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).
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.
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.
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.
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.
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?
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 discrete 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 glutenthat’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.