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.