The Bloated Belly Whisperer: See Results Within a Week and Tame Digestive Distress Once and for All

PART I

INTRODUCTION

1.

Every Unhappy Belly Is Unhappy in Its Own Way: The Many Ways to Be Bloated

I STARTED MY CAREER AS a dietitian in a gastroenterology practice, fresh out of graduate school. I was light on real-life experience with people who had digestive problems, but I arrived full of textbook knowledge about all of the conditions I thought I’d encounter in my new job. I’d done my homework and read up about how to use diet to manage diarrhea and constipation, the pain of irritable bowel syndrome (IBS), and the heartburn associated with acid reflux. I felt ready to address whatever complaints my patients would bring.

But in the three years of my dietetics education and all those months spent training in the hospital, I had never once heard of the problem that patient after patient showed up complaining about: bloating.

Bloating? What did that even mean? It wasn’t a clinical condition I had ever learned about, and as far as I could tell, there was no official definition of what it was and how it should be treated. So each time patients told me they were bloated, I probed deeply to understand exactly what they meant. I asked them to describe the feeling of being bloated, what times of day it happened, what circumstances brought it on, how long it lasted, what made it better, what made it worse, whether it was painful, what it looked like, what other symptoms accompanied it. I needed to understand what this bloating thing was so that I could help fix it.

The more bloated patients I questioned, the more I came to understand that bloating was not a single, uniform experience that could be fixed with a one-size-fits-all solution. To some, bloating described a feeling of excessive fullness after eating—sometimes even after eating very little. To others, it described a distended belly that looked pregnant after eating. Some people belched when bloated; others farted. When bloating was accompanied by gas from either end, it might be painful … or not. And when bloating was painful, it was sometimes a pressure-type pain at the top of the stomach underneath the rib cage, a series of sharp gas pains on the sides, or a crampy pain below the belly button. Some bloating was relieved after going to the bathroom, and some wasn’t. Some people woke up feeling bloated, while others found that their bloating built as the day progressed. Bloating meant so many different things.

Bloating is a symptom of something else, not a medical condition unto itself, and after spending years in my medical nutrition practice interviewing thousands of patients with digestive problems, I came to recognize distinct patterns among the different types of bloating that patients presented. As these patterns became clear to me, I became better and better at matching a patient’s description of their bloating experience with its most likely underlying medical cause. I was then able to recommend tailored dietary advice that would address my patient’s unique brand of bloating and collaborate with their doctor to help them get the proper diagnosis and, when appropriate, the right treatment. My bloated patients were getting better, often within days of initiating the right diet regimen.

So I started writing about bloating online in an attempt to share what I’d learned with people who might not have access to a local dietitian who was highly specialized in digestive disorders. And that’s when the emails and calls started pouring in. I’ve heard from athletes in the Middle East battling bloating as they trained for endurance competitions and computer programmers from India who suffered tough digestive consequences when following their family’s traditional vegetarian diet. Mostly, though, I heard from countless people all across America who just couldn’t figure out why they were so darn bloated all the time, who felt that they’d tried everything and were desperate for a solution.

A grateful patient once remarked to me that I was like her bloating whisperer, and my husband got a good laugh about that nickname. But it stuck. While it’s certainly not a title I ever aspired to as a little girl fantasizing about what I’d be when I grew up, I embrace it nonetheless. As fate would have it, learning the secret language of bloating has become something of my calling in life, and this book is my way of sharing this knowledge with all the bloated bellies I won’t have occasion to meet personally. I hope it helps you or someone you love.

Every Unhappy Belly Is Unhappy in Its Own Way

A hundred and fifty years ago, the Russian author Leo Tolstoy wrote in his famous book Anna Karenina: Happy families are all alike; every unhappy family is unhappy in its own way. I think the same can be said about bellies. All happy bellies are alike; every unhappy belly is unhappy in its own way. What I mean by this is that people with happy bellies have digestive systems that function exactly as they’re supposed to. Their stomachs secrete the right amount of acid to get the digestion process under way efficiently. The muscle separating their stomach from their esophagus (food pipe) prevents acid or other stomach contents from refluxing backward. The nerves that control their stomachs and abdominal wall muscles direct these muscles to stretch just the right amount after eating a meal. The pacemaker cells that control stomach emptying keep food moving along into the intestines at a normal rate. Their stomachs and small intestines have sufficient levels of enzymes to break down food into absorbable nutrients effectively. Their small intestines harbor the right number of bacteria and fully absorb the nutrients in their food. Their large intestines (colons) keep undigested fiber and waste moving along at a regular pace, resulting in bathroom patterns that are as predictable as a Swiss train schedule.

Then there’s everyone else.

People with unhappy bellies have digestive systems that misbehave along any number of these dimensions. Bloating can result from dysfunction at one or more of these steps in the digestive process. The trick is to figure out the underlying cause of your bloating so that effective dietary—and, when appropriate, medical—remedies can be applied. After all, every bloated belly can be bloated in its own way.

When You Hear Hoofbeats, Look for Horses, Not Zebras

Most of my bloated patients have sought answers elsewhere before they ended up in my office. They’ve seen at least one doctor—and often several of them. They’ve consulted the internet and sometimes even seen a variety of alternative medicine practitioners. Often they’ve undergone many tests: colonoscopies, endoscopies, blood tests, stool tests, and ultrasounds. (All normal.) Sometimes they’ve also tried a variety of medications, supplements, gone gluten-free, and spent hundreds of dollars on food sensitivity tests, still to no avail. This lack of diagnosis and resolution despite what feels like an extensive search invariably leaves my patients with the impression that whatever is causing their problems must be pretty rare, exotic, and serious.

In reality, though, almost all of the bloated patients I see are afflicted by one of just ten reasonably common and easily diagnosable medical conditions. If your doctor or other health-care provider knows what she or he is looking for, a very detailed food and symptom history is often all it takes to narrow down the possibilities to one or two leading contenders. From there, you may be just a blood test, breath test, motility test, or diet trial away from the answers you’ve been looking for.

To be sure, there are plenty of rarer medical conditions that cause bloating—what we call zebras in the clinical world—that are not covered in this book. That’s why books like mine aren’t meant to be a substitute for personalized medical advice from a well-credentialed doctor. Some very serious medical conditions—including ovarian cancer—can first appear with a bloated, pregnant-looking belly—in that case, one that’s filling with fluid. If things don’t feel quite right, I encourage you to make an appointment to see a medical doctor to rule out the more serious stuff.

But the odds are still overwhelming that the medical explanation for your bloating—and the range of treatment options—is indeed contained somewhere in this book. You’ll understand what I mean when you encounter that one paragraph that describes your bloating experience to a T, and you feel as though I’m talking exactly about you.

This book describes those ten most common medical causes of bloating I encounter in my clinical practice—the horses rather than the zebras. Chapter 2 will help you navigate this book by introducing you to your digestive anatomy, equipping you with some vocabulary, and giving you a short quiz that will help you prioritize which chapters in parts 2 and 3 to start reading first. These chapters are grouped based on the origin of your bloating—stomach or intestines—and describe each type of bloating in great detail and its medical cause, including:

■ a detailed description of what that type of bloating feels like and other symptoms with which it’s typically associated;

■ an explanation of the underlying cause of that type of bloating;

■ a discussion of the types of tests a doctor might use to diagnose the cause;

■ a review of medical treatments commonly used to treat that type of bloating;

■ a review of dietary remedies that are effective for the condition; and

■ stories about patients of mine who experienced that type of bloating, with details about how they were diagnosed and then treated with diet, supplements, medication, and/or lifestyle changes.

The fourth part of the book goes deeper into the specifics of the various therapeutic diets I recommend for each type of bloating, with specific food lists and meal ideas. Rather than focus on laundry lists of everything you can’t eat, I focus more on teaching you what you can eat. That’s why I teamed up with world-class recipe developer Kristine Kidd, who created fifty fantastic recipes for this book that are tailored to the specifications required for each therapeutic diet. Kristine spent twenty years as food editor at Bon Appétit magazine and is no stranger to restricted diets herself; she’s got celiac disease and a garlic allergy. But when life hands a true foodie a couple of diet restrictions, she hits the kitchen and finds delicious work-arounds. In other words, don’t think for a minute that you’ll need to subsist on bland chicken and white rice for the rest of your life just to keep your bloating at bay!

Finally, I’ve included an encyclopedia of dietary supplements commonly used for digestive health, with a science-based evaluation of their effectiveness and safety. Because there is so much contradictory information on these products in circulation, I believe it’s important to offer an unbiased opinion about which products may be helpful and which products may be hype. For the record, I do not sell any dietary supplements; I don’t get commissions or kickbacks for referring people to supplement marketers. To avoid conflicts of interest, my clinical practice has a policy of refusing visits from pharmaceutical company representatives. If I green-light a product, it’s because I’ve seen published evidence—or have firsthand clinical experience—that it works and that it’s safe.

*   *   *

My intention is for you to use this book to facilitate a productive conversation with your doctor. I want to equip you with the descriptive language and relevant issues to mention during your appointment so that you can help your doctor home in on the problem most likely afflicting you. I also want to familiarize you with the diagnostic process associated with these common digestive disorders so that you won’t be surprised when your doctor suggests various tests, procedures, or medications. Most important to me as a dietitian, I want to empower you with effective nutritional remedies so that you can control your own symptoms. In some cases, dietary change alone can completely control bloating. In other cases, medical therapy may be called for in addition to diet. Your doctor will help you decide on the most appropriate plan for your individual case, and your belly will offer feedback as to what’s working best.

This book should not replace the advice of a doctor. I am not a doctor, and I cannot dispense medical diagnoses. Even if you recognize your brand of bloating to a T in this book, you cannot assume that the associated medical diagnosis applies to you without proper testing. Your doctor may look at other pieces of information, including family history, your personal medical history, blood test results, and any other symptoms you may be experiencing to determine whether there might be another cause of your bloating that should be investigated other than the one(s) I’ve suggested in this book. A good gastroenterologist is worth his or her weight in gold. Find one—and never let him or her go.

Finally, if your bloating is accompanied by any of the following symptoms, you should see a doctor promptly:

■ blood in your stool

■ difficulty swallowing

■ recurrent vomiting

■ unintentional weight loss of more than a few pounds

■ nutritional deficiencies, including anemia

■ sudden onset of constipation not related to a change in diet

■ fever

■ jaundice (yellowing of your skin and the whites of your eyes)

■ a pregnant-looking belly that is always equally distended, even when you wake up and/or haven’t eaten anything in hours (in other words, there are no circumstances under which it gets flatter)

■ persistent, excessive hiccuping

Now: If you’re ready to figure out how to get rid of that bloated belly of yours once and for all, then let’s move on to chapter 2 so you can learn the language and take my diagnostic quiz!

2.

How to Use This Book and Diagnostic Quiz (Don’t Skip This Chapter!)

IF YOU’RE READING THIS BOOK, then you’ve got a bloated belly in need of some answers. Your quickest path to finding them is to start reading the chapters most likely to pertain to you. To help steer you to the right ones, I’ve designed a quiz to help you identify the causes of bloating that are most consistent with your symptoms, and I’d recommend you start reading the chapters indicated by your quiz results. Once you recognize your brand of bloating in one of the chapters, you can skip ahead to part 4 to learn more about using fiber to manage your bloating, the therapeutic diet I recommend for your type of bloating, and what supplements may be helpful—or harmful.

Another, less direct approach would be to flip directly to the section of each chapter that describes what bloating from that condition feels like and to read each one consecutively until you find the description that feels like you’re reading about yourself. Then, start reading that chapter from the beginning, in its entirety, before moving on to part 4.

If you’re a fellow dietitian or other clinician using this book for continuing education, then get out your highlighter and read it start to finish. Pay special attention to the types of questions asked in the quiz below as key clues to your assessment detective work, and study the descriptions of bloating in each chapter; this will help you discern the unique characteristics of each type so you’ll recognize it readily when you see it.

Know the Lingo

I use a lot of terms throughout this book to describe different parts of your digestive system and its, ahem, outputs. Let’s take a moment to make sure we’re all on the same page with terminology.

■ I use the terms stool, bowel movement, and poop interchangeably to refer to solid waste or feces. It’s the stuff that comes out of your anus.

■ I use the term defecation interchangeably with pooping and moving your bowels.

■ I use the terms gut and bowel interchangeably to refer to the entirety of your intestines—both the small intestine and the colon combined. (Purists would correctly point out that, biologically speaking, gut should also include the stomach, but, for our purposes, we’re going to use the term more narrowly, in the way most of my patients think of it.)

■ I use the terms abdomen and belly interchangeably to refer to the entire midsection of your body where the digestive organs are housed. Looking from the outside, your abdomen’s borders start underneath the breastbone and end all the way down where your pubic area starts.

■ I use the terms intestinal gas, flatus, and farts interchangeably to refer to the gas that comes out of your anus. Your British grandmother might have called it wind.

■ I use the terms abdominal distension, distended, and bulge/bulging to refer to an increase in girth or circumference in your waistline, such as when your belly is protruding out from its flatter, emptier state. It’s what forces you to unbutton your pants when you’re bloated.

■ FOS is a common abbreviation that some doctors use when talking among themselves; it stands for full of stool. It describes a situation in which there is so much stool in your colon that it extends all the way back, practically right up to the junction with your small intestine. I use the terms FOS and backed up interchangeably. Do not confuse it with fructo-oligosaccharides, a type of carbohydrate that causes gas in susceptible folks as described in chapters 6 and 9 that is also sometimes referred to by this acronym.

Next, on to your anatomy. The location of your bloating and/or pain can often provide a clue as to its origin, so I’ve provided the diagrams on the following pages to help orient you to the organs that play a role in your digestive drama and show you where they reside. For starters, note that the abdomen is divided into four quadrants: the right upper and lower, and left upper and lower. The labels right and left refer to your right and left, so the labels will actually appear flipped on the diagrams (since the model is facing you). These quadrants are markers that doctors often use to describe the location of abdominal pain and discomfort.

The diagram here shows the outlines of the stomach, small intestine, and colon; they are shaded so you can see roughly where they dwell beneath external landmarks. The stomach, you may note, is quite high up—right underneath the rib cage and a bit over to your left (in the picture, it will be on the model’s left side, which is on your right side, since you are facing her). The small intestine is squarely in the middle of the belly, and the colon is pretty spread out: A portion of it lives in the center of the abdomen beneath the belly button, but segments of it actually snake up and down the perimeters of your abdominal cavity, crossing over above your small intestine.

If you’re feeling a bit rusty as to what each of these organs actually does, the list below offers a mini refresher. We’ll be talking a lot more about all of these in later chapters, where I’ll explain how they may play a role in various types of bloating.

■ ESOPHAGUS: The food pipe that carries swallowed food to your stomach. It’s separated from your stomach by a ringlike muscle, called a sphincter, that opens to let food into your stomach.

■ STOMACH: The food storage chamber and blender that liquefies your meals so they can continue on their digestive journey. It uses acid and strong muscular contractions to work its blending magic. If you were feeling your abdomen from the outside, your stomach would be toward the top and a little to your left, just underneath the breastbone, above the belly button.

■ PYLORUS: The muscular passageway separating your stomach from the next segment of the digestive tract, your small intestine.

■ SMALL INTESTINE: The part of your intestines where most of digestion and nutrient absorption takes place. This is where enzymes are either delivered or manufactured to break down foods into their building blocks so they can be absorbed. If you were feeling your abdomen from the outside, much of the small intestine is located right behind and beneath your belly button, front and center.

■ COLON: This is also called the large intestine, and it’s where fiber and any leftover undigested food, which is now waste, arrive after leaving the small intestine. Trillions of bacteria live in the colon, and they will feast on whatever undigested food arrives here. Your colon’s cells reabsorb water and some salt to help keep you hydrated, and this helps turn mushy waste into more-formed stools. If you were feeling your abdomen from the outside, the colon would cluster in the lower center portion of your abdomen beneath the belly button and then snake up the left side of your lower abdomen until just above your belly button, turning right and extending across your belly, then turning downward toward the right side of your abdomen. See the illustration here if you need help visualizing it.

■ RECTUM: This is the six- to eight-inch, straight, final segment of your colon, where stool waits when it’s ready to be eliminated.

■ ANUS: This is the strong, ringlike (sphincter) muscle at the end of your rectum that tightens to hold in your stool and loosens when you’re ready to let it pass. You can squeeze it voluntarily. In elementary school, you probably referred to your anus as your butthole. (In fact, you may still!)

All of these organs are pictured in the following diagram, so you can visualize how they relate to one another and where they lay underneath familiar landmarks, such as your breastbone, rib cage, and belly button.

The Bloated Belly Whisperer Quiz

I developed this quiz in collaboration with my gastroenterologist colleague Dr. Eric Goldstein as a simplified version of the detective process that goes on in our office when a new patient arrives complaining of being bloated. If you were sitting in my office, I’d pepper you with a variety of questions such as the ones following, first to help me isolate which section of your digestive tract the bloating seems to originate in, and then to narrow down the most likely one or two possibilities. While this nine-question quiz certainly doesn’t cover every medical possibility under the sun, it should certainly help focus your attention on a few of the most likely possibilities.

Two types of bloating that result from malabsorption that is disease-related—celiac disease and pancreatic insufficiency—are not included in the quiz. That is because a bloated belly from either of these conditions often takes a backseat to several more troubling symptoms: copious amounts of (foul-smelling) diarrhea; stomach pain; a significant amount of unintentional weight loss; unexplained vitamin and iron deficiencies. If this sounds familiar, then call a gastroenterologist to make an appointment and flip straight to chapter 10 while his or her office has you on hold. If chapter 10 doesn’t resonate with you, then check out chapter 8, on SIBO, next before trying out the quiz.

Directions for Taking the Quiz:

1. Read each question and identify the most fitting option(s) that best describe your bloating experience. For questions that allow it, you may choose more than one answer.

2. Alongside each answer, you will find one or more empty circles. Fill in all of the empty circles in the row alongside the answer(s) of your choice. You can use a separate piece of paper to mark your answers if you’re reading an ebook.

3. For any given question, if there are no answers provided that you feel are accurate for your situation, or if you are simply unsure of an answer, leave that question blank. Do not choose an answer that is the closest thing to something you experience if it is not an accurate representation of your experience.

4. When you are finished taking the quiz, count the total number of shaded boxes in each column, which are labeled A through H, and write the sum in the total box at the bottom of each column.

5. Make note of which column numbers have the highest number of shaded boxes. Look for the corresponding diagnosis and chapter/ page number in the key provided after the quiz. You should start reading the chapter/section that corresponds to the diagnosis with which you scored the most symptom matches.

6. After reading your top-ranked chapter/section, if you feel that it did not accurately describe your type of bloating, proceed to the chapter/section where you had the second-highest number of symptom matches. (And so