A wonderful reader of the blog recently brought it to my attention that I forgot to follow-up the 1st post in this series. My apologies, this has been written and filed since the first post went up but I forgot to actually publish it.
In the first post in this series I discussed what diverticular disease is, what the scientific evidence point to as the underlying cause as well as what the conventional medical treatment is and the side effects of such treatment. Today’s post will focus on outlining a holistic approach to prevention and how to support your body through the healing process from a diverticulitis flare up. Outlined below are 2 protocols to consider depending on your current status.
Diverticulitis Holistic/Natural Approach
As previously mentioned, the scientific literature on the underlying causes of diverticular disease holds true in both an allopathic and holistic medical view of the condition. However, the difference lies in the treatments and preventative measures recommended by these disciplines. As noted, the major underlying causes of diverticular disease are movement from a traditional, whole foods diet, to a Westernized (standard American Diet) diet; chronic intestinal inflammation; pathogenic bacterial overgrowth; and altered intestinal motility (1, 3, 7, 9). In the prevention and treatment of diverticular disease, one should address not only the presenting symptoms such as intestinal inflammation and bacterial overgrowth, but also address the root causes of the disease via a whole foods diet focused on anti inflammatory, probiotic, and intestinal motility regulatory foods. Below is a sample evidence based approach to the prevention of and healing support of diverticular disease. Given the range of symptom severity under the umbrella of diverticular disease, the protocols have been separated by symptom category: asymptomatic diverticular disease, acute uncomplicated diverticulitis, chronic complicated diverticulitis.
**Important – If you are currently experiencing symptoms of diverticular disease please discuss any of the below changes with your treating medical practitioners prior to implementation of any of the below suggestions**
Asymptomatic Diverticular Disease
It is estimated that while 70% of the American population will have diverticulosis (the presence of diverticula without symptoms) by age 80, only 15-20% of those with diverticulosis will develop uncomplicated diverticulitis and only 1-5% would be hospitalized with complicated diverticulitis (1). Therefore, the goal in treating asymptomatic diverticular disease (diverticulosis) is to prevent the occurrence of diverticulitis symptoms.
Based on historical evidence it is clear that the occurrence of diverticular disease increased along with the adoption of an industrialized Western diet and lifestyle. There is very little documentation surrounding diverticular disease prior to the early 1900s (10). Once the early 1900s arrived, there began to be mention of diverticulosis and diverticulitis in the medical literature; however, the condition was described as curious since it was quite rare (10). By 1930, estimates of diverticulosis in the american and British population was approximately 5%-10% in individuals over 40 years (10). Over the course of the last 90 years this incidence has increased to at least 50% of those aged 40 and higher presenting with diverticulosis, and 70% of those over 80 years (10, 1). The main goal for those with diverticulosis is to move away from a processed standard American type diet to a traditional whole foods diet. The following outlines what would be included in a traditional diet and how it would prevent diverticulitis by addressing the underlying diverticulosis pathology of chronic inflammation, pathogenic bacterial overgrowth, and altered intestinal motility.
- Limit processed foods and food additives: Many of the ingredients such as glucose, salt, emulsifiers, organic solvents, microbial transglutaminase, and nanoparticles found in modern processed foods have been shown to cause intestinal inflammation and leaky gut (11).
- Limit sugar/refined carbohydrate: It is clear that excess sugar intake, particularly fructose, is related to obesity and metabolic syndrome, both of which are risk factors for diverticulitis. Excess sugar and fructose is also tied to intestinal inflammation and leaky gut (12).
- Limit industrial seed oil: Excess Omega 6 intake, leading to a higher Omega 6 to Omega 3 ratio, is clearly linked to increased systemic inflammation and the risk of chronic disease. Not surprisingly, it has also been linked to inflammatory bowel disease which shares many symptoms and pathology with diverticular disease (13, 14)
- Limit Dairy: Lactose intolerance and cow’s milk allergy are fairly common in the population, estimates range from 15% – 85% of the population, depending on geographical location and cultural history of bovine agriculture (15, 16, 17). These conditions lead to many gastrointestinal and immune symptoms and may be more common in those with inflammatory bowel and diverticular disease (18, 19).
- Limit gluten: While currently controversial in the allopathic medical community, there is continued growing evidence that gluten consumption can lead to intestinal inflammation, leaky gut, and low grade systemic inflammation in the non-celiac population (20); all of which can be classified as underlying causes of chronic illness, including diverticulitis.
- Limit all grains: Support for the notion the whole grains are good for our health comes from epidemiological studies. However, individuals who consume more whole grains tend to also participate in many other healthy activities, skewing the results of these studies. In fact, the anti-inflammatory benefits of whole grain consumption are not seen in the results of clinical intervention trials (21), and some evidence indicates they may have a negative effect on gut and immune function (20). Additionally, a higher intake of whole grains increases the overall carbohydrate content of the diet which may also increase the risk of obesity, metabolic syndrome, and low grade systemic inflammation, all of which can be tied to an increased risk of diverticular disease via their link with intestinal inflammation, intestinal bacteria overgrowth (see below), and leaky gut (see below).
- Control/Limit stress: Recent evidence shows that the fight or flight stress response can lead to increased intestinal and systemic inflammation, particularly in those with existing immune, inflammatory, and gastrointestinal conditions (22). Stress management interventions will be individualized and could include meditation, physical exercise, counselling, recreational activities, or hobbies.
Support Beneficial Bacteria
- Dietary changes: Many industrialized food choices can have a negative impact on small intestine and colon bacteria, feeding pathogenic bacteria and starving beneficial bacteria. Therefore, making the above changes should have a positive impact on any bacterial overgrowth.
- Include Probiotics: Probiotics have been shown effective in the treatment and prevention of SIBO (23, 24) as well as having anti-inflammatory and antibacterial effects (24). Probiotic supplements and/or foods will assist in balancing intestinal bacteria, reducing inflammation, and preventing diverticula infection via antibacterial action. With asymptomatic patients, probiotic foods and/or a simple supplement would be sufficient.
Maintain/Promote Appropriate Intestinal Motility
- Include Probiotics: An added benefit of probiotics is that they have also been shown to also treat constipation and regulate intestinal motility (25, 26, 27).
- Increase soluble fiber: Soluble fibre, or prebiotics, is important to include in the diet as it has been shown to increase/normalize intestinal motility (28, 29, 30). Soluble fiber also feeds beneficial bacteria, producing short chain fatty acids which are intestinal cells main fuel source (30). With the above dietary changes, plenty of soluble fibre will be eaten via root vegetables and fruits.
- Include Quality Fats: Grass-fed butter and/or ghee is recommended as a source of the short chain fatty acid butyrate. Sufficient intake of Omega 3 fats to improve inflammation and improve gastrointestinal function is also recommended.
- Squat (or use a stool) to Poop: Increased hip flexion, maximally achieved by a full squat position, straightens the rectoanal angle, reducing the effort required for a complete bowel movement (31).
- Consider 5-HTP: Colonic serotonin deficiency is shown to negatively impact intestinal motility (32) and patients with symptomatic diverticulitis have colonic serotonin deficiency (33). However, asymptomatic patients do not express colonic serotonin deficiency; therefore, 5-HTP supplementation would only be considered a last resort for motility regulation
Acute Uncomplicated Diverticulitis
With an acute, uncomplicated diverticulitis attack, there will more more pronounced inflammation, bacterial imbalance, and motility irregularity; therefore, the initial intervention will require more potent dietary changes and supplement additions compared to diverticulosis.
1. Reset Inflammation:
- Liquid Diet: To eliminate the present inflammation and bacterial imbalance as well as limit food based mechanical intestinal irritation and ease digestive demands, it may be necessary to implement a close to liquid diet. It is essential to ensure that a liquid diet eliminates all of the foods outlined above and is a whole food, nutrient dense diet that provides the nutrients required for intestinal healing. The introductory phase of the Gut and Psychology Syndrome diet would be recommended. This involves a period of only eating bone/fish broths (meat and connective tissue included), very well cooked low fiber vegetables (boiled with broth), and small amounts of probiotic foods such as sauerkraut juice and kefir (GAPS BOOK). The length of this protocol will differ depending on the severity of the attack, anywhere from 1-5 days should be sufficient to eliminate acute symptoms.
- Anti-Inflammatory Herbs: Herbs effective at reducing intestinal inflammation and promote cellular growth should also be included. Deglycerized licorice, slippery elm, marshmallow root, and collagen have all been shown to cool intestinal inflammation and support tissue/cellular healing (35, 36). All of the above herbs can be used in tea or tincture form to ensure the liquid diet is maintained.
- Control/Limit Stress: See asymptomatic diverticulosis recommendations.
2. Restore Beneficial Bacteria:
- Include Probiotics: With the implementation of the GAPS introductory phase, probiotic foods will be consumed; however, following the introductory phase it will be important to supplement with a quality probiotic having a more potent effect than what would be used for asymptomatic patients. Consult your holistic healthcare practitioner for recommendations.
3. Restore Intestinal Motility
- Consider 5-HTP: The above steps should assist with intestinal motility; however, if this has not been fully restored, the use of a 5-HTP supplement could be included as the colons of patients with symptomatic diverticulitis have been shown to be serotonin deficient. Again, discuss this with your holistic healthcare practitioner.
- Squat to Poop: See asymptomatic diverticulosis recommendations.
4. Asymptomatic Protocol:
One acute diverticulitis episode increases the risk for future episodes; therefore, it is very important for individuals that have experienced an acute attack to reduce their risk of future events. To reduce future risk, the asymptomatic protocol should be implemented, indefinitely, once acute diverticulitis symptoms have resolved.
Chronic Complicated Diverticulitis
If an individual has reached this stage there is likely severe complications such as significant infection, bowel obstructions, or perforation. In such cases, allopathic surgery or antibiotics may be acutely necessary. Following such intervention, or if no allopathic intervention has been deemed necessary, the acute diverticulitis protocol will be required. However, it will likely need to occur for a longer period of time prior to moving to the asymptomatic protocol. Again, the length of this protocol will be individual and determined by the elimination of acute symptoms.
The Barefoot Golfer
- Gut and Psychology Syndrome Diet