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The rise of bloating post pandemic
And the practical steps you can take if it's happening to you
In my gastroenterology clinic, I’ve always seen a lot of patients suffering from bloating. But there’s a new reason that patients are coming … it’s related to modern working practices and the pandemic, but it isn’t what you may think.
Abdominal Bloating - What is it?
Bloating is a feeling of tightness or pressure in the tummy, while distension is a visual swelling of the abdomen. Bloating and distension often occur together, but many patients suffer from one without the other.
Some people describe their bloating as being like the feeling of over-fullness you get after a very large meal. Bloating can range from a mildly uncomfortable feeling that passes quickly on its own, to an intensely uncomfortable and recurring problem that makes you want to reach for the medicine cabinet or seek out a doctor. An important thing to remember is that a bit of bloating can be part of our normal digestion. Gas production is a by-product of the digestive work of the trillions of bacteria in our gut microbiome.
This article will introduce some of the main reasons for bloating and tricks to help you identify the cause and manage it. Depending on the underlying cause, treatment can be relatively straightforward, involving simple changes to your diet and lifestyle, rather than medication or other invasive and expensive treatments.
How common is bloating?
It shouldn’t be a surprise to hear that almost everyone will experience bloating in some form at some point, given that gas production is a normal part of everyday digestion. It’s not usually considered a problem, though, when it’s occasional, mildly aggravating at worst and eases within a few hours of eating and drinking.
In the US, between 1 in 6 and 1 in 3 people (16-30%) report bloating problem symptoms and the figures are similar for other Western countries. It is a common symptom in irritable bowel syndrome (IBS), with one study demonstrating that 90% of IBS sufferers reported bloating and distension problems (more about IBS in future newsletters). Women experience chronic bloating more often than men, and have been found to be two to six times more likely than men to be diagnosed with IBS.
Why do I get it?
A short amount of extra time spent exploring the many factors that may be causing your bloating, can go a long way to arming you with insights and lasting interventions for reducing, and hopefully removing, your bloating problems (plus it can aid your doctor in helping you if you need to seek a medical review).
Here are the four main modifiable factors that commonly cause bloating:
What (and how!) you are eating and drinking:
Air-swallowing (“aerophagia”) occurs every single time we eat or drink. However when higher than usual volumes of air are swallowed, most often by eating or drinking too quickly or by chewing gum, sipping through a straw or smoking, this can lead to major bloating. If your bloating symptoms come on straight after eating, particularly if belching is an issue, then this may be your cause! What we drink can also impact our symptoms; fizzy drinks naturally contribute to surplus gas in the digestive system, especially if we are also drinking it whilst air-swallowing. Artificial sweeteners, such as in many low-calorie fizzy drinks and chewing gum, contain ingredients that cannot be absorbed in the gut. Anything that cannot be absorbed continues in the digestive tract until the colon, where the gut bacteria will ferment (feed on) it, a process which produces a lot of gas.
Overeating is an obvious cause of short-term bloating. This is the classic “indigestion bloat” which usually resolves a few hours after the meal. Regular overeating will result in weight gain which can also cause a longer lasting bloat. Food intolerance is when you have difficulty in digesting certain foods or ingredients. Lactose and gluten intolerance are the most well-known. For people with these intolerances, these undigested foodstuffs remain in the gut until they reach the colon where bacteria ferment them.
Counterintuitively, certain high fibre foods can cause bloating, because they can be tougher to break down and take longer to digest, so they ferment for longer in the digestive system. However, this definitely does not mean that high fibre foods should be avoided. Fibre is an essential source of fuel and nutrients for our good gut bacteria. Fibre also holds on to water, which can soften stool and support quicker bowel transit times. I talk about how best to manage this delicate balancing act further below.
There are different definitions for constipation. These include difficulty or straining at passing motion, passing stool that is hard, or going less frequently than usual or less than three times per week. At its simplest, though, constipation is the build-up of your bowel contents for a variety of reasons, that include diet, lifestyle, medications or an underlying condition, all of which may slow the usual speed (“motility”) at which digested food passes through the bowel system. And yes, this not only gives you the “backed up” feeling, but it also blocks the gas from coming out. To make things even worse, the poo also ferments, contributing to more gas and bloating.
The condition and sensitivity of you and your gut
An imbalance in the communities of good and potentially harmful bacteria that makeup the gut microbiome (known as dysbiosis) can cause excess gas production. This imbalance can be due to a variety of factors including stress, diet, medication such as antibiotics and other environmental or inflammatory insults generated in tandem with chronic conditions like irritable bowel disease (IBD).
But bloating isn’t always about excess gas. For some people, it is about abnormally heightened sensitivity to a normal amount of gas. So how does that happen? Well, the gut also has its own nerve system, called the enteric nervous system, which is increasingly referred to as our ‘second brain’. It has over half a billion nerve cells - more than the central nervous system. The vagus nerve connects the brain to the gut (and vice versa) and has many functions in our normal health. In certain situations, however, the vagus nerve can be overstimulated and this can cause sensitivity to normal stimuli such as food and gas. The cause of this “visceral hypersensitivity” of the enteric system is not currently well understood, but our emerging understanding of the ‘gut-brain axis’ shows that stress, emotional trauma and poor mental health all play a significant role.
Oestrogen and progesterone are both female hormones that influence the experience of bloating during the menstrual cycle. High oestrogen levels can increase fluid retention and contribute to an increased feeling of bloating, whilst elevated levels of progesterone can cause the muscles in the digestive tract to relax, which can reduce gut motility and slow down the movement of food, leading to constipation and bloating. These symptoms are worse in the days prior to menstruation. Some studies have also suggested that female sex hormones cause increased nerve sensitivity and pain responses, and so women may experience a bloated sensation and discomfort without actually having too much gas at all.
Practical steps you can take to reduce your bloating
So now I’ve covered some of the key everyday causes of bloating, let’s look at some simple steps you can take to identify and modify the factors that are causing your bloating:
1. Think about how you’re eating and drinking
And we’ve got to the first reason why I’m seeing more bloated patients in my clinic these days! Modern working practices mean up to 60% of us eat at our desk, in front of the computer. We already know that this absent-minded eating leads to a higher calorie intake and more frequent snacking. But gobbling down your lunch as quickly as possible, like it’s a chore, also leads to significant aerophagia (air-swallowing). Observing how you eat and drink (and why) can help identify ways to change things, to reduce your bloating due to aerophagia. Tricks to reduce air swallowing include:
Making sure you keep your mouth closed when you chew and eating smaller amounts more slowly. Tilting your chin towards your chest when swallowing can help as well.
Eating whilst sitting up, rather than whilst ‘hunched’ over a desk at work, or perhaps whilst watching TV in bed.
Eating together! This has many health and social benefits but home working post-pandemic has reduced this practice. One advantage of communal meal time (and communal time in general) is the sharing of the microbiome. This gets depleted in socially isolated people.
Try to get into a good routine and eat your meals at roughly the same time.
2. Think about what you’re eating
Keep a food diary that helps you keep tabs on foods that may be aggravating your bloating. Once possible culprits have been identified, you (or your doctor or dietician if you have an existing condition where your dietary intake requires monitoring) can experiment with removing these and reintroducing them gradually into your diet in smaller quantities and seeing what happens.
The following are “frequent offenders” for causing bloating and so a trial cutting out these might be a good first step: artificial sweeteners, non-fermented dairy (cheese, butter and yoghurt are okay, as the lactose is mostly removed in the production processes) and wheat-containing products.
Where high fibre foods are found to be contributing to your symptoms, it may be worth speaking to an expert to get the optimum balance and approach. As we discussed earlier, fibre plays a varied and highly beneficial role in overall gut health and so is not something you want to cut out dramatically or long term if possible.
The low FODMAP diet (more in later articles) is a dietician guided diet that can cut out the foods that cause the most bloating, whilst still maintaining fibre in your diet. Again, the long term goal is to reintroduce gradually.
If you use chewing gum (and particularly if you chew gum with an open mouth) is this something you can do less or stop altogether to see what effect it has on your symptoms?
3. Resolve constipation
And here’s the second thing I’ve been seeing more of. For many people the daily commute was the way of hitting the 10,000 per day step count. An exercise session for free. So if you work from home every day now, or if you’re doing hybrid working and travelling less to the office, then this easy source of exercise has gone. Body movement is key to bowel movement, by speeding up the passage of bowel contents through the colon. If this “backed up” bloating rings a bell with you, try the following steps:
Increase fibre intake - bear in mind the points made above about getting the balance right, given that fibre can have both a positive and negative impact on bloating symptoms.
Stay well hydrated. Drinking plenty of water aids the composition of your stool and the overall motility (speed) of the digestive system.
Exercise regularly. Movement is known to stimulate bowel movement, so if exercising is not your thing, at least make sure you avoid being completely sedentary for long periods.
Use the bathroom when needed. Ignoring the need to go to the bathroom can increase your risk of constipation. The longer that stool sits in your colon, the more water is absorbed from it, and the harder it becomes to go.
Manage stress. Gut sensitivity can be directly influenced by stress, so making sure you have ways to switch off and relax is an important part of any approach.
Review your regular medicine with your doctor or pharmacist. Lots of drugs, including opiates and antidepressants, can cause constipation.
Laxatives or stool softeners. If the above measures fail to provide relief, these can be considered under the guidance of a health professional.
If constipation persists or is accompanied by severe pain, bleeding, or other symptoms, it's important to seek medical attention.
4. Treat gut hypersensitivity
Dietary changes. Identify then avoid (or at least reduce) foods that trigger symptoms. The overall goal is for a varied and well-balanced diet, and so if the food that you are cutting out is a healthy, whole food that is causing you bloating, then the aim is to re-introduce it gradually to give your gut microbes time to adapt.
Manage stress. Alongside taking time to switch off and relax, making a conscious effort to identify and eliminate (or at least modify) external stressors like a toxic working environment or relationship can help. Where the source of the stress may be internal (anxiety, depression) or unknown, psychological or talking therapies, such as CBT (Cognitive Behavioural Therapy), have an increasing role to play in the management of chronic gut symptoms.
Medications such as antispasmodics can help reduce the muscle contractions in your gut that contribute to pain and visceral hypersensitivity. In addition, your doctor may wish to prescribe anti-depressant drugs, which can be highly effective for treating troublesome functional gut symptoms.
What if none of this sounds like my bloating?
There are many other causes of bloating and distension which we haven’t covered here, some of which can be serious. If you are experiencing severe bloating problems that don’t improve, occur with other symptoms or that affect your quality of life, it is important to speak to your doctor in a timely fashion to determine the underlying cause and develop an appropriate treatment plan.
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See you next week.
Dr Philip Hendy
The Better Gut Doctor
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