A diet high in fiber (particularly fruit and vegetable fiber) and low in fat and red meat may help to decrease the risk of symptomatic diverticular disease (strength of recommendation [SOR]: C, case-control studies and a large prospective cohort study). For people with diverticular disease, a diet high in fiber might decrease the risk of complications (SOR: C, case series). No studies have evaluated the effect of nut and seed avoidance

Eglash, Anne

Lane, Chris Hooper

University of Missouri: MOspace

VOL 55, NO 9 / SEPTEMBER  2006 813w w w. j f p o n l i n e . c o mFrom the Family PhysiciansInquiries NetworkCLINICAL INQUIRIESWhat is the most beneficial diet for patients with diverticulosis?Anne Eglash, MD,Chris Hooper Lane, MLSUniversity of Wisconsin,MadisonE V I D E N C E - B A S E D A N SW E RC L I N I C A L C O M M E N TA R YRecommend natural sources of fiberfor diverticulosis“Conventional wisdom” dictates that physicians recommend a high-fiber diet toprevent symptoms in patients who are foundto have diverticuli on endoscopic or radiographic studies, or who are diagnosedclinically with diverticulitis. Although there isa relative paucity of data, the clinical evidence, as set forth in this review, supportsthis practice. Insoluble fiber, and cellulose inparticular, appears to be especially helpful.1I tend to recommend natural dietary fiberin the form of vegetables and whole grains (primarily insoluble fiber), as well as legumes(soluble fiber to help reduce cholesterol andblunt glucose absorption). No studies areavailable to endorse the advice to avoidseeds and nuts; a survey of colorectal surgeons showed that half believed eatingthese foods made no difference in the disease course.2It is noteworthy that acute diverticulitis istreated with clear liquids and a low-fiber dietduring the exacerbation. This therapy isbased on experience and conventional wisdom, and while there is no convincingevidence to support it, I still adhere to thisrecommendation.David M. Schneider, MDSutter Santa Rosa Family Medicine Residency ProgramA diet high in fiber (particularly fruit and vegetable fiber) and low in fat and red meatmay help to decrease the risk of symptomaticdiverticular disease (strength of recommenda-tion [SOR]: C, case-control studies and alarge prospective cohort study). For peoplewith diverticular disease, a diet high in fibermight decrease the risk of complications(SOR: C, case series). No studies have evalu-ated the effect of nut and seed avoidance.z Evidence summaryApproximately 60% of people living inWesternized countries who are older than60 years will develop diverticulosis of thecolon. Colonic diverticuli are thought todevelop from an increase in intraluminalpressure. This pressure can be caused bycolonic motility abnormalities, but a low-fiber diet can also result in a smaller stoolmass and a less distended colon, therebyincreasing intraluminal pressure.3Because of strong epidemiological evi-dence that people from cultures with high-fiber diets are far less likely to developdiverticulosis than are people who live incultures of low-fiber diets, it has beenassumed that a diet high in fiber can prevent diverticulosis.4 Many small,uncontrolled studies have also investigatedthe effect of high-fiber diets and supple-ments on symptoms of diverticulosis andprevention of diverticulitis episodes. One large, prospective study of 47,888male health professionals gathered base-line dietary information in 1986. In 1990and 1992, follow-up questionnaires askedthe subjects if they had been diagnosedwith diverticular disease in the interim,and whether they had symptoms of diver-ticulitis. The study showed a strong inverserelationship between fruit and vegetablefiber intake and risk of symptomatic diver-ticular disease. It also demonstrated adirect relationship between fat intake, par-ticularly red meat, and symptomatic diver-ticular disease. For men in the highestquintile of total fat intake and lowest quin-tile of total fiber intake, the relative risk(RR) of diverticular disease was 2.35(95% confidence interval [CI], 1.38–3.98)compared with men in the highest quintileof total fiber intake and lowest quintile oftotal fat intake. Men in the highest groupof red meat intake and lowest quintile offiber intake had a RR of 3.22 (95% CI,1.46–7.54) compared with men with thelowest red meat intake and highest dietaryfiber intake. In this study, cereal fiber didnot reduce the risk of symptomatic diver-ticular disease.1Two small randomized crossover stud-ies evaluated the benefit of dietary fibersupplementation on symptomatic divertic-ular disease, with conflicting results(TABLE).5,6 One study found that sterculiagum with an antispasmodic, a highroughage diet, and bran tablets allimproved symptomatic diverticular dis-ease, with bran tablets associated with thegreatest improvement.5 Another study814 VOL 55, NO 9 / SEPTEMBER  THE JOURNAL OF FAMILY PRACTICECLINICALINQUIRIESTA B L EStudies on dietary fiber for diverticulosisTRIAL DESCRIPTION INTERVENTION/COMPARISON RESULTS20 adults with symptomatic Bran tablets (18 g of fiber total) vs high 20% were symptom free with a HRD, 40% withdiverticular disease roughage diet (HRD, amount of fiber sterculia gum and antispasmodic, and 60% diagnosed by barium enema. unspecified) vs sterculia gum and with bran tabletsRandomized crossover trial5 antispasmodic58 adults with uncomplicated Bran crispbread (6.99 g/d fiber), No significant difference among treatments for symptomatic diverticular  ispaghula (psyllium) husk drink composite symptom scores. Stools were softdisease double-blind, (9.04 g/d fiber), and placebo er, more frequent, and straining with bowelcrossover RCT, treated for 16 (2.34 g/d fiber) movements was less with fiber supplements weeks with each intervention6 (P<.001)43 adults with symptomatic Lactulose 15 mL bid vs high-fiber diet Pain frequency with a bowel movement wasdiverticular disease. (30–40 g/d) for 12 weeks reduced with lactulose (P=.017). Pain severityRandomized trial7 was reduced with lactulose (P=.028) and highfiber diet (P=.043). Abdominal pain frequencywas decreased with lactulose (P=.0015) and with a high fiber diet (P=.022). Abdominal painseverity was decreased with lactulose (P=.009)and with a high fiber diet (P=.028)40 adults with symptomatic Wheat bran 24 g/d for at least The 40 patients had 391 total symptoms, anddiverticular disease diagnosed 6 months 60% were abolished, 28% relievedby barium enema. Case series8100 adults with a history of High-fiber diet (40 g/d) 91% of patients remained asymptomatic oversymptomatic diverticular 5 to 7 years, although only 75% adhered todisease. Case series9 their high-fiber dietBeneficial diet for diverticulosis sVOL 55, NO 9 / SEPTEMBER  2006 815found no significant differences betweenpsyllium, bran, and placebo in reducingsymptomatic diverticular disease.6 How-ever, the amount of total fiber supplemen-tation for each treatment regimen was lessthan in other studies.A small randomized trial of lactulosevs dietary fiber showed both treatments tobe effective in alleviating symptoms ofdiverticular disease.7 Two small case seriesof adults treated with dietary fiber foundthat fiber alleviated symptoms of divertic-ular disease,8,9 and possibly reduced com-plications of diverticulosis.9We found no studies that investigatedthe common medical advice to avoid smallnuts and seeds, which are thought to causeobstruction of the diverticuli and lead todiverticulitis.Recommendations by othersThe American College of Gastroenterol-ogy states that it is reasonable to recom-mend a diet high in fruit and vegetablefiber to patients with uncomplicated diverticulosis.10R E F E R E N C E S1. Aldoori WH, Giovannucci EL, Rimm EB, Wing AL,Trichopoulos DV,Willett WC.A prospective study of diet andthe risk of symptomatic diverticular disease in men. Am JClin Nutr 1994; 60:757–764.2. Schechter S, Mulvey J, Eisenstat TE. Management ofuncomplicated acute diverticulitis: results of a survey. DisColon Rectum 1999; 42:470–475.3. Floch M, Bina I. The natural history of diverticulitis: fact andtheory. J Clin Gastroenterol 2004; 38(Suppl 1):S2–S7.4. Aldoori W, Ryan-Harshman M. Preventing diverticular dis-ease: review of recent evidence on high-fibre diets. CanFam Physician 2002; 48:1632–1637.5. Taylor I, Duthie HL. Bran tablets and diverticular disease. BrMed J 1976; 1(6016):988–990.6. Ornstein MH, Littlewood ER, Baird IM, Fowler J, North WR,Cox AG.Are fibre supplements really necessary in divertic-ular disease of the colon? A controlled clinical trial. Br MedJ (Clin Res Ed) 1981; 282:1353–1356.7. Smits BJ, Whitehead AM, Prescott P. Lactulose in the treat-ment of symptomatic diverticular disease: A comparativestudy with high-fibre diet. Br J Clin Pract 1990; 4:314–318.8. Brodribb AJ, Humphreys DM. Diverticular disease: Threestudies. part II—treatment with bran. Br Med J 1976;1(6007):425–428.9. Hyland JM,Taylor I. Does a high fibre diet prevent the com-plications of diverticular disease? Br J Surg 1980;67:77–79.10. Stollman, N, Raskin, J. Diagnosis and management ofdiverticular disease of the colon in adults. Ad Hoc PracticeParameters Committee of the American College ofGastroenterology. Am J Gastroenterol 1999; 94:3111–3112.

What is the most beneficial diet for patients with diverticulosis?

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