Constipation, Irritable Bowel Syndrome and other bowel disorders are common issues that can affect someone’s quality of life physically, emotionally and socially. The cross over effect of gut issues to mood, mental health, pain and a myriad of other health issues is significant and when we consider the pelvic floor, constipation and other bowel issues can be involved in bladder weakness, pelvic organ prolapse and pelvic pain.
As a pelvic health physiotherapist, I often ask questions to my clients about their bowel habits. Often, I suggest that bowel care is our first line of treatment. As we normalise the bowels, we reduce excessive pressures from the back passage on the bladder and pelvic organs, reduce excessive straining on the toilet that might encourage the pelvic organs to descend and improve discomfort that may be amplifying other pelvic pain conditions such as endometriosis or painful bladder syndrome.
Laxative and fibre supplements are often recommended for those suffering from constipation or disorders of the bowels. Some of the benefits may include:
- Protection against diverticular disease
- Reduce the risk of haemorrhoids
- Reduce the need to excessively strain on the toilet
- Improve constipation and chronically loose stools
- Protect against chronic disease such as heart disease and diabetes
“While very important to our health, not all fibres are created equal. It is important to understand the difference between different fibre supplements and how they work to ensure that you are getting the best possible outcomes for your bowels.”
What is fibre?
Fibre in its simplest form is the remnants of the plant cell wall. Dietary fibre is the carbohydrates that pass undigested through the intestine, and are mostly found in fibre rich plant foods. For a guide on fibre rich plant foods visit the Continence Foundation of Australia’s guide to “Healthy Diet & and Bowels” .
Insoluble vs soluble fibre.
Fibre can be separated into soluble, intermediate soluble or insoluble fibre. This has to do with the fibre’s ability to dissolve in water. Soluble fibre for example dissolves in water and forms a gel within the stool, essentially swelling or bulking up the stool. Obviously, this is great for loose stools or diarrhoea. But what about constipation? While this sounds counter-productive for the treatment of constipation, it is thought that the bulking of the stool creates a mechanical stimulation of the nerves of the bowel wall, essentially stimulating the bowels to move a bit quicker and to increase the frequency of the bowel movement.
Soluble fibres include:
- The flesh of fruits and vegetables
- Legumes, lentils and soy products
- Wholemeal breads, cereals, oats etc
- Psyllium, ispaghula
- Metamucil supplements
Insoluble fibre on the other hand, attracts water into the stool and absorbs water to create the bulking effect, making it softer and easier to pass. Insoluble fibre is often more likely to be suggested for constipation for this reason.
Insoluble fibres include:
- The skins of fruits, vegetables and legumes
- Wholegrain breads, cereals, rice etc
- Nuts and seeds
- Normafibe and Normacol supplements
Fermentability refers to the enzymatic actions of the fibre by microflora. In other words, fermentation stimulates bacterial growth within the gut. It was thought that this process increases the microbial biomass of the stool which basically then stimulates the colon and eventually results in more frequent bowel movements. On the other hand, certain studies have found that even once the microbial properties have been taken away, e.g., through the use of antibiotics, that the laxative effect of the fibre is not reduced. Interestingly, another study found that plastic flakes similar to bran could have a similar effect on increasing bowel frequency and stool consistency, even without the use of fermentability.
So do we need fermentability in our fibre?
High fermentability in fibre and other foods can create excess wind or flatus. Not only is this process uncomfortable at the best of times, but it can be embarrassing and difficult to control if you already have pelvic floor problems and can cause increased discomfort. Often people will avoid fibre supplements because of this.
Sterculia, aka Normafibe and Normacol, is a non-fermentable fibre, meaning it does not tend to have the side effect of excessive wind production, bloating or flatus. Many people have not heard of Sterculia supplements before, and they are often only found in pharmacies. Products such as Normafibe and Normacol are great options for an insoluble, non-fermentable fibre supplement to assist in the management of constipation.
The verdict on common fibre supplements?
Psyllium husks & Metamucil:
Soluble, meaning it has great water holding capacity that transitions into a soft gel when mixed with water, and finally a stiff gel. It can help with increasing the frequency of the bowel movement but is often not well tolerated by people with constipation as it can create too much bulk and wind due to its moderate fermentability. It may be more useful for loose stools or diarrhoea.
Wheat Bran & Benefibre:
Intermediate solubility and low fermentability (meaning it may create less wind that Psyllium but more than Sterculia). This fibre bulks the stool and speeds up the bowels. This speed though can be quite irritative to people with IBS or sensitive bowels, causing pain and discomfort.
Sterculia, Normacol & Normafibe.
Insoluble, meaning it will absorb water and stimulate the bowels without creating a gel. It is non fermentable, which avoids the side effect of excessive wind, flatus or discomfort from bloating. Sterculia products can be quite useful for constipation.
Overall, the research to support the use of fibre supplements for constipation and disorders of the bowel is weak and low quality. It certainly seems that the use of fibre is better than a placebo for softening the stool and increasing the frequency of bowel movements but also may lead to side effects such as wind production. Basically, it is moderately effective and has moderate gastrointestinal side effects which can obviously leave people confused about how to use fibre supplements most effectively to improve bowel health. For more individual assessment on the use of fibre and how to take care of your bowels perhaps considering visiting a pelvic health physiotherapist by booking online at Calm & Connection Physiotherapy [here] or visiting the Continence Foundation of Australia to find a pelvic health physiotherapist near you.
For more information on bowel care you can also access “Looking after your bowel. A guide to improving bowel function” by the Continence Foundation of Australia”.
Be kind to yourself,