Understanding How to Prevent Diverticular Disease

By Frederick Gandolfo MD,

man holding stomach in pain

Diverticular disease is the term that covers both diverticulosis and diverticulitis. While almost everyone has heard these terms, many people still mix up the difference between diverticulosis and diverticulitis. Furthermore, there is a lot of misinformation out there regarding these common conditions, so it’s time to review what is new in the world of diverticular disease!

Let’s start with some basics: The tiny pockets that occur on the outside of the colon that we call diverticula are actually better described as pseudodiverticula (false diverticula) due to the fact that they only contain the inner two layers of the colon wall, called the mucosa and submucosa.

These inner two layers that form the lining of the bowel become pseudodiverticula by herniating through small natural weak points in the muscle layer of the colon. The weak points exist as natural openings where small blood vessels called vasa recta penetrate the bowel wall to feed blood to the inner layers of the colon. For various reasons that we will cover below, the inner mucosal and submucosal layers of the colon can pop through these openings and luckily will become contained by the outermost layer of the colon (called serosa) to form a small pocket, now called a diverticula.

Since pseudodiverticula is a mouthful, people just refer to these pockets as diverticula. The condition of simply having these small pockets is called diverticulosis.

Diverticulosis is typically asymptomatic, but can also cause several symptoms. Minor symptoms of constipation and chronic left lower abdominal discomfort may be related to diverticulosis and are thought to be caused by altered colon motility (loss of normal movement), narrowing of the colon, loss of compliance (lack of “stretchiness”) of the left side of the colon, and mild inflammation of the bowel in the affected area. The symptoms of diverticulosis often overlap with symptoms of a condition called irritable bowel syndrome (IBS).

The more severe complications of diverticulosis are diverticular bleeding and diverticulitis.

Diverticular bleeding is typically painless and may present as massive bleeding. Fresh red blood is usually passed from the rectum as one of the small penetrating vasa recta arteries ruptures and bleeds into the bowel lumen (inside the colon). Diverticular bleeding often results in hospitalization, and may require blood transfusion and/or procedures to control bleeding such as colonoscopy, angiography with embolization, and even surgery if the bleeding does not stop. Fortunately, most cases of diverticular bleeding are self-limited, that is, the bleeding stops on its own and the treatment mainly consists of supportive care.

Diverticulitis is the term used to describe inflammation of a diverticula and the surrounding segment of colon. This is typically quite a painful process and is often associated with a fever, sometimes constipation, and decreased appetite. The abdominal pain from acute diverticulitis is often present in the mid lower abdomen, the left lower abdomen, or a combination of both of these sites.

Laboratory testing in acute diverticulitis will often reveal an elevated white blood cell count and elevated inflammatory markers such as C-reactive protein (CRP). A CT scan of the abdomen and pelvis is the diagnostic test of choice, and will reveal a thickened and inflamed bowel wall, often with inflammatory changes extending outside the bowel wall into the surrounding fatty tissues, and possibly with evidence of “microperforation” or other complications. Treatment typically involves antibiotics, bowel rest or a limited diet, and local management of any complications (such as draining an abscess). Eventually surgical resection may be needed in cases of complicated or recurrent diverticulitis.

Now that we have reviewed the basics, I would like to cover some of the common questions that I get asked by patients about diverticular disease.

How did I get diverticulosis?

Diverticulosis is often though of as a disease of Western society, and is associated with several diet and lifestyle factors. Most notably, diverticular disease is associated with a low-fiber diet, a diet high in processed foods and red meat, a sedentary lifestyle, obesity, and smoking.

However, diverticular disease also has a genetic component. It is likely that genetic factors and lifestyle factors both play a role in developing diverticular disease.

Age is also a factor: The older you become, the higher the likelihood that you will develop diverticulosis!

Is there a special diet to follow for diverticulosis?

Yes! To prevent diverticulosis, you should eat a high-fiber diet of mostly plants, whole grains, and legumes. A high-fiber diet means about 30 grams of fiber a day for women, and about 35 grams of fiber a day for men, but more is better (to a point).

However, a high-fiber diet is not the whole picture! It is also important to eat anti-inflammatory foods such as seeds, nuts, fish, and olive oil! Diverticular disease is an inflammatory process, and foods like red meat, processed meat (bacon etc.), and processed carbs (sweets, snack foods, fast foods, etc.) are pro-inflammatory and can cause issues like diverticulitis to occur more frequently.

Can I eat seeds and nuts if I have diverticulosis?

Yes you can! It is not necessary to avoid seed and nuts if you have diverticular disease. Probably the best evidence we have that seeds, nuts, corn, and popcorn do not cause complications in patients with diverticular disease comes from a study published in JAMA in 2008 showing that not only was intake of nuts, seeds, popcorn, and corn NOT associated with developing diverticulitis, but in fact the opposite was true. Eating more seeds, nuts, corn, and popcorn actually seemed to be associated with LESS of a chance of developing diverticulitis! These foods are thought to be somewhat anti-inflammatory, and therefore may protect against diverticulitis.

What other lifestyle factors should I consider if I have diverticulosis?

The big four things to consider with diverticular disease (and every other disease) are smoking, alcohol use, obesity, and exercise.

Smoking: Bad in every way and increases inflammation throughout the body. Smoking is associated with diverticulitis. Smoking is also associated with poor wound healing after surgery. Don’t do it! (If you’re serious about quitting, ask your primary care doctor for help.)

Alcohol: Not great for your colon and can sometimes cause inflammation in the bowel. To be enjoyed sparingly.

Obesity: Associated with total-body inflammation and correlated with diverticular disease. Increases risk of surgery if needed for diverticular disease. (If you suffer from obesity, the best time to start working on your weight was 10 years ago, and the second best time is today! Check out my simple starter plan here.)

Exercise: Aside from the role of exercise in weight loss, exercise also promotes a healthy colon, and can help keep your other healthy lifestyle changes in check by creating a positive-feedback cycle. Try to do a little exercise every day, or at least four days a week!

Does diverticulosis ever go away?

No, not really. Once the pockets are there, they don’t regress and disappear. They’re similar to wrinkles in that way. However, the goals are to prevent new diverticula from forming and to prevent the pockets that are there already from worsening or developing complications such as diverticulitis.

Following a healthy diet and lifestyle is still important, even if it won’t turn back time and remove the diverticula from your colon! In fact, it is estimated that you can reduce your risk of developing diverticulitis by up to 75% by following the basic diet and lifestyle advice above!

New knowledge about diverticular disease

“Old School”“New Knowledge”
Diverticulosis is caused by constipationDiverticulosis may be associated with constipation but no causative role has been established
Diverticulosis is caused by a lack of dietary fiberDiverticulosis is related to a low-fiber Western diet, but fiber may not be the most important factor
Seeds and nuts are dangerous and should be avoided!Eat as many seeds and nuts as you want. The more the better actually!
Diverticular disease affects elderly people onlyDiverticular disease is common in young people (especially men) and the prevalence is rising!
Diverticular disease just happens to people randomlyThere is a strong genetic predisposition to diverticular disease. It might be your parents fault!
Diverticular disease is due to small pockets herniating through the colon wall, a purely mechanical process due to high pressures in the colonDiverticular disease is an inflammatory condition, and there are chronic cellular changes found throughout the entire colon wall
Lifestyle and diet are not associated with diverticular diseaseThe Western diet and lifestyle (obesity, smoking, high red meat intake, alcohol use, and physical inactivity) dramatically increases the risk of diverticular disease!


Diverticulosis and diverticulitis are very common diseases. Many people have mild cases of diverticular disease and never need medical attention, but there are several common complications of diverticulosis that do require medical attention and can be quite dangerous.

Overall, the paradigm is shifting and we are beginning to think of diverticular disease as a type of inflammatory condition with a genetic predisposition, rather that purely a mechanical problem related to constipation and high pressures in the colon.

Following a healthy diet and lifestyle can dramatically reduce your risk of suffering complications from diverticular disease, so make sure to eat your vegetables, limit processed foods and red meat, get a little exercise every day, stop smoking, and work on maintaining a normal body weight.

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Lose weight and get healthier with my free 40-day fitness program!

By Frederick Gandolfo MD,

fit woman and man after workout
fit woman and man after workout

Is it finally time for you to make that healthy lifestyle change you’ve been thinking about?

As a GI doctor, I hear all of these statements on a daily basis from my patients:

  • “I can’t seem to lose weight no matter what I do!”
  • “I feel tired and sluggish all the time. What can I do?”
  • “I am bloated and inflamed all day. What should I be eating?”
  • “I want to get off all of these pills but my reflux is out of control! Help!”
  • “I want to start doing something about my fatty liver disease, but where do I start”

It’s no secret that weight loss, healthy eating, exercise, and lifestyle change in general is hard and frustrating work! But I believe that anyone can start down the path of healthy living by making small changes right now and taking things one day at a time! 

To help you get started, I created a unique system called MDFITRx! It’s designed for beginners and will take you from wherever you are right now and get you well on your way to creating a healthier you!

My free program teaches you everything you need to know to get started:

  • Learn how to eat for health in the real-world
  • Learn simple body-weight exercises that you can do at home with no equipment and with limited time
  • Learn how to plan your day for success and reach your goals
  • Get the psychological tools and tactics needed to remain disciplined and consistent over the long-run

The free program is called Q15 and is specifically designed to kick-start a serious lifestyle change! So if you have tried and failed before, of if you have never tried at all, here is another chance at improving your health the natural way by good old-fashioned hard work…without pills, powders, supplements, or crazy restrictive diets! Learn more about Q15.

When you sign up, you will get access to:

  • a 100+ page ebook with all the basic information you need to get started
  • a bunch of my favorite go-to healthy recipes
  • the workout plan with video demonstrations that you can scale down to almost any fitness level
  • workout logs so you can chart your daily progress
  • 40 days of weekly emails that cover more advanced topics about fitness, motivation, discipline, and nutrition (the best part of the program!)
  • a whole bunch of interesting videos to keep you motivated and educated!

Get the free Q15 program from MDFITRx today!

Fitness is for everybody! Feel free to share the program with a friend or a loved one!

-Dr. Gandolfo

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VIDEO: See how a gastroenterologist does the colonoscopy prep!

By Frederick Gandolfo MD,

In this video, Dr. Gandolfo will show you what NOT to do if you want to have an easier colonoscopy prep experience. He will also share five tips to help you handle the pre-colonoscopy clean-out like a champ!

If you want more information about colonoscopy, be sure to download our free ebook today! It will answer any question you can think of about colonoscopy, even questions you didn’t know you had!

Click the picture of the book below to get it delivered to your inbox!

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Video: How to prevent colorectal cancer!

By Frederick Gandolfo MD,

March is Colorectal Cancer Awareness Month, but this video holds true all year!

Dr. Gandolfo will review the basics about colon cancer here: What it is, how to prevent it with diet and lifestyle, and how to get screened for this common and deadly disease.

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Is your gas and bloating due to small intestinal bacterial overgrowth (SIBO)?

By Frederick Gandolfo MD,

Excessive gas and abdominal bloating are two of the most common reasons why patients seek the help of a gastroenterologist. In fact, who hasn’t suffered from gas and bloating on occasion? Many times these symptoms are just normal unfortunate byproducts of digestion, and can be caused by eating high-fiber foods, or certain foods that are commonly associated with gas production (e.g., broccoli, beans, onions).

But what about when this excess gas and bloating is present all or most of the time? What about when you have associated symptoms of nausea, abdominal discomfort, diarrhea, and even fatigue and loss of concentration? Searching Google for these terms will bring up the following diseases as possibilities: irritable bowel syndrome (IBS), Crohn’s disease, ulcerative colitis, lactose intolerance, stomach ulcers, H. pylori infection, pancreatic cancer and several other types of cancer, parasites, Whipple disease, Giardiasis, depression, and about twelve other conditions that are either very common or very dangerous. The point is, these symptoms are both common and vague: That is, many different diseases can present with nausea, abdominal bloating, gas, and fatigue. One of these diseases is the condition known as small intestinal bacterial overgrowth (SIBO).

What is SIBO?

SIBO is defined as “a clinical syndrome of GI symptoms caused by the presence of excessive numbers of bacterial within the small intestine.” In layman’s terms, SIBO is when normal (or sometimes abnormal) bacteria that are usually found in the small intestine in low quantities are allowed to multiply and as a result cause distressing symptoms due to their metabolic activity in the small intestine. The small intestine is normally where the products of digestion of food are absorbed into the body. Instead with SIBO, the excess bacteria will feed on your nutrients, possibly causing malabsorption and/or the breakdown of the normal mucosal barrier of the bowel leading to inflammation or immune activation. This can cause the symptoms you may feel as bloating, distension, gas, pain, diarrhea, and “inflammation.”

Who is at risk for SIBO?

There is usually always an underlying cause of SIBO. That is, the normal healthy person who has no risk factors for SIBO usually doesn’t get it!

That being said, there are a host of conditions that put one at risk for developing SIBO. If you have one or more of these conditions, it may be worth considering SIBO as a possible cause of your bloating, gas, and other related symptoms:

  • Irritable bowel syndrome (IBS)
  • History of prior intestinal surgery
  • Diabetes
  • Gut motility disorders
  • Opiate use
  • Chronic proton pump inhibitor (PPI) use
  • Tumors or diverticular disease of the small bowel
  • Pancreatic disease
  • Celiac disease
  • Cirrhosis
  • Immune deficiencies (HIV, IgA deficiency, etc.)
  • Scleroderma
  • Advanced age
  • Miscellaneous conditions such as Parkinson disease, chronic kidney disease, amyloidosis, hypothyroidism, alcoholism, cystic fibrosis, multiple sclerosis, and several others.

What are the symptoms of SIBO?

The most common symptom of SIBO is bloating. Excess gas, flatulence, nausea, abdominal distension, cramping, pain, diarrhea, and even constipation have been attributed to SIBO. Other more systemic complaints such as fatigue, joint pains, loss of motivation, and poor concentration (so-called “brain fog”) are often attributed to SIBO but there is little actual evidence that SIBO causes these issues. That being said, it is hard to design a scientific study to evaluate the presence or absence of something as nebulous as “brain fog.”

In severe cases of SIBO, patients can develop steatorrhea (greasy stools that cling to the toilet bowl, a sign of fat malabsorption), weight loss, anemia, and deficiencies in vitamin B12, iron, and fat soluble vitamins such as vitamin D.

How do you test for SIBO?

The most practical way to test for SIBO is by performing a hydrogen breath test. This test is easy, noninvasive, and widely available. The basic idea is that human cells do not produce hydrogen, while bacterial cells do. If you feed sugar or other substances to gut bacteria, hydrogen is produced and diffuses into the blood stream and is exhaled in the breath. Since the small intestine usually should have a very low concentration of bacteria, drinking sugar water should not produce much hydrogen from the small bowel. If some of this sugar gets to the large intestine, which is replete with bacteria, then large amounts of hydrogen are normally produced.

By giving some sugar or other substance (usually lactulose) to a person, and taking serial breath hydrogen samples over the course of a few hours, we can determine if there is a significant small bowel bacterial load based on the hydrogen response. If there is no increase in breath hydrogen measured by 90 minutes after drinking the sugar water, then there is no SIBO. That is unless the patient is producing methane!

Methane is another volatile gas that is produced by certain gut organisms called methanogenic archaea (technically different from bacteria). In the minority of patients with SIBO, the hydrogen that the excess small bowel bacteria produce is rapidly converted into methane by these methanogenic gut organisms, and therefore there is no elevation in the exhaled hydrogen (because it’s all used up by the bacteria), which leads to a false-negative hydrogen breath test for SIBO. To avoid this issue, there also exists a breath test for methane. This will eliminate the issues of missing patients with SIBO who produce methane instead of hydrogen. However, the cost of the equipment to measure methane is somewhat prohibitive, and therefore the methane breath test is less widely-available than the hydrogen breath test.

Interestingly, patients who produce methane have an increased risk of developing constipation associated with SIBO, rather than diarrhea. So methane testing should be considered in patients with risk factors for SIBO, with a negative hydrogen breath test, and who have constipation as one of the symptoms.

Breath testing is by no means a perfect test however. There are many ways that a breath test can give a false-positive and a false-negative result. That being said, breath tests are the most convenient way to currently diagnose SIBO, outside of invasive procedures done mainly for research studies.

This hand-held machine measures hydrogen levels in the breath and is what we use to test for SIBO.

What is the treatment for SIBO?

The treatment for SIBO usually involves taking antibiotics to reduce the number of bacteria in the small bowel. There are many different antibiotic regimens that work, although most of the studies done on antibiotic use in SIBO are small and of low quality. Typical antibiotics used to treat SIBO are rifaximin (Xifaxan), amoxicillin-clavulanic acid (Augmentin), ciprofloxacin (Cipro), metronidazole (Flagyl), neomycin, doxycycline, and many others.

Is there a diet to treat or prevent SIBO?

This is one of the most common questions asked by patients with SIBO, and the answer is both yes and no! I say this because there are some dietary manipulations that may help reduce the risk of developing SIBO again, or may treat SIBO that is already present, but for the most part there is limited data to guide us and there is no clear best diet for SIBO supported by the research at this time.

The current thought process in using diet to treat SIBO is to reduce the intake of fermentable foods, such as eating a relatively low-fiber diet, avoiding artificial sweeteners such as sucralose (Splenda), and avoiding sugar alcohols such as sorbitol, xylitol, isomalt, and others. Also, reduce intake of foods rich in the prebiotic inulin, which is found in beets, onions, garlic, asparagus, leeks, and other foods. These suggestions may sound familiar: That’s because they’re also part of the low FODMAP diet, which is popularly used to treat irritable bowel syndrome. If you are going to take this dietary manipulation seriously, it is a good idea to consult with a licensed dietitian to understand what foods fit into the low FODMAP category, as the diet can get somewhat restrictive.

Furthermore, most high-fiber and fermentable foods are considered to be healthy overall. So it is probably not great to eat a low-fiber diet indefinitely. If poor diet is part of the reason that you have developed SIBO, after cutting out processed foods, artificial sweeteners, and high-fiber fermentable foods, and after treating the SIBO, it is worth slowly reintroducing natural sources of plant fiber back into the diet as soon as possible. Again, this may best be accomplished by consulting with a dietician.

Although there is no research that I am aware of on this topic, the intermittent fasting approach to eating may also be beneficial in preventing SIBO. It turns out that our gut has a separate neurologic control center responsible for coordinating our digestive processes and interfacing with our brain, called the enteric nervous system. One function of the enteric nervous system is to generate the migrating motor complex (MMC) which is a natural coordinated contraction of the entire GI tract that begins in the stomach and propagates down the small bowel and through the colon, essentially pushing any undigested debris down the digestive tract and into the colon. There are three phases of the MMC, and the third phase is when strong contractions completely sweep down the lumen of the gut in one direction, like people doing the wave in a crowded baseball stadium. This is one of the protective housekeeping functions of the gut, and may act to prevent stasis in the gut and therefore reduce the risk of developing SIBO.

But there is one catch about the migrating motor complex…it only happens between meals when we are fasting. In the fed state (after a meal), the gut is preoccupied with digestion and it’s not the time to perform housekeeping. After digestion is complete, it takes about 1.5-2 hours for a full MMC cycle to occur, with the cleansing phase III cycle only lasting for about 5-10 minutes. So it stands to reason that the more time spent in prolonged fasting, the more cleansing phase III cycles will occur. Intermittent fasting is a way of eating that promotes long periods of fasting and can be done many different ways. The easiest way to start is just to enforce a 12 hour fast period each day (for example, no food intake from 8 PM to 8 AM). If that is easy (it should be), then you can do a 16 hour fast each night, eating your last meal before 8 PM and not eating the next day until noon. Intermittent fasting promotes several metabolic pathways of cellular cleansing, while also pushing all that debris out of the gut with MMC phase III contractions!

Should I take probiotics if I have SIBO?

The short answer is NO. The longer answer is that there are many low-quality studies showing both improvement and worsening in SIBO from probiotic use. There is no good evidence that probiotics help much in SIBO, but we do know that introducing even more bacteria into the gut with probiotics can actually cause SIBO. My advice is usually to stop taking probiotics if you have SIBO or similar symptoms.

Final thoughts on SIBO…

  • SIBO has many nonspecific symptoms that can also be attributed to several other physical and mental ailments. Not all bloating and gas is due to SIBO.
  • If you have risk factors for SIBO and concerning symptoms, a hydrogen breath test is the best way to start testing.
  • If SIBO is confirmed, treatment with antibiotics is usually helpful.
  • To prevent recurrent episodes of SIBO, it is important to identify and manage the risk factors that caused SIBO in the first place.
  • Diet and lifestyle changes may help prevent SIBO, but high-quality research is lacking. Consider cutting back on fermentable foods, processed foods, artificial sweeteners, and perhaps give intermittent fasting a try.

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Get Dr. Gandolfo’s free ebook today!

By Frederick Gandolfo MD,

If you’ve got questions about colonoscopy, this is the book you need to read!

Everything You Need To Know Before Your First Colonoscopy is packed with everything you could ever want to know about having a colonoscopy! I will take you step-by-step through the procedure, and answer all of the common questions that I usually get from patients about the test.

Here is the table of contents from the book:

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Your email will never be shared or sold. It will be used to occasionally send you new articles as I publish them on my informational blog Retroflexions.

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Everyone should know these key facts about colorectal cancer

By Frederick Gandolfo MD,

March is Colorectal Cancer Awareness Month, so I made this infographic to highlight the key facts that everyone should know about colorectal cancer!

For much more about this and other important health topics, please visit my informational site Retroflexions.com!

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Help! The colonoscopy prep isn’t working! What can I do?

By Frederick Gandolfo MD,

This is an excerpt from a longer article I wrote on Retroflexions.com. You can read the full article here, or you can cut to the chase and just read the important points below…

Bowel prep, or that stuff you need to drink to get cleaned out for your colonoscopy, is never something that one looks forward to doing. You knew that drinking the prep was a necessary evil to ensure a high-quality colonoscopy, but what do you do if you followed all the instructions but the prep simply didn’t work?

If you’re reading this while in the midst of a potentially failed bowel prep don’t despair! There are many ways to salvage a bowel prep and still have a safe, high-quality colonoscopy the next day. It all depends on what time you take action; If you wait until 2 hours before the procedure is scheduled than yes, it’s probably too late to do much. However, if you’re already having issues the night before you can totally recover from this and be fine. This is what I usually recommend, based on the issue at hand:

“I drank the first dose of the prep and nothing happened.” I usually tell patients to wait several hours before panicking. If you have waited 6 hours and there is no bowel activity whatsoever then at that point I would recommend taking either 10 mg of bisacodyl by mouth, or giving yourself an enema. If you’ve done all that and still nothing happens, then it’s probably time to call your doctor and ask for suggestions.

“I drank the first dose of the prep but vomited most of it up.” Unfortunately, you will need more prep then. This usually requires a phone call to the doctor explaining the issue and often an alternative prep is recommended. In selected patients, I would usually recommend Miralax prep or using magnesium citrate instead–both of which can be purchased over the counter.

“I can’t drink the first dose of the prep because it tastes horrible! Yuck!” Try putting the prep in the refrigerator and making it as cold as you can tolerate. Much of the taste disappears when you really chill the prep. You can also call your doctor to see if an alternative prep is an option for you. Ultimately this is also a case of mind-over-matter…it’s unpleasant but sometimes you just have to do it anyway!

“I drank both doses of the prep and my bowels are still not clear” This is a common issues with some bowel preps. It really depends on what time this happens. If you did all the prep the night before, then there is plenty of time to follow the prep with a bottle of magnesium citrate and a large volume of clear liquids. If you notice that you are not clear the morning of the procedure, you can still drink magnesium citrate but really need to finish drinking it about 4-5 hours before the procedure is scheduled to start. This gives it enough time to have an effect, and also keeps you well within the 2 hours safety window for ingestion of clear liquids with respect to receiving anesthesia. However, if the procedure time is close (2-3 hours away)  and you’re still not clear, then the only real option is to give yourself an enema or two. You can always reschedule the procedure if you have to, but realize that you already completed the bowel prep and will therefore have to do the entire prep again if you need to reschedule!

Happy prepping!

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Fermented dairy products like kefir may reduce the risk of colon cancer!

By Frederick Gandolfo MD,

Fermented dairy sounds rather disgusting, as the name suggests something akin to spoiled milk, but in reality most fermented milk products are actually quite delicious! Fermented dairy products are foods like yogurt, cheese, sour cream, and kefir among others. The process of fermentation is usually done by bacteria such as Lactobacillus species, and results in a product that is more shelf-stable than milk, while retaining all of the protein and other substances that give milk its healthy reputation. Fermented dairy has been enjoyed by people dating back to about 10,000 B.C., so that trendy kefir stuff you are now seeing at the local food store is really nothing new…

Please click here to read the full article on my informational site ‘Retroflexions.’ 

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American Cancer Society recommends colorectal cancer screening to begin at age 45

By Frederick Gandolfo MD,

On May 30, 2018, the American Cancer Society (ACS) released new guidelines regarding colorectal cancer screening for the average-risk individual. The big news is that they now recommend that screening for colorectal cancer begin at age 45 rather than age 50. This reduction in the starting age was in reaction to recent data showing that colon cancer is increasing in younger Americans for unclear reasons. By screening people at a younger age, the hope is that we can detect and prevent colon cancer in more people.

The ACS states that 20% of new cases of colorectal cancer occur in the younger-than-55 crowd. Furthermore, despite a general downward trend in colorectal cancer in the over-50 population, the risk is actually rising slightly in the subgroup of people aged 50-54. These are the cases of cancer the new guidelines are trying to prevent. The ACS is pragmatic in acknowledging that people don’t typically sign up for a colonoscopy exactly on their fiftieth birthday…in fact many wait a few years or more after age 50 to get screened. By pushing the starting age up by 5 years there will likely be a benefit to these patients who would otherwise be late to the colonoscopy party.

The consequences of these recommendations are potentially huge. If these guidelines are followed, an estimated twenty million additional people are now eligible for colon cancer screening. However, the ACS does not specify any one best choice for colorectal cancer screening and states that colonoscopy, stool DNA testing (Cologuard), virtual colonoscopy, and stool testing for occult blood with Guaiac-based tests or FIT testing are all equivalent. I think that by now we know that all tests are not really equivalent, with colonoscopy being the gold-standard test, but with millions of people not getting any type of screening at all, any test is better than nothing.

“My thirties are going great! And in a few short years, I’ll need my first colonoscopy!”

A few caveats about these new recommendations:

  • The ACS states that the recommendation to start screening at age 45 is a qualified recommendation, meaning that there are clear benefits of screening at this younger age but there is less certainty about the exact risk-to-benefit ratio of the recommendation. This is opposed to a strong recommendation, which means the benefit is clear and almost everyone should do it. (Beginning screening at age 50 remains a strong recommendation from the ACS.)
  • Other guideline-producing organizations such as the US Preventive Services Task Force (USPSTF) have not changed their recommendations for colorectal screening, which still remain at age 50 to start.
  • Just because the American Cancer Society changed the recommendation to age 45, doesn’t mean that insurance companies are going to cover the testing! This is perhaps the most interesting part of these new guidelines…who is going to pay for this?
  • Starting screening earlier is definitely going to pick up and prevent more cancers than starting later, however is 45 the best age to start? Surely starting at 44 would pick up even more cancers! I bet starting at 40 would pick up even more than that! What I’m trying to illustrate is how there can be a slippery-slope with these type of recommendations: You will always find more cases of colorectal cancer if you start looking for it in younger and younger people. At what point do the risks of screening more and more people start to outweigh the benefits? Only time and more research will help answer this question.
  • What about the truly early-onset colorectal cancer patients? These are patients diagnosed in their twenties and thirties…how do we detect them before they develop the disease? I doubt anyone will recommend starting routine screening colonoscopies at age 18! This very young onset colorectal cancer may just behave differently than the typical sporadic colon cancer that develops later in life. We need to develop different ways of finding the young patients at risk, and determine why the risk is rising in the younger population.

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