Heart Health vs Systemic Stress

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At The Heart Of Good Health

This is Dr. Michelle Albert. She’s a cardiologist with a decades-long impressive career, recently including a term as the president of the American Heart Association. She’s the current Admissions Dean at UCSF Medical School. She’s accumulated enough awards and honors that if we list them, this email will not fit in your inbox without getting clipped.

What does she want us to know?

First, lifestyle

Although Dr. Albert is also known for her work with statins (which found that pravastatin may have anti-inflammatory effects in addition to lipid-lowering effects, which is especially good news for women, for whom the lipid-lowering effects may be less useful than for men), she is keen to emphasize that they should not be anyone’s first port-of-call unless “first” here means “didn’t see the risk until it was too late and now LDL levels are already ≥190 mg/dL”.

Instead, she recommends taking seriously the guidelines on:

  • getting plenty of fruit, vegetables, whole grains, lean protein
  • avoiding red meat, processed meats, refined carbohydrates, and sweetened beverages
  • getting your 150 minutes per week of moderate exercise
  • avoiding alcohol, and definitely abstaining from smoking

See also: These Top Five Things Make The Biggest Difference To Health

Next, get your house in order

No, not your home gym—though sure, that too!

But rather: after the “Top Five Things” we linked just above, the sixth on the list would be “reduce stress”. Indeed, as Dr. Albert says:

❝Heart health is not just about the physical heart but also about emotional well-being. Stress management is crucial for a healthy heart❞

~ Dr. Michelle Albert

This is where a lot of people would advise mindfulness meditation, CBT, somatic therapies, and the like. And these things are useful! See for example:

No-Frills, Evidence-Based Mindfulness

…and:

How To Manage Chronic Stress

However, Dr. Albert also advocates for awareness of what some professionals have called “Shit Life Syndrome”.

This is more about socioeconomic factors. There are many of those that can’t be controlled by the individual, for example:

Adverse maternal experiences such as depression, economic issues and low social status can lead to poor cognitive outcomes as well as cardiovascular disease.

Many jarring statistics illuminate a marked wealth gap by race and ethnicity… You might be thinking education could help bridge that gap. But it is not that simple.

While education does increase wealth, the returns are not the same for everyone. Black persons need a post-graduate degree just to attain similar wealth as white individuals with a high school degree.

~ Dr. Michelle Albert

Read in full: AHA president: The connection between economic adversity and cardiovascular health

What this means in practical terms (besides advocating for structural change to tackle the things such as the racism that has been baked into a lot of systems for generations) is:

Be aware not just of your obvious health risk factors, but also your socioeconomic risk factors, if you want to have good general health outcomes.

So for example, let’s say that you, dear reader, are wealthy and white, in which case you have some very big things in your favor, but are you also a woman? Because if so…

Women and Minorities Bear the Brunt of Medical Misdiagnosis

See also, relevant for some: Obesity Discrimination In Healthcare Settings ← you’ll need to scroll to the penultimate section for this one.

In other words… If you are one of the majority of people who is a woman and/or some kind of minority, things are already stacked against you, and not only will this have its own direct harmful effect, but also, it’s going to make your life harder and that stress increases CVD risk more than salt.

In short…

This means: tackle not just your stress, but also the things that cause that. Look after your finances, gather social support, know your rights and be prepared to self-advocate / have someone advocate for you, and go into medical appointments with calm well-prepared confidence.

Take care!

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  • Blue Light At Night? Save More Than Just Your Sleep!

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    Beating The Insomnia Blues

    You previously asked us about recipes for insomnia (or rather, recipes/foods to help with easing insomnia). We delivered!

    But we also semi-promised we’d cover a bit more of the general management of insomnia, because while diet’s important, it’s not everything.

    Sleep Hygiene

    Alright, you probably know this first bit, but we’d be remiss if we didn’t cover it before moving on:

    • No caffeine or alcohol before bed
      • Ideally: none earlier either, but if you enjoy one or the other or both, we realize an article about sleep hygiene isn’t going to be what changes your mind
    • Fresh bedding
      • At the very least, fresh pillowcase(s). While washing and drying an entire bedding set constantly may be arduous and wasteful of resources, it never hurts to throw your latest pillowcase(s) in with each load of laundry you happen to do.
    • Warm bed, cool room = maximum coziness
    • Dark room. Speaking of which…

    About That Darkness…

    When we say the room should be dark, we really mean it:

    • Not dark like “evening mood lighting”, but actually dark.
    • Not dark like “in the pale moonlight”, but actually dark.
    • Not dark like “apart from the light peeking under the doorway”, but actually dark.
    • Not dark like “apart from a few LEDs on electronic devices that are on standby or are charging”, but actually dark.

    There are many studies about the impact of blue light on sleep, but here’s one as an example.

    If blue light with wavelength between 415 nm and 455 nm (in the visible spectrum) hits the retina, melatonin (the sleep hormone) will be suppressed.

    The extent of the suppression is proportional to the amount of blue light. This means that there is a difference between starting at an “artificial daylight” lamp, and having the blue LED of your phone charger showing… but the effect is cumulative.

    And it gets worse:

    ❝This high energy blue light passes through the cornea and lens to the retina causing diseases such as dry eye, cataract, age-related macular degeneration, even stimulating the brain, inhibiting melatonin secretion, and enhancing adrenocortical hormone production, which will destroy the hormonal balance and directly affect sleep quality.❞

    Read it in full: Research progress about the effect and prevention of blue light on eyes

    See also: Age-related maculopathy and the impact of blue light hazard

    So, what this means, if we value our health, is:

    • Switch off, or if that’s impractical, cover the lights of electronic devices. This might be as simple as placing your phone face-down rather than face-up, for instance.
    • Invest in blackout blinds/curtains (per your preference). Serious ones, like these ← see how they don’t have to be black to be blackout! You don’t have to sacrifice style for function
    • If you can’t reasonably do the above, consider a sleep mask. Again, a good one. Not the kind you were given on a flight, or got free with some fluffy handcuffs. We mean a full-blackout sleep mask that’s designed to be comfortable enough to sleep in, like this one.
    • If you need to get up to pee or whatever, do like a pirate and keep one eye covered/closed. That way, it’ll remain unaffected by the light. Pirates did it to retain their night vision when switching between being on-deck or below, but you can do it to halve the loss of melatonin.

    Lights-Out For Your Brain Too

    You can have all the darkness in the world and still not sleep if your mind is racing thinking about:

    • your recent day
    • your next day
    • that conversation you wish had gone differently
    • what you really should have done when you were 18
    • how you would go about fixing your country’s socio-political and economic woes if you were in charge
    • Etc.

    We wrote about how to hit pause on all that, in a previous edition of 10almonds.

    Check it out: The Off-Button For Your Brain—How to “just say no” to your racing mind (this trick really works)

    Sweet dreams!

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  • If You’re Getting Acne Now & Didn’t Before, This Is Why

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Dr. Andrea Suarez, dermatologist, explains:

    Ringing the changes

    It’s not just you! Acne in women—especially up the 40s—is very common and that prevalence seems to be increasing, but greater awareness, social media visibility, and more people seeking diagnosis also make it seem even more common than it is.

    In women in particular, it’s often more inflammatory, persistent, and concentrated around the jaw, chin, and mouth.

    If you guessed the reason is mostly hormonal, you’re right: hormones—particularly androgens and insulin-like growth factor (IGF)—stimulate oil production and inflammation, and even normal hormone levels can trigger acne if your skin is more sensitive to them.

    And yes, this happens because of all kinds of hormonal changes, as menstrual cycles, pregnancy, breastfeeding, starting or stopping hormonal contraception, let alone hormone replacement therapy (HRT), perimenopause, and menopause can all provoke new or worsening acne later in life.

    It’s not all about sex hormones though; high-glycemic foods and drinks, refined sugars, and frequent snacking raise insulin and IGF, which can also worsen inflammation and sebum production, while overall eating patterns matter more than any single food.

    And more hormones: because chronic stress and poor sleep raise cortisol, and thus also slow down healing, increase inflammation, and create a cycle where stress worsens acne and acne itself becomes a source of stress.

    There are more things too—otherwise unrelated metabolic issues, pollution, paradoxically overdoing skincare, genetics even, but the above more-discussed things are the main drivers, and thus the main things to try to manage.

    Which will come as a surprise to many who focus on skincare as the be-all and end-all of skin health!

    For more on all of this, enjoy:

    Click Here If The Embedded Video Doesn’t Load Automatically!

    Want to learn more?

    You might also like:

    The Diets & Supplements That Can Mess Up Your Skin

    Take care!

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  • In Crisis, She Went to an Illinois Facility. Two Years Later, She Still Isn’t Able to Leave.

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    Series: Culture of Cruelty:Inside Illinois’ Mental Health System

    State-run facilities in Illinois are supposed to care for people with mental and developmental disabilities. But patients have been subjected to abuse, neglect and staff misconduct for decades, despite calls for change.

    Kaleigh Rogers was in crisis when she checked into a state-run institution on Illinois’ northern border two years ago. Rogers, who has cerebral palsy, had a mental health breakdown during the pandemic and was acting aggressively toward herself and others.

    Before COVID-19, she had been living in a small group home; she had been taking college classes online and enjoyed going out with friends, volunteering and going to church. But when her aggression escalated, she needed more medical help than her community setting could provide.

    With few viable options for intervention, she moved into Kiley Developmental Center in Waukegan, a much larger facility. There, she says she has fewer freedoms and almost nothing to do, and was placed in a unit with six other residents, all of whom are unable to speak. Although the stay was meant to be short term, she’s been there for two years.

    The predicament facing Rogers and others like her is proof, advocates say, that the state is failing to live up to the promise it made in a 13-year-old federal consent decree to serve people in the community.

    Rogers, 26, said she has lost so much at Kiley: her privacy, her autonomy and her purpose. During dark times, she cries on the phone to her mom, who has reduced the frequency of her visits because it is so upsetting for Rogers when her mom has to leave.

    The 220-bed developmental center about an hour north of Chicago is one of seven in the state that have been plagued by allegations of abuse and other staff misconduct. The facilities have been the subject of a monthslong investigation by Capitol News Illinois and ProPublica about the state’s failures to correct poor conditions for people with intellectual and developmental disabilities. The news organizations uncovered instances of staff who had beaten, choked, thrown, dragged and humiliated residents inside the state-run facilities.

    Advocates hoped the state would become less reliant on large institutions like these when they filed a lawsuit in 2005, alleging that Illinois’ failure to adequately fund community living options ended up segregating people with intellectual and developmental disabilities from society by forcing them to live in institutions. The suit claimed Illinois was in direct violation of a 1999 U.S. Supreme Court decision in another case, which found that states had to serve people in the most integrated setting of their choosing.

    Negotiations resulted in a consent decree, a court-supervised improvement plan. The state agreed to find and fund community placements and services for individuals covered by the consent decree, thousands of adults with intellectual and developmental disabilities across Illinois who have put their names on waiting lists to receive them.

    Now, the state has asked a judge to consider ending the consent decree, citing significant increases in the number of people receiving community-based services. In a court filing in December, Illinois argued that while its system is “not and never will be perfect,” it is “much more than legally adequate.”

    But advocates say the consent decree should not be considered fulfilled as long as people with disabilities continue to live without the services and choices that the state promised.

    Across the country, states have significantly downsized or closed their large-scale institutions for people with developmental and intellectual disabilities in favor of smaller, more integrated and more homelike settings.

    But in Illinois, a national outlier, such efforts have foundered. Efforts to close state-operated developmental centers have been met with strong opposition from labor unions, the communities where the centers are located, local politicians and some parents.

    U.S. District Judge Sharon Johnson Coleman in Chicago is scheduled in late summer to decide whether the state has made enough progress in building up community supports to end the court’s oversight.

    For some individuals like Rogers, who are in crisis or have higher medical or behavioral challenges, the state itself acknowledges that it has struggled to serve them in community settings. Rogers said she’d like to send this message on behalf of those in state-operated developmental centers: “Please, please get us out once and for all.”

    “Living Inside a Box”

    Without a robust system of community-based resources and living arrangements to intervene during a crisis, state-operated developmental centers become a last resort for people with disabilities. But under the consent decree agreement, the state, Equip for Equality argues, is expected to offer sufficient alternative crisis supports to keep people who want them out of these institutions.

    In a written response to questions, Rachel Otwell, a spokesperson for the Illinois Department of Human Services, said the state has sought to expand the menu of services it offers people experiencing a crisis, in an effort to keep them from going into institutions. But Andrea Rizor, a lawyer with Equip for Equality, said, “They just don’t have enough to meet the demand.”

    For example, the state offers stabilization homes where people can live for 90 days while they receive more intensive support from staff serving the homes, including medication reviews and behavioral interventions. But there are only 32 placements available — only four of them for women — and the beds are always full, Rizor said.

    Too many people, she said, enter a state-run institution for short-term treatment and end up stuck there for years for various reasons, including shortcomings with the state’s discharge planning and concerns from providers who may assume those residents to be disruptive or difficult to serve without adequate resources.

    That’s what happened to Rogers. Interruptions to her routine and isolation during the pandemic sent her anxiety and aggressive behaviors into overdrive. The staff at her community group home in Machesney Park, unsure of what to do when she acted out, had called the police on several occasions.

    Doctors also tried to intervene, but the cocktail of medications she was prescribed turned her into a “zombie,” Rogers said. Stacey Rogers, her mom and legal guardian, said she didn’t know where else to turn for help. Kiley, she said, “was pretty much the last resort for us,” but she never intended for her daughter to be there for this long. She’s helped her daughter apply to dozens of group homes over the past year. A few put her on waitlists; most have turned her down.

    “Right now, all she’s doing is living inside a box,” Stacey Rogers said.

    Although Rogers gave the news organizations permission to ask about her situation, IDHS declined to comment, citing privacy restrictions. In general, the IDHS spokesperson said that timelines for leaving institutions are “specific to each individual” and their unique preferences, such as where they want to live and speciality services they may require in a group home.

    Equip for Equality points to people like Rogers to argue that the consent decree has not been sufficiently fulfilled. She’s one of several hundred in that predicament, the organization said.

    “If the state doesn’t have capacity to serve folks in the community, then the time is not right to terminate this consent decree, which requires community capacity,” Rizor said.

    Equip for Equality has said that ongoing safety issues in these facilities make it even more important that people covered by the consent decree not be placed in state-run institutions. In an October court brief, citing the news organizations’ reporting, Equip for Equality said that individuals with disabilities who were transferred from community to institutional care in crisis have “died, been raped, and been physically and mentally abused.”

    Over the summer, an independent court monitor assigned to provide expert opinions in the consent decree, in a memo to the court, asked a judge to bar the state from admitting those individuals into its institutions.

    In its December court filing, the state acknowledged that there are some safety concerns inside its state-run centers, “which the state is diligently working on,” as well as conditions inside privately operated facilities and group homes “that need to be addressed.” But it also argued that conditions inside its facilities are outside the scope of the consent decree. The lawsuit and consent decree specifically aimed to help people who wanted to move out of large private institutions, but plaintiffs’ attorneys argue that the consent decree prohibits the state from using state-run institutions as backup crisis centers.

    In arguing to end the consent decree, the state pointed to significant increases in the number of people served since it went into effect. There were about 13,500 people receiving home- and community-based services in 2011 compared with more than 23,000 in 2023, it told the court.

    The state also said it has significantly increased funding that is earmarked to pay front-line direct support professionals who assist individuals with daily living needs in the community, such as eating and grooming.

    In a statement to reporters, the human services department called these and other improvements to the system “extraordinary.”

    Lawyers for the state argued that those improvements are enough to end court oversight.

    “The systemic barriers that were in place in 2011 no longer exist,” the state’s court filing said.

    Among those who were able to find homes in the community is Stanley Ligas, the lead plaintiff in the lawsuit that led to the consent decree. When it was filed in 2005, he was living in a roughly 100-bed private facility but wanted to move into a community home closer to his sister. The state refused to fund his move.

    Today, the 56-year-old lives in Oswego with three roommates in a house they rent. All of them receive services to help their daily living needs through a nonprofit, and Ligas has held jobs in the community: He previously worked in a bowling alley and is now paid to make public appearances to advocate for others with disabilities. He lives near his sister, says he goes on family beach vacations and enjoys watching professional wrestling with friends. During an interview with reporters, Ligas hugged his caregiver and said he’s “very happy” and hopes others can receive the same opportunities he’s been given.

    While much of that progress has come only in recent years, under Gov. JB Pritzker’s administration, it has proven to be vulnerable to political and economic changes. After a prolonged budget stalemate, the court in 2017 found Illinois out of compliance with the Ligas consent decree.

    At the time, late and insufficient payments from the state had resulted in a staffing crisis inside community group homes, leading to escalating claims of abuse and neglect and failures to provide routine services that residents relied on, such as help getting to work, social engagements and medical appointments in the community. Advocates worry about what could happen under a different administration, or this one, if Illinois’ finances continue to decline as projected.

    “I acknowledge the commitments that this administration has made. However, because we had so far to come, we still have far to go,” said Kathy Carmody, chief executive of The Institute on Public Policy for People with Disabilities, which represents providers.

    While the wait for services is significantly shorter than it was when the consent decree went into effect in 2011, there are still more than 5,000 adults who have told the state they want community services but have yet to receive them, most of them in a family home. Most people spend about five years waiting to get the services they request. And Illinois continues to rank near the bottom in terms of the investment it makes in community-based services, according to a University of Kansas analysis of states’ spending on services for people with intellectual and developmental disabilities.

    Advocates who believe the consent decree has not been fulfilled contend that Illinois’ continued reliance on congregate settings has tied up funds that could go into building up more community living options. Each year, Illinois spends about $347,000 per person to care for those in state-run institutions compared with roughly $91,000 per person spent to support those living in the community.

    For Rogers, the days inside Kiley are long, tedious and sometimes chaotic. It can be stressful, but Rogers told reporters that she uses soothing self-talk to calm herself when she feels sad or anxious.

    “I tell myself: ‘You are doing good. You are doing great. You have people outside of here that care about you and cherish you.’”

    This article is republished from ProPublica under a Creative Commons license. Read the original article.

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  • Macadamias vs Hazelnuts – Which is Healthier?

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    Our Verdict

    When comparing macadamias to hazelnuts, we picked the hazelnuts.

    Why?

    In terms of macros first, hazelnuts have 2x the protein, and slightly more carbs and fiber. We call this a win for hazelnuts.

    When it comes to vitamins, macadamias have more of vitamins B1, B2, and B3, while hazelnuts have more of vitamins A, B5, B6, B7, B9, C, and E. Notably, 28x more vitamin E, so that’s not inconsiderable. Also 10x the vitamin B9, and 5x the vitamin C, and the rest, more modest wins. In any case, clearly a strong win for hazelnuts here.

    In the category of minerals, macadamias have more selenium, while hazelnuts have more calcium, copper, iron, magnesium, manganese, phosphorus, potassium, and zinc. Another clear win for hazelnuts.

    In short, hazelnuts win in all categories. However, by all means enjoy either or both (unless you have a nut allergy, in which case, obviously don’t).

    Want to learn more?

    You might like to read:

    Why You Should Diversify Your Nuts

    Take care!

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  • Lime vs Tangerine – Which is Healthier?

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    Our Verdict

    When comparing limes to tangerines, we picked the tangerines.

    Why?

    It was close!

    In terms of macros, limes start off strong with nearly 2x the fiber, while the other macros are approximately equal. So this round is nominally a win for limes, although it’s worth noting that you only get that fiber benefit with the whole fruit—a shot of lime juice in your drink won’t give you this! Given that very few people eat limes and tend to just use the juice, this is a relevant thing to consider.

    In the category of vitamins, limes have more of vitamins A, B5, and K, while tangerines have more of vitamins B1, B2, B3, B6, B7, B9, and C. Yes, tangerines have more of the vitamin C for which limes are famous. In any case, a clear win for tangerines in this round!

    Looking at minerals, limes have more copper, iron, selenium, and zinc, while tangerines have more magnesium, manganese, phosphorus, and potassium, for a 4:4 tie here.

    Adding up the sections one win for each and a draw, but we say the tangerines win overall on tiebreakers, since their win (on minerals) was abundant and clear, whereas limes’ win (on macros) was based on a technicality and not very practical given how limes are usually consumed.

    Want to learn more?

    You might like:

    What’s Your Plant Diversity Score?

    Enjoy!

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  • Why do I keep getting urinary tract infections? And why are chronic UTIs so hard to treat?

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    Dealing with chronic urinary tract infections (UTIs) means facing more than the occasional discomfort. It’s like being on a never ending battlefield against an unseen adversary, making simple daily activities a trial.

    UTIs happen when bacteria sneak into the urinary system, causing pain and frequent trips to the bathroom.

    Chronic UTIs take this to the next level, coming back repeatedly or never fully going away despite treatment. Chronic UTIs are typically diagnosed when a person experiences two or more infections within six months or three or more within a year.

    They can happen to anyone, but some are more prone due to their body’s makeup or habits. Women are more likely to get UTIs than men, due to their shorter urethra and hormonal changes during menopause that can decrease the protective lining of the urinary tract. Sexually active people are also at greater risk, as bacteria can be transferred around the area.

    Up to 60% of women will have at least one UTI in their lifetime. While effective treatments exist, about 25% of women face recurrent infections within six months. Around 20–30% of UTIs don’t respond to standard antibiotic. The challenge of chronic UTIs lies in bacteria’s ability to shield themselves against treatments.

    Why are chronic UTIs so hard to treat?

    Once thought of as straightforward infections cured by antibiotics, we now know chronic UTIs are complex. The cunning nature of the bacteria responsible for the condition allows them to hide in bladder walls, out of antibiotics’ reach.

    The bacteria form biofilms, a kind of protective barrier that makes them nearly impervious to standard antibiotic treatments.

    This ability to evade treatment has led to a troubling increase in antibiotic resistance, a global health concern that renders some of the conventional treatments ineffective.

    Underpants hanging on a clothesline
    Some antibiotics no longer work against UTIs.
    Michael Ebardt/Shutterstock

    Antibiotics need to be advanced to keep up with evolving bacteria, in a similar way to the flu vaccine, which is updated annually to combat the latest strains of the flu virus. If we used the same flu vaccine year after year, its effectiveness would wane, just as overused antibiotics lose their power against bacteria that have adapted.

    But fighting bacteria that resist antibiotics is much tougher than updating the flu vaccine. Bacteria change in ways that are harder to predict, making it more challenging to create new, effective antibiotics. It’s like a never-ending game where the bacteria are always one step ahead.

    Treating chronic UTIs still relies heavily on antibiotics, but doctors are getting crafty, changing up medications or prescribing low doses over a longer time to outwit the bacteria.

    Doctors are also placing a greater emphasis on thorough diagnostics to accurately identify chronic UTIs from the outset. By asking detailed questions about the duration and frequency of symptoms, health-care providers can better distinguish between isolated UTI episodes and chronic conditions.

    The approach to initial treatment can significantly influence the likelihood of a UTI becoming chronic. Early, targeted therapy, based on the specific bacteria causing the infection and its antibiotic sensitivity, may reduce the risk of recurrence.

    For post-menopausal women, estrogen therapy has shown promise in reducing the risk of recurrent UTIs. After menopause, the decrease in estrogen levels can lead to changes in the urinary tract that makes it more susceptible to infections. This treatment restores the balance of the vaginal and urinary tract environments, making it less likely for UTIs to occur.

    Lifestyle changes, such as drinking more water and practising good hygiene like washing hands with soap after going to the toilet and the recommended front-to-back wiping for women, also play a big role.

    Some swear by cranberry juice or supplements, though researchers are still figuring out how effective these remedies truly are.

    What treatments might we see in the future?

    Scientists are currently working on new treatments for chronic UTIs. One promising avenue is the development of vaccines aimed at preventing UTIs altogether, much like flu shots prepare our immune system to fend off the flu.

    Gynaecologist talks to patient
    Emerging treatments could help clear chronic UTIs.
    guys_who_shoot/Shutterstock

    Another new method being looked at is called phage therapy. It uses special viruses called bacteriophages that go after and kill only the bad bacteria causing UTIs, while leaving the good bacteria in our body alone. This way, it doesn’t make the bacteria resistant to treatment, which is a big plus.

    Researchers are also exploring the potential of probiotics. Probiotics introduce beneficial bacteria into the urinary tract to out-compete harmful pathogens. These good bacteria work by occupying space and resources in the urinary tract, making it harder for harmful pathogens to establish themselves.

    Probiotics can also produce substances that inhibit the growth of harmful bacteria and enhance the body’s immune response.

    Chronic UTIs represent a stubborn challenge, but with a mix of current treatments and promising research, we’re getting closer to a day when chronic UTIs are a thing of the past.The Conversation

    Iris Lim, Assistant Professor, Bond University

    This article is republished from The Conversation under a Creative Commons license. Read the original article.

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