Following the Plant Proof Podcast Episode 17 with Dr B on Gut Health we thought a specific blog on bloating would be helpful. So here it is…
I have to admit, bloating is one of the most challenging symptoms for gastroenterologists in 2018. It’s an epidemic, and I’m going to explain to you why. But a huge part of the challenge is that we don’t have great diagnostic tests or powerful medications to eliminate bloating. As a result, most doctors are at a loss with this one.
But for me, I always try to come back to a simple question: “What’s the root cause of my patient’s problem?” And if you think about it intuitively, there are really only 4 root causes for gas and bloating:
See the thing is that air that gets into your intestinal system has to come out, one way or the other (meaning a belch or a toot). Air generally can’t enter the system from below, unless you’re doing something crazy down there and if that’s the case, please stop! But air can definitely be swallowed, and once it gets in you’ll either have to belch it out or you’ll have it wiggle its way through 25 feet of intestine and cause discomfort and distension the entire way.
Keep in mind, almost ALL belches are air that is swallowed. There’s a reason why belches don’t have the sulfur type smell that you get with toots. So if belching is a big part of the bloating problem then you need to pay attention here!
It’s important to identify where the air is sneaking in, because people generally aren’t even aware that it’s happening. If you’re a fast eater or take big gulps when you drink, you have to slow it down! Other sources include sipping through straws (which have air in them), chewing on gum or sucking on candy (because when you swallow your saliva you also swallow air), or carbonated beverages (because the carbonation is air, of course). So bottom line – take your time with eating and drinking and make sure to have good, controlled swallows, and avoid straws, chewing gum and carbonated beverages when you’re bloated.
I’m going to be honest. This is the number one cause of gas and bloating that I come across, and that is constipation or altered GI motility. Essentially 100% of people who are constipated have gas and bloating… It’s one of the clues that forces me to consider the possibility of constipation, even if my patient has a bowel movement every day.
And yes, you can have a BM every day and still be constipated! The way this works is that if you incompletely empty your colon when you have a bowel movement, then you by definition are retaining stool. Pretend that 80% of your poop bombs get dropped on Siberia, but 20% are still on board the plane. If that keeps happening every day, that plane is going to be overloaded with bombs in a few days. Or in your case, you’ll be full of you know what!
SIDENOTE ON STOOL FREQUENCY: I think bowel regularity should be a vital sign. Like blood pressure, heart rate, temperature…. and how many bowel movements you have per day. I say this because bowel frequency does reflect the health of the microbiome in my opinion. 60% of your stool is made up of gut bacteria. Sixty percent! So when your gut is flourishing, you will go more often. And this is why people who eat a plant based diet have 2-3 healthy, formed bowel movements per day. Not just because the fiber is passing through, but even more so because the fiber is feeding the healthy bacteria in the gut and allowing them to multiply and thrive!
When GI motility slows down there is more gas production. It may be that the bugs are given unlimited time to process the food and extract every last bubble of gas from it. [REF: PLoS Pathog 11(6): e1004833] It may also be more complicated, in that we have recent studies showing us that methane gas directly affects GI motility, slowing it down. [REF: Neurogastroenterol Motil. 2012;24:185–190.] This suggests the possibility of a vicious cycle, where methane gas slows down GI motility, which causes constipation and further gas production… You see where I’m going with this.
Thankfully there is hope. I have found in my clinical experience that when you correct the constipation, generally the gas and bloating become much better. Some simple measures to consider that can help promote healthy bowel movements include drinking lots of water, regular cardiovascular exercise, and establishing a daily bowel routine.
What this means in terms of routine is that you sit on the toilet for 5 minutes every day at the same time (generally after breakfast), but don’t force yourself to go. After doing this for a few days in a row, your body will become conditioned to promote a bowel movement, even potentially revving up GI motility in anticipation of the (glorious) event!
For many people there’s benefit to adding a fiber supplement, some variety of stool softener that may include magnesium, and a probiotic. Of course, these should be done under the guidance of your doctor.
If we’re going to talk about altered GI motility and gas and bloating we absolutely have to include the gut microbiome in the equation here. Damage to the gut microbiome affects the way that we process our food. Have you noticed the rise in food sensitivities lately?!?
A loss of balance in our gut microbial ecosystem, which we refer to as dysbiosis (and others may call “leaky gut”), has been clearly associated with IBS and even with intestinal gas production. [REF: Gastroenterology. 2007 Jul;133(1):24-33] Therefore, our treatment plan to address gas and bloating should, of course, strive to optimize gut health and correct any dysbiosis.
Low hanging “fruit” in this scenario is the use of probiotics. There are now numerous studies to suggest that probiotics may be beneficial for intestinal bloating. Some specific strains that have been shown to be beneficial in studies include: Lactobacillus plantarum[REF: Am J Gastroenterol. 2000 May;95(5):1231-8.], which by the way is also found in fermented sauerkraut; Bifidobacterium infantis[REF: Gastroenterology. 2005;128:541–551]; and Lactobacillus acidophilusand Bifidobacterium lactis[REF: J Clin Gastroenterol. 2011;45:518–525]. In the setting of diarrhea predominant irritable bowel syndrome, VSL#3 has shown to improve bloating symptoms in both adults [REF: Neurogastroenterol Motil. 2005;17:687–696] and children [REF: Am J Gastroenterol. 2008;103:A134.]
A word of caution with probiotics… They are not entirely without risk. Dr. Satish Rao, an international expert on GI motility disorders, recently published a series of 30 patients who experienced “brain fog” with the use of probiotics. These patients generally had altered motility and small intestine bacterial overgrowth. Clearly additional study is needed to more clearly define this possibility, but based upon the available knowledge it appears that this is a potential adverse effect that can occur in patients with severely altered GI motility and possibly small intestine bacterial overgrowth. The point being that all things have potential side effects, and it’s important to be aware of this possibility so that the probiotics can be stopped immediately if there are any concerns.
This brings us to small intestine bacterial overgrowth, or SIBO. This is a large, complicated topic that is a moving target and has plenty of nuance. Suffice it to say that most of what you’ll read about SIBO on the internet is not accurate. Anytime a new disease comes along, there will be people who run away with it before the research is given a chance to catch up. In general, SIBO appears to be a form of dysbiosis. Most modern treatments for SIBO recommend destroying the excess bacterial, either with prescription antibiotics or herbal antimicrobials. Either way, the strategy is to destroy the bad guys. Although this is a huge topic, I generally do not agree with this strategy and instead believe that we should be supporting the good guys and trying to restore a healthy gut microbiome rather than bombing the bad guys, which has the potential to provide short term gain and long term loss due to further damage to the microbiome and worsening of dysbiosis. [REF: Front Microbiol. 2015; 6: 1543]
SIDENOTE ON THE GUT MICROBIOME: Tracing back to our prior discussion on methane causing impairment of gut motility and promoting bloating, there are unique organisms inside of us that are responsible for a large portion of the methane production, and they are called archaea. These are not bacteria, but instead ancient single cellular organisms that have been around for 4 billion years, predating oxygen on our planet. You’ll find them in rift vents at the bottom of the ocean, and inside your intestine. They are not affected by diet, remain relatively stable through life, and can be inherited from your mother. “Thanks Mom!” The bad news is that they produce methane gas, which slows motility, which leads to more archaea, which leads to more methane gas… And the cycle continues. At the same time, they may actually be beneficial and prevent heart disease! So we’re not at a point where we should necessarily be trying to destroy them in order to reduce gas and bloating, because there may be unintended consequences. But that said, the thing that appears to destroy archaea are statin drugs. [REF: PLoS Pathog 11(6): e1004833; World J Gastroenterol. 2014 Nov 21; 20(43): 16062–16078]
The last contributor to gas and bloating is the food that you eat! It comes as no surprise that people who are lactose intolerant with get intestinal gas if they drink too much milk. Alternatively, if someone isn’t used to eating Brussels sprouts and they overdo it then they, too, will be feeling the gas pains.
The key here is to be smart in your approach. There are some who advocate for eliminating gas producing foods. I will whole heartedly support the elimination of dairy, processed sugar, and artificial sweeteners from the diet. But I will not support the categorical elimination of healthy plant foods such as beans or even gluten. The problem with any elimination diet is that you are narrowing the diversity of your diet, and if you listened to Plant Proof Podcast episode 17 with Simon and I then you know that the number one predictor of a healthy gut is your microbiome. Science has my back on this one… When you eliminate foods, there is a loss of diversity. [REF: Gut Microbes. 2010 May-Jun; 1(3): 135–137; J Nutr. 2012;142(8):1510–1518; Gut. 2015;64(1):93–100].
The low FODMAPs diet bears mention here. FODMAPs are the fermentable parts of your food, often times found in plant foods and in many cases being extremely healthy. The challenge is that people who have dysbiosis may have difficulty processing these foods. I would make an analogy to being a weight lifter who breaks their arm and has it in a cast for 6 months. When the cast comes off, your arm is going to be atrophied and weak. You can’t go to the gym and bang out reps the way you used to! If you did, you might hurt yourself. So what do you do? You start really low and you work your strength up as tolerated until you get yourself back to the level of strength that you had before.
In similar fashion, if your gut is in a place of weakness and you are struggling to process plant based foods, namely the ones that contain FODMAPs, it doesn’t mean that you should abandon these foods and go back to eating meat. We know from our studies that while you may feel better in the short term, you are going to do damage to your microbiome in the long term with that strategy.
And again, you shouldn’t try to eliminate foods that cause symptoms. Once again, this may make you feel better in the short term but your gut will suffer in the long term with an elimination strategy.
Instead, you should use the low FODMAPs diet as a guide to help you identify which foods cause trouble for you. Rather than eliminating these foods, you should take the perspective of the weight lifter with the weak arm and acknowledge that it’s not going to be easy to build your strength up but that with moderation and slow introduction of these foods over time, you can get your gut back and absolutely be thriving on these types of foods.
I’ll share an anecdote with y’all from personal experience. Yesterday I ate a salad and literally threw 2 scoops each of four different types of beans onto this salad. Eight scoops of beans, y’all! And guess what? I didn’t feel gassy or bloated one bit. If anything, my stomach felt content, satiated, but still light. There was no afternoon hangover at all. I had a productive afternoon and didn’t need coffee or an energy drink to get me through, just water.
In sum, there are four major causes of gas and bloating: air that is swallowed, altered motility, damage to the microbiome, and the food that you choose to eat.
Keep your Space Suit Plant Proof,
Guest post by Will Bulsiewicz, MD MSCI (“Dr. B”)
Dr. Bulsiewicz is a gastroenterologist in Charleston, South Carolina, United States who believes that all health starts in the gut and that the secret to a healthy gut starts with the food that you eat.
Copyright 2018, Dr B Gut Health LLC. All rights reserved.
All content is provided for informational and educational purposes only. Please consult your healthcare provider in regards to recommendations and opinions that may relate to your medical condition or symptoms.
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