Keto Diet and Diverticulitis: A Comprehensive Overview

Diverticulitis, characterized by painful flare-ups, occurs when small pockets in the lining of the colon become irritated and inflamed. Diverticulosis is simply the presence of these small pockets, also called diverticula, which are formed when the muscles of the colon become too weak in certain areas. Those diagnosed know it’s worth taking measures to avoid future episodes. The risk of diverticulosis increases as we grow older, to about 70% of people aged 80 and above. The cause of this disease is complex and still poorly understood.

This article explores the potential impact of the ketogenic (keto) diet on diverticulitis, considering both potential benefits and risks.

Understanding Diverticulitis

Diverticula are fairly common, especially after age 40, but most of the time, they don’t cause any problems. An estimated 60% of all Americans will develop the condition by the time they reach age 60. When one or more of the bulging pouches gets inflamed or infected, it’s known as diverticulitis. Diverticulitis attacks are described as being especially painful. If you have diverticulitis, you might have had times when you were doubled over in pain, clutching your abdomen, typically on the lower left side. The pain might have radiated to your back, leaving you unable to function properly. In severe cases, diverticulitis attacks can lead to hospitalization and even emergency surgery.

Symptoms of Diverticulitis

Symptoms of diverticulitis include:

• Fever
• Nausea
• Vomiting
• Severe abdominal pain or tenderness
• Changes in bowel habits (constipation or diarrhea)

Complications of Diverticulitis

In rare cases, diverticula can become inflamed and infected, leading to diverticulitis and further complications:

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• Abscesses: A painful and swollen pocket of pus that causes abdominal pain, nausea, vomiting, and fever. Abscesses from diverticulitis can also be found in distant locations such as the liver, lungs, brain, and spine.
• Fistula: A fistula is an abnormal connection between organs.
• Peritonitis: A diverticulum can rupture, resulting in a painful infection in the abdomen.
• Pylephlebitis: The inflammation of the renal portal vein, the blood vessel that carries blood from the gastrointestinal tract and spleen to the liver.
• Bleeding: Diverticula tend to occur in areas where blood vessels penetrate the muscular layer of the colonic wall.

The good news is that diverticulitis only affects between 1% and 5% of people with diverticulosis.

Risk Factors for Diverticulitis

Risk factors for developing diverticulitis are obesity, advanced age, smoking, lack of exercise, and certain medications. In those younger than 50, men are more likely to develop diverticulitis and need surgical treatment, outnumbering women 3 to 1. The cause of diverticula isn’t always clear, but the pouches can appear in naturally weaker places in your colon when they give way under pressure. Diverticulitis happens when the diverticula tear, leading to inflammation and, in some cases, infection.

Treatment for Diverticulitis

Mild diverticulitis might go away with rest, while other cases require treatment. Conventional treatments for diverticulitis include diet changes, antibiotics, and, in more severe cases, surgery. Acute flare-ups of diverticulitis are treated with a clear fluid and low-residue diet for several days to allow the gut time to heal.

The Ketogenic Diet: An Overview

The ketogenic diet is a popular eating plan that involves significantly cutting carbs while increasing your intake of heart-healthy fats. The keto diet reduces your total carb intake to less than 50 grams a day. This is the equivalent of a cup of white rice. The keto diet excludes carb-rich foods like grains, beans, fruits and starchy vegetables. The keto diet is all about cutting carbs and eating more fat, similar to the Atkins diet from the 1970s. A well-formulated keto diet can be great for your health.

By depriving your body of carbs - your primary energy source - you’re forced to start burning fat instead. Roshini G. Merneedi, RD, a dietitian at Northwestern Medicine, explains that your body's primary energy source is glucose, which comes from the breakdown of carbohydrates. The keto diet limits carbohydrates, forcing your body to burn fat for fuel instead. When these stores are full, they are converted into fat. In this state, your body breaks down fats into molecules called ketones. Ketones serve as an alternative fuel source. When your body enters ketosis - burning fat instead of carbs - it makes compounds called ketones.

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Potential Benefits of the Keto Diet

The keto diet has been shown to benefit cholesterol levels, blood sugar control, weight loss, and brain health. There is evidence that the keto diet can help specific groups of people. The keto diet helps reduce seizures in children with epilepsy. Endurance athletes and body builders also use it to scrap fat in short timeframes. The keto diet is being studied for reducing symptoms for patients with progressive neurological disorders like Parkinson’s disease.

Potential Risks and Considerations of the Keto Diet

1. Because of the stringent food restrictions, many find the keto diet hard to stick to. “The ketogenic diet can be effective for weight loss when used in a short time period followed by the adoption of healthier eating habits,” says Baljash Singh Cheema, MD, a cardiologist at Northwestern Medicine Bluhm Cardiovascular Institute. “However, we know in studies of these types of diets that once people stop following that diet, they regain at least half of the weight that they lost. Ketosis is difficult to achieve because it’s like a light switch: either on or off. Individuals who consistently track food intake are more likely to remain in ketosis.
2. “Because the keto diet is so restricted, you’re not receiving the nutrients - vitamins, minerals, fibers - that you get from fresh fruits, legumes, vegetables and whole grains,” says Dr. Ring. People report feeling foggy, irritable, nauseous and tired. “In particular, low fiber intake can disrupt gut microbiota and lead to chronic constipation, while inadequate magnesium, vitamin C and potassium can contribute to muscle cramps, fatigue and weakened immune function,” explains Dr.
3. The high-fat nature of the diet could also have negative impacts on heart health. The American Heart Association recommends limiting saturated fat intake to less than 6%. “In practice, many people eat high amounts of saturated fats, which could increase your risk of heart disease,” says Dr. Cheema. “You may be eating a lot of fatty meat thinking it’s a good thing for you because it's high in fat. This can dramatically alter your lipid profile. While high-fat diets can elevate LDL (“bad”) cholesterol, the type of saturated fat matters. The bottom line is that having more fats in your diet can lead to higher cholesterol. “We know that higher cholesterol tends to increase your chances of heart attacks and strokes,” says Dr. Cheema.
4. The keto diet may not be appropriate for everyone, specifically people with kidney disease. “Although more research is needed in that area, there is some suggestion that it can make kidney disease worse over time,” says Dr. Some people also experience dehydration on the keto diet because they’re eliminating glycogen, which holds water, from the bloodstream.
5. When you micromanage your food intake by tracking how much you eat, it disconnects you from what your body is asking for. You start using outside numbers to determine what to eat instead of listening to your body. “Being intuitive and understanding what your body needs is essential for proper nourishment,” says Merneedi. Monitoring food so closely can lead to psychological distress, such as shame and binge eating.
6. The keto diet can cause your blood pressure to drop in the short term due to a reduction in blood volume and changes in your fluid balance. Symptoms of low blood pressure include dizziness, lightheadedness or fainting, especially when standing up quickly. Following a keto diet can also cause your blood sugar to drop, which can be dangerous for people living with diabetes. Common symptoms of low blood sugar include weakness or shaking, sweating, a fast heartbeat and dizziness.

Keto Diet and Gut Health: Potential Impacts

This article examines how the keto diet affects gut health.

Potential Negative Impacts

Several studies indicate that the keto diet may harm your digestion in the following ways.

• May be lower in fiber: The keto diet eliminates high-carb foods like fruits, starchy vegetables, grains, and legumes. Many of these foods are also high in fiber, an essential nutrient for digestion. Fiber passes through your digestive tract slowly, helping maintain bowel regularity. Insufficient fiber intake could increase your risk of constipation. High fiber intake is also thought to protect against several digestive disorders, including hemorrhoids, stomach ulcers, gastroesophageal reflux disease (GERD), and diverticulitis.
• May alter your gut microbiome: The microorganisms in your digestive tract are collectively known as the gut microbiome. It’s thought to play a central role in several aspects of health, including digestion, immune function, mental health, and disease prevention. Some research notes that the keto diet could damage the concentration and composition of your gut bacteria. One 6-month study in 217 people linked a high-fat diet to several unfavorable gut changes, including increased inflammation and reduced beneficial fatty acids. Another study in 23 children with epilepsy showed that 3 months of the keto diet damaged gut microbiome composition, compared with a control group.

Potential Positive Impacts

Interestingly, some research suggests that the keto diet could benefit digestive health.

• May reduce inflammation: Acute inflammation is an immune response that protects your body against illness and infection. However, chronic inflammation may contribute to inflammatory disorders, including digestive issues like Crohn’s disease and ulcerative colitis. Some studies suggest that the keto diet could help decrease inflammation in your body. A 6-month study in 59 people found that following a low-carb diet decreased several markers of inflammation to a greater extent than following a low-fat diet.
• May benefit some digestive disorders: The keto diet may also aid some digestive disorders. For instance, in a study in 13 people, a very-low-carb diet improved multiple symptoms of irritable bowel syndrome (IBS), a disorder that causes issues like gas, stomach cramps, and diarrhea. Other studies note that limiting specific types of carbs known as FODMAPs may also help treat IBS symptoms. Given that the keto diet naturally limits many foods rich in FODMAPs, it may benefit those with IBS. What’s more, a 15-month case study of a 14-year-old boy reported that following a combined keto and paleolithic diet relieved symptoms and side effects of Crohn’s disease.

Keto Diet and Diverticulitis: The Connection

Unfortunately, no high-quality studies have looked specifically at the ketogenic diet and diverticulitis. However, scientific and anecdotal evidence tells us that a ketogenic diet reduces metabolic syndrome, obesity, and chronic inflammation in numerous ways, such as by removing problematic sugar and refined carbohydrates from the diet. The keto diet has been shown to benefit the digestive system, lower inflammation, and boost overall health, so it’s likely it could also benefit diverticulitis.

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A healthy, well-formulated ketogenic diet certainly isn’t the standard Western diet of burgers and fries, sugary milkshakes and candy, cakes and chips, and a lack of quality veggies, protein, and fats. Diverticular disease appears far more frequently in Westernized countries, leading many health advocates and experts to comment that it’s likely a disease of Western civilization, and nutrition and lifestyle factors could help. As people adopt a Western lifestyle heavy in carbohydrates, sugar, and processed foods, the incidence of diverticular disease increases, including in places like Asia and Africa, where the condition used to be especially rare.

How Keto May Help with Diverticulitis

To summarize, a ketogenic diet may reduce the risk of diverticulitis and flare-ups by:

• Reducing chronic inflammation with powerful ketones like beta-hydroxybutyrate.
• Strengthening the mitochondria and promoting the growth of new mitochondria.
• Increasing your body’s antioxidant production.
• Supporting healthy gut bacteria by including more nutritious low-carb foods and prebiotic fiber and ditching refined sugars and carbohydrates.
• Increasing workout performance and exercise, which has been shown to improve diverticulitis.

Dietary Considerations for Diverticulitis and Keto

When it comes to diet and diverticulitis, different experts have different opinions. Some believe food doesn’t play a big role, while others believe dietary changes can be pivotal in managing this condition.

Fiber: A Balancing Act

The effect of fiber on diverticulitis varies, with one camp of researchers and doctors believing low fiber is the way to go and the other believing fiber improves colon health and gut motility. Recent research shows dietary fiber can improve bowel function and reduce symptoms of diverticular disease. To add to this, other studies reveal that a low fiber diet could heighten the risk of diverticulitis. Fiber softens stools and makes them easier to pass. However, results from clinical trials have been inconsistent. Nonetheless, doctors and medical organizations continue to recommend high-fiber foods for patients with diverticulosis.

Foods high in fiber include veggies and beans. Drink plenty of water and stay hydrated when adding more fiber to your keto diet. Keep in mind that during a diverticulitis flare-up, fiber could bulk up the stool and increase colon contractions, potentially making matters worse or more painful, so it might be best to lower fiber intake during a flare-up. Low fiber foods include cooked animal proteins like poultry, fish, and eggs, cooked spinach, beets, asparagus, and healthy oils like olive oil.

Low-FODMAP Approach

A low-FODMAP diet is one popular recommendation. FODMAPS refers to types of carbohydrates: fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. On a low-FODMAP diet, you limit or avoid foods higher in FODMAPS, such as:

• Fermented foods like sauerkraut or kimchi
• Fruits like apples and pears
• Legumes and beans
• Foods high in trans fats
• Veggies like Brussel sprouts, onion, garlic, and cabbage
• Soy protein

Some researchers found that a low FODMAP diet prevented high pressure in the colon, which could possibly be helpful for diverticulitis. Note that I’ve modified this to be low FODMAP, as the new evidence strongly indicates minimizing problem FODMAPs is beneficial for diverticulitis patients. Portion sizes of low FODMAP foods is extremely important for a diverticulitis diet, so please make sure you are not exceeding the recommendations.

The Role of Sugar and Problematic Foods

Once again, sugar could be problematic for diverticulitis and inflammatory gastrointestinal conditions. Acellular carbohydrates like flour and sugar are common in the standard American diet. They have a high carbohydrate density and promote inflammatory gut microbiota, which could possibly aggravate diverticulitis. Cellular carbohydrates like whole fruits are different and promote gut health by fueling anti-inflammatory gut bacteria. A keto diet requires a significantly reduced sugar intake, so, in theory, it could be a useful nutritional tool or adjunct therapy for diverticulitis.

Nuts and Seeds: Clearing Up Misconceptions

One prevailing theory is that hard, undigested bits of food like nuts and seeds get caught in the diverticular pouches and irritate them, but there’s no scientific evidence to back up this theory. In fact, a 2008 large prospective study following over 47,000 men for over 18 years found no relationship between diverticulitis and eating nuts, seeds, and popcorn. Men who ate the most popcorn and nuts actually had less diverticulitis than men who ate the least. So evidence is really a mixed bag, it might be better to err on the side of caution and avoid seeds at least.

Gut Bacteria and Probiotics

Gut bacteria are involved in the development of diverticular disease, according to a 2016 study. Studies show that a variety of different probiotic strains are effective in reducing symptoms of diverticulitis. Probiotics have also been successfully combined with the anti-inflammatory drug Mesalamine to help reduce symptoms of diverticulitis. Probiotic supplements are also a great option, but recommended strains and dosage have yet to be determined. Consuming fiber-rich foods and probiotics along with a well-formulated nutritious diet of natural whole foods can boost the health of your gut microbiome-the microorganisms in your gut. There is also some evidence that probiotics (particularly some strains of lactobacilli) are useful for treating symptoms.

Gut-Friendly Keto Foods

You can easily enjoy several gut-friendly foods as part of a healthy keto diet. Foods low in carbs but high in gut-boosting benefits include:

• Avocados: Avocados are not only rich in heart-healthy fats but also fiber, supplying a whopping 10 grams of fiber per cup (150 grams).
• Leafy greens: Vegetables like arugula, spinach, kale, and cabbage are low in carbs while high in fiber and other beneficial nutrients like antioxidants and vitamins C and K.
• Coconut oil: Some animal studies suggest that coconut oil may reduce inflammation and boost the gut microbiome.
• Kimchi: This staple Korean dish is made from vegetables like cabbage that have undergone fermentation, which boosts their content of beneficial bacteria to support gut health.
• Butter.

Lifestyle Considerations

A well-formulated keto diet can be great for your health. But diet alone won’t help prevent diverticulitis. These results suggest that high-intensity cardio may help prevent diverticulitis. It’s worth mentioning that this study only examined the effects of running and jogging.

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