“My belly looks like I’m pregnant.” As a gastroenterologist, who treats bloating, I hear this daily. I hear it from women who’ve been pregnant and those who have not. I even hear it from my male patients—I typically respond to the guys with a Different Strokes‘,”Whatchu talking about Willis?” Bloating is a common problem with common causes. For most people, bloating is just an annoying sensation of fullness. For others, it can be a distressing source of pain and mental anguish. Unfortunately, I’ve even seen spouses ridicule their partner’s appearance for bloating. Although bloating is a frequent complaint, I often see patients who’ve had previous doctors that never addressed any of the common dietary causes of bloating. Many of these patients had colonoscopies, upper endoscopies, and CT scans to evaluate bloating. They’ve had every test a doctor can order when the solution was as simple as avoiding gum-chewing. I’m not claiming to be the ‘belly whisperer,’ but avoiding, or at least reducing, certain foods has a helped a significant portion of my patients. I want to discuss bloating and a share few simple dietary approaches for addressing it.
What is bloating?
I am a fan of people understanding helpful terms for describing their symptoms. I have no expectation for the average person to turn into a medical dictionary, but there’s value in equipping people with the words to clearly express what they are experiencing. I’ve waded through my fair share of murky metaphors to understand someone’s symptoms—let’s just say most people aren’t poets. I respect the effort, but understanding some basic terminology can be helpful. According to a recent review article in the American Journal of Gastroenterology, bloating is defined as “a feeling of increased abdominal pressure that may or may not be accompanied by objective abdominal distension, i.e., visible enlargement of the waist.” Distension refers to the physical swelling or protrusion of the abdomen. Similarly, distension may occur without the sensation of bloating. In reality, people, even doctors, use these terms interchangeably. Despite their interchangeable use, being aware of the distinction between these terms may facilitate a mutual understanding during the patient-physician conversation. It’s also worth noting that bloating often occurs with gas, but bloating and gas are not the same. If you have issues with passing gas, merely saying ‘passing gas’ or ‘flatulence’ is more appropriate.
6 common dietary causes of bloating
There are plenty of reasons for bloating. Diet, constipation, and irritable bowel syndrome are the three most common reasons for bloating that I encounter. These are all benign causes that are typically easily treated. I have seen people with bloating as a symptom of an underlying medical condition—these are generally rare cases. In these scenarios, other symptoms usually accompany the bloating. For people whose sole complaint is bloating, my assessment always begins with discussing eating/drinking habits. This list represents the six most common diet-related causes of bloating that I encounter.
I’ve seen gum-chewing contribute to bloating so frequently that I refer to patients who chew gum in the clinic while talking to me about bloating as having the “gum-chewing sign.” Gum-chewing can trigger bloating for a couple of different reasons. Swallowing air unconsciously while chewing gum is one of the main reasons it causes bloating. The gastrointestinal tract absorbs most of the oxygen and carbon dioxide in swallowed air, but the nitrogen in air is poorly absorbed and generates the sensation of bloating as it passes through the body. I’ve seen bloating miraculously improve in relentless gum-chewers once they cut back or stop chewing gum. Be careful, switching over to breath mints as an alternative to gum chewing can also lead to bloating for similar reasons.
Using sugar substitutes
Another reason gum contributes to bloating is that most gum is “sugar-free.” “Sugar-free” just means that the gum contains artificial sweeteners that are poorly absorbed by your digestive tract. These sweeteners aren’t only found in gum—they’re in almost every low calorie, diet, sugar-free product you can imagine since they don’t contribute many calories due to their inefficient absorption. You can spot these artificial sweeteners by looking closely at a product’s ingredients. Typically the fake sugars end in ‘-ol.’ Common examples include sorbitol, erythritol, xylitol, etc. These artificial sweeteners contribute to bloating by not being absorbed in the intestine and ending up in the colon, the home of most of the gut’s bacteria. These bacteria can break down the artificial sweeteners and produce gas as a waste product through a process called fermentation. Too much fermentation can lead to the sensation of bloating and even some flatulence.
Got Milk? You may have bloating to go along with it. Cow’s milk is rich in the sugar lactose. Lactose is also common in soft cheeses. Yogurt and aged, hard cheeses have lesser amounts lactose. There’s nothing notably harmful about lactose itself. The issue is that many people are lactose intolerant, especially people of Asian or African descent. Lactose intolerance occurs when the enzyme lactase, a key component that makes lactose absorbable, is absent or reduced in the digestive tract. Lactase is typically abundant in babies to help digest breast milk, but it gradually dissipates as we age. When lactase is absent or reduced, lactose is poorly absorbed, giving the gut’s bacteria the opportunity to convert it into gas, just like artificial sweeteners.
Not all lactose intolerance was created equal. Some people can drink milk and feel slightly bloated or gassy, whereas others may have a marathon session of the “runs” after a small bowl of cereal. Aside from the unfortunate few who have those marathon sessions, most people aren’t aware of their lactose intolerance since few people undergo a formal lactose intolerance evaluation. Additionally, the intolerance can begin in adulthood without an apparent precipitating cause.
I’ve seen patients who drink liters of milk daily have complete resolution of their bloating with switching to non-dairy alternatives or lactose-free milk. If you are suffering from bloating, you should consider lactose intolerance as a possibility. If you are thinking about trying non-dairy options, consider trying carrageenan free versions or making your own milk from almonds, walnuts, etc.
Excessive intake of carbonated beverages
Pop, soda, or coke—it doesn’t make a difference which name you prefer (As a Mid-westerner, pop is definitely the correct term)—carbonated beverages, including sparkling water, lead to bloating due to the carbonation. Carbon dioxide is the gas that makes these beverages sparkle. When you drink a lot of carbonated drinks, you are simultaneously taking in a lot of gas. This gas is a common culprit behind bloated sensations. One occasional can of pop may not be enough to cause bloating. However, for those bloated souls who drink liters daily, you may want cut back. Plus, too much pop is terrible for your overall health.
Eating quickly or eating large amounts of foods
I experience bloating every Thanksgiving and every time I go to New Orleans. Eating quickly and eating in large amounts will fill up your stomach and make you feel bloated. If you are a fast eater, try slowing down. Drinking liquids while eating may also help you feel less bloated because liquids help food empty from the stomach. Also, staying away from fatty foods may decrease bloating since these foods empty from the stomach slowly.
A diet high in FODMAP-containing foods
“Beans, beans, the magical fruit, the more you eat, the more you toot.” That popular kid’s song is rooted in truth because beans containing poorly absorbable carbohydrates and starches called FODMAPs. FODMAP is an acronym that stands for Fermentable Oligo-saccharides, Di-saccharides, Mono-saccharides, and Polyols. Don’t get too intimidated by the chemical terms, there won’t be a quiz at the end of this post. You should be aware that these poorly absorbed sugars are common in fruits and veggies such as beans, apples, onions, broccoli, etc. FODMAP containing foods are usually extremely healthy despite their contributions to bloating. I frequently put people on a low FODMAP diet depending on the severity of their bloating and whether their symptoms resolve with avoiding the other dietary culprits associated with bloating. Given the health benefits of FODMAP containing foods, a low FODMAP diet only serves as a temporary intervention and should not be used for extended periods of time. The diet is relatively difficult to follow for most people. Having a dietician guide your through a low FODMAP diet is helpful. I am blessed because I get to work with some of the best dietitians in the country. Here is a resource for a low FODMAP diet to help you get started.
How to approach bloating initially and when to see a doctor
A one-size-fits-all approach doesn’t really work in medicine—everyone is different. Despite these variations, addressing the dietary culprits above and treating any underlying constipation are excellent starting points for managing bloating. With the treatment of constipation, I typically tell people with bloating to stay away from lactulose (unless they have cirrhosis of the liver) and fermentable fiber supplements since both of these can worsen bloating. As I mentioned previously, bloating can be symptom of an underlying medical condition, so there are times when involving a physician or gastroenterologist is necessary. Here are a few signs that should encourage you to discuss your symptoms with a doctor:
- If you feel like you need to talk to a doctor, you probably should.
- Experiencing additional symptoms such as bloody stools, diarrhea, severe abdominal pain, nausea/vomiting, severe constipation, weight loss, decreased appetite, changes in your menstrual cycle, and jaundice.
- Bloating that is not responding to dietary changes and treating constipation.
- Having a family history of cancers of the gastrointestinal tract
- If you have had surgeries on your gi tract (acid reflux surgeries, gastric bypass, etc.)
What’s the bottom line?
- Bloating and distension can frequently occur together.
- If you are experiencing bloating, adjusting your diet may improve your symptoms
- Have low threshold for discussing your bloating with a doctor, especially if you fail to improve with cutting back on foods associated with bloating.
- If you think you are pregnant, check a pregnancy test
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- Malagelada JR, Accarino A, Azpiroz F. Bloating and Abdominal Distension: Old
Misconceptions and Current Knowledge. Am J Gastroenterol. 2017