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Is There Really Anything New on Dietary Fiber in Colonic Diverticular Disease?
Clinical Gastroenterology and Hepatology 2014;-:1
LETTERS TO THE EDITOR Readers are encouraged to write letters to the editor concerning articles that have been published in Clinical Gastroenterology and Hepatology. Short, general comments are also considered, but use of the Letters to the Editor section for publication of original data in preliminary form is not encouraged. Letters should be typewritten and submitted electronically to http://www. editorialmanager.com/cgh.
Is There Really Anything New on Dietary Fiber in Colonic Diverticular Disease? Dear Editor: The editors of Clinical Gastroenterology and Hepatology are to be complimented on gathering 3 articles on diverticular disease1–3 and publishing them with an excellent editorial by Burgell et al.4 In the first article, Shahedi et al1 reviewed 2222 patients with baseline colonic diverticulosis over an 11-year follow-up period from the Veterans Affairs Greater Los Angeles Healthcare System. The data showed that only about 4% of patients with diverticulosis developed acute diverticulitis, which contradicted the common belief that diverticulosis has a high rate of progression.5–7 However, one must keep in mind this information is limited and did not include the entire population of Los Angeles but only the Veterans Affairs patients. This is somewhat contrary to the large amount of data that we reviewed with our National Diverticulitis Study Group that was reported in 3 review articles.5–7 Most studies show a greater rate than 7%.7 Cohen et al,2 working with the same group at the Veterans Affairs as Shahedi et al, reviewed the Veterans’ data carefully, and they found that cases were 4.7-fold more likely to be diagnosed later in life with irritable bowel syndrome and functional bowel disorders. They proposed calling this disorder postdiverticulitis irritable bowel syndrome. I am sure many clinicians have had this experience, and this is a concept worthy of further evaluation. Certainly, because we do not know the exact cause of diverticular disease or most irritable bowel syndromes, it is fertile ground to investigate. In the third article, Peery et al3 again submit data concluding that constipation and a low-fiber diet are not associated with diverticulosis. Some of this material was published in Gastroenterology in 2012. It was reviewed thoroughly by Strate et al.8,9 Studies from Great Britain
on the role of dietary fiber have substantiated the concept that deficiency of dietary fiber was important in the role of colonic diverticular formation.10 Certainly, our extensive reviews of the literature and the analysis by Strate et al9 confirmed that the dietary fiber hypothesis is still important. The editorial by Burgell4 et al that analyzed this information is important. It is important for us to keep an open mind because we do not really know the exact mechanisms and only have theories of the cause of diverticular formation. Nevertheless, to quote the editorial, “Overall, there are still considerable benefits to fiber (such as preventing constipation or improving cholesterol management) with minimal risk. Based on the available evidence to date, we should continue to recommend a high-fiber intake as part of a healthy diet.”4 Although Clinical Gastroenterology and Hepatology have published important articles on the subject, there really is nothing new on the fiber hypothesis. MARTIN H. FLOCH, MD Section of Digestive Diseases Yale University School of Medicine New Haven, Connecticut
References 1. Shahedi K, et al. Clin Gastroenterol Hepatol 2013;11:1609–1613. 2. Cohen E, et al. Clin Gastroenterol Hepatol 2013;11:1614–1619. 3. Peery AF, et al. Clin Gastroenterol Hepatol 2013;11:1622–1627. 4. Burgell RE, et al. Clin Gastroenterol Hepatol 2013;11:1628–1630. 5. Bogardus ST Jr. J Clin Gastroenterol 2006;40:S108–S111. 6. Korzenik JR. J Clin Gastroenterol 2006;40:S112–S116. 7. Sheth AA, et al. Am J Gastroenterol 2008;103:1550–1556. 8. Strate LL. Gastroenterology 2012;142:205–207. 9. Strate LL, et al. JAMA 2008;300:907. 10. Crowe FL, et al. BMJ 2011;343:d4131. Conflicts of interest The author discloses no conflicts. http://dx.doi.org/10.1016/j.cgh.2014.01.015
LETTERS TO THE EDITOR Readers are encouraged to write letters to the editor concerning articles that have been published in Clinical Gastroenterology and Hepatology. Short, general comments are also considered, but use of the Letters to the Editor section for publication of original data in preliminary form is not encouraged. Letters should be typewritten and submitted electronically to http://www. editorialmanager.com/cgh.
Is There Really Anything New on Dietary Fiber in Colonic Diverticular Disease? Dear Editor: The editors of Clinical Gastroenterology and Hepatology are to be complimented on gathering 3 articles on diverticular disease1–3 and publishing them with an excellent editorial by Burgell et al.4 In the first article, Shahedi et al1 reviewed 2222 patients with baseline colonic diverticulosis over an 11-year follow-up period from the Veterans Affairs Greater Los Angeles Healthcare System. The data showed that only about 4% of patients with diverticulosis developed acute diverticulitis, which contradicted the common belief that diverticulosis has a high rate of progression.5–7 However, one must keep in mind this information is limited and did not include the entire population of Los Angeles but only the Veterans Affairs patients. This is somewhat contrary to the large amount of data that we reviewed with our National Diverticulitis Study Group that was reported in 3 review articles.5–7 Most studies show a greater rate than 7%.7 Cohen et al,2 working with the same group at the Veterans Affairs as Shahedi et al, reviewed the Veterans’ data carefully, and they found that cases were 4.7-fold more likely to be diagnosed later in life with irritable bowel syndrome and functional bowel disorders. They proposed calling this disorder postdiverticulitis irritable bowel syndrome. I am sure many clinicians have had this experience, and this is a concept worthy of further evaluation. Certainly, because we do not know the exact cause of diverticular disease or most irritable bowel syndromes, it is fertile ground to investigate. In the third article, Peery et al3 again submit data concluding that constipation and a low-fiber diet are not associated with diverticulosis. Some of this material was published in Gastroenterology in 2012. It was reviewed thoroughly by Strate et al.8,9 Studies from Great Britain
on the role of dietary fiber have substantiated the concept that deficiency of dietary fiber was important in the role of colonic diverticular formation.10 Certainly, our extensive reviews of the literature and the analysis by Strate et al9 confirmed that the dietary fiber hypothesis is still important. The editorial by Burgell4 et al that analyzed this information is important. It is important for us to keep an open mind because we do not really know the exact mechanisms and only have theories of the cause of diverticular formation. Nevertheless, to quote the editorial, “Overall, there are still considerable benefits to fiber (such as preventing constipation or improving cholesterol management) with minimal risk. Based on the available evidence to date, we should continue to recommend a high-fiber intake as part of a healthy diet.”4 Although Clinical Gastroenterology and Hepatology have published important articles on the subject, there really is nothing new on the fiber hypothesis. MARTIN H. FLOCH, MD Section of Digestive Diseases Yale University School of Medicine New Haven, Connecticut
References 1. Shahedi K, et al. Clin Gastroenterol Hepatol 2013;11:1609–1613. 2. Cohen E, et al. Clin Gastroenterol Hepatol 2013;11:1614–1619. 3. Peery AF, et al. Clin Gastroenterol Hepatol 2013;11:1622–1627. 4. Burgell RE, et al. Clin Gastroenterol Hepatol 2013;11:1628–1630. 5. Bogardus ST Jr. J Clin Gastroenterol 2006;40:S108–S111. 6. Korzenik JR. J Clin Gastroenterol 2006;40:S112–S116. 7. Sheth AA, et al. Am J Gastroenterol 2008;103:1550–1556. 8. Strate LL. Gastroenterology 2012;142:205–207. 9. Strate LL, et al. JAMA 2008;300:907. 10. Crowe FL, et al. BMJ 2011;343:d4131. Conflicts of interest The author discloses no conflicts. http://dx.doi.org/10.1016/j.cgh.2014.01.015