Management of Diverticulosis
For asymptomatic diverticulosis, recommend a high-quality, fiber-rich diet (20-30 grams daily from fruits, vegetables, whole grains, and legumes) combined with regular vigorous physical activity, maintaining normal body weight, and smoking cessation—no antibiotics, no routine imaging, and no dietary restrictions on nuts, seeds, or popcorn are needed. 1
Dietary Management
Primary Recommendation:
- Aim for >22.1 grams of fiber daily, as this threshold demonstrates statistically significant protective effects against progression to diverticulitis 1
- Prioritize dietary fiber sources over supplements alone, with fiber from fruits showing the most protective benefit compared to other sources 1
- Gradually increase fiber intake to minimize abdominal bloating and improve tolerance 1
- A high-quality diet should be high in fiber from fruits, vegetables, whole grains, and legumes while low in red meat and sweets 2
What NOT to Restrict:
- Do not advise patients to avoid consumption of nuts, seeds, popcorn, or small-seeded fruits—this outdated recommendation lacks evidence and may actually reduce beneficial fiber intake 3, 1
Lifestyle Modifications
Physical Activity and Weight Management:
- Advise patients to engage in vigorous physical activity regularly, as this decreases the risk of progression to diverticulitis 3, 2
- Recommend achieving or maintaining normal body mass index, as obesity increases diverticulitis risk 2, 1
Medication Considerations:
- Advise patients to avoid nonaspirin NSAIDs when possible, as these medications are associated with increased risk of diverticulitis 3, 2
- Aspirin use does not need to be routinely avoided 3
- Minimize opioid use when possible, as opioids increase diverticulitis risk 1
Smoking Cessation:
- Strongly recommend smoking cessation, as smoking is an established risk factor for disease progression 2, 1
What NOT to Do
Critical Pitfalls to Avoid:
- Do not prescribe chronic antibiotics prophylactically—there is no role for mesalamine, rifaximin, or probiotics in preventing progression of asymptomatic diverticulosis 3, 1
- Do not order routine imaging or colonoscopy for asymptomatic diverticulosis 1
- Do not rely solely on fiber supplements instead of dietary modification 1
Genetic Considerations
- Counsel patients that approximately 50% of diverticulitis risk is attributable to genetic factors, so family history matters in risk stratification 2, 1