Diverticulosis and Diverticular Disease
Several trials of high fiber diets and various forms of fiber supplements have shown benefit in terms of pain reduction and overall improvement in patients with diverticular disease (Hobson 2004; Unlu 2012).
Consumption of 20–30 g of fiber daily has been recommended by some diverticular disease researchers. Supplemental fiber in the form of agents like psyllium seed husk and ground flaxseed can help increase total daily fiber intake. Patients with diverticular disease who begin fiber supplementation or a program of increased dietary fiber should do so gradually, over a period of weeks, and simultaneously increase their fluid intake. This is because increasing one’s fiber intake too rapidly can cause symptoms of digestive upset such as gas and bloating. Also, for those recovering from a bout of acute diverticulitis, a low-fiber diet may be advised; people in this situation should talk with their healthcare provider before increasing fiber in their diet, including supplemental fiber (Saul 2015; Thaha 2015; Slavin 2013; Wick 2012).
Probiotics are living microorganisms (LPI 2015; Haukioja 2010) that exert health benefits through immune modulation and anti-inflammatory effects, as well as their ability to inhibit intestinal colonization by harmful microorganisms (Tursi 2014).
Diverticular disease is increasingly being recognized as an inflammatory disorder that may be related to a disturbed intestinal microbial ecosystem, sometimes called “dysbiosis.” By helping restore the balance of intestinal flora and reduce inflammation in the colon, probiotic supplementation may be of benefit in both acute and chronic diverticular problems (Boynton 2013; Mengheri 2008).
Most probiotic supplements are made with strains of lactobacilli and bifidobacteria (Guarner 2012; CDRF 2015).
In an open-label trial, a combination of Lactobacillus acidophilus 145 and Bifidobacterium species 420 was found to be effective for preventing disease recurrence in people with symptomatic uncomplicated diverticular disease (SUDD) (Lamiki 2010). Several controlled trials have demonstrated a positive effect of probiotics in SUDD. In one trial, a high-fiber diet plus the probiotic Lactobacillus paracasei B21060 was compared to a high-fiber diet alone. After three and six months of treatment, abdominal pain was significantly improved in both groups, while bloating improved significantly only in the probiotic group (Lahner 2012). Another study compared a high-fiber diet alone to a high-fiber diet plus either low-dose or high-dose Lactobacillus paracasei F19. Both probiotic-treated groups had significant reductions in bloating; no subjects in the probiotic group reported persistent pain lasting longer than 24 hours (Annibale 2011).
Results from two additional open-label studies suggest a probiotic containing Lactobacillus casei DG may help reduce symptoms and prevent recurrence of acute diverticulitis in people with SUDD. The effect of this probiotic was comparable to mesalamine in both studies, but the combination of mesalamine plus Lactobacillus casei DG appeared to perform slightly better than either alone (Tursi 2006; Tursi 2008). A randomized controlled trial in 210 subjects with SUDD appeared to confirm these findings: the trial compared Lactobacillus casei DG and mesalamine, together and separately, with placebo. Cyclic schedules of 10 days per month were used for all interventions. After one year, both the probiotic and mesalamine were found to be more effective than placebo for maintaining remission; additionally, the combination of probiotic plus mesalamine appeared to work better than either alone (Tursi 2013).
Butyrate is a short-chain fatty acid produced in humans by intestinal bacteria that digest and metabolize fiber. Butyrate is critical to colonic mucosal health; is the preferred fuel of the cells that line the interior of the colon; helps maintain the intestinal barrier; has anti-inflammatory and anti-cancer effects; and helps regulate colonic motility (Slavin 2013; Leonel 2012; Sossai 2012).
In a randomized clinical trial of sodium butyrate in 52 people with diverticular disease, subjects received either a twice daily dose of 150 mg of oral microencapsulated sodium butyrate or placebo. After one year, just 7% of those in the butyrate group experienced diverticulitis symptoms compared with 31% in the placebo group (Krokowicz, Stojcev 2014).
A preclinical trial studied the effect of calcium butyrate introduced directly into the colon of rodents in an induced model of inflammatory bowel disease (IBD). Calcium butyrate completely prevented the weight loss typical of rats with induced colitis and significantly reduced the tissue damage and fluid accumulation of colitis, by 48% and 22.7%, respectively. In a laboratory component of this study, calcium butyrate also exhibited antitumor effects (Celasco 2014).
Clinical studies have shown that butyrate, in the form of sodium butyrate, reduced the frequency of symptoms of irritable bowel syndrome and eased traveler’s diarrhea (Banasiewicz 2013; Krokowicz, Kaczmarek 2014). It has been proposed that supplemental butyrate may be beneficial in IBD as well as colorectal cancer and certain metabolic diseases (Sossai 2012).
Natural anti-inflammatory compounds may counteract some of the inflammatory processes that contribute to diverticular disease. These include the omega-3 fatty acids from fish, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); curcumin from the turmeric plant, Curcuma longa; and Boswellia serrata extract. Clinical trials to evaluate the specific effect of these natural anti-inflammatory agents in diverticular disease are still needed.
Omega-3 fatty acids. EPA and DHA have been extensively studied for their general anti-inflammatory activity, and many studies have demonstrated that omega-3 fats are beneficial in IBD (Farrukh 2014). Low levels of omega-3 fats have been found in patients with IBD, and almost all trials using fish oil supplements have demonstrated a beneficial effect, with the best results in ulcerative colitis (Farrukh 2014; Siguel 1996).
Emerging evidence suggests an overlap between the inflammation that characterizes chronic diverticular disease and that of IBD (Peppercorn 2004; Strate, Modi 2012). For this reason, treatments that are of benefit in IBD are worthy of consideration in diverticular disease. Several university-associated medical centers recommend supplementing omega-3 fatty acids, including from fish oil, in diverticular disease, in doses ranging from 1–5.5 g per day (UMMC 2013; PSH 2015; LHMC 2015).
Curcumin. Curcumin is an anti-inflammatory compound from the culinary and medicinal herb turmeric (Curcuma longa) (Iqbal 2003). Preclinical studies suggest curcumin may be of benefit in inflammatory bowel disease including ulcerative colitis. Studies in animal models of IBD have shown that curcumin can inhibit tumor necrosis factor-alpha, one of the inflammatory chemical messengers associated with diverticular disease and acute diverticulitis (Tursi, Elisei 2012; Tursi, Elisei, Giorgetti 2014). Early research suggests curcumin is safe and effective at preventing relapse when used with anti-inflammatory drugs to manage IBD (Baliga 2012).
Boswellia extract. Resin from the Boswellia serrata tree contains a powerful anti-inflammatory compound called acetyl-11-keto-β-boswellic acid, or AKBA (Siddiqui 2011). One randomized controlled trial found that Boswellia extract was as effective as mesalamine at improving symptoms of Crohn’s disease with far fewer side effects (Gerhardt 2001). In another trial, Boswellia extract was compared to the medication sulfasalazine (Azulfidine) in 30 patients with chronic colitis. Seventy percent of those treated with Boswellia extract entered remission compared to only 40% in the sulfasalazine group (Gupta 2001). This confirmed an earlier report of Boswellia’s efficacy in the treatment of ulcerative colitis (Gupta 1997). In a preclinical model of intestinal inflammation, both Boswellia extract and pure AKBA protected against oxidative damage and prevented inflammatory, structural, and functional changes in cells of the intestinal lining that were exposed to inflammatory stimuli (Catanzaro 2015). An improved extract, called AprèsFlex, or Aflapin, which combines AKBA with other non-volatile Boswellia oils, has demonstrated improved anti-inflammatory activity at a lower concentration when compared to other preparations standardized to the same percentage of AKBA (Sengupta 2011).
L-glutamine . The amino acid L-glutamine is an important energy source for cells that line the intestinal mucosa (Peng 2004; Fleming 1997). L-glutamine has been extensively studied for its ability to preserve structural and functional health of the intestine, and to promote intestinal recovery during and after injury or stress, such as occurs in infection or surgery. Animal and laboratory studies show the potential for L-glutamine, by protecting cells from inflammatory damage, to be a useful therapeutic for IBD (Xue 2011). Because of the relationship between chronic mucosal inflammation and diverticular disease, and the frank tissue injury that occurs with acute diverticulitis, L-glutamine may also be helpful in treating these conditions; however, clinical studies are needed to clarify the therapeutic role of L-glutamine in diverticular disease.
Mucilaginous herbs. Mucilages are complex sugars found in many plants that form a thick, gel-like film when mixed with water (Watts 2012). Psyllium seed husk (Plantago psyllium), flaxseed (Linum usitatissimum), and the medicinal plants slippery elm (Ulmus fulva) and licorice (Glycyrrhiza glabra) contain mucilage (Saeedi 2010; Dugani 2008; Gill 1946; Shenefelt 2011; Alok 2014).
When ingested, mucilages are believed to form a barrier or lining on the intestinal mucosa, protecting against infection and injury, soothing irritation, and promoting tissue healing (Pengelly 2006). Slippery elm bark, for example, has demonstrated anti-inflammatory effects in laboratory studies, and appears to protect against mucosal hypersensitivity in animal studies, while deglycyrrhizinated licorice (DGL) has demonstrated an ability to help heal peptic ulcers (Langmead 2002; Watts 2012). These protective properties of mucilaginous herbs may play a role in helping soothe and heal irritated or inflamed tissues lining the digestive tract in diverticular disease; however, clinical trials demonstrating such beneficial effects are needed.
Readers of this protocol should also review the Inflammatory Bowel Disease protocol, which describes several nutrients with anti-inflammatory activity that may be of benefit in conditions involving intestinal inflammation. Although the nutrients described in the Inflammatory Bowel Disease protocol may not have been directly studied in people with diverticular disease, the emergence of inflammation as an important mediator of diverticular problems suggests that supplementation with nutrients possessing anti-inflammatory properties may be helpful.
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