Note: The Prescript-Assist supplements discussed in this article are no longer available. Please click here to learn more about a substitute, the Daily Synbiotic from Seed.
If you’ve ever experienced a diverticulitis attack, I’m sure you’d be the first to say that it’s not a pleasant experience. I bet you’d be willing to do a lot of things to prevent it from happening again! Or maybe you’re someone who has been diagnosed with diverticulosis by your gastroenterologist, but you’re not quite sure what to do to prevent those painful attacks you’ve heard about and you want to learn more. Whatever brought you here, I’m happy to have you. Today I’ll be providing tips on how to prevent diverticulitis attacks naturally.
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What Is Diverticular Disease?
Diverticular disease is the term used to encompass a spectrum of issues from diverticulosis (the presence of sac-like pouches called diverticula that protrude from the colonic wall) to diverticulitis (the inflammation of these pouches and the accompanying symptoms). Diverticular disease is common in the Western world, with the highest rates seen in the United States and Europe. Even in those countries the disease was almost unheard of in 1900, but by the 1970s it was the most common affliction of the colon. (1)
Diverticular disease has been shown to increase with age – by 80, it is estimated that approximately 70% of individuals have diverticular disease. (2) The highest estimates suggest that approximately 20% of patients with diverticulosis (remember these are the people with the pouches, not the acute inflammation of the pouches) will at some point develop diverticulitis. (3) However, newer and more accurate estimates suggest that this rate is somewhere between 1 and 5%, depending on the strictness of qualifying criteria. (4) This is important to note for those who have been diagnosed with diverticulosis but are currently asymptomatic – according to these newer estimates, it is unlikely that you will develop diverticulitis. However, if you have diverticulosis and want be sure to prevent any problems or you’ve had diverticulitis attacks in the past, continue reading!
Despite the fact that diverticular disease is so common, we know relatively little about it and the common recommendations are based on limited data. If you’ve been diagnosed with diverticulosis, you may have received advice from your gastroenterologist about avoiding nuts and seeds and eating more fiber. However, these recommendations are based on inconclusive research and may not provide much benefit to you. In fact, few studies show any benefit to avoiding nuts and seeds and one study even showed that intake of nuts and popcorn was associated with a decreased risk of diverticulitis and diverticular bleeding. (5) High fiber diets are also often recommended, despite inconclusive evidence. (6) It is evident that recommendations for diverticular disease are due for an update.
Underlying Factors That Contribute to Diverticulosis
While inflammation is well-accepted in the model of acute diverticulitis, more and more research points to the involvement of chronic low grade inflammation in the development of symptomatic diverticulosis. In fact, of 930 patients undergoing surgery for symptomatic uncomplicated diverticular disease (SUDD), approximately 75% of them had evidence of chronic inflammation in and around the diverticula. (9) It is for this reason that drugs used for treating inflammatory bowel disease like mesalamine are being used to treat diverticular disease with good results as well (but hang tight, we’ll talk about natural ways to prevent diverticulitis, of course!). This is also why chronic use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen have been shown to increase the risk of diverticular complications (10, 11), since they are known to increase intestinal inflammation. (12, 13)
Fecal calprotectin can be measured to identify intestinal inflammation, and is high in those with symptomatic diverticular disease compared to those with functional digestive tract disorders like IBS and those with asymptomatic diverticular disease. (14) If you’re wondering whether you may have intestinal inflammation, it’s a great thing to get tested (and you can order a stool test from a specialty lab like Genova Diagnostics which will measure it). It is clear that chronic inflammation is involved in the development of diverticular disease, and that those who wish to prevent attacks should take steps to reduce intestinal inflammation.
Thankfully, one of the best ways to decrease intestinal inflammation is to eat a paleo diet! By avoiding potentially irritating and inflammatory foods such as grains, omega-6 fatty acids and lactose, we can reduce intestinal inflammation and encourage proper gut health. A paleo diet also positively influences gut bacteria, which in turn results in reduced inflammation as well. A paleo diet for diverticular disease should focus on gelatinous cuts of meat, bone broths, well-cooked vegetables, starchy tubers, and fermented foods.
Reducing your stress level is also important for bringing down levels of intestinal inflammation, as stress has been shown to activate inflammation in the intestine. (15) Stress can absolutely wreak havoc on the gut, so it is essential that any program focused on preventing diverticulitis attacks include proper stress management. This means incorporating mind-body activities such as yoga, meditation, tai chi, etc on a regular basis. If you’re someone who’s constantly stressed out and never takes time to take care of your own well-being, it’s unlikely you’ll be successful in preventing diverticulitis attacks even if you implement all the other suggestions outlined in this article. This one is important!
Another way to reduce an inflamed intestine is to supplement with soothing and healing demulcent herbs – deglycyrrhizinated licorice (DGL) has been shown to reduce mucosal damage and inflammation in rodents (16, 17) and it is likely that other demulcent herbs such as slippery elm and marshmallow root may have the same effect. Take chewable DGL tablets or mix a spoonful of slippery elm or marshmallow root powder in a small amount of water and drink 1-3 times per day to help soothe and heal an inflamed intestine. Another healing substance for the gut – bone broth – should be liberally consumed for this purpose as well.
Altered Intestinal Bacteria
Small intestinal bacterial overgrowth (SIBO) is common in diverticulitic patients. (18) Rifaximin, a non-absorbable antibiotic (meaning it only affects the gut, not the rest of the body), has been shown to effectively treat SIBO (19) and this treatment has also been shown to improve diverticular disease outcomes. (20) Bacterial overgrowth, along with fecal stasis inside the diverticula, can contribute chronic dysbiosis which can lead to low-grade inflammation (21), so improving gut bacterial balance is crucial to reducing intestinal inflammation.
Probiotic supplementation has been shown to be safe and potentially useful in diverticular disease (22) and is likely to be even more beneficial when combined with other therapies. If you’re not already consuming probiotics from your food (in the form of kefir, kombucha, kimchi, etc) then you should consider adding a supplement like VSL #3 or Prescript Assist (though even if you are consuming probiotics, a supplement isn’t a bad idea!). As Chris has mentioned, Prescript Assist tends to be the probiotic of choice for those suffering from constipation so start with that if you tend to err on the side of decreased motility.
Prebiotics are also very useful for correcting dysbiosis, and should be considered by those with diverticular disease. Prebiotics “stimulate selectively the growth and/or activity of intestinal bacteria associated with health and well-being” (23), which is exactly what we want when we’re trying to shift the balance of the microbes back to the good guys. My go-to prebiotic is Pure Encapsulations fructo-oligosaccharide (FOS) powder, but others include GOS and even lactulose. Supplementation with 10g of FOS per day has been shown to increase counts of bifidobacteria. (24) As with all prebiotics, it’s important to start with a very small amount and increase slowly. If you’re sensitive to FODMAPs you’ll want to be particularly careful as prebiotics are also FODMAPs. However, if you tolerate them well I think prebiotics can be a powerhouse when it comes to correcting imbalanced gut flora.
Most importantly, it’s crucial to treat SIBO or dysbiosis. As we’ve discussed, these conditions are very common in those with diverticular disease so it’s worth checking on your gut bacteria to see how they’re doing, using specialty labs such as Genova Diagnostics (and get your calprotectin tested while you’re at it!). It’s best to work with a practitioner who can test and treat you for these conditions.
Abnormal Colonic Motility
Researchers have found that those suffering from symptomatic uncomplicated diverticular disease have what they like to call a “spastic colon” in the areas affected by diverticulosis. (25) This is similar to what is found in patients with constipation predominant IBS and in functional constipation. These same researchers also found that patients with diverticulitis disease have reduced density of interstitial cells of Cajal (ICC for short – a fun name for the “pacemaker cells” of the intestine). (26) In studies on animals with a lack of ICC networks, delayed or absent intestinal motility is noted. (27, 28) What this means for diverticular patients is that these lack of networks and a spastic colon can cause increased symptoms in terms of constipation and bloating/pain. Though we’re not entirely sure what we can do to directly affect these cells (yet), it’s important to use therapies aimed toward improving motility if this is an issue for you.
Know that correcting SIBO and dysbiosis will go a long way toward improving constipation, so this is a good place to start. Given that our stool is mostly made up of dead bacteria, one can imagine that without proper amounts of good bacteria we’re going to have a tough time bulking the stool. Prebiotics can be particularly useful for constipation given that they selectively increase good bacteria like bifidobacteria. However, if you’re still struggling after correcting dysbiosis, here are some additional recommendations.
First, serotonin is an important player in gut motility. Serotonin concentrations in those with colonic diverticulosis are significantly lower than normal controls and contribute to the type of bowel habit following a test meal. (29) Serotonin transporter (SERT) transcript levels are also lower in those with a history of diverticulitis compared to controls and those with asymptomatic diverticulosis. (30) Inflammation is also known to decrease SERT expression and function (31, 32), so following the recommendations to lower intestinal inflammation is of course the first step to improving gut motility. In addition, it is also likely that supplementation with 5-HTP (a precursor to serotonin) may alleviate constipation and increase motility since it will increase serotonin levels. Note: do not take 5-HTP without talking to your doctor first if you are on an SSRI medication.
Second, if you’re currently on a low carbohdyrate paleo diet, you may want to consider increasing your carbohydrate intake. In my experience working with those with constipation on a paleo diet, this is the single most effective diet-based recommendation I’ve seen. If you’re at a loss as to what starches to add in, check out this excellent handout from Balanced Bites. Note: since SIBO is so common for those with diverticulosis, this step may need to wait until that has been treated, and may not be appropriate for some people.
Magnesium supplementation can also be very useful for people with constipation. Given that only about half of US adults consume the RDA for magnesium (33), it’s safe to say that a lot of us probably aren’t getting enough. This is due to the fact that not many foods naturally contain high amounts of magnesium, and even those that do have less due to the depletion of magnesium from our soil. Check out this magnesium soil content map to see how your local area is doing (and think about where most of your food comes from – if you’re not eating local you may not even know what soil your food is being grown in!).
By reducing our intestinal inflammation, balancing our gut bacteria, and improving our intestinal motility it is likely that we can prevent diverticulitis attacks. I’ll leave you with a set of action steps so you remember exactly what to do to improve these underlying factors.
Action Steps to Prevent Diverticulitis Attacks:
- Eat a paleo diet!
- Reduce stress
- Use demulcent herbs such as DGL, slippery elm, and marshmallow root to soothe and heal the intestine
- Take probiotics like VSL #3 or Prescript Assist
- Take prebiotics like FOS powder
- Treat SIBO or dysbiosis
- Reduce intestinal inflammation to increase SERT functioning, and consider supplementation with 5-HTP
- If you’re currently on a low carbohdyrate paleo diet, consider adding some starchy tubers to your diet
- Supplement with magnesium