Warning: only mildly funny, quite educational, and gross.
Ok, the following will be graphic. Leave now if you don’t want to change the way you view your poo.
Right, all you coprophiles, here goes.
We like to think of ourselves as a single entity. In fact, we are a hotel, and not a very upscale hotel at that. The number of bacteria in our gut outnumber the number of cells in our bodies by about ten to one. These bacteria provide, on average, about a third of our daily protein. They manufacture a number of our essential vitamins. And they change the color and consistency of our poo.
If you don’t go poo very often, this is a problem. It means the type, nature, and aggression of your bacteria changes. Sometimes they get downright mean and nasty. If they do, the body flushes them out (diarrhea) and sometimes empties both ends (vomiting). Barring things like cholera and parasites, the body does a pretty good job of cleaning things out. But sometimes bacteria manage to swell up the inside of the colon and cause outpouching or diverticula. They can be helped by years of not going poo enough (how much is enough? Let’s try for once a day, not once a week).
When the diverticular outpouchings occur, we have preliminary studies than show switching around bacteria makes a difference in how much pain and outpouching occurs.
Given the effect of bacteria on poo, what about the diet? What diet would be best for, say, people recovering from having diverticulitis surgery? Would, say, nuts and seeds be a problem for someone recovering from this surgery? Do you know?
Of course you do. Nuts and seeds would be a big no-no. They tear up the bowel like big boulders, absolutely not. And better keep it low on the roughage as well.
So, what do the surgeons think? They all gave antibiotics, but all different ones. Most of them recommended a low fiber diet, some said the regular diet is fine, and ten percent recommended a high fiber diet. In terms of nuts and seeds, half of them said they weren’t a problem.
Horrendous, right? How could half the surgeons not know nuts and seed are a problem?
Because they’re not.
In a free article by JAMA, 47 thousand men were followed from 1986 to 2004. Those eating the most nuts and seeds had less risk of getting diverticulitis. That’s right, more nuts and seeds, less problems.
In an article on how to prevent the return of diverticulitis, the author states that fiber is the only proven effective solution. A recent UNC study found the opposite, that too many bowel movements and too much fiber also caused problems. The UNC study surveyed 2,000 people, so we would still use the 47 thousand person study above to say that nuts and seeds aren’t a problem.
As late as April of 2011, a review was still trying to bury the dinosaur of a low-fiber diet: “Historically, low-residue diets have been recommended for diverticulosis because of a concern that indigestible nuts, seeds, corn, and popcorn could enter, block, or irritate a diverticulum and result in diverticulitis and possibly increase the risk of perforation. To date, there is no evidence supporting such a practice. In contrast, dietary fiber supplementation has been advocated to prevent diverticula formation and recurrence of symptomatic diverticulosis, although this is based mostly on low-quality observational studies.” (Nutr Clin Pract. 2011 Apr;26(2):137-42.)
So, despite the “common wisdom,” we should all enjoy our nuts and seeds. The real question is why half the surgeons treating diverticulitis still believe the myth?
Oh, but don’t believe me. Here are the studies.
Nutr Clin Pract. 2011 Apr;26(2):137-42.
Tarleton S, DiBaise JK.
Residue refers to any indigestible food substance that remains in the intestinal tract and contributes to stool bulk. Historically, low-residue diets have been recommended for diverticulosis because of a concern that indigestible nuts, seeds, corn, and popcorn could enter, block, or irritate a diverticulum and result in diverticulitis and possibly increase the risk of perforation. To date, there is no evidence supporting such a practice. In contrast, dietary fiber supplementation has been advocated to prevent diverticula formation and recurrence of symptomatic diverticulosis, although this is based mostly on low-quality observational studies. This report focuses on the evidence that fiber intake may be beneficial in the prevention and recurrence of symptomatic and complicated diverticular disease and provides recommendations regarding fiber supplementation in individuals with diverticulosis.
JAMA. 2008 Aug 27;300(8):907-14.
http://jama.ama-assn.org/content/300/8/907.long Free Full Article
Nut, corn, and popcorn consumption and the incidence of diverticular disease.
Strate LL, Liu YL, Syngal S, Aldoori WH, Giovannucci EL.
Patients with diverticular disease are frequently advised to avoid eating nuts, corn, popcorn, and seeds to reduce the risk of complications. However, there is little evidence to support this recommendation.
To determine whether nut, corn, or popcorn consumption is associated with diverticulitis and diverticular bleeding.
DESIGN AND SETTING:
The Health Professionals Follow-up Study is a cohort of US men followed up prospectively from 1986 to 2004 via self-administered questionnaires about medical (biennial) and dietary (every 4 years) information. Men reporting newly diagnosed diverticulosis or diverticulitis were mailed supplemental questionnaires.
The study included 47,228 men aged 40 to 75 years who at baseline were free of diverticulosis or its complications, cancer, and inflammatory bowel disease and returned a food-frequency questionnaire.
MAIN OUTCOME MEASURES:
Incident diverticulitis and diverticular bleeding.
During 18 years of follow-up, there were 801 incident cases of diverticulitis and 383 incident cases of diverticular bleeding. We found inverse associations between nut and popcorn consumption and the risk of diverticulitis. The multivariate hazard ratios for men with the highest intake of each food (at least twice per week) compared with men with the lowest intake (less than once per month) were 0.80 (95% confidence interval, 0.63-1.01; P for trend = .04) for nuts and 0.72 (95% confidence interval, 0.56-0.92; P for trend = .007) for popcorn. No associations were seen between corn consumption and diverticulitis or between nut, corn, or popcorn consumption and diverticular bleeding or uncomplicated diverticulosis.
In this large, prospective study of men without known diverticular disease, nut, corn, and popcorn consumption did not increase the risk of diverticulosis or diverticular complications. The recommendation to avoid these foods to prevent diverticular complications should be reconsidered.
J Fam Pract. 2009 Feb;58(2):82-4.
Dig Dis. 2007;25(2):151-9.
Diverticular disease in the elderly.
Comparato G, Pilotto A, Franzè A, Franceschi M, Di Mario F.
University of Parma, Parma, Italy.
There are few diseases whose incidence varies as greatly worldwide as that of diverticulosis. Its prevalence is largely age-dependent: the disease is uncommon in those under the age of 40, the prevalence of which is estimated at approximately 5%; this increases to 65% in those > or =65 years of age. Of patients with diverticula, 80-85% remain asymptomatic, while, for unknown reasons, only three-fourths of the remaining 15-20% of patients develop symptomatic diverticular disease. Traditional concepts regarding the causes of colonic diverticula include alterations in colonic wall resistance, disordered colonic motility and dietary fiber deficiency. Currently, inflammation has been proposed to play a role in diverticular disease. Goals of therapy in diverticular disease should include improvement of symptoms and prevention of recurrent attacks in symptomatic, uncomplicated diverticular disease, and prevention of the complications of disease such as diverticulitis. Diverticulitis is the most usual clinical complication of diverticular disease, affecting 10-25% of patients with diverticula. Most patients admitted with acute diverticulitis respond to conservative treatment, but 15-30% require surgery. Predictive factors for severe diverticulitis are sex, obesity, immunodeficiency and old age. Surgery for acute complications of diverticular disease of the sigmoid colon carries significant rates of morbidity and mortality, the latter of which occurs predominantly in cases of severe comorbidity. Postoperative mortality and morbidity are to a large extent driven by patient-related factors.
Copyright 2007 S. Karger AG, Basel.
Drugs Aging. 2004;21(4):211-28.
Epidemiology and management of diverticular disease of the colon.
Kang JY, Melville D, Maxwell JD.
Department of Gastroenterology, St George’s Hospital and Medical School, London, England.
Colonic diverticula are protrusions of the mucosa through the outer muscular layers, which are usually abnormally thickened, to form narrow necked pouches. Diverticular disease of the colon covers a wide clinical spectrum: from an incidental finding to symptomatic uncomplicated disease to diverticulitis. A quarter of patients with diverticulitis will develop potentially life-threatening complications including perforation, fistulae, obstruction or stricture. In Western countries diverticular disease predominantly affects the left colon, its prevalence increases with age and its causation has been linked to a low dietary fibre intake. Right-sided diverticular disease is more commonly seen in Asian populations and affects younger patients. Its pathogenesis and relationship to left-sided diverticular disease remains unclear. Diverticular disease of the colon is a significant cause of morbidity and mortality in the Western world and its frequency has increased throughout the whole of the 20th century. Since it is a disease of the elderly, and with an aging population, it can be expected to occupy an increasing portion of the surgical and gastroenterological workload. It is uncertain what symptoms uncomplicated diverticular disease gives rise to: there is an overlap with irritable bowel syndrome. Diagnosis is primarily by barium enema and colonoscopy, but more sophisticated imaging procedures such as computed tomography (CT) are increasingly being used to assess and treat complications such as abscess or fistula, or to provide alternative diagnoses if diverticulosis is not confirmed. Initial therapy for uncomplicated diverticulitis is supportive, including monitoring, bowel rest and antibacterials. CT is used to guide percutaneous drainage of abscesses to avoid surgery or allow it to be performed as an elective procedure. Surgery is indicated for complications of acute diverticulitis, including failure of medical treatment, gross perforation, and abscess formation that cannot be resolved by percutaneous drainage. Complications of chronic diverticulitis (fistula formation, stricture and obstruction) are also usually treated surgically. However, the indications for, and the timing and staging of operations for diverticular disease are often difficult decisions requiring sound clinical judgement. Factors such as the number of episodes of inflammation, the age of the patient, and his/her overall medical condition play a role in determining whether or not a patient should undergo surgical resection. Laparoscopic surgery may be associated with less pain, less morbidity and shorter hospital stays, but its exact role is yet to be defined. Diverticular disease of the colon is the most common cause of acute lower gastrointestinal haemorrhage, which can be massive. Although the majority of patients stop bleeding spontaneously, angiographic and surgical treatment may be required, while the place of endoscopic haemostasis remains to be established.
J Fam Pract. 2009 Jul;58(7):381-2.
Clinical inquiries: How can you help prevent a recurrence of diverticulitis?
Weisberger L, Jamieson B.
University of Illinois/Advocate Illinois Masonic Hospital, Chicago, IL, USA.
EVIDENCE-BASED ANSWER: A high-fiber diet may help; available evidence does not support other interventions. A high-fiber diet is often prescribed after recovery from acute diverticulitis, based on extrapolation from epidemiologic data showing an association between low-fiber diets and diverticulosis. No direct evidence establishes a role for fiber in preventing recurrent diverticulitis, however. No evidence supports the common advice to avoid nuts and seeds to prevent diverticulitis. Eating nuts, corn, and popcorn does not increase the risk; in fact, nuts and popcorn may have a protective effect. There is not enough evidence to recommend the anti-inflammatory drug mesalamine or a polybacterial lysate for immunostimulation. Retrospective data do not support routine prophylactic colectomy after 1 or 2 episodes of acute diverticulitis.
Dis Colon Rectum. 1999 Apr;42(4):470-5; discussion 475-6.
Management of uncomplicated acute diverticulitis: results of a survey.
Schechter S, Mulvey J, Eisenstat TE.
Department of Surgery, The Miriam Hospital/Brown University, Providence, Rhode Island, USA.
A survey was conducted to document current medical treatment of patients with uncomplicated acute diverticulitis.
A survey was mailed to 667 fellows of The American Society of Colon and Rectal Surgeons certified by the American Board of Colon and Rectal Surgery. Queries were based on a clinical scenario of a patient with uncomplicated diverticulitis.
Three hundred seventy-three surveys (56 percent) were returned completed. The majority (66 percent) chose an abdominal computed tomographic scan as the initial diagnostic test. One-half used a single intravenous antibiotic with second-generation cephalosporins (27 percent) and ampicillin/sulbactam (16 percent) being the most common. Oral antibiotics given at discharge were ciprofloxacin (18 percent), amoxicillin/clavulanate (14 percent), metronidazole (7 percent), and doxycycline (6 percent). Combinations chosen were ciprofloxacin/metronidazole (28 percent) and metronidazole/trimethoprim sulfamethoxazole (6 percent), whereas 21 percent chose a variety of other antibiotics. The majority (74 percent) prescribed oral antibiotics for 7 to 10 days. Dietary recommendations at discharge were low residue (68 percent), regular (21 percent), and high residue (10 percent). Half of those surveyed believed avoidance of seeds and nuts were of no value. Follow-up examinations chosen included sigmoidoscopy and barium enema (29 percent), colonoscopy (25 percent), sigmoidoscopy (17 percent), barium enema (13 percent), and other (16 percent). Sixty-five percent of colon and rectal surgeons claim to handle more than half of their patients with uncomplicated diverticulitis on an outpatient basis.
Variations in the management of uncomplicated sigmoid diverticulitis are noted among colon and rectal surgeons, especially in terms of antibiotic choice, discharge instructions, and follow-up outpatient studies. The survey results are compared with the conclusions reached in The American Society of Colon and Rectal Surgeons practice parameters. Documentation of practice pattern variation may serve as an educational tool for physicians to improve their quality and cost of medical care. Consideration should be given to better publicize already existing American Society of Colon and Rectal Surgeons practice parameters for this common entity.
- Diverticulitis Diets (answers.com)
- Fiber May Not Prevent Diverticular Disease (webmd.com)
- Nuts and Popcorn: OK for the Colon? (time.com)
- RaK added a discussion to the group Health Tips For The Week (community.humanityhealing.net)
- Digestive diseases (therapycollect.wordpress.com)
- High-Fiber Diet: It Doesn’t Help, May Worsen, Diverticulosis (aarp.org)
- Researchers Challenge Commonly-Held Beliefs About The Causes Of Diverticulosis (medicalnewstoday.com)
- Diets high in fiber won’t protect against diverticulosis (eurekalert.org)
- Reversal on diverticulosis? (healthsass.blogspot.com)
- Fresh Friday: Not Losing Weight? Check Your Fiber Intake (doubleeaglefitness.wordpress.com)
- Was Brock Lesnar’s Diverticulitis Illness What Really Forced His Retirement? (bleacherreport.com)
- Butyrate research and the connection between vegetable fiber and vitamin D3 (examiner.com)
- SuperiorNutStore.com Expands Seeds Offering For A Healthier Diet (prweb.com)
- Small Bowel Follow Through and Diverticulitis (foodstaycation.com)
- Kombucha Tea, Cure All Or Flatulence Factory? (humanbodyengineer.wordpress.com)
- Swapping Germs (scientificamerican.com)
- Ulcerative Colitis Treatment: Can Probiotics Help? (webmd.com)