No More Normafibe – What Do I Do Instead?

Normafibe No More – does this spell no more help for bowel troubles?

Normafibe was a big help for some, but not any longer.

Normafibe was a fibre supplement that had been around forever. (You could tell by the 70s-style label that had never been updated, but perhaps that’s a bit unkind. At least it distracted you from the original ingredient, which you can see in the picture above.) Many people trusted Normafibe for help with constipation – or (paradoxically) loose bowels and faecal incontinence (or accidental bowel leakage). I say “had been” and “trusted” because it is now officially discontinued, due to issues sourcing its key ingredient.

As a pelvic physiotherapist, I occasionally used Normafibe with some patients. As a naturopath, I wasn’t thrilled with some of the ingredients in it, including the talc and titanium dioxide (not to mention it being yet another source of sugar we generally eat too much of). This combination of ingredients turned it into a semi-palatable, if strange to consume, bunch of tiny sweet chalky rocks you were expected to swallow with a spoon. This strange preparation was mercifully remote from the original appearance of the mystery raw ingredient (again, see above picture), but made it a pretty unnatural concoction. Because of that, I often looked for alternatives. For those of you missing Normafibe in your clinics (or in your life), here is a quick Q&A designed to help you choose an alternative now that Normafibe is No More.

What made Normafibe different to other fibre supplements?

The mystery key ingredient in Normafibe was sterculia. This is a dried pod of the plant Sterculia urens or Sterculia lychnophora, native to India. The standout feature of sterculia is that its fibre composition is overwhelmingly insoluble – 90-95%. (Although we have moved away from simply classifying fibre as soluble or insoluble, the classification is still sometimes useful.) A fibre source that is almost fully insoluble can:

-hasten transit time by virtue of its physical effect on the gut wall (stimulating motility and mucus secretion)

-reduce diarrhoea when replacing soluble fibres, as in contrast to them, insoluble fibre is unable to increasing water-holding capacity of the stool

-be well tolerated by those with FODMAPs issues (e.g. many people with IBS) due to a lack of fermentation.

This makes Normafibe very different to Metamucil, for example, whose principal ingredient is Plantago ovata, or psyllium husk. Psyllium is only sometimes (and partially) effective for constipation  that is due to low fibre intake. This is because it is a form of fibre called a mucilage. Mucilages are viscous, which means they have a high water-absorbing capacity and readily convert to a gel when in the presence of water. Both mucilages and soluble fibres are less effective than insoluble fibres for speeding up transit time and promoting laxation (i.e. bowel motions).

Confused yet? It IS confusing! The only point you need to get here is that you can’t necessarily expect to reproduce the results you got in your patients with Normafibe by using Metamucil (psyllium husk, mucilage) or Benefibe (wheat dextrin, soluble fibre) or even the increasing-in-popularity prebiotics like inulin or fructo-oligosaccharide (also soluble fibres).

So then…what are some possible substitutes for Normafibe/sterculia?

If you are looking to promote laxation (bowel motions), start here.

To imitate the effects of sterculia’s insoluble fibre in Normafibe, try:

-chia seed, which is also predominantly insoluble (90-95%). Amounts should start low and build up slowly to patient tolerance. This is my main recommendation. However, someone recently told me it gave them an itchy throat, which prompted me to find a potential alternative…

-poppy seed, which is almost all insoluble fibre. Due to its weird texture, it might need to be stirred into yoghurt or porridge. Amounts should start low and build up slowly to patient tolerance.

-passionfruit, swallowing, not chewing the seeds, which are very high in insoluble fibre. Start with 1-2 small fruit per day.

-kiwifruit, 2 per day. Despite a lower insoluble fibre proportion, something about these makes them very effective for laxation, as well as well-tolerated by most people. Check for latex allergy, which may be associated with kiwifruit allergy.

-sugar cane fibre (KFibre), as per the instructions on the side. Sugar cane fibre is also predominantly insoluble fibre (at least 73%), which is not as high as chia or poppy seed.

-wheat bran. I can’t leave this out, because it is high in insoluble fibre, but it may irritate some sensitive guts, and I don’t use it often.

Caution

Always ensure your patient is drinking not only the recommended amount of fluid per day, but extra fluid (150-200mL) at the time of consuming these. If the chia seed is pre-soaked in fluid, that fluid counts in the total.

Avoid if the patient has any risk or history of gut obstruction or any swallowing difficulties such as those caused by eosinophilic esophagitis.

If you are looking to reduce looseness of stools, start here.

Always get any medical causes ruled out and consider exploring functional causes, like digestive capacity and gut microbiome. But as far as what can give relief in the meantime, try:

-Psyllium, which holds water very effectively and forms a gel, so may hold together the stool form better, reducing looseness (start at 1 tsp and work up the patient’s best dose)

-Soluble fibres to allow the stool to “hold its shape” e.g. wheat dextrin (Benefibe) or oat beta-glucan

-Green banana flour with high resistant starch content

Caution

Avoid if the patient has any risk or history of gut obstruction or any swallowing difficulties such as those caused by eosinophilic esophagitis.

What about partially hydrolysed guar gum and other prebiotics?

Partially hydrolysed guar gum, galacto-oligosaccharides, acacia gum – these are just a few of the many prebiotics available. There is definitely scope for using all of these in practice, but I would recommend you have more understanding of the gut microbiome and disorders of gut-brain interaction before you delve too deeply into these. Similarly, inulin and fructo-oligosaccharides are prebiotics that I would not use indiscriminately (or even experimentally) without a deeper understanding of their effects. The side effects could make you rather unpopular with your patients, and there are usually other preferred options.

Should I just use Normacol Plus instead?

No. Normacol Plus contains sterculia, but also contains frangula bark. Frangula is a stimulant laxative and best avoided in most circumstances. On the occasion you need to use a stimulant with patients, there are many easier and more consistent to dose than this.

What if I want to learn more as a health professional?

There is so much to know in this field. While pelvic physiotherapy has always skirted on the edge of gut/bowel-related supplementation, the explosion in research in gut microbiome and gut function means you can quickly become out of your depth. If you want to know more about prebiotic use in practice, gut function and dysfunction, the gut microbiome, or disorders of gut-brain interaction, or you want tangible, immediate help with a specific case, consider a shorter or longer mentoring session with me at a time that suits you. This is easy to book on my website here.

What are your experiences with the options I’ve mentioned? I’d love to hear from you!

Connect with me on social media in a physiotherapy professional group, or on my Facebook page Manual Therapists in Functional Medicine or in my group Nutrition and Functional Medicine for Manual Therapists.