Pancreatitis: What’s fibre got to do with it?

Pancreatitis is inflammation of the pancreas. There are two main types of pancreatitis: acute (abrupt onset) and chronic (long-standing disease). The inflammation can damage pancreatic tissue and cause symptoms such as abdominal pain, nausea, weight loss, diabetes, and malabsorption.

You may have already heard about the role of fat in the management of pancreatitis, but what about the role of fibre? Is there one? Newer research is showing that fibre may very well play an important role in the management of pancreatic disorders, including acute and chronic pancreatitis. The latest evidence in this area remains controversial, and more studies are needed to confirm these findings, but it is still interesting to check out what they are discovering. Keep reading to learn more about what science has shown so far about the nutrition management of pancreatitis, and how to apply these findings to your everyday life and practice.

Acute Pancreatitis

In the hospital setting, when an individual is admitted with acute pancreatitis, the doctor will write a nil per os (NPO) diet order, which is Latin for “nothing by mouth”. The person will get plenty of intravenous (IV) fluids to stay hydrated, as they will often have symptoms of nausea, vomiting, and abdominal pain that prevent them from eating or wanting to eat. Eating when the pancreas is inflamed will stimulate the pancreas and trigger these undesirable symptoms. If the case is mild, then the diet will be gradually advanced from liquids to solids (low-fat with or without a low-fibre restriction, or regular diet as tolerated) over the next few days, and in very mild cases, within 24 hours.¹ The ultimate goal is to return to a regular diet over time. In cases of severe acute pancreatitis, nutrition support (e.g., tube feeding) is necessary for those who are not able to, or not expected to, tolerate oral intake anytime soon.² This is because these individuals will have increased energy and protein needs that can only be met through nutrition support. Nutrition is also key for preserving gut barrier function. When the gut barrier function is compromised, it can lead to the translocation of bacteria across the gut barrier, which can cause infection of the pancreas and, worst case scenario, systemic inflammatory response syndrome (SIRS).¹

Fibre, specifically prebiotic fibre, has been shown to help preserve gut barrier function and integrity. This helps prevent the translocation of bacteria across the gut barrier that can lead to the increased infection rates seen in acute pancreatitis.1 A prebiotic-rich diet is associated with lower rates of pancreatic infection, hospital stay, SIRS and multiorgan failure.1 One randomized, double-blind study of 30 participants with severe acute pancreatitis found that those given nutrition support (tube feeding) with a prebiotic formula had a shorter hospital stay and fewer complications than those given standard nutrition support without prebiotics.³ Prebiotics act as food for our healthy gut bacteria. They feed and stimulate the growth of the friendly bacteria that live in the gut, helping to keep the immune system strong and healthy. Prebiotic-rich foods include asparagus, artichokes, beans, bananas, garlic, green peas, oats, and onions. A banana topped oatmeal, banana oat smoothie, or banana oat bars, could be easier prebiotic-rich foods to tolerate during recovery. You can also find prebiotics in supplement form, which is okay, but, if you can tolerate prebiotics in food form, why not start with food first? That way, you get all the beneficial nutrients found in the food, instead of just the isolated prebiotic in supplement form.

Chronic Pancreatitis

There is a greater risk of malnutrition in chronic pancreatitis. This is due to malabsorption caused by a decreased level and/or activity of pancreatic enzymes, which are needed to digest food for optimal absorption.1 However, pancreatic enzyme supplementation can help. Individuals with pancreatic insufficiency take these enzymes with meals to optimize nutrient absorption. While some foods do contain natural digestive enzymes (e.g., pineapple), they are not in amounts high enough to prevent malabsorption in chronic pancreatitis. Also, we need a mix of enzymes to break down all the macronutrients (protein, carbohydrates, and fat), and this mix cannot be found in one single food. Chewing foods really well, taking the time to eat, and enjoying smaller, frequent meals (e.g., eat half a sandwich and then eat the other half a few hours later) can also help optimize absorption, because the body will have more time to process and properly digest these foods.

Fat can stimulate the pancreas and trigger abdominal pain; however, health experts still recommend that you try to eat some fat. Avoiding fat completely can make it even more difficult to tolerate when you do add it to your diet because the enzyme that breaks down fat (lipase) needs to have some fat in order to stay active and working well.⁴ In addition, fat is crucial to good health and is needed to absorb the fat-soluble vitamins A, D, E, and K. The recommended macronutrient range for fat is 20-35% of total daily calories, and a 30% range is reasonable for someone with chronic pancreatitis. It is important to know that since a keto diet is up to 80% of total calories from fat, it would not be a good dietary option for individuals who have pancreatitis.

Fibre may decrease the activity of pancreatic enzymes in people who have pancreatic enzyme insufficiency. This association of a high-fibre diet on decreased pancreatic enzyme activity has been shown mostly through laboratory (in vitro) studies, and human (in vivo) studies are needed to confirm these findings.1 A high-fibre diet in people with pancreatic exocrine insufficiency can also increase fat excretion in the stool, meaning that less fat will be absorbed and used by the body. Fibre may also stimulate the pancreas through an undefined neurohormonal mechanism, which could trigger symptoms.1 Again, these findings are associations, and more research is needed before making any drastic changes. That being said, a very-high-fibre diet (> 50 g/day) may not be a good idea, especially if more symptoms are triggered.

Ten Nutrition Goals for Pancreatitis

1. ensure nutritional adequacy of meals
2. correct nutrient deficiencies (e.g., vitamins A, D, E, K)
3. limit malabsorption (e.g., pancreatic enzymes)
4. prevent weight loss
5. eat smaller, frequent meals to optimize digestion and absorption
6. manage symptoms (abdominal pain, bloating, nausea, vomiting, diarrhea, steatorrhea) by choosing well tolerated foods
7. preserve gut barrier function and integrity (e.g., prebiotics)
8. avoid unnecessary food restrictions (e.g., very low-fat diet)
9. control blood sugars as needed (higher risk of diabetes with chronic pancreatitis)
10. avoid alcohol

Conclusion

Pancreatitis is a complex disease and nutrition management depends on whether it is acute or chronic. Although there is still a lot to learn about fibre in pancreatitis, a low-fibre diet is initially recommended in the early stages of acute pancreatitis until symptoms subside. Afterward, prebiotic fibre could be encouraged in acute pancreatitis to help preserve the integrity of the gut barrier and help reduce the risk of infection and other complications. It may be prudent to avoid a very-high-fibre diet in cases of chronic pancreatitis because fibre may reduce pancreatic enzyme function, increase fat malabsorption, and trigger symptoms. Ultimately, it will be interesting to see what the future research will show and if the use of prebiotic fibre may become a standard in the treatment of acute pancreatitis.

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By Anne-Marie Stelluti, RD
Anne-Marie Stelluti is a registered dietitian and business owner of Modern Gut Health, a private practice with special focus in digestive health nutrition.

First published in the Inside Tract® newsletter issue 215 – 2020

1. Ribichini E et al. Role of Fibre in Nutritional Management of Pancreatic Diseases. Nutrients. 2019;11(2):2219.
2. PEN The Global Resource for Nutrition Practice. Gastrointestinal System – Pancreatitis Key Practice Points. Available at https://www-pennutrition-com. Accessed 2020-08-01.
3. Karakan, T et al. Comparison of early enteral nutrition in severe acute pancreatitis with prebiotic fibre supplementation versus standard enteral nutrition: A prospective randomized double-blind study. World J. Gastroenterol. 2007;13:2733-2737.
4. Holtmann G et al. Survival of human pancreatic enzymes during small bowel transit: Effect of nutrients, bile acids, and enzymes. Am. J. Physiol. 1997(1):553-558.

Photo: © bit24 | bigstockphoto.com

Advances in Diverticular Disease and Diet

New evidence is shedding light on the ways diet influences diverticular disease and is reinforcing some of the Gastrointestinal Society’s long-held positions, such as how nuts and seeds are safe to eat. This article will focus on the latest research and how that influences recommendations on what you can do to help reduce the risks of diverticular disease through food and lifestyle changes.

Diverticular disease and diverticulosis are interchangeable terms meaning the presence of small out-pouches (diverticula) in the large intestine (colon). It occurs in about 5% of the Western adult population who are younger than forty years of age, but it rises sharply to occur in at least 50% of those who are older than 60 years of age. It’s a disease most prevalent in the elderly, with the prevalence approaching 65% in those 85 years of age and older, and the majority not experiencing any symptoms or complications.¹ Diverticulitis occurs when these pouches become inflamed or infected, which causes symptoms such as nausea, vomiting, abdominal pain, and bleeding. Why does this happen? Scientists suggest that it is likely due to several factors, including genetics, the environment, and more recently, inflammation and the intestinal microbiome.^2,3

The traditionally accepted theory that a low fibre diet causes diverticulosis comes from a paper published in 1971 by Painter and Burkitt in the British Medical Journal.⁴ They hypothesized that the reason why diverticulosis was so common in the West was that the typical Western diet was much lower in fibre when compared to countries in Africa, where diverticulosis was rare. However, the researchers did not actually measure diet nor diverticulosis; it was just a hypothesis. Research in this area then stagnated for some time, but has picked up during the last two decades.²

Fibre

When a patient with acute diverticulitis comes to the hospital, their diet will consist of liquids (e.g., juice, broth, jello) to give the colon a rest. Gradually, the person can expand to a low fibre diet as symptoms improve and they start to feel better. Before hospital discharge, a registered dietitian will advise the patient to increase their fibre intake gradually, toward a high fibre diet at home, with the hope of reducing the risk of recurrent diverticulitis.

Current guidelines still recommend a high fibre diet to prevent diverticular disease, despite being based on low quality evidence from observational studies.^5,6,7 A review of several studies (meta-analysis) published last year in the European Journal of Nutrition⁸ concluded that a high fibre diet may reduce the risk of diverticular disease. They found that people who consumed 40 g of fibre per day had a 58% reduction in risk of diverticular disease when compared to those who consumed only 7.5 g of fibre per day. They also noted that people who eat higher fibre diets tend to have healthier lifestyles in general.

Another study, published in 2019,⁹ looked at the association between fibre intake and risk of diverticulitis in 50,019 women, 43-70 years of age, from the Nurse’s Health Study that took place from 1990 to 2014. They found that a higher fibre intake was associated with a reduced risk of diverticulitis in women, especially when they consumed more whole grains and whole fruits, particularly apples, pears, and prunes.

Fibre might help reduce the risk of diverticular disease through its anti-inflammatory effects and by how it alters the intestinal microbiome versus how it helps reduce constipation and promote bowel regularity.^5,7,9,10 Clearly, to confirm this, we need more high-quality research, and it will be interesting to see what is discovered.

Table 1 – High Fibre Diet (40 g) Example

*Source = Canadian Nutrient File

Nuts, Seeds, and Popcorn

My grandmother had diverticulosis and she ended up avoiding nuts and seeds for years, including the fresh blueberries and strawberries that she loved so much. A large groundbreaking study published in 2008¹⁰ set out to test the theory that nuts, seeds, and popcorn cause diverticulitis. They followed 47,228 men from the Health Professional’s Follow-up Study from 1986 to 2004 and found that these foods were not associated with a risk of diverticulitis or diverticular bleeding.

They also specifically did not find any association between eating blueberries and strawberries and diverticular complications. What they found instead, was that men who ate more of these foods actually had fewer cases of diverticulitis than those who didn’t. They concluded that nuts and seeds may actually be protective against diverticulitis, perhaps due to their anti-inflammatory effects. ^2,6,10,11 The NICE guidelines from the UK, and the PEN Guidelines from Dietitians of Canada, state that there is no need to avoid nuts, seeds, popcorn, or fruit skins for diverticulosis.¹² It turns out that my grandmother could have enjoyed those berries that she loved so much after all!

Red Meat, Poultry, and Fish

Some studies have shown that red meat intake increases the risk of diverticular disease, whereas others have found no association.^2,5 A large prospective cohort study, published in 2018, looked at 51,529 men from the Health Professional’s Follow-up Study from 1986 to 2012. The researchers observed an association with red meat intake and an increased risk of acute diverticulitis but observed no association with a higher consumption of poultry or fish.¹³ Overall, whether red meat increases the risk remains controversial. However, given the many other health benefits of limiting red meat intake, I would suggest decreasing consumption anyway.

Caffeine, Alcohol, and Smoking

Consuming caffeine or alcohol does not affect your risk of diverticular disease.^2,6,7 Smoking might increase the risk of diverticulitis, and current guidelines recommend that people stop smoking, even though no significant association has been found.^6,7,12

Vitamin D

A risk factor for diverticular disease that might play a role in the development of diverticulitis is low levels of serum vitamin D (25-OH D).² A similar connection exists with low vitamin D levels playing a role in other inflammatory conditions, such as Crohn’s disease.³ The PEN guidelines from Dietitians of Canada currently recommend ensuring adequate vitamin D levels in those who have diverticular disease.⁶

Probiotics

There is insufficient evidence for the use of probiotics in acute diverticulitis. The 2015 American Gastroenterology Association guidelines actually recommend against the use of probiotics for uncomplicated diverticulitis.^3,6 A systematic review looking at eleven studies with various probiotics in the treatment of diverticular disease showed a positive trend in the reduction of abdominal symptoms; however, given the various strains and doses of probiotics used, the study authors could not make any recommendations.³

Physical activity

Physical activity is associated with a reduced risk of diverticulitis and diverticular bleeding, ^2,5,7 and the NICE guidelines from the UK recommend exercise to reduce the risk of symptomatic diverticular disease.¹² The American Gastroenterology Association recommends vigorous physical activity, such as running, for people who have experienced diverticulitis.³ It is important to note that these associations and guidelines are based on low quality evidence,⁷ but given the numerous health benefits of being physically active, if you’re not already active and can be, why not give it a try?

Obesity

There is an increased risk of diverticular disease in obesity, especially abdominal obesity, including complications such as diverticular bleeding and diverticulitis.^2,3,5,7,8 Obesity is considered to be an inflammatory state, so eating foods rich in fibre, some of which have anti-inflammatory effects, might help reduce obesity-induced chronic inflammation.⁹

Conclusion

It’s time to say goodbye to popular but unproven theories about diet and diverticular disease. If you have diverticulosis, there is no need to restrict yourself by avoiding nuts, seeds, and berries, which are nutrient dense and have anti-inflammatory effects that may actually help prevent diverticulitis from occurring in the first place. I am looking forward to new research that will delve deeper into the role diet plays in inflammation and altering the intestinal microbiome, and what this will mean for preventing and treating diverticular disease in the future. In the meantime, there are many healthy lifestyle strategies that may help reduce our risk of diverticular disease, and they are worth giving a try.

Ten lifestyle strategies that might help reduce the risk of diverticulitis

1. Eat a high fibre diet (35-40 g/day).
2. Eat more insoluble fibre (e.g., whole flaxseeds, nuts, berries, raw vegetables, skins of fruits and vegetables).
3. Eat whole fruits regularly, especially apples, pears, and prunes.
4. Add nuts and seeds to the foods that you love (e.g., walnuts on oatmeal, sesame seeds on top of asparagus, toasted pumpkin seeds on top of a spinach salad).
5. Eat chicken and fish more often than red meat.
6. Do you have constipation? Consider a fibre supplement (e.g., psyllium) and drink more water.
7. Maintain adequate vitamin D levels and consider supplementation if blood levels are low.
8. Be physically active (e.g., jogging, running).
9. Lose weight if greater than normal/ideal.
10. Stop smoking.

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By Anne-Marie Stelluti, RD
Anne-Marie Stelluti is a registered dietitian and business owner of Modern Gut Health, a private practice with special focus in digestive health nutrition.

First published in the Inside Tract® newsletter issue 214 – 2020

1. Weizman AV et al. Diverticular disease: Epidemiology and management. Can J Gastroenterol. 2011; 25(7): 385 389.
2. Strate LL, et al. Epidemiology, Pathophysiology, and Treatment of Diverticulitis. Gastroenterology. 2019; 156(5): 1282-1298.
3. Rezapour M et al. Diverticular Disease: An Update on Pathogenesis and Management. Gut and Liver. 2018; 12(2): 125-132.
4. Painter NS, Burkitt DP. Diverticular Disease of the Colon: A Deficiency Disease of Western Civilization. British Medical Journal. 1971; 2: 450-454.
5. Tursi A, Elisei W. Diet in colonic diverticulosis: is it useful? Pol Arch Intern Med. 2020; 130:232-239.
6. PEN The Global Resource for Nutrition Practice. Gastrointestinal System – Diverticular Disease page. Available at https://www.pennutrition.com. Accessed 2020-04-20.
7. UpToDate. Diverticular Disease page. Available at https://www.uptodate.com. Accessed 2020-04-20.
8. Aune D et al. Dietary fibre intake and the risk of diverticular disease: a systematic review and meta-analysis of prospective studies. Eur J Nutr. 2020; 59(2): 421-432. 
9. Ma W et al. Intake of Dietary Fiber, Fruits, and Vegetables and Risk of Diverticulitis. Am J Gastroenterol. 2019; 114: 1531-1538.
10. Strate LL, et al. Nut, corn and popcorn consumption and the incidence of diverticular disease. JAMA. 2008; 300(8): 907-914.
11. Peery AF, Sandler RS. Diverticular disease: Reconsidering Conventional Wisdom. Clin Gastroenterol Hepatol. 2013; 11(12): 1532-7.
12. NICE. Diverticular Disease: diagnosis and management page. Available at https://www.nice.org.uk/guidance/ng147. Accessed 2020-04-24.
13. Cao Y et al. Meat intake and risk of diverticulosis among men. Gut. 2018; 67(3): 466-472.

Photo: © Nadezhda Nesterova | bigstockphoto.com

Health & Nutrition

On this page you will find links to many articles about good health and proper nutrition. Many of our nutrition pages are written by registered dietitians. Click the links below to see the articles we have available.

• Campylobacter
• H. pylori and Halitosis (Bad Breath)
• 4 Myths About Food and Nutrition
• 5 Fun Facts About Fruit and the Gut
• 5 Gluten-Free Grains You Might Not Have Tried
• 6 Things to Know about Going Gluten-Free
• A Traditional Chinese Medicine Look at Summer Foods
• Add Spice to your Life
• Andrew Wakefield’s Harmful Myth of Vaccine-induced “Autistic Entercolitis”
• Anemia and Diet
• Anti-Inflammatory Nutrition
• Are You Getting Enough Zinc?
• Are You Washing Your Hands Correctly?
• Berries: Bursting With Health Benefits
• Best Before and Expiry Dates for Food and Drugs
• Can exercise improve your IBS?
• Caring for Your Gut While Travelling Abroad
• Celiac Disease and Diet
• Cinnamon: The Good, the Bad, and the Tasty
• Comfort Food
• Compromised Bowel and Diet
• Constipation and Diet
• Contaminated Natural Health Products
• Customized Diet Advice
• Dangerous Food Bacteria Are Here To Stay
• Diarrhea and Diet
• Diet and GERD
• Diet for Ulcer Disease
• Diet That’s Good for the Gut & the Heart
• Dietary Fibre
• Dietary Fibre Q & A
• Dietitian or Nutritionist?
• Folic Acid
• Folic Acid and Methionine Intake may Affect Colon Cancer Risk
• Food Allergy vs. Intolerance
• Functional Foods
• Genetically Modified Food
• Get Keen for Quinoa!
• Glutamine
• Glycemic Index and Diet
• Go For Colour!
• Goodness of Eggs
• Goodness of Milk & Lactose Intolerance
• Headline Foods
• Healthy Grains Institute
• How to Avoid GERD Symptoms While Working Out
• Hunger and Appetite
• IBD and Malnutrition
• IBD and the Balanced Dinner Plate
• IBS Associated with Western Diet
• IBS Diet: The Foods You Can Eat
• Inflammatory Bowel Disease Nutrition Tips (Crohn’s Disease and Ulcerative Colitis)
• Intestinal Gas from Complex Carbohydrates or Lactose Intolerance
• Low FODMAP Diet for IBS
• Low Residue Diet
• Many Benefits of Turmeric
• Maybe it isn’t Gluten’s Fault
• Milk Alternatives
• Minerals: We are What we Absorb
• Nutrition and Stomach Cancer: Prevention
• Nutrition Month
• Omega-3 Fatty Acids
• Oral Nutritional Supplements
• Oxalate Stones
• Plant-Based Low FODMAP Diet
• Prebiotics: The Latest Food for Thought
• Prednisone and Diet
• Probiotics, Prebiotics, and the Microbiome
• Prunes vs. Psyllium for Reducing Constipation
• Pulses
• Recipe Book – IBD Kitchen
• Resistant Starch
• Role of Fats in Ulcerative Colitis
• Short Bowel Syndrome and Diet
• Sugar-free Gum and Candies
• Sulphite-Restricted Diet
• The Low-FODMAP Solution
• The Simplified Low FODMAP Diet
• Ultra-Processed Foods
• Vitamin B12
• Vitamin D
• Who Says You Can’t Eat Nuts?
• Yeast and Mould Allergy

 

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