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Low-Residue Diet in Diverticular Disease: Putting an End to a Myth

Sherry Tarleton and John K. DiBaise
Nutr Clin Pract 2011 26: 137
DOI: 10.1177/0884533611399774

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 Nutrition in Clinical Practice
Invited Review Volume 26 Number 2
April 2011 137-142

Low-Residue Diet in Diverticular © 2011 American Society for

Parenteral and Enteral Nutrition

Disease: Putting an End to a Myth

10.1177/0884533611399774
http://ncp.sagepub.com
hosted at
http://online.sagepub.com

Sherry Tarleton, RD, CNSC; and John K. DiBaise, MD, FACG

Financial disclosure: none declared.

Residue refers to any indigestible food substance that remains in although this is based mostly on low-quality observational studies.
the intestinal tract and contributes to stool bulk. Historically, low- This report focuses on the evidence that fiber intake may be ben-
residue diets have been recommended for diverticulosis because eficial in the prevention and recurrence of symptomatic and
of a concern that indigestible nuts, seeds, corn, and popcorn complicated diverticular disease and provides recommendations
could enter, block, or irritate a diverticulum and result in diver- regarding fiber supplementation in individuals with diverticulosis.
ticulitis and possibly increase the risk of perforation. To date, (Nutr Clin Pract. 2011;26:137-142)
there is no evidence supporting such a practice. In contrast, die-
tary fiber supplementation has been advocated to prevent diver- Keywords:   dietary fiber; diverticulum; diverticulosis, colonic;
ticula formation and recurrence of symptomatic diverticulosis, diverticulitis, colonic

A diet leaving little residue is the one generally Colonic diverticulosis, one of the most common and
advised but I am not sure that a diet leaving a bulky costly gastrointestinal disorders among industrialized
residue is not better, providing that the bowels act societies, is characterized by the formation of sac-like
once per day. outpouchings or pockets within the colon that form when
colonic mucosa and submucosa herniate through weak-
Sir Berkeley Moynihan, British War ened areas in the muscle layer (pseudo-diverticula).2,3
Surgeon, 19271 There is a spectrum of clinical manifestations of diver-
ticular disease (Figure 1). Although most people with

A
diverticulosis remain asymptomatic, up to 25% will
  53-year-old man presented to his primary care cli- develop uncomplicated symptoms of episodic abdominal
  nician with the recent onset of severe left lower pain, bloating, and bowel dysfunction (ie, symptomatic
  quadrant abdominal pain with associated nausea, diverticulosis), and up to 25% of these will develop a com-
anorexia, and loose stools. He is otherwise healthy and plication of diverticulosis, including diverticulitis or hem-
taking no medications. On examination, he appears orrhage (ie, complicated diverticular disease).4 There is
acutely ill with a temperature of 101.66°F and mild often difficulty in differentiating patients with irritable
tachycardia. His abdomen is notable for tenderness to bowel syndrome with coexisting diverticula from patients
palpation on the left side without peritoneal signs. He is with symptomatic diverticulosis,5 however, the clinical
subsequently admitted to the hospital for management of importance of this distinction is unclear. Approximately
suspected acute diverticulitis. He responds rapidly to 15% of those with diverticulitis will develop a serious
intravenous antibiotics and a short period of bowel rest. complication such as an abscess, fistula, obstruction, or
What is the optimal dietary management in terms of perforation.6 The process whereby a diverticulum bleeds
resuming oral diet and attempting to prevent recurrent or becomes inflamed is unclear but is thought to relate to
diverticulitis? stasis or obstruction of the neck of the diverticulum, lead-
ing to local irritation, tissue ischemia, and/or bacterial
overgrowth, a mechanism similar to that implicated in
appendicitis.3,7
From the Division of Gastroenterology, Mayo Clinic, Scottsdale, The prevalence of diverticulosis is difficult to deter-
Arizona. mine given that most individuals remain asymptomatic,
Address for correspondence: John K. DiBaise, Mayo Clinic,
however, this condition is clearly age-related, with post-
Division of Gastroenterology, 13400 East Shea Blvd, Scottsdale, mortem studies estimating the prevalence to be 5%-10% of
AZ 85259; e-mail: [email protected]. patients up to the age of 50, 50% of those >60 years of age,

137
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138   Nutrition in Clinical Practice / Vol. 26, No. 2, April 2011

there is an absence of high-quality data supporting the

Diverticulosis benefit of a low-residue diet. Instead, the ADA recom-
mends using fiber in place of residue, because this can be
-May be
-Perforation
asymptomatic more easily quantified.
-Fistula
-Blood
-May have lower The role of fiber in both uncomplicated and compli-
abdominal cramping
-Obstruction
related to food
cated diverticular disease and the most appropriate man-
ner to advance the diet in the setting of complicated
diverticular disease continue to be controversial topics.
The role of fiber in the pathogenesis of diverticulosis has
Complicated DD DD Spectrum Painful DD been recently reviewed and will not be covered further
here.2,13-15 Instead, this report focuses on the evidence
that fiber intake may be beneficial in the prevention and
recurrence of symptomatic and complicated diverticular
-No evidence
-May progress of inflammation
disease. Additionally, recommendations regarding fiber
to complicated DD -Considerable supplementation and suggestions for diet advancement,
-Inflammation overlap with
of diverticula functional
including fiber, following an episode of diverticulitis are
bowel disease provided.

Diverticulitis
Nuts and Seeds in Diverticulosis:
To Avoid or Not to Avoid
Figure 1.   The spectrum of the clinical presentation of diver-
ticular disease may progress from asymptomatic to symptomatic A common question regarding diet in diverticulosis is
and complicated disease. DD, diverticular disease. whether nuts, seeds, and popcorn should be avoided to
prevent symptoms or complications of diverticular dis-
and 66% of those >85 years of age.4 Diverticulosis appears ease. Historically, it has been common in clinical practice
to affect men and women equally.4 Although the pathogen- to recommend avoidance of nuts, seeds, corn, hulls, and
esis of this condition is poorly understood, the well- popcorn,16 however, there is no evidence supporting such
described geographic variation in its prevalence has led to a practice. In fact, a recent study suggests the opposite.
a widely accepted “fiber hypothesis,” which suggests that As part of the large, prospective Health Professionals
diverticulosis occurs as a consequence of pressure-induced Follow-up Study, 47,228 male healthcare professionals
damage to the colon caused by a low-fiber diet.8 Other fac- between the ages of 40 and 75 completed a food-fre-
tors that are postulated to play a role in both the develop- quency questionnaire and were followed over an 18-year
ment of diverticulosis and its complications include aging, period.17 The subjects reported information via periodic
inflammation, disturbed colonic sensorimotor function, self-administered medical and dietary questionnaires.
altered colonic microbiota, and genetics.9 During the follow-up period, 801 cases of diverticulitis
Residue refers to any indigestible food substance that and 383 cases of diverticular bleeding occurred. No asso-
remains in the intestinal tract and contributes to stool ciation was found between corn consumption and diver-
bulk. The restriction of residue results in a reduction in the ticulitis or between nut, corn, or popcorn consumption
size and number of stools. Low-residue diets have been and diverticular hemorrhage or uncomplicated diverticu-
recommended for a variety of gastrointestinal symptoms litis. Importantly, an inverse relationship between nut
and disorders since the early 1900s.10 With specific regard (hazard ratio [HR] 0.80; 95% confidence interval [CI],
to diverticulosis, there has historically been a concern that 0.63-1.01) and popcorn (HR 0.72; 95% CI, 0.56-0.92)
indigestible nuts, seeds, corn, and popcorn could enter, consumption and the risk of diverticulitis was demon-
block, or irritate a diverticulum and result in diverticulitis strated, suggesting a protective effect. Because the preva-
and possibly increase the risk of perforation.3,7 The low- lence of undiagnosed asymptomatic diverticulosis was
residue diet originally consisted of lean meat, rice, hard- likely high in this cohort, the findings from this study
boiled eggs, sugars other than lactose, and small amounts seem to apply to individuals with established diverticular
of fruit juice, tea, and coffee. In subsequent years, other disease.
foods were added to this diet including vegetable juice
without pulp, white pasta, refined breads and cereals, and
2 cups of dairy products per day.11 Importantly, the Role of Dietary Fiber in the Management
American Dietetic Association (ADA) recently removed the of Diverticular Disease
low-residue diet from the Nutrition Care Manual because
residue cannot be sufficiently quantified, nor is there sci- Dietary fiber supplementation has been advocated to pre-
entific consensus on a definition of residue.12 Additionally, vent diverticula formation and recurrence of symptomatic
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 Low-Residue Diet in Diverticular Disease / Tarleton, DiBaise   139

Table 1.   Summary of Studies Evaluating Dietary Fiber in the Management of Diverticular Disease

Year Population Study Design Description Results

197222 70 adults with sympto- Prospective, • I mplementation of unproc- Decreased symptoms and nor-
matic diverticulosis uncontrolled trial essed bran into a high-fiber malized bowel habits in 62 of
diet 70 subjects
• Average bran consumption
~12 g/d (range, 3-45 g/d)
197623 40 adults with sympto- Prospective, • Received
 24 g of wheat bran 33 subjects experienced a clini-
matic diverticulosis uncontrolled daily for 6 months cal benefit, with 60% of the
diagnosed by barium study symptoms eliminated and
enema 23% improved
197720 18 symptomatic subjects Randomized, • Wheat
 crispbread (0.6 g/d Greater pain relief and progres-
with radiographically controlled study fiber) or bran crispbread (6.7 sive improvement in the
confirmed diverticulosis g/d fiber) higher fiber crispbread group
• Followed monthly for 3
months using standardized
symptom questionnaires
198024 100 consecutive adults Retrospective case • High-fiber
 diet beginning at 91% of patients remained
hospitalized with series discharge (40 g/d) asymptomatic, although only
diverticulitis • Followed up 5-7 years later 75% adhered to their high-
fiber diet
198121 58 subjects with symp- Randomized, • Received
 crispbread (6.99 • No
 significant differences in
tomatic diverticulosis double-blind, g/d fiber), ispaghula husk pain, lower bowel, or total
placebo- drink (9.04 g/d fiber), or pla- symptom scores
controlled, cebo (2.34 g/d fiber) • Improvement in constipation
crossover study • Each given for 16 weeks and stool characteristics and
• Completed a symptom ques- frequency in the higher fiber
tionnaire and 7-day stool col- group
lection at the end of each
treatment period
198525 56 patients hospitalized Retrospective case • High-fiber
 diet (≥25 g/d) • Reduced
 symptoms, develop-
with symptomatic series administered to 43 patients ment of complicated divertic-
diverticular disease ular disease, and need for
surgery

diverticulosis.5 For reference, the daily fiber intake of the dysfunction scores was noted. The total amount of daily
typical American is approximately 13-15 g/d.18,19 Table 1 fiber included in both the diet and crispbread supplement
summarizes clinical studies investigating the role of was not reported for the 2 groups. These findings could
dietary fiber in the management of diverticular disease. not be replicated in a study conducted by Ornstein et al.21
The only randomized controlled study involved just 18 In this randomized, double-blind, placebo-controlled,
symptomatic subjects with radiographically confirmed crossover study, 58 subjects with uncomplicated, symp-
diverticulosis who were followed over 3 months.20 These tomatic diverticulosis received, in addition to their usual
subjects completed a detailed symptom questionnaire and fiber-containing diet, crispbread (6.99 g/d fiber), ispagh-
were then randomly assigned to either wheat crispbread ula husk drink (9.04 g/d fiber), or placebo (2.34 g/d fiber),
(0.6 g/d fiber) or bran crispbread (6.7 g/d fiber) instead of each given for 16 weeks. Subjects completed a monthly
their usual bread and in addition to their otherwise usual self-administered symptom questionnaire and 7-day stool
fiber-containing diet. They were then followed monthly collection at the end of each treatment period. There were
for 3 months using standardized symptom questionnaires. no significant differences in pain, lower bowel, or total
Those receiving the higher fiber crispbread had greater symptom scores; however, there was improvement in con-
pain relief and overall decreased symptoms over stipation with expected changes in stool characteristics and
the 3-month period. No significant difference in bowel frequency with the higher fiber diet. This study has been

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140   Nutrition in Clinical Practice / Vol. 26, No. 2, April 2011

criticized for providing insufficient fiber in the treatment Fiber can be classified by chemical structure, solubil-
group and too small of a difference in fiber intake between ity, viscosity, and fermentability, but is most commonly
the treatment and control group. classified into 2 categories: soluble or insoluble forms.
Much of the evidence supporting fiber supplementa- Soluble fibers include β-glucans, gums, psyllium, pectins,
tion in diverticular disease comes from retrospective, uncon- and some hemicelluloses.26-28 Food sources rich in soluble
trolled studies. In one prospective, uncontrolled trial of 70 fiber are legumes, apples, and citrus fruits. Insoluble fib-
adults with symptomatic diverticulosis, a decrease in symp- ers include cellulose, lignin, some pectins, and some
toms and normalization in bowel habits after implementing hemicelluloses. Examples of foods rich in insoluble fiber
unprocessed bran into a high-fiber diet were seen in 62 are wheat bran, fruit skins, nuts, flax, and rye.26-28 Most
subjects.22 The average bran consumption was about 12 g/d foods contain both soluble and insoluble fibers. Insoluble
(range, 3-45 g/d). Participants were instructed to start with fiber passes through the gut relatively unaffected by
2 teaspoons of unprocessed bran 3 times daily and to digestive processes, acting mainly in the colon to modu-
increase the dose after 2 weeks if they did not have a bowel late intestinal transit and water absorption, whereas solu-
movement once or twice per day or if they continued to ble fiber slows gastric emptying, binds bile acids (but not
experience straining at the toilet. The amount of bran that micronutrients), and undergoes fermentation by microbes
the subjects consumed varied because they were also within the colon releasing short-chain fatty acids, the
instructed to consume a higher fiber diet. These instruc- principal energy source of the colonic epithelium.27,28 The
tions focused on choosing fruit, vegetables, All-Bran, Institute of Medicine recently proposed that the terms
Weetabix, porridge, and wholemeal bread, and to decrease soluble and insoluble be eliminated because the health
intake of refined sugar. The precise amount of fiber was benefits of fiber are not encompassed in its solubility but
unspecified. Therefore, the total daily fiber intake was rather in its viscosity and fermentability.29
dependent on the participants’ other dietary choices and was Although the amount of fiber consumed seems to be
difficult to quantify. In another prospective, uncontrolled an important determinant of its benefit, the specific type
study, 40 adults with symptomatic diverticular disease diag- of fiber may also play a role. A large prospective study
nosed by barium enema received 24 g of wheat bran daily involving 51,529 male health professionals (Health
for 6 months. Thirty-three of the subjects experienced a Professionals Follow-up Study) without a history of diag-
clinical benefit with 60% of the symptoms being eliminated nosed diverticular disease and followed up to 4 years sug-
and 23% of the symptoms improved.23 Hyland and Taylor gested a benefit from a prophylactic high-fiber diet.30 In
enrolled 100 consecutive adults admitted to a hospital with 188,252 person-years of follow-up, only 385 cases of
a clinical presentation consistent with acute diverticulitis symptomatic diverticular disease were diagnosed during
and treated them with a high-fiber diet beginning at dis- the follow-up period, and an inverse association with the
charge (40 g/d). Five to seven years later, 91% of patients high-fiber diet was seen. An inverse relationship between
remained asymptomatic, however, only 75% adhered to a diverticular disease and energy-adjusted fiber intake was
high-fiber diet.24 In a retrospective review of 56 patients found. Furthermore, fruit and vegetable intake, cellulose,
hospitalized with symptomatic diverticular disease over a hemicellulose, and lignin were inversely associated with
10-year period, a high-fiber diet (at least 25 g/d) adminis- the risk of symptomatic diverticular disease; however,
tered to 43 of them appeared to provide protection against cereal fiber was not. These investigators subsequently
continued symptoms, the development of complicated found that insoluble fiber (Relative Risk [RR] 0.63;
diverticular disease, and the need for surgery.25 95% CI, 0.44-0.99) and cellulose (RR 0.52; 95% CI,
0.36-0.75) significantly reduced the risk of diverticular
disease.31
Does the Type of Fiber Make a Difference?

Although there is no convincing evidence that a high- Advancement of Diet After an Episode of
fiber diet can reverse the pathophysiology of diverticular Complicated Diverticular Disease
disease, there is reasonable evidence that this type of diet
can improve diverticular symptoms. The original fiber There is a paucity of evidence supporting any dietary
hypothesis suggested that the mechanism resulting in change during and while recovering from an episode
symptom improvement related to changes in stool charac- of diverticulitis or diverticular hemorrhage. Therefore,
teristics in addition to both decreased colonic transit time recommendations are based on clinical experience.
and intraluminal pressures.8 Fiber is also an important During an episode of diverticulitis or diverticular hemor-
energy substrate for the colonic epithelium because of its rhage, oral intake is generally reduced until symptoms
fermentation by colonic microbes to short-chain fatty subside. Complicated cases requiring prolonged periods
acids, which in turn play a role in mucosal growth and of bowel rest may require the initiation of parenteral
colonic blood flow.9,14 nutrition support. Once oral intake has been resumed or

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 Low-Residue Diet in Diverticular Disease / Tarleton, DiBaise   141

in mild to moderate cases, in order to reduce the potential References

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