Exercise with diverticular disease and diverticulitis: staying active, flares and after surgery

Diverticula are common, and mostly harmless

About 5% of people have them by 40 and at least half by 80, and most people with them never get symptoms. Symptoms from them are diverticular disease; inflamed or infected pouches are diverticulitis.

Sources 1, 2

Active people get diverticulitis and bleeding less often

In 47,228 US men followed for 18 years, the most vigorously active had about a third less diverticulitis and 39% less diverticular bleeding. Across 5 cohort studies, high activity went with about a quarter less diverticular disease. These studies observed people, mostly men, and the link was mostly with vigorous exercise; no trial has tested exercise.

Sources 3, 4

Guidelines say be active

NICE says to tell people about the benefits of exercise, losing weight if they're overweight, and stopping smoking in reducing the risk of diverticulitis. US gastroenterologists advise regular physical activity to lower the chance of another attack.

Sources 5, 6, 7

How much: the usual amount, with some vigorous activity if you can

Build towards 150 minutes of moderate activity a week, plus strength exercises on 2 days. In the studies, running and other vigorous exercise carried most of the link; in one, about 2 hours a week of vigorous exercise counted as the low-risk level.

Sources 8, 9, 10

During a flare, rest; build back afterwards

No trial or guideline gives a timeline for exercise after a flare. Rest while you're unwell; mild attacks often settle within days. Once the pain and any fever have gone, start with short walks and build back over a week or two (our suggestion). Some tummy symptoms linger for a third of people, and they're not a reason to stop moving.

Sources 1, 11

After surgery, walk from the start and build up slowly

After a colostomy, the National Health Service (NHS) says avoid strenuous activity and heavy lifting for 8 weeks. One NHS hospital's physiotherapy leaflet aims for 30 minutes of walking a day by 2 to 3 months, and moderate exercise such as swimming or cycling after that. Your surgical team's advice comes first.

Sources 12, 13

You don't need to avoid nuts and seeds

NICE says there's no need to avoid seeds, nuts, popcorn or fruit skins, and in a large study, eating nuts and popcorn didn't raise the risk of diverticulitis; if anything, it was lower.

Sources 5, 14

Three words

The NHS describes diverticula as small bulges or pouches in the wall of the large bowel. Having them without symptoms is diverticulosis. Diverticular disease means they cause symptoms such as tummy pain. Diverticulitis means they've become inflamed or infected, usually with constant, severe pain low on the left side of your tummy, and sometimes a fever. NICE calls it complicated when there's an abscess, a narrowing or blockage, a hole in the bowel, a connection to another organ, or sepsis.

Sources 2, 5

How common it is

NHS inform says about 5% of people have diverticula by 40 and at least 50% by 80, and about 1 in 4 people with them get symptoms; if you've never had symptoms, there's a 70% to 80% chance you never will. A person's lifetime chance of diverticulitis is about 3% to 5%. Men and women are affected equally, and diverticulitis is most likely over 70, though Guts UK says more people under 45 are being diagnosed.

Sources 1, 15, 16, 7

Causes and risk factors

Diverticula form where the bowel wall becomes weak, which can happen with age. They're linked with a low-fibre diet, though that isn't proven. Smoking, being overweight, a history of constipation, anti-inflammatory painkillers and having a close relative with diverticular disease are linked with it, and Guts UK lists not being physically active. About half the risk of diverticulitis is down to genes.

Sources 15, 1, 6

Symptoms

The NHS lists:

• pain low on the left side of your tummy (a small number of people get it on the right, including many people of Asian origin)
• tummy pain that gets worse after you eat, and better after you poo or fart
• constipation or diarrhoea, bloating, or blood in your poo
• with diverticulitis: severe, constant tummy pain, a high temperature, and bleeding or slime from your bottom

Sources 2, 5, 1

Complications

Rarely, diverticulitis leads to an abscess, a blockage, a connection to the bladder or vagina (a fistula), or a hole in the bowel that causes a serious infection. NHS inform says complications affect 1 in 5 people with diverticulitis, and about 15% have bleeding, which usually stops on its own. Complications are most likely with the first attack, and about 1 in 5 people have another attack within 10 years.

Sources 2, 1, 6

Treatment

For diverticular disease, painkillers such as paracetamol, fibre, bulk-forming laxatives and medicines for cramps. Mild diverticulitis can usually be treated at home: NICE suggests your GP may not need to give antibiotics if you're otherwise well, and people who are more unwell need antibiotics or hospital care. Surgery to remove part of the bowel is for complications or symptoms that keep coming back, and sometimes means a stoma, often temporary; the NHS lists diverticulitis among the reasons for a colostomy.

Sources 2, 5, 1, 17

Bowel cancer

Guts UK says there's no evidence that diverticular disease raises your risk of bowel cancer. Some symptoms overlap, though, so you may be offered a test to look inside your bowel after an attack.

Sources 15, 6

Men in the Health Professionals Follow-up StudyEmerging evidence

In 47,678 US men followed for 4 years, the most active had about a third less symptomatic diverticular disease (risk ratio 0.63), mostly from vigorous activity; jogging and running was the only single activity with a clear trend, and a low-fibre diet with little activity carried 2.56 times the risk. Followed for 18 years, the most vigorously active men had about a third less diverticulitis (risk ratio 0.66) and 39% less bleeding (0.61), while moderate activity such as walking wasn't linked either way.

Sources 18, 3

RunnersEmerging evidence

In 10,736 runners aged 50 and over followed for about 8 years, the risk of diverticular disease fell about 6% for each extra kilometre run a day, and was 48% lower in those running more than 8 km a day. The diagnoses were reported by the runners themselves.

Source 9

Women, and fitness in youthEmerging evidence

In 36,592 Swedish women followed for 12 years, exercising 30 minutes a day or less went with 42% more diverticular disease needing hospital care than exercising more. In 43,772 Swedish men examined at 18 to 20, good fitness went with less diverticular disease needing hospital care over the next 39 years, and being overweight doubled it.

Sources 19, 20

Pooled studiesEmerging evidence

Across 5 cohort studies with 147,869 people, high physical activity went with 24% less diverticular disease (risk ratio 0.76), and vigorous activity with about a quarter less diverticulitis in 2 studies. Each step up in body mass index (BMI) raised the risk.

Source 4

Healthy habits togetherEmerging evidence

Men with all 5 low-risk habits (vigorous exercise, a healthy weight, plenty of fibre, little red meat and not smoking) had about a quarter of the risk of diverticulitis (risk ratio 0.27), and the authors estimated about half of cases could be prevented. Across three large US cohorts, the healthiest lifestyle halved the risk, whatever people's genes. In UK Biobank, sitting a lot, smoking and poor sleep went with more diverticular disease. A genetic study supports weight, type 2 diabetes and smoking as causes, but didn't test activity.

Sources 10, 21, 22, 23

What the guidelines sayStrong evidence

NICE says to tell people about the benefits of exercise, losing weight and stopping smoking in reducing the risk of diverticulitis and symptoms; it made this recommendation by expert agreement, noting evidence that vigorous exercise was linked with a lower risk. The American Gastroenterological Association advises people who have had diverticulitis to be physically active routinely, keep a healthy weight, eat a high-quality diet and not smoke, and the American College of Gastroenterology says regular physical activity may help lower the chance of another attack. Guts UK says take regular exercise.

Sources 5, 24, 6, 7, 15

Exercise and flaresEmerging evidence

We found no study linking exercise with bringing on an attack. In the cohort studies, the most active people had fewer attacks and less bleeding, not more.

Sources 24, 3

When you're well

At least 150 minutes of moderate activity a week, or 75 minutes of vigorous activity, plus strength exercises on at least 2 days. Over 65, be active every day and add balance exercises. Moderate means you can talk but not sing; vigorous means you can't say more than a few words without pausing for breath.

Sources 8, 25

Include some vigorous activity if you can

Running, fast cycling, uphill walking and sport match the studies best, and about 2 hours a week of vigorous exercise counted as the low-risk level in one. Any activity counts, though, and building up gradually is wise for everyone (our suggestion).

Sources 18, 3, 9, 10

Running and lifting are fine when you're well

No study links them with attacks, and running was the activity most linked with a lower risk. After surgery or with a stoma, follow your team's advice and our stoma guide.

Sources 9, 18

Weight and other habits

A healthy weight, plenty of fibre, not smoking and limiting red meat all count alongside exercise. Our weight loss guide covers losing weight.

Sources 5, 4, 10

No trials, and no guideline timeline

We found no study of exercise during or after an attack of diverticulitis, and no guideline gives a timeline. NHS inform says mild diverticulitis is usually treated at home and you should recover within about 4 days. NICE says go back to your GP if symptoms don't settle or get worse.

Sources 1, 5, 6

While you're unwell

With constant pain, a fever or feeling sick, rest, drink fluids, move gently around the house and follow your GP's or hospital's treatment. No exercise sessions. What to eat during a flare is your GP's or hospital team's call.

Sources 1, 6

Symptoms that lingerEmerging evidence

In 528 people followed after an uncomplicated attack, about a third still had some symptoms, such as wind, rumbling, bloating or frequent stools, 1 to 2 years later. Ongoing tummy pain is common too, often from a bowel that's become oversensitive, though it should be checked. These aren't a reason to stop exercising; see your GP about pain that lingers.

Sources 11, 6

After a complicated attack

If you had an abscess or a hole in the bowel treated without surgery, your hospital team decides when you can exercise again (our suggestion). Another attack is more likely after an abscess.

Source 6

Your surgical team's advice comes first

Advice after bowel surgery varies, and your own team may give you different timings. All of it starts with walking and gentle exercises for your tummy muscles. Our stoma guide and bowel cancer guide cover the recovery in detail.

Sources 12, 13

After a colostomy

The NHS says try gentle exercise like a short walk when you feel ready, avoid strenuous activities or heavy lifting for 8 weeks while your tummy muscles heal, and that a colostomy shouldn't stop you living a full and active life.

Source 12

After major tummy surgery

One NHS hospital's physiotherapy leaflet advises:

• walk every day, on level ground at first, building up to 30 minutes a day by 2 to 3 months
• with a large wound, lift nothing heavier than 2 to 3 kg, about a full kettle, at first, and nothing that causes pain
• gentle tummy exercises twice a day, building up over time
• moderate exercise such as swimming or cycling after 2 to 3 months, and a yoga or Pilates class to progress your core work
• it takes about 2 years for the strength of your tummy wall to return fully

Source 13

Recovery and reversal

People recover faster after keyhole surgery than after open surgery. A stoma made in an emergency is often temporary and reversed a few months later; after a reversal, build up gradually in the same way.

Source 1

Hernias

A hernia through the scar or beside a stoma is a known risk after bowel surgery. Our hernia and stoma guides cover lowering the risk and exercising with one.

Nuts, seeds and popcorn are fineStrong evidence

NICE says there's no need to avoid seeds, nuts, popcorn or fruit skins, and the NHS says there are no specific foods you need to avoid. In 47,228 men, eating nuts or popcorn at least twice a week didn't raise the risk of diverticulitis or bleeding; if anything, the risk of diverticulitis was lower, clearly so for popcorn. Some older advice, including NHS inform's, still mentions avoiding them.

Sources 5, 14, 2, 1

Fibre, for lifeStrong evidence

Eat a healthy, balanced diet with whole grains, fruit and vegetables, increase fibre gradually and drink enough fluid. NICE says the benefits of fibre may take several weeks, and if you tolerate it, keep a high-fibre diet for life. There's no good evidence that a low-fibre diet helps you recover from an uncomplicated attack.

Sources 5, 15, 26

PainkillersStrong evidence

NICE advises avoiding anti-inflammatory painkillers such as ibuprofen, and opioid painkillers such as codeine, if possible, because they may increase the risk of a hole in the bowel. Talk to your GP or pharmacist about pain relief, and don't stop a prescribed medicine, such as aspirin for your heart, yourself.

Sources 5, 2, 6

Weight and smokingStrong evidence

NICE includes losing weight if you're overweight and stopping smoking alongside exercise.

Sources 5, 4

Older age

Diverticulitis is most common over 70. The usual advice for older adults applies, with balance exercises added, and so does the advice on painkillers.

Sources 1, 25, 5

Steroids and a weakened immune system

People on long-term steroids or other medicines that weaken the immune system are more likely to have a severe attack, and may have milder symptoms at first, so get help early. Never change these medicines yourself.

Source 6

Younger people

More people under 45 are being diagnosed, and complications are relatively more common under 50.

Sources 15, 1

Call 999

The NHS says call 999 or go to accident and emergency (A&E) if you or someone you care for:

• has severe tummy pain and is vomiting, has a swollen tummy, or can't poo or fart
• is bleeding heavily from their bottom
• is acting confused, has pale or blotchy skin, has a very high or low temperature, or is breathless or breathing fast: these can be signs of sepsis

Sources 2, 1

Heavy bleeding

NHS inform says heavy bleeding can make you feel very dizzy or confused, with pale, clammy skin or shortness of breath: get medical help at once.

Source 1

Ask for an urgent GP appointment or call NHS 111

The NHS says get urgent help if:

• there's blood or slime in your poo
• you have tummy pain that's getting worse or won't go away
• you have a high temperature, or feel hot, cold or shivery
• you keep being sick and can't keep fluids down
• you have diarrhoea for more than 7 days, or have been sick for more than 2 days
• after an attack treated at home, your symptoms don't settle or get worse, or you can't start eating again after 3 to 5 days

Sources 2, 5, 6

See a GP

For new or different symptoms, blood in your poo, or losing weight or frequent changes in your bowel habit, because diverticular disease doesn't cause weight loss. Pain when you pee, needing to pee more often, air or poo in your pee, or a foul-smelling discharge from the vagina can mean a fistula and need a GP.

Sources 15, 1

During exercise

Stop and get advice if tummy pain comes back or gets worse during or after exercise, or you get a fever (our suggestion). After bowel surgery or with a stoma, the warning signs in our stoma guide apply too.

"Exercise brings on diverticulitis"Emerging evidence

We found no study linking exercise with attacks. In large cohort studies, the most active people had less diverticulitis and bleeding, especially with vigorous exercise, and the NICE committee was aware of evidence that vigorous exercise went with a lower risk.

Sources 18, 3, 4, 24

"With diverticular disease, you shouldn't run or lift weights"Emerging evidence

No guideline says so. Running was the activity most linked with a lower risk, and NICE and the American Gastroenterological Association advise exercise. The exceptions are a flare, when you rest, and the weeks after surgery, when your team's limits apply.

Sources 18, 9, 5, 6, 12

"Avoid nuts, seeds, popcorn and fruit skins"Strong evidence

NICE says there's no need to avoid them, and in a large study, nuts and popcorn didn't raise the risk of diverticulitis; if anything, it was lower.

Sources 5, 14

"After a flare, eat low fibre for life"Strong evidence

NICE says if you tolerate it, keep a high-fibre diet for life, and there's no good evidence that low fibre helps recovery. What to eat during a flare is your GP's or hospital team's call.

Sources 5, 15, 26

"Diverticula always turn into diverticulitis"Strong evidence

70% to 80% of people found to have diverticula without symptoms never get any, and the lifetime chance of diverticulitis is about 3% to 5%.

Sources 1, 7

"Diverticular disease turns into bowel cancer"Strong evidence

Guts UK says there's no evidence it raises your risk of bowel cancer, though a test after an attack may be offered to check your bowel.

Sources 15, 6

"After two attacks you'll need an operation"Strong evidence

Not any more: US gastroenterologists advise against planned surgery based on the number of attacks alone, and NHS inform says surgery after 2 attacks is no longer routine.

Sources 6, 1

"Only diet matters; exercise makes no difference"Emerging evidence

NICE tells people about the benefits of exercise, US guidelines advise regular activity to lower the chance of another attack, and healthy habits together roughly halved the risk in large studies.

Sources 5, 6, 7, 10, 21