once when my sister-in-law had a UTI, our mutual father in law, a physician, openly said something pretty nasty judging her on her lack of hygiene. However, everything I ever read extolling cranberries said that one could NOT use the ordinary juice cocktail, for all the reasons given above. The supposed effective dose meant way way too much sugar.

  25. Narad says:

    Cranberry juice is gross. My theory on the persistence of the belief in cranberry juice as a biological cleanser is that it tastes like something you would use to clean your bathroom.

    Or maybe you’re just a big baby with a restricted palate. How do you feel about tonic water? Swedish bäsk?

  26. ConspicuousCarl says:

    I don’t know what point you are trying to make with tonic water. I’ve seen lists of things which can be done with tonic water, and drinking it doesn’t even usually make the top 5 (typically filled out with suggestions such as “removing rust” or “cleaning underwear stains”).

    I had to look up bäsk. The best Wikipedia has to say is that it’s not illegal everywhere, and it can help to digest things that maybe you should not eat. Pass.

  27. TsuDhoNimh says:

    One reason for the survival of the zombie … adequate fluid consumption is important for symptomatic relief of UTIs.

    Most people won’t drink enough water, but if told to drink X glasses of magic juice, have no problem with it.

  28. Narad says:

    I don’t know what point you are trying to make with tonic water.

    Just probing the daintiness of your palate.

  29. Kereru says:

    I also used to be subject to frequent UTIs when I was a student, and experimented a lot on what worked to resolve them. It took days to get a free appointment at Student Health, and the treatment they offered then was a single dose antibiotic that gave me horrible stomach cramps for the next twelve hours or so. My more expensive family doctor was easier to get hold of, but still a day or two, and gave me a lower dose taken over a few days; no side effects. A 1.5 litre bottle of Ocean Spray Cranberry I could get anytime from the supermarket for $5, and if I drank it as fast as I could stand, it tended to work. I figured it could have worked in at least three ways – lots of liquid flushing out the system, a high dose of vitamin C, or special cranberry power. Probably a bit of each, but the Cranberry/Blackcurrant blend which tasted a lot better didn’t seem to work as well. I’m interested to see whether the study design isolated those factors. It would suck to be the control, though.

    Eventually I was prescribed a low daily dose of Nifuran, which saw most of the UTIs off; but they disappeared for good when I broke up with my then partner. I like to think he was the germy source of it all.

  30. AndersB says:

    You’ve only consider the two options of prophylactic antibiotic treatment or cranberry juice/supplements, how are the evidence for methenamine? As we are rather restrictive when it comes to antibiotics here in Norway (and thus have some of the lowest rates of resistant bacteriae), we’ve been using methenamine as a prophylactic (marketed as “Hiprex”) for recurring uncomplicated acute cystitis in otherwise healthy individuals.

  31. BillyJoe7 says:

    Kereru,

    “…which saw most of the UTIs off; but they disappeared for good when I broke up with my then partner. I like to think he was the germy source of it all.”

    Sorry to break this to you, but the germy source was almost certainly your own perianal area. The infecting bacteria are almost always enteric bacteria. He just pushed them up there for you. Perhaps your new partner is a little more gentle on the upstroke.
    (There are a few more observations I could make, but I think I’ll stop there)

  32. Alia says:

    @AndersB – Well, over here the treatment of choice for UTIs seems to be furagin/furazidin, not antibiotics. And it used to work just fine for me.

  33. norrisL says:

    So who is Amy Howell Ph.D.? See Below.

    http://www.berryhealth.org/Bios/AmyHowellBio.html

    75% of Canine UTI’s will spontaneously resolve in 7 days or in a week if treated with cranberry! :)

    Cats are often more difficult that dogs with UTI’s

  34. Earthman says:

    “Their [Cochrane] conclusion is a reasonable analysis of the evidence base.”

    My take on Cochrane is that they concentrate too much on the statistics and not enough on the merit of the data. They all too often find something to be not statistically significant, but then say that it needs more data rather than saying that the result is negative i.e. in stat-speak, the null hypothesis cannot be rejected.

    The science-based approach takes into account prior probability, such as whether or not all the rest of science is compatible with the proposition being analysed, and this is what is lacking in Cochrane. Is it therefore possible for them to get a true ‘reasonable analysis of the evidence base’ when their methodology is non-Bayesian?

  35. Flower says:

    First of all, whole cranberries and natural juice and extracts from the berry are very LOW in sugar!
    Though many commercially prepared juices contain added sugar, as with many other cheap supermarket juices available.

    Cranberry extract has been proven to be effective as a urinary antiseptic and is widely used in nursing homes for the elderly.

    Cranberry is an effective bacteriostatic agent in UTIs because it inhibits bacterial adhesion to the host’s epithelium.

    The therapeutically effective dose for UTI treatment is 10,000 mg TDS to QID, not the few hundred mg doses given in clinical trials, as shown below.

    Sample research excerpt:

    “108 mg of cranberry induced a significant reduction in bacterial adherence to T24 cells as compared with placebo (p <0.001). "
    http://www.ncbi.nlm.nih.gov/pubmed/18190583

    As you can see even as little as 108mg can have a bacteriostatic effect.

    In clinical reality, naturopaths do not treat UTIs with a single agent alone; our treatment protocols address the whole person to permit the patient to regain his or health health.

  36. Scott says:

    First of all, whole cranberries and natural juice and extracts from the berry are very LOW in sugar!

    Which is why they’re so very hard for people to drink in significant quantities.

    Cranberry extract has been proven to be effective as a urinary antiseptic and is widely used in nursing homes for the elderly.

    And yet, you don’t present any evidence for that.

    Sample research excerpt:

    Preliminary. Does not demonstrate any efficacy in actual people against actual UTIs.

    In clinical reality, naturopaths do not treat UTIs with a single agent alone; our treatment protocols address the whole person to permit the patient to regain his or health health.

    In clinical reality, naturopaths can’t effectively treat anything at all because the entire profession is terminally detached from reality.

  37. WilliamLawrenceUtridge says:

    First of all, whole cranberries and natural juice and extracts from the berry are very LOW in sugar!

    Yep, and they’re basically inedible because of it for the same reason lemonade has significant amounts of sugar in it. Or for that matter, apple juice, orange juice, strawberry juice, pineapple juice and the like. We drink juices because they taste good – because they’ve got a lot of sugar in them. For the most cases it’s fruit sugar because fruit has sugar in it, but it’s not like that’s any better than processed sugar bar some accompanying vitamins.

    Cranberry extract has been proven to be effective as a urinary antiseptic and is widely used in nursing homes for the elderly. Cranberry is an effective bacteriostatic agent in UTIs because it inhibits bacterial adhesion to the host’s epithelium.

    Well if it’s proven, it should be easy to demonstrate this fact. Also, you should read the article Scott actually wrote. For instance, the lines “An ingredient in cranberry, proanthocyanidins, is thought to block some variants of E. coli bacteria from adhering to bladder cells, which might reduce the risk of infection. But these “fimbriated” bacteria are uncommon in species isolated from urinary tract infections. So even if the theoretical mechanism of action is correct (which remains unproven), the real-world effect, based on this assumption, should be minimal. And that’s largely what the evidence shows, when you account for the poor research quality.” Emphasis added to the relevant parts.

    Again, like all science – real effects, particularly clinically relevant effects, should be easy to demonstrate and the results should be converging on effective solutions within a relatively short period of time. If you’re still getting only borderline results after decades of research, chances are even if there is something there, it’s not clinically significant.

    The therapeutically effective dose for UTI treatment is 10,000 mg TDS to QID, not the few hundred mg doses given in clinical trials, as shown below.

    Sample research excerpt:

    “108 mg of cranberry induced a significant reduction in bacterial adherence to T24 cells as compared with placebo (p <0.001). "
    http://www.ncbi.nlm.nih.gov/pubmed/18190583

    What you refer to as “sample research”, others (like me) might refer to as “cherry-picked” research. Possibly “cranberry-picked” in this case, ahahaha. Note for instance, the date (2008, is there nothing more recent from this lab?) the number (n=8) and the location (test tubes; people aren’t test tubes and I’m pretty sure cranberry juice doesn’t reach the bladder unmodified). Chances are, if cranberry juice is ever demonstrated, reliably and replicably, to be effective in treating UTIs, whatever the active ingredient, once purified, standardized and modified to survive the gut and liver, will be far more effective.

    As you can see even as little as 108mg can have a bacteriostatic effect.

    Which might be relevant were I a clump of epithelial cells floating in a test tube. However, since I have hands and I know what a keyboard is, I am probably not.

    In clinical reality, naturopaths do not treat UTIs with a single agent alone; our treatment protocols address the whole person to permit the patient to regain his or health health.

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