REVIEW ABSTRACTRecentlylowresiduedietswereremovedfromtheAmericanAcademyofNutritionandDietetics SupportedbyagrantfromtheUniversityCollegeLeuvenLimburgincooperationwiththeLeuvenUniversityKULeuvenan ID: 938119
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REVIEW Low-ResidueandLow-FiberDietsinGastrointestinalDiseaseManagementErikaVanhauwaert,3,4*ChristopheMatthys,4,6LiesVerdonck, ABSTRACTRecently,low-residuedietswereremovedfromtheAmericanAcademyofNutritionandDietetics SupportedbyagrantfromtheUniversityCollegeLeuven-LimburgincooperationwiththeLeuvenUniversity(KULeuven)andtheUniversityHospitalLeuven(UZLeuven,Belgium).Authordisclosures:EVanhauwaert,CMatthys,LVerdonck,andVDePreter,noconflictsofinterest.*Towhomcorrespondenceshouldbeaddressed.E-mail:erika.vanhauwaert@ucll.be.Abbreviationsused:DP,degreeofpolymerization;GIT,gastrointestinaltract;IBS,irritablebowelsyndrome.2015AmericanSocietyforNutrition.AdvNutr2015;6:8207;doi:10.3945/an.115.009688. narrativereview,wecriticallyreviewthediagnosticandther-apeuticvaluesoflow-residueandlow-fiberdietsingastroin-testinaldiseasemanagement.CurrentStatusofKnowledgeanddietaryfiberUntilnow,therehasbeennoscienticallyaccept-abledenitionofresidue.Theimpossibilityofestimatingtheamountofresidueproducedbythedigestionofvariousfoodscomplicatesaconsensusdenitionforresidue.Intheliterature,residuemostlyreferstoanyindigestiblefoodsub-stancethatremainsintheintestinaltractandcontributestostoolbulk(3,5).Thismeansthattheresidueofdigestionisprimarilyindigestiblematerial(i.e.,dietaryber),mi-croorganisms,andsecretionsandcellsshedfromtheali-mentarytract.Thelatter2increasethefecaloutputafterdigestion(3).DietaryÞber.Originally,Trowell(6)deberascom-ponentsderivedfromthecellwallofaplantthatresisthy-drolysisbydigestiveenzymesandabsorptioninthesmallintestine.Typicalplantcellwallcomponentsarepectin,cel-lulose,andhemicellulose.Thisdenitionwasascertainedasbeingtoostrictandothersubstances,suchasstarchandfructans,werealsodenedasber.However,untilnow,auniversallyaccepteddenitionfordietaryberhasbeenun-available.TheCodexCommitteeonNutritionandFoodsforSpecialDietaryUsesdeneddietaryberascarbohydratepolymerswithadegreeofpolymerization[DP;ormono-meric(singlesugar)units]notlowerthan3,whicharenei-therdigestednorabsorbedinthesmallintestine.ADPnotlowerthan3isintendedtoexcludemono-anddisaccha-rides.Dietaryberconsistsofoneormore)ediblecarbo-hydratepolymersnaturallyoccurringinthefoodasconsumed;)carbohydratepolymers,whichhavebeenob-tainedfromfoodrawmaterialbyphysical,enzymatic,orchemicalmeans;and)syntheticcarbohydratepolymers(7).ThisdefinitionissupportedbytheAmericanAssocia-tionofCerealChemists(8).TheWHOandFAOagreewiththelatterdefinitionbutwithaslightvariation.Theystatethatdietaryfiberisapolysaccharidewith10mono-mericunits(9).ArecentreportfromtheNinthVahounyFiberSymposiumindicatedthatthescientificcommunityagreesonmaintainingaworldwideconsensuswithregardtotheinclusionofnondigestiblecarbohydrateswithamin-imumDPof3asdietaryfiberandonacore,nonexhaustivelistofbeneficialphysiologiceffectsofdietaryfibers(10).TheEuropeanFoodSafetyAuthorityPanelonDieteticProducts,NutritionandAllergiespublishedin2010asci-entificopinionondietaryreferencevaluesfortheintakeofcarbohydrates,dietaryfiber,fats,andwater.Inthisopin-ion,dietaryfiberwasdefinedasnondigestiblecarbohy-dratespluslignin(11).Inaddition,intheUnitedStates,theFDAproposedtoacceptthisdefinition(12).givesanoverviewofdifferenttypesofcarbohydratesandtheircommonfoodsource,averageDP,andmainproperties(13,14).Differenttypesofberscanalsobedistinguishedonthebasisoftheirchemicalorphysicalproperties(Table1andTable2).Chemically,fibersaredividedintocarbohydratesandnoncarbohydrates,suchaslignin.Physically,dietaryfi-berisdifferentiatedin2groupsonthebasisofitssolubility:insolubleinwaterandnonfermentableandnonviscousfi-berscomparedwithsolubleandfermentablefibers.Nonfermentablebersareveryslowlyornotfermentedbythebacteriainthecolon,theyretainwater,andtheywillcausealaxativeeffectbecauseoftheirdirectcontribu-tiontostoolbulkasundigestedmaterialwithoutaffectingfermentationormicrobialgrowth,aso-calledbulkingeffect(15,16).Fermentablebersarefermentedbythecolonicmicrobiota.Becausebacteriacomprise55%offecaldryweight,anincreaseinmicrobialmasscausesanincreaseinfecaloutput,therebyinducingapossiblelaxativeeffect17)(Figure1Alow-r
esiduecomparedwithalow-berdietIntheliterature,therehavebeendiscrepanciesamongdietrecommendationsastotheactualcompositionoflow-berand/orlow-residuediets.Untilnow,nocleardenitionhasbeenproposedforalow-residuediet.Cunningham(3)de-scribedthatallfoodsproducesomegastrointestinalresidue,asdoesnormalgastrointestinalfunction,andber-containingfoodsproducethebulkofthegastrointestinalresidue.Inaddition,nocleardenitionhasbeenprovidedforaberdiet.Lijoietal.(18)describedalow-berdietasadietwithatotaldailyberintakeg.Similarly,inaclin-icalstudyontheeffectsofalow-fiberdietinIBS,fiberintakewasalsosetat10gfiber/d(19).Althoughthesestudiesde-finedalow-fiberdietinaquantitativeway,noreferencewasmadetothetypeofdietaryfiber.Otherstudiesonlydefinedexamplesoffoodsthatwereandwerenotallowedinalow-fiberdiet(20).Low-residueorlow-berdietsingastrointestinaldiseasemanagementDiagnostic:bowelpreparationprotocols.Bowelprepara-tionisoftenconductedbeforeacolonoscopy,colonography,orgynecologicalsurgery.Currently,mechanicalbowelprep-arationwithorallavagesolutionssuchaspolyethylenegly-col,sodiumphosphate,sodiumpicosulfate,ormagnesiumcitrate,oftenprecededby1or2dofaclear-liquiddiet,arecommonlyused.Inaddition,stimulantlaxativesand/orprokineticagentscanbecombinedwiththesecatharticagents.However,patientsoftenndthispreparationtobeunpleasantandtime-consuming.Themostcommonprob-lemsthatleadtolessthanadequatecoloncleansingincludelackofcompliancewiththeclear-liquiddietanddifcultytakingthepreparation(21).Inaddition,catharticagentsarenotwithoutreportedsideeffectssuchasnausea,vomit-ing,bloating,abdominalcramping,sleepdiscomfort,head-aches,dizziness,andabsencefromschoolorwork(22).Anumberofstudiesinvestigatedtheintakeofalow-berorlow-residuedietasanadjuvanttocatharticregimenswithregardtocolon-cleansingefcacyandpatientcompliance.Low-residuecomparedwithlow-berdiets821 Dietaryrestrictionofberorresiduemayresultinareduc-tioninthesizeandnumberofstoolsforthepatients,result-inginlessdiscomfortforthepatient(23,24).AnoverviewofthestudiesinhumansispresentedinTable3DeleggeandKaplan(21)rstcomparedthetolerabilityandefcacyofalow-residuedietwithaclear-liquiddiet1dbeforearoutinecolonoscopy.Inaddition,Parketal.(25)andSipeetal.(26)comparedaprepackagedlow-residuedietwithaclear-uidregimen.Alldietswerecombinedwithcatharticagents.InarecentstudybyKimetal.(27),theclinicalefcacyofreduced-volumesodiumpicosulfateandaprepackagedlow-residuedietwascomparedwiththatofthestandardbowelpreparationbyusing4Lpolyeth-yleneglycolsolution.Inall4formerstudies,thelow-residueregimendidnotimpairthequalityofthebowelpreparationandabettercoloncleansingwasachieved.Furthermore,theyconrmedthatthelow-residuedietwasbettertoleratedandanimprovementinpatientsatisfactionwasobserved.Inanotherstudy,theefcacyofaber-freedietwascomparedwithaclear-liquiddietforcolonoscopypreparation.Similartotheresultsofthelow-residuediets,theber-freedietwasbettertoleratedbypatients(28).Inaddition,arecentran-domizedcontrolledtrialshowedthatthequalityofbowelpreparationwasnotcompromisedbyalow-residuebreak-fastonthedayprecedingthecolonoscopy.Inaddition,thisregimenwasbetteracceptedbypatientsandtherewasanincreasedcompliancewiththelow-residuedietthanwithaclear-uiddiet(29).Incontrasttothepreviousstud-ies,Stolpmanetal.(30)foundthatbowelpreparationquality,polypdetectionrates,andpatienttoleranceandac-ceptanceweresimilarbetweenalow-residueandaclear-liquiddietandproposedalow-residuedietasanalternativeapproachforbowelpreparation.Wuetal.(31)determinedinaprospectivestudywhethertheresiduecontentofthedietbeforeacolonoscopyinde-pendentlypredictsinadequatebowelpreparation.There-fore,theyscoredtheresiduecontent(1=highresidue,2=normalresidue,3=lowresidue,and4=noresidue)ofallmealsconsumedduringthe2dprecedingthecolo-noscopy.Immediatelyaftertheprocedure,thequalityofthebowelcleansingwasratedbyuseoftheOttawabowelpreparationscale(32).Agoodcorrelationbetweenthedie-taryresiduecontentscoreandtheOttawabowelpreparationscorewasfound(0.475,=0.001),indicatingthatalow-residuedietresultedinbetterbowelcleansingthandidaregulardiet.Computedtomog
raphiccolonographyisanalternativetocolonoscopyinthedetectionofpolypsandcarcinomaofthecolonandrectum.Liedenbaumetal.(20)demonstratedthatlimitedbowelpreparationincombinationwithalow-dietforcomputedtomographiccolonographyresultedinimprovedsubjectivetaggingqualityofresidualfecesandshowedatrendtowardbetterresiduehomogeneity.Inaddition,inlaparoscopicgynecologicalsurgeryabowelpreparationisconductedtodecreaseperitonealcon-taminationincaseofbowelinjuryandtoemptythebowelofitscontentsinordertoimprovetheaccesstothesurgicaleldandtofacilitatethehandlingofthebowelitself(33). TABLE1ClassificationofcarbohydratesaccordingtoaverageDPandtheirmainproperties CarbohydrateExampleAverageDPDigestionFermentationUpperGITColonFoodsource MonosaccharidesGlucose,fructose,galactose1CompleteFruit(juice)DisaccharidesSucrose,lactose,maltose2CompleteCaneandrootbeetsugar,candy,softdrinks,milk,beerLactuloseNotdigestedGoodDelayedGEFOligosaccharidesRafnose,stachyose,kestose,verbascose,9GoodLegumes,beanssweetpotatoesMaltodextrin39GoodPotatoes,wheatFructo-oligosaccharides39NotdigestedGoodNoFLeeks,onions,Galacto-oligosaccharides39NotdigestedGoodNoFFruitArabino-xylo-oligosaccharides39NotdigestedGoodNoFWheatPolydextrose39NotdigestedGoodNoFPolysaccharidesInulin9NotdigestedVerygoodNoFChicory,onionStarch:freshlycooked9CompleteWarmpotatoesRawcereals9CompleteGrainsResistantstarch9NotdigestedVariableVariableF+stoolbulkGreenbananas,coldpotatoesCellulose,hemicelluloses9NotdigestedNoSmallStoolbulkVegetables9VariableVariableF+stoolbulkVegetables9GoodViscosityViscosityFVegetablesRelatedcompoundsLignin9NotdigestedNoStoolbulkWheat,vegetablesTheclassificationofcarbohydratesandtheirmainpropertieswasadaptedfromtheEuropeanFoodSafetyAuthorityPanelonDieteticProductsNutritionAllergies(11)andJones(12).DP,degreeofpolymerization;F,fermentation;GE,gastricemptying;GIT,gastrointestinaltract;tract;,increase.Resistantstarchincludesphysicallyinaccessiblestarch(RS1),resistantgranules(RS2),andretrogradedamylose(RS3).822Vanhauwaertetal. Lijoietal.(18)rstcomparedtheeffectsofalow-berpre-operativedietwithatypicalmechanicalbowelpreparationinlaparoscopicgynecologicalsurgeryontheexposureofthesurgicaleld.Thelow-berdietandmechanicalbowelpreparationprovidedsimilarqualityofsurgicaleldexpo-sure.However,increasedcompliancewasnotedbythepa-tientsconsumingthelow-berdiet.Recently,theEuropeanSocietyofGastrointestinalEndos-copystatedintheirguidelinesthattheyrecommendalow-berdietonthedayprecedingcolonoscopy.Theguidelinewasbasedonatargetedliteraturereviewtoevaluatetheevidencesupportingtheuseofbowelpreparationforcolon-oscopy.AGradingofRecommendationsAssessment,Devel-opment,andEvaluation(GRADE)systemwasadoptedtonethestrengthoftherecommendationandthequalityofevidence.Therecommendationforalow-berdietonthedayprecedingcolonoscopyhadonlyamoderatequalityofevidencebecausethepotentialbenetsofarestricteddietbeforecolonoscopyarenotwellstudied.Inaddition,theEu-ropeanSocietyofGastrointestinalEndoscopydoesnotmakeanyrecommendationsregardingtheuseofalow-berdietfor�24hbeforetheexamination.Someendoscopistsrou-tinelyprescribealow-fiberdietduringthe3dprecedingco-lonoscopyratherthanonasingledaybecauseoftheslowtransittimeinsomepatients.However,nostudyhassofarcomparedtheuseofa1-dregimenwitha3-dregimen(34).Treatmentinboweldisorders.Low-residueorlow-dietsmayalsobeofvalueinspecicallyindicatedclinicalsituations.GastrointestinaldiseasessuchasCrohndisease,ulcerativecolitis,bowelobstruction,diverticulitis,pre-and/orpostabdominalsurgery,andothergastrointestinalorinammatorydisorderssuchasinpatientswithinfec-tiousgastrointestinaldiseaseorneoplasticdiseasearecondi-tionsthatmayrequirealow-residueorlow-berdiet.Incaseofaare-up,thedietcanreducethefrequencyandvol-umeofstoolsandinduceaprimaryremissionindisease.Insomecountries,suchasJapan,enteralnutrition(i.e.,liquiddietsconsistingofnutrientsbrokendownintotheirsmallerunits)isusedforremissioninductioninpatients(35).Inchildrenwithpersistentdiarrhea,adietwithgreenbananaandpectinreducedtheamountsofstoolanddiarrhealdu-ration(36).Currently,anumberofhum
anstudies,stillpreliminary,areinvestigatingtheinuenceoflow-berin-takeonthesymptomsignatureofseveralgastrointestinaldisorders.IBSisamultifactorialfunctionaldisorderoftheGITthat15%oftheadultpopulation.Theexactetiologyhasnotbeenidentified.Yet,environmental,psychosocial,physiologic,andgeneticfactorsarebelievedtoplayarole.Ahigh-fiberdiet,ortheadditionofsupplementarybrantothediet,haslongbeenthemostcommonfirst-linetreat-mentforIBS.However,differentstudieshaveshownthatpatientswithIBSreportedaworseningofsymptomsuponconsumingahigh-fiberdiet(3739).Aby-productoffiberfermentationisgas,whichcanleadtounpleasantsideeffectssuchasabdominalpain,cramps,anddistension.WoolnerandKirby(19)determinedinacontrolledtrialin204pa-tientswithIBSwhetheralow-fiberdiet(10gfiber/dfor4wk)couldbeaneffectivetreatmentforIBS.Beforeandafterthelow-fiberdiet,patientssymptomswereassessedbyusingaquestionnaire.Theirresultsindicatedthatapproximatelyhalfofthepatients(49%)treatedwithalow-fiberdietandbulkingagents,ifrequired,reportedasubstantialimprove-mentinsymptoms(60100%improvement)after4wkofthedietaryregimen.Analternatingbowelhabitanddiarrheaweremostlikelytobehelpedbythediet,followedbybloat-ing,urgency,pain,andflatulence.Currently,afermentableoligosaccharide,disaccharide,monosaccharide,andpolyol(FODMAP)restricteddietisincreasinglyrecommendedasthefirst-linetherapyinthemanagementofIBS(40).Diverticulosisinthelargeintestineisaconditionresult-ingfromherniationofthemucosathroughdefectsintheco-lonicmusclelayer.InWesternandindustrializedcountries,60%ofadults�60ywilldevelopcolonicdiverticula(41).Inthemajorityofcases,theconditionisasymptomatic,withonly1025%ofaffectedindividualsdevelopingsymptoms(38).Asymptomaticdiverticulosisiscommonlyattributedtoconstipationcausedbyalow-fiberdiet,althoughevidenceforthismechanismislimited.Peeryetal.(42)examinedtheassociationsbetweenconstipationandlowdietaryfiberin-takewiththeriskofasymptomaticdiverticulosisin539pa-tients.Participantsunderwentcolonoscopyandassessmentofdiet,physicalactivity,andbowelhabits.Theresultsofthisstudyindicatedthatneitherconstipationnoralow-fiberdietwasassociatedwithanincreasedriskofdiverticulosis. TABLE2Classificationoffibersbasedonchemicalandphysical Dietaryfiberclassificationclassification LigninNoncarbohydrateInsoluble,nonfermentable,nonviscousCelluloseNPS:celluloseInsoluble,nonfermentable,nonviscousHemicelluloseNPS:noncellulose(non)fermentable,(non)viscousPectinNPS:noncellulosefermentable,(non)viscousGumNPS:noncellulosefermentable,(non)viscousFructo-oligosaccharidesNondigestibleoligosaccharidefermentable,(non)viscousGalacto-oligosaccharidesNondigestibleoligosaccharidefermentable,(non)viscousResistantstarch(RS1,RS2,andRS3)ResistantstarchSoluble,fermentable,(non)viscousNPS,nonstarchpolysaccharide;RS1,resistantstarchwithphysicallyinaccessiblestarch;RS2,resistantstarchwithresistantgranules;RS3,resistantstarchwithretro-gradedamylose.Low-residuecomparedwithlow-berdiets823 Thesameauthorspreviouslyshowedthatahigh-fiberdietdoesnotprotectagainstasymptomaticdiverticulosis(43).Inanotherstudy,Wick(44)suggestedthatpatientswithdi-verticulardiseaseexperiencefewersymptomswiththecon-sumptionoflow-fiber,blanddietsduringsymptomaticperiodsbutrecommendedthatoncetheacuteepisodeorhighlysymptomaticperiodisresolvedorchronicdiseaseismanagedthatpatientsshouldgraduallyincreasedietaryfi-berto2030gdaily.High-berdietsareoftenusedinthemanagementofconstipation.Theamountofberconsumedbypatientsinthetreatmentofconstipationwasatleast10g/d(45).Theadditionofdietaryberincreasesfecalmassandcolonictransittime.However,somestudiesreportedaworseningofsymptoms(i.e.,increasedbloatednessandabdominaldis-comfort)inpatientswithchronicconstipationwhendietaryberintakewasincreased(46,47).Hoetal.(48)investi-gatedinaprospectivecase-controlstudytheeffectofaberdietfor2wkin63patientswithidiopathicconsti-pation.Patientsweretheninstructedtocompletelystoptheirintakeofdietaryber,includingvegetables,cereals,fruit,whole-mealbread,andbrownricefor2wk.After2wk,patientswereaskedtoreducedietaryberintaketoanamountthattheyfou
ndacceptableforthelongterm.Pa-tientswerefollowedupat1-mointervalsandnalresultswereanalyzedafter6mo.Thestudyshowedthatconstipa-tionanditsassociatedsymptomscanbeeffectivelyreducedbystoppingorevenloweringtheintakeofdietaryber.Recently,Lauetal.(49)comparedforthersttimethefeasibilityandpatienttoleranceofaclear-uid(=54)andlow-residue(=50)dietstartedonpostoperativeday1afterelectivecolorectalsurgery.Theyshowedthatalow-residuediet,ratherthanaclear-fluiddiet,onpostoperativeday1aftercolorectalsurgerywasassociatedwithlessnausea,fasterreturnofbowelfunction,andashorterhospitalstaywithoutincreasingpostoperativemorbidity.Theuseoflow-ber/low-residuedietswasexploredinbothdiagnosticandtherapeuticsituations.Themajorconcernwithanybowelpreparation,beforecolonoscopy,colonogra-phy,orlaparoscopicgynecologicalsurgery,istheabilitytoprovideacleanbowel.Previousstudiesinvestigatingtheef-ciencyofbowelpreparationprotocolsmostlyfocusedonthecomparisonofeffectivenessamongdifferenttypesofca-tharticsandquantitiesofsolutionsaswellasdosingintervals52).However,dietaryadaptationsmayprovideanalter-nativewayofbowelpreparation.Thecomparisonoftheapplicabilityofalow-residue/low-fiberregimen(aloneorincombinationwithcatharticagents)withtraditionalbowel-cleansingmethodsshowedthatthelow-residue/low-fiberregimendidnotimpairthequalityofthebowelpreparation.Inaddition,thepatientstoleratedthelow-residue/low-fiberdietbetterandtheirsatisfactionim-proved.Furthermore,thecompliancewiththedietaryregimenwasbettercomparedwithaliquiddietoranormaldietwithoutrestrictions.Inadditiontoadiagnosticvalue,low-ber/low-residuedietshavetherapeuticpotentialinthetreatmentofdifferentgastrointestinaldisorders.Theamountofberinthedietdiffersbetweenacutephasesofdiseaseandperiodsofremis-sion.Inasituationofrelapse,thesameadviceisgivenasforthepreparationforacolonoscopy(i.e.,alow-berdietoramaximumof10gber/d).Aftertheinductionofremission,theamountofberinthedietisgraduallyincreasedtotheamountofberinahealthydiet.Surprisinglyandcontrarytostronglyheldbeliefs,arecentstudyshowedthatstoppingorreducingdietaryberintakeimprovesconstipationanditsassociatedsymptoms(44).Morestudiesarewarrantedtoinvestigatetheeffectofreducingberintakeinthetreat-mentofconstipation.Becauseofthelackofascienticallyacceptedquantita-tivedenitionandtheunavailabilityofamethodtoestimate FIGURE1Overviewofpossibleeffectsofdifferentfibersongastrointestinaldigestionandfermentation.824Vanhauwaertetal. TABLE3Overviewofstudiesinvestigatingtheeffectofalow-residueorlow-fiberdietonbowelpreparationinhumans (reference)Studygroup,DesignInvestigationResults DeleggeandKaplan(21)506(64%F)RCTComparisonoftheefcacyof2bowel-cleansingregimensbeforecolonoscopyThelow-residueregimenresultedinsignicantlybettercoloncleansingandbetterpatienttoleranceandwillingnesstorepeatthecatharticbowelpreparationClearliquid=222Low-residue=284Parketal.(25)214(44%F)RCTEfcacyandtolerabilityofbowelpreparationprotocolswithalow-residuedietcomparedwiththetraditionalclear-liquiddietThelowresidue1-ddietprovidedcleansingefcacysimilartothatofaclearliquiddietandofferedthebenetofimprovedtolerabilityClearliquid=106Low-residue=108Sipeetal.(26)230PRTCTostudywhetheralow-residuedietaffectsbowelpreparationwithoralsulfatesolutionAlow-residuedietdidnotimpairthequalityofbowelpreparationachievedwithoralsulfatesolutionClearliquid=114Improvementofpatientsatisfactionwithlow-residuedietLow-residue=116Kimetal.(27)184(53.8%F)PRTCSuccessrateofthebowelpreparation,adverseevents,tolerability,cecalintubationtime,polypandadenomadetectionrateTheadverseevents,includingabdominaldistension,pain,nausea,vomiting,andabdominaldiscomfort,weresignicantlylowerinthepicosulfate+low-residuegroupthaninthePEGgroupSodiumpicosulfate+low-residue=94PEG-ES=90Soweidetal.(28)200(47.8%F)PCSEfcacyandtolerabilityofPEG-ESgivenwithaclear-liquiddietcomparedwithaber-freedietforcolonoscopypreparationFiber-freedietgivenwithPEG-ESonthedaybeforecolonoscopyisamoreeffectiveregimenthanthestandardclear-liquiddietregi-menandisbettertoleratedbypatientsClearliquid=98Fiber-free=102Melicharkovaetal.(29)248(
56%F)PRCTEfcacyandtolerabilityofalow-residuebreakfastingestedonthedaybeforecolonoscopyascomparedwithaclear-uiddietAlow-residuebreakfastimprovedpatienttolerancewithoutaffect-ingqualityoflow-volumecoloncleansingbeforecolonoscopyCFs=122Low-residue+CFs=126Stolpmanetal.(30)201(43.28%F)PRTCToexaminewhetherachangeinprecolonoscopydietaryrestrictionleadstobetterpatienttolerancewithoutcompromisingcolon-oscopyexaminationqualityPatientsallowedtohavealimitedlow-residuedietbeforecolonos-copyachieveabowelpreparationqualitythatisnoninferiortopatientsonastrictclear-liquiddietlimitationClearliquids=101Low-residue=100Wuetal.(31)804(43.6%F)PCSImpactofa2-dlow-residuedietonthequalityofbowelpreparationbeforecolonoscopyAlow-residuedietbeforecolonoscopyprovidedbetterbowelcleansingthananunrestricteddietLiedenbaumetal.(20)50(42%F)RCTComparisonofbowelpreparationswithandwithoutalow-berdiettodeterminetheimagequalityandaccuracyinpolypdetectionatCTcolonographyTheuseofalow-berdietinbowelpreparationforCTcolonographyresultsinsignicantlylessuntaggedfecesandshowsatrendto-wardbetterresiduehomogeneityNodiet=25Low-fiber=25Lijoietal.(18)83(100%F)RCTComparisonofa7-dminimal-residue(lowberintake)preoperativedietwithamechanicalbowelpreparationbeforelaparoscopicgynecologicalsurgeryThelow-berdietandmechanicalbowelpreparationprovidedsimilarqualityofsurgicaleldexposureFibergroup=42Thelow-berdietwasbettertoleratedbythepatients(increasedcompliance)Controls=41CF,clearfluid;CT,computedtomographic;PCS,prospectivecohortstudy;PEG,polyethyleneglycol;PEG-ES,polyethyleneglycolelectrolytesolution;PRCT,prospectiverandomizedcontrolledtrial;RCT,randomizedcontrolledtrial.Low-residuecomparedwithlow-berdiets825 theamountoffoodresiduesproducedwhilepassingthroughtheGIT,low-residuedietswereremovedfromtheNutritionCareManualintheUnitedStatesafter2011.Ad-ditionalargumentsforthisremovalincludedthatfoodcomponentsarenottheonlysourceofresiduegivingvol-umetostoolsandnocriteriahavebeendenedtodifferen-tiatelow-,medium-,andhigh-residuediets(17,20,26).Inpractice,informationrelatedtothequantityofresidueinthedietusuallyreferstotheamountofber.Often,low-berdietsareconsideredasanalternativeforalow-residuedietandbothtermsareusedinterchangeably(3,5).Alow-residuedietcurrentlyisnolongerusedforbowelresection,ileostomy,Crohndisease,andulcerativecolitis,butlow-bertherapyisrecommendedfortheseacute-phaseconditions.Althoughseveralauthorsmentionedtheimportanceoftheamountofberinthediet,onlyLijoietal.(18)andWoolnerandKirby(19)quantitativelydenedalow-dietasadietwith10gfiber/d.Thelatterdefinitionofalow-fiberdietisagoodrecommendationtobeusedinclinicalpractice.Inadditiontotheamountoffiber,thetypeoffibermayalsobeofimportance.Inalmostallstudies,nodistinctionwasmadebetweenthedifferenttypesoffiber.Asmentionedabove,fiberscanbeclassifiedasinsolublefibers,whichdonotdissolveinwater,andassolublefibers,whichdissolveinwater(15).Bothsolubleandinsolublefiberscanincreasethevolumeofstool.Foracolonoscopy,itisimportantthatthecoloncleansingissufficientandthattherearenomorefiberresiduespresent.Ingeneral,theuseoflow-berdietsforgastrointestinaldiseasemayhavepreviouslybeenoverlookedduetothegen-eralbeliefthatahighberintakeisassociatedwithspecihealthbenets.Forinstance,SCFAs(acetate,propionate,andbutyrate)areendproductsofcolonicberfermentationthathavebeenshowntocontributetocolonichealth.SCFAsprovideenergytocolonicepithelialcells,decreaseluminalpH,andimprovemineralabsorption(2).However,theuseoflow-berdietsinbowelpreparationisrestrictedto1d,sotherewillbenoconcernaboutlackofmineralsorvi-tamins.Inthecaseofacutediseaserelapse,thelow-residue/berdietismaintainedseveraldays,but,ifsupervisedbyadietician,nutritionalorenergydecienciesareunlikelytooccur.Inconclusion,thereisinsufcientevidencetofurtherjustifytheclinicaluseofalow-residuediet.Onthebasisofthisliteraturereview,wesuggestredeningalow-residuedietasalow-berdietandtoquantitativelydenealow-berdietasadietwithamaximumof10gber/d.Aberdietcanbeappliedinbothdiagnosticandthera-peuticsituations.Diagnostically,alow-berdietisusedinthepreparationforacolonosco
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