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Low-Residue and Low-Fiber Diets in Gastrointestinal Disease Management

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  • University Colleges Leuven-Limburg

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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-residue diets are further explored 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.
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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 DieteticsNutrition 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 residueand low fiberare 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;6:8207.
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 inammation, 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 scientically accept-
able denition for the term residueor residue-lowand
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 ber. 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
residueand low fiberare 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
Dening residueand dietary fiber
Residue. Until now, there has been no scientically accept-
able denition of residue. The impossibility of estimating
the amount of residue produced by the digestion of various
foods complicates a consensus denition 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 ber), mi-
croorganisms,andsecretionsandcellsshedfromtheali-
mentary tract. The latter 2 increase the fecal output after
digestion (3).
Dietary fiber. Originally, Trowell (6) dened ber 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 denition was ascertained as
being too strict and other substances, such as starch and
fructans, were also dened as ber. However, until now, a
universally accepted denition for dietary ber has been un-
available. The Codex Committee on Nutrition and Foods for
Special Dietary Uses dened dietary ber 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 ber 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 bers 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 bers 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 bers 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
(1517) (Figure 1).
A low-residue compared with a low-ber diet
In the literature, there have been discrepancies among diet
recommendations as to the actual composition of low-ber
and/or low-residue diets. Until now, no clear denition 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 ber-containing
foods produce the bulk of the gastrointestinal residue.
In addition, no clear denition has been provided for a
low-ber diet. Lijoi et al. (18) described a low-ber diet as
a diet with a total daily ber 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-ber 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 nd 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 difculty
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-ber
or low-residue diet as an adjuvant to cathartic regimens with
regard to colon-cleansing efcacy and patient compliance.
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Dietary restriction of ber 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) rst compared the tolerability
and efcacy 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-uid regimen. All diets were combined
with cathartic agents. In a recent study by Kim et al. (27),
the clinical efcacy 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 conrmed that the low-residue diet was better tolerated
and an improvement in patient satisfaction was observed. In
another study, the efcacy of a ber-free diet was compared
with a clear-liquid diet for colonoscopy preparation. Similar
to the results of the low-residue diets, the ber-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-uid 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-ber
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
eld 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 Rafnose, stachyose,
kestose, verbascose,
nystose
39 Good Legumes, beans
(stachyose),
sweet potatoes
(rafnose),
wheat
Maltodextrin 39 Good Potatoes, wheat
Fructo-oligosaccharides 39 Not digested Good No F Leeks, onions,
soybeans
Galacto-oligosaccharides 39 Not digested Good No F Fruit
Arabino-xylo-oligosaccharides 39 Not digested Good No F Wheat
Polydextrose 39 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).
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Lijoi et al. (18) rst compared the effects of a low-ber pre-
operative diet with a typical mechanical bowel preparation
in laparoscopic gynecological surgery on the exposure of
the surgical eld. The low-ber diet and mechanical bowel
preparation provided similar quality of surgical eld expo-
sure. However, increased compliance was noted by the pa-
tients consuming the low-ber diet.
Recently, the European Society of Gastrointestinal Endos-
copy stated in their guidelines that they recommend a low-
ber 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
dene the strength of the recommendation and the quality
of evidence. The recommendation for a low-ber diet on
the day preceding colonoscopy had only a moderate quality
of evidence because the potential benets 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-ber 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-ber
diets may also be of value in specically indicated clinical
situations. Gastrointestinal diseases such as Crohn disease,
ulcerative colitis, bowel obstruction, diverticulitis, pre-
and/or postabdominal surgery, and other gastrointestinal
or inammatory disorders such as in patients with infec-
tious gastrointestinal disease or neoplastic disease are condi-
tions that may require a low-residue or low-ber diet. In
case of a are-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 inuence of low-ber in-
take on the symptom signature of several gastrointestinal
disorders.
IBS is a multifactorial functional disorder of the GIT that
affects ;1015% 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 (3739). 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, patientssymptoms 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 (60100% 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 1025% 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.
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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 2030 g daily.
High-ber diets are often used in the management of
constipation. The amount of ber consumed by patients
in the treatment of constipation was at least 10 g/d (45).
The addition of dietary ber 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
ber intake was increased (46, 47). Ho et al. (48) investi-
gated in a prospective case-control study the effect of a
no-ber diet for 2 wk in 63 patients with idiopathic consti-
pation. Patients were then instructed to completely stop
their intake of dietary ber, including vegetables, cereals,
fruit, whole-meal bread, and brown rice for 2 wk. After
2 wk, patients were asked to reduce dietary ber intake to
an amount that they found acceptable for the long term. Pa-
tients were followed up at 1-mo intervals and nal 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 ber.
Recently, Lau et al. (49) compared for the rst time the
feasibility and patient tolerance of a clear-uid (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-ber/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-
ciency 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
(5052). 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-ber/low-residue
diets have therapeutic potential in the treatment of different
gastrointestinal disorders. The amount of ber 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-ber diet or a
maximum of 10 g ber/d). After the induction of remission,
the amount of ber in the diet is gradually increased to the
amount of ber in a healthy diet. Surprisingly and contrary
to strongly held beliefs, a recent study showed that stopping
or reducing dietary ber intake improves constipation and
its associated symptoms (44). More studies are warranted
to investigate the effect of reducing ber intake in the treat-
ment of constipation.
Because of the lack of a scientically accepted quantita-
tive denition and the unavailability of a method to estimate
FIGURE 1 Overview of possible effects of
different fibers on gastrointestinal digestion
and fermentation.
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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 efcacy of 2 bowel-cleansing regimens before
colonoscopy
The low-residue regimen resulted in signicantly 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 Efcacy 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 efcacy similar to that of
a clear liquid diet and offered the benet 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 signicantly 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 Efcacy and tolerability of PEG-ES given with a clear-liquid diet
compared with a ber-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 Efcacy and tolerability of a low-residue breakfast ingested on the
day before colonoscopy as compared with a clear-uid 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-ber diet
to determine the image quality and accuracy in polyp detection at
CT colonography
The use of a low-ber diet in bowel preparation for CT colonography
results in signicantly 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 ber intake) preoperative
diet with a mechanical bowel preparation before laparoscopic
gynecological surgery
The low-ber diet and mechanical bowel preparation provided
similar quality of surgical eld exposureFiber group = 42
The low-ber 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-ber 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 dened 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 ber. Often,
low-ber 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-ber therapy is recommended for these acute-
phase conditions.
Although several authors mentioned the importance of
the amount of ber in the diet, only Lijoi et al. (18) and
Woolner and Kirby (19) quantitatively dened a low-ber
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-ber diets for gastrointestinal
disease may have previously been overlooked due to the gen-
eral belief that a high ber intake is associated with specic
health benets. For instance, SCFAs (acetate, propionate,
and butyrate) are end products of colonic ber 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-ber 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-ber diet is maintained several days, but, if supervised
by a dietician, nutritional or energy deciencies are unlikely
to occur.
In conclusion, there is insufcient evidence to further
justify the clinical use of a low-residue diet. On the basis
of this literature review, we suggest redening a low-residue
diet as a low-ber diet and to quantitatively dene a low-
ber diet as a diet with a maximum of 10 g ber/d. A
low-ber diet can be applied in both diagnostic and thera-
peutic situations. Diagnostically, a low-ber diet is used in
the preparation for a colonoscopy. Therapeutically, a low-
ber diet is part of the treatment in acute relapses of IBS,
inammatory bowel diseases, or diverticulitis. Upon achiev-
ing remission, the amount of ber should be systematically
increased until achieving the recommended amount of ber
in a healthy diet.
Acknowledgments
All authors read and approved the nal version of the
manuscript.
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A comprehensive dietary fiber (DF) definition was adopted by the CODEX Alimentarius Commission (CAC) (1) to reflect the current state of knowledge about DF, (2) to recognize that all substances that behave like fiber regardless of how they are produced can be named as DF if they show physiological benefits, and (3) to promote international harmonization for food labeling and food composition tables. This review gives the history and evolution of the state of DF knowledge as looked at by refinements in DF methods and definitions subsequent to the launch of the DF hypothesis. The refinements parallel both interventional and epidemiological research leading to better understanding of the role of DF in contributing to the numerous physiological benefits imparted by all the various digestion resistant carbohydrates. A comparison of the CODEX definition (including its footnote that authorizes the inclusion of polymers with DP 3-9) and approved CODEX Type 1 methods with other existing definitions and methods will point out differences and emphasize the importance of adoption of CODEX-aligned definitions by all jurisdictions. Such harmonization enables comparison of nutrition research, recommendations, food composition tables and nutrition labels the world over. A case will be made that fibers are analogous to vitamins, in that they vary in structure, function and amount needed, but each when present in the right amount contributes to optimal health. Since the intake of DF is significantly below recommended levels throughout the world, the recognition that 'all fibers fit' is an important strategy in bridging the 'fiber gap' by enfranchising and encouraging greater intake of foods with inherent and added DF. Fortifying foods with added DF makes it easier to increase intakes while maintaining calories at recommended levels.
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Following a request from the European Commission, the Panel on Dietetic Products, Nutrition and Allergies (NDA) derived Dietary Reference Values (DRVs) for biotin. Biotin is a water-soluble vitamin which serves as a co-factor for several carboxylases that play critical roles in the synthesis of fatty acids, the catabolism of branched-chain amino acids and gluconeogenesis. Dietary biotin deficiency is rare. Data on biomarkers of biotin intake or status are insufficient to be used in determining the requirement for biotin. Data available on biotin intakes and health consequences are very limited and cannot be used for deriving DRVs for biotin. As there is insufficient evidence available to derive an Average Requirement and a Population Reference Intake, an Adequate Intake (AI) is proposed. The setting of AIs is based on observed biotin intakes with a mixed diet and the apparent absence of signs of deficiency in the EU, suggesting that current intake levels are adequate. The AI for adults is set at 40 µg/day. The AI for adults also applies to pregnant women. For lactating women, an additional 5 µg biotin/day over and above the AI for adults is proposed, to compensate for biotin losses through breast milk. For infants over six months, an AI of 6 µg/day is proposed by extrapolating from the biotin intake of exclusively breastfed infants aged zero to six months, using allometric scaling and reference body weight for each age group, in order to account for the role of biotin in energy metabolism. The AIs for children aged 1–3 and 4–10 years are set at 20 and 25 µg/day, respectively, and for adolescents at 35 µg/day, based on observed intakes in the EU.
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Objective: To achieve an excellent bowel preparation, it is routine to require a clear liquid diet on the day before the procedure. Unfortunately, this dietary modification may be poorly tolerated. We examine whether a change in precolonoscopy dietary restriction can lead to better patient tolerance without compromising examination quality. Methods: This is a prospective, blinded, randomized controlled trial of patients undergoing screening or surveillance colonoscopy. The primary objective measures the effect of dietary modification on bowel prep quality. Secondary endpoints include polyp detection, patient tolerance, withdrawal time, and patient acceptance. A total of 200 patients were randomized to either (a) a low-residue diet for breakfast and lunch the day before the procedure or (b) clear liquids all day before the procedure. All patients underwent an identical low-volume sodium sulfate split prep. Bowel prep quality was scored using the Boston Bowel Preparation Scale (BBPS). A t test with TOST was used for noninferiority. Secondary endpoints were compared using χ analysis. Results: Overall, 96.5% of patients had a good or excellent bowel prep (BBPS=6, 7, 8, or 9). LRD prep quality was noninferior to CLD prep quality (LRD 7.8 vs. CLD 8.1). Polyp detection rates were similar (68% vs. 65.4%, P=0.6899). Patient tolerance and acceptance did not differ. Withdrawal times were equivalent between both groups (16.2 vs. 16.5 min, P=NS). Conclusions: Patients allowed to have a limited low-residue diet before colonoscopy achieve a bowel prep quality that is noninferior to patients on a strict clear liquid diet limitation. Furthermore, polyp detection rates, patient tolerance, and patient acceptance were similar between the 2 groups.
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Objective: Compare the feasibility and patient tolerance to either a clear fluid (CF) or low residue diet (LRD) started on postoperative day (POD) 1 after elective colorectal surgery. Background: Diet advancement after surgery traditionally starts gradually with liquids, on the basis of fears that early solid intake may increase nausea, vomiting, and overall complications. A randomized controlled trial comparing LRD and CF on POD 1 was performed. Methods: 111 elective colorectal surgery patients were randomized to CF (n = 57) or LRD (n = 54). The primary end point was vomiting on POD 2. Secondary endpoints included nausea score, days to flatus, length of hospital stay (LOS), and postoperative morbidity. Results: Patient characteristics, surgical technique, intraoperative characteristics, and postoperative opioid use were similar between study arms. CF versus LRD results were as follows: POD2 vomiting (28% vs 14%; P = 0.09), and significant increase in mean nausea score (4.7 vs 3.5; P = 0.01), days to flatus (4.8 vs 3.7 days; P = 0.04), and LOS (7.0 vs 5.0 days; P = 0.01). LOS remained significantly shorter even after adjusting for significant covariates (laparoscopic technique, surgical site, postoperative comorbidity, stoma, and nasogastric tube) with LRD patients having an adjusted 1.4-day decrease in LOS (P < 0.01). There was no significant difference in postoperative morbidity between study arms. Multivariate analysis of all secondary endpoints confirmed an overall significant improvement in outcomes for LRD vs CF (P < 0.01). Conclusions: LRD, rather than CF, on POD1 after colorectal surgery is associated with less nausea, faster return of bowel function, and a shorter hospital stay without increasing postoperative morbidity.
Irritable bowel syndrome (IBS) was previously left poorly treated despite its high prevalence and cost. Over the past decade, significant research has been conducted providing new dietary strategies for IBS management. The 'low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet' has shown symptom improvement in 68-76% of patients. Randomized, controlled trials have now proven its efficacy. The diet, low in poorly absorbed and fermentable carbohydrates, uses dietary restriction and re-challenge to determine individual tolerance to various short-chain carbohydrates. However there may be potential detrimental effects of the diet in the long term, due to potential changes to the gastrointestinal microbiota. Appropriate dietary education and management of the diet is imperative. Future research should focus on the relevance of changes to the microbiota and ways to liberalize the dietary restrictions.
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Reduced-volume bowel preparation with a low-residue diet prior to colonoscopy would result in better patient compliance and sufficient bowel preparation. To compare the clinical efficacy of reduced-volume sodium picosulfate and a prepackaged low-residue diet with that of the standard bowel preparation using 4 L of PEG solution. Prospective, single center, single blind, active control, randomized study (NCCCTS-12-619, KCT0000470). Ambulatory outpatient clinic at the National Cancer Center, Republic of Korea. A total of 194 subjects were randomly assigned for this study, 97 in each group. After exclusions, 94 subjects in the Picolight group and 90 in the PEG group completed the study and were analyzed. Sodium picosulfate with a prepackaged low-residue, one-day diet or 4-L PEG for bowel preparation. Success rate of the bowel preparation, tolerability, adverse events, cecal intubation time, polyp detection rate and adenoma detection rate. The bowel preparation success rate was significantly higher (91.5% vs. 81.1%, p = 0.04) and the rates of adverse events, including abdominal distension, pain, nausea, vomiting and abdominal discomfort, were significantly lower in the picosulfate group than the PEG group. Cecal intubation times and the polyp and adenoma detection rates were similar in the 2 groups. Single center, limited population, all colonoscopies were performed in the morning. Bowel preparation with low-volume oral picosulfate and a prepackaged low-residue diet enhances colon cleansing and is better tolerated than the standard bowel preparation.
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Objectives: We compared the efficacy and patient tolerance of two dietary regimens used as an adjunct to standard bowel cleansing in preparation for elective colonoscopy. Methods: Our prospective, randomized, single-blind, controlled, noninferiority trial compared two dietary regimens administered the day before colonoscopy. Subjects received low-volume bowel preparation. The primary outcome was efficacy of colon cleansing, rated by the Ottawa bowel preparation scale (OBPS). Patient acceptance of the assigned dietary regimen was assessed as a secondary outcome. Results: The mean OBPS score for the standard clear-fluid diet group was 4.47, compared with 4.62 for the low-residue breakfast group, meeting criteria for noninferiority. The groups reported similar mean intensity of hunger on a visual analog hunger scale. However, overall satisfaction was higher with the low-residue diet than with the clear-fluid diet. Conclusions: A low-residue breakfast on the day before elective colonoscopy does not compromise the overall quality of bowel preparation as compared with a standard clear-fluid diet and is likely to be preferred by patients.
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Asymptomatic diverticulosis is commonly attributed to constipation secondary to a low-fiber diet, although evidence for this mechanism is limited. We examined the associations between constipation and low dietary fiber intake with risk of asymptomatic diverticulosis. We performed a cross sectional study, analyzing data from 539 individuals with diverticulosis and 1569 without (controls). Participants underwent colonoscopy and assessment of diet, physical activity and bowel habits. Our analysis was limited our analysis to participants with no knowledge of their diverticular disease, to reduce the risk of biased responses. Constipation was not associated with an increased risk of diverticulosis. Participants with less frequent bowel movements (BM: <7/wk) had reduced odds of diverticulosis compared to those with regular (7/wk) BM (odds ratio [OR] 0.56, 95% confidence interval [CI], 0.40-0.80). Those reporting hard stools also had a reduced odds (OR, 0.75; 95% CI, 0.55-1.02). There was no association between diverticulosis and straining (OR, 0.85; 95% CI, 0.59-1.22) or incomplete BM (OR, 0.85; 95% CI, 0.61-1.20). We found no association between dietary fiber intake and diverticulosis (OR, 0.96; 95% CI, 0.71-1.30) in comparing the highest quartile to the lowest (mean intake 25 versus 8 g/day). In our cross-sectional, colonoscopy-based study, neither constipation nor a low-fiber diet was associated with an increased risk of diverticulosis.