Liquid-Formula Diet with Fiber9
Tohoku J. Exp. Med., 2004, 203, 9-16
Received January 28, 2004; revision accepted for publication March 4, 2004.
Address for reprints: Shigeyuki Nakaji, Department of Hygiene, Hirosaki University School of Medicine, 5
Zaifu-cho, Hirosaki 036-8562, Japan.
Nutritional Effects of Supplementing Liquid-Formula
Diet with Dietary Fiber on Elderly Bed-Ridden Patients
SEIKO WADA, SHIGEYUKI NAKAJI,1 TAKASHI UMEDA,1 IPPEI TAKAHASHI,1 TAKAO
OYAMA,1 DAISUKE CHINDA,1 KAZUO SUGAWARA,1 TADASHI SHIMOYAMA,1 JUICHI
SAKAMOTO2 and SHINSAKU FUKUDA2
Department of Nursing, Akita Keijo Junior College, Odate 017-0046,
1Department of Hygiene, Hirosaki University School of Medicine, and
2First Department of Internal Medicine, Hirosaki University School of
Medicine, Hirosaki 036-8562
WADA, S., NAKAJI, S., UMEDA, T., TAKAHASHI, I., OYAMA, T., CHINDA, D.,
SUGAWARA, K., SHIMOYAMA, T., SAKAMOTO, S., and FUKUDA S. Nutritional Effects
of Supplementing Liquid-Formula Diet with Dietary Fiber on Elderly Bed-Ridden
Patient. Tohoku J. Exp. Med., 2004, 203 (1), 9-16 ─ ─ In the past few decades, the
number of bed-ridden elderly patients has been increasing. This group of patients
is frequently fed with a liquid formula diet. The aim of this study was to evalu-
ate the usefulness of a liquid formula diet containing dietary fiber (DF) for elderly
bed-ridden patients. Eighteen elderly, bed-ridden patients were given L-3 Fiber®,
a DF-containing liquid formula diet (DF-LFD), for 4 weeks, while a number of
parameters were monitored, including serum levels of total cholesterol, triglyceride,
total protein, creatinine, uric acid, glucose, sodium, potassium, and calcium, urine
protein/sugar, and defecation frequency. Total protein, albumin and total cholesterol
significantly increased following the administration of the DF-LFD, associated with
an average increase in body weight of 1.94 kg (5.0%). Defecation frequency signifi-
cantly increased one week after DF-LFD administration was started, but this effect
was transient. Although a few patients complained of nausea, vomiting or abdominal
pain, no severe side effects were seen. In conclusion, DF-LFD supplementation
appears to be beneficial for elderly bed-ridden patients, and can increase nutritional-
related parameters, such as body weight, total protein, albumin and total cholesterol,
without severe side effects. ─ ─ ─ ─ dietary fiber; cellulose; nutrition; liquid-formula
diet; elderly bed-ridden patients
© 2004 Tohoku University Medical Press
S. Wada et al.10
A liquid formula diet (LFD) is used for
patients who cannot take a meal orally or intra-
venously, and is more physiological than intrave-
nous feeding. LFD has the additional advantage
of being adaptable for home patients, as it does
not require the high levels of sterility that are
required for intravenous feeding. LFD can in-
clude natural foods and, a variety of nutrients, and
is the most nutritionally appropriate dietary intake
for elderly long-term bed-ridden patients.
In Japan and elsewhere world-wide, life
expectancies have been increasing, leading to a
steady increase in the so-called “graying popula-
tion.” This has in turn led to an expanding num-
ber of bed-ridden elderly patients, both in home-
care and inpatient environments. Finding an
appropriate diet for this growing elderly patient
population has therefore become extremely im-
In the past, dietary fiber (DF) was referred
to as unavailable carbohydrate, and was thought
to be a burden on the digestive tract and an in-
hibitor of absorption and digestion of nutrients.
However, Burkitt’s fiber hypothesis (Burkitt 1971;
Burkitt and Marshall 1972) during the 1970’s pro-
vided stimulus for research in this area. Since that
time, DF has attracted considerable attention for
its beneficial physiological actions. These include
improvement/maintenance of digestive tract func-
tion (Burkitt 1971; Burkitt et al. 1972; Munakata
et al. 1995), inhibition of absorption of toxic
substances (Burkitt 1971; Ershoff and Marshall
1975), improved glucose tolerance (Wolever et
al. 1994), reduction of serum cholesterol (Keys
et al.1960; Jenkins et al. 1980; Kris-Etherton et
al. 2002) and the prevention of colorectal cancer
(Burkitt 1971; Block et al. 1992) Furthermore,
DF plays a role in ameliorating diarrhea (Zimmaro
et al.1989). Thus, a DF-containing LFD
(DF-LFD) was developed in the 1980s (Shinnick
et al. 1989).
However, there is a possible major disadvan-
tage associated with DF-LFDs: DF inhibits the ab-
sorption of nutrients, especially minerals (Ismail-
Beigi et al. 1977; Slavin and Marlett1980), with
even potentially fatal results in elderly bed-ridden
patients, particularly those with an underlying
pathological condition. This aspect must there-
fore be taken into very careful consideration.
To date, although there are a few stud-
ies which have comprehensively examined the
effects of the administration of DF-LFD on the
nutritional status, defecation frequency, blood –
and other physiological parameters in human
subjects (Ismail-Beigi et al. 1977; Slavin and
Marlett1980; Lampe et al. 1991; Rahman et al.
2003), no studies have examined such effects of
a DF-LFD on bed-ridden elderly subjects. The
elderly, especially bed-ridden patients, are prone
to have an imbalanced nutritive intake leading to a
tendency towards malnutrition, creating a vicious
circle by further exacerbating any underlying
pathology or disease. A properly balanced food
intake is necessary to maintain the nutritional
state of this growing patient population. The use
of DF-LFDs has become more common recently,
therefore a study is required to examine the ben-
efits or otherwise of feeding elderly bed-ridden
patients with a DF-LFD.
This study was therefore designed to exam-
ine the effects of a DF-LFD (an LFD containing
powdered crystal cellulose) on elderly bed-ridden
patients, monitoring their body weight, defecation
frequency, blood parameters and urine parameters
to evaluate the effects of the DF-LFD.
SUBJECTS AND METHODS
Seventeen elderly patients (eight men and
nine women) who were hospitalized in West
Odate Hospital (Odate City, Akita Prefecture,
Northern Japan) were enrolled in this study. The
age of these patients ranged from 62 to 85 years
with a mean of 74.8 years (Table 1).
Patients in this study were afflicted with a
variety of underlying conditions; these included
cerebral infarction (13 cases), cerebral hemor-
rhage (4 cases) and 1 case of Alzheimer’s demen-
tia (Table 1).
Written informed consent was obtained from
Liquid-Formula Diet with Fiber11
each subject/subject’s family before participation.
The study was approved by the Ethics Committee
of Hirosaki University School of Medicine.
Liquid-formula diet. L-3 Fiber® (Asahi
Kasei Corporation, Tokyo) was used as the DF-
LFD, which contains 2.4 g crystal cellulose per
200 ml (Table 2).
L-2 (Asahi Kasei Corporation, Tokyo), an
LFD which does not contain DF, was adminis-
tered to all subjects as a comparative autocontrol
before L-3 Fiber® administration was commenced.
The nutritional contents of both these diets are
shown in Table 2.
Method of supplementation. Of the 18 pa-
tients participating in this study, 17 were tube-fed
via the nose and one was tube-fed via a gastros-
toma. The experimental schedule involved daily
LFD administration for 2 weeks, followed by dai-
ly administration of DF-LFD for 4 weeks, 1200
kcal per day. The daily supplementary DF dose
in the DF-LFD was 14.4 g per person, which is
equivalent to the average daily DF intake in Japan
(Nakaji et al., using the modified Prosky method)
Both the LFD and DF-LFD were adminis-
tered three times per day at a rate of approximate-
ly 250-300 ml/hour.
Body weight, defecation frequency and
stool appearance. The body weight, defecation
frequency, stool appearance and any subjective
symptoms were monitored daily in all subjects
throughout the trial period. Before DF-LFD ad-
ministration, three patients were severe constipa-
tion, who had a defecation per one week or more.
Blood and urine parameters. A number of
blood and urine parameters were measured at two
time points: one day before and three weeks after
DF-LFD administration. Blood parameters in-
cluded red blood cell (RBC) and white blood cell
(WBC) counts, hemoglobin (Hb), platelet count,
and hematocrit (Ht) in whole blood. The total
protein (TP), albumin (Alb), glutamic oxaloacetic
TABLE 1. Subjects and their basic diseases
Age Basic disease Combination disease
Sick Sinus Syndrome
S. Wada et al.12
transaminase (GOT), glutamic pyruvic trans-
aminase (GPT), lactate dehydrogenase (LDH),
γ glutamic transpeptitase (γ GTP), alkaline phos-
phatase (ALP), loicinaminopeptidase (LAP),
total bilirubin (T-Bil), blood nitrogen urea (BUN),
creatinine (Creat) and uric acid (UA) levels
were monitored. Additionally, total cholesterol
(T-Cho), HDL-cholesterol (HDL-Cho), triglyce-
ride (TG), free fatty acid (FFA), phospholipid,
glucose, sodium (Na), potassium (K), calcium
(Ca), chloride (Cl) and phosphate (P) levels in
serum were also monitored. Analysis of urine
samples included parameters such as glucose and
protein, which were checked four times during
this study. The atherogenic Index (AI) was addi-
tionally calculated by the following equation:
AI = (T−Cho)−(HDL−Cho)
The difference in values/frequencies of pa-
rameters were tested using the χ2 test or paired
t-test. A probability (p) of < 0.05 was considered
TABLE 2. Contents of L-2 and L-3 Fiber (per 200 ml)
L2 L3 Fiber
Liquid-Formula Diet with Fiber13
Significant increases in TP, Alb and T-Cho
were seen in patients after DF-LFD administra-
tion (p<0.05 in each). However, there was no
change in either HDL-Cho and AI.
There were no major changes in electrolytes
or liver function. Although one patient exhibited
a temporary impairment of liver and kidney func-
tion and a temporary electrolyte imbalance, these
changes spontaneously improved without any
need for intervention (Table 3).
There were no significant changes in the
urine samples during the course of this study
After two weeks of DF-LFD administra-
tion, the patients’ body weight was found to have
increased by an average of 0.69 kg (no significant
difference from the value immediately before DF-
LFD administration). After four weeks of treat-
ment with the DF-LFD, the patients’ body weight
had increased by an average of 1.94 kg (5%),
which was significant (p<0.05) when compared
with the value before DF-LFD administration.
Of the 18 patients given the DF-LFD, 14
showed an increase in body weight, seven of
whom showed increases of over 5% with 1-5%
seen in the remaining 7. Of the other 4 patients,
one showed no change and three experienced
weight losses ranging from 1% to 5% of their
TABLE 3. Laboratory data
One day before
L-3 Fiber® diet
3 weeks after
L-3 Fiber® diet
Atherogenic Index 2.7±0.9 2.8±0.9
Significant difference from pre-administration. *p<0.05.
S. Wada et al.14
Defecation frequency and stool appearance
Administration of the DF-LFD initially
resulted in a significantly increased frequency
of defecation and fecal output when compared
with those observed during LFD administration
(p<0.05); however, the frequency subsequently
decreased. There was a tendency (not statistically
significant) towards an increased proportion of
watery stools during the first 2 weeks of DF-LFD
administration (Fig. 1).
One patient showed a change from watery
stools to formed stools after DF-LFD adminis-
tration. However, the overall defecation state
(e.g., chronic constipation) did not change in any
other patients after DF-LFD administration. One
patient had diarrhea after starting DF-LFD admin-
istration, but recovered during the course of this
Three patients complained of abdominal
distension immediately after starting DF-LFD ad-
ministration, but this improved after two or three
days of observation. Although a few patients
complained of such effects as nausea, vomiting
and abdominal pain, there were no severe side
effects. No loss of feeding tube patency was ex-
perienced during the course of this study.
The source of DF in the DF-LFD used in
this study was crystal cellulose, which is a water-
insoluble fiber known to increase stool volume
and shorten transit time within the large intestine.
In the current study, the DF-LFD significantly
increased defecation frequency without causing
diarrhea. Therefore, a DF-containing formula
diet might be useful for maintaining or improv-
ing large intestinal function. While this was a
significant finding, it was also true that the DF-
LFD could not improve chronic constipation. The
TABLE 4. Urinary data
Fig. 1. Changes in defecation frequency and stool appearance. , formed stool; □, watery stool.
Different in defecation frequency from one week after DF-LFD administration. *p<0.05, **p<0.01.
Liquid-Formula Diet with Fiber15
reason for this may be explained by the fact that
the constipation of elderly, bed-ridden patients is
a result of marked relaxation of the large intestine,
i.e., physiological rather than pathological.
One of the main purposes behind adding DF
to LFD is to prevent diarrhea due to administra-
tion of the latter. In the current study, there was
only one case who had watery stools after LFD
administration, but who showed a change from
watery stools to formed stools after DF-LFD ad-
The inhibition of the absorption of nutri-
ents (especially minerals) by DF administration
(Ismail-Beigi 1977; Slavin 1980) demands much
attention, because elderly patients easily become
nutritionally insufficient. It should be noted,
however, that this study showed a increase in
nutritional parameters such as TP, Alb, and T-Cho
associated with L-3 Fiber® administration. On
the other hand, one patient showed a drop in the
plasma potassium level during the administration
period, but this change spontaneously improved
without any need for intervention. Therefore, we
can say that, in general, the administration of DF-
LFD improved the nutritional status of the sub-
The very elderly are extremely prone to tak-
ing a nutritionally insufficient diet, which can
easily lead to cardiopulmonary/kidney dysfunc-
tion and electrolytic imbalance with dehydration
(Eisenberg 2002). In the current study, there was
one case of transient liver dysfunction, but it is
not clear whether this was associated with the en-
This study has two limitations. Firstly,
the stool weight was not assessed, so we can-
not examine the relationship between DF-LFD
administration fecal output in detail. Secondly,
four weeks of L-3 Fiber® administration might be
insufficient to evaluate definitively its effects.
Despite these limitations, this study demon-
strates that a DF-LFD is useful to furnish nutri-
ents for bed-ridden elderly patients, and indicates
that DF-LFD administration can be applied for
home medical/health care. However, long-term
observation of these patients is required in further
multicenter studies with larger patient popula-
tions, and perhaps LFDs with different types and
amounts of DF, to elucidate completely both the
beneficial effects and the side effects of DF-LFDs.
We would like to thank Dr. Mitsuyoshi Ikeda,
the Hospital Director of West Odate Hospital in
Akita Prefecture in Japan, for his assistance with the
study design and execution of this study.
Block, G., Patterson, B. & Subar, A. (1992) Fruit,
vegetables, and cancer prevention. A review of
the epidemiological evidence. Nutr. Cancer,
Burkitt, D.P. (1971) Epidemiology of cancer of the
colon and rectum. Cancer, 28, 3-13.
Burkitt, D.P., Walker, A.R. & Painter, N.S. (1972) Ef-
fect of dietary fibre on stools and the transit-
times, and its role in the causation of disease.
Lancet, 2, 1408-1412.
Eisenberg, P. (2002) An overview of diarrhea in the
patient receiving enteral nutrition. Gastroen-
terol. Nurs., 25, 95-104.
Ershoff, B.H. & Marshall, W.E. (1975) Protective ef-
fects of dietary fiber in rats fed toxic doses of
sodium cyclamate and polyoxymethylene sorbi-
tan monostearate (Tween 60). J. Food Sci., 40,
Ismail-Beigi, F., Reinhold, J.G., Faraji, B. & Abadi,
P. (1977) Effects of cellulose added to diets of
low and high fiber content upon the metabolism
of calcium, magnesium, zinc and phosphorus
by man. J. Nutr., 107, 510-518.
Jenkins, D.J.A., Wolever, T.M.S., Taylor, R.H.,
Reynolds, D., Nineham, R. & Hockaday, T.D.
(1980) Diabetic glucose control, lipids and
trace elements on long-term guar. Br. Med. J.,
Keys, A., Anderson, J.T. & Grande, F. (1960) Diet-
type (fats constant) and blood lipid in man. J.
Nutr., 70, 257-261.
Kris-Etherton, P.M., Taylor, D.S., Smiciklas-Wright,
H., Mitchell, D.C., Bekhuis, T.C., Olson, B.H.
& Slonim, A.B. (2002) High-soluble-fiber
foods in conjunction with a telephone-based,
personalized behavior change support service
result in favorable changes in lipids and life-
S. Wada et al.16 Download full-text
styles after 7 weeks. J. Am. Diet. Assoc., 102,
Lampe, J.W., Slavin, J.L., Baglien, K.S., Thompson,
W.O., Duane, W.C. & Zavoral, J.H. (1991)
Serum lipid and fecal bile acid changes with
cereal vegetable, and sugar-beet fiber feeding.
Am. J. Clin. Nutr., 53, 1235-1241.
Munakata, A., Iwane, S., Todate, M., Nakaji, S. &
Sugawara, K. (1995) Effects of dietary fiber
on gastrointestinal transit time, fecal properties
and fat absorption in rats. Tohoku J. Exp. Med.,
Nakaji, S., Sugawara, K., Saito, D., Yoshioka, Y.,
MacAuley, D., Bradley, T., Kernohan, G. &
Baxter, D. (2002) Trends in Dietary Fiber
Intake in Japan over the Last Century. Eur. J.
Nutr., 41, 222-227.
Rahman, S.H., Catton, J.A. & McMahon, M.J. (2003)
Randomized clinical trial of specific lactobacil-
lus and fibre supplement to early enteral nutri-
tion in patients with acute pancreatitis. Br. J.
Surg., 90, 123.
Shinnick, F.L., Hess, R.L., Fischer, M.H. & Marlett, J.
(1989) Apparent nutrient absorption and upper
gastrointestinal transit with fiber-containing en-
teral feedings. Am. J. Clin. Nutr., 49, 471-475.
Slavin, J.L. & Marlett, J.A. (1980) Influence of refined
cellulose on human bowel function and calcium
and magnesium balance. Am. J. Clin. Nutr., 33,
Wolever, T.M.S., Nguyen, P-M., Chiasson, J.L., Hunt,
J.A., Josse, R.G., Palmason, C., Rodger, N.W.,
Ross, S.A., Ryan, E.A. & Tan, M.H. (1994)
Determinants of diet glycemic index calculated
retrospectively from diet records of 342 indi-
viduals with non-insulin-dependent diabetes
mellitus. Am. J. Clin. Nutr., 59, 1265–1269.
Zimmaro, D.M., Rolandelli, R.H., Koruda, M.J.,
Settle, R.G., Stein, T.P. & Rombeau, J.L. (1989)
Isotonic tube feeding formula induces liquid
stool in normal subjects: reversal by pectin.
JPEN J. Parenter. Enteral Nutr., 13, 117-123.