“Why am I so bloated?” That’s a question I hear nearly every day in my gastroenterology practice. Over the course of my medical career, I’ve gone from helping a handful of women a week with bloating, sluggish fullness, and constipation to feeling like I’m dealing with a full-on epidemic. For many, the symptoms are daily, relentless, and life altering, but even when they’re not that severe, they’re always annoying.
The causes of bloating vary tremendously, from common benign conditions to rare, life-threatening illnesses. Some may be connected to behaviors you don’t even think about. (Do you talk with your mouth full? You could be swallowing enough air to go up a dress size!) Some you may have heard of but need more information and aren’t quite sure whether you should be worried. (Is celiac disease the same as gluten intolerance?) Some may surprise you. (Taking antacids to settle your stomach can make your jeans un-zippable!) In this book you’ll learn about these issues and many more, including how to tell if your bloating is serious . . . or if you’re just seriously bloated.
Your Inner Doctor
The information in this book incorporates aspects of both conventional and alternative medicine to create an intuitive, commonsense approach to digestive wellness. The goal is not to scare you into having an unnecessary procedure or taking a pill you don’t need, but to encourage you to explore the cause of your symptoms and to implement some useful basic strategies, many of which are already in your toolbox.
I believe that buried deep beneath the information overload we all receive from consumer marketing is our own innate sense of what we need to make ourselves well. I like to call it our “inner doctor.” This book will help you access that deep inner sense, building your understanding by providing reliable information on what helps and what hinders when it comes to your digestive health.
Many digestive problems that a decade ago we thought were “all in people’s heads” we now know are caused by very real gastrointestinal disturbances—conditions like bacterial overgrowth and gluten intolerance. I refuse to believe that millions of women who suffer from bloating but don’t have a diagnosis are “crazy” or “just stressed out.” I’ve seen how often, by thinking outside the box, we’re able to find both the problem and the remedy.
I want to help you trust your inner doctor. If you think there’s something going on, there probably is, and you need to keep searching till you find the right person who can help you figure it out. They may not always have a white coat on and an MD behind their name. Much of what I know I’ve learned from patients, nutritionists, biofeedback practitioners, holistic health coaches, naturopathic doctors, acupuncturists, farmers, and even my yoga instructor. I hope the information in this book will serve as a guide to help you understand what’s going on in your body and offer you some real solutions.
My Promise to You
I’ve spent a lot of time inside the digestive tract, observing what’s gone wrong and why. This book contains the information I think is most important to share, in short, digestible (pardon the pun) chapters. When I don’t know something, I’ll tell you I don’t know. When I think a particular practice is shady or suspect, I’ll tell you that, too. I’ll give you the information that has been helping my patients make real improvements in their digestive health—including a comprehensive 10-Day Gutbliss Plan to heal yourself from the inside out, based on twenty years of experience. It’s helped thousands of women tighten their tummies and end their discomfort. Many have reported a surge in energy and mood, too! This easy-to-follow integrative approach to digestive wellness will help you banish bloat, flush toxins, and dump your digestive baggage—the healthy way.
The world these days can be an intimidating place. We worry about environmental toxins, drugs can be dangerous, and Mother Nature would hardly recognize much of what’s available at the grocery store. But left to its own devices, the human body is still a marvel, with an amazing capacity to recover and heal itself, particularly when injurious practices are identified and stopped. My sincere hope is that you’re able to use the information in this book to find your own gutbliss and that when you and I meet, it’ll be at the farmer’s market or on the yoga mat, and not in my office.
Finding My Gutbliss
In 2004 I decided to leave the hallowed halls of academia and set up my own practice. Georgetown Hospital had been my first job when I finished my training in New York in 1997, but after almost eight years, hospital-based medicine no longer seemed to have the answers my patients and I were looking for. I owed a lot to the institution—my career had flourished there: I had a sixteen-page résumé of published articles, book chapters, and speaking engagements throughout the United States and Europe; I had helped to train over thirty gastroenterologists; I had colleagues I respected and admired; and I enjoyed the teaching opportunities. My salary was more than generous. My professional life was bountiful and I should have been happy, but I wasn’t. I had lost my faith.
Over the years my priorities had gradually shifted from high-tech procedures that diagnose and treat disease to no-tech lifestyle modifications that prevent them. It was becoming difficult for me to emphasize the industry message in my speaking and teaching that colonoscopy saves lives (which it does) without giving equal billing to what I had come to believe: that diet and lifestyle were more important in achieving and maintaining digestive health than any procedure I could recommend. Philosophically, I felt a lack of alignment. I was interested in an integrative and more holistic approach to digestive diseases and I wanted that to be part of my message. My colleagues seemed more interested in technical innovation. Their mission and approach hadn’t changed, but mine had.
The practice of gastroenterology had also changed and was feeling more and more like a business venture, with the patients as the consumers and endoscopy as the product. Many gastroenterologists now owned their own endoscopy units, as well as the pathology services used to process their biopsy specimens. While this allowed for better quality control and closer collaboration, it also greatly incentivized doctors to do more procedures and biopsies.
The gastroenterologists I knew were people who cared deeply about their patients, but many of them struck me as overly committed to doing procedures. I wanted to provide patients with equally relevant lifesaving information—like the fact that switching to a plant-based diet can cut your risk for colon cancer in half; or that exercise and a low-fat diet can prevent gallstones—not just perform procedures.
A screening colonoscopy takes from fifteen to thirty minutes to perform. The reimbursement to the physician when done in an outpatient facility that they own can be several times what they make for an office visit of the same length. It’s not hard to do the math and see why the nature of my specialty was changing. The economics simply don’t encourage problem solving and exploration beyond the endoscope.
At the same time that gastroenterologists are being incentivized to do more procedures and spend less time talking to patients, the nature of digestive illnesses is changing, too. We’re seeing more conditions related to diet, lifestyle, and environmental factors, and diagnosing and treating those conditions requires more than just a quick endoscopy.
Not all gastroenterologists are singularly focused on the revenue stream that endoscopic procedures like colonoscopies provide. Many have the kind of medical practices that embrace more integrative solutions, educating their patients about the importance of dietary intervention and other preventive measures, and exploring alternative diagnoses, while performing endoscopy in a responsible manner.
But providing comprehensive digestive care is not always easy or straightforward. It requires extra time for us to sit down and talk with patients about what they’re eating and how they’re living. It requires research into things we’re unfamiliar with, and consideration of the possibility that maybe our colleagues in the alternative medicine world know a thing or two. That kind of care means a lot of additional education in things we learned nothing about in medical school and that we can’t touch and see with our endoscopes.
Thanks to the Internet, some patients know more about their digestive disorder than their gastroenterologist, although they may not have the tools and context that allow them to manage it. So they’re turning to their yoga instructors, massage therapists, life coaches, and social network for medical advice. Visits to alternative practitioners outnumber visits to conventional doctors four to one, even though they usually aren’t covered by insurance. Conventional gastroenterology, while flourishing in the realm of advanced procedures and screening of healthy populations, is falling short in providing people with what they really need: reliable information on how to achieve and maintain digestive wellness.
I knew these were vitally important issues that needed to be addressed with patients. But I was still spending most of my time doing procedures and prescribing complicated drugs with lots of side effects. My philosophy had changed; now my practice needed to change, too.
An Integrative Solution
In 2004, while pregnant with my first child and renovating a house down to the studs, I decided to open a practice that was more in line with my philosophy of an integrative approach to digestive disease. In addition to providing patients with resources in nutrition, stress reduction, and exercise, there were three basic principles I wanted to adhere to:
• Ensure sufficient time with my patients to explore problems in detail.
• Abide by my belief that most people aren’t crazy, even if their symptoms don’t always make sense.
• Make and keep a commitment to think outside the box.
I gave notice at Georgetown, found an ideal location, applied for a tax ID number, and opened my doors. I called the practice the Digestive Center for Women, although it turns out women aren’t the only ones interested in more integrative solutions to their digestive troubles, and men constitute about 20 percent of our patients. I remained a voluntary faculty member at Georgetown and continued to perform procedures at the hospital, although the number of procedures was much lower than what I had previously been doing.
Slowly but surely, patients came.
Many of them had already been evaluated and diagnosed by very competent gastroenterologists. They didn’t come because I was smarter than their last doctor; they came to have a dialogue and to get ideas and feedback on what they could do to improve their digestive health. We talked in detail about symptoms, test results, nutrition, and stress and the possible relationship among them. I didn’t always have the answers, but I usually knew where to look.
I built an integrative practice that relied a great deal on the excellent skills of my collaborators: a biofeedback practitioner, integrative nutritionists, exercise physiologists, and referrals to practitioners in counseling, acupuncture, and massage.
I continued to see patients with complex problems related to Crohn’s disease and ulcerative colitis, which had been my area of expertise at Georgetown. I found that these patients, too, benefited greatly from an integrative approach that included nutritional intervention and stress reduction.
My focus shifted from scientific papers in medical journals on the role of endoscopy to articles in yoga, health, and women’s magazines on the role of diet and lifestyle in preventing and treating digestive diseases. My talks at national gastroenterology meetings were now about obesity and the gastroenterology practice of the future, which would incorporate cooking classes, biofeedback, meditation workshops, and exercise sessions, not just endoscopy facilities.
I was grateful for the opportunity to merge my personal beliefs with my professional practice and engage a larger audience with what I believed to be the truth about digestive health. I decided to write a book to share what I had learned over the years about how to achieve a blissful gut, and I enthusiastically began work on the outline and manuscript.
On the last day of my tenure on the governing board of the American Society for Gastrointestinal Endoscopy (ASGE), I pitched an idea for a nonprofit called Gutrunners, which would focus on improving digestive health through educating the public about the benefits of nutrition and exercise. I was delighted when the ASGE agreed to be the founding sponsor and provided a loan as seed money. Gutrunners incorporated as a nonprofit in the state of Maryland and I dove into my new role as executive director, race director, and fund-raiser, arranging races at national gastroenterology conferences and meeting with potential sponsors and participants. Life was very busy but filled with meaningful work that I loved.
I had witnessed firsthand with many of my patients what happened when work-life balance was disrupted, but, ironically, I failed to see the warning signs in my own life.
Although my practice was incredibly rewarding, the decrease in the number of lucrative procedures relative to what I’d been doing at Georgetown and the fact that I was in solo practice (i.e., there was no one with whom to share expenses) meant a drop in income.
My days at the office were long and I spent my nights working on the book, writing articles, and trying to get Gutrunners off the ground. It was thrilling to have founded an organization dedicated to the principles I believed in, but now I was responsible for running it, and in the hole personally for the loan amount, which was to be repaid to the ASGE within five years.
My schedule was a brutal six a.m.-to-midnight routine that was difficult to maintain. My leisurely daily runs and regular yoga practice fell by the wayside. I now only had time for occasional weekend warrior workouts that left me sore the next day and did little to improve my fitness level. My daughter was the joy of my life, but there was never enough time with her.
I had grown up eating fresh produce from my grandfather’s farm and home-cooked meals every day and had continued those traditions in our household. But now dinner was frequently takeout and not always healthy. I didn’t have time for lunch most days and was eating way too much sugary and starchy food for quick energy. Some days half my calories came from cookies. The more sugar I ate, the more of it I craved, and my consumption increased dramatically. I’m not a coffee drinker so sugar became my caffeine, causing wide swings in my mood and blood sugar, which left me feeling even more tired.
I also started drinking champagne at night while I worked. I’d not been much of a drinker in college, medical school, or the years since, but as life got busier and more stressful, it became part of my routine to have a glass or two after dinner. The sugar in the champagne was what attracted me. It opened the floodgates for more cravings, so there was often a sweet dessert happening along with the champagne. The late nights and excessive sugar gave me a terrible headache the next day and left me bleary-eyed and exhausted.
Here I was, preaching attention to proper nutrition, leisure, stress reduction, and exercise to my patients—and I was having a hard time practicing what I preached.
Out of Balance
I’d never had any serious medical problems, and my only experience as a patient had been with labor and delivery, so I was unprepared for poor health when it finally arrived. And because I still thought of myself as a healthy person with good habits, it took me a while to recognize what was going on.
For the first time in my life, I was bloated. And constipated. It gets worse: I had persistent rectal itching at night that drove me absolutely crazy. At first I thought the itching was from a hemorrhoid, but close inspection proved that diagnosis to be incorrect. Then I was sure it must be pinworms, since night itching is a characteristic symptom, but that wasn’t what I had, either.
Other symptoms that I developed included rosacea (misdiagnosed as acne), chronic sinus infections, fatigue, brain fog, dark circles under my eyes, thinning hair, a ten-pound weight gain, food intolerances (especially to dairy and nuts), and body odor. I know this last one is somewhat subjective, but even after running ten miles or doing ninety minutes of hot yoga, my sweat had previously been profuse but odorless.
I looked and felt terrible. And despite all my knowledge, or maybe because of it (a subconscious belief that sickness happens to other people, not to us, can be a common trait among physicians), it took me several months to figure out the diagnosis. I had severe bacterial imbalance, also known as dysbiosis. My starchy, sugary diet, excessive dessert, after-dinner champagne, lack of exercise, and skyrocketing stress had altered the delicate balance of “good” and “bad” bacteria in my gut, and I was experiencing the fallout. My less-than-healthy diet and lifestyle had changed my entire body chemistry, and the results were manifest both internally (bloating and constipation) and externally (rosacea and hair thinning). After a sugar binge I could feel my face burning as the rosacea flared and the rectal itching became intense as my gut bacteria shifted. Clumps of hair filled the shower drain, and I was exhausted all the time.
As varied and disparate as they seemed, my symptoms were all a result of dysbiosis, except for the brain fog and episodes of extreme fatigue, which turned out to be manifestations of gluten sensitivity.
How I Found My Gutbliss
As disconcerting as it was to lose control of my own health, the experience was valuable and meaningful. It affirmed some of the difficult choices I’d made about the kind of medical practice I believed in and highlighted a lot of the shortcomings of gastroenterology as it’s practiced today. Dysbiosis can’t be detected or treated with an endoscopic procedure. It’s the sort of diagnosis that can only be made through a careful evaluation of someone’s history, as well as the ability to recognize the relationship among a number of ostensibly unrelated symptoms. It’s a condition that might easily escape conventional detection and be written off as stress or anxiety.
In this book, you’ll learn a lot more about dysbiosis and how to recognize and address it. Having firsthand experience with a condition like this has given me a renewed sense of purpose. It has made me more confident than ever that the future of medicine depends on doctors’ willingness to listen, to use food and fitness as tools in the pursuit of health, and to think outside the proverbial prescription and procedure box. Lifestyle-related conditions such as dysbiosis significantly disrupt your quality of life yet can’t be detected through a standard procedure. They represent the new kind of digestive illness so prevalent today. Dysbiosis and conditions such as food allergies, leaky gut, parasitic infections, candida overgrowth, gluten intolerance, and many others can lead to frustration and self-doubt for undiagnosed patients stumbling around in the dark looking for answers.
Even after I realized the cause of my symptoms, it took me a while to implement the changes I needed to feel better. Despite my good dietary foundation of fruits and vegetables, the addictive nature of some of the not-so-healthy food I was eating had taken hold, and it was hard to let go. I continued to experiment with gluten, avoiding it for several days and then eating a bagel to see what would happen. Invariably the symptoms of brain fog and intense fatigue would return. I’d do well avoiding dessert and alcohol during the week but continued to indulge on the weekends, paying the price with an increase in symptoms and the slow burn of suboptimal health.
The strategy that ultimately worked for me was to finally completely eliminate the foods I knew were causing my symptoms and affecting my health. It was easy to identify what those foods were: I felt awful after consuming them, and they were the same culprits responsible for many of my patients’ digestive problems. Incremental change may seem like less of a challenge, but it can be hard to maintain because it takes a while before you experience a tangible difference in your symptoms, and so people frequently give up. I knew from experience with my patients that it took about ten days for a dietary change to be experienced physically and also for it to become psychologically easier to maintain. Withdrawal symptoms from sugar and other carbohydrates are the most prominent in the first week and then tend to become less intense. Going through the process of habit change myself helped me better understand and help my patients as they did the same.
I found my gutbliss by getting rid of GAS: gluten, alcohol, and sugary treats. I also slowed things down a little at work and at home and rediscovered the healthful habits that had previously sustained me. Green juices instead of champagne kept me company at night, and a few pieces of dark chocolate became my new splurge. I had more energy in the mornings to start running and practicing yoga again, and my daughter took on the role of sous-chef as we spent time together in the kitchen whipping up healthy meals. With the help of a good probiotic, more kale than I ever thought I could eat, regular exercise, and eliminating GAS, the dysbiosis and all its symptoms gradually improved and I got back to looking and feeling healthy and strong. These days I enjoy the occasional dessert, croissant, or glass of champagne, but I pay attention to how I nourish myself, and my diet, as well as my digestive tract, feels balanced and joyful.
The Journey Continues . . . Together
Gutbliss is truly a journey, not a destination, and I continue to explore what feels best and is the right path for me. There’s still lots on my to-do list, including deepening my yoga practice, completing a full Ironman Triathlon, experimenting with veganism, moving my gastroenterology practice to a farm, and learning to play the guitar, but I appreciate where I am and the good health that I have right now.
We live differently but we suffer similarly. My sincere hope is that if you’re suffering from bloating or any form of digestive distress, you’ll find your gutbliss within the pages of this book.