Last Updated: 2017-02-28 Description and Key Nutrition Issues Description Urinary tract infections (UTIs) involve the upper and/or lower urinary tract, affecting the kidneys, bladder, urethra or prostate. Bacterial infections are the most common, though fungal, viral, or parasitic can also occur. The majority of bacterial UTIs are due to bacteria ascending the urethra to the bladder; particularly enteric (colonic) bacteria with E. coli being the most common. Bacterial UTIs are more common among women than men, among the elderly, the immune-compromised and among those requiring catheterization. Nutrition intervention may play a role in the prevention of UTIs. Key Nutrition Issues This toolkit discusses the following key nutrition issues: the role of cranberry products in the prevention of UTIs the role of cranberry products in the treatment of UTIs the role of probiotics in the prevention of UTIs health concerns with cranberry product consumption (dried cranberries, supplements and juice) health concerns with cranberry product consumption during pregnancy and lactation, interaction with warfarin, and effect on kidney stones. Nutrition Assessment The nutrition assessment of an individual with a UTI or wanting to prevent a UTI may include the following parameters using NCP terminology: Anthropometric Measurements Anthropometric Comparative Standards Food/Nutrition-related History Food and Nutrient Intake Food and beverage intake Fluid/beverage intake (oral fluids, water intake, cranberry juice) 1
Food intake Types of food/meals Medication and Complementary/Alternative Medicine Use Medications Prescription medication use (antibiotics, warfarin) Complementary/alternative medicine Nutrition-related complementary/alternative medicine use (cranberry juice, cranberry tablets, other) Food/Nutrition-related Comparative Standards Nutrition-focused Physical Findings Biochemical Data, Medical Tests and Procedures Client History Personal History Personal data Age Patient/Client/Family Medical/Health History Patient/client or family nutrition-oriented medical/health history Excretory (history of bladder infection) Nutrition Diagnosis Sample PES Statements (problem, etiology, signs and symptoms using some NCP terminology) This statement is provided as an example only, and will not apply to all individuals: Food-medication interaction related to food and nutrition knowledge-deficit concerning food-drug interactions (in an individual who has been on warfarin therapy for years with stable INR levels), as 2
evidenced by increased INR level after starting to drink 1.5 litres of cranberry juice daily for a week. Nutrition Intervention Nutrition Prescription A nutrition prescription is often developed at the beginning of the nutrition intervention step. The nutrition prescription is comprised of recommendations for the intake of nutrients or foods that are specific to the individual. The recommendations are based on reference standards (e.g. Dietary Reference Intakes, dietary guidelines, standards for specific health conditions) and the individual s nutrition diagnosis(es). The nutrition prescription communicates the recommendations that the dietitian and the client develop, after completing the nutrition assessment and developing the nutrition diagnosis(es). It can also be used as a comparative standard during the nutrition care process, such as, during the assessment, and monitoring and evaluations steps. Nutrition Prescription Example Recommend: regular diet food intake (e.g. cranberry juice). Note: Evidence for cranberry juice for treatment or prevention of UTI is mixed and inconsistent and this information should be conveyed to the patient/client. NCP Terminology for Nutrition Intervention Nutrition interventions may be in the area of food and/or nutrient delivery if the individual with a UTI is an inpatient in a facility, or in the area of nutrition education if seen in an outpatient setting, or before discharge from an inpatient setting. Food and/or Nutrient Delivery Example Meals and Snacks General/healthful diet Specific foods/beverages or groups (e.g. cranberry juice) Note: Evidence for cranberry juice for treatment or prevention of UTI is mixed and inconsistent and this information should be conveyed to the patient/client. Nutrition Education Example Content Purpose of the nutrition education Nutrition relationship to health/disease Recommendations (e.g., consume cranberry juice each day). Note: Evidence for cranberry juice for treatment or prevention of UTI is mixed and inconsistent and this information should be conveyed to the patient/client. Goals Goals for an individual with UTI or wanting to prevent UTIs should be determined in conjunction with the 3
client, and should be specific to the individual. Goals that are set should be time-sensitive, easily measured, and achievable by the nutrition intervention. Both short-term and long-term goals may be set. Examples of short- and long-term goals include: by the next scheduled nutrition visit in one month, drink cranberry juice daily and report on the effect on UTI occurrence. to adjust overall diet and exercise to prevent weight gain from extra calories consumed due to daily consumption of cranberry juice to help prevent UTIs. Key Findings and Recommendations Key findings and recommendations include those regarding: the role of cranberry products in the prevention of UTIs the role of cranberry products in the treatment of UTIs the role of probiotics in the prevention of UTIs health concerns with cranberry product consumption (dried cranberries, supplements and juice) health concerns with cranberry product consumption during pregnancy and lactation, interaction with warfarin, and effect on kidney stones. Treatment of Pre-existing UTI Cranberry Products Clinical research is lacking to support that cranberry products treat or aid treatment of an existing UTI. Individuals experiencing symptoms of a UTI should see their doctor for diagnosis and treatment. Prevention of UTI Cranberry Products and Prevention of UTI An important step in the development of a UTI is bacteria binding to the cells lining the urinary tract. Ingestion of cranberry products can help prevent that binding. However, in research trials taking cranberry products did not always prevent symptomatic UTIs. Results were inconsistent. Specifically: There may be some benefit in children, women with recurrent UTIs and individuals undergoing pelvic pelvic radiation therapy. Trials did not find a benefit in elderly or older adults, pregnant women or individuals with neurogenic/neuropathic bladder. Practitioners can discuss with clients the pros and cons of trying cranberry for UTI prevention. Factors to balance against the inconsistent evidence on efficacy include: financial cost of cranberry products unpalatability of regular juice ingestion sugar and caloric content. Because products tested in trials were so variable it is not clear what type and amount of cranberry would be most beneficial, if any. Additionally, proanthocyanidins, which are thought to be the active ingredient in cranberry preventing binding of bacteria to cells lining the urinary tract, are found in varying levels in different cranberry products and can break down from heat and light exposure. Probiotics and Prevention of UTI 4
Lactobacilli dominate the urogenital flora of healthy premenopausal women, but when E. coli and Enterobacteriaciae colonize the urethra and vagina, urinary tract infections may result. It has been suggested that restoration of the urogenital flora with Lactobacilli taken orally or intravaginally may protect against UTIs by several mechanisms, including reducing bacterial adherence, growth and colonization, as well as modulating the host s immune response to the pathogens. A meta-analysis of nine RCTs did not provide adequate evidence to show either a benefit or lack of benefit of oral or intravaginal probiotics compared to placebo on the prevention of recurrence of UTIs. However, some results were promising, such as those from one RCT that found a 50% reduction in recurrence rates of UTIs in premenopausal women treated with vaginal suppositories containing Lactobacillus crispatus compared to placebo. In this RCT, the probiotics were well tolerated. Additional research is needed on both the safety and efficacy of the use of probiotics to prevent recurrent UTIs in women before they can be recommended for this purpose. Evidence is lacking regarding the role of probiotics in the treatment of UTIs. Health Concerns with Cranberry Product Consumption Form of Cranberry Findings and Recommendations Sweetened, Dried Cranberries There is no research on sweetened dried cranberries or crushed cranberry seeds for symptomatic UTI prevention. However, sweetened dried cranberries do contain significant amounts of proanthocyanidins (PACs), which are currently considered the active constituent in cranberry thought to help inhibit bacterial adhesion to uro-epithelial cells. Additionally, one small trial did find a decrease in bacterial adhesion activity in the urine of women consuming dried sweetened cranberries. More research is needed on this form of cranberry. Cranberry Supplements Supplements may be more cost-effective, easier to consume than large volumes of juice, and do not deliver the calories and sugar of juice. Each 250 ml of cranberry juice cocktail provides 36 grams of carbohydrate and 144 kcalories and each 250 ml of unsweetened cranberry juice provides 32.6 grams of carbohydrate and 123 kcalories. Cranberry Juice Proanthocyanidins (thought to be the active constituent in cranberry) are sensitive to light and temperature. Numerous steps from juicing, processing, distribution 5
and storage expose cranberry products to light and temperature. Research studies rarely standardized cranberry test products for PAC levels. It would be extremely difficult for consumers purchasing cranberry juice at the store to know if or how much active ingredient is present. Additionally, many cranberry juices are also blends of cranberry with other juices. Some individuals have complained of gastrointestinal upset when drinking large volumes of cranberry juice and compliance was often poor in research trials. Health Concerns with Cranberry Product Consumption Health Concern Findings and Recommendations Pregnancy/Lactation There is currently a lack of evidence on the safety or harm of using cranberry products during pregnancy or lactation, other than reports of gastrointestinal side-effects (such as nausea, diarrhea or vomiting) when consuming 240-720 ml per day. Cranberries and cranberry juice have a long history of use and there is no evidence they would be toxic or harmful during pregnancy or lactation. Less is known about cranberry supplements and extracts. Potential Warfarin (Coumadin) Interaction The evidence that cranberry products interact with blood thinning medications, such as warfarin, is mixed. Case reports suggest there is a risk (although usually the volumes of cranberry juice ingested were very large at litres/day) while most controlled experiments, which usually tested lower more moderate dosages, have not observed an interaction. However, because of the potential interaction between warfarin and cranberry, individuals on warfarin are encouraged to talk to their health care professional before making substantial dietary changes and to continue to have their international normalized ratio (INR) monitored regularly. Oxalate Kidney Stones While cranberry does contain oxalate, the evidence for a relationship between ingestion of cranberry products and the risk of oxalate kidney stones is inconclusive. 6
Nutrition Monitoring and Evaluation Nutrition Education Materials Key Additional Client Handouts Urinary Tract Infections (UTI) Urinary Tract Infections in Adults Additional Information Nutrition Care Process Terminology See country-specific information on Nutrition Care Process Terminology: Nutrition Care Process and Terminology Web Links. See Additional Content: Nutrition Care Process and Terminology Background. References This toolkit provides an overview of practice recommendations and other relevant information contained in Practice Questions and Backgrounds in PEN Knowledge Pathways. To view the key practice points and other relevant information (including the associated references) see the Urology - Urinary Tract Infection Knowledge Pathway. In addition, the source of the NCP terminology used in this toolkit is: The Academy of Nutrition and Dietetics. encpt: Nutrition Terminology Reference Manual. 2014. Available from: Nutrition Care Process and Terminology Web Links. Disclaimer: The information included on this website is based on the best available evidence at the time of writing. It 7
has been independently researched, written and reviewed by dietitians and other health professionals using established protocols, to assist practitioners to make practice decisions. It should be used to complement, not replace, sound clinical judgment. While every effort is made to ensure information contained on this website is accurate and up-to-date, errors may occasionally occur. Neither Dietitians of Canada nor any dietetic associations contributing to or licensing the content in PEN: Practice-based Evidence in Nutrition assumes any responsibility or liability arising from any error in or omission of information, or from the use of any information or advice contained within this website or provided by your health care professional. Because PEN content is updated regularly, printed web pages or PDF documents may become obsolete. PEN users should ensure that they are referring to the most recent version available. The PEN website may contain links to other external websites that do not fall under the pennutrition.com domain. Pennutrition.com is not responsible for the privacy practices or the content of such external websites. Neither Dietitians of Canada nor any dietetic associations contributing to or licensing the content in PEN endorses the content, products or services on other websites. All PEN authors and reviewers are required to complete a Declaration of Affiliations and Interests Form that is kept on file with Dietitians of Canada. Dietitians of Canada 2005-18. All rights reserved. While individual copies of documents may be reproduced for the convenience of the licensed subscriber according to the end user license, distribution to non subscribers or reproduction of multiple copies of PEN content is strictly prohibited without prior written permission. Licensed subscribers may download, duplicate and distribute copies of the PEN branded client handouts for educational use with their own clients. Institutions must have sufficient numbers of site or group licenses in order to make multiple copies to meet client needs. The PEN website may also contain information which is copyrighted by others; multiple copies of these documents may not be reproduced without the prior written permission of the copyright holder. 8