Primary and Secondary Prevention of Diverticular Disease · 2017. 10. 13. · Primary and Secondary...

Primary and Secondary Prevention of Diverticular Disease

Walid.H. AldooriWyeth Consumer Healthcare Inc.CANADA

Falk Symposium

Diverticular Disease: Emerging Evidence in a Common Condition

Munich, June 17-18,2005

Outline• Introduction

• Health Professionals Follow-Up Study

• Dietary Factors

• Non-Dietary Factors

• Gaps in our knowledge

• Can we reduce the risk of Diverticular Disease ?

Introduction

• Diverticular disease (DD)is one of the most common disorders of the colon in Western societies.

• It is suggested that lifestyle factors can explain the increase in the prevalence of DD.

• Identifying these factors is important in the prevention of DD and/or the complications of DD.

Burkitt and Painter’s Dietary Fiber Hypothesis

• Three decades have passed since this hypothesis was widely publicized

• Several studies have investigated dietary and non-dietary factors and the risk of DD

• Almost all the studies were either case-control studies which are more prone to bias or did not control for potential confounding variables

Health Professionals Follow-up Study (HPFS)

• To minimize the potential of bias, dietary and non-dietary factors were investigated prospectively among 51,529 health professional US men participating in an ongoing cohort study

• The study began in 1986 when cohort members completed a dietary questionnaire and provided other relevant information

• Follow-up questionnaires every two years and dietary questionnaires every four years

Health Professionals Follow-up Study

47,678 Men

40-75 Years Old 382 cases

1986 1988 1990 1992FUQ FUQ FUQ

Follow-up Time

Baseline Questionnaire

and FFQ

Identification of DD Cases

• After four years of follow-up, 503 newly diagnosed cases of DD were identified

• Of the 503 new cases, 382 were classified as symptomatic ( pain, change of bowel habits, or bleeding)

• To reduce the possibility of detection bias, the symptomatic cases were used as our primary end point

• In 96 percent of the cases, the diverticula were located in the left colon

54321

<0.00001

<0.00001

8.8

61

0.62 (0.45-0.86)

0.61 (0.43-0.87)

5.5

57

0.54 (0.39-.076)

0.60 (0.43-0.85)

3.8

84

0.85 (0.63-1.15)

0.90 (0.66-1.23)

2.3

98

1.03 (0.77-1.38)

1.10 (0.82-1.47)

1.1

85

1.0

1.0

Fruit Fiber (median g/d)

Cases

RR† (95% CI)

Multivariate RR‡ (95% CI)

<0.00001

0.01

8.3

54

0.48 (0.35-0.67)

0.54 (0.38-0.76)

6.4

72

0.71 (0.52-0.96)

0.78 (0.57-1.06)

5.4

86

0.72 (0.54-0.96)

0.76 (0.57-1.02)

4.5

72

0.78 (0.58-1.06)

0.81 (0.59-1.10)

3.3

101

1.0

1.0

Total Crude Fiber (median g/d)

Cases

RR† (95% CI)


0.0002

0.01

32.0

55

0.51 (0.37-0.71)

0.58 (0.41-0.83)

24.0

83

0.78 (0.58-1.05)

0.87 (0.64-1.17)

21.0

73

0.73 (0.54-0.99)

0.77 (0.57-1.05)

18.0

75

0.76 (0.57-1.03)

0.79 (0.58-1.07)

13.0

99

1.0

1.0

Total Dietary Fiber (median g/d)

Cases

RR† (95% CI)


P Value for

Trend*

QuintileVariable

TABLE 1: Relative Risk of DD by quintiles of total dietary fiber, crude fiber, and by dietary fiber from fruits, vegetables and cereals

TABLE 1: Relative Risk of DD by quintiles of total dietary fiber, crude fiber, and by dietary fiber from fruits, vegetables and cereals

*Test for trend was calculated by using the median intake of nutrients in each quintile as a continuous variable in a multiple logistic regression.†Adjusted for age and total energy. ‡Adjusted for age, physical activity, and energy-adjusted total fat.( Modified from Aldoori WH, et al. Am J Clin Nutr 1994;60:757-764)

54321

0.23

0.72

13.5

78

1.09 (0.77-1.54)

1.06 (0.76-1.47)

8.2

61

0.85 (0.58-1.24)

0.87 (0.61-1.22)

5.7

78

1.10 (0.79-1.54)

1.08 (0.78-1.49)

3.7

91

1.21 (0.89-1.66)

1.23 (0.90-1.67)

1.7

77

1.0

1.0

Cereal Fiber (median g/d)

Cases

RR† (95% CI)


0.003

0.003

12.4

54

0.55 (0.37-0.84)

0.59 (0.41-0.86)

8.6

78

0.90 (0.64-1.26)

0.87 (0.63-1.20)

6.6

87

0.98 (0.71-1.35)

1.0 (0.73-1.36)

5.1

82

0.93 (0.68-1.28)

0.96 (0.70-1.31)

3.4

84

1.0

1.0

Vegetable Fiber (median g/d)

Cases

RR† (95% CI)


P Value for

Trend*

QuintileVariable

TABLE 2: Relative Risk of DD by quintiles of soluble and insoluble fiber components

† Adjusted for age and total energy.‡ Adjusted for age, physical activity, and energy-adjusted total fat.(Aldoori WH, et al. J Nutr 1998;128:717-719)

54321

0.001

0.02

22.70

0.55 (0.39-0.78)

0.63 (0.44-0.91)

17.90

0.80 (0.59-1.10)

0.87 (0.63-1.20)

15.20

0.78 (0.57-1.07)

0.80 (0.58-1.10)

13.0

0.89 (0.65-1.22)

0.91 (0.66-1.24)

10.1

1.0

1.0

Insoluble Fiber (g/d)

RR† (95% CI)


0.05

0.40

8.60

0.82 (0.59-1.16)

0.90 (0.62-1.29)

9.90

0.83 (0.59-1.17)

0.91 (0.65-1.29)

5.90

1.00 (0.72-1.38)

1.04 (0.75-1.44)

5.10

1.03 (0.75-1.43)

1.05 (0.76-1.45)

4.10

1.0

1.0

Soluble Fiber ( g/d)

RR† (95% CI)


P Value for

Trend

QuintileVariable

TABLE 3: Relative Risk of DD by quintiles of hemicellulose, cellulose, and lignin intake

54321

0.0002

0. 01

2.40

0.53 (0.38-0.76)

0.62 (0.43-0.89)

1.80

0.65 (0.47-.090)

0.71 (0.51-1.00)

1.50

0.87 (0.64-1.19)

0.89 (0.65-1.21)

1.20

0.82 (0.60-1.12)

0.83 (0.61-1.14)

1.00

1.0

1.0

Lignin (g/d)

RR† (95% CI)


0.0002

0.002

8.00

0.47 (0.33-0.66)

0.52 (0.36-0.75)

6.20

0.78 (0.57-1.06)

0.83 (0.61-1.14)

5.30

0.71 (0.52-0.97)

0.74 (0.54-1.01)

4.40

0.75 (0.55-1.03)

0.76 (0.56-1.05)

3.40

1.0

1.0

Cellulose (g/d)

RR† (95% CI)


0.01

0.11

11.70

0.78 (0.56-1.08)

0.88 (0.62-1.25)

8.90

0.78 (0.56-1.09)

0.84 (0.60-1.18)

7.30

0.77 (0.55-1.07)

0.79 (0.56-1.10)

6.00

1.27 (0.94-1.71)

1.29 (0.95-1.74)

4.40

1.0

1.0

Hemicellulose (g/d)

RR† (95% CI)


P Value for

Trend

QuintileVariable

†Adjusted for age and total energy.‡Adjusted for age, physical activity, and energy-adjusted total fat.(Aldoori WH, et al. J Nutr 1998;128:717-719)

Fig. 1: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Red Meat Intake

00.5

11.5

22.5

33.5

Low (<17) Medium (17-28)

High (29+)

Low (<28.5)

Medium (28.6-116.6)

High (>116.6)

*Adjusted for age and total energy.(Aldoori WH, et al. Am J Clin Nutr 1994; 60:757-764)

RED MEAT INTAKE (g/d)

DIETARY FIBRE INTAKE (g/d)

1.96 1.79

1.0

3.162.60

1.90

3.22

2.53

1.73

Rel

ativ

e R

isk

TABLE 4: Relative Risk of DD by quintiles of total fat and specific dietary fats

54321

0.13

0.10

43.0

87

1.28 (0.94-1.76)

1.32 (0.96-1.81)

35.0

70

1.06 (0.76-1.48)

1.08 (0.77-1.51)

30.0

85

1.28 (0.93-1.75)

1.30 (0.94-1.79)

25.0

73

1.06 (0.76-1.47)

1.07 (0.77-1.49)

18.0

70

1.0

1.0

Vegetable Fat (median g/d)

Cases

RR† (95% CI)


0.12

0.80

52.0

74

1.43 (1.02-2.01)

1.08 (0.75-1.56)

43.0

83

1.57 (1.13-2.19)

1.27 (0.90-1.80)

37.0

80

1.39 (0.99-1.94)

1.20 (0.85-1.69)

31.0

88

1.66 (1.20-2.03)

1.50 (1.08-2.10)

22.0

60

1.0

1.0

Animal Fat (median g/d)

Cases

RR† (95% CI)


0.005

0.20

82.0

98

1.71 (1.0-2.37)

1.38 (0.96-1.96)

76.0

58

1.25 (0.86-1.83)

1.09 (0.74-1.60)

70.0

100

1.57 (1.13-2.19)

1.40 (1.0-1.98)

60.0

76

1.27 (0.90-1.81)

1.17 (0.82-1.67)

47.0

55

1.0

1.0

Total Fat (median g/d)

Cases

RR† (95% CI)


P for Trend*

QuintileFats

54321

0.19

0.16

17.4

88

1.25 (0.92-1.71)

1.28 (0.94-1.76)

14.6

79

1.14 (0.83-1.57)

1.14 (0.83-1.58)

12.8

66

0.95 (0.68-1.32)

0.95 (0.68-1.32)

11.3

79

1.14 (0.83-1.57)

1.15 (0.83-1.58)

8.6

73

1.0

1.0

Polyunsaturated Fatty Acids (median g/d)

Cases

RR† (95% CI)


0.01

0.26

31.2

86

1.53 (1.10-2.11)

1.24 (0.87-1.75)

28.6

79

1.41 (1.01-1.97)

1.19 (0.84-1.68)

26.0

86

1.45 (1.04-2.01)

1.29 (0.92-1.81)

22.4

73

1.26 (0.90-1.77)

1.15 (0.81-1.62)

16.5

61

1.0

1.0

Monounsaturated Fatty Acids (median g/d)

Cases

RR† (95% CI)


0.01

0.47

30.3

82

1.61 (1.16-2.25)

1.22 (0.85-1.76)

26.7

80

1.51 (1.08-2.13)

1.27 (0.89-1.81)

24.3

82

1.54 (1.10-2.15)

1.34 (0.94-1.89)

20.9

82

1.45 (1.04-2.02)

1.30 (0.92-1.83)

15.1

59

1.0

1.0

Saturated Fatty Acids (median g/d)

Cases

RR† (95% CI)


P for Trend*

QuintileFats


54321

0.002

0.25

4.6

77

1.49 (1.06-2.09)

1.29 (0.91-1.84)

3.7

76

1.70 (1.22-2.37)

1.46 (1.03-2.07)

3.2

106

1.73 (1.27-2.35)

1.52 (1.10-2.10)

2.7

64

1.28 (0.90-1.81)

1.17 (0.82-1.67)

1.9

62

1.0

1.0

Trans Fatty Acids (median g/d)

Cases

RR† (95% CI)


0.20

0.38

0.5

67

0.86 (0.61-1.19)

0.97 (0.69-1.36)

0.3

77

0.92 (0.67-1.27)

1.02 (0.74-1.41)

0.2

83

1.17 (0.86-1.61)

1.25 (0.91-1.71)

0.1

86

1.08 (0.79-1.47)

1.11 (0.81-1.52)

<0.1

72

1.0

1.0

Omega-3 Fatty Acids (median g/d)

Cases

RR† (95% CI)


P for Trend*

QuintileFats

*Test for trend was calculated by using the median intake of nutrients in each quintile as a continuous variable in a multiple logistic regression.†Adjusted for age and total energy. ‡Adjusted for age, energy-adjusted dietary fiber and physical activity.(Aldoori WH, et al. Am J Clin Nutr 1994;60:757-764)


Fig. 2: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Total Fat Intake

0

0.5

1

1.5

2

2.5

Low (<17) Medium (17-28)

High (+29)

Low (<47) (g/d)

Medium (47-81)

High (>81.1)


TOTAL FAT INTAKE (g/d)

TOTAL FIBRE INTAKE (g/d)

1.501.26

1.0

1.881.62

1.14

2.35

1.72

0.86

Rel

ativ

e R

isk

*Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat.† Test for trend was calculated by using the median alcohol intake in each category as continuous in a multiple logistic regression.(Aldoori WH, et al. Ann Epidemiol 1995;5:221-228)

TABLE 5: Relative Risk of DD according to alcohol intake

1.38 (0.98-1.95)1.20 (0.86-1.67)6231,3235.1-10.0 g/day

1.36 (0.94-1.97)

(P value for trend†

=0.37)

1.40 (0.95-2.07)

(P value for trend†

=0.15)3814,33630.1+

1.16 (0.81-1.66)1.28 (0.92-1.80)5825,75115.1-30.0 g/day

1.13 (0.77-1.66)1.09 (0.74-1.60)3920,75610.1-15 g/day

1.30 (0.96-1.76)1.28 (0.95-1.71)10851,0070.1-5.0 g/day

ReferenceReference7744,265None

Multivariate*Age adjusted

Relative risk (95% CI)Observed

casesPerson-

yearsAlcohol

*Number of cases do not always add up to 382, because of missing information for specific beverages.** Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat. ‡Test for trend was calculated by using the

median intake specific beverages in each category as continuous in a multiple logistic regression.(Aldoori WH, et al. Ann Epidemiol 1995;5:221-228)

TABLE 6: Relative Risk of DD by levels of total caffeine, coffee, tea, and decaffeinated coffee

(P value for trend‡

=0.98)(P value for trend‡

=0.25)

1.11 (0.78-1.57)1.23 (0.87-1.73)7337,388615 mg/day

1.26 (0.91-1.77)1.37 (0.98-1.90)8437,839355 mg/day

1.14 (0.81-1.61)1.23 (0.88-1.71)7637,185165 mg/day

1.34 (0.97-1.86)1.14 (1.01-1.94)8837,48682 mg/day

ReferenceReference6137,5946.0 mg/day

CAFFEINE (median mg/day)

Multivariate**Age adjusted


cases*Person-

yearsVariable




=0.53)

0.95 (0.65-1.38)1.09 (0.75-1.58)3919,890š4-5/day

1.01 (0.76-1.34)1.09 (0.82-1.45)8942,8132-3/day

1.0 (0.78-1.30)1.05 (0.81-1.35)13565,6721-3/month to 1/day

ReferenceReference10454,696Almost never

COFFEE (cups)



cases*Person-

yearsVariable




=0.09)

1.04 (0.42-2.54)1.04 (0.43-2.55)52,718š4-5/day

1.53 (1.04-2.26)1.53 (1.04-2.24)3242,8132-3/day

1.14 (0.91-1.42)1.11 (0.89-1.38)18165,6721-3/month to 1/day


TEA (cups)



cases*Person-

yearsVariable




=0.02)

1.12 (0.62-2.02)1.08 (0.60-1.95)126,456š4-5/day

1.56 (1.13-2.15)1.45 (1.00-1.95)5320,6002-3/day

1.51 (1.20-1.90)1.41 (1.12-1.76)16769,9411-3/month to 1/day


DECAFFEINATED COFFEE (cups)



cases*Person-

yearsVariable

54321

0.001

0.01

41.0

0.53 (0.37-0.75)

0.60 (0.41-0.87)

15.0

0.79 (0.61-1.03)

0.88 (0.67-1.15)

3.5

0.74 (0.57-0.97)

0.78 (0.60-1.02)

0

1.0

1.0

Vigorous activity (median of Total MET) 2

RR * (95% CI)


0.41

0.65

20.8

0.93 (0.67-1.30)

0.93 (0.67-1.69)

7.6

1.06 (0.77-1.46)

1.09 (0.79-1.49)

3.4

0.78 (0.56-1.10)

0.79 (0.56-1.12)

1.4

1.13 (0.83-1.55)

1.15 (0.84-1.58)

0.1

1.0

1.0

Non-vigorous activity (median of Total MET)§

RR * (95% CI)


0.0002

0.008

46.8

0.57 (0.41-0.79)

0.63 (0.45-0.88)

22.6

0.68 (0.50-0.92)

0.74 (0.54-1.01)

11.3

0.67 (0.49-0.91)

0.71 (0.52-0.97)

4.8

0.89 (0.67-1.18)

0.91 (0.68-1.21)

0.9

1.0

1.0

Total physical activity (median of Total MET) ¶

RR* (95% CI)


P Value for

Trend †

CategoryVariable

TABLE 7: Relative Risk of DD by physical activity, non-vigorous, and vigorous activity levels

*Adjusted for age. †Test for trend was calculated by using the median Total MET value of exercise in each category as a continuous variable in a multiple logistic regression. ‡Adjusted for age, energy-adjusted dietary fiber and energy-adjusted total fat.§Included flight of stairs climbed and walking or hiking outdoors (including walking at golf).2Included running (10 minutes/mile or faster), jogging (slower than 10 minutes/mile), lap swimming, tennis, squash or racquetball, calisthenics or rowing, bicycling (including stationary machines).¶Total MET = sum of the average time/week spent in each activity x MET value of each activity. MET value = caloric need/kg body wt/hour during activity

caloric need/kg body wt/hour at rest(Aldoori WH, et al. Gut 1995;36:276-282).

0

0.5

1

1.5

2

2.5

3

Low (<17) Medium (17-28)

High (+29)

High (>32.5)

Medium (1-32.5)

Low (<1.0)

Fig. 3: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Physical Activity

*Adjusted for age and total energy.(Aldoori WH, et al. Gut 1995; 36:276-282)

PHYSICAL ACTIVITY(Total MET)


0.851.21

1.0

1.811.43

0.80

2.56

1.551.20

Rel

ativ

e R

isk

Body Mass Index (BMI)

• There was a positive association between increasing age adjusted BMI and and the risk of DD

• This association was attenuated and non significant when we adjusted for other confounding variables

• Total caloric intake was not associated with risk of DD

TABLE 8: Relative Risk of DD by smoking status

1.28 (0.78-2.11)1.52 (0.93-2.47)185,81015-24 cig/day



=0.05)

1.25 (0.75-2.09)1.55 (0.94-2.55)175,34725+ cig/day

0.94 (0.50-1.80)1.03 (0.55-1.96)104,8201-14 cig/day

Current smokers (cig/day)

0.96 (0.77-1.19)0.98 (0.79-1.22)16377,912Past smokers

ReferenceReference15984,506Non-smokers

SMOKING STATUS

Multivariate†Age adjusted


cases*Person-

yearsVariable

* Numbers of cases do not always add up to 382, because of missing information for smoking.† Adjusted for age, energy-adjusted dietary fiber, and energy-adjusted total fat. ‡ Test for trend is calculated by using the median number of cigarettes smoked across categories of current smoking in a multiple logistic regression.(Aldoori WH, et al. Ann Epidemiol 1995;5:221-228).

TABLE 9: Relative risk of DD by NSAIDs and acetaminophen use in the HPFS

0.0040.01P Value

2.24 (1.28 - 3.91)1.50 (1.09 - 2.06)Multivariate RR (95% CI)‡

2.19 (1.28 - 3.76)1.52 (1.11 - 2.08)Age-adjusted RR (95% CI)†

34 / 8, 74545 / 13, 682Users, Cases/person-years*

118 / 51, 475265 / 122, 249Nonusers, Cases/person-years

NSAID§

1.81 (0.79 - 4.11)1.33 (0.88 - 2.03)Multivariate RR (95% CI) ‡

0.160.18P Value



133 / 55,314286 / 128, 091Nonusers, Cases/person-years

Acetaminophen

1990 to 19921988 to 1992Follow-up Period

1988 + 19901988NSAIDs and acetaminophen Use

Variable

*Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was 1988-1992; for 1988 and 1990, 1990-1992); nonusers reported no NSAID or acetaminophen use during the specified time periods. †Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. ‡ Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. § Does not include aspirin. NSAID indicates nonsteroidal anti-inflammatory drug.(Aldoori WH, et al. Arch Fam Med 1998;7:255-260)

TABLE 10: Relative risk of DD for participants whose main symptoms were abdominal pain and change in bowel habits, by NSAIDs and acetaminophen use in the HPFS.

0.0090.14P Value





NSAID§

1.18 (0.37 - 3.71)1.04 (0.60 -1.79)Multivariate RR (95% CI) ‡

0.780.89P Value




Acetaminophen



Variable

*Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was 1988-1992; for 1988 and 1990, 1990-1992); nonusers reported no NSAID or acetaminophen use during the specified time periods. †Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. ‡ Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. § Does not include aspirin. (Aldoori WH, et al. Arch Fam Med 1998;7:255-260)

TABLE 11: Relative risk of DD for participants whose main symptoms were bleeding, by NSAIDs and acetaminophen use in the HPFS.

0.050.07P Value





NSAID§

13.63 (3.53 - 52.6)3.75 (1.63 - 8.64)Multivariate RR (95% CI) ‡

0.00020.002P Value




Acetaminophen



Variable

*Participants who reported NSAIDs and acetaminophen use (the follow-up period for1988 was 1988-1992; for 1988 and 1990, 1990-1992); nonusers reported no NSAID or acetaminophen use during the specified time periods. †Age-adjusted relative risk and 95% CI for users compared with nonusers of NSAID or acetaminophen for each of the specified time periods. ‡ Relative risk adjusted for age, physical activity, energy-adjusted dietary fiber and total fat. § Does not include aspirin. (Aldoori WH, et al. Arch Fam Med 1998;7:255-260)

Gaps in our Knowledge

• Better understanding of the interactions between colonic structures, motility, diet, lifestyle and genetic factors

• Better understanding why symptoms develop

• Better understanding whether specific factors are important for the formation of diverticula, and whether different factors contribute to the symptomatic presentation and / or complications

Can we reduce the risk of DD?

• A diet high in fiber mainly from fruits and vegetables and low in total fat and red meat decreases risk of DD

• Insoluble component of fiber is strongly associated with lower risk of DD. This association was particularly strong for cellulose

Fig. 1: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Red Meat Intake

00.5

11.5

22.5

33.5

Low (<17) Medium (17-28)

High (29+)

Low (<28.5)

Medium (28.6-116.6)

High (>116.6)


RED MEAT INTAKE (g/d)


1.96 1.79

1.0

3.162.60

1.90

3.22

2.53

1.73

Rel

ativ

e R

isk

Fig. 2: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Total Fat Intake

0

0.5

1

1.5

2

2.5

Low (<17) Medium (17-28)

High (+29)

Low (<47) (g/d)

Medium (47-81)

High (>81.1)


TOTAL FAT INTAKE (g/d)

TOTAL FIBRE INTAKE (g/d)

1.501.26

1.0

1.881.62

1.14

2.35

1.72

0.86

Rel

ativ

e R

isk

• Caffeine, smoking and alcohol do not substantially increase risk of DD, nor does obesity

• Higher levels of physical activity seem to reduce risk of DD

0

0.5

1

1.5

2

2.5

3

Low (<17) Medium (17-28)

High (+29)

High (>32.5)

Medium (1-32.5)

Low (<1.0)

Fig. 3: Relative Risk* of DD by levels of Calorie-adjusted Dietary Fiber and Physical Activity

*Adjusted for age and total energy.(Aldoori WH, et al. Gut 1995; 36:276-282)

PHYSICAL ACTIVITY(Total MET)


0.851.21

1.0

1.811.43

0.80

2.56

1.551.20

Rel

ativ

e R

isk

• There is evidence that regular and consistent use of NSAIDs and acetaminophen is associated with complicated DD

• Most of this positive association was attributable to cases associated with bleeding

THANK YOU

Primary and Secondary Prevention of Diverticular Disease · 2017. 10. 13. · Primary and Secondary...

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Transcript of Primary and Secondary Prevention of Diverticular Disease · 2017. 10. 13. · Primary and Secondary...