Content uploaded by Christophe Matthys
Author content
All content in this area was uploaded by Christophe Matthys on Nov 04, 2016
Content may be subject to copyright.
REVIEW
Low-Residue and Low-Fiber Diets in
Gastrointestinal Disease Management
1,2
Erika Vanhauwaert,
3,4
* Christophe Matthys,
4,6
Lies Verdonck,
3
and Vicky De Preter
3,5
3
Knowledge and Innovation Centre Food and Nutrition, University College Leuven-Limburg, Leuven, Belgium;
4
Department of Clinical and
Experimental Medicine and
5
Translational Research Center for Gastrointestinal Disorders ( TARGID), KU Leuven, Leuven, Belgium; and
6
Clinical
Nutrition Unit, Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
ABSTRACT
Recently, low-residue diets were removed from the American Academy of Nutrition and Dietetics’Nutrition Care Manual due to the lack of
a scientifically accepted quantitative definition and the unavailability of a method to estimate the amount of food residue produced. This
narrative review focuses on defining the similarities and/or discrepancies between low-residue and low-fiber diets and on the diagnostic and
therapeutic values of these diets in gastrointestinal disease management. Diagnostically, a low-fiber/low-residue diet is used in bowel preparation.
A bowel preparation is a cleansing of the intestines of fecal matter and secretions conducted before a diagnostic procedure. Therapeutically,
a low-fiber/low-residue diet is part of the treatment of acute relapses in different bowel diseases. The available evidence on low-residue and low-
fiber diets is summarized. The main findings showed that within human disease research, the terms “low residue”and “low fiber”are used interchangeably,
and information related to the quantity of residue in the diet usually refers to the amount of fiber. Low-fiber/low-residuedietsarefurtherexplored
in both diagnostic and therapeutic situations. On the basis of this literature review, the authors suggest redefining a low-residue diet as a low-fiber diet and
to quantitatively define a low-fiber diet as a diet with a maximum of 10 g fiber/d. A low-fiber diet instead of a low-residue diet is recommended as
a diagnostic value or as specific therapy for gastrointestinal conditions. Adv Nutr 2015;6:820–7.
Keywords: dietary intake, fiber, gastrointestinal disorders, low-fiber diet, low-residue diet, bowel preparation
Introduction
Digestion in the human gastrointestinal tract (GIT)
7
in-
volves a complex series of organs and glands that process
food. During passage through the GIT, food digestion starts
in the mouth and is completed in the small intestine. Some
material passes undigested through the small intestine and is
fermented in the colon. Both mechanical forces and chem-
ical reactions break down ingested food into small molecules
(1). Most digested molecules of food, as well as water and
minerals, are absorbed through the small intestine. Nondi-
gested nutrients are further metabolized in the large intes-
tine by the intestinal microbiota and partly made available
to the host (2). However, some remnants, such as indigest-
ible food material, microorganisms, and secretions and
desquamated intestinal cells, the so-called residue of diges-
tion, remain and are discharged from the GIT as feces.
In some gastrointestinal conditions, such as Crohn dis-
ease, ulcerative colitis, bowel inflammation, irritable bowel
syndrome (IBS), and diverticulitis, as well as pre- and/or
postabdominal surgery, low-residue diets are prescribed to
limit the amount of food waste that has to move through
the large intestine. The American Academy of Nutrition
and Dietetics removed the low-residue diet from the Nutri-
tion Care Manual because there is no scientifically accept-
able definition for the term “residue”or “residue-low”and
the lack of qualitative studies limits scientific evidence on
the effects of low-residue diets (3). In addition, the amount
of residue produced during passing through the GIT cannot
be estimated.
In most studies, information on the quantity of residue in
the diet refers to the amount of fiber. Fiber is the part of
fruit, vegetables, and grains that is not digested by the
body and is proposed as a necessary component of a healthy
diet and required for normal bowel movements (4). In prac-
tice, within human disease research, both the terms “low
residue”and “low fiber”are used interchangeably. In this
1
Supported by a grant from the University College Leuven-Limburg in cooperation with the
Leuven University (KU Leuven) and the University Hospital Leuven (UZ Leuven, Belgium).
2
Author disclosures: E Vanhauwaert, C Matthys, L Verdonck, and V De Preter, no conflicts of
interest.
* To whom correspondence should be addressed. E-mail: erika .vanhauwaert@ucll.be.
7
Abbreviations used: DP, degree of polymerization; GIT, gastrointestinal tract; IBS, irritable
bowel syndrome.
820 ã2015 American Society for Nutrition. Adv Nutr 2015;6:820–7; doi:10.3945/an.115.009688.
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
narrative review, we critically review the diagnostic and ther-
apeutic values of low-residue and low-fiber diets in gastroin-
testinal disease management.
Current Status of Knowledge
Defining “residue”and “dietary fiber”
Residue. Until now, there has been no scientifically accept-
able definition of residue. The impossibility of estimating
the amount of residue produced by the digestion of various
foods complicates a consensus definition for residue. In the
literature, residue mostly refers to any indigestible food sub-
stance that remains in the intestinal tract and contributes
to stool bulk (3, 5). This means that the residue of digestion
is primarily indigestible material (i.e., dietary fiber), mi-
croorganisms,andsecretionsandcellsshedfromtheali-
mentary tract. The latter 2 increase the fecal output after
digestion (3).
Dietary fiber. Originally, Trowell (6) defined fiber as com-
ponents derived from the cell wall of a plant that resist hy-
drolysis by digestive enzymes and absorption in the small
intestine. Typical plant cell wall components are pectin, cel-
lulose, and hemicellulose. This definition was ascertained as
being too strict and other substances, such as starch and
fructans, were also defined as fiber. However, until now, a
universally accepted definition for dietary fiber has been un-
available. The Codex Committee on Nutrition and Foods for
Special Dietary Uses defined dietary fiber as carbohydrate
polymers with a degree of polymerization [DP; or mono-
meric (single sugar) units] not lower than 3, which are nei-
ther digested nor absorbed in the small intestine. A DP not
lower than 3 is intended to exclude mono- and disaccha-
rides. Dietary fiber consists of one or more 1) edible carbo-
hydrate polymers naturally occurring in the food as
consumed; 2) carbohydrate polymers, which have been ob-
tained from food raw material by physical, enzymatic, or
chemical means; and 3) synthetic carbohydrate polymers
(7). This definition is supported by the American Associa-
tion of Cereal Chemists (8). The WHO and FAO agree
with the latter definition but with a slight variation. They
state that dietary fiber is a polysaccharide with $10 mono-
meric units (9). A recent report from the Ninth Vahouny
Fiber Symposium indicated that the scientific community
agrees on maintaining a worldwide consensus with regard
to the inclusion of nondigestible carbohydrates with a min-
imum DP of 3 as dietary fiber and on a core, nonexhaustive
list of beneficial physiologic effects of dietary fibers (10).
The European Food Safety Authority Panel on Dietetic
Products, Nutrition and Allergies published in 2010 a sci-
entific opinion on dietary reference values for the intake
of carbohydrates, dietary fiber, fats, and water. In this opin-
ion, dietary fiber was defined as nondigestible carbohy-
drates plus lignin (11). In addition, in the United States,
the FDA proposed to accept this definition (12). Table
1gives an overview of different types of carbohydrates
and their common food source, average DP, and main
properties (13, 14).
Different types of fibers can also be distinguished on the
basis of their chemical or physical properties (Table 1 and
Table 2). Chemically, fibers are divided into carbohydrates
and noncarbohydrates, such as lignin. Physically, dietary fi-
ber is differentiated in 2 groups on the basis of its solubility:
insoluble in water and nonfermentable and nonviscous fi-
bers compared with soluble and fermentable fibers.
Nonfermentable fibers are very slowly or not fermented
by the bacteria in the colon, they retain water, and they
will cause a laxative effect because of their direct contribu-
tion to stool bulk as undigested material without affecting
fermentation or microbial growth, a so-called bulking effect
(15, 16). Fermentable fibers are fermented by the colonic
microbiota. Because bacteria comprise ;55% of fecal dry
weight, an increase in microbial mass causes an increase in
fecal output, thereby inducing a possible laxative effect
(15–17) (Figure 1).
A low-residue compared with a low-fiber diet
In the literature, there have been discrepancies among diet
recommendations as to the actual composition of low-fiber
and/or low-residue diets. Until now, no clear definition has
been proposed for a low-residue diet. Cunningham (3) de-
scribed that all foods produce some gastrointestinal residue,
as does normal gastrointestinal function, and fiber-containing
foods produce the bulk of the gastrointestinal residue.
In addition, no clear definition has been provided for a
low-fiber diet. Lijoi et al. (18) described a low-fiber diet as
a diet with a total daily fiber intake <10 g. Similarly, in a clin-
ical study on the effects of a low-fiber diet in IBS, fiber intake
was also set at ;10 g fiber/d (19). Although these studies de-
fined a low-fiber diet in a quantitative way, no reference was
made to the type of dietary fiber. Other studies only defined
examples of foods that were and were not allowed in a low-
fiber diet (20).
Low-residue or low-fiber diets in gastrointestinal
disease management
Diagnostic: bowel preparation protocols. Bowel prepara-
tion is often conducted before a colonoscopy, colonography,
or gynecological surgery. Currently, mechanical bowel prep-
aration with oral lavage solutions such as polyethylene gly-
col, sodium phosphate, sodium picosulfate, or magnesium
citrate, often preceded by 1 or 2 d of a clear-liquid diet,
are commonly used. In addition, stimulant laxatives and/
or prokinetic agents can be combined with these cathartic
agents. However, patients often find this preparation to be
unpleasant and time-consuming. The most common prob-
lems that lead to less than adequate colon cleansing include
lack of compliance with the clear-liquid diet and difficulty
taking the preparation (21). In addition, cathartic agents
are not without reported side effects such as nausea, vomit-
ing, bloating, abdominal cramping, sleep discomfort, head-
aches, dizziness, and absence from school or work (22).
A number of studies investigated the intake of a low-fiber
or low-residue diet as an adjuvant to cathartic regimens with
regard to colon-cleansing efficacy and patient compliance.
Low-residue compared with low-fiber diets 821
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
Dietary restriction of fiber or residue may result in a reduc-
tion in the size and number of stools for the patients, result-
ing in less discomfort for the patient (23, 24). An overview
of the studies in humans is presented in Table 3.
Delegge and Kaplan (21) first compared the tolerability
and efficacy of a low-residue diet with a clear-liquid diet
1 d before a routine colonoscopy. In addition, Park et al.
(25) and Sipe et al. (26) compared a prepackaged low-residue
diet with a clear-fluid regimen. All diets were combined
with cathartic agents. In a recent study by Kim et al. (27),
the clinical efficacy of reduced-volume sodium picosulfate
and a prepackaged low-residue diet was compared with
that of the standard bowel preparation by using 4 L polyeth-
ylene glycol solution. In all 4 former studies, the low-residue
regimen did not impair the quality of the bowel preparation
and a better colon cleansing was achieved. Furthermore,
they confirmed that the low-residue diet was better tolerated
and an improvement in patient satisfaction was observed. In
another study, the efficacy of a fiber-free diet was compared
with a clear-liquid diet for colonoscopy preparation. Similar
to the results of the low-residue diets, the fiber-free diet was
better tolerated by patients (28). In addition, a recent ran-
domized controlled trial showed that the quality of bowel
preparation was not compromised by a low-residue break-
fast on the day preceding the colonoscopy. In addition,
this regimen was better accepted by patients and there was
an increased compliance with the low-residue diet than
with a clear-fluid diet (29). In contrast to the previous stud-
ies, Stolpman et al. (30) found that bowel preparation
quality, polyp detection rates, and patient tolerance and ac-
ceptance were similar between a low-residue and a clear-
liquid diet and proposed a low-residue diet as an alternative
approach for bowel preparation.
Wu et al. (31) determined in a prospective study whether
the residue content of the diet before a colonoscopy inde-
pendently predicts inadequate bowel preparation. There-
fore, they scored the residue content (1 = high residue,
2 = normal residue, 3 = low residue, and 4 = no residue)
of all meals consumed during the 2 d preceding the colo-
noscopy. Immediately after the procedure, the quality of
the bowel cleansing was rated by use of the Ottawa bowel
preparation scale (32). A good correlation between the die-
tary residue content score and the Ottawa bowel preparation
score was found (r=20.475, P= 0.001), indicating that a
low-residue diet resulted in better bowel cleansing than
did a regular diet.
Computed tomographic colonography is an alternative
to colonoscopy in the detection of polyps and carcinoma of
the colon and rectum. Liedenbaum et al. (20) demonstrated
that limited bowel preparation in combination with a low-fiber
diet for computed tomographic colonography resulted in
improved subjective tagging quality of residual feces and
showed a trend toward better residue homogeneity.
In addition, in laparoscopic gynecological surgery a
bowel preparation is conducted to decrease peritoneal con-
tamination in case of bowel injury and to empty the bowel of
its contents in order to improve the access to the surgical
field and to facilitate the handling of the bowel itself (33).
TABLE 1 Classification of carbohydrates according to average DP and their main properties
1
Effects
Carbohydrate Example Average DP Digestion Fermentation Upper GIT Colon Food source
Monosaccharides Glucose, fructose, galactose 1 Complete Fruit (juice)
Disaccharides Sucrose, lactose, maltose 2 Complete Cane and root
beet sugar,
candy, soft
drinks, milk, beer
Lactulose Not digested Good Delayed GE F
Oligosaccharides Raffinose, stachyose,
kestose, verbascose,
nystose
3–9 Good Legumes, beans
(stachyose),
sweet potatoes
(raffinose),
wheat
Maltodextrin 3–9 Good Potatoes, wheat
Fructo-oligosaccharides 3–9 Not digested Good No F Leeks, onions,
soybeans
Galacto-oligosaccharides 3–9 Not digested Good No F Fruit
Arabino-xylo-oligosaccharides 3–9 Not digested Good No F Wheat
Polydextrose 3–9 Not digested Good No F
Polysaccharides Inulin .9 Not digested Very good No F Chicory, onion
Starch: freshly cooked .9 Complete Warm potatoes
Raw cereals .9 Complete Grains
Resistant starch
2
.9 Not digested Variable Variable F + stool bulk Green bananas,
cold potatoes
Cellulose, hemicelluloses .9 Not digested No Small Stool bulk Vegetables
Pectin .9 Variable Variable F + stool bulk Vegetables
Gums .9 Good Viscosity [F Vegetables
Related compounds Lignin .9 Not digested No Stool bulk Wheat, vegetables
1
The classification of carbohydrates and their main properties was adapted from the European Food Safety Authority Panel on Dietetic Products Nutrition Allergies (11) and
Jones (12). DP, degree of polymerization; F, fermentation; GE, gastric emptying; GIT, gastrointestinal tract; [, increase.
2
Resistant starch includes physically inaccessible starch (RS1), resistant granules (RS2), and retrograded amylose (RS3).
822 Vanhauwaert et al.
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
Lijoi et al. (18) first compared the effects of a low-fiber pre-
operative diet with a typical mechanical bowel preparation
in laparoscopic gynecological surgery on the exposure of
the surgical field. The low-fiber diet and mechanical bowel
preparation provided similar quality of surgical field expo-
sure. However, increased compliance was noted by the pa-
tients consuming the low-fiber diet.
Recently, the European Society of Gastrointestinal Endos-
copy stated in their guidelines that they recommend a low-
fiber diet on the day preceding colonoscopy. The guideline
was based on a targeted literature review to evaluate the
evidence supporting the use of bowel preparation for colon-
oscopy. A Grading of Recommendations Assessment, Devel-
opment, and Evaluation (GRADE) system was adopted to
define the strength of the recommendation and the quality
of evidence. The recommendation for a low-fiber diet on
the day preceding colonoscopy had only a moderate quality
of evidence because the potential benefits of a restricted diet
before colonoscopy are not well studied. In addition, the Eu-
ropean Society of Gastrointestinal Endoscopy does not make
any recommendations regarding the use of a low-fiber diet
for >24 h before the examination. Some endoscopists rou-
tinely prescribe a low-fiber diet during the 3 d preceding co-
lonoscopy rather than on a single day because of the slow
transit time in some patients. However, no study has so far
compared the use of a 1-d regimen with a 3-d regimen (34).
Treatment in bowel disorders. Low-residue or low-fiber
diets may also be of value in specifically indicated clinical
situations. Gastrointestinal diseases such as Crohn disease,
ulcerative colitis, bowel obstruction, diverticulitis, pre-
and/or postabdominal surgery, and other gastrointestinal
or inflammatory disorders such as in patients with infec-
tious gastrointestinal disease or neoplastic disease are condi-
tions that may require a low-residue or low-fiber diet. In
case of a flare-up, the diet can reduce the frequency and vol-
ume of stools and induce a primary remission in disease. In
some countries, such as Japan, enteral nutrition (i.e., liquid
diets consisting of nutrients broken down into their smaller
units) is used for remission induction in patients (35). In
children with persistent diarrhea, a diet with green banana
and pectin reduced the amounts of stool and diarrheal du-
ration (36). Currently, a number of human studies, still
preliminary, are investigating the influence of low-fiber in-
take on the symptom signature of several gastrointestinal
disorders.
IBS is a multifactorial functional disorder of the GIT that
affects ;10–15% of the adult population. The exact etiology
has not been identified. Yet, environmental, psychosocial,
physiologic, and genetic factors are believed to play a role.
A high-fiber diet, or the addition of supplementary bran
to the diet, has long been the most common first-line treat-
ment for IBS. However, different studies have shown that
patients with IBS reported a worsening of symptoms upon
consuming a high-fiber diet (37–39). A by-product of fiber
fermentation is gas, which can lead to unpleasant side effects
such as abdominal pain, cramps, and distension. Woolner
and Kirby (19) determined in a controlled trial in 204 pa-
tients with IBS whether a low-fiber diet (10 g fiber/d for
4 wk) could be an effective treatment for IBS. Before and after
the low-fiber diet, patients’symptoms were assessed by using
a questionnaire. Their results indicated that approximately
half of the patients (49%) treated with a low-fiber diet and
bulking agents, if required, reported a substantial improve-
ment in symptoms (60–100% improvement) after 4 wk of
the dietary regimen. An alternating bowel habit and diarrhea
were most likely to be helped by the diet, followed by bloat-
ing, urgency, pain, and flatulence. Currently, a fermentable
oligosaccharide, disaccharide, monosaccharide, and polyol
(FODMAP)–restricted diet is increasingly recommended
as the first-line therapy in the management of IBS (40).
Diverticulosis in the large intestine is a condition result-
ing from herniation of the mucosa through defects in the co-
lonic muscle layer. In Western and industrialized countries,
;60% of adults >60 y will develop colonic diverticula (41).
In the majority of cases, the condition is asymptomatic, with
only 10–25% of affected individuals developing symptoms
(38). Asymptomatic diverticulosis is commonly attributed
to constipation caused by a low-fiber diet, although evidence
for this mechanism is limited. Peery et al. (42) examined the
associations between constipation and low dietary fiber in-
take with the risk of asymptomatic diverticulosis in 539 pa-
tients. Participants underwent colonoscopy and assessment
of diet, physical activity, and bowel habits. The results of
this study indicated that neither constipation nor a low-fiber
diet was associated with an increased risk of diverticulosis.
TABLE 2 Classification of fibers based on chemical and physical
properties
1
Dietary fiber
type
Chemical
classification
Physical
classification
Lignin Noncarbohydrate Insoluble,
nonfermentable,
nonviscous
Cellulose NPS: cellulose Insoluble,
nonfermentable,
nonviscous
Hemicellulose NPS: noncellulose
polysaccharide
(In)soluble,
(non)fermentable,
(non)viscous
Pectin NPS: noncellulose
polysaccharide
Soluble,
fermentable,
(non)viscous
Gum NPS: noncellulose
polysaccharide
Soluble,
fermentable,
(non)viscous
Fructo-oligosaccharides Nondigestible
oligosaccharide
Soluble,
fermentable,
(non)viscous
Galacto-oligosaccharides Nondigestible
oligosaccharide
Soluble,
fermentable,
(non)viscous
Resistant starch (RS1, RS2,
and RS3)
Resistant starch Soluble,
fermentable,
(non)viscous
1
NPS, nonstarch polysaccharide; RS1, resistant starch with physically inaccessible
starch; RS2, resistant starch with resistant granules; RS3, resistant starch with retro-
graded amylose.
Low-residue compared with low-fiber diets 823
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
The same authors previously showed that a high-fiber diet
does not protect against asymptomatic diverticulosis (43).
In another study, Wick (44) suggested that patients with di-
verticular disease experience fewer symptoms with the con-
sumption of low-fiber, bland diets during symptomatic
periods but recommended that once the acute episode or
highly symptomatic period is resolved or chronic disease is
managed that patients should gradually increase dietary fi-
ber to 20–30 g daily.
High-fiber diets are often used in the management of
constipation. The amount of fiber consumed by patients
in the treatment of constipation was at least 10 g/d (45).
The addition of dietary fiber increases fecal mass and colonic
transit time. However, some studies reported a worsening
of symptoms (i.e., increased bloatedness and abdominal dis-
comfort) in patients with chronic constipation when dietary
fiber intake was increased (46, 47). Ho et al. (48) investi-
gated in a prospective case-control study the effect of a
no-fiber diet for 2 wk in 63 patients with idiopathic consti-
pation. Patients were then instructed to completely stop
their intake of dietary fiber, including vegetables, cereals,
fruit, whole-meal bread, and brown rice for 2 wk. After
2 wk, patients were asked to reduce dietary fiber intake to
an amount that they found acceptable for the long term. Pa-
tients were followed up at 1-mo intervals and final results
were analyzed after 6 mo. The study showed that constipa-
tion and its associated symptoms can be effectively reduced
by stopping or even lowering the intake of dietary fiber.
Recently, Lau et al. (49) compared for the first time the
feasibility and patient tolerance of a clear-fluid (n= 54)
and low-residue (n= 50) diet started on postoperative day
1 after elective colorectal surgery. They showed that a low-
residue diet, rather than a clear-fluid diet, on postoperative
day 1 after colorectal surgery was associated with less nausea,
faster return of bowel function, and a shorter hospital stay
without increasing postoperative morbidity.
Conclusions
The use of low-fiber/low-residue diets was explored in both
diagnostic and therapeutic situations. The major concern
with any bowel preparation, before colonoscopy, colonogra-
phy, or laparoscopic gynecological surgery, is the ability to
provide a clean bowel. Previous studies investigating the ef-
ficiency of bowel preparation protocols mostly focused on
the comparison of effectiveness among different types of ca-
thartics and quantities of solutions as well as dosing intervals
(50–52). However, dietary adaptations may provide an alter-
native way of bowel preparation. The comparison of the
applicability of a low-residue/low-fiber regimen (alone
or in combination with cathartic agents) with traditional
bowel-cleansing methods showed that the low-residue/
low-fiber regimen did not impair the quality of the bowel
preparation. In addition, the patients tolerated the low-
residue/low-fiber diet better and their satisfaction im-
proved. Furthermore, the compliance with the dietary
regimen was better compared with a liquid diet or a normal
diet without restrictions.
In addition to a diagnostic value, low-fiber/low-residue
diets have therapeutic potential in the treatment of different
gastrointestinal disorders. The amount of fiber in the diet
differs between acute phases of disease and periods of remis-
sion. In a situation of relapse, the same advice is given as for
the preparation for a colonoscopy (i.e., a low-fiber diet or a
maximum of 10 g fiber/d). After the induction of remission,
the amount of fiber in the diet is gradually increased to the
amount of fiber in a healthy diet. Surprisingly and contrary
to strongly held beliefs, a recent study showed that stopping
or reducing dietary fiber intake improves constipation and
its associated symptoms (44). More studies are warranted
to investigate the effect of reducing fiber intake in the treat-
ment of constipation.
Because of the lack of a scientifically accepted quantita-
tive definition and the unavailability of a method to estimate
FIGURE 1 Overview of possible effects of
different fibers on gastrointestinal digestion
and fermentation.
824 Vanhauwaert et al.
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
TABLE 3 Overview of studies investigating the effect of a low-residue or low-fiber diet on bowel preparation in humans
1
Authors
(reference)
Study group,
nDesign Investigation Results
Delegge and Kaplan (21) 506 (64% F) RCT Comparison of the efficacy of 2 bowel-cleansing regimens before
colonoscopy
The low-residue regimen resulted in significantly better colon
cleansing and better patient tolerance and willingness to repeat
the cathartic bowel preparation
Clear liquid = 222
Low-residue = 284
Park et al. (25) 214 (44% F) RCT Efficacy and tolerability of bowel preparation protocols with a low-
residue diet compared with the traditional clear-liquid diet
The low residue 1-d diet provided cleansing efficacy similar to that of
a clear liquid diet and offered the benefit of improved tolerabilityClear liquid = 106
Low-residue = 108
Sipe et al. (26) 230 PRTC To study whether a low-residue diet affects bowel preparation with
oral sulfate solution
A low-residue diet did not impair the quality of bowel preparation
achieved with oral sulfate solutionClear liquid = 114
Improvement of patient satisfaction with low-residue dietLow-residue = 116
Kim et al. (27) 184 (53.8% F) PRTC Success rate of the bowel preparation, adverse events, tolerability,
cecal intubation time, polyp and adenoma detection rate
The adverse events, including abdominal distension, pain, nausea,
vomiting, and abdominal discomfort, were significantly lower in
the picosulfate + low-residue group than in the PEG group
Sodium picosulfate
+ low-residue = 94
PEG-ES = 90
Soweid et al. (28) 200 (47.8% F) PCS Efficacy and tolerability of PEG-ES given with a clear-liquid diet
compared with a fiber-free diet for colonoscopy preparation
Fiber-free diet given with PEG-ES on the day before colonoscopy is a
more effective regimen than the standard clear-liquid diet regi-
men and is better tolerated by patients
Clear liquid = 98
Fiber-free = 102
Melicharkova et al. (29) 248 (56% F) PRCT Efficacy and tolerability of a low-residue breakfast ingested on the
day before colonoscopy as compared with a clear-fluid diet
A low-residue breakfast improved patient tolerance without affect-
ing quality of low-volume colon cleansing before colonoscopyCFs = 122
Low-residue + CFs = 126
Stolpman et al. (30) 201 (43.28% F) PRTC To examine whether a change in precolonoscopy dietary restriction
leads to better patient tolerance without compromising colon-
oscopy examination quality
Patients allowed to have a limited low-residue diet before colonos-
copy achieve a bowel preparation quality that is noninferior to
patients on a strict clear-liquid diet limitation
Clear liquids = 101
Low-residue = 100
Wu et al. (31) 804 (43.6% F) PCS Impact of a 2-d low-residue diet on the quality of bowel preparation
before colonoscopy
A low-residue diet before colonoscopy provided better bowel
cleansing than an unrestricted diet
Liedenbaum et al. (20) 50 (42% F) RCT Comparison of bowel preparations with and without a low-fiber diet
to determine the image quality and accuracy in polyp detection at
CT colonography
The use of a low-fiber diet in bowel preparation for CT colonography
results in significantly less untagged feces and shows a trend to-
ward better residue homogeneity
No diet = 25
Low-fiber = 25
Lijoi et al. (18) 83 (100% F) RCT Comparison of a 7-d minimal-residue (low fiber intake) preoperative
diet with a mechanical bowel preparation before laparoscopic
gynecological surgery
The low-fiber diet and mechanical bowel preparation provided
similar quality of surgical field exposureFiber group = 42
The low-fiber diet was better tolerated by the patients (increased
compliance)
Controls = 41
1
CF, clear fluid; CT, computed tomographic; PCS, prospective cohort study; PEG, polyethylene glycol; PEG-ES, polyethylene glycol electrolyte solution; PRCT, prospective randomized controlled trial; RCT, randomized controlled trial.
Low-residue compared with low-fiber diets 825
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
the amount of food residues produced while passing
through the GIT, low-residue diets were removed from the
Nutrition Care Manual in the United States after 2011. Ad-
ditional arguments for this removal included that food
components are not the only source of residue giving vol-
ume to stools and no criteria have been defined to differen-
tiate low-, medium-, and high-residue diets (17, 20, 26). In
practice, information related to the quantity of residue
in the diet usually refers to the amount of fiber. Often,
low-fiber diets are considered as an alternative for a low-
residue diet and both terms are used interchangeably (3,
5). A low-residue diet currently is no longer used for bowel
resection, ileostomy, Crohn disease, and ulcerative colitis,
but low-fiber therapy is recommended for these acute-
phase conditions.
Although several authors mentioned the importance of
the amount of fiber in the diet, only Lijoi et al. (18) and
Woolner and Kirby (19) quantitatively defined a low-fiber
diet as a diet with <10 g fiber/d. The latter definition of a
low-fiber diet is a good recommendation to be used in
clinical practice. In addition to the amount of fiber, the
type of fiber may also be of importance. In almost all
studies, no distinction was made between the different
types of fiber. As mentioned above, fibers can be classified
as insoluble fibers, which do not dissolve in water, and as
soluble fibers, which dissolve in water (15). Both soluble
and insoluble fibers can increase the volume of stool.
For a colonoscopy, it is important that the colon cleansing
is sufficient and that there are no more fiber residues
present.
In general, the use of low-fiber diets for gastrointestinal
disease may have previously been overlooked due to the gen-
eral belief that a high fiber intake is associated with specific
health benefits. For instance, SCFAs (acetate, propionate,
and butyrate) are end products of colonic fiber fermentation
that have been shown to contribute to colonic health. SCFAs
provide energy to colonic epithelial cells, decrease luminal
pH, and improve mineral absorption (2). However, the
use of low-fiber diets in bowel preparation is restricted to
1 d, so there will be no concern about lack of minerals or vi-
tamins. In the case of acute disease relapse, the low-residue/
low-fiber diet is maintained several days, but, if supervised
by a dietician, nutritional or energy deficiencies are unlikely
to occur.
In conclusion, there is insufficient evidence to further
justify the clinical use of a low-residue diet. On the basis
of this literature review, we suggest redefining a low-residue
diet as a low-fiber diet and to quantitatively define a low-
fiber diet as a diet with a maximum of 10 g fiber/d. A
low-fiber diet can be applied in both diagnostic and thera-
peutic situations. Diagnostically, a low-fiber diet is used in
the preparation for a colonoscopy. Therapeutically, a low-
fiber diet is part of the treatment in acute relapses of IBS,
inflammatory bowel diseases, or diverticulitis. Upon achiev-
ing remission, the amount of fiber should be systematically
increased until achieving the recommended amount of fiber
in a healthy diet.
Acknowledgments
All authors read and approved the final version of the
manuscript.
References
1. Kong F, Singh RP. Disintegration of solid foods in human stomach.
J Food Sci 2008;73:R67–80.
2. Hamer HM, De Preter V, Windey K, Verbeke K. Functional analysis of
colonic bacterial metabolism: relevant to health? Am J Physiol Gastro-
intest Liver Physiol 2012;302:G1–9.
3. Cunningham E. Are low-residue diets still applicable? J Acad Nutr Diet
2012;112:960.
4. Anderson JW, Baird P, Davis RH, Ferreri S, Knudtson M, Koraym A,
Waters V, Williams CL. Health benefits of dietary fiber. Nutr Rev
2009;67:188–205.
5. Tarleton S, DiBaise JK. Low-residue diet in diverticular disease: putting
an end to a myth. Nutr Clin Pract 2011;26:137.
6. Trowell H. Definition of dietary fiber and hypotheses that it is a
protective factor in certain diseases. Am J Clin Nutr 1976;29:
417–27.
7. Codex Alimentarius 2008. Report of the 30th session of the Codex
Committee on Nutrition and Foods for Special Dietary Uses. Cape
Town, South Africa, 3–7 November 2008, ALINORM 09/32/26. [cited
2013 Aug 20]. Available from: http://www.codexalimentarius.net.
8. American Association of Cereal Chemists. AACC Intl. provides
comments on the proposed FAO/WHO definition of dietary
fib er, March 200 7 [c ited 20 13 Au g 20]. Available from: http://
www.aaccnet.org/initiatives/definitions/Documents/DietaryFiber/
AACCIntlCODEXDietaryFibreMarch07.pdf
9. FAO/WHO Codex Alimentarius Commission. [cited 2013 Aug 20].
Available from: http://www.codexalimentarius. net/download/standards/
34/CXG_002e.pdf.
10. Howlett JF, Betteridge VA, Champ M, Craig SA, Meheust A, Jones JM.
The definition of dietary fiber—discussions at the Ninth Vahouny Fiber
Symposium: building scientific agreement. Food Nutr Res 2010;54:
5750–5.
11. EFSA Panel on Dietetic Products Nutrition Allergies. Scientific opinion
on dietary reference values for carbohydrates and dietary fibre. EFSA J
2010;8:1462–1539.
12. Jones JM. CODEX-aligned dietary fiber definitions help to bridge the
‘fiber gap’. Nutr J 2014;13:34.
13. Slavin J. Fiber and prebiotics: mechanisms and health benefits. Nutri-
ents 2013;5:1417–35.
14. De Preter V, Hamer HM, Windey K, Verbeke K. The impact of pre-
and/or probiotics on human colonic metabolism: does it affect human
health? Mol Nutr Food Res 2011;55:46–57.
15. Schneeman BO. Fiber, inulin and oligofructose: similarities and differ-
ences. J Nutr 1999;129:1424S–7S.
16. Stephen AM, Cummings JH. Mechanisms of dietary action of fibre in
the human colon. Nature 1980;284:283–4.
17. Stephen AM, Cummings JH. The microbial contribution to human fae-
cal mass. J Med Microbiol 1980;13:45–56.
18. Lijoi D, Ferrero S, Mistrangelo E, Casa ID, Crosa M, Remorgida V,
Alessandri F. Bowel preparation before laparoscopic gynaecological sur-
gery in benign conditions using a 1-week low fibre diet: a surgeon
blind, randomized and controlled trial. Arch Gynecol Obstet 2009;
280:713–8.
19. Woolner JT, Kirby G. Clinical audit of the effects of low-fibre diet on
irritable bowel syndrome. J Hum Nutr Diet 2000;13:249–53.
20. Liedenbaum MH, Denters M, De Vries A, Van Ravesteijn V, Bipat S,
Vos F, Dekker E, Stoker J. Low-fiber diet in limited bowel preparation
for CT colonography: influence on image quality and patient accep-
tance. AJR 2010;195:W31–7.
21. Delegge M, Kaplan R. Efficacy of bowel preparation with the use of a
prepackaged, low fibre diet with a low sodium, magnesium citrate ca-
thartic vs. a clear liquid diet with a standard sodium phosphate cathar-
tic. Aliment Pharmacol Ther 2005;21:1491–5.
826 Vanhauwaert et al.
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
22. Hookey LC, Depew W, Vanner S. The safety profile of oral sodium
phosphate for colonic cleansing before colonoscopy in adults. Gastro-
intest Endosc 2002;56:895–902.
23. Dachman AH, Dawson DO, Lefere P, Yoshida H, Khan NU, Cipriani N,
Rubin DT. Comparison of routine and unprepped CT colonography
augmented by low fiber diet and stool tagging: a pilot study. Abdom
Imaging 2007;32:96–104.
24. Virkki R, Mäkelä P. Low residual diet and hydration improving double
contract examination of the colon. Eur J Radiol 1983;3:212–4.
25. Park DI, Park SH, Lee SK, Baek YH, Han DS, Eun CS, Kim WH, Byeon
JS, Yang SK. Efficacy of prepackaged, low residual test meals with 4L
polyethylene glycol versus a clear liquid diet with 4L polyethylene glycol
bowel preparation: a randomized trial. J Gastroenterol Hepatol 2009;
24:988–91.
26. Sipe BW, Fischer M, Baluyut AR, Bishop RH, Born LJ, Daugherty DF,
Lybik MJ, Shatara TJ, Scheidler MD, Wilson SA, et al. A low-residue
diet improved patient satisfaction with split-dose oral sulfate solution
without impairing colonic preparation. Gastrointest Endosc 2013;77:
932–6.
27. Kim YS, Hong CW, Kim BC, Han KS, Park JW, Seong Choi H, Joo J,
Sohn DK. Randomized clinical trial comparing reduced-volume oral
picosulfate and a prepackaged low-residue diet with 4-liter PEG solu-
tion for bowel preparation. Dis Colon Rectum 2014;57:522–8.
28. Soweid AM, Kobeissy AA, Jamali FR, El-Tarchichi M, Skoury A, Abdul-
Baki H, El-Zahabi L, El-Sayyed A, Barada KA, Sharara AI, et al. A ran-
domized single-blind trial of standard diet versus fiber-free diet with
polyethylene glycol electrolyte solution for colonoscopy preparation.
Endoscopy 2010;42:633–8.
29. Melicharkova A, Flemming J, Vanner S, Hookey L. A low-residue
breakfast improves patient tolerance without impacting quality of
low-volume colon cleansing prior to colonoscopy: a randomized trial.
Am J Gastroenterol 2013;108:1551–5.
30. Stolpman DR, Solem CA, Eastlick D, Adlis S, Shaw MJ. A randomized
controlled trial comparing a low-residue diet versus clear liquids for co-
lonoscopy preparation: impact on tolerance, procedure time, and ade-
noma detection rate. J Clin Gastroenterol 2014;48:851–5.
31. Wu K-L, Rayner K, Chuah S-K, Chiu K-W, Chiu Y-C. Impact of a low-
residue diet on bowel preparation for colonoscopy. Dis Colon Rectum
2011;54:107–12.
32. Rostom A, Jolicoeur E. Validation of a new scale for the assessment of
bowel preparation quality. Gastrointest Endosc 2004;59:482–6.
33. Muzii L, Angioli R, Zullo MA, Calcagno M, Panici PB. Bowel prepara-
tion for gynecological surgery. Crit Rev Oncol Hematol 2003;48:311–5.
34. Hassan C, Bretthauer M, Kaminski MF, Polkowski M, Rembacken B,
Saunders B, Benamouzig R, Holme O, Green S, Kuiper T, et al. Bowel
preparation for colonoscopy: European Society of Gastrointestinal En-
doscopy (ESGE) guideline. Endoscopy 2013;45:142–50.
35. Brown AC, Rampertab SD, Mullin GE. Existing dietary guidelines for
Crohn’s disease and ulcerative colitis. Expert Rev Gastroenterol Hepatol
2011;5:411–25.
36.RabbaniGH,TekaT,ZamanB,MajidN,KhatunM,FuchsGJ.Clin-
ical studies in persistent diarrhea: dietary management with green
banana or pectin in Bangladeshi children. Gastroenterology 2001;
121:554–60.
37. Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for
reappraisal. Lancet 1994;344:39–40.
38. Parker TJ, Naylor SJ, Riordan AM, Hunte r JO. Man agement of pa-
tients with food intolerance in irritable bowel syndrome: the de-
velopment and use of an exclusion diet. J Hum Nutr Diet 1995;8:
159–66.
39. Hammonds R, Whorwell PJ. The role of fibre in IBS. Ital J Gastroen-
terol 1997;2:9–12.
40. Tuck CJ, Muir JG, Barrett JS, Gibson PR. Fermentable oligosaccharides,
disaccharides, monosaccharides and polyols: role in irritable bowel syn-
drome. Expert Rev Gastroenterol Hepatol 2014;8:819–34.
41. Floch MH, Bina I. The natural history of diverticulitis: fact and theory.
J Clin Gastroenterol 2004;38:S2–7.
42. Peery AF, Sandler RS, Ahnen DJ, Galanko JA, Holm AN, Shaukat A,
Mott LA, Barry EL, Fried DA, Baron JA. Constipation and a low-fiber
diet are not associated with diverticulosis. Clin Gastroenterol Hepatol.
2013;11:1622–7.
43. Peery AF, Barrett PR, Park D, Rogers AJ, Galanko JA, Martin CF,
Sandler RS. A high-fiber diet does not protect against asymptomatic
diverticulosis. Gastroenterology 2012;142:266–72.e1.
44. Wick JY. Diverticular disease: eat your fiber! Consult Pharm 2012;27:
613–8.
45. Suares NC, Ford AC. Systematic review: the effects of fibre in the man-
agement of chronic idiopathic constipation. Aliment Pharmacol Ther
2011;33:895–901.
46. Müller-Lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and mis-
conceptions about chronic constipation. Am J Gastroenterol 2005;100:
232–42.
47. Johanson JF. Review of the treatment options for chronic constipation.
MedGenMed 2007;9:25.
48. Ho KS, Tan CY, Mohd Daud MA, Seow-Choen F. Stopping or reducing
dietary fiber intake reduces constipation and its associated symptoms.
World J Gastroenterol 2012;18:4593–6.
49. Lau C, Phillips E, Bresee C, Fleshner P. Early use of low residue diets is
superior to clear liquid diet after elective colorectal surgery: a random-
ized controlled trial. Ann Surg 2014;260:641–7.
50. Park JS, Sohn CI, Hwang SJ, Choi HS, Park JH, Kim HJ, Park DI, Cho
YK, Jeon WK, Kim BI. Quality and effect of single dose versus split
dose of polyethylene glycol bowel preparation for early-morning colon-
oscopy. Endoscopy 2007;39:616–9.
51. Chen CC, Ng WW, Chang FY, Lee SD. Magnesium citrate-bisacodyl
regimen proves better than castor oil for colonoscopic preparation.
J Gastroenterol Hepatol 1999;14:1219–22.
52. Gupta T, Mandot A, Desai D, Abraham P, Joshi A, Shah S. Comparison
of two schedules (previous evening versus same morning) of bowel
preparation for colonoscopy. Endoscopy 2007;39:706–9.
Low-residue compared with low-fiber diets 827
at KU Leuven University Library on November 4, 2016advances.nutrition.orgDownloaded from
