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Low Residue Diet
Definition/Introduction
Digestion in the gastrointestinal tract is a highly complex process involving both mechanical forces and chemical reactions to disintegrate and metabolize food material.[1] A low residue diet is a diet that restricts the ingestion of indigestible material. The term residue refers to the indigestible content of food material that remains in the gastrointestinal tract and ultimately contributes to fecal bulking.[2] In theory, a low residue diet would result in a reduction of stool quantity and frequency. This diet includes eggs, refined grains, white rice, seafood, and poultry. Dairy intake is limited, and high fiber-containing food and whole grains are typically entirely avoided.[3]
Issues of Concern
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Issues of Concern
The main issue of concern results from the lack of standardization of the actual composition of a low residue diet.[2] The exact volume of residue produced by the digestion of various foods is challenging to calculate and reproduce consistently given the microbiota and bowel function variability of the population.[3] Healthy gastrointestinal function and all foods can contribute to a certain degree of intestinal residue.[4] Incorrectly, a low residue diet is often interchangeably referred to as a low fiber diet. While fiber-containing foods contribute to fecal bulking, there are some exceptions. Milk, which is classically considered low in fiber, results in high colonic residue and fecal bulking.[5] For all these concerns, the American Dietetic Association has removed the low residue diet from the Nutrition Care Manual.[2]
Clinical Significance
A low residue diet is advocated for various clinical situations and illnesses. Until recently, a diet consisting of only liquids was recommended with bowel preparation before colonoscopies and colorectal surgeries. Numerous studies have shown either improved or equivalent bowel cleanliness in patients who consumed a low residue diet rather than a liquid diet with their bowel preparation. These same studies revealed enhanced overall patient satisfaction with a low residue diet and they were less likely to cancel their procedure.[6][7][8][9][10][11] Both the American Society of Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy now recommend the use of a low residue diet along with their bowel preparation.[12][13]
Clinicians often advise a low residue diet for patients during a flare-up of their inflammatory bowel disease; however, a recent systemic review did not find support for a therapeutic benefit in such patients.[14] For the same theoretical reason to reduce the risk of aggravating existing inflammation by decreasing colonic motility and allowing for “bowel rest,” a low residue diet is also advised for patients with infectious colitis or acute diverticulitis. This recommendation is based mostly on the clinical experience of healthcare providers as there is a paucity of high-quality evidence supporting any dietary change.[15] An additional potential role for a low residue diet was demonstrated in patients with irritable bowel syndrome in a randomized controlled trial.[3] In another randomized control trial, starting a low residue diet, rather than a liquid diet, on the first day after colorectal surgery was associated with better patient tolerance, quicker normalization of bowel function, and shorter length of hospitalization stay without increasing postoperative morbidity.[16]
Nursing, Allied Health, and Interprofessional Team Interventions
In summary, a low residue diet is a restrictive diet that has both diagnostic and therapeutic roles. Regardless of the clinical indication, a low residue diet requires patient education to encourage compliance and to ensure that the patient is adequately following the diet as directed. The responsibilities of this education are deliverable by dietitians, nursing staff, and clinicians. Education is key to enhanced patient-centered care as it reinforces insight and understanding. It provides the patient with the complete opportunity to more likely obtain the desired outcomes of the diet.
Nursing, Allied Health, and Interprofessional Team Monitoring
When a clinician prescribes a patient a low residue diet, they should also be encouraged to maintain daily records of which foods they consume. Documentation will allow the healthcare team to support and ensure that patients are adherent to the dietary changes. The primary responsibility belonging to the patient will enable them to contribute to their care. This integrated approach is essential to deliver the best possible care and to improve patient outcomes.
References
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Cunningham E. Are low-residue diets still applicable? Journal of the Academy of Nutrition and Dietetics. 2012 Jun:112(6):960. doi: 10.1016/j.jand.2012.04.005. Epub [PubMed PMID: 22709819]
Vanhauwaert E, Matthys C, Verdonck L, De Preter V. Low-residue and low-fiber diets in gastrointestinal disease management. Advances in nutrition (Bethesda, Md.). 2015 Nov:6(6):820-7. doi: 10.3945/an.115.009688. Epub 2015 Nov 13 [PubMed PMID: 26567203]
Level 3 (low-level) evidenceWEINSTEIN L, OLSON RE, VAN ITALLIE TB, JOHNSON D, INGELFINGER FJ. Diet as related to gastrointestinal function. JAMA. 1961 Jun 17:176():935-41 [PubMed PMID: 13783971]
Christian GM, Alford B, Shanklin CW, DiMarco N. Milk and milk products in low-residue diets: current hospital practices do not match dietitians' beliefs. Journal of the American Dietetic Association. 1991 Mar:91(3):341-2 [PubMed PMID: 1997558]
Level 3 (low-level) evidencePark 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. Journal of gastroenterology and hepatology. 2009 Jun:24(6):988-91. doi: 10.1111/j.1440-1746.2009.05860.x. Epub [PubMed PMID: 19638081]
Level 1 (high-level) evidenceNguyen DL, Jamal MM, Nguyen ET, Puli SR, Bechtold ML. Low-residue versus clear liquid diet before colonoscopy: a meta-analysis of randomized, controlled trials. Gastrointestinal endoscopy. 2016 Mar:83(3):499-507.e1. doi: 10.1016/j.gie.2015.09.045. Epub 2015 Oct 13 [PubMed PMID: 26460222]
Level 1 (high-level) evidenceGómez-Reyes E, Tepox-Padrón A, Cano-Manrique G, Vilchis-Valadez NJ, Mora-Bulnes S, Medrano-Duarte G, Chaires-Garza LG, Grajales-Figueroa G, Ruiz-Romero D, Téllez-Ávila FI. A low-residue diet before colonoscopy tends to improve tolerability by patients with no differences in preparation quality: a randomized trial. Surgical endoscopy. 2020 Jul:34(7):3037-3042. doi: 10.1007/s00464-019-07100-6. Epub 2019 Sep 3 [PubMed PMID: 31482360]
Level 2 (mid-level) evidenceSipe BW, Fischer M, Baluyut AR, Bishop RH, Born LJ, Daugherty DF, Lybik MJ, Shatara TJ, Scheidler MD, Wilson SA, Rex DK. A low-residue diet improved patient satisfaction with split-dose oral sulfate solution without impairing colonic preparation. Gastrointestinal endoscopy. 2013 Jun:77(6):932-6. doi: 10.1016/j.gie.2013.01.046. Epub 2013 Mar 23 [PubMed PMID: 23531424]
Level 1 (high-level) evidenceWu KL, Rayner CK, Chuah SK, Chiu KW, Lu CC, Chiu YC. Impact of low-residue diet on bowel preparation for colonoscopy. Diseases of the colon and rectum. 2011 Jan:54(1):107-12. doi: 10.1007/DCR.0b013e3181fb1e52. Epub [PubMed PMID: 21160321]
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. The American journal of gastroenterology. 2013 Oct:108(10):1551-5. doi: 10.1038/ajg.2013.21. Epub [PubMed PMID: 24091500]
Level 1 (high-level) evidenceASGE Standards of Practice Committee, Saltzman JR, Cash BD, Pasha SF, Early DS, Muthusamy VR, Khashab MA, Chathadi KV, Fanelli RD, Chandrasekhara V, Lightdale JR, Fonkalsrud L, Shergill AK, Hwang JH, Decker GA, Jue TL, Sharaf R, Fisher DA, Evans JA, Foley K, Shaukat A, Eloubeidi MA, Faulx AL, Wang A, Acosta RD. Bowel preparation before colonoscopy. Gastrointestinal endoscopy. 2015 Apr:81(4):781-94. doi: 10.1016/j.gie.2014.09.048. Epub 2015 Jan 14 [PubMed PMID: 25595062]
Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, Bretthauer M, Dekker E, Dinis-Ribeiro M, Ferlitsch M, Fuccio L, Awadie H, Gralnek I, Jover R, Kaminski MF, Pellisé M, Triantafyllou K, Vanella G, Mangas-Sanjuan C, Frazzoni L, Van Hooft JE, Dumonceau JM. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy. 2019 Aug:51(8):775-794. doi: 10.1055/a-0959-0505. Epub 2019 Jul 11 [PubMed PMID: 31295746]
Charlebois A, Rosenfeld G, Bressler B. The Impact of Dietary Interventions on the Symptoms of Inflammatory Bowel Disease: A Systematic Review. Critical reviews in food science and nutrition. 2016 Jun 10:56(8):1370-8. doi: 10.1080/10408398.2012.760515. Epub [PubMed PMID: 25569442]
Level 1 (high-level) evidenceTarleton S, DiBaise JK. Low-residue diet in diverticular disease: putting an end to a myth. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2011 Apr:26(2):137-42. doi: 10.1177/0884533611399774. Epub [PubMed PMID: 21447765]
Lau C, Phillips E, Bresee C, Fleshner P. Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: a randomized controlled trial. Annals of surgery. 2014 Oct:260(4):641-7; discussion 647-9. doi: 10.1097/SLA.0000000000000929. Epub [PubMed PMID: 25203881]
Level 1 (high-level) evidence