Reconsidering the Diverticulosis Diet

People with the digestive disorder diverticulosis may no longer have to worry about eating hard-to-digest foods like popcorn, corn and nuts. For many years, it was suspected that these foods increase the risk of complications, such as infection, but a new study found that they may actually have protective effects.

The study, published in The Journal of the American Medical Association (JAMA), is believed to be the first large study to investigate the effects of these foods on diverticulosis. This disorder occurs when small pouches develop in the lining of the colon, but it does not usually cause symptoms. If the pouches become swollen, a condition called diverticulitis, intense abdominal pain and sometimes nausea, vomiting, bleeding and cramping may occur.

Beginning in the 1950s, many doctors advised patients with diverticulosis to avoid eating popcorn, corn and nuts. Some even warned against eating fruits and vegetables with seeds, such as tomatoes. These restricted diets were recommended based on the theory that the indigestible parts of foods would get stuck in the pouches and cause complications, such as infection, inflammation and bleeding. Until now, studies on this correlation were lacking.

Researchers used data from an ongoing Harvard School of Public Health study. They analyzed 47,228 men who were 40-75 years old at enrollment and had no history of diverticular disease. For 18 years, the participants completed biennial questionnaires about the foods they ate and their health status.

By the end of the study, 801 men were diagnosed with diverticulitis and 383 had diverticular bleeding. Those who frequently ate popcorn, corn or nuts did not have an increased risk of developing diverticulitis or diverticular bleeding compared to men who rarely ate these foods. Also, none of these foods were associated with the development of uncomplicated diverticulosis.

In fact, eating nuts at least twice a week was associated with a 20 percent reduced risk of diverticulitis, while eating popcorn twice a week or more was linked to a 28 percent lower risk. The authors concluded that the current diet recommendations for patients with diverticular disease should be reconsidered.

Comments

[Polly T.]

It's interesting that nuts (particularly almonds and pistachios) and popcorn are both good sources of fiber and that low-fiber intake is one of the risk factors for diverticulosis. (Other risk factors include passing the 40-year-mark and being a couch potato.) It makes me wonder if this angle -- avoiding these foods -- actually made things worse for patients with diverticulosis instead of better? Food for thought.

[wendy]

I am especially interested in dietary modifications to prevent/cure disease states. Here is a good example of a caution based on theory vs. evidence-based findings. Of interest is that this was a cohort study - which indicates to me that people who gravitate towards corn/nuts/popcorn may naturally be seeking out protective foods that fit their personal constitutions. However, I am not convinced that this dietary caution should be abandoned in all diverticulitis patients, as it is possible that these foods may aggravate the condition in certain populations.

[Brit]

It's surprising that doctors would recommend something for so long, just based on theory. Why did it take so long for researchers to actually test this theory? If I had been told to avoid eating strawberries and peanuts (two of my favorite foods), only to find out that they were harmless, I think I'd be pretty upset.

[HC]

Ten percent of the population is affected by diverticulosis, which is a pretty significant amount of people. However, many of these people are asymptomatic and most likely do not follow the diet. The purpose of the diverticulosis diet is to decrease the symptoms, so why on earth did it take so many years to figure out the diet might not be effective? I need to see more information, perhaps in a non-cohort trial before I can believe this. Keep in mind the dietary questionnaires were only answered every four years.

[cassie]

I agree with Wendy. Based on this research study alone, people should not completely ignore the fact that corn and nuts might make the condition worse. The study focuses on how corn and nuts contributes to the development of diverticulosis, but not specifically how these foods can increase the severity of the symptoms.

[lindsay]

A low-fiber diet often can be pinpointed as a cause for diverticular disease. This is probably because not having enough fiber often results in constipation. The strain to pass stool when constipated causes increased pressure in the colon and may result in a bulge in the colon lining, called a diverticula. This study leaves me in limbo between theory and evidence. I can reason out why nuts, corn, and seeds would be cautioned in patients with diverticulosis because it seems to “make sense.” However, the study seems to be proving us all wrong. It “makes sense” too since nuts and corn are good sources of fiber, and diverticular disease often results from a low-fiber diet.

[Mel]

Is this study enough for doctors to change their recommendations? Do you think they'll still discourage foods like popcorn until other studies come out?

[Jane]

During the last 50 or so years, it seems that a lot of conventional “wisdom” as it applies to nutrition science has actually been questioned and studied. Think about the whole cholesterol debacle and the assumption that cholesterol in the foods you eat equates with cholesterol in your blood. However, history has shown us that there are more details to be discovered than we'd ever imagined possible. I would think it’s likely we’ll discover that certain people with diverticulosis should avoid the aforementioned foods, while others can safety eat them in moderation. Only time will tell.

[Ivan]

Diverticulosis is thought to be from increased colonic pressure. The mechanism usually involves constipation, leading to increased pressure within the colon. The pressure begins to weaken and compromise the muscles along the colonic walls, leading to the pouch-like diverticula. Normal treatment for constipation includes a diet rich in soluble and insoluble fibers. These fibers help draw water into the large intestine, softening the stool, and allowing easier passage through the colon. Vegetables and fruits contain a large amount of soluble and insoluble fibers, which can help reduce constipation, thus reducing the pressure within the colon. Popcorn and corn also have large amounts of fiber, so it correlates well that eating corn or popcorn can help prevent diverticulosis. Nuts also provide good dietary fiber, which can assist in constipation.

[Tanya]

Another study that was published in February of 2008 claimed that consuming peanuts increased HDL-C levels (good cholesterol) and decreased A1c levels (average blood sugar for least three months). This means that peanuts may have protective effects against cardiovascular disease and diabetes.

One thing that healthcare professionals should remember before recommending peanuts to patients is the possibility of an allergic reaction. Patients who have not ate peanuts for an extended period of time may have developed an allergy. Without proper counseling, results may be deadly.

[Jackie B]

I had my fist bout of diverticulitis in December but did not realize what it was until I was hospitalized in April. Since April, I had been watching what I was eating (no seeds, popcorn or corn), although I am not very active, as I have a desk job and work about 10 hours per day. I had no problems until just last week. I read an article that said popcorn, corn, nuts, etc. may not be bad for diverticular patients. It was the end of summer and so I thought 'what the heck' - I'll have an ear of corn. Three days later - severe symptoms of diverticulitis! I say - "if ain't broke, don't fix it!"

[Shawn]

Diverticulosis is rare in underdeveloped countries where diets contain more fiber. Many people who have diverticulosis do not even know they have it, as only 20-30 percent of patients with diverticulosis develop symptomatic disease. The incidence of diverticulosis increases with age. There are some differential diagnoses, including sigmoid malignancy, IBS, colorectal cancer and appendicitis, among others. It seems that many problems could be avoided all together if our diets contained more fiber and less fat.

[justin]

I don’t think doctors will change their recommendations on corn and nuts 180 degrees based on this study alone. Many doctors may consider the caution a “better safe than sorry” approach. Fiber can be obtained through numerous other fruits, vegetables and grains (like artichokes, pears and apples), so avoiding these few foods just-in-case may be an acceptable sacrifice. Of course, I feel bad for those lovers of corn and nuts, but perhaps this study may encourage that anything in moderation might be all right?

[Helen F.]

Common treatment for uncomplicated acute diverticulosis without fever, excessive vomiting or peritonitis, would be to target gram-negative rods and anaerobic bacteria with either a single or multiple antibiotics regimen. Metronidazole would cover the anaerobic bacteria, and ciprofloxacin could be used in conjunction to cover the gram-negative bacteria in this case. Oral administration for these antibiotics would be fine, as long as there is follow-up after the course of the antibiotics. An increase in fiber intake is also recommended and can decrease recurrence by up to 70 percent.

[SUMA]

Interesting article. Questions that come to mind:

*What did the Participants’ overall dietary intake include? For example what was their fiber intake - both soluble and insoluble? Did they have a diet rich in fats, and how often did they eat red meat? Was this taken into account in addition to the nuts, corn and popcorn?

*Also, were there any other factors that warranted consideration - family history, GI conditions such as reflux and/or digestive issues (i.e. constipation)?

*Were there any other co-morbidities that may have affected “gut” function and compromised immune status, thereby making the subject more susceptible to the condition?

*Was “age specific” data taken into account?

I do agree with the authors that current diet recommendations should be reconsidered. Diverticulosis has been considered a disease of the elderly, and as our aging population continues to increase, these findings could have important clinical implications in the prevention and treatment of the condition and ultimately healthcare costs. (Alias SUMA)

[Stacie]

Before I read what Jackie wrote, I would agree with Justin that eating these foods in moderation probably wouldn't cause much of a problem, but now I’m not too sure. Jackie mentions that she only had one ear of corn and suffered severe symptoms of diverticulosis! It is hard to pinpoint and determine how foods can exactly affect our bodies, so I guess it is best to be cautious, and see how your body reacts.

[johnny]

Helen F. is correct, except that antibiotics are usually used for the treatment of diverticulitis, not diverticulosis. If the case of diverticulitis is severe, the patient may be admitted to the hospital and IV antibiotics may be started. Antibiotics can be chosen based on their IV and oral routes of administration, so the patient can transition to oral treatment upon discharge from the hospital. Patients normally are discharged home when the have stabilized, are able to eat and have normal bowel movements. However, some cases of diverticulitis are severe enough to require surgery.

[Sean]

I agree with Jackie B - without sufficient information, why risk eating something that would cause such an adverse event? The overall benefits of an increased-fiber diet don't just stop at reducing the risk of diverticulitis. A high-fiber diet keeps bowel habits regular and can also reduce cholesterol. My concern lies mostly in the fiber supplements, particularly the ones made from plantago, like Metamucil®. They have the potential to cause a GI obstruction when not taken with adequate fluids.

[Paul O.]

Diverticulosis can become the condition diverticulitis when a diverticulum ruptures. The natural flora, bacteria within the colon, can spread into the tissues surrounding the colon causing diverticulitis. Constipation or diarrhea may also occur. A collection of pus can develop around the inflamed diverticulum, leading to formation of an abscess, usually in the pelvis. Rarely, the swollen diverticula may erode into the urinary bladder, causing an infection and gas to pass during urination. Inflammation in the colon can also lead to bowel obstruction. Sometimes, although not common, a diverticulum ruptures into the abdominal cavity, causing a life-threatening infection called peritonitis.

[Seth]

Fiber in your diet is great for many reasons. It can help with your digestive tract by keeping you regular. It can also help lower cholesterol. Soluble fibers are the ones that contribute to the lowering of cholesterol, while insoluble fibers are primarily the ones that help prevent constipation by drawing water into the colonic tract.

[liz]

Fiber is known to have many beneficial effects in our health and particularly in GI disorders. I had experienced severe cases of GI symptoms and was able to manage it with a diet rich in fiber. However, since certain sources of fiber could aggravate symptoms in some (for example in Tanya’s case), they should be taken cautiously once you develop the problem. The participants were men in the age group of 40-75 years old with no history of diverticular disease. I would like to know what other risk factors were considered in the study. Besides popcorn, nuts and corn what kind of diet regimen and lifestyle were followed to have a preventative effect in the participants?

[S. White]

The disease seems to be more common in the United States, Britain, Australia and Canada. For some reason or another, it is not as common in Asia or Africa. I wonder if it has to do with the diets that they have in those countries, since high-fiber diets seem to decrease the risk of diverticula formation.

[Sunny]

Why would eating an offending food once cause symptoms of diverticulitis? This is not like celiac disease, where if a person eats gluten, they experience severe abdominal symptoms. I guess I am confused as to why eating one ear of corn would cause such symptoms. In celiac disease, the individual in unable to tolerate the gluten protein, and when one tries to eat gluten, the immune system attacks the small intestine. When the gluten-free diet is followed, the small intestine is able to heal. This is documented evidence of success and is not like the diverticulosis diet, which has questionable outcomes.

[Crystal]

To address Sean’s concerns about fiber supplements, many patients with diverticular disease are advised to take psyllium fiber supplements to regulate bowel movements. I hope that physicians are reminding patients to drink adequate amounts of water.

Metamucil is a bulk-producing laxative and fiber supplement. The active ingredient is psyllium seed husks. It is often used to treat constipation, hemorrhoids, diverticular disease and irritable bowel syndrome. It may also reduce cholesterol when taken daily. Metamucil is sold in powdered drink mixes, capsules and wafers. Metamucil is available in several flavors, including Orange, Berry and Pink Lemonade. The adult dosing as a fiber supplement is: mix one serving with eight ounces of liquid three times daily for Powdered Drink Mixes, Wafers, and Capsules; or four times daily for Capsules Plus Calcium.

[Chris O.]

Sunny -

Since Jackie B. had been watching her diet carefully and did not ingest any seeds or corn, maybe her system became used to that diet. When Jackie B. had an ear of corn, her body may not have been familiar with processing the food and unluckily, a kernel entered a diverticula and caused inflammation. Though I am not certain of the chances of this happening, it may have been luck of the draw. I guess it is better to be safe than sorry in this situation.

[James]

I think that there needs to be a few more large studies on diet and diverticulosis before recommendations about diets can change for this disease state. Basing guidelines on just one study can be a major problem since any potential flaws in the study, such as confounding variables etc., can skew the results one way or another. Until repeated studies show the same results, we cannot draw this conclusion.

[Tamara]

Insoluble fiber has been shown to be effective in reducing the risk of colon cancer, preventing diverticular disease and treating constipation. The recommended a dietary fiber intake is 20 - 35 grams/day for the healthy adult. Dietary fiber, if increased suddenly, can cause gas, diarrhea and bloating. It should be added gradually instead. It is also very important to drink plenty of fluids since fiber draws water into the intestines. Incorporate regular exercise on a daily basis is very important.

[stephanie]

This is an interesting study, but it doesn’t seem to be a reason to change the current standard of recommending that patients with diverticulosis avoid nuts and corn. This study looked at patients with no history of diverticular disease, to see weather nuts or corn had any effects in causing diverticular disease over 18 years. This seems to be different than looking at whether or not patients with diverticulosis would develop diverticulitis if they eat nuts and corn. Although interesting, I don’t think the conclusion of avoiding nuts and corn could really be applied to patients with diverticulosis, as they studied patients with no history of diverticular disease.

[Becca]

As a dietitian, I am surprised that studies are showing that eating seeds, nuts and corn do not increase the risk of developing diverticulitis, but I am also always open to what is new and optimal for my patient’s health and quality of life!

[Thad]

Kudos to Stephanie for double-checking the methods of the study! I hadn’t noticed that the researchers focused on patients who were healthy at the beginning. Considering the age of the patients at baseline, there is no telling what other dietary differences they had leading up to the beginning. It would be nice to know some of the other patient demographics that could help explain why they experienced diverticulitis.

[mike]

I agree with Stephanie. The study focused on people without diverticular disease. I think that it would be more realistic if there was a study on patients WITH diverticular disease whose diets consisted of seeds, corn and nuts. This would actually have more correlation and substance, though I feel like a study like that would not be ethically sound because what if corn and nuts really can trigger a bout of diverticulitis? In my opinion, better safe than sorry applies in this circumstance.

[J]

It is interesting that such recommendations about treating diseases are just based on theory, and that there are no studies showing that avoiding corn and vegetables containing indigestible seeds will help prevent the worsening of diverticulosis. Although this seems to be an interesting study to see if this theory is true, as Stephanie wrote, these patients in the study do not even have the disease to begin with. High-fiber diets may help prevent diverticulitis in a patient with no diverticular disease, but what about those with the disease already?

[Anna H.]

I agree that people facing this disorder should consider the new diet. It's supported by the fact that eating nuts at least twice a week was associated with a 20 percent reduced risk of diverticulitis, while eating popcorn twice a week or more was linked to a 28 percent lower risk.

[diana]

In response to Anna H’s comment: Although the study may show that eating these foods reduced risk of diverticulitis, there are so many other factors coming into play before we can go ahead and recommend corn, nuts and seeds to patients with diverticular disease. I believe Stephanie brought up a great point about the patients being healthy at the start of the study. Many habits and genetics come into play. We shouldn’t hastily jump to conclusions and completely change our former thoughts. However, I do feel it is important to keep an open mind, and perhaps trying small amounts of the foods at a time to reintroduce them to the body.

[michelle]

I agree with Stephanie as well. If the studied patients did not have diverticulitis, this information cannot be applied to those patients with the disease. It would be difficult to repeat a similar study in patients with diverticulitis, as it would be unethical to induce inflammation and pain in these patients. Perhaps it is better to use the "better-safe-than-sorry" approach and avoid nuts and corn in these patients, rather than changing our recommendations based on this study.

[betty jean]

After being told that I had the beginning stages of diverticulitis, I avoided popcorn, nuts and seeds in my diet. So far, I have not suffered any further symptoms. As much as I miss some foods (particularly popcorn), I am reluctant to throw caution to the wind and start indulging. The prevailing wisdom has seemed so logical. I don’t know what to make of this new evidence.

[Bert]

I have a family friend who would take great exception to this new information. Any time he ingests foods on the "forbidden" list, he is likely to end up at the emergency room in terrible pain. Perhaps there is another aspect to this condition that is not being factored in and therefore, the contradictory information. Bottom line, if it hurts, don’t do it!

[lt]

Interesting study, but we have to keep in mind that this study was a prospective study, which only suggests an association and does not prove causality. I do agree with the authors that the recommended diet for patients with diverticulosis should be reviewed and reconsidered. However, adjusting the diet content for these patients solely based on the study’s findings would not be wise. More studies are needed in order to have a better understanding of why nuts, corn and popcorn consumption, especially eating nuts twice a week, has a 20 percent reduced risk of diverticulitis.

[ch]

As mentioned above, since the 1950s, patients with diverticulosis were advised against a diet that consisted of popcorn, corn and nuts, as they may increase the risk for diverticulitis and/or bleeding. Strate et al in this JAMA 2008 article concluded that there was no increased risk for these complications with popcorn and nuts. This goes to show that recommendations are easily outdated and that any recommendation is strengthened/weakened by evidence. What is worth noting from this article is that the p-values listed are p-values for trend.

[PK]

The first thing I noticed when reading this article were the demographics of the study participants. Although the dietary recommendation for diverticulosis patients is based on theory rather than evidence, I do not feel that this study is sufficient to recommend that patients with a history of diverticulosis begin eating such indigestible foods as popcorn and seeds. I would suggest, however, that it may pose sufficient evidence that eating a diet that includes insoluble fiber could certainly decrease the risk of healthy individuals developing diverticulosis.

[Donna]

I was diagnosed with diverticulitis back in August of this year when I was admitted to the hospital for 2 1/2 days. I had pain so severe that I couldn't even stand up. I had no clue of any problems before that. I have faithfully stayed away from the foods that I love -- popcorn, peanuts, corn -- and I haven't had any problems since. (Except for when I tried to take the Metamucil three times a day with plenty of water to make sure that I was getting enough fiber. That just binds me up and made my stomach hurt.) I am terrified to do anything out of the norm of what I have been instructed.

[Steve]

My question is: why did it take so many years to figure out the diet is not effective? I would be pretty upset if I loved nuts and popcorn and knew I could not have any. However, I don't believe many doctors will change their practice based on this one study. Then again, anything in moderation should be acceptable right?

[Weight Loss Pills]

With newer methods, namely impedance reflux monitoring, we can diagnosis reflux as acid or nonacid. In populations failing to respond to acid suppression medical therapy, 40 percent or more patients have nonacid reflux. The nonacid reflux may account for persistent symptoms while on medical treatment. But I have doubts. Should people with diverticulitis stop eating nuts if they are prone to heart disease?

[Cyber Rainbow]

Sounds like good news. There is no minimum daily requirement for refined sugar.