What's new: October 2013

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(YvesHerman/Reuters; TobyMelville/Reuters; DeanFosdick/AP)

Robynne Chutkan, MD, is an integrative gastroenterologist and founder of
the Digestive Center for Women, just outside of Washington, D.C. She
trained at Columbia University and is on faculty at Georgetown, but her
approach to practicing medicine and understanding disease is more
holistic than many specialists with academic backgrounds. She has also
appeared on The Dr. Oz Show (of which I've been openly skeptical in the
past, because of Oz's tendency to divorce his recommendations from
evidence).

Chutkan's first book comes out today. You might pick out an Oz-ian air
to the title: Gutbliss: A 10-Day Plan to Ban Bloat, Flush Toxins, and
Dump Your Digestive Baggage. Oz even endorses it on the back of the
jacket: "Dr. Chutkan blasts away the bloat as she tastefully explains
the guts of our problems."

Dr. Chutkan helped me reconcile some of this—blast away a little bloat,
if you will—on simplifying medicine, subspecialists embracing therapies
aimed at overall wellness, why a gastroenterology clinic would be
sex-specific, and how to think about the whole gluten-free idea; among
other answers to questions I wouldn't have thought to ask.

The title of your book is catchy and uses this evocative term
"gutbliss." I'd not heard it before. Did you come up with it, and what
does it mean?

I did come up with it. The earlier part of my career, my first eight
years after my training I was at Georgetown full-time in an academic
practice seeing patients in my area of expertise, which is Crohn's
disease and Ulcerative Colitis. I was treating people who had serious
medical problems, we were doing complex procedures, and prescribing
complicated drugs with a lot of side effects. And then things sort of
shifted for me. I began to feel like academic medicine didn't pay enough
attention to the contribution of diet and lifestyle and stress, to
digestive health, which felt, to me, like an obvious connection.

So I decided to open an integrative practice where we focus on
additional things besides the illness, like the things that created the
illness. I switched from being at the top of the pyramid treating people
at the end-stage of the disease, to the base of the pyramid counseling
more people who were starting to have symptoms, but didn't necessarily
have bad diseases yet. So "gutbliss" for me evokes this idea of how you
can create wellness in your digestive tract. And this blissful
gastrointestinal tract has a lot to do with how you eat and how you
live, since most diseases don't just fall out of the sky into your lap.

I had started a nonprofit in '09 called Gutrunners, which was sponsored
by one of the large GI societies, and we put on races at our national GI
meetings, and the idea was to focus on the contribution of nutrition and
exercise in preventing digestive disorders. So, this whole "gut" thing
for me was very natural.

People advised against calling the book Gutbliss and said, "Oh, it's
sort of in your face; it makes me think of stool and intestines." But I
think the intestines are beautiful and marvelous, so I wanted to include
that. And I wanted to show how something that is, in many ways,
closeted, mainly bowel movements and intestinal function, could actually
be this wonderful, blissful thing. In fact, there's a little bit of
focus on this in the book. There's a chapter on "Beauty and the Bloat,"
on how what you put into your body, mainly your GI tract, profoundly
affects how you look. So that was how I came up with the term "gut
bliss." Sort of combining the intestines, which people think of as not
so lovely, with a blissful state of health.

You mentioned some things we could eat that might influence appearance.

Skin disorders like rosacea, which a lot of people confuse with acne is
a good example. A lot of people are using harsh things on their skin for
this sort of redness on the cheeks and nose. Rosacea's actually an
autoimmune disease and, like most autoimmune diseases, we don't actually
know what causes it, but there's a very strong association with
something called dysbiosis, a bacterial imbalance and overgrowth of the
wrong kinds of bacteria in the gut.
[IMAGE DESCRIPTION] (stefnoble/flickr)

When I work with people on their diet, whether it's cutting back on
dairy, or switching them from a starchier, sugary processed diet, to a
more plant-based way of eating, their skin often clears up. And I sort
of joke with my friends because they're like, "Aren't you a butt doctor?
Why are you so obsessed with the skin?" And I'm like, "Well, I'm more
than a butt doctor."

But, I find there's such a fascinating skin-gut connection. One of the
things I talk about in the book is the idea that the skin actually
represents the outside of our GI tract, and the GI tract represents the
inside of our skin.

You probably don't know this because you probably don't wear makeup, but
when you put makeup on, like foundation and eye makeup and so on in the
morning, by the end of the day it's gone. Literally gone—it looks like
you don't have anything on. Where does it go? It gets absorbed into our
body. And the opposite thing can happen when you eat certain foods; you
can see the effect coming out on your skin. There's this incredible
connection between the two. And the same way we overuse antibiotics and
expose our digestive tract to chemicals that alters this delicate
balance between good bacteria and bad bacteria, we do the same thing to
our skin. We use harsh soaps that contain chemicals that kill off a lot
of the skin bacteria that are really important for healthy skin, and
then our skin is dry and unhealthy and peeling. So there are a lot of
parallels there. I think most of us have had that experience of seeing a
person who has a real inner glow. Maybe if you're 20 you just have good
genes and you can have pizza and beer every day and still glow. But if
you're over 40, often there is a fair amount of kale involved. There
could be some cookies and ice cream too, but usually the people who have
that glow are doing something right, and it often involves getting
sweaty on a regular basis and eating the right food.
[IMAGE DESCRIPTION] Chutkan

The tagline of the book is "A ten-day plan to ban bloat, flush toxins,
and dump your digestive baggage." Can you give us a preview of what that
is working towards, or some of the steps?

Sure. Full disclosure, I didn't love that tagline. This really is not a
diet book, and I wanted to be very clear on that. This is a book about
how to achieve and maintain digestive wellness. Hippocrates said it
first: All disease begins in the gut. The 10-day plan makes the
information in the book more accessible to people. It's very similar to
the advice that I give patients in my practice. It's not about eating a
perfect diet every day. But ten days is actually enough time to make
some changes and see some results. Maybe get rid of a lot of the sugary
stuff, maybe get off the gluten, eat more plants, do some exercises
using a light dumbbell on your tummy to get rid of gas. So it gives
people some very simple but very effective things that they can do so
that they can experience what it feels like to get rid of the bloat, to
be regular, to not have digestive upset. And beyond not just having
digestive upset, to experience a little of this gut bliss.

So once you do that, what about the rest of your life? It's really about
the 80 percent rule. Most of us are "toxing" 80 percent of the time and
detoxing 20 percent of the time. And we should really think about
flipping that—we should think about detoxing 80 percent of the time. And
I'm not suggesting anything extreme. Today I did some work at home, I
made a fruit and veggie smoothie for breakfast, went to spin class, I
met some people for lunch, and I had a kale salad with roasted chicken
and a big bottle of water. Nothing so profound, but all healthy stuff
that made me feel good. And if you're doing that 80 percent of the time,
you can tolerate that 20 percent of debauchery in whatever form that
might be, whether you're drinking a bit too much, or not exercising,
eating the wrong food, having too much ice cream. And then we don't have
this need to constantly be detoxing and cleansing all the time.

Try to maintain these healthy habits about 80 percent of the time, and
then 20 percent of the time you'll have something that is not
necessarily the best, but that you enjoy. It means you can go out to
dinner and not be so rigid or careful about what you eat, but that most
of the time you are paying attention. Because there's this incredible
disconnect I find in medicine today (and obviously there's lots of
commerce involved in this), that promotes the notion that disease just
falls out of the sky and there's no connection between how you live and
what happens to you from a health point of view.

Of course there are diseases where we don't know the cause, or they're
environmental, or it's bad genes or bad luck, but certainly for a lot of
the illnesses we see there is this connection. So this book tries to
help people, and women, more specifically, make that connection that if
you're bloated—which can be such a large and confusing expression for
women of things not being quite right in your GI tract—there are
actually things that you can do to try and figure it out. You can be a
bit of a medical detective, and you can look at these areas: is it the
food you're eating, is it something you're drinking, is it lactose
intolerance, is it gluten sensitivity, is it hormonal imbalance? Or, is
it an anatomical problem? Do you have ovarian cancer, is it bad
endometriosis, do you have a voluptuous female colon where your colon's
wrapped around your uterus?

Without giving specific medical advice, the book gives people ideas on
what sort of places they can look. Because one of the things I see so
often is women who come in and they're given that pat on the head, and,
"Oh, you have irritable bowel syndrome and here's a Xanax. You're just
stressed out." Sometimes there's some truth to that, but when you dig a
little deeper and slice up that irritable bowel syndrome pie, there
often is something more tangible as well as a solution. There's an
undiagnosed parasite, there's a food sensitivity, there's undiscovered
hypothyroidism. There's estrogen dominance. There's some reason,
physiological, functional—or it's because of something in the medicine
cabinet. Some vitamin, prescription pill or supplement that's not
agreeing with you.
[IMAGE DESCRIPTION] Image from "virtual colonoscopy" (Dr. Perry J.
Pickhardt/AP)

To just sort of say your bowel is irritable but we don't know why, I
feel like that's not a real diagnosis. It's like saying, "You're tired,"
and that's your diagnosis: Well, you have tired disease and here's a
pill to take for the rest of your life to pep you up. So, again, why are
you tired? And I think that's what people, not just women, want. They
want answers. And I think that's why there's so much investigation on
the Internet that can lead to all kinds of problems down the road when
you're self-diagnosing pancreatic cancer and you really just have
heartburn. The book provides sensible, practical information. It's a bit
of a roadmap and a guide for the woman who is bloated or has digestive
problems, not instead of a doctor, but in addition to, to help her
figure out where she should be looking.

Do you only see female patients in your practice?

Even though my clinic is called the Digestive Center for Women, I do see
male patients. A lot of the patients I see have Crohn's disease and
ulcerative colitis, which affects men and women equally. About 10
percent of the patients I see are male.

What are some differences in the way you approach female patients as
opposed to men? In my mind, at least, the digestive tract isn't
something commonly thought of as a gendered part of the body.

I'm glad you asked that. There actually are some profound differences
between the female and male digestive tracts. To start with, the female
colon is longer than the male colon, on average, about 10 centimeters
longer. We don't know why, but we think part of that is to allow for
more absorption of water or fluid during childbearing. Because you have
to keep the amniotic fluid replete, and the circulation and blood volume
increases during pregnancy.. And what that extra length in the colon
does is create this redundancy, these sort of extra twists and turns,
and that's why women are so much more bloated and constipated than their
male counterparts. So there's that difference in length as well as
redundancy. Think of the male colon as kind of a gentle horseshoe, and
the female colon as being a tangled-up Slinky.

Not only is that due to the difference in length, but think of the
pelvis. Women have this rounded, gynecoid pelvis so that when the uterus
expands there's room for a baby. Men have a narrow, android pelvis. What
happens in women is that more of the colon drops down deep into the
pelvis. In women, the colon is really right there mixed up with the
uterus, and the ovaries, and the Fallopian tubes, and the bladder. In
men, the only hardware you have is this little bitty prostate gland, and
the bladder, and that's it. So in men, most of the colon is up in the
abdomen where there's tons of room and not fighting for space with the
reproductive organs, like in women. So that's anatomical difference
number two.

The third thing is that because of differences in hormonal levels with
men having more testosterone on board, you guys have a well-developed
abdominal wall. So even a man who's overweight and has a big beer belly
still has a tighter, more robust abdominal wall just because of the
testosterone. Men will complain that they're fat, but will rarely
complain that they're bloated because that tighter, more defined
abdominal wall, the rectus abdominis sheath, which is, to some degree
dependent on testosterone, that holds the bowel in place. It's sort of a
Spanx-type thing that muscular wall. In women, our abdominal wall is
much less rigid and tight and doesn't hold things in place as much,
because of the difference in hormonal levels, so our bowels bulge out
more, and we bloat more. And of course many women have had children, and
their abdominal wall is stretched, and they may have something called a
diastasis recti where there's a split in the abdominal wall muscles
because of the pressure from pregnancy. So the abdominal wall is the
other big reason why men complain of being fat, and women complain of
being bloated. Estrogen and progesterone can have really profound
effects on the GI tract, whether you retain water or not, and how things
move through your intestines. So, these are just some of the factors,
not even getting into brain differences, but just from a hormonal and
anatomical point-of-view.

Pelvic floor disorders in women are another big difference in the male
and female GI tract. The pelvic floor is sort of like a hammock that all
of the organs that are down in that area sit on—the bladder rests on it,
the uterus rests on it, the bowels rest on it, and it often becomes
stretched out after childbirth, or just with age, and things can start
to descend. The uterus can change position and it can press on the
bowels. So when you approach constipation in a woman, you always have to
be aware of these pelvic floor issues. Because if you just do the basic
things like give them a fiber supplement to help them get stuff out, and
the problem is a pelvic floor issue, they're actually going to feel
worse; they're going to be more bloated. You have to consider whether
the sphincter may have been damaged during pregnancy or childbirth, or
if the pelvic floor may have dropped. These are not considerations in
men.

There are lots of different gender factors. Thyroid disease is much more
common in women than in men, so that's one of the first things that I
check in a constipated women. Perimenopause is another factor. And that
isn't just when you stop having your period. It's really that decade
before you stop menstruating, which for most women is going to be 40 to
50, sometimes 35 to 45 — and it can profoundly affect the gut and bowel
habits. Men don't go through that; that's not a factor with men at all.
So there are lots of different things that you have to think about when
you're approaching bowel issues in women.

You mentioned going gluten-free, and I wanted to get your take on that.
It seems like a lot of people going in that direction don't have a
diagnosis of celiac disease. What do you tell people who are interested
in trying it? Is there evidence that people who tested negative for
celiac disease still benefit?

First of all, I think it's important to distinguish celiac disease from
gluten sensitivity, because celiac disease is an autoimmune disease that
is associated with a lot of other problematic things, like osteoporosis,
iron deficiency anemia, arthritis, diabetes, even cancer. And if you
have celiac disease, whether or not you have symptoms, it's important to
come as close as you can to 100 percent avoidance of gluten, because the
ongoing exposure to gluten can damage the small intestine and lead to
some of these other associated problems. So that's the first thing I
tell patients, is that we have to figure out what's going on. And some
patients say, Well, can't I just empirically avoid gluten? And I tell
them, no, because if you have celiac disease, you have to be 100 percent
regardless of whether you have symptoms. If you have gluten sensitivity
(but don't have celiac disease) and you want to eat an almond croissant,
go for it. Part of the issue is that the wheat itself is not what it
used to be. It's been hybridized and had different things done to it to
increase the crop yield and shorten how long it takes for the wheat to
bear. One can make all sorts of scientific and unscientific arguments
about what we're meant to eat, but I don't think we're meant to eat
animal crackers, for example. I think it's a stretch to call the
refined, processed wheat products a food group, but I also don't think
everyone needs to empirically avoid them all the time.
[IMAGE DESCRIPTION] Gluten-free porridge (elenaspantry/flickr)

Certainly if you're having digestive problems, it's worth trying. I
usually tell people to do a six-week elimination trial; if you don't
notice a difference there's no reason to avoid it. But my biggest caveat
is to tell people there's no point in doing this and then eating
gluten-free bread, and gluten-free pancakes, and gluten-free cookies.
It's sort of like sugar-free. If you're diabetic, I would say to you,
you should think about having fruit for dessert. I would never recommend
that someone have sugar-free ice cream or a sugar free drink, because
that stuff's worse than the sugar quite frankly. The same thing applies
to gluten. If you think you're gluten sensitive and you feel poorly when
you eat gluten, you should avoid wheat. It just makes sense. If you're
lactose intolerant you should avoid dairy. This is your body giving you
feedback saying no, I don't like this thing. But if you decide once a
month, I'm going to have a sandwich using regular bread and I may not
feel so great, but I don't have celiac disease, just a sensitivity, I
think that's okay and I think that is preferable to eating gluten-free
garbage every day. Gluten-free processed products can be just as bad for
you as the regular stuff that contains gluten. They're not providing you
any nutrients, they're empty calories. So that's a big challenge that I
face with some of my patients. If you're just gluten sensitive, have a
pancake on the weekend if you really want it, but don't eat gluten-free
cookies every day of the week and think that somehow this is being
healthy. Just like I would never eat low-fat or sugar free ice cream. If
I'm going to have ice cream I'm going to have the real thing—I'm just
not going to eat it every day.

In terms of a mechanism for gluten sensitivity, do you think we're going
to find antibodies that we're going to be able to quantify for people in
the future? Or is this akin to an allergy?
Related Story

Gluttony Without Gluten

I think it's not going to be something that we can pinpoint easily. Like
if you have rheumatoid arthritis and your joints are destroyed and we
can see that on a X-ray and you have antibodies that we can measure. I
think it belongs in that very grey area of food intolerances, and I
think we have to have common sense about it. If you eat something and
you feel sick, I don't think you need a doctor, an antibody test, or an
allergist to tell you that maybe you shouldn't eat that thing. I love
the point Michael Pollan makes about nutritionism and trying to make
everything so scientific. We've just lost our common sense a little bit.
If you drink milk and then you have gas and diarrhea and bloating and
you feel terrible, I don't think you need a doctor to tell you [that]
you shouldn't drink milk, or you should drink less of it. So much of
food science is driven by food manufacturers and this huge market for
products. I cringe when I see the gluten-free section of the
supermarket—which is getting bigger and bigger. And it's mostly a whole
bunch of junk. If the package says gluten-free, don't buy it because
guess what, a potato doesn't say gluten-free. A pineapple doesn't say
gluten-free, and a piece of chicken doesn't say gluten-free. So if it
says gluten-free on it, be wary. There are incredible fortunes being
made in the gluten-free world, and I'm not sure they're doing consumers
much of a favor.

I feel inundated by gluten-free product marketing. It's on labels right
next to "sugar-free" and "low fat," as if it's becoming understood to be
universally a good thing. Knowing that there's a discreet mechanism
behind lactose intolerance—we make less lactase [the enzyme that breaks
down lactose] as we get older, some people genetically make less than
others; not breaking down lactose leads to gas. The condition is
explainable. We still wonder what it is about the insensitivity toward
gluten—in people who don't have celiac disease, if it really is gluten
that's making us have these symptoms like mental fogginess, or whatever
constellation of things some people associate with it.

This is sort of a simple way to look at it, but I think the farther
differentiated the food is from the original source, the more likely you
are to have some of these issues. That's a huge oversimplification, but
a thought, nonetheless.

This article available online at:

http://www.theatlantic.com/health/archive/2013/10/what-we-eat-affects-everything/279922/
Copyright © 2013 by The Atlantic Monthly Group. All Rights Reserved.

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