Authors: Jamie Schnuck Olapo, Sarah A. Gunby, Lisa L. Strate, David R. Flum
Categories: Research Note, Dietary patterns, Mediterranean diet, Diverticulitis, Recurrence
Source: BMC Research Notes
Authors: Jamie Schnuck Olapo, Sarah A. Gunby, Lisa L. Strate, David R. Flum
Each year, millions of people experience an episode of diverticulitis, accompanied by abdominal pain, gastrointestinal symptoms, and expensive healthcare utilization. Rates of recurrence following recovery from an episode are high, ranging from 20 to 50% depending on how this is measured. A number of dietary and lifestyle factors have been found to be associated with an increased risk of developing incident diverticulitis; while these have been suggested to play a role in preventing recurrence, there is limited evidence to support this claim. Clinicians often recommend a high fiber diet after recovery from an episode of diverticulitis, however, numerous other dietary patterns have been proposed to provide benefit. Anecdotal evidence suggests that there are widespread beliefs among patients with diverticulitis about dietary triggers and modifications that are effective at reducing disease recurrence and symptom burden. We aimed to gain a better understanding of what current dietary modifications are being attempted by patients with a history of diverticulitis episode and surveyed 430 people. We found that a high fiber diet was the most common dietary change, made in 59% of survey respondents, followed by the Mediterranean diet by 26%. Among patients who adopted a Mediterranean diet, adherence was modest in 45% and strict/high in 20%. These findings suggest patients commonly make dietary changes motivated by a history of diverticulitis, and that further research in dietary interventions for this condition may be embraced by patients.
Diverticulitis is one of the most common gastrointestinal indications for inpatient hospital admission, outpatient clinic and emergency room visits in the United States, generating an estimated 2 billion dollars in healthcare costs annually [1, 2]. Diet and lifestyle factors are modifiable targets for prevention of diverticulitis. Specifically diets rich in fruits, vegetables, complex carbohydrates, nuts, and lean proteins are negatively associated with incident diverticulitis [3, 4]. However, diet has not been studied in the context of recurrence, and there are no proven non-surgical interventions to prevent events [5]. A Mediterranean Diet (MD) pattern that is rich in foods known to decrease the risk of diverticulitis is a promising target for secondary prevention of diverticulitis [6].
Prior observational studies of incident diverticulitis suggest that patients with a history of diverticulitis consume at least 25 g/day of fiber to reduce the risk of recurrence [7]. However, dietary patterns that consider the entire diet and interactions between individual dietary components may be more beneficial than fiber alone. A MD pattern has become well-known and the US dietary guidelines recognize it as one of the healthiest dietary patterns [8]. It has been demonstrated to reduce gut and systemic inflammation, having a pronounced and beneficial impact on the reduction of both cardiometabolic risk factors and all-cause mortality [9, 10].
However, the degree to which patients with a history of diverticulitis use different dietary modifications to prevent episodes of recurrence is unknown. We conducted a nationwide survey of individuals with diverticulitis to better assess what dietary patterns patients are adopting to prevent recurrence and their adherence to these patterns. Understanding what dietary patterns are most widely utilized and their success in adoption may be helpful in designing future dietary interventions to prevent recurrence.
We conducted a REDCap survey through Amazon Mechanical Turk (MTurk), Amazon’s crowdsourcing marketplace. Only survey responses from participants who had a self-reported history of diverticulitis were included. Survey records were excluded if they were incomplete, had suspected AI-generated responses, or contained exact duplicate responses to another record. Participants were asked to answer a series of questions related to their demographic characteristics, past and present diet patterns, and to complete a food intake questionnaire, which was used to calculate the Mediterranean Diet Adherence Screener (MEDAS) score. The MEDAS score ranges from weak adherence (0–5 points), moderate-fair adherence (6–9 points), to strong adherence (≥ 10 points). Descriptive statistics of central tendency and variability are presented overall and among subgroups. Patients were provided $2 for completing surveys.
585 surveys were completed;155 records were excluded due to no history of diverticulitis, incomplete records, or concern for AI-generated responses. A total of 430 completed surveys were included in the analysis. The mean age of respondents was 41.8 years, and 46% of respondents were female. The mean number of diverticulitis episodes was 3.6 (range 1–55) with 38% (n = 165) requiring hospitalization for a prior episode. Overall, 89% reported they had attempted to make a change to prevent diverticulitis. The most adopted dietary change among participants was a high fiber diet in 59% (257) followed by the MD in 26% (112), low fiber diets in 20% (85), and 13% (55) another dietary change. The MEDAS score was calculated in all respondents as a measure of adherence to MD principles. The average score was 6.8 (range 2–11) representing modest adherence. Among participants who described using the MD, the mean MEDAS score was 7.1 (range 3–11), with 17% exhibiting high (score 9+), 40% with modest (score 7–8) and 43% low adherences (≤ 6).
Participants were divided into quartiles based on the number of previous diverticulitis episodes they experienced (1 episode, 2 episodes, 3 episodes, and ≥ 4 episodes). Attempt at any dietary change, adoption of a high fiber diet, or adoption of the Mediterranean diet was then stratified based on quartile (Table 1). The highest percent of participants who attempted any dietary change was among those who had a history of 2 prior diverticulitis episodes (94%). Those who had 3 prior episodes most frequently attempted a high fiber diet (67%) and patients with 2 prior episodes most frequently attempted the MD (32%). Among participants who attempted to adopt the MD, all quartiles displayed moderate dietary adherence based on MEDAS scores.
Table 1Attempted dietary patterns across quartiles of diverticulitis episode frequency. Participants were divided into quartiles based on number of prior diverticulitis episodes. Attempt at any dietary change, a high fiber diet, or a mediterranean diet were stratified based on quartile. Among participants who attempted to adopt the MD, average MEDAS scores, a measurement of diet adherence, was calculated. A score ≤ 6 indicates low adherence and scores 7–8 is moderate adherence1 episodeAge(avg. years)Attempted any dietary change(%, n)Attempted high fiber diet(%, n)Attempted Mediterranean Diet (%, n)MEDAS score among MD users (avg)4186% (104)53% (64)25% (30)6.8 2 episodes4294% (115)58% (73)32% (40)7.3 3 episodes4092% (70)67% (51)24% (18)7.4≥ 4 episodes4387% (93)64% (69)22% (24)6.7
Individual dietary changes made by participants included eating more vegetables (68%), and fruits (62%). Of those who increased vegetable intake, 61% believed this was beneficial to their health while only 50% of those who increased fruit intake believed it was beneficial. Regarding the relationship between diet and diverticulitis recurrence, half (50%) of respondents agreed/strongly agreed it is “very important” to focus on the impact diet has on recurrence.
This national survey of over 300 individuals with a history of diverticulitis shows that changes in diet are widely accepted as an important strategy for preventing diverticulitis recurrence. Historically, clinicians have recommended a high fiber diet to patients after recovery from diverticulitis, so it is not surprising that this was the most common dietary change. The Dietary Guidelines for Americans first recognized a MD in 2015–2020 and a MD is becoming well known to health professionals [11]. A systemic review demonstrated that each two-point increase in adherence in the MEDAS score was associated with a 10% reduction in risk of all-cause mortality [12]. The MD also shares many features with other diets that are inversely associated with incident diverticulitis. We observed moderate adherence to a MD evidenced by MEDAS scores in both participants who intentionally adopted the Mediterranean Diet and all survey respondents (average MEDAS score 7.1 vs. 6.8 respectively).
Secondary prevention of diverticulitis currently relies on segmental colectomy, which is associated with a ~ 10% risk of major complications and does not entirely eliminate the possibility of future attacks, making secondary prevention a high priority [13]. Our study demonstrates that nearly 90% of participants attempted to make a dietary change to prevent recurrence which highlights the popularity of diet as a modifiable target for prevention. The IMPEDE Trial (Investigating Medical Management to Prevent Episodes of Diverticulitis) is an ongoing randomized clinical trial comparing the MD vs. standard high fiber recommendations on diverticulitis recurrence as well as serum and stool inflammatory biomarkers (ClinicalTrials.gov ID NCT05681559) [14]. Our study provides knowledge on what diet patterns patients are currently adopting to address barriers to the eventual development of large-scale dietary intervention studies.
Most participants increased both fruit and vegetable intake in an attempt to prevent recurrence, aligning with a MD even if a MD was not intentionally adopted. Overall, these findings suggest that while a traditional high-fiber diet remains the most adopted strategy, many patients are embracing dietary patterns consistent with the Mediterranean diet. It is important to acknowledge the numerous barriers participants face to adoption of dietary patterns as well as adherence. Food pyramids traditionally have been structured around a “western” diet pattern limiting the generalizability among all patients. The development of diet patterns based on African, Asian, and Latin heritage as well as development of recipes and grocery lists individualized to a patient’s food budget and preferences all may help with dietary adoption and adherence. Attempting to adopt a specific dietary pattern is common amongst patient’s with a history of diverticulitis and represents a target for future intervention to prevent recurrence.
Our work has several limitations. Interpreting data from large nationwide surveys must be done with caution given the self-reported more of the responses that may over or underestimate dietary behaviors. In addition, patients who were most recently affected by diverticulitis or have had more episodes may be more likely to respond, and results may not be generalizable to all patients with diverticulitis.