What is the recommended diet for managing recurrent diverticulitis flares?

Diet Management for Recurrent Diverticulitis Flares

A high-fiber diet is recommended for patients with recurrent diverticulitis flares, as it may help reduce the risk of future episodes and complications. 1 While the evidence quality is very low, fiber supplementation is considered beneficial with minimal risk to patients.

Recommended Dietary Approach

High-Fiber Diet Components

• Fruits and vegetables: Incorporate a variety of fresh produce daily
• Whole grains: Choose whole wheat bread, brown rice, oats, and other unrefined grains
• Legumes: Include beans, lentils, and peas regularly
• Fiber supplements: Consider psyllium or methylcellulose if dietary intake is insufficient

The American Gastroenterological Association (AGA) suggests a fiber-rich diet or fiber supplementation for patients with a history of acute diverticulitis 1. This recommendation is based on the understanding that while direct evidence for preventing recurrence is limited, fiber intake is unlikely to pose substantial risk and may provide benefit.

Foods That Do NOT Need to Be Avoided

• Nuts and popcorn: Contrary to old beliefs, these do not need to be avoided 1
• Seeds and small-seeded fruits: Strawberries, blueberries, and other small-seeded fruits are safe 1
• Corn: No evidence supports restricting corn consumption 1

The AGA explicitly recommends against advising patients to avoid nuts and popcorn, as observational studies show no increased risk and possibly even a protective effect 1, 2.

Additional Dietary and Lifestyle Considerations

Beneficial Approaches

• Mediterranean dietary pattern: High in fiber from fruits, vegetables, whole grains, and legumes; low in red meat and sweets 1
• Vegetarian diet: Associated with decreased risk of diverticulitis 1
• Vigorous physical activity: The AGA suggests advising patients to consider vigorous physical activity to reduce risk 1

Items to Avoid or Limit

• Non-aspirin NSAIDs: The AGA suggests avoiding these medications when possible, as they are associated with a moderately increased risk of diverticulitis 1
• Red meat and sweets: These should be limited as part of an overall healthy diet pattern 1

Important Clinical Considerations

Medication Management

• Aspirin: The AGA suggests against routinely advising patients to avoid aspirin, as its cardiovascular benefits may outweigh the slight increased risk of diverticulitis 1
• Mesalamine, probiotics, and rifaximin: The AGA recommends against using these medications to prevent recurrent diverticulitis 1

Common Pitfalls to Avoid

1. Outdated dietary restrictions: The long-standing recommendation to avoid nuts, seeds, and popcorn has been debunked 1, 3, 4
2. Overreliance on fiber supplements alone: Supplements should not replace a high-quality diet 1
3. Ignoring patient tolerance: Some patients may experience bloating with increased fiber; gradual introduction may improve tolerance 1

Monitoring and Follow-up

• Gradually increase fiber intake to minimize bloating and discomfort
• The optimal daily dose of fiber necessary to achieve benefit is not well defined 1
• Consider individual patient preferences and side effects when counseling about fiber intake 1

While the evidence for high-fiber diet in preventing recurrent diverticulitis is of very low quality 5, it remains a standard recommendation in clinical practice due to its safety profile and potential benefits for overall digestive health.