YO U R G U I D E T O A

Healthy Gut
What Makes a Probiotic?

How Doctors Take Care of Their Guts

Mood-Boosting Meal Plans

 YOUR GUIDE TO A

Healthy Gut
 Contents
4 Introduction
The Power of a Healthy Gut

CHAPTER ONE

What’s in Your Gut?

10 A User’s Guide to the Gut-Brain
Connection
16 10 Probiotic-Packed Foods
26 What Makes a Probiotic?
34 Improving the Path to Digestive Wellness

CHAPTER TWO

Digestive Distress
38 The Intolerances
46 Crohn’s Disease Explained
48 Healthy Eating for Crohn’s Disease
52 The Ins and Outs of IBS
56 Everyone Thinks I’m the
Picture of Health
62 Recipes: Good Gut, Good Mood

CHAPTER THREE

The Feel-Good
Lifestyle
72 How Doctors Take Care of Their Guts
78 Feeling Stressed? Why You May Feel
It in Your Gut
80 5 Ways to Boost Your Kids’ Gut Health
84 The Coffee & Alcohol Buzz
86 The Animal Effect
90 Meal Plan: Boosting Your Plate
and Microbiome with a Day of
Gut-Healthy Eating
96 Last Word

Parts of this special edition were previously published

by Health, Parents, and Cooking Light.

2 H E A LT H
H E A LT H 3
 I N TRODUCT ION

THE POWER OF A
HEALTHY GUT
The balance of bacteria and other bugs in your
GI system impacts your health in surprising ways. Experts
are still unraveling the microbiome’s full potential.
BY LISA LOMBARDI

INSIDE YOUR GUT RIGHT NOW there are literally
trillions of bacteria, viruses, fungi, and other
microorganisms doing their thing. It may sound
gross, but this brew of bugs—officially known as
the microbiome—plays a surprisingly important role
in your overall health.
By simply treating your gut right, you are helping
your body in a whole slew of ways. “A healthy gut is
really the key to a healthy body and mind,” says
Samantha Cassetty, MS, RD, a nutrition expert with
a virtual counseling practice based in New York City.
“An unhealthy gut may influence your risk of excess
body weight, type 2 diabetes, heart disease, mood
disorders, and autoimmune conditions like rheuma-
toid arthritis.”
While everyone’s microbiome is unique (“like fin-
gerprints,” says Cassetty), healthy microbiomes have
a few basics in common. They have diverse strains of
bacteria (so there isn’t an overgrowth of one type),
higher levels of health-promoting bacteria and other
microbes, and lower levels of the unfavorable ones.
When the delicate balance gets thrown off, “bad”
strains of microbes multiply. And some experts
believe that this shift may lead to a so-called leaky
gut. According to this still-controversial theory, out-
of-control bacteria and other microbes get into the
bloodstream, where they travel around you and trig-
ger inflammation throughout your body.
So what causes bad bugs to take charge? A few com-
mon habits may give them the upper hand. For one
thing, subsisting on a steady stream of takeout and
processed foods does your gut no favors. “A Western
diet that’s low in fiber and high in sugar, heavily pro-
cessed foods, and meat protein leads to unfavorable
shifts in the microbiome that promote inflamma-
tion,” explains Cassetty.
Some meds also throw your flora out of whack.
Antibiotics and antacids are particularly disruptive

4 H E A LT H
 THE
GUT IS
A COMPLEX,
INDIVIDUALIZED
STRUCTURE THAT
AFFECTS MORE
THAN OUR
TUMMIES.
 IN TRO DUCTI O N
to gut health. Although antibiotics kill the bacteria
that are making you sick, they also remove beneficial
bacteria, and this can lead to an imbalance. That’s
why experts recommend avoiding unnecessary
rounds of antibiotics and taking probiotics whenever
you do need to be on these meds.
Our obsession with germ-free homes and Purell at
the ready may also be harming our microbiome.
According to a scientific theory called the hygiene
hypothesis, growing up in overly sterilized environ-
ments deprives our bodies of the opportunity to get
exposed to germs and build tougher immune systems
in the process.
How we come into the world also leaves its mark
on our microbiome. A large 2019 study published in
the journal Nature added to the evidence that babies
born via C-section don’t have the same healthy gut
bacteria as babies born through
the vaginal canal. The research
discovered that the vaginal-birth
newborns got most of their bacte-
While there’s
ria from their mothers, while the
much researchers
cesarean infants got the bulk of
don’t know
their bacteria from hospital patho-
the potential
gens. Not surprisingly, the hospital
microbiomes,
bugs were less than ideal.
much is clear
This study adds to other research
now: Everyday
suggesting that a vaginal birth
habits matter.
gives children at least a temporary
advantage in the gut-health
department. “When newborns don’t pass through the
vaginal canal, they miss the natural immunity that
comes from direct contact with bacteria that is neces-
sary to kick-start immune response,” says Lawrence
Hoberman, MD, a gastroenterologist based in San
Antonio who was not involved with this research.
Cesarean babies who aren’t breastfed may be partic-
ularly vulnerable to an unhealthy gut makeup. To
counteract the effect, researchers are experimenting
with vaginal seeding, or swathing a baby born via
C-section with their mother’s bacteria.
SCIENTISTS HAVE KNOWN about bacteria inside
of us for centuries, but the current wave of research
really got going in 2008 when the National Institutes
of Health (NIH) started the Human Microbiome
Project. NIH scientists got samples of microbes from
volunteers’ oral and nasal cavities, skin, gastro-
intestinal tract, and urogenital tract. They then
sequenced the microbes’ DNA, which paved the way
6 H E A LT H
for research on bacterial differences between
healthy and unhealthy people, as well as research
into possible treatments using probiotics and fecal
transplants (when doctors transfer poop from
healthy subjects into people with a condition to
rebalance their gut bacteria).
While microbiome research is still in its infancy,
there have been some headline-grabbing findings:
People with conditions like schizophrenia and autism
have gut bacteria that are different from the bacteria
in people without those conditions. In addition, cer-
tain kinds of gut bacteria may speed the progression
of Alzheimer’s, according to research in mice pub-
lished in Nature. The mice given antibiotics developed
fewer of the plaques associated with the disease.
And an unfavorable mix of bacteria may be linked
to the inflammatory GI disorder Crohn’s disease.
Experts are studying whether
fecal transplants can help improve
the condition.
still so A person’s blend of bugs may
also play a role in whether he or
about she develops allergic diseases,
of our says Tania Elliott, MD, an aller-
this gist and clinical instructor in the
right department of medicine at NYU
Langone Health. “The micro-
biome is not limited just to the
gut—there is a microbiome of the
skin and respiratory tract. And
just as the gut microbiome is different in people with
food allergies versus not, there are differences in
the respiratory microbiome in people with asthma
and in the skin microbiome in people with atopic
dermatitis [eczema].”
Eczema isn’t the only skin condition that a bal-
anced microbiome may help. One 2016 study in
Beneficial Microbes revealed that taking a strain of
the probiotic Lactobacillus improved adult acne more
than a placebo.
THANKFULLY, MOST OF US can stack our flora in
our favor without popping probiotics or considering
a fecal transplant. “To shift your individual micro-
biome, it’s important to eat a fiber-rich diet from a
range of sources. Your gut bacteria need fiber to
thrive,” says Cassetty. Build your meals around plants
and you almost can’t go wrong. “You don’t need to
eliminate meat—instead, elevate plants,” she adds.
The reason prioritizing produce helps transform

an unhealthy gut into a healthier one is that plants
are full of fiber and probiotics, as well as polyphenols—
antioxidants key to gut health. When you eat
polyphenol-rich foods, your body produces byprod-
ucts that influence your gut health and your overall
health, Cassetty explains.
At meals, aim for a generous helping of nonstarchy
veggies (think spinach, broccoli, zucchini, green
beans), some plant-based fats (like avocados, nuts,
seeds, or their butters; olives or olive oil), and a portion
of either fruits, starchy veggies (like butternut squash
or sweet potatoes) or whole grains, Cassetty advises.
“Swap some of the meat for plant-based protein—
pulses [the term for beans, legumes, and lentils].”
And although the jury is still out on probiotic
supplements—particularly because the supplement
industry isn’t regulated—enjoying probiotic foods
STARCHY
AND
NONSTARCHY
VEGGIES ALIKE
HELP NURTURE
HEALTHY GUT
BACTERIA.
(yogurt, miso paste, kombucha, sauerkraut, kimchi,
sourdough bread) is a smart gut move. “These foods
help enrich your gut with healthy bacteria,” Cassetty
explains. Also prioritize prebiotics—nondigestible
carbs that feed healthful gut bacteria. Some good
picks: Jerusalem artichokes, garlic, leeks, bananas,
and asparagus.
While there’s still so much researchers don’t know
about the potential of our microbiomes, this much is
clear right now: Everyday habits matter. “Some stud-
ies show that you can alter your microbiome in just
two days,” says Cassetty. That means that while a
single course of antibiotics or a week of bingeing on
junk food messes with your bacterial balance, you
can quickly correct course and get back on track.
“That’s pretty dramatic, considering that it sets you
up for a healthier life.” ●
H E A LT H 7
 CH A PT ER ON E

What’s in
Your Gut?
A road map through
digestive wellness.

8 H E A LT H
 A USER’S GUIDE
TO THE GUT-BRAIN
CONNECTION
The axis that connects the brain, central nervous
system, and digestive tract is the basis for understanding
our microbiome and nurturing all of our gut feelings.
BY HALLIE LEVINE

IF YOU’VE EVER HAD A “gut-wrenching” experience
or felt butterflies in your stomach before a big event,
you know your GI tract is sensitive to your emotions.
It turns out there’s a real scientific reason for that.
“Research is increasingly showing not only that your
brain affects your gut health and vice versa, but that
your gut may impact your overall health in general,”
says Ali Keshavarzian, MD, the chair of gastroenter-
ology at Rush University Medical Center in Chicago.
Here’s a look at what the latest science reveals.
The Gut-Brain Connection
Your gut is often referred to as your “second brain,”
and for good reason: There’s a clear connection
between your brain and the gastrointestinal tract,
known as the gut-brain axis. “The primary part of this
axis is the vagus nerve, which connects your brain to
your gastrointestinal tract,” explains Robert Hirten,
MD, a gastroenterologist at the Susan and Leonard
Feinstein Inflammatory Bowel Disease Center at
Mount Sinai Hospital in New York City. This brain-gut
axis is bidirectional, meaning it works in both direc-
tions. “This nerve allows both the brain to alter the
function of the gastrointestinal tract, but also the gas-
trointestinal tract to impact the brain,” says Hirten.
Scientists have recognized communication
between the brain and the gut for almost 200 years,
with studies going as far back as the early 19th century
showing that a person’s emotional state can alter the
GI tract. Keshavarzian says one of the best-known
examples is the work of William Beaumont, an army
surgeon who in the 1830s took care of a patient who
had an open hole in his stomach due to a gunshot
wound. Beaumont was able to see the patient’s stom-
ach lining and noticed that there was a link between
his changing moods and his gastric secretions.
This second brain in your gut is sometimes called
your “little brain” or, more scientifically, your enteric

H E A LT H 11
 W H AT ’S I N YOU R GU T ?

nervous system (ENS). It’s made of two layers of more This may help explain why people with a chronic
than 100 million nerve cells that line your entire GI bowel disease such as IBS are more susceptible to
tract. While its main job is to help you digest food, it anxiety and depression, notes Ramsey. It also helps
also communicates regularly with the big brain in shed light on why some people with IBS respond well
your head, through neurotransmitters, chemicals to antidepressants and even to a popular form of talk
that are normally released by your nerves. Most of therapy known as cognitive behavioral therapy, he
these neurotransmitters originate in your gut: About adds—not because the problem is all in their heads,
90 percent of your body’s production of the but because these treatment methods help boost
mood-boosting hormone serotonin, for example, can levels of neurotransmitters in the gut, which in turn
be found there, and your gut produces a neuro- soothe symptoms.
transmitter called gamma-aminobutyric acid
(GABA), which is also linked to mood. The Impact
How much—or how little—of these neurotrans- The gut-brain axis does more than impact your
mitters you make may be due in large part to the mood—it also affects your immune system, since it’s
trillions of microbes that live in your gut, otherwise estimated that about 70 percent of the immune sys-
known as your microbiome. We all have a variety of tem is found in the digestive tract. This can trigger
bacteria in our body, explains Keshavarzian, many inflammation that raises your risk of a whole host of
of which are good for us. The ones found in our GI autoimmune disorders as well as neurological condi-
tract not only help us digest our tions such as Parkinson’s and
food but appear to have effects Alzheimer’s. Here’s a closer look at
throughout our bodies, boosting The best way to keep what it can affect:
both our physical and mental our microbiome Your weight. Your microbiome
health. One way they do this is by healthy is through may impact your risk of obesity. A
keeping bad bacteria in check, probiotics. These 2015 review published in the jour-
multiplying so often that the bad are “good” bacteria nal Nature, for example, found
critters don’t have time to grow. like the ones already there were specific bacterial
Studies have in fact shown that if in your gut. changes in the guts of obese indi-
you have too much of these bad viduals that caused changes in
bacteria in your gut microbiome, their levels of hunger hormones,
you’re more likely to have bowel-related disorders which can lead to obesity.
such as Crohn’s disease, ulcerative colitis, and irri- Diabetes. Patients with type 2 diabetes have dif-
table bowel syndrome (IBS). “These bad bacteria ferences in their microbiome compared with people
actually increase inflammation throughout the without the disease. For example, a 2018 study in
whole body,” says Keshavarzian. “Good bacteria, on Clinician Reviews found that patients had lower
the other hand, ramp down inflammation.” amounts of butyrate-producing bacteria in their
When researchers looked at more than 2,100 microbiomes. Butyrate is a short-chain fatty acid
adults, they found that those who were depressed that’s important when it comes to regulating weight,
had lower levels of specific gut bacteria, such as mood, and the overall immune system.
Coprococcus and Dialister, according to a study Heart disease. Your gut microbiome may influ-
published in February 2019 in the medical journal ence whether you become obese or develop type 2
Nature Microbiology. “We think that these are prob- diabetes, both of which are risk factors for heart dis-
ably good bacteria in your gut, which produce a lot of ease. But it also appears to affect levels of LDL (“bad”)
neurotransmitters implicated in mood, like nore- cholesterol in the blood, as well as blood pressure. In
phedrine and gamma-aminobutyric acid,” explains addition, as gut bacteria age, they produce harmful
Drew Ramsey, MD, a psychiatrist at Columbia substances that damage your arteries and blood ves-
University Medical Center and the author of Eat sels, according to a 2019 study published in the
to Beat Depression. Your gut bacteria also produce Journal of Physiology.
short-chain fatty acids (SCFAs), such as butyrate, Your immune system. Patients with autoimmune
propionate, and acetate, which have likewise been disorders, such as multiple sclerosis and rheumatoid
linked to improved mood, he adds. arthritis, have higher-than-normal levels of the

12 H E A LT H
 ABOUT
70 PERCENT
OF THE IMMUNE
SYSTEM LIVES
WITHIN THE
DIGESTIVE
TRACT.
bacteria Bacteroides fragilis, according to a 2018 study
published in the journal Clinical and Experimental
Immunology. These bacteria churn out a protein, ubiq-
uitin, that tricks the body into attacking itself, trig-
gering autoimmune disease.
Parkinson’s disease. Parkinson’s appears to begin
among cells in the gut and travels up your body’s
neurons to your brain via the vagus nerve, according
to a 2019 review in the Journal of Parkinson’s Disease.
Alzheimer’s disease. Gut bacteria seem to accel-
erate the development of Alzheimer’s, according to a
2017 Swedish study published in the journal Scientific
Reports. When researchers examined both healthy
and diseased mice, they found that those who had
Alzheimer’s had different microbiomes than healthy
ones. They also discovered that the brains of mice
without bacteria had much less beta-amyloid, a pro-
tein deposit that has been linked to Alzheimer’s.
Staying Healthy and Happy
The best way to keep our microbiome healthy is
through probiotics, says Gail Cresci, PhD, RD, the
director of the Nutrition Research Center at the
Cleveland Clinic. These are “good” bacteria like the
ones already in your gut. The best way to get them
is through food. They’re found in dairy products like
yogurt and aged cheeses (just check the ingredient
list to make sure “live cultures” is on the label) and
fermented veggies such as kimchi, sauerkraut, and
tempeh. You also want your diet to include prebiot-
ics, which are substances that the good bacteria in
your gut like to snack on. They’re found in fruits and
veggies like bananas, onions, garlic, leeks, asparagus,
artichokes, and soybeans, and in whole-wheat prod-
ucts like breads, flour, and pasta. A 2016 study pub-
lished in the medical journal Science found that a
high-fiber diet that included plentiful consumption
H E A LT H 13
 THERE ARE
“GOOD” AND
“BAD” BACTERIA
THAT CAN
INFLUENCE
MICROBIOME
HEALTH.

14 H E A LT H
 WH AT ’S IN YOU R GU T?

of these foods—as well as coffee, tea, and wine— months after a course of antibiotic treatment ends,
helped keep gut bacteria healthy. Foods high in explains Cresci. (This helps explain why about 5 to
sugar, on the other hand, such as whole milk and 30 percent of patients who take antibiotics get diar-
sodas, had the opposite effect. One good idea is to rhea.) If you do need to take antibiotics, talk to your
make meals that combine both, such as bananas and doctor about a course of probiotics—either prescrip-
yogurt, or tempeh stir-fried with onions, leeks, and tion or over the counter—since there’s some evidence
garlic, advises Cresci. And while the Paleo diet is still that it could help. Other drugs that can impact your
all the rage, a 2013 Harvard study found that an gut microbiome are medicines that kill off stomach
animal-protein-rich diet filled with meat and cheese acid, like antacids and protein pump inhibitors, and
dramatically alters the microbiome, and not posi- the diabetes drug metformin.
tively: It promotes the rise of one type of bacteria, While you may have heard that probiotic supple-
Bilophila, which is linked to inflammation. ments are a must for gut health, most doctors don’t
Along with what you eat, when you eat is also recommend taking them routinely. “It’s true that
important, adds Keshavarzian. Chowing down at some strains have been shown to help with GI prob-
night, when you’re less active, can promote the lems like diarrhea, some have been shown to boost
growth of unhealthy gut bacteria. You’re also more immunity, and some may even help with vaginal
likely to snack on sugary and fatty food, which is toxic health or inflammatory conditions like eczema,” says
to your microbiome. If nighttime Cresci. The problem is that since
snacking is a temptation for you, probiotics are sold over the
have a microbiome-friendly counter as dietary supplements,
option on hand, like a banana or
Along with what their manufacturers don’t have to
some whole-wheat toast.
you eat, when you prove to the FDA that the products
In addition to a healthy diet,
eat is also important. are safe and effective. A 2018 study
make sure you’re getting plenty of
Chowing down at published in the Annals of Internal
exercise, which appears to posi-
night, when you’re Medicine concluded that there’s
tively impact your microbiome,
less active, can not enough evidence to show that
according to a 2018 University of
promote the growth they actually work and that they
Illinois study published in the
of unhealthy gut don’t carry health risks.
medical journal Medicine in Sports
bacteria. You may have also heard of
and Exercise. In the study, 32 men microbiome-screening tests,
and women who were couch pota- which are being offered through
toes were asked to do 30 minutes of supervised exer- some doctors’ offices and sold online. These involve
cise, like brisk walking, three times a week for six having your physician take a stool sample and send
weeks. The researchers found that the subjects had it to a testing company for a bacterial analysis. The
increases in certain microbes that help reduce company compares your microbiome to a catalog
inflammation in the gut and the rest of the body. containing hundreds of thousands of other micro-
Another must-do: Get enough sleep. Lack of sleep biomes to try to figure out if your gut contains
has long been associated with obesity, and now new specific bugs linked to certain diseases, such as
research suggests that may be because sleep depri- irritable bowel syndrome, depression, and rheuma-
vation changes your microbiome—and not in a good toid arthritis.
way. After just two nights of clocking less than five But there’s not enough research yet to show
hours of z’s, normal-weight patients had gut flora whether these specific gut microbes are responsible
that resembled those of people who were obese, for specific conditions, cautions Cresci. “There’s still
according to a 2016 study published in the journal a lot to learn about how the microbiome affects us
Molecular Metabolism. It’s also important to be aware and how we affect the microbiome,” adds Hirten.
of how any drugs you’re taking could affect your “We don’t have great means to proactively alter our
microbiome. In addition, you should avoid taking microbiome in a specific way, and we still don’t know
antibiotics unnecessarily, since they kill the good doing so would improve our health. That’s why I tell
bacteria in your gut along with harmful ones else- my patients that the best thing they can do for their
where, and your microbiome may not recover for microbiome is to eat right and exercise.” ●

H E A LT H 15
 10
PROBIOTIC-
PACKED
FOODS
Foods with healthy bacteria
can help you get slim, stay
healthy, and feel better than
ever. Reap the benefits of the
best probiotic foods.
BY JESSICA MIGALA

16 H E A LT H
THE GOOD NEWS keeps WITH
stacking up for probiotics, the FIBER AND
good-for-you bacteria that LACTIC ACID,
keep your GI system function- SOURDOUGH IS AN
ALTERNATIVE
ing in tip-top shape. “Research TO WHITE
is finding that a healthy micro- BREAD.
biome may play a role in reduc-
ing inflammation, a risk factor
involved in illnesses ranging
from colds to cancer, heart
disease, arthritis, and cognitive
decline,” says Katherine
Tallmadge, RD, the author of
Diet Simple. Here are 10 truly
yummy probiotic foods.

‹
Fortified
Chocolate
Certain brands, like Attune,
have pumped up the dessert
by adding probiotics. (Attune
boasts 6.1 billion CFUs, or
“colony forming units,” a
measure of live, active
microorganisms per serving.
As a comparison, some
probiotic supplements may
contain 1 billion to 50+ billion
CFUs.) One study in the
International Journal of Food
Microbiology found that
probiotics added to chocolate
were able to reach the GI tract,
where they could colonize the
gut with healthy bacteria.

›
Sourdough Bread
This mildly sour, chewy bread
is made with a lactic acid
starter that contains strains of
Lactobacillus, a type of
bacteria that adds good
microbes. Sourdough may be
the healthiest bread choice if
diabetes is a concern for you:
One 2008 study found that
people with prediabetes who
ate sourdough bread had less
of a blood-sugar spike than
when they ate bread made with
baker’s yeast. (Experts say
fiber-rich whole-grain bread
can also reduce a post-meal
blood-sugar spike.) The
researchers credit the lactic
acid for the favorable effect.
 W H AT ' S I N YOUR GU T?

FERMENTED
CUCUMBERS—
ALSO KNOWN AS
PICKLES!—HAVE
PROBIOTICS.

‹
Pickles
Some—but not all—pickles
are fermented. To get that
good bacteria, look for those
made with brine (salt and
water) rather than vinegar.
These brands will list “live
cultures” on the label
(Bubbies is one brand). You
can also use water, salt, and
spices to naturally culture
pickles and other veggies—
such as beets, green beans,
and carrots—at home with
delicious results. One
warning: Remember that
pickles are salty—one dill can
contain more than 10 percent
of your sodium needs in a day.

›
Kimchi
This Korean staple relies on
lactic acid fermentation (also
called lacto-fermentation) to
turn cabbage or other
vegetables into a spicy,
pungent side dish that’s
packed with vitamin C. Order
it at Korean restaurants or
buy it in the refrigerated
section of your grocery store.
For some guidance on
making your own, turn to
The Art of Fermentation by
Sandor Ellix Katz. Use kimchi
to spike veggie-laden rice
bowls, top a soup with it, or
serve alongside meat.
 KIMCHI IS
VERSATILE AND
CAN BE PAIRED
WITH RICE
OR SOUP.
 KEFIR IS A
SWITCH FROM
DAIRY YOGURT
FOR THOSE WITH
TUMMIES
SENSITIVE TO
LACTOSE.

20 H E A LT H
 WH AT 'S IN YOU R GUT ?

LASSI COMES
IN A VARIETY OF
FLAVORS, SUCH
AS MANGO,
STRAWBERRY,
AND MINT.

‹
Kefir
This smooth, slightly tangy,
and sippable yogurt contains
a dozen different types of live
active cultures. It’s also 99
percent lactose-free, making
it easier to digest for those
with intolerant tummies. “If
you have lactose intolerance,
start slowly on kefir as a test.
If you have no symptoms, go
ahead and slowly increase
your intake,” advises
Tallmadge. Plus, with 8 to 11
grams of protein per cup, it
can help fill you up for around
100 calories.

›
Lassi
If you’ve ever been to an
Indian restaurant, then you’ve
probably seen a lassi—a
smoothie made of milk,
yogurt, fruit, honey, and
cardamom. The drink goes
well with spicy Indian food
because it helps extinguish
the fiery feeling in your
mouth. If you want to try it at
home, you can pick up bottles
from brands like Dahlicious,
which contain 15 billion live
probiotics per serving and are
available in flavors like mango
and turmeric.
 W H AT ' S I N YOUR GU T?

‹
Yogurt
We have to give a nod to the
most famous probiotic food:
yogurt. Whether you love
Greek or regular, low-fat or
PLAIN full-fat, look for the phrase
YOGURT HAS
“live active cultures” on the
THE LEAST
SUGAR, BUT label. Although plain yogurt
FLAVORED KINDS has less added sugar than the
ARE STILL GUT flavored kinds, Tallmadge
FRIENDLY.
gives you the OK to choose a
fruit-infused flavor if that’s the
only way you’ll eat it. Just be
sure to aim for fewer than 15
grams of the sweet stuff per
serving; sugar can feed the
bad bugs in your gut.

›
Miso Paste
Made from aged, fermented
soybeans, this paste is brim-
ming with probiotics. You can
buy miso paste in a bunch of
varieties (white, yellow, red,
brown), and the darker the
color, the deeper the taste.
Miso is a great way to add a
burst of earthy, savory flavor
for few calories (only 25 to 30
per tablespoon), plus protein,
fiber, and bone-strengthen-
ing vitamin K, says Sharon
Palmer, RDN, the author of
Plant-Powered for Life. “While
we need more research
about how these types of
fermented foods contribute
to health, it’s a good idea to
introduce more of them into
your diet,” she says. Use miso
to glaze fish or chicken before
cooking, mix it into a stir-fry
recipe, or add it to liquid for
a miso broth. One caveat:
Miso is very high in sodium.
One teaspoon, enough to
make a cup of miso soup, has
473 mg of sodium, 21 percent
of the daily recommended
limit and 32 percent of the
daily limit for those with high
blood pressure.

22 H E A LT H
 THE DEEPER
THE COLOR OF
MISO PASTE, THE
DEEPER AND
RICHER THE
TASTE.
W H AT ' S I N YOUR GU T?

GREAT
IN SOUP OR
ALONGSIDE
PORK,
SAUERKRAUT CAN
EASILY BE MADE
AT HOME.
‹
Sauerkraut
This cabbage condiment can
frequently be found atop a
hot dog, but its roots trace all
the way back to the 4th
century B.C. Cabbage was
fermented to preserve the
veggie, resulting in what we all
know as sauerkraut. Palmer
points out that modern
techniques for canning
sauerkraut result in a product
packed in a vinegar solution
without live, active bacteria in
the mix. For the most
probiotic power, eat fresh
sauerkraut (look for “live
cultures” on the label or buy it
in the refrigerated section) or
make it at home.

›
Kombucha Tea
Fizzy, tangy, and even slightly
vinegar-esque, kombucha
has a cult following for a
reason. The tea gets its
natural carbonation from the
“scoby” (that float-y thing you
see in some bottled varieties),
which is actually the bacteria
and yeast that ferment the
drink and create the
probiotics. “There’s not much
scientific evidence specifi-
cally on the benefits of
kombucha, but it is another
strategy to introduce more
live, active bacteria into your
lifestyle,” says Palmer. Many
are made with fruit juice for
added flavor, so read the label
to see what you’re getting,
she advises. Stick to
store-bought kombucha; it’s
tough to keep the tea sanitary
when you make it yourself,
and home-brewed kombucha
THIS
has been linked to nausea and TRENDY
even toxicity. Also note that DRINK, OFTEN
due to the fermentation MADE WITH FRUIT
process, kombucha contains JUICE, CONTAINS
TRACE AMOUNTS
trace amounts of alcohol, so OF ALCOHOL.
it’s best to stick to one
12-ounce bottle a day.

H E A LT H 25
 PROBIOTIC
BACTERIA IS
CONSUMABLE
AND CAN BE
FOUND IN A
VARIETY OF
FOODS.

WHAT MAKES A
PROBIOTIC?
Probiotics and prebiotics are
temporary, transient visitors to our
gut, but this book excerpt shows their
lasting impact on the microbiome.
BY JUSTIN SONNENBURG AND
ERICA SONNENBURG, PHDS

PROBIOTIC MEANS “FOR LIFE” and was officially defined by the

World Health Organization as “live micro-organisms which, when
administered in adequate amounts, confer a health benefit on the
host.” This definition, however, leaves a gray area for collections of
microbes that offer potential health benefits (like those found in
fermented foods) but fail to qualify under the formal definition simply
because they haven’t been studied. For this reason, and for the pur-
poses of this excerpt, we will use the term “probiotic” to refer to
consumable bacteria that may provide a health benefit or are marketed
as providing a health benefit.
Probiotic bacteria, unlike the long-term bacterial residents that
make up our microbiota, are transient visitors to the gut. But their
fleeting transit through the gut does not mean that their impact is
unfelt by us and the microbes we house. There is growing evidence
that probiotic bacteria can help reduce our chance of catching certain
infections and, when we do, help us recover from them faster.
Probiotics offer a method distinct from diet to tune the microbiota
and together with diet can impact health in a beneficial manner. As
they drift through the digestive tract, probiotics communicate with

26 H E A LT H
 W H AT ’S I N YOU R GU T ?
the resident microbes and intestinal cells. The
immune system profits from these interactions, as
people who consume probiotics are better able to fight
off colds, flu, and diarrheal illness. While there is
much conflicting information about probiotics, con-
suming bacteria is a practice as old as humanity itself.
The gut has not only evolved to deal with the constant
passage of ingested bacteria, but has also learned how
to benefit from these daily guests.
Gut Tourists: Passing Through
and Leaving Their Mark
One common misconception about probiotics is that
these living bacteria take up permanent residence in
our gut. Probiotic bacteria are typically only transient
members of our microbiota, passing into the gut upon
consumption and then exiting. In the case of the
Lactobacillus that are found in fermented dairy prod-
ucts, they are most at home in envi-
ronments that contain lactose, like
milk. Even breast-fed babies are
typically not colonized by lactic
When
acid bacteria, like those that fer-
bacteria
ment dairy products, because lac-
the immune
tose from mother’s milk is digested
adopts a ready
and absorbed by the infant and not
the equivalent
available to microbes that live in
“on your mark.”
the colon.
So while many probiotic bac-
teria can survive in our gut, most are not well-
suited for this environment. They are not equipped
to consume the exotic foods found in our gut—like
the dinner we ate or the mucus layer coating our
intestine. Therefore these bacteria are only tem-
porary residents that pass through our digestive
tract. A reason why proponents of probiotics rec-
ommend their regular consumption is to ensure a
steady stream passing through. Probiotic bacteria
are similar to tourists visiting a foreign land—our
gut—from their native land—the yogurt or other
fermented food that they grew in.
Probiotic bacteria, through their ability to rein-
force the intestinal border and prime the immune
system, should be effective allies in the fight against
gastrointestinal infections. To test this notion
directly, a group of researchers from Georgetown
University Medical Center looked at whether con-
suming probiotics could protect young children from
gastrointestinal infections. They recruited 638 chil-
dren between the ages of 3 and 6 years old who were
28 H E A LT H
attending a day-care center in the Washington, D.C.,
area. Half of the children were randomly assigned to
consume a fermented dairy drink containing probi-
otic bacteria, and the other half drank a placebo con-
taining no bacteria daily, for 90 days. Parents filled
out weekly questionnaires that addressed the health
of the child, asking if they had missed school due to
illness; if they had experienced vomiting, constipa-
tion, stomach pain, or fever; or if they had been pre-
scribed antibiotics. Children who had consumed the
probiotic drink were 24 percent less likely to have
suffered from gastrointestinal infections compared
with the children not receiving probiotics. The
probiotic-consuming children were also less likely to
have used antibiotics during the course of the three-
month study.
This study is not alone in documenting the ability
of probiotics to protect against gastrointestinal
infections. A number of studies
have shown that probiotics in gen-
eral (not one specific strain or
probiotic product) can have a positive
are present, impact on people suffering from
system infectious diarrhea, reducing
state, both its severity and duration.
of Probiotic bacteria, while not per-
manent residents of our microbi-
ota, can be allies in our skirmishes
with pathogens in the gut.
Not Just a Gut Effect
It makes sense on an intuitive level that consuming
probiotic bacteria can impact health within the gut.
They are in close proximity to the intestine and the
microbiota as they travel through. But, similar to the
resident gut microbes, probiotic bacteria, as they drift
through the digestive tract, appear to impact our
biology beyond the gut and serve to promote health
throughout the body.
When studying the children at the Washington,
D.C., day-care center, researchers found, somewhat
unexpectedly, that not only did the probiotic-
consuming children have lower rates of gastrointes-
tinal infections, but they also had fewer upper-
respiratory-tract infections as well. Other trials
encompassing thousands of people have also found
fewer acute upper respiratory infections and less
antibiotic use among probiotic consumers of all ages.
These findings are building support for a view of
probiotic bacteria that takes into account their ability
 PROBIOTIC
BACTERIA ARE
NOT WELL-SUITED
TO LIVE IN THE
GUT FOREVER.
to tap into the functioning of our immune system,
not just within the local environment of the gut, but
on a global scale.
Several studies have shown that probiotic consump-
tion among healthy human volunteers coincides with
changes in immune system function to aid in the fight
against infections. The immune system seems to be
constantly performing a census of the microbial life
in the gut. When probiotic bacteria are present, the
immune system adopts a ready state, the equivalent
of “on your mark.” When an infection appears, even
if that infection is in the upper respiratory tract, the
immune system is poised to “get set” and then “go.”
Wait a minute—if this is the case, why aren’t doctors
everywhere encouraging probiotic consumption?
Here’s the catch: of the thousands of published studies
performed on probiotics, most focus on relatively
small groups of people, and their specific findings
have not been replicated in other studies. In addition,
few studies in humans are able to ascribe specific
beneficial effects to specific strains of probiotic bac-
teria. This failure to reveal the mechanisms or spe-
cific molecular interactions and genes that are
involved in, for example, a specific immune system
effect increases skepticism.
Why do probiotic effects seem so erratic? When an
individual ingests probiotic bacteria, those bacteria
interact with the microbes living within that person’s
microbiota. Because each person’s microbiota is
unique, probiotic A in Person 1 may behave differently
than it would in Person 2. Maybe Person 2 needs to
consume probiotic B or 10 times more probiotic A to
see the same effect observed in Person 1. Since the
microbiota can fluctuate from day to day, even within
H E A LT H 29
 ARTICHOKES
CAN IMPROVE
GUT FLORA IN A
PROBIOTIC
DIET.
 WH AT ’S IN YOUR GU T?

an individual, a probiotic’s effect may also vary over metabolized by the host (us) and therefore provide
time. Presently, our understanding of the microbiota nourishment to the bacteria in the colon. Upon arriv-
is not complete enough to predict what specific effects ing in the colon, prebiotics can be fermented by bac-
a particular probiotic could have on an individual’s teria within the microbiota to promote their growth
microbiota. For this reason, we feel that fermented and abundance, and positively impact health.
foods, which contain a diverse collection of micro- One of the most common commercially available
organisms, offer the best chance of encountering a prebiotics is inulin, a polymer of up to 60 molecules of
microbe that will have a positive effect. fructose that are joined together like links on a chain.
The most common type of probiotic-containing Inulin can be purchased as a dietary supplement, but
foods in the United States is fermented dairy products it is naturally found in many fruits and vegetables
like yogurt and cultured sour cream (although sour (especially bulbs such as onions and tubers like
cream can also be produced without bacteria, so not Jerusalem artichokes). With the justified backlash
all sour cream contains living microbes). Kefir, a less against consuming large amounts of fructose—usually
common probiotic dairy beverage, is fermented using in the form of high fructose corn syrup—it may seem
a diverse collection of up to 100 different species of counterintuitive to consume large polymers of fruc-
bacteria and yeast and, like yogurt, contains billions tose with the goal of improving health. However, in this
of living microbes per serving. Its vast assortment of case the devil is in the details. The fact that inulin is a
microorganisms makes it a favorite in our household, polymer of fructose changes its fate in our digestive
especially during cold and flu sea- tract from that of a single molecule
son. The diverse set of microbes in of fructose found in corn syrup.
kefir maximizes the chances that, Probiotics may Like a sponge in water, our digestive
within our family of four, each per- be most beneficial system is very adept at absorbing
son’s microbiota will respond to at in helping healthy single fructose molecules and shut-
least one of the microbes within people prevent tling them into our bloodstream.
this drinkable probiotic zoo. disease rather than Bacteria are also good at ferment-
In the West, other familiar fer- treating a medical ing fructose, but because we absorb
mented foods include sauerkraut condition. it so early in the digestive process,
(fermented cabbage), pickles (fer- little, if any, of it ever reaches the
mented cucumbers or other vege- microbes in our large intestine. In
tables), and more recently kombucha, a popular contrast, the human genome does not encode the
fermented, sweetened tea. In addition to these more capacity to snip the chemical bonds that link fructose
readily available options, people around the globe have together in inulin, so these linkages function like a
figured out how to ferment just about everything, locked cage, making fructose molecules unavailable
including beans, fruits, vegetables, grains, and even to us. Once this “cage” reaches the microbiota, which
meat and fish. Hakarl, a traditional dish in Iceland, is is filled with bacteria that have the key to unlock it, the
shark meat that has fermented for up to three months doors of the cage are opened and the microbiota can
in a sand-and-gravel-filled hole dug into the side of a feast on its contents—the single fructose molecules. If
hill. (The angle allows for the draining of juices.) we didn’t have a microbiota, inulin would pass straight
Although we cannot personally attest to the palatabil- through us and emerge virtually unaltered.
ity of this dish, we imagine it must be an acquired taste! Gut bacteria ferment inulin and produce short-
chain fatty acids. SCFAs can be absorbed for energy
Prebiotics and Synbiotics: and can protect our gut from inflammation. So while
Probiotic Shelf-Mates fructose has received a bad reputation, it’s important
Prebiotics, unlike probiotics, are not living organisms, to think about the form in which you are consuming
but as with probiotics, the ultimate goal in ingesting fructose. In its polymeric form, like inulin, it can
them is to increase the number of good bacteria in provide sustenance to the microbiota.
your colon. Prebiotics are food-derived compounds, Many prebiotics are simply purified forms of
usually long chains of linked sugar molecules known dietary fiber and therefore are also found naturally
as complex carbohydrates or polysaccharides—a puri- in abundance in plants. For instance, inulin and fruc-
fied form of dietary fiber—that are not absorbed or tooligosaccharides, or FOS, along with many other

H E A LT H 31
 W H AT ’S I N YOU R GU T ?
carbohydrate polymers, are abundant in onions, gar-
lic, and Jerusalem artichokes. In fact, almost all plant-
based carbohydrate polymers and dietary fiber can
be thought of as prebiotics that can be consumed by
members of the microbiota.
A Probiotics User’s Guide
Before you use probiotics to treat a medical condition,
it is important to confer with your physician to deter-
mine which particular probiotics might be best for you.
While probiotics have been consumed safely for hun-
dreds of years, there can be concerns for immuno-
compromised patients, underlining the need to talk
with your physician. Probiotics may be most beneficial
in helping healthy people prevent disease rather than
treating a medical condition.
Consumable, living bacteria are available in a
variety of forms, such as supplements, fermented
foods that have not been sterilized
(like yogurt, unpasteurized sauer-
kraut or pickles, kimchee, and
miso paste), and nonfermented A little trial and
foods that have had live bacteria error with
added to them (such as Good- probiotic-containing
belly, a bacteria-supplemented foods
fruit juice). Sour cream, butter, supplements
and some cheeses are examples needed to find
of foods that may or may not be that agrees
fermented and contain live bac- your system.
teria. The bacteria- containing
versions of these products com-
monly contain fewer microbes than required for the
“live and active cultures” label (at least 100 million
bacteria per gram), but often can be identified by the
word “cultured” on the label. Other foods that have
traditionally been fermented, like pickles, are now
often pickled using vinegar brine, bypassing the use
of bacteria. Some fermented foods are pasteurized, a
process that kills the bacteria, and are therefore not
a source of living microbes. If a fermented food is not
refrigerated but stored at room temperature in jars
or cans (e.g., canned sauerkraut), it likely contains no
living microbes. So it’s important to read labels care-
fully if you want to ensure that the product contains
living microbes. Most probiotic products proudly
display that fact on their label.
Because of the individual nature of each person’s
microbiota and the inability to predict which type
and how much probiotic might be helpful and for what
conditions, it is important to find probiotics that work
32 H E A LT H
well with your microbiota. Any probiotic product that
causes uncomfortable bloating, excessive gas, or head-
aches is not a good match for you. One of the more
obvious benefits you should experience with pro-
biotics is more regular and easily passed stools. It may
require a little trial and error with various types of
probiotic-containing foods or supplements to find
one that agrees best with your system.
There are a number of probiotic foods you can
experiment with, many of which are dairy products,
but there are also nondairy options. There are also
great online suppliers of starter cultures to help you
produce your own yogurt, kefir, kombucha, and even
fermented soy products, rice, and vegetables. One
example of a company that we have used is Cultures
for Health. If none of these options are right for you
or you feel that you would be better served with a
supplement, remember that you have many options
derived from different sources. To
avoid potentially shady probiotic
manufacturers, it is important to
buy from trustworthy companies.
various Most reputable probiotic compa-
nies provide information about
or studies conducted with their prod-
may be ucts and have labels that clearly
one provide the names of the bacteria
best with contained within, as well as infor-
mation on their shelf life. Products
that specify only the date of man-
ufacture should be treated with
suspicion. Organizations like the U.S. Pharmacopeial
Convention (USP), a scientific nonprofit organization,
provide third-party product evaluation indicated on
the product’s label.
In the search for the right probiotic, it is important
to systematically try different ones until you find
something that seems to work well for you. How can
you tell? In the absence of symptoms that you are
trying to eliminate, the biggest clue we have about
what is happening to the microbiota is your stool. The
ideal stool is smooth, soft, and easy to pass and comes
out in one long snake-like piece without any cracking,
which is an indication of constipation. The lack of a
splash means you are on the right track. ●
From The Good Gut by Justin Sonnenburg and Erica
Sonnenburg. Foreword by Andrew Weil, MD. Published by
Penguin Press, Penguin Random House LLC. Copyright
© 2015 by Justin Sonnenburg and Erica Sonnenburg.
 SOME
FERMENTED
FOODS MAY
NOT CONTAIN
BACTERIA. CHECK
LABELS TO BE
SURE.

AS A
REGISTERED
DIETITIAN,
FIGUEROA HAS
A PASSION FOR
HEALTH
ADVOCACY.
IMPROVING NUTRITIONAL HEALTH is
about embracing an eating
THE PATH TO philosophy that promotes gut
health and overall well-being.
DIGESTIVE
For the past few decades, the
conversation around healthy
WELLNESS
eating and nutrition focused
mostly on finding magical
foods and miraculous
supplements that will help us
While gut health has become lose weight, burn fat, and
build buns of steel. While
a hot topic in recent years, there is no shame in wanting
improving accessibility of vital to feel and look our best, I am
resources and support is crucial. excited for our collective
consciousness around
BY ALICE FIGUEROA, MPH, RDN
nutrition to evolve beyond our
society’s fixation on restric-
tion and to focus instead on
promoting gut health.
I was inspired to become a
registered dietitian nutrition-
ist because I struggled with
debilitating gut-health issues.
34 H E A LT H
After Hurricane Katrina
devastated my beloved
hometown of New Orleans,
I silently struggled with
chronic gastritis and irritable
bowel syndrome (IBS) for
years, which disrupted my
enjoyment of food and life.
When my symptoms flared
up to their worst, I lived in
fear of not being close to a
bathroom, dreaded eating
out with friends, and endured
chronic stomach pain. If there
is a lesson I’ve learned, it’s
that nurturing your gut health
is key to leading a happy and
healthy life.
Why should we dedicate
our efforts to promoting gut
health in our diverse commu-
nities? Gut health influences
optimal digestion, efficient
absorption of nutrients, a
diverse microbiota, and a
strong immune system. It
not only affects the bodily
functions involved in the
digestion of food, like nutrient
absorption and bowel move-
ments, but also affects overall
health. Although the field of
gut-health research is still
new, studies show that it plays
a crucial role in skin, heart,
kidney, immune, hormonal,
and mental health.
It is vital for people of all
ages, ethnicities, races,
genders, and socioeconomic
statuses to nurture gut
health. Although digestive
diseases are found in every
segment of the population,
there are some groups that
are disproportionately
affected by specific gut-
health conditions. Women are
more commonly diagnosed
with autoimmune digestive
conditions like celiac disease
and inflammatory bowel
disease. Latinos, Asians,
Native Americans, and
African Americans have the
highest death rates from
digestive-system cancers like
stomach and pancreatic
cancer. Additionally, a lack of
access to primary care

doctors, gastroenterologists,
and dietitians, high rates of
uninsurance or under­
insurance, limited access to
healthy foods, cultural and
linguistic barriers, and sparse
economic resources play a
role in gut­health disparities.
Whether you have an
amazing insurance plan or
are currently uninsured or
underinsured, there are
telltale signs that you may
need to seek medical
attention.
In the United States,
around 60 million to 70 million
people suffer from digestive
diseases that directly affect
gut health, such as colon
cancer, chronic inflammatory
bowel diseases, autoimmune
diseases like celiac, functional
gastrointestinal disorders,
foodborne infections like
salmonella, and digestive
conditions, such as chronic
constipation, related to food
and pharmaceutical intake.
While frequently suffering
from an upset stomach or
constipation may not seem
life­threatening, it can lead to
severe health complications
in the future. The “IBS Global
Impact Report 2018” found
that it “takes four years for an
individual to receive a
definitive diagnosis of IBS.”
A health survey from Harris
Interactive on behalf of AbbVie
found that 74 percent of
people reported experiencing
gastrointestinal symptoms
like gas, bloating, diarrhea,
and stomach pain for more
than six months. More than
half of the people surveyed
who experienced digestive­
health issues did not speak
with their primary care
physicians about their
symptoms. Generally, patients
do not speak to their doctors
because they may be
self­conscious about their
symptoms or suspect their
doctor won’t take their
symptoms seriously. Our
current medical system is not
holistic and lacks a continuum
of care that could link patients
to gut­health services.
Gut­health disparities affect
economically disadvantaged
and underserved rural and
urban communities that lack
access to basic affordable
health care. Although the
medical community is making
an effort to shift health care to
a more patient­centric model
and increase the number of
doctors working in under­
served communities, much
work remains.
Making fiber­rich foods
affordable and available for
communities that lack access
to them is key to improving
gut health in our society.
We can increase access to
digestive­friendly nutrition
by championing healthy food
options at schools, hospitals,
5 to 7 restaurants, and workplaces
The and supporting efforts to
estimated bring farmers’ markets,
percentage of community­supported agri­
adults in the culture, and local produce into
U.S. suffering our communities.
from IBS who Public health efforts to
have been improve digestive health must
diagnosed. bring together departments of
SOURCE: American
College of
health, hospitals, research
Gastroenterology universities, insurance and
pharmaceutical companies,
and public health organiza­
tions to implement policies
and regulations that raise
gut­health awareness,
streamline the process of
accessing digestive­health
screenings like colonoscopies,
and reduce the costs of
digestive­health services,
nutrition therapy, and
medications. The medical
community needs to focus on
implementing a patient­
centered continuum of care
that educates patients and
medical professionals about
gut health, allows primary
care physicians to effectively
screen for digestive diseases,
and links patients to gastro­
enterologists and dietitians for
specialized treatments and
interventions. ●
WH AT ’S IN YOU R GU T?
You may be thinking that
you’re too busy to nurture your
digestive health, but there are
attainable, realistic, and
affordable changes you can
implement.
1
Eat a plant-centric diet
high in fiber and prebiotic­
and probiotic­rich foods to
nurture gut­friendly microbes
and promote healthy bowel
movements. Foods rich
in fiber and prebiotics
include garlic, onions, leeks,
bananas, cauliflower, beans,
nuts, seeds, brown rice,
and lentils.
2
Eat in a way that fits your
budget and cultural
identity. Purchase afford­
able whole foods including
fruits, vegetables, and whole
grains that you find familiar
and delicious. When your
budget and time allow it,
explore ways to incorporate
new gut­friendly foods into
your favorite family recipes.
For example, you can add
fiber­rich vegetables like
broccoli or carrots to your
go­to stew, curry, or pot
roast recipe.
3
Do not ignore digestive-
health issues. If you are
uninsured, inquire about
community health centers
that provide low­cost medical
services and check your
eligibility for affordable health
insurance at healthcare.gov.
4
Build an open and honest
relationship with your
primary care physician and
gastroenterologist. Ask
your doctor to refer you to a
registered dietitian or find one
at eatrightpro.org.
H E A LT H 35
36 H E A LT H
CHA PT ER TWO

Digestive
Distress
When tummy trouble
gets serious.
 THE INTOLERANCES
Food intolerances are on the rise—but thankfully,
so are the options for diagnosing, understanding, and
managing these potentially debilitating conditions.
BY AMANDA M ac MILLAN

YOU KNOW THE FEELING: that sinking sensation in
your gut—literally—that sends you running to the
bathroom, doubles you over in pain, or leaves you
squirming uncomfortably for hours. It happens to all
of us occasionally, but for some, it happens more often
than it should. And when those occasions can be
traced to specific eating patterns, doctors say a food
intolerance may be to blame.
A food intolerance, also called a food sensitivity, is
not the same as an allergy. The former has to do with
the body’s inability to digest a specific food or ingre-
dient, which results in gastrointestinal distress, while
the latter is an immune reaction. Allergies can trigger
digestive issues, too, but they can also cause hives,
itching, trouble breathing, and even changes in heart
rate and blood pressure.
Food intolerances are much more common than
true food allergies, and research suggests that they’ve
increased over the past 50 years. They’re not usually
life-threatening the way an allergic reaction can be,
but that doesn’t mean they’re not worthy of medical
attention. “Food intolerances can be seriously debil-
itating to quality of life, especially if they go undiag-
nosed or untreated,” says Yamini Natarajan, MD, an
assistant professor of gastroenterology at Baylor
College of Medicine.
The good news is that doctors have gotten better at
diagnosing food intolerances, and there are more
options available than ever before for people following
restricted diets. There’s also ongoing research into
treatments that may help reduce symptoms and aid
digestion. Here are some of the most common food
groups associated with intolerance, and what to do if
you think you might be affected.
Dairy
One of the most common food intolerances is to lactose,
a sugar found in dairy products. The human body

38 H E A LT H
 ABOUT
65 PERCENT
OF PEOPLE
HAVE TROUBLE
DIGESTING
LACTOSE.
 BREAD IS THE
MOST COMMON
FOOD PEOPLE
GOING
GLUTEN-FREE
SWAP OUT.

breaks down lactose with the help of an enzyme
produced in the small intestine, called lactase. But
some people don’t produce enough lactase, espe-
cially as they get older.
The ability to produce lactase is governed by a gene
called the LCT gene. Some people are born with a
mutation in this gene that interferes with lactase
production, even as infants. (These babies can’t even
digest breast milk and need dairy-free formula to
stay healthy.) But for many others, lactose intoler-
ance comes on later in childhood or in adulthood,
when the LCT gene is switched off. “When that hap-
pens, that milk sugar acts more like a laxative, and it
can cause abdominal distress,” says Joseph Murray,
MD, a gastroenterologist at the Mayo Clinic in
Rochester, Minnesota.
About 65 percent of the human population has a
reduced ability to digest lactose
after infancy, according to the
National Institutes of Health. This
includes more than 90 percent of
“A growing
people of East Asian descent, and
of individuals
it’s also common in people of West
deciding,
African, Arab, Jewish, Greek, and
without
Italian backgrounds. By contrast,
diagnosis,
only about 5 percent of people of
simply
Northern European descent are
when they
lactose intolerant.
eat gluten.”
When the small intestine can’t
break down lactose, bacteria in the
large intestine has to do the job instead—which can
cause pain, bloating, gas, nausea, and diarrhea, usu-
ally 30 minutes to two hours after eating or drinking
dairy. Some people have trouble with any amount and
any type of dairy, while others can have yogurt and
cheese (which go through a fermentation process that
breaks down most of their lactose) or small amounts
of milk without symptoms.
Lactose intolerance can be diagnosed with a
blood test, a breath test, or a stool test. “But unfor-
tunately, none of these tests are as precise as we’d
like them to be,” says Dr. Natarajan. So in addition,
she asks patients to avoid all dairy for two to four
weeks and see how they feel. “This is just a short-
term trial,” she adds. “Once we establish that this
is the cause of your symptoms, you don’t have to
avoid all dairy forever.”
As with most intolerances (as opposed to allergies),
Dr. Natarajan says that it’s important to remember
that consuming lactose once in a while won’t
DIGESTIV E DIST RESS
physically harm you—although it may make for an
unpleasant few hours. “I have patients who really
crave ice cream, and they just decide to stay home that
night and use the bathroom a lot.”
Fortunately, there are lots of dairy-free milk,
cheese, and ice cream alternatives on the market
today. To name just a few, consumers can choose from
oat, soy, coconut, or nut “milks” for their coffee or
cereal, along with nondairy creamers made from
sodium caseinate—an ingredient that’s derived from
milk but is lactose-free. Over-the-counter lactase
enzymes—available in tablet, liquid, or powder form—
may also help some people digest dairy products with-
out symptoms.
Scientists are also studying ways in which altering
the gut microbiome might help people become more
lactose tolerant. Early studies have shown that
encouraging the growth of lactic
acid bacteria—by “feeding” them
a special prebiotic known as
number RP-G28—seems to help improve
are people’s ability to break down
with or dairy products. Results are
a medical expected soon from a recently
that they completed clinical trial by Ritter
feel better Pharmaceuticals involving 377
don’t lactose-intolerant patients, with
hopes that the prebiotic will be
FDA-approved and brought to
market in the near future.
Wheat
The trend of “going gluten-free” isn’t going away
anytime soon: The global gluten-free-product mar-
ket is expected to grow from approximately $4.7 bil-
lion in 2018 to $7.6 billion by 2024, according to a
recent report from Zion Market Research. One rea-
son? The prevalence of celiac disease—an autoim-
mune disorder in which gluten, a wheat protein,
damages the intestines—has increased fivefold in the
past 50 years and is now estimated to affect at least
1 percent of the population.
People with celiac disease experience long-term
damage to their intestines, which may or may not
come with acute symptoms like stomach pain and
digestive issues. More awareness and better tests can
explain some of the increase in celiac diagnoses, says
Dr. Murray. But studies also show that, for reasons
scientists don’t quite understand, more people simply
have the disease.
H E A LT H 41
 DI GESTI V E D I ST R ESS
It’s not just people with celiac disease who are
avoiding bread and pasta, though. “A growing number
of individuals are deciding, with or without a medical
diagnosis, that they simply feel better when they don’t
eat gluten,” says Dr. Murray. “We don’t know why
exactly, but this seems to be a real and entirely sepa-
rate type of sensitivity.”
People with a gluten intolerance (and some people
with celiac disease as well) may notice bloating,
cramping, or diarrhea after eating wheat-based prod-
ucts. Some people also report nondigestive issues,
such as rashes or headaches, says Dr. Murray,
although it’s less clear whether these symptoms are
truly related to gluten.
Bonnie Jortberg, RD, an associate professor of
family medicine at the University of Colorado
School of Medicine, urges anyone who suspects that
gluten is causing digestive distress to keep a food
and symptom diary and report
their findings to their doctor.
While there’s not a definitive test
for gluten intolerance, there is
“People
one for celiac disease—but,
underestimate
because it tests for antibodies
how much
produced in response to wheat
can help when
consumption, it has to be con-
comes
ducted before patients start a
gastrointestinal
gluten-free diet.
comfort.”
If you do have celiac disease, it’s
important to know for sure. You’ll
have to be extra careful to avoid even small traces of
gluten—which can be found in unexpected products,
like sauces, soups, salad dressings, and even some
processed meat and dairy items. You may also need
additional tests to see if your disease has caused other
health problems, like nutritional deficiencies that can
result in anemia and bone loss.
On the other hand, testing negative for celiac dis-
ease doesn’t mean your symptoms aren’t real—and
limiting wheat-based foods may still help. Plus, says
Dr. Murray, products that contain gluten often have
other ingredients with proven health risks, like the
refined sugars in white bread, cookies, pastries, and
fast food. Eating fewer processed foods like these can
benefit anyone’s diet, he points out, whether gluten
is an issue or not.
But keep in mind that cutting out an entire food
group has its own drawbacks as well. Wheat (espe-
cially whole wheat) is a big source of fiber, so if
you’re no longer eating bread, pasta, or cereal on a
42 H E A LT H
regular basis, make sure you’re getting plenty of
high-fiber fruits, vegetables, legumes, and
gluten-free grains, like brown rice. You may also
want to ask your doctor about taking a fiber sup-
plement if you don’t think you’re reaching the rec-
ommended 25 to 30 grams a day.
Fructose
While gluten and dairy are the best-known food
intolerances, they’re not the only ones out there.
Another is fructose intolerance, also known as fruc-
tose malabsorption. This occurs when the small
intestine isn’t able to break down fructose, a simple
sugar that occurs naturally in fruit, honey, and some
vegetables, and is often added to sugar-sweetened
foods and beverages.
This problem has become much more common
in the past couple of decades, likely due to the
increased use of fructose (includ-
ing high-fructose corn syrup) in
processed foods—a more than
really 1,000 percent jump from 1970
to 1990, according to the USDA.
fiber “Fructose has become the main
it sweetener in the United States,
to your and it seems that maybe our bod-
ies haven’t fully adapted to it,” says
Dr. Murray.
Research suggests that fructose
intolerance can also be caused by
inflammation in the body, or an imbalance of good
and bad bacteria in the gut. Today it’s estimated that
up to one in three people who are diagnosed with
irritable bowel syndrome (IBS) can blame their symp-
toms at least partially on fructose malabsorption.
A breath test, similar to the test for lactose intol-
erance, may be able to determine if your body is hav-
ing trouble absorbing fructose. Keeping a detailed
record of the foods you eat and any symptoms you
experience can also help you and your doctor deter-
mine the cause. If fructose is suspected, you might be
instructed to limit or avoid high-fructose foods and
beverages such as soda, fruit juice, apples, grapes,
watermelon, peas, and zucchini. (Most people can
still eat small servings of other fruits, like berries,
bananas, and avocados, without problems.) People
with fructose intolerance should also check ingre-
dient labels on foods for hidden forms of fructose,
including honey, agave syrup, molasses, palm or
coconut sugar, sorghum, and invert sugar.
 FRUCTOSE
CAN BE HIDDEN
IN FOODS LIKE
HONEY, AGAVE
SYRUP, AND
MOLASSES.
 FRUCTANS
CAN BE FOUND
IN LEGUMES
SUCH AS PEAS.
 DIGESTIV E DIST RESS

FODMAPs
There are also people who have diges-
tive issues not related to one specific
food or food group. These people are
often given a general diagnosis of IBS,
but recent research suggests there may
be dietary cues involved after all.
“Some IBS patients report that symp-
toms are worse when they eat specific
things and better when they avoid
them,” says Dr. Murray. “One example
of that is a FODMAP intolerance.”
The term FODMAP stands for fer-
mentable oligosaccharides, disaccha-
rides, monosaccharides, and polyols,
which are different types of carbohy-
drates. FODMAPs include fructose and
lactose, but they also include fructans
(found in grains like wheat and barley),
galactans (found in legumes), and sugar
alcohols (like xylitol, sorbitol, maltitol,
and mannitol, found in many foods
marketed as low-calorie or sugar-free). really underestimate how much fiber can help when
When FODMAPs reach the large intestine, they’re it comes to your gastrointestinal comfort,” says
broken down by bacteria that produce hydrogen—a Jortberg. On the other hand, eating too much at once
contributor to gas, bloating, and stomach pain for can also cause digestive issues, she adds. “If you
some people. Digestion of FODMAPs can also cause haven’t been getting much fiber and suddenly you’re
abdominal dissension (which, in other words, makes eating a bunch of Brussels sprouts and beans, you’re
your stomach look larger than normal) and can draw also going to have some stomach discomfort until
water into the intestines, which can cause diarrhea. your body adjusts.” (Before you give up on these foods
The term FODMAP was first described in 2005, and entirely, try adding them in more gradually.)
research on low-FODMAP diets is still in its infancy, Eating large quantities of fatty food can also cause
says Jortberg—but she agrees the idea is intriguing. “If stomach discomfort, as anyone who’s ever scarfed
I’m working with someone and we’ve gone the gluten down a burger or a New York strip steak can likely
route and the lactose route and they’re still having attest. “Fat takes a really long time to digest, so it sits
issues, then I’ll start looking into the FODMAPs,” she in your gut longer than carbs or protein and has more
says. “Or if they’re experiencing symptoms after a food time to interact with all that bacteria,” says Jortberg.
that fits the profile for the FODMAPs, that’s another No matter what, that process of figuring out what,
clue.” A 2019 study in the gastroenterology journal exactly, is causing digestive problems can be frustrating
JGH Open concluded that many studies support the and involve a lot of trial and error. But for many people,
idea of restricting FODMAPs for people with IBS but Dr. Natarajan says, it’s worth it to finally understand
that larger studies with better methodology are still their symptoms and how to manage them.
needed “to establish a definite conclusion.” In the meantime, it’s important not to feel scared or
alone. “A lot of people come in very anxious, worried
Other Potential Triggers that they might have cancer or something life-
There are, of course, other dietary causes of gastro- threatening,” she says. “It helps to reassure people that
intestinal discomfort that don’t exactly qualify as this is really common, that they’re not doing anything
intolerances. Not eating enough fiber, for example, wrong, and that we have a lot of decent tools to evaluate
can cause constipation and chronic bloating. “People what’s going on and get them the help they need.” ●

H E A LT H 45
 CROHN’S
SYMPTOMS
INCLUDE
ABDOMINAL PAIN,
DIARRHEA, AND
WEIGHT LOSS.

CROHN’S
CROHN’S DISEASE is one or the end of the small
form of inflammatory bowel intestine. First described by

DISEASE
disease (IBD), a condition Burrill B. Crohn, MD, in 1932,
that’s characterized by Crohn’s disease affects about

EXPLAINED
Here is a rundown of the cause,
symptoms, diagnosis, and
treatment options for living
with this GI issue.
inflammation in the gastro­
intestinal (GI) tract. (The
other main form of IBD is
called ulcerative colitis, which
can cause similar symptoms
and is sometimes mistaken
for Crohn’s.) Although
Crohn’s can affect any area in
the GI tract, from the mouth
to the anus, the inflammation
usually occurs in the ileum,
780,000 people in the United
States. The disorder may be
partly genetic: It tends to
cluster in families and is more
common in certain ethnic
groups, like Eastern
Europeans.
The Cause
Experts aren’t entirely sure
what causes IBD, but they

46 H E A LT H

suspect that a combination
of genetic and environ­
mental factors may be to
blame. One of the causes of
Crohn’s disease may be a
“sensitive” immune system,
which mistakes harmless
bacteria for dangerous
pathogens, triggering long­
term inflammation and other
GI symptoms.
In terms of genetics,
people are 5 percent to
20 percent more likely to
develop Crohn’s disease if
one of their close relatives
has the condition. Scientists
have found that people with
variations in the NOD2
gene—which is responsible
for producing a protein that
helps protect the body
against viruses and
bacteria—are more likely to
have a form of Crohn’s that
affects the ileum.
Although stress and
an unhealthy diet could
exacerbate the disease itself,
neither causes Crohn’s.
However, because Crohn’s
disease is more common in
urban areas and developed
countries than in rural areas
and underdeveloped
countries, researchers
believe that a person’s
environment may be partly
to blame, too.
Figuring Out the
Symptoms
The signs of Crohn’s disease
can overlap with those of
other conditions—not just
ulcerative colitis but also
other GI disorders like
stomach ulcers, pancreatitis,
gallbladder disease, and
colorectal cancer. Some of
the most common symp­
toms include diarrhea and
bouts of loose, watery stools
that occur more than a few
times each day. In some
cases, you may even find
blood in your stool.
Abdominal pain is another
thing to be on the lookout for.
Crohn’s disease causes
inflammation, which can
trigger cramping and pain in
the abdomen.
Inflammation caused by
Crohn’s disease can also
lead to anemia. Anemia is
characterized by a
lower­than­average num­
ber of red blood cells in the
body or a lower­than­average
amount of hemoglobin, an
iron­packed protein that
helps shuttle oxygen from
the lungs to tissues, in the
cells themselves. The result:
The blood isn’t providing
enough oxygen to the rest
of the body, causing
breathlessness, fatigue,
and more.
Joint pain is the most
common nongastrointestinal
complication of IBD,
affecting up to one in four
people with the condition,
according to the Crohn’s &
Colitis Foundation. Three
types of arthritis appear in
people of any age with
Crohn’s disease: periph­
eral arthritis (which affects
the major joints of the arms
and legs), axial arthritis
(which affects the lower
spine), and ankylosing
spondylitis (which also
affects the spine but can lead
to eye, lung, and heart­valve
inflammation).
Skin changes can be a
factor too. Up to 10 percent of
people with Crohn’s disease
develop skin reactions
including erythema nodosum
(painful, tender bumps),
pyoderma gangrenosum (red
bumps that become open
sores), and aphthous
stomatitis (mouth sores),
according to a study
published in the United
European Gastroenterology
Journal in 2016.
Getting Diagnosed
There’s no specific test for
this condition. Rather,
doctors diagnose the disease
by using a combination of lab
tests and imaging
DIGESTIV E DIST RESS
procedures. A blood test can
determine whether a person
has a low red­blood­cell
count (which could signal
anemia) or a high white­
blood­cell count (which could
indicate inflammation), while
a stool test will help detect
inflammation and rule out
infections with similar
symptoms to Crohn’s
disease, like C. difficile
and E. coli.
Other tests use tiny
cameras affixed to long,
narrow tubes to help
diagnose Crohn’s disease
while ruling out ulcerative
colitis, diverticulitis, and
cancer. These include
colonoscopies (in which the
camera, or endoscope, is
50% used to examine the rectum,
The colon, and ileum), an upper
approximate GI endoscopy (in which an
portion of endoscope is inserted down
people with the esophagus and into the
Crohn’s stomach), and a capsule
disease who endoscopy (in which a
will be in capsule that contains a tiny
remission camera is swallowed, and
over the next images of the digestive
five years tract are transmitted to
after getting a receiver).
medical or Lastly, doctors can use a
surgical computed tomography (CT)
treatment. scan, which can create
SOURCE: Crohn’s & images of the digestive tract,
Colitis Foundation
to diagnose Crohn’s disease
and check for possible
complications.
Seeking Treatment
There are many different
treatments for this gastro­
intestinal disease, including
medication and surgery.
There’s no one type of
treatment that will work for
everyone, however; instead,
a doctor will take a detailed
history of your symptoms
and run tests before
deciding which option may
work best for you. Although
there are many types of
medications available, up to
75 percent of people with
Crohn’s disease may one day
need surgery. ●
H E A LT H 47
 KEEPING
TRACK OF WHAT
YOU EAT COULD
HELP IDENTIFY
CROHN’S
TRIGGERS.
 HEALTHY EATING
FOR CROHN’S
DISEASE
Crohn’s can feel difficult to manage, but you can avoid
discomfort and enjoy food with these strategies.
BY AMANDA M ac MILLAN

Talk to a Nutritionist what types of food worsen your IBD symptoms.

If you have Crohn’s disease and are concerned about
your nutrition, it would be a good idea to talk to a
registered dietitian, especially one who is familiar
with inflammatory bowel disease (IBD), says Julie
Cepo, RD, who works with IBD patients at Mount
Sinai Hospital in Toronto and is a coauthor of The
Crohn’s & Colitis Diet Guide. “I help them come up
with an eating strategy that they can tolerate but that
also works with their personal and cultural prefer-
ences and food philosophies,” Cepo says. Seeing a
nutritionist who doesn’t understand IBD, on the other
hand, may do more harm than good, warns Sunanda
Kane, MD, a professor of medicine at the Mayo Clinic
in Rochester, Minnesota.
Write It Down
Keep track of everything you eat, how you feel after
you eat it, and the status of your disease to determine
Because they’re different for every person, recording
the details is the best way to learn what your body can
and can’t process.
“Also, I ask people not to introduce a lot of new foods
too quickly,” says Cepo. “Introduce them one at a time,
and wait a day or two to see if it affects your symp-
toms.” And it’s not a bad idea to try new foods at home
first, before eating them in a social situation.
Eat Small, Frequent Meals
Portion control is important because eating too much
at one time can make it hard for the body to digest food.
Eating more frequently can help. You can still eat
three meals a day, but make them a bit smaller than
usual, and supplement them with several well-
balanced snacks in between. “You won’t go into your
next meal as hungry, and you’ll be less likely to over-
eat, which may lead to bloating,” says Cepo.

H E A LT H 49
 DI GESTI V E D I ST R ESS
Go Easy on the Grease
Fatty foods can be hard for the body to digest and
make diarrhea worse, especially if you’ve had certain
parts of your bowel removed during surgery for
Crohn’s disease. (Plus, certain fats are bad for your
heart.) So people with Crohn’s disease should stay
away from greasy or deep-fried foods. Creamy
sauces, like mayonnaise and Alfredo sauce, can also
be problematic.
Try a Reduced-Fiber Diet
While fiber is an important part of a healthy diet,
doctors and nutritionists may recommend a low-fiber
diet for those who are having a flare-up, healing after
surgery, or experiencing bowel narrowing due to
inflammation or scar tissue.
This diet can help reduce cramps, diarrhea, and
the volume, consistency, and frequency of stool.
One thing to keep in mind: Fruits
and vegetables, which are typi-
cally high in fiber, aren’t off-
limits—cook them to cut their
“Working
fiber, or remove the seeds, skins,
dietitian
and fibrous membranes.
can help you build
Cepo recommends the diet only
back confidence
to manage symptoms in the short
and improve
term. If you’re feeling better and
relationship
your doctor says it’s OK, go back
with food.”
to a more robust diet.
Be Careful with Dairy
Just like the general population, lots of people with
Crohn’s disease have some level of lactose intolerance.
The conditions are usually unrelated, but they do
share many of the same symptoms.
For these people, dairy may explain some of their
pain and GI problems. “If you realize that dairy does
affect you, it may not be a case of avoiding it
completely, but it’s a question of finding out how
much you can tolerate,” says Cepo. “Two pieces of
pizza with cheese might be OK, but three might be
too much.”
Avoid Roughage
Corn, beans, and stringy vegetables like raw celery
and broccoli aren’t easily digested; in Crohn’s they
can cause cramping, bloating, and diarrhea.
“We call it roughage, and it’s rough on your system,”
says Dr. Kane. “For a healthy intestine, that is a good
thing, but for an inflamed one, it can be bad. Having
50 H E A LT H
to process things that are still intact will make some
people really uncomfortable.”
Dr. Kane suggests trying a “low-residue diet” that
is low in fiber and other foods that are difficult to
digest like raw fruit, vegetable peels, and seeds.
“When you have active IBD symptoms, these foods
are just going to make you feel lousy,” she says.
Prep Foods in a New Way
Many foods that are a problem when raw or whole can
be eaten if prepared differently, says Cepo. “We try
to focus on what people can still have; often that
means cooking foods well, like string beans, cauli-
flower, or carrots and sweet potatoes.”
Stringy foods like onions may be better tolerated
if chopped into very small pieces, just as seeds and
nuts seem to cause fewer symptoms when they’re
ground. Chickpeas and sesame seeds, for example,
may cause problems, but hummus,
which is made with ground chick-
peas and tahini, a sesame-seed
with a paste, may not.
or a doctor
Stay Hydrated
Water intake is always important,
that but critically so if you experience
diarrhea frequently. Cepo cau-
tions patients to limit beverages
with caffeine, carbonation, or too
much sugar—all things that can
make GI symptoms worse.
Water is a good choice, she says, as are diluted fruit
juices without a high sugar content. For people who
are very sick and at risk of becoming dehydrated, an
over-the-counter rehydration beverage can replenish
fluids and electrolytes.
Pump Up Your Electrolytes
Replenish lost electrolytes such as sodium and
potassium if you’re having loose stools. “One option
is to sprinkle salt liberally on your food,” says Cepo.
You can also sip broths or bouillons and choose salty
snacks like pretzels, crackers, rice cakes, and
potato chips.
To get more potassium, eat potatoes (without the
skin), bananas, tomato juice or sauce, avocados,
melon, and citrus fruits like grapefruits and oranges
(with the membrane removed, if needed). Coconut
water is also a good source of potassium and a good
way to stay hydrated.

Don’t Skimp on Protein
People with Crohn’s disease often give up meat,
beans, and cheese. But without protein, you can lose
muscle mass.
“People say to me, ‘I gave up red meat because I
can’t digest it,’ but it’s because they’re trying to eat a
normal American-size helping of steak or a giant
burger,” says Dr. Kane. “I tell them to eat 6 ounces
[per day] of really good quality red meat; that way,
they’ll get the iron and protein they need without
overdoing it.” Fish, tofu, beans, and eggs, if they’re
well tolerated, are also good protein sources.
DRINKING
PLENTY OF
WATER CAN EASE
THE SYMPTOMS
OF CHRONIC
DIARRHEA.
Eat Normally When You’re Well
In between Crohn’s flare-ups, if you’re feeling better,
eat normally and enjoy your food. “It can be hard for
someone knowing that the last time they ate celery
they had a terrible experience, but it may be tolerated
again when the disease is in remission,” Cepo says.
“Working with a dietitian or a doctor can help you
build back confidence and improve that relationship
with food.” As long as you don’t have any ongoing
bowel issues or long-term narrowing of your intes-
tine, following general healthy-eating guidelines is a
good strategy, says Cepo. ●
H E A LT H 51
 THE INS AND OUTS
OF IBS
Nobody likes to talk about bathroom troubles—but
ignoring irritable bowel syndrome can make the
symptoms much worse. Experts share what you need to
know about this digestive disorder.
BY MAGGIE PUNIEWSKA

OCCASIONAL GUT WOE is nothing to worry about.
Tummy issues that show up on the regular, however,
are worth paying attention to.
“IBS is the most common issue GI doctors come
across,” says Shanti Eswaran, MD, a gastroenterol-
ogist and clinical associate professor at the University
of Michigan in Ann Arbor. That doesn’t mean the
condition is easy to spot, though. It can be tricky to
diagnose because every case is unique, Dr. Eswaran
explains. “People have different symptoms and trig-
gers, so it may take time to identify IBS and then
figure out how to manage it.”
Another complicating factor: IBS triggers can be
both dietary (from coffee to fructose) and emotional—
think toxic stress levels or just situational jitters. The
good news is that all the detective work usually pays
off. “Many patients who are able to pin down what’s
causing their symptoms eventually reach a point
where they’re having them a lot less often,” says
Samantha Nazareth, MD, a gastroenterologist based
in New York City.
Getting to a Diagnosis
IBS is more than just an upset stomach now and
then. “You have to experience a few specific symp-
toms at least once a week for three months,” says
Dr.  Nazareth. One of the classic signs is abdomi-
nal pain that gets better after a bowel movement.
The other hallmark is a change in your bathroom
habits. Some people become constipated; others
get diarrhea. A small percentage alternate between
constipation and diarrhea. Symptoms can also
include cramping, bloating, and gas. And they
may not be consistent over time. Although IBS

52 H E A LT H
 DI GESTI V E D I ST R ESS

is  considered to be a chronic condition, it can wax And yet a third possibility is that IBS occurs when,
and wane. for some reason, a person’s gut isn’t moving at a
If you have a mild case, you may be managing OK healthy pace—it’s either too fast or not fast enough.
without treatment. (You might not even realize you
have a medical issue.) But for folks with more severe The Female Link
cases, the symptoms can be debilitating, causing Statistics show that IBS is more common among
them to skip social events, avoid travel, and even women than men, and for that, we can probably
miss work. thank our chemistry. “Female sex hormones could
There isn’t any way to test specifically for IBS, so
impact how we perceive stress, how we perceive
diagnosing the condition typi- pain, how slowly or quickly the
cally involves some poking and gut works—and all of these factors
prodding. Your doctor may order are related to IBS,” says Shilpa
blood work, X-rays, a stool Ravella, MD, an assistant pro-
a na lysis, a nd potentia lly a fessor of medicine at Columbia
colonoscopy. University Medical Center in New
“We basically have to rule York City. Take the fluctuations in
out other GI issues that might estrogen and progesterone that
have similar symptoms,” says happen during a normal men-
Dr. Eswaran, “like gastrointesti- strual cycle. “Those changes
nal infections, celiac disease, and can throw muscle contractions
ulcerative colitis.” in the intestines out of whack,”
Dr. Ravella says. Then there’s the
The Possible Causes hike in progesterone that occurs
Here’s what experts know: People right before a woman’s period.
with a family history of IBS are “That may slow down the gut,
more likely to get it. The condition leading to constipation.”
seems to be linked to anxiety and Fortunately, IBS seems to sub-
depression. And cases can be side naturally with the passage of
brought on by a stomach bug. But time. “We’re not sure why, but for
why IBS develops in some people a lot of women, symptoms tend to
and not others is less clear.
Researchers suspect that it has
1 in 3 get better as they get older,” says
Dr. Eswaran.
The number of
to do with the gut-brain connec- IBS patients who
tion. “Everyone’s gut and brain say they avoid Therapies That Work
talk thousands of times a day, situations in which There’s a range of drugs that treat
but we think that in people with there won’t be the less-than-pleasant effects of
IBS, that communication goes a a bathroom IBS. Depending on your symp-
little haywire,” says Dr. Eswaran. nearby. toms, your doc might suggest a
“The brain may be essentially SOURCE: “IBS in America” fiber supplement or prescription
survey, 2015
overthinking what’s going on in laxatives, antidiarrheal medica-
the gut and become hyperaware tion, or antispasmodics to relax
of the sensations there.” Most the smooth muscles in the GI tract.
folks aren’t bothered by what’s happening in their A low-dose antidepressant may make a difference
GI tract. But IBS patients seem to experience that too, even if you’re not depressed and you don’t have
activity in a dif ferent way: “If you don’t have IBS, anxiety. “Antidepressants adjust serotonin levels in
you might feel a little gassy and move on. But if you both the brain and the gut, which can help regulate
do have IBS, your brain might register that normal bowel movements and decrease painful IBS symp-
gassiness as pain,” she explains. toms like cramping,” says Dr. Eswaran.
Another working theory is that the disorder is Alternatively, your MD might recommend see-
caused by an imbalance of microbes in the intestines. ing a mental-health professional. A 2018 study in

54 H E A LT H
the American Journal of Gastroenterology found
that psychotherapy could be as effective as anti­
depressants in treating IBS. And another study
reported that IBS patients who went to therapy
experienced improvements in their symptoms up
to a year after they had ended their sessions.
Talking things out with a professional can also
help you manage IBS­specific worries, adds Kelsey
Laird, PhD, a postdoctoral scholar at the Semel
Institute for Neuroscience and Human Behavior at
UCLA. Sometimes people who have the disorder
start to dread situations in which they don’t have
easy access to a restroom, such as road trips and
backcountry hikes.
“Psychotherapy can teach long­term skills for
reframing scary situations, so people can still
SYMPTOM CHECKER
participate in activities that are important to them,”
Laird explains. “Oftentimes, reductions in stress—
and gastrointestinal symptoms—follow.”
Hit Reset
By making a few changes to your everyday lifestyle,
you might help your gut function better overall so
that you’re dealing with fewer bothersome flare­ups
of IBS. Sticking to a steady exercise routine is one
of those belly­friendly steps you can take:
Researchers found that when people with IBS who
worked out three hours a week upped their regimen
to five hours, their symptoms improved. And it
didn’t take long. They noticed a real difference
within the first 12 weeks.
Exercise is a well­known stress buster, Dr. Naza­
reth points out. And physical activity may have a
direct impact on the gastrointestinal system too,
she adds. “New research suggests that exercise
could hike up certain types of good bacteria in the

3 Issues That Seem

gut. Since IBS might be related to an imbalanced
microbiome, working out may help reduce
Like IBS—but Aren’t symptoms.”
Another measure to consider: cutting back on
Abdominal pain can be caused by many gluten or dairy, or both. “Many people with IBS have
GI culprits. Here’s how to use other clues difficulty with these foods,” says Dr.  Eswaran.
to zero in on the problem. “When the bacteria in the gut go to break them
down, they end up producing a lot of gas and other
metabolites, which may irritate the gut and lead to
1 colitis, a bowel disease that
pain or bloating.”
leads to inflammation and
You’re bloated and gassy ulcers in the colon and If you’re ready for a more dramatic dietary change,
If pooping doesn’t solve rectum. Like IBS, ulcerative you might try a low­FODMAP diet. FODMAP stands
things, or if you don’t feel colitis has no cure. But for fermentable oligosaccharides, disaccharides,
the urge to go No. 2, you medications can keep monosaccharides, and polyols (whew)—a family of
may just have an upset symptoms at bay.
tough­to­digest carbs. “It’s thought that FODMAPs
tummy. Belly discomfort
could increase or lead to changes in the microbiome
that’s not related to your 3 that trigger IBS symptoms,” says Dr. Eswaran. In
bowel movements is a sign
of indigestion. Possible The discomfort is her research, she found that more than half of
causes include eating in your pelvis patients who followed a strict low­FODMAP diet for
quickly, choosing the Deeper aches plus the
four weeks saw an improvement in their symptoms
extra-hot sauce, and feeling that you have to
overdoing it on caffeine. pee could be painful and quality of life.
(Maybe time to nix those bladder syndrome. Docs Just don’t try this experiment on your own, warns
Venti Doubleshots?) think that it happens when Dr. Eswaran. The diet is not easy—FODMAPs are
there’s a rupture in the found all over the food pyramid—and it needs to be
2 lining of the bladder, so
executed correctly to find the real offenders behind
urine starts to irritate the
Your stools are bloody bladder wall. Avoiding your gastro distress. Seek out a nutritionist who can
Passing a small amount of bladder-irritating foods, guide you.
blood during BMs is a like citrus, and Rx drugs There is no cure for IBS, unfortunately. But man­
symptom of ulcerative should help. aging your triggers can be an empowering step
toward feeling a whole lot better. ●

H E A LT H 55
 EVERYONE THINKS
I’M THE PICTURE
OF HEALTH
After she was diagnosed with ulcerative colitis,
Holly Schmidt had to adjust to her new normal of battling
an invisible illness. Here’s her personal account of what
that means and what daily life is like.
BY HOLLY SCHMIDT

“HOW DID YOU KNOW you had ulcerative colitis?”
is the question people ask me that makes me the most
uncomfortable. An awkward pause usually follows.
Does this person really want to know? I think to
myself. Because if she did, here’s what I would say:
Abdominal cramping so curl-in-a-ball crippling
that it takes the breathing that got me through the
labor and deliveries of my three kids to hold in my
cries. An urgency to go to the bathroom so sudden
that I never leave the house without a panty liner on
and an extra pair of underwear concealed in a
makeup bag in my purse, just in case I can’t make it
in time. And flares so bad that after even the tiniest
of meals, I’m on the toilet every 20 minutes with
bloody diarrhea making it basically impossible to
leave the house at all.
No, my disease makes for pretty unappetizing chit-
chat over lunch. It all just sounds gross. So I usually
answer, “Gastro symptoms,” and leave it at that.
A Bewildering Diagnosis
If there were early clues that my digestive system was
messed up, they didn’t register with me. It took blood
pooled in the toilet and smeared on tissue paper one
October evening five years ago when I was not even
close to my period to spiral me into freakout mode. I
scheduled an appointment with a gastroenterologist
the next day and had a colonoscopy within a week.
I remember my post-procedure anesthesia cloud,
feeling overwhelming relief that the doctor did not
say I had cancer. But once the drugs wore off, my
diagnosis slapped me into reality. At 43, I went from

H E A LT H 57
 DI GESTI V E D I ST R ESS
a model patient who was pronounced to be in perfect
health at every checkup—I’ve never even had a
cavity—to the prisoner of a chronic disease that
causes my immune system to attack my colon.
Because of ulcerative colitis, I’ll alternate between
flares, or episodes, of horrific symptoms and then
periods of remission for the rest of my life.
As I sat in my Honda outside our local library, three
pages into a woman’s devastating memoir about the
pain and isolation from living with ulcerative colitis,
I was ugly crying. I did not want to be her. My fate
suddenly seemed to be veering out of my control.
My official diagnosis is “indeterminate colitis”
because the inflammation in my colon presents like
Crohn’s disease as well, so the doctors are unsure
which form of inflammatory bowel disease (IBD) I
have. Most people don’t know the difference between
the conditions. For the record, ulcerative colitis
affects the large intestine and rec-
tum, while Crohn’s can hit any-
where from the mouth to the anus.
Still, I don’t view it as my mission
An underlying
to educate them. If it comes up in
nervousness
conversation—maybe they know
me, even with
someone who has IBD, or they’re
seemingly
pressing me on why I’m such a
innocuous
picky eater—then I’ll confess.
like going
Otherwise, I go out of my way to
with
keep my disease hidden. That’s
fairly simple because on the out-
side, I’m the picture of health. I’ve always been thin
with natural muscle tone. People mistook me for a
runner, though “couch potato” was often more accu-
rate. Now at 48, I’m finally trying to live up to my
reputation. Ironic, yes, that it took getting sick to
motivate me to work at being healthy.
My New Normal
I choke down four horse pills a night—at a cost of $500
a month—and the gastroenterologist predicts I’ll
always need some form of meds. He also says that my
diet has little impact on my disease, an assertion I’m
not buying. With the guidance of a functional-
medicine doctor and dietitian, I went through in-depth
poop tests (I kid you not, I had to mail a vial of my poop
to a lab—talk about humiliating) and found, surprise,
surprise, that my gut health was a mess.
To bring the inflammation in my large intestine
under control, out went gluten, dairy, starches, and
as much sugar (even from fruit) as possible. I
58 H E A LT H
remember the first time my husband and I went out
with friends after my diet overhaul to cheer on LeBron
James; we sat in one of the basketball arena loges,
known for ridiculously lavish food spreads. Before I
left the house, I stood at my kitchen counter, trying
to fill up on a loaded salad and a few handfuls of
almonds I was sure would tide me over.
But once we were out, I was tortured by the breaded
chicken wings, nachos with cheese, and hot fudge
sundae bar—all indulgences I would have dug into
without reservation just a few weeks earlier. And
everyone around me was doing just that. I sulked,
feeling totally deprived with my cup of water and
appetizer plate of a few measly carrot sticks. Had I
known this diagnosis was coming, I would have rev-
eled in two heaping pieces of my favorite chocolate
chip Bundt cake one last time.
Resisting temptation is my new normal, especially
since my family hasn’t embraced
my spartan diet. I’m usually
cooking a “regular” dinner for
them and an altered one for me.
rules I suppose knowing that what I
put in my mouth could devastate
my insides scares me from stray-
events ing. It also gives me back a feeling
out of control, and I believe it keeps
friends. my worst symptoms to a mini-
mum, all while I maintain my
everything-is-great front.
Making Adjustments at Work
and at Home
The only change in me anyone would notice is that I
ask waiters for salads without feta cheese and sand-
wiches minus bread, and I turn down pecan pie and
ice cream after holiday dinners with relatives. In
private, though, even when my disease is in remission,
my day to day is totally altered.
Take my morning routine. In my past life, I started
out by unloading the dishwasher; that changed after
a couple of mortifying incidents when the urge to go
to the bathroom came on so strongly that even suck-
ing in my breath and squeezing my butt cheeks
together during the 10 steps to the guest bathroom
failed. I now set my alarm 20 minutes earlier, stum-
bling straight from bed to the bathroom so I can head
to work confident (I’m a writer with no coworkers to
navigate around) that I’ve given myself plenty of time
to take care of business.
 ULCERATIVE
COLITIS CAN
DISRUPT YOUR
PRODUCTIVITY
BOTH AT WORK
AND AT HOME.

H E A LT H 59

The downside of this new routine is that it inter-
feres with another type of business: With night-owl
teenagers, my husband and I have taken to fooling
around in the mornings. But with my brain repro-
grammed to wake up and instantly worry about park-
ing my rear on the potty, getting into the mood for sex
at that hour is challenging. I’ve even bailed mid-act,
scared that the slightest gas pain would lead to a full-
blown crisis.
The Anxiety of an Invisible Illness
That underlying nervousness rules me, even with
seemingly innocuous events like going out with friends.
I take my pills with dinner, each one requiring big gulps
of water to get down, and I’m always waiting for the
moment when I can discreetly slip them out of my
purse, cup them in my palm, and quickly pop one onto
the back of my tongue when no one is looking.
I know it’s my own hangup, and I’ll admit to more.
Like getting on the scale obsessively to check during
flares if my already underweight frame is dropping
additional pounds. Or wiping three extra times to
60 H E A LT H
FLARE-UPS
ARE OFTEN
UNPREDICTABLE,
BUT STRESS CAN
EXACERBATE
THEM.
detect the slightest tinge of red. So much about this
disease worries me.
During my busy season at work, when I’m skipping
meals and workouts and carrying extra stress, will I
eventually see the repercussions in the toilet? How
bad will the next flare be? Will it happen before we’ve
met our deductible so we’re on the hook for the entire
several-thousand-dollars cost of a colonoscopy?
Will I end up on another course of steroids, hostage
to sleepless nights and layers of undereye concealer
until the inflammation settles down? If that treat-
ment is ineffective, will my doctor ratchet up my meds
to a more potent regimen? And most terrifying of all:
With the genetic component of this disease, have I
doomed my children to this same invisible illness?
All of these secrets that I keep from most every-
one make me feel inauthentic, which can be lonely.
But I hate pity and relying on others, so I guess if I
have to have a chronic disease, one I can hide is a
good one for me. If anything, it’s a constant reminder
never to assume I know what someone else is
going through. ●
 DI GEST IVE DISTRESS

THREE DIAGNOSES

The IBD Breakdown

Often misdiagnosed and mistaken for one another, these are the types of IBDs,
their differences, and how to manage them.
BY PATRICK ROGERS

Conditions that disrupt normal digestion in the intestines, which fall under the umbrella of inflammatory bowel
diseases (IBDs), are a way of life for millions of Americans. Although generally incurable, they can be managed with
lifestyle changes, medications, and, in more severe cases, surgery.

IRRITABLE BOWEL CROHN’S DISEASE ULCERATIVE COLITIS

SYNDROME
This common disorder of the large
intestine affects up to 10 percent of
the population, causing cramping,
bloating, gas, abdominal pain, and
both diarrhea and constipation. IBS
is a functional disorder that affects
digestion without physically
damaging the intestine.
Although the cause is unknown,
irregular contractions of the
muscles that make food move along
the GI tract may produce symp­
toms. If the contractions are too
strong, they can cause gas, bloating,
and diarrhea; if they’re too weak,
stools may be hard and dry, causing
constipation. Abnormal nerves in
the intestine may also make some
people more sensitive to pain
associated with stretching of the gut
as food passes through.
There is no definitive diagnostic
test for IBS, which may be triggered
by certain foods (wheat, dairy
products, citrus fruits, beans, and
cabbage), as well as stress and
hormones. These may also cause
flare­ups around a woman’s
menstrual period. Women are twice
as likely as men to be diagnosed.
Many people control the
symptoms by managing diet
(reducing high­gas foods such as
cabbage, broccoli, and cauliflower)
and alleviating stress. If symptoms
remain, IBS can be treated with
nutritional supplements, anti­
diarrheal medications, pain
relievers, and antidepressants.
Crohn’s disease is a chronic
inflammation of the gastrointestinal
tract that can occur along its entire
length, from the mouth to the
rectum, although it is most com­
monly found at the end of the small
intestine and the beginning of the
large intestine, or colon.
Inflammation damages the lining
of the intestine and impedes
absorption of water and nutrients,
causing diarrhea, often with blood
and mucus; abdominal pain; lack of
appetite leading to weight loss; and
fatigue. Symptoms tend to wax and
wane, with periods of remission
following flare­ups.
There is no known cause of the
disease, although interaction
between the immune system,
genes, and environmental factors is
suspected. Doctors use blood and
stool tests, CT and MRI scans, and
colonoscopies to diagnose Crohn’s,
typically in adolescents and young
adults between ages 20 and 30.
There is no cure for the disease.
Patients can make dietary changes
to reduce the intake of foods that
trigger or aggravate flare­ups and
take medications including
antibiotics, corticosteroids,
immunomodulators, and biologic
agents. Surgery is an option to drain
abscesses and to repair perfora­
tions that can develop in the
intestinal wall.
Ulcerative colitis affects only the
inner lining of the large intestine and
rectum, where ulcers (open sores)
produce blood and mucus. The
cause of the condition is unclear,
although it’s thought that bacteria, a
virus, an antigen, or food in the gut
may trigger an immune response
that produces inflammation. Or the
body may react to its own tissue,
producing an autoimmune response.
The symptoms, which in some
cases go into periods of remission,
are persistent diarrhea, rectal
bleeding, stomach pain, constipation,
fever, weight loss, and fatigue. In
extreme cases, a life­threatening
constriction of the colon may occur.
People with UC also have a higher risk
of colon cancer. The disease usually
appears between ages 15 and 30 but
can occur at any age. It affects an
estimated 750,000 Americans.
There is no proof that particular
foods cause the condition, but dairy
products, foods that are high in
fiber—such as fruits, vegetables,
and grains—alcohol, and caffeine
may aggravate symptoms.
If symptoms persist, doctors
treat UC with antibiotics, anti­
diarrheal drugs, corticosteroids and
other anti­inflammatory medica­
tions, immune­system suppres­
sants, and biologic therapies.
Nonprescription pain relievers and
nutritional supplements may also be
helpful. Surgery to remove the colon
and rectum (proctocolectomy) can
be performed when treatment with
drugs is ineffective.

H E A LT H 61
 REC IPES

GOOD GUT, GOOD MOOD

Science tells us that probiotics, prebiotics, and fiber are
just some of the key nutrients for feeling optimal inside and
out. Here are some recipes to nurture these good vibes.
BY JENNA HELWIG; RECIPES BY ROBIN BASHINSKY

BY NOW YOU PROBABLY KNOW that a healthy gut is
key to keeping your digestive system running smoothly.
But according to an increasing number of doctors,
a happy gut could also promote, well, overall happi-
ness—along with stable moods and a stronger memory.
Michelle Babb, RD, the author of Anti-Inflammatory
Eating for a Happy, Healthy Brain, explains, “Every
piece of food we put into our mouth communicates to
our genes, cells, organs, and tissues, so every time we
eat, we make a choice about what kind of communica-
tion we want to send and how we want to feel.”
So what kind of foods actually give your gut that
boost? The often-lauded probiotics (think yogurt,
kimchi, and other fermented foods) are a great place
to start, but they aren’t the only things that matter
when it comes to good tummy vibes. Prebiotics are
equally important. Found in foods like onions,
walnuts, and oats, prebiotics are foods that probiotics
feast on. Translation: These do best together. And you
don’t have to stress about eating them at the same
meal; just include both in your diet. Omega-3 fatty
acids—which are found in salmon, chia seeds, wal-
nuts, and more—reduce inflammation and help speed
up neuronal communication, which promotes more
stable moods and better focus. Tryptophan (tofu,
eggs, and chicken are great sources) is not only essen-
tial for a good night’s sleep but is also a precursor for
serotonin, which regulates mood and appetite. And
polyphenols, like those found in spinach and broccoli,
help stimulate the growth of good bacteria and stifle
the growth of bad bacteria.
All of the following recipes have a combo of these
ingredients—and they’re not just good for you, the
flavors will make you smile too.

62 H E A LT H
 JICAMA IS
A PREBIOTIC
VEGGIE WITH
6.4 GRAMS
OF FIBER
PER CUP.

GRILLED SHRIMP WITH
BLACK BEANS, JICAMA,
AND AVOCADO
ACTIVE TIME 20 minutes
TOTAL TIME 20 minutes
SERVES 4
Lime vinaigrette and roasted
pepitas—pumpkin seeds—add
south-of-the-border flavor to this
substantial salad. In addition to
being a fiber-rich prebiotic, jicama is
also an excellent source of vitamin C.
1 lb. large peeled, deveined
raw shrimp
1/2 tsp. black pepper
3/4 tsp. kosher salt, divided
Olive oil cooking spray
5 Tbsp. avocado oil or olive oil
1/4 cup fresh lime juice
(from 3 limes)
2 Tbsp. honey
3 oz. baby arugula (5 cups)
3 cups matchstick-cut jicama
1/2 cup loosely packed fresh
cilantro leaves
1 15-oz. can no-salt-added black
beans, drained and rinsed
1 ripe avocado, peeled, pitted,
and cut into 12 wedges
1/4 cup roasted pepitas
(pumpkin seeds)
Tajín seasoning or smoked
paprika (optional)
Lime wedges, for serving
1. Heat a grill pan over high. Sprinkle
shrimp with pepper and ¼ teaspoon
of the salt. Coat grill pan with cook-
ing spray. Cook shrimp until opaque,
about 2 minutes per side.
2. Whisk avocado oil, lime juice,
honey, and remaining ½ teaspoon
salt in a small bowl; set aside.
Combine arugula, jicama, cilantro,
beans, and avocado in a large bowl.
Add half of the dressing, and toss
very gently to coat. Serve topped
with shrimp and pepitas. If desired,
sprinkle with Tajín or smoked pa-
prika. Serve with additional dressing
and lime wedges.
PER SERVING 540 Calories, 30g Fat,
183mg Chol., 14g Fiber, 33g Pro., 39g Carb.,
11g Sugar, 523mg Sod.

H E A LT H 63
 TUNA IS A
GREAT SOURCE
OF OMEGA-3S
—AND A TASTY
ALTERNATIVE TO
STEAK.

TUNA STEAKS WITH
TURMERIC DRESSING
ACTIVE TIME 20 minutes
TOTAL TIME 20 minutes
SERVES 4
Prebiotic-rich asparagus adds a
pretty pop of color and spring flavor
to the plate. Hemp seeds are a good
plant-based source of omega-3s.
Use any leftover dressing as a dip for
veggies or pita chips.
1 lb. fresh asparagus, trimmed
GROUND
NUTS AND 1 medium-size (10-oz.) red onion,
SEEDS CAN PACK cut into 12 wedges
A HEALTHIER 2 Tbsp. canola oil, divided
PUNCH THAN 3/4 cup plain whole-milk
BREADCRUMBS.
Greek yogurt
1 1/2 Tbsp. grated turmeric root or
2 tsp. ground turmeric
1 Tbsp. rice vinegar
1/2 tsp. honey
1/4 tsp. ground coriander
2 Tbsp. hemp seeds, divided
1 tsp. kosher salt, divided
3/4 tsp. black pepper, divided
4 (6-oz.) tuna steaks
2 Tbsp. thinly sliced
fresh mint
WALNUT-CRUSTED TURKEY
WITH LEEKS AND APPLES
ACTIVE TIME 30 minutes
TOTAL TIME 30 minutes
SERVES 4
Using ground nuts and seeds on a cut-
let instead of breadcrumbs ups both
the nutrition and flavor. Even better,
walnuts contain omega-3 fatty acids,
and flaxseeds add a prebiotic kick.
3/4 cup finely chopped walnuts
3/4 cup flaxseed meal
8 turkey cutlets (1 lb.)
3 Tbsp. country-style Dijon
mustard
1 tsp. kosher salt, divided
1/2 tsp. black pepper, divided
2 Tbsp. canola oil, divided
3 medium carrots, cut into
2-in. pieces
3/4 cup unsalted chicken stock,
divided
3 cups thinly sliced leeks (from
2 medium leeks)
1 Honeycrisp apple, cut into
thin wedges
1 Tbsp. chopped fresh thyme,
plus more for garnish
1 Tbsp. unsalted butter
RECIP ES
1. Preheat oven to 425°F. Toss
asparagus and onion with 1 table-
spoon of the oil on a baking sheet.
Roast until both are just tender, about
12 minutes.
2. Whisk together yogurt, turmeric,
vinegar, honey, coriander, 1 table-
spoon of the hemp seeds, and
¼ teaspoon each of the salt and
pepper in a bowl.
3. Heat a grill pan over high.
Coat tuna steaks with remaining
1 tablespoon oil, and sprinkle with
remaining ¾ teaspoon salt and
½ teaspoon pepper. Grill tuna to
desired degree of doneness (about
90 seconds per side for rare).
Remove from pan.
4. Divide yogurt mixture among
4 plates; spread slightly into a circle.
Divide vegetables among plates;
slice tuna, and place atop vegetables.
Sprinkle with mint and remaining
1 tablespoon hemp seeds.
PER SERVING 412 Calories, 20g Fat,
71mg Chol., 2g Fiber, 47g Pro., 9g Carb.,
5g Sugar, 566mg Sod.
1. Combine walnuts and flaxseed meal
in a shallow dish. Rub turkey cutlets
with mustard, and sprinkle with
½ teaspoon of the salt and ¼ tea-
spoon of the pepper. Dredge turkey in
walnut mixture, pressing to adhere.
2. Heat 1 tablespoon of the oil in a large
nonstick skillet over medium-high. Add
half of the cutlets; cook until lightly
browned on 1 side, 2 to 3 minutes. Turn
and cook until cooked through, 2 to
3 more minutes. Remove to a plate;
cover with aluminum foil to keep warm.
Repeat with remaining oil and cutlets.
3. Wipe skillet clean. Add carrots
and ½ cup of the stock. Cook over
medium-high, stirring occasionally,
until carrots are slightly softened, 5 to 6
minutes. Add leeks, apple, thyme, and
remaining ¼ cup stock, ½ teaspoon
salt, and ¼ teaspoon pepper. Cook,
stirring often, until apple is softened,
3 to 4 minutes. Add butter, and cook
until leeks begin to caramelize, about 3
more minutes. Serve vegetables with
turkey, garnished with more thyme.
PER SERVING 472 Calories, 27g Fat,
53mg Chol., 7g Fiber, 34g Pro., 24g Carb.,
9g Sugar, 913mg Sod.
H E A LT H 65
 REC IPES

KIMCHI AND
BRUSSELS
SPROUTS ADD
SOME HEALTHY
COLOR TO YOUR
PLATE.
SOY-GLAZED PORK
TENDERLOIN WITH KIMCHI
BRUSSELS SPROUTS
ACTIVE TIME 30 minutes
TOTAL TIME 30 minutes
SERVES 4
Still a kimchi skeptic? Give this recipe
a try. The sweetness of the Asian pear
helps balance out the intensity of this
probiotic food.
3 Tbsp. low-sodium soy sauce
or tamari
2 Tbsp. honey
1 Tbsp. rice vinegar
1/2 tsp. black pepper
2 Tbsp. canola oil, divided
1 (1-lb.) pork tenderloin
12 oz. Brussels sprouts, trimmed and
halved (quartered if large)
1/4 cup water
1 cup prepared kimchi, chopped
1 cup finely chopped Asian pear
2 tsp. toasted sesame seeds

1. Preheat oven to 400°F. Stir together soy

sauce, honey, and vinegar in a saucepan
over medium-high. Cook, stirring occa-
sionally, until reduced by half, 4 to 5 min-
utes. Remove from heat; stir in pepper.
2. Heat 1 tablespoon of the oil in a large
nonstick skillet over medium-high.
Add pork, and cook until browned on
all sides, about 6 minutes. Place on
an aluminum-foil-lined baking sheet.
Brush with 1 tablespoon of the soy sauce
mixture, reserving remaining mixture.
Transfer pork to oven, and bake until a
thermometer inserted in thickest portion
registers 140°F, about 15 minutes. Trans-
fer to a cutting board, and let rest 5 min-
utes. (Temperature will rise as pork rests.)
3. While pork finishes in the oven, wipe
skillet clean. Add remaining 1 tablespoon
oil and Brussels sprouts, and cook over
medium-high, stirring occasionally, until
Brussels sprouts begin to brown, about
4 minutes. Add water, and cook until
tender, about 5 more minutes. Stir in
kimchi. Remove from heat, and cover to
keep warm.
4. Slice pork across grain. Serve with
Brussels sprouts mixture and reserved
glaze. Sprinkle with chopped pear and
sesame seeds.
PER SERVING 290 Calories, 11g Fat (1g Sat),
74mg Chol., 5g Fiber, 28g Pro., 22g Carb., 14g Sugar,
698mg Sod.

66 H E A LT H
 FEEL FREE
TO TWEAK THIS
DISH BY USING
OTHER VEGGIES
AND TYPES OF
PROTEIN.

BROWN RICE BOWLS
WITH TOFU, BROCCOLI,
AND MISO-YOGURT
DRESSING
ACTIVE TIME 20 minutes
TOTAL TIME 1 hour
SERVES 4
Customize this bowl with what-
ever protein and veggies you have
on hand; just be sure to keep the
polyphenol-packed broccoli.
1 1/2 cups uncooked brown rice
1/2 cup plain whole-milk
Greek yogurt
1/4 cup fresh orange juice
(from 1 orange)
2 Tbsp. gluten-free white miso
1/2 tsp. black pepper
1 tsp. kosher salt, divided
2 Tbsp. canola oil, divided
14 oz. extra-firm tofu, drained,
cut into rectangles,
patted dry
12 oz. broccoli florets
(4 cups)
1/2 cup water
1 cup radish sprouts
6 radishes, thinly shaved
Sriracha chile sauce
(optional)
1. Cook rice according to package
directions. (This will take about an
hour on the stovetop.)
2. Meanwhile, whisk together
yogurt, orange juice, miso, pepper,
and ½ teaspoon of the salt in a bowl
until smooth; set aside.
3. Heat 1 tablespoon of the oil in
a large nonstick skillet over high.
Add tofu, and cook, stirring often,
until browned on all sides, 4 to 5
minutes. Remove from skillet. Add
remaining 1 tablespoon oil to skil-
let. Reduce heat to medium-high;
add broccoli and water. Cook, stir-
ring occasionally, until broccoli is
bright green and tender and water
has evaporated, 5 to 6 minutes.
Sprinkle with remaining ½ tea-
spoon salt.
4. Divide rice among 4 bowls.
Top evenly with tofu, broccoli,
sprouts, and radishes. Drizzle
each serving with 2 tablespoons of
the dressing. Serve with remaining
dressing.
PER SERVING 337 Calories, 16g Fat,
4g Chol., 6g Fiber, 19g Pro., 31g Carb.,
5g Sugar, 852mg Sod.

68 H E A LT H
 RECIP ES

CHICKEN, BUTTERNUT
SQUASH, AND BARLEY
SKILLET DINNER
ACTIVE TIME 20 minutes
TOTAL TIME 40 minutes
SERVES 6
This one-pot dinner is simple and
satisfying. Onions and yogurt mean
you get both pre- and probiotics in
one meal.
2 Tbsp. canola oil, divided
1 1/2 pounds boneless, skinless
chicken thighs
1/2 tsp. black pepper
1 1/4 tsp. kosher salt, divided
2 cups chopped yellow onion
6 garlic cloves, sliced
1 1/2 tsp. ground cumin
2 cups precut butternut
squash (10 oz.)
1 1/2 cups uncooked pearled
barley
2 cups unsalted chicken stock
1 15-oz. can no-salt-added
diced tomatoes, drained
1 15-oz. can no-salt-added
chickpeas, rinsed and
drained
1/3 cup plain whole-milk Greek
yogurt
2 Tbsp. water
1/2 cup chopped toasted,
unsalted almonds
1/4 cup chopped fresh cilantro
(optional)
1. Heat 1 tablespoon of the oil in a
large, high-sided skillet over high.
Season chicken with pepper and
½ teaspoon of the salt. Cook in hot
oil until well browned on 1 side, 4 to
5 minutes. Remove from skillet.
2. Reduce heat to medium-high.
Add remaining 1 tablespoon oil to
skillet. Add onion and garlic; cook,
stirring often, until softened, 3 to 4
minutes. Add cumin; cook, stirring
often, 30 seconds. Add squash and
barley; cook, stirring occasionally,
until barley is lightly toasted, 2 to
3 minutes. Add stock, tomatoes,
chickpeas, and remaining ¾ tea-
spoon salt; bring to a boil. Cover
and simmer until barley and squash
are tender, about 20 minutes.
Return chicken to skillet, nestling
with browned side up. Cover and
simmer until a thermometer in-
serted in thickest portion of chicken
registers 160°F, about 5 minutes.
Remove from heat. (Temperature
will continue to rise to 165°F.)
3. Whisk together yogurt and water
in a small bowl. Drizzle over chicken.
Sprinkle with almonds and, if de-
sired, cilantro.
PER SERVING 552 Calories, 15g Fat,
108mg Chol., 36g Pro., 67g Carb.,7g Sugar,
608mg Sod.

THIS DREAM
DISH IS
HEALTHY, QUICK,
AND SATISFYING.
CLEANUP IS
EASY TOO!
 C H APT E R T HR E E

The Feel-Good
Lifestyle
Everyday methods for
nurturing your gut.

70 H E A LT H
 YOGURT AND
SALADS ARE
COLORFUL AND
CUSTOMIZABLE
FIBER-FILLED
MEALS.

HOW DOCTORS
TAKE CARE OF
THEIR GUTS
Eating fiber, timing their meals,
getting a restful night’s sleep. Such
core principles guide these experts as
they nurture their gut health.
BY MAGGIE PUNIEWSKA

AS YOU’RE READING THIS SENTENCE, there are trillions of

microbes hard at work in your large intestine. These little guys are
not only helping digest and process the food you’ve eaten, but they’re
also playing a role in what goes on outside the gut. Research has found
that our immunity, our mental health, and even how well we sleep are
all linked to the health of our gastrointestinal system, says Robin
Miller, MD, an integrative-medicine physician in Medford, Oregon,
and a coauthor of Healed: Health and Wellness for the 21st Century.
How can you keep your gut happy and healthy? We tapped a few
medical experts to share what they do every day to keep their gut—and
therefore overall health—in top shape.

Fiber Is a Must
One of the most important habits for good gut health is one you’ve
probably heard a million times: Make sure you’re getting enough fiber.
“Fiber is a plant-based carbohydrate that helps keep you regular, and
it also feeds the good bacteria in the gut, who use it to produce short-
chain fatty acids that our gut needs to curb inflammation and keep
the immune system strong,” says Samantha Nazareth, MD, a

72 H E A LT H
 TH E F E E L- G O OD L I FEST YL E

gastroenterologist in New York City. Research has your immune system. These microbes are available in
also found that fiber can slash your risk of developing fermented foods, but there are also supplements that
colon cancer and breast cancer. Dr.  Nazareth makes claim to deliver these microorganisms to your gut in a
sure she gets enough by eating several servings of pill. This sounds convenient, but the science is still out
fiber-rich foods, like whole grains, legumes, and pro- about whether they’re legit. “We don’t know if the
duce, at every meal. “I start with the foods that have bacteria ever make it to your gut,” says Dr. Miller. Most
fiber and build my meal around that,” she says. probiotic supplements aren’t subject to FDA approval,
It’s recommended that women eat 25 grams of so their claims might be unverified. “Instead of taking
fiber a day, yet most people reach only about 15 grams. a chance, I eat foods that are loaded with good-for-you
Not sure if you’re getting it all in? Keep track using bacteria like yogurt, miso, and kimchi,” Dr. Miller says.
an app, says Shanthi Srinivasan, MD, a gastroenter- And don’t forget to add prebiotics to your plate, too.
ologist and the director of digestive diseases at Prebiotics are a type of fiber that passes undigested
Emory University in Atlanta who uses MyFitnessPal into the colon, where probiotics and good bacteria
to see if she’s meeting the daily dose. “I think that feast on them; they’re found in foods like asparagus,
sometimes it can be hard to know how much you’re onions, oatmeal, and walnuts. You might have seen
really getting,” she says. “An app like this can show celebrity nutritionists touting them in pill form, but
you what your true eating patterns are and guide you again, Dr. Miller suggests skipping the supplements
to make changes.” and going straight to the fridge.
They eat fruits and veggies—but Note: You don’t have to eat pre-
not the same ones every day. While and probiotics together; just
it’s good to get any kind of produce
“The gut and brain include both in your diet.
in during the day (hello, fiber!), it’s
are constantly
even better to switch up your
communicating, They Make
greens...and reds and yellows.
but when you’re Meals Mindful
Dr. Nazareth now aims to eat at
rushing, they don’t Eating lunch at your desk while
least 30 different kinds of plants
fully get the filling out a spreadsheet. Picking
every week, after reading a 2018
message across up dinner and eating it in your car.
study from the American Gut
that you’re full.” Sound familiar? When we’re busy,
Project that found that people who it’s often mealtime that gets blown
ate that amount of plant life had through. But docs, who know what
much more diverse microbiomes. It’s thought that a it’s like to be pressed for time, still aim to slow down
wide range of microbes keeps inflammation at bay, during breakfast, lunch, and dinner. “At work, I try
boosts the immune system—70 percent of which is in to step out on the patio for lunch and not eat in front
the gut—and lowers your risk for diseases like diabetes of my computer,” says Lauri Nandyal, MD, a
and colon cancer. functional-medicine physician and member of the
Thirty may seem like a high number, but it doesn’t University of Cincinnati’s Center for Integrative
have to be all produce—items like seeds, nuts, and Health and Wellness. “It helps me pay attention to
legumes count, too. An easy way to hike up your plant and appreciate what I am eating, and I notice that I
intake is to prepare meals that call for a lot of toppings stay fuller longer if I’m mindful.”
like oatmeal, salads, and omelets. Dr. Nazareth likes Eating on the go is a recipe for tummy woes, like
to top her morning porridge with seasonal produce indigestion and not feeling full. “The gut and brain
and rotates through six kinds of nuts and seeds, are constantly communicating, but when you’re rush-
including chia, walnuts, and Brazil nuts. If you’re a ing, they don’t fully get the message across that you’re
creature of habit or meal prepping to save time, aim full,” Dr. Nandyal explains. “So you can eat a good
to diversify a few meals a week to keep your gut happy. meal but leave the table and still be hungry.” Blitzing
through the contents of your plate probably means
Their Good Bacteria Don’t you’re not chewing well, which can spell trouble later
Come from Supplements on. “If bacteria in the gut have access to undigested
You have probably heard of probiotics: live bacteria foods, it can lead to gassiness and bloating,” she adds.
that aid digestion, help keep you regular, and boost “But this food can also be misinterpreted as an

74 H E A LT H
 AFTER
JUST TWO
NIGHTS OF
NON-RESTFUL
SLEEP, YOU CAN
LOSE HEALTHY
BACTERIA.
invader by the immune system, which may hike up
inflammation in the gut.”
They Do a Longer Fast Between
Dinner and Breakfast
During the day, the gut is hard at work breaking down
all the food and beverages you’ve swallowed. At night,
it wants to do a deep clean. “During the week, I wait
12 hours between dinner and breakfast the next
morning,” says Dr.  Nazareth. Here’s why that’s
important: “Think of your gut as having a Roomba
function that cleans up a mess,” she adds. “Every 90
to 120 minutes it goes through a series of contractions
that sweep digested and undigested food down
toward the colon.” These contractions happen during
the day, too—they are activated about two to three
hours after you finish a meal—but at night your gut
is able to go through more of them, essentially leading
to a more thorough cleanup.
Snacking before bed also sends mixed signals to
the body. “Your gut thought it was going to clean, but
now it has to digest. It’s also part of the reason why
you may feel bloated, gassy, or have heartburn if you
eat right before bed: The food wasn’t properly broken
down,” adds Dr. Nazareth.
Sleep Is a Priority
You know you need sleep to make it through the work-
day and spin class and PTA meetings, but shut-eye is
also key for gut health. “Not sleeping is just as bad as
a poor diet, and inadequate rest can impact the micro-
biome,” says Marvin Singh, MD, an integrative gas-
troenterologist at Scripps Health in San Diego, who
aims to get at least seven hours of sleep every night.
H E A LT H 75
 THERE
ARE SIMPLE
WAYS TO GET
ACTIVE: WALKING,
LIGHT JOGGING,
AND DANCING
ARE AMONG
THEM.
 TH E FEEL- GOOD LIFEST YLE

A small study published in the journal Molecular water plus trees and greenery really calm me down. I
Metabolism found that after just two nights of poor can feel my breath and rushing thoughts slow down,”
sleep, people had less beneficial bacteria in their gut. she says. Spending time outdoors has also been linked
Skimping on sleep also impacts your gut via food to less anxiety and increased happiness.
choices. “You might notice that you’re craving a lot of Almost all the experts surveyed for this story
sugar or carbs when you’re not well-rested, and that’s revealed that they practice some sort of meditation.
your body trying to get a quick hit of energy,” says “In the last year, my husband and I have started med-
Dr. Nazareth. When you’re reaching for indulgent itating for 12 minutes each day, which is the amount
foods, it’s likely you’re skimping on the fiber-rich ones of time studies have found leads to health benefits,”
that keep you full and feed your microbes. says Dr. Srinivasan, who uses the app Headspace for
If you’re having trouble dozing off, keep tabs on its wide selection of guided meditations. “Studies
screen time. Research has found that blue light from have found that stress reduction, whether it’s through
devices can disrupt the body’s release of the sleep meditation or another activity, improves the micro-
hormone melatonin. “I try not to check the news or biome for the better.” Dr. Singh starts his day by doing
social media before bed,” Dr. Singh says. “I also find a simple 4-7-8 breath-work exercise: Inhale for four
that it’s helpful to dim the lights in my house a few seconds, hold for seven, exhale for eight. “If you’re
hours before bedtime, which can help increase mela- just starting meditation, doing and focusing on your
tonin levels as well.” breathing is a free stress buster,”
In addition to getting enough he adds. “I used to be able to med-
sleep, try to stick with the same itate for only a few breaths. Now
sleep schedule seven days a week.
Cutting back on I’m up to 20 minutes.”
“We know the gut likes a consistent
stress or reframing
routine, so I get to bed and wake at
it can be a game They Make Time for
the same time all throughout the
changer. There’s no Working Out
week,” says Dr. Nazareth.
one way to There’s no magic pill for good
de-stress—whatever health, but exercise comes pretty
They Find Ways you do will be darn close. Working out has been
to Chill Out helpful, as long as shown to benefit heart and brain
Stress is a foe to many organs,
it’s healthy. health, immunity, and mood (just
including the gut. “When the body to name a few advantages); it can
senses stress, it gets ready to fight even slash your odds of developing
or flee a situation, shifting resources and energy to certain cancers. So it makes sense that breaking a sweat
pump the heart faster or elevate breathing,” explains has perks for the gut, too. “I try to work out five days a
Dr. Singh. “This is why so many people get backed up week, whether it’s Pilates or cardio, plus some strength
or have stomach issues when they’re worked up. The training,” says Dr. Srinivasan. “Working out also
body is basically saying, ‘Now is not the time to think reduces stress, which takes a toll on the gut and keeps
about digestion or going to the bathroom!’ ” Some things moving, which could all be part of the reason
research has found that stress flips a switch in the why it promotes a good environment.” Exercise also
gut, leading neutral microbes to turn into harmful seems to hike up the diversity and number of good
ones, which could bring on GI symptoms and poten- bacteria: A 2018 study in Medicine & Science in Sports
tially hike inflammation. It’s also thought that anx- & Exercise found that it increased microbes that help
iety damages the protective lining of the gut, says reduce inflammation, fight insulin resistance, and
Dr. Srinivasan, leaving microbes to travel outside the support a healthy metabolism.
colon, leading to inflammation. Aim to be active at least 150 minutes per week and
Cutting back on stress or reframing it can be a game don’t discount smaller bouts of movement during the
changer. There’s no one way to de-stress—whatever day, says Dr. Miller. “In addition to dance four days a
you do will be helpful, as long as it’s healthy. Think: a week, I try to make exercise part of my life with
relaxing bath, a long run, or cuddling with a pet. When micro-activities: I’ll park farther, choose the stairs
she’s feeling overwhelmed, Dr. Miller gets out in nature. instead of the elevator, and take my dog out for walks,”
“There’s a creek right by my office, and the flowing she says. “Any and all movement helps the gut.” ●

H E A LT H 77
 TRY
STRESS-
RELIEVING
STRATEGIES TO
AVOID REACHING
A BREAKING
POINT.

FEELING FROM BUTTERFLIES in

your stomach before giving
it’s unlikely to be the
underlying cause of your

STRESSED?
a big speech at work to an chronic heartburn. In the past,
ulcer that acts up whenever stress was thought to be the

WHY YOU
things get tough, our gastro­ culprit in a variety of gastro­
intestinal health seems to be intestinal problems, including

MAY FEEL IT
IN YOUR GUT
Busy week at work? Big family
gathering coming up? Stressful
events or lingering anxiety
could wreak havoc on your
digestive system.
BY DENISE MANN
intimately connected to our
emotions. Gastroesophageal
reflux disease (GERD), or
acid reflux, is no exception,
and heartburn symptoms
can escalate right along with
your workload.
However, the relationship
between stress and heart­
burn is a tricky one; just as
one man’s stress is another’s
adrenaline rush, stress may
be more difficult for some
people who have GERD.
And although stress may
exacerbate GERD symptoms,
ulcers and inflammatory
bowel diseases such as
Crohn’s disease. Now it’s
known that bacterial infections
(in the case of ulcers) and
underlying inflammation (in
bowel diseases) are to blame,
not stress.
Stomach Acid May
Rise, but Not Everyone
Feels the Burn
Even if excess weight,
smoking, alcohol, or other
GERD­triggering factors are
the underlying cause of your

78 H E A LT H

heartburn, stress can make
you feel the symptoms of acid
reflux more acutely.
“Stress can affect many
gut functions, and we know
that patients who are under a
lot of psychological stress
suffer from more severe
reflux symptoms—without
necessarily having more
severe reflux,” says Mitchell
Cappell, MD, PhD, the chief of
gastroenterology at Beau­
mont Hospital in Royal Oak,
Michigan. “We live in stressful
times, and heartburn is
incredibly common,” he says.
In surveys, a majority of
people who experience acid
reflux identify stress as a
common trigger. The problem
is that studies have failed to
find a connection between
the stress and the amount of
stomach acid in the esopha­
gus, which is the ultimate
cause of heartburn pain. One
explanation for this discrep­
ancy is that stress may cause
what’s known as hyper­
vigilance. In other words,
stressed people become
more sensitive to and have a
greater awareness of physical
symptoms that may not
bother them if they weren’t
stressed.
In a 2005 study in the
Journal of Psychosomatic
Research, researchers
measured the esophageal
acid levels in more than 40
patients who had chronic
heartburn and acid reflux.
While the measurement was
taking place, the researchers
induced stress in half the
participants by requiring
them to prepare and deliver a
five­minute speech. The acid
levels in both groups were
nearly identical; patients in
the “stressed” group,
however, reported more
intense acid­reflux symp­
toms, suggesting that their
sensitivity to their symptoms
had been heightened.
Findings such as this don’t
necessarily mean that
stress­related reflux is “all in
your head.” Some experts
suggest that stress may
excite areas of the brain that
in turn make pain receptors
in the esophagus more
active. So acid levels may not
rise that much more in
stressed people than
carefree ones, but each drop
of acid may become that
much more painful.
In addition, it’s known that
people who are stressed can
have a drop in levels of
hormone­like substances
known as prostaglandins,
which can help coat the lining
of the stomach and protect it
from acid, says Jonathan
Schreiber, MD, a gastro­
enterologist at Mercy Medical
Center in Baltimore. “Once
you are under stress,
prostaglandin levels go
down.” Certain drugs block
the production of prosta­
glandins, including anti­
inflammatory drugs such as
ibuprofen and naproxen,
which is why this common
class of drug is often a cause
of stomach problems,
including nausea and ulcers.
The bottom line? “There is
a strong connection between
stress and acid reflux,” says
Dr. Schreiber. No matter how
the body and mind sense
them, GERD symptoms are
equally real.
Stress Reduction
Is Key
Reducing stress can ease
heartburn and other
gastrointestinal problems,
but this is easier said than
done, Dr. Schreiber says. “I
often tell patients if I could
write a prescription to relieve
stress, I would write myself
one first.”
There are, however, things
that people can do to alleviate
stress that may help lessen
heartburn. For example,
exercise is a great stress
reducer. “This doesn’t mean
running a marathon,”
TH E FEEL- GOOD LIFEST YLE
Dr. Schreiber says. “It could
be walking for a half an hour a
day. You really need to devote
enough time to caring for
yourself, whether reading a
book, going for a walk, or
doing yoga.” Creative pursuits
such as writing, artwork, and
music also play a role in
stress reduction.
“It’s really different strokes
for different folks,” Dr. Cappell
says. “Do whatever it is that
calms you. Sometimes it is as
simple as listening to music.”
Talking to a therapist, a
clergy member, or even a
good friend about your
problems can also help
mitigate stress, he says.
Healthy habits go a long
way toward combating stress.
It’s easy to resort to things
that we know are not good for
us, such as smoking and
20 consuming excess alcohol or
Estimated too much caffeine, when
percentage of times are tough.
adults in the And it’s no coincidence
U.S. who that these are some of the
suffer from same things that doctors
GERD know increase our risk of
symptoms. heartburn. Caffeine, smoking,
SOURCE: National and alcohol may relax the
Institute of Diabetes
and Digestive and lower esophageal sphincter,
Kidney Diseases which is the muscle connect­
ing the esophagus with the
stomach, and allow acid easy
access up the food pipe.
If you’re under stress, be
extra careful to avoid known
heartburn triggers such as
chocolate, citrus fruits and
juices, tomatoes and tomato
sauces, spicy or fatty foods,
full­fat dairy products, and
peppermint. Other tips
include trying to make
mealtime as relaxing as
possible, perhaps by playing
some soothing music. Eating
smaller meals also helps.
Don’t lie down too soon after
eating, and try to sleep with
your head raised. The good
news is that there are many
types of medications to help
combat heartburn if none of
these methods help you
feel better. ●
H E A LT H 79
 5 WAYS
TO BOOST YOUR KIDS’
GUT HEALTH
If you want to set them up for a lifetime of good health,
strive to bolster the bacteria in their bellies.
Microbiologist and mom Erica Sonnenburg shares these
science-based strategies for doing just that.
BY ERICA SONNENBURG, PHD

I SPEND MY WEEKDAYS studying the human micro-
biome (a fancy word for the trillions of bacteria that
inhabit the gastrointestinal tract) and examining how
dietary choices, antibiotic use, and other factors affect
it. Weighing in at a whopping three to five pounds per
person, these bacteria help control the immune system,
determining such things as whether your child has an
allergic reaction to a peanut and how effectively she
fights off a cold virus. In addition, the microbiome is
involved in regulating metabolism and weight gain,
and it may be wired to the brain—meaning it could
influence mood and potentially protect your child from
mental-health disorders such as autism and depres-
sion. Needless to say, these findings have impacted the
way my husband (who, like me, works as a microbiol-
ogist at Stanford University) and I are raising our
daughters, Claire, 13, and Camille, 11. We’ve also writ-
ten about it in our book, The Good Gut: Taking Control
of Your Weight, Your Mood, and Your Long-Term Health.
Unlike the human genome, which is fixed at con-
ception, the human microbiome is largely a product
of lifestyle and environment—and it’s most malleable
in infancy and childhood. By the time kids reach
school age, the general makeup of their microbiome
has been established and will remain with them for
years, decades, or even their entire life. Fortunately,
nurturing your kids’ microbiomes doesn’t have to be
hard. These are the simple guidelines that we follow
in our family.
1 Feed the Good Bacteria
They thrive on dietary fiber, the complex
carbohydrates found in plants. What happens if your
child’s gut bacteria don’t get enough dietary fiber?
They will start eating her! Research suggests that a
starving gut microbe eats the mucus that lines and
protects the inner walls of the intestine. If bacteria get

H E A LT H 81
 TH E F E E L- G O OD L I FEST YL E
too close to these walls, they can set off alarm bells
within the immune system, resulting in a simmering
state of inflammation that can eventually lead to auto-
immune disorders, such as inflammatory bowel dis-
ease, allergies, and asthma. Feeding your child a diet
rich in fruits, vegetables, whole grains, nuts, and
legumes ensures that her developing microbiome has
lots of nourishment.
Of course, many high-fiber foods don’t have instant
kid appeal, to say the least. So start with familiar
choices: carrots dipped in hummus, steamed eda-
mame, or black-bean quesadillas with avocado on
whole-grain tortillas. If you think your child will appre-
ciate it, you could also put her imagination to work. We
have taught Claire and Camille that we all have a “pet”
named bacteria living inside of us that needs care.
When faced with a plateful of vegetables (as is the norm
at our house), we remind our girls
that their pet is hungry, and they
are usually happy to oblige. To
really bring home the message, we
It is more
used to give each daughter a stuffed
important
bacterium to hold on her lap during
that parents
mealtimes. I love the website
pediatricians
GiantMicrobes.com, which carries
reserve
adorable plush ones.
only for illnesses
for which they are
necessary.
2 Eat Bacteria
Itself
Consuming live and active cultures (another word
for good bacteria), such as those found in many
yogurts, may reduce the frequency of illness in chil-
dren, particularly pesky gastrointestinal infections,
according to research from Georgetown University
Medical Center.
The fermented dairy drink kefir is another form of
edible bacteria (so are miso and unpasteurized
sauerkraut—but I find they’re less kid-friendly). But
shop carefully: Many yogurts marketed to children
are packed with sugar, and foods like yogurt-covered
pretzels and yogurt-based salad dressings often don’t
contain live cultures at all. To get my children to appre-
ciate the unique tang of unsweetened yogurt, I added
a teaspoon of maple syrup and then slowly reduced
the amount over a number of weeks. I’ll never forget
the day we wound up staying at a hotel that served
sweetened yogurt. My children complained that
“something tasted weird” about it—proof that you can
change which flavors young kids find “normal.”
82 H E A LT H
3 Don’t Sanitize Everything
As parents, we naturally want to protect our
children from illness-causing bacteria like strep and
E. coli, but by sterilizing everything our kids touch,
we also reduce their contact with the good bacteria
needed in their gut. A group of Swedish scientists
recently found that children whose parents sucked
their pacifiers to clean them (as opposed to boiling
them on the stove) were less likely to develop eczema
and asthma. It’s likely that by not sterilizing the pac-
ifiers, these parents increased their child’s exposure
to bacteria, which in turn helped bolster their child’s
developing immune system. Dentists may point out
that this practice could raise the chance of tooth
decay, but I still contend that we need to curb how
often we sterilize our kids’ environment. If you’re not
comfortable with the pacifier
trick, try exercising some restraint
with hand sanitizer or switching
from bleach-based cleaning prod-
than ever ucts to natural ones. In our family,
and we are constantly performing a
cost-benefit analysis when it
antibiotics comes to bacteria. If my children
have been gardening in our
pesticide- and herbicide-free yard,
I feel comfortable having them
skip handwashing before eating a
snack. But if we’ve spent the day at
the zoo or a public park—a place that is potentially
rife with contagious viruses as well as bacteria—
handwashing before mealtime is a must.
4 Avoid Unnecessary Antibiotics
These drugs can be lifesaving, but that
doesn’t mean they don’t have drawbacks. Because
they kill bacteria indiscriminately, they get rid of the
good parts of your microbiome along with the bad.
And that loss can have a broader impact on your
child’s long-term health than you might realize. A
2014 University of Chicago study on mice has linked
antibiotics with peanut allergies, and a recent Johns
Hopkins University study connected antibiotic use
in children with excess weight gain throughout child-
hood. As I see it, this effect likely resulted from anti-
biotics’ progressive alteration of the functionality of
the microbiome. In light of this new research, it is
more important than ever that parents and

pediatricians reserve antibiotics only for illnesses for
which they are necessary. So far this strategy has paid
off with my kids: Claire has never been prescribed
oral antibiotics, and Camille has taken them only once
in her life—for an ear infection.
5 Play in the Garden and
Snuggle with Your Pets
Both activities are easy ways for your child to
encounter good bacteria while avoiding the ones that
can make him sick. Our dog actually serves as an
ideal conduit between the bacteria-laden dirt in our
yard and our children. Instead of cringing when I
see him nuzzling my daughters and licking their
LETTING
KIDS HELP
IN THE GARDEN
COULD
DIVERSIFY THEIR
GOOD
BACTERIA.
faces, I think about the benefits that the bacteria
he’s carrying can bestow on them. For example, a
recent study published in JAMA Pediatrics sug-
gested that babies who grow up exposed to dogs are
less likely to develop asthma before they reach age
6. As for gardening, it exposes children to bacteria
from soil and animals. My kids routinely dig carrots
out of our garden with their bare hands and quickly
brush the dirt off before snacking on them. In fact,
I view each unwashed carrot my girls eat as the
ultimate vitamin: a fiber-filled supplement that
nourishes the gut microbiome. And though I don’t
have any lab results to prove that my kids’ guts are
benefiting, they rarely get sick, and when they do,
their illnesses never last long. ●
H E A LT H 83
 GENES,
LACK OF
SLEEP, AND
POOR DIET CAN
INFLUENCE
CAFFEINE
TOLERANCE.

THE COFFEE
AMERICA IS a hopped­up continue to climb year after
nation. Every day, nearly year. Perhaps it’s no

& ALCOHOL
two­thirds of Americans surprise: Caffeinated and
down a cup of coffee or alcoholic beverages are part

BUZZ
more, according to a survey
of 3,000 people commis­
sioned by the National Coffee
Association. About 56
The impact of your percent of people over 18 say
they have had at least one
morning caffeine fix and alcoholic drink in the
happy-hour go-to on your previous month. And there
overall digestive health. are no signs of waning
popularity—revenues for the
BY RYAN HATCH coffee and alcohol industries
of our culture, and they’re
often woven into people’s
lives on a regular basis.
Study upon study details the
good, the bad, and the ugly of
their impacts on cancer and
other diseases, along with
how daily coffee or alcohol
shape mental health and
personal relationships. The
effects of caffeine and

84 H E A LT H

alcohol on gut health,
however, are commonly
less known.
When influenced by
caffeine—a central nervous
system stimulant classified
as a psychoactive drug—
people report increased
mental alertness and energy
boosts. Elements of coffee
(an eight­ounce cup has
about 95 milligrams of
caffeine) are also shown in
about a third of people to
keep things, well, moving
along, by stimulating bowel
movements and increasing
muscle motility in the colon.
Experts say drinking
coffee can, in moderation,
help build a healthy gut,
especially when it is a light
roast, which contains
antioxidants and more plant
chemicals called polyphe­
nols than darker blends.
These help feed the
microbiome.
But not everyone reacts
well to caffeine, no matter
how exceptional the coffee
is; sometimes it’s simply too
powerful of a drug or a
tolerance hasn’t yet
developed. “For some, the
body doesn’t welcome
caffeine,” says Tracy
Lockwood Beckerman, RD,
the author of the newly
released book The Better
Period Food Solution. “That’s
why we experience things
like heart palpitations. We
get jittery. We get sweaty.”
Like so much else, experts
say genetics and circum­
stances share in the blame.
Insufficient sleep, poor diet,
stress, and hormonal
imbalance can lead to an
adverse reaction to caffeine,
but so too can body
composition. The gene
known as CYP1A2 helps
determine the way humans
process caffeine. Those with
two “fast” versions of
CYP1A2 (one from each
parent) metabolize caffeine
quickly and can better reap
coffee’s benefits. About half
of us fall into this group.
Around 40 percent have a
copy of either the fast or the
slow variation and metabo­
lize caffeine at a more
moderate pace. The final 10
percent of us carry two of the
slow genes and, in turn, can
suffer from more immediate
and harsher effects, like
nausea or diarrhea,
especially if coupled with
other factors. Fair warning:
Belonging to faster­
metabolizing groups doesn’t
mean being granted carte
blanche. “No matter how you
slice it, [caffeine] becomes
too much of an artificial
stimulant,” says Raphael
Kellman, MD, the author of
The Microbiome Break­
through: Harness the Power
of Your Gut Bacteria to Boost
Your Mood and Heal Your
Body. “It’s a very
fine balance.”
Alcohol, a depressant,
does its own work on the gut.
Too much can wreak havoc
and damage tissue in the
digestive tract, leading to
malabsorption of key
nutrients, along with
bloating and gas. (While one
can mentally develop a
tolerance for higher volumes
of alcohol in the body, the
gut never gets used to it.)
But recent research shows
that the proper amount and
kind of alcohol might actually
have benefits.
In August 2019, King's
College London conducted
one of the largest studies of
its kind. Researchers
reported that people who
drank red wine had a more
diverse gut microbiome. The
compounds in red wine
release polyphenols (found
in fruits and vegetables) and
may also lead to a lower risk
of heart disease and being
overweight. Beer, white wine,
and other spirits did not
produce these same results.
Still, drinking either coffee
TH E FEEL- GOOD LIFEST YLE
56 or alcohol requires caution.
Megan Rossi, PhD, the
Percentage
author of the recent book
of people
Eat Yourself Healthy, says
over the age
that any more than two
of 18 who
glasses of red wine starts to
have had at
derail any benefits in the time
least one
frame. “[Alcohol] can
alcoholic
increase or change gut
drink in the
motility,” Dr. Rossi says.
past month.
“People can feel quite
SOURCE: National
Institute on bloated and full and get a bit
Alcohol Abuse and
Alcoholism
of indigestion.”
At the same time, she
adds, too much alcohol can
speed things up elsewhere in
the gut, which, she says, “is
why often a lot of people can
get diarrhea the next
morning.” However, there
remains a silver (gut) lining:
Dr. Rossi notes that even
several nights out imbibing
alone will not devastate
your digestive health in the
long term.
Each person, however, is
unique. What’s good for
one person may not be for
another. But, for now, go
ahead and drink light­roast
coffee and enjoy small
amounts of red wine until
your body tells you
otherwise. ●
H E A LT H 85
 EXPOSURE TO
BARN DUST HAS
BEEN SHOWN TO
INCREASE GOOD
BACTERIA IN
KIDS.

THE ANIMAL
EFFECT
Whether they’re in barns or in
our homes, spending time with our
furry friends could promote
a diverse, healthy microbiome.
BY COURTNEY MIFSUD

IN 2016, A GROUP OF INVESTIGATORS noticed that something

peculiar was happening among children in two farming groups: the
Amish of Indiana and the Hutterites of North Dakota. Both groups
are communal branches of Anabaptist Christians descended directly
from the Radical Reformation of the 16th century. The investiga-
tors found that the Amish children rarely suffered from asthma: It
affected a mere 2 to 4 percent of the overall population. But among
the Hutterites, up to 20 percent were affected. Gut microbiota are in
charge of training the immune system and the ability to fight off cer-
tain allergens. But the Amish and the Hutterites had similar genetic
backgrounds and lifestyles. Both groups follow Germanic farming
diets, have minimal exposure to polluted air, and vaccinate their
children. And both groups have meticulously clean homes and don’t
keep traditional pets, such as dogs and cats, in the home.
The researchers at the University of Chicago examined the key differ-
ence between these two groups that affects their immune response. To
understand this disparity, the researchers studied 30 Amish children 7
to 14 years old and 30 Hutterite children of the same ages. They exam-
ined the children’s genetic profiles, which confirmed the remarkable

86 H E A LT H
 TH E F E E L- G O OD L I FEST YL E

similarities between Amish and Hutterite children. of Arizona, in an email to Health. “Cats do not enrich
But the first moment of clarity came when researchers homes as much as dogs because they are smaller (less
compared the types of immune cells in the children’s hair covered in bacteria to bring in) and they tend to be
blood. “The Amish had more and younger neutro- indoors.” While we do know that the microbes from
phils, blood cells crucial to fight infections, and fewer dogs help protect our health, there have not been
eosinophils, blood cells that promote allergic inflam- enough feline studies to say the same about cats.
mation,” said study coauthor and immunologist Anne But can dogs do more? Is there a connection between
Sperling, PhD, at the time of the study’s publication. the microbes that prevent allergies from developing and
Although both groups’ lifestyles depend on agri- the microbes that affect our digestive tract? Research
culture, the Amish children have more and consis- over the past decade is still at an early stage, but accord-
tent exposure to farm animals. The Hutterites live ing to Gilbert there’s promise. “Exposure to animal
on large communal farms and have no objection to bacteria may trigger bacteria in our gut to change how
electricity. Their cows are housed away from their they metabolize the neurotransmitters that have an
homes in an industrialized setting and not in a place impact on mood and other mental functions.” In 2013,
where young children would play. The Amish live Susan Lynch from the University of California pub-
much simpler lives. They don’t use electricity, and lished a study in which her research team fed mice
they rely on horses as transporta- dust samples collected from two
tion. Their homes are close to their homes: one that had a dog and one
barns, which are also places where without any pets. As expected, the
the children often play. In the New
Just as children mice that ingested dog dust pro-
England Journal of Medicine, the
benefit from duced fewer immune cells and had
researchers revealed that micro-
mingling with cows less immunoglobulin (an antibody
scopic particles that were present in
and horses and bring associated with allergic diseases,
the house dust from Amish homes
that dust inside, such as asthma and atopic der-
but not present in the Hutterite
exposure to the matitis). But the researchers also
homes were able to engage and
microorganisms that showed that the dog dust changed
shape the immune system (the
come with a pet dog the microbe communities in the
body’s response to microbes). “If
can help keep a rodents’ guts and increased the
we can’t bring our kids to the farm,
person healthy. numbers of more than 100 groups.
maybe we can bring the farm to One particularly enriched genus
kids,” Jack Gilbert, a coauthor of the was Lactobacillus, and one species
study and the director of the Microbiome Center at the within it—Lactobacillus johnsonii. “L. johnsonii is a
University of Chicago, told the New York Times in 2017. known human gut colonizer and becomes a dominant
In a world where there’s a growing urge to banish member of the maternal vaginal microbiome just before
bacteria from our lives, being too clean creates the birth,” said Lynch at the time of the study’s publication.
risk of filtering out the microscopic creatures that She theorizes that this genus helps form the initial
our gut and immune system need to stay healthy. Just community of microbes in an infant’s guts.
as children benefit from mingling with cows and But animal-borne microbes might not always be good
horses and bring that dust inside, exposure to the for us: Cats carry toxoplasmosis—a disease from com-
microorganisms that come with a pet dog can help mon parasites—and frogs and turtles can carry salmo-
keep a person healthy, even if you aren’t on a farm. nella on their skin (just wash your hands). But in general
A 2015 study found that owning a dog increased the we don’t have to worry. “Most bacteria in the environ-
levels of 56 different classes of bacterial species in the ment are ‘good’ or at least they do not care much about
home, while cat ownership boosted 24 categories. us,” says Barberán. “That means that most environ-
“Homes with pets (dogs in particular) tend to have more mental bacteria transported by pets are innocuous.”
different species of microbes (that is, more diverse).
This observation is likely due to dogs bringing inside AS RESEARCHERS ARE LEARNING more about how
microbes from dirt, plants, water, etc.,” says the study’s our furry friends can protect our gut health, what can
coauthor Albert Barberán, an assistant professor of the pet owners do to protect their pets’? “Approximately
department of Environmental Science at the University 70 percent of a pet’s immune system is in the

88 H E A LT H
 BABIES’
INDIRECT
EXPOSURE TO
DOGS CAN BE
BENEFICIAL, EVEN
WHILE THEY’RE
STILL IN THE
WOMB.
gastrointestinal tract,” said Kurt Venator, the chief
veterinary officer at Purina, in a statement to Health.
“These gut bacteria have many different functions in
maintaining pet health—both physical and behavioral—
and they form a crucial part of the interaction between
gut and brain known as the gut-brain axis.” Venator also
emphasized that the pet’s diet is critical.
In fact, in a paper published in 2017 in mBio,
researchers from Nestlé Purina PetCare Company
found that the ratio of proteins and carbohydrates in
a dog’s daily diet have a significant influence on the
balance of microbes in its gut. Specifically, research-
ers observed that dogs that were fed a high-protein,
low-carbohydrate diet had decreases in the ratio of
Bacteroidetes to Firmicutes bacteria, which could lead
to more successful weight management in obese dogs,
and additionally had enriched microbial gene net-
works associated with weight loss in humans. “We do
believe dogs have become heavier over the last decade,
and that it’s an epidemic,” computational biologist
Johnny Li, who led the new study, told ScienceDaily
after the research was published.
The effects of diet on the microbiome were more
pronounced in overweight dogs than dogs of a healthy
weight. “That seems to suggest that obese dogs and
overweight dogs are more susceptible to dietary inter-
vention,” said Li.
That doesn’t mean you should start feeding Fido
kimchi and kefir. And according to Venator, few pet
probiotics on the market have proven efficiency. The
American Kennel Club recommends seeking out
dog foods that are labeled “complete and balanced”
to make sure your pet is getting all the gut-friendly
nutrients it needs. “Probiotics are extremely strain-
specific, and different strains within the same species
can have very different effects, making them tricky
to implement into a diet correctly and with a predict-
able effect,” says Venator. “Probiotics are also dose
dependent. Therefore clinical research is needed to
establish the correct required amount of a particular
strain of bacteria.” But in terms of fully understanding
this connection in dogs, more research is needed to
translate into real-world ways to feed your pet.
It is good news for dog lovers everywhere that our
four-legged companions can diversify the home’s
microbiome, and that the research to keep our dogs’
guts healthy is within reach. As if we needed another
reason to get a dog. ●
H E A LT H 89
 M E AL PL AN

BOOSTING YOUR
PLATE AND MICROBIOME
WITH A DAY OF
GUT-HEALTHY EATING
This high-fiber, plant-based meal plan can give your gut
bacteria a boost and switch up all three of the day’s meals
to pave the way for long-term digestive health.
BY ANN TAYLOR PITTMAN

A FEW YEARS AGO, a study published in the journal
Nature found that eating a high-fiber, plants-only
diet positively shifted people’s microbiome makeup
in just 24 hours, compared with eating a meat- and
cheese-heavy diet—suggesting that the former might
be a better way of eating for gut health. (Conversely,
the animal-based diet rapidly shifted the microbiome
in a way that implies it could trigger inflammatory
bowel disease.)
Interestingly, one group of gut bacteria—the genus
Prevotella—that represents microbiome diversity
(which you want) did not change on the short-term
plants-only diet, suggesting that to see the full bene-
fits, you will need to make a commitment to a high-
fiber diet for the long haul.
But to help you quickly reboot your gut flora, we
offer this easy-to-follow one-day plan. It’s an all-
plants (a.k.a. vegan) diet based on whole foods, zero
added sugars, and lots of fiber to feed the good bugs
in your belly. It’s high in fiber, so if your usual diet
is lacking in fiber, you might want to start slow here
to prevent—ahem—ill side effects from going too
hard too fast.
It’s affordable, and servings are generous—so you’ll
stay satisfied over the three meals. Make-ahead sta-
ples such as roasted chickpeas and seasoned bulgur
can carry you through breakfast, lunch, and dinner
with ease and flavorful taste. And none of the meals
take more than 30 minutes to prepare!
Use the plan to jump-start your commitment to
better gut health or as a guide to long-term changes.
Either way, your gut will thank you.

90 H E A LT H

Make Ahead
SMOKY ROASTED
CHICKPEAS
ACTIVE TIME 10 minutes
TOTAL TIME 1 hour
SERVES 5
These crunchy chickpeas will serve
you well throughout the day as both
a snack and a crunchy, protein- and
fiber-rich topping for salads. For the
crunchiest texture, cook them until
they’re just shy of burning. They’ll
stay crisp in an airtight container at
room temperature for up to a week.
1 (15-oz.) can unsalted
chickpeas, rinsed
and drained
1 1/2 Tbsp. olive oil
1/2 tsp. smoked paprika
1/4 tsp. kosher salt
1/4 tsp. cayenne pepper
1. Preheat oven to 400°F.
ROASTED
CHICKPEAS
AND SEASONED
BULGAR CAN
FIND THEIR WAY
INTO EVERY
MEAL.
2. Spread chickpeas on several
layers of paper towels, and pat
dry. Spread in an even layer on a
small rimmed baking sheet lined
with parchment paper. Drizzle with
oil, and shake pan to coat. Bake at
400°F for 30 minutes.
3. Remove pan from oven. Sprinkle
chickpeas evenly with paprika,
salt, and cayenne pepper; stir well.
Return to oven; bake at 400°F
until chickpeas are very crisp and
crunchy (but not burned), 15 to 20
minutes. Cool completely; store in
an airtight container for up to 1 week.
PER SERVING 115 Calories, 5g Fat, 3g Fiber,
4g Pro.,13g Carb., 1g Sugar, 114mg Sod.
SIMPLY SEASONED BULGUR
ACTIVE TIME 5 minutes
TOTAL TIME 30 minutes
SERVES 4
Make a batch of whole grains ahead
of time to enjoy in various forms
throughout the day—as part of
breakfast, lunch, and dinner. For a
gluten-free option, you can use the
same amounts and cook times to
make a batch of quinoa. Per serv-
ing, the quinoa version will contain
124 calories, 4g fat, 4g protein, and
2g fiber.
1 1/3 cups water
2/3 cup uncooked bulgur
2 tsp. olive oil
3/8 tsp. kosher salt
Bring 11/3 cups water to a boil in a
small saucepan over medium-high.
Stir in bulgur; cover, reduce heat
to medium-low, and simmer 12
minutes. Remove from heat, and let
stand, covered, 10 minutes. Uncover.
Drizzle with oil, and sprinkle with
salt. Fluff with a fork to combine.
PER SERVING 100 Calories, 3g Fat, 3g Fiber,
3g Pro., 18g Carb., 0g Sugar, 184mg Sod.
H E A LT H 91
 THIS
INSTANT
OATMEAL
ALTERNATIVE HAS
NO ADDED SUGAR
WHILE STAYING
SWEET.

Breakfast
STRAWBERRY BULGUR
BOWL
ACTIVE TIME 20 minutes
TOTAL TIME 10 minutes
SERVES 1
While you might not think of turning
bulgur into porridge, it’s a delicious
whole-grain breakfast with a texture
similar to instant oatmeal. Mashed
dates naturally sweeten and enrich
almond milk for a creamy, satisfying,
no-added-sugar bowl. You can make
the porridge ahead of time and sim-
ply reheat before serving; then add
the berries and nuts.
1/2 cup unsweetened almond
milk
2 dates, pitted and finely
chopped
3/4 cup Simply Seasoned Bulgur
1/4 tsp. vanilla extract
3/4 cup halved small strawberries
2 Tbsp. unsalted roasted
almonds, chopped
1. Place almond milk and dates
in a small saucepan; mash dates
with a fork to break them up and
incorporate them into milk. Add
Simply Seasoned Bulgur. Cook over
medium, stirring often, until mixture
just comes to a simmer. Remove
from heat, and stir in vanilla.
2. Spoon bulgur mixture into a bowl.
Top with strawberries and almonds.
A.M. SNACK: 5 oz. frozen edamame
pods, steamed and tossed with
1/8 tsp. kosher salt (155 calories,
7g fiber)
PER SERVING 352 Calories, 15g Fat,
10g Fiber, 36g Pro., 50g Carb., 16g Sugar,
371mg Sod.

92 H E A LT H

Lunch
TABBOULEH WITH
AVOCADO
ACTIVE TIME 10 minutes
TOTAL TIME 10 minutes
SERVES 1
Crunchy, lemony, fresh, and filling—
this hearty tabbouleh makes a great
lunch. If you’re packing it up to go,
store the chickpeas separately so
they’ll keep their crunch. Save the
other avocado half; you’ll use it in the
next day’s lunch. Keep the pit in the
avocado half, and wrap it tightly with
plastic wrap to limit browning.
2/3 cup chopped English
cucumber
1 medium tomato, chopped
(about 2/3 cup)
1/2 cup Simply Seasoned Bulgur
1/3 cup chopped fresh
flat-leaf parsley
1/4 cup finely chopped
lacinato kale
2 Tbsp. finely chopped
red onion
1 Tbsp. fresh lemon juice
1 1/2 tsp. olive oil
1/8 tsp. kosher salt
1/2 ripe avocado, chopped
1/3 cup Smoky Roasted
Chickpeas
MEAL P LAN
Combine cucumber, tomato,
Simply Seasoned Bulgur, parsley,
kale, and onion in a medium bowl.
Drizzle with lemon juice and oil,
and sprinkle with salt; toss well to
combine. Gently fold in avocado.
Arrange tabbouleh in a serving
bowl or on a plate; sprinkle evenly
with Smoky Roasted Chickpeas.
P.M. SNACK: 3 dates and 12 unsalted
roasted almonds (152 calories,
4g fiber)
PER SERVING 498 Calories, 27g Fat,
15g Fiber, 13g Pro., 67g Carb., 7g Sugar,
622mg Sod.
THIS LEMONY,
CRUNCHY DISH
WORKS WELL FOR
LUNCH IN ANY
SEASON.

Dinner
PASTA WITH GREEN PEAS
AND ALMOND GREMOLATA
ACTIVE TIME 20 minutes
TOTAL TIME 20 minutes
SERVES 1 parsley
Chickpea pasta has a mild flavor and
higher fiber content (compared with
whole­wheat pasta). The gremolata
topping truly makes the dish; it’s
herby, crunchy, fragrant, and citrusy.
Serve the pasta immediately for the
best texture and taste.
2 oz. uncooked chickpea
spaghetti (such as Banza)
1/4 cup frozen green peas
94 H E A LT H
1 Tbsp. olive oil
2 garlic cloves, thinly sliced
1/4 tsp. black pepper
1/4 tsp. plus a dash of kosher
salt, divided
2 Tbsp. chopped fresh flat-leaf
11/2 Tbsp. chopped unsalted
roasted almonds
1 tsp. lemon zest
1. Cook pasta in boiling water until
almost al dente, about 5 minutes.
Add green peas; cook until peas
are warmed through and pasta is
tender, about 1 minute. Drain pasta
mixture, reserving 1/2 cup cooking
CHICKPEA
PASTA HAS MORE
FIBER THAN ITS
WHOLE-WHEAT
ALTERNATIVE.
liquid. Cover pasta mixture to
keep warm.
2. Heat oil in a small skillet over
medium-low. Add garlic; cook until
tender, about 2 minutes. Add pasta
mixture, pepper, 1/4 teaspoon salt,
and 1/4 cup reserved cooking liquid;
toss to combine. If necessary, add
up to 1/4 cup additional cooking liq-
uid to reach desired consistency.
3. Make the gremolata: Stir together
parsley, almonds, lemon zest, and
remaining dash of salt. Sprinkle over
the pasta and serve immediately.
PER SERVING 426 Calories, 24g Fat,
12g Fiber, 19g Pro., 42g Carb., 7g Sugar,
702mg Sod.
 Editor-In-Chief Amy Conway
Creative Director Michael McCormick Photo Credits
Editorial General Manager Meesha Diaz Haddad
Front cover: Stomach: Cecilie Arcurs/
Getty Images (2); smoothie: Ma-k/
Your Guide to a Healthy Gut Getty Images; yogurt: Noor Raihan Binti
Muhamad Noordin/EyeEm/Getty Images;
Editorial Director Kostya Kennedy artichoke: LuVo/Getty Images
Editor Emily Joshu Back cover: Top: Westend 61/Getty
Designer Dean Abatemarco Images; bottom (from left): Laflor/Getty
Photo Editor Sarah Rozen Images; Diana King/The Licensing Project
Writers Robin Bashinsky, Ryan Hatch, Jenna Helwig, Hallie Levine, Lisa Lombardi,
Amanda MacMillan, Denise Mann, Courtney Mifsud, Jessica Migala, Ann Taylor Pittman, P. 1 Aleksandr Davydov/Alamy
Maggie Puniewska, Patrick Rogers, Holly Schmidt, Erica Sonnenburg, Justin Sonnenburg Stock Photo
Copy Editor Ben Ake PP 2–3: Nensuria/istock/Getty Images
Reporter Ryan Hatch
P. 5 Trunk Archive
Production Designer Sandra Jurevics
P. 7 Ruslan Dashinsky/Getty Images
Premedia Trafficking Supervisor Justin Atterberg
P. 8–9 Daniel Ward/Gallery Stock
Color Quality Analyst Tony Hunt
PP. 10–13 Francesco Zerilli/
MEREDITH SPECIAL INTEREST MEDIA Gallery Stock (2)
Vice President & Group Publisher Scott Mortimer P. 14 Sam Armstrong/Gallery Stock
Vice President, Group Editorial Director Stephen Orr P. 16 Rich Begany/The Licensing Project
Vice President, Marketing Jeremy Biloon P. 17 Andy Grimshaw/Gallery Stock
Executive Account Director Doug Stark P. 18 Robert George Young/Getty Images
Director, Brand Marketing Jean Kennedy P. 19 Sung Yoon Jo/istock/Getty Images
Associate Director, Brand Marketing Bryan Christian P. 20 Ping Pong Cat/istock/Getty Images
Senior Brand Manager Katherine Barnet P. 21 Adam Albright
P. 22 Lucas Zarebinski/The Licensing
Editorial Director Kostya Kennedy
Project
Creative Director Gary Stewart
P. 23 Westend 61/Getty Images
Director of Photography Christina Lieberman
P. 24 Fotografia Basica/Getty Images
Editorial Operations Director Jamie Roth Major
Manager, Editorial Operations Gina Scauzillo P. 25 Shannon Douglas/Offset
PP. 26–27 Jutta Klee/Stone/Getty Images
Special thanks Brad Beatson, Melissa Frankenberry, P. 29 Eric Grave/Medical Images
Samantha Lebofsky, Joseph McCombs, Kate Roncinske, Laura Villano P. 30 Cristina Favaro/Getty Images
P. 33 Bonninstudio/Offset
MEREDITH NATIONAL MEDIA GROUP P. 34 Juliet Clare Warren
President, Meredith Magazines Doug Olson
P. 36–37 G-stockstudio/Getty Images
President, Consumer Products Tom Witschi
P. 39 Neal Grundy/Gallery Stock
President, Chief Digital Officer Catherine Levene
P. 40 LightField Studios/istock/
Chief Revenue Officer Michael Brownstein
Getty Images
Chief Marketing & Data Officer Alysia Borsa
P. 43 Adam Voorhes/Gallery Stock
Marketing & Integrated Communications Nancy Weber
P. 44 Frema/istock/Getty Images
SENIOR VICE PRESIDENTS P. 45 Will Styer/The Licensing Project
Consumer Revenue Andy Wilson P. 46 Zephyr/Science Photo Library
Corporate Sales Brian Kightlinger P. 48 Humanmade/istock/Getty Images
Direct Media Patti Follo P. 51 The Good Brigade/Digital Vision/
Research Solutions Britta Cleveland Getty Images
Strategic Sourcing, Newsstand, Production Chuck Howell PP. 52–54 James Yang (2)
Digital Sales Marla Newman P. 56 Carlo107/istock/Getty Images
The Foundry Matt Petersen P. 59 Layla Bird/istock/Getty Images
Product & Technology Justin Law P. 60 Nensuria/istock/Getty Images
PP. 62–69 Greg DuPree (6)
VICE PRESIDENTS
PP. 70–71 Kevin Kosicki/Getty Images
Finance Chris Susil
PP. 72–73 Peter Karasev/Offset
Business Planning & Analysis Rob Silverstone
P. 75 Andresr/Getty Images
Consumer Marketing Steve Crowe
Brand Licensing Steve Grune P. 76 Sam Edwards/OJO Images/
Corporate Communications Jill Davison Getty Images
P. 78 Paul Kooiman/Gallery Stock
Vice President, Group Editorial Director Stephen Orr PP. 80–83 James Yang (2)
Director, Editorial Operations & Finance Greg Kayko P. 84 Bonninstudio/Offset
P. 85 Jose A. Bernat Bacete/Getty Images
MEREDITH CORPORATION PP. 86–87 Treasure Photo/istock/
President & Chief Executive Officer Tom Harty
Getty Images
Chief Financial Officer Joseph Ceryanec
P. 89 Sergey Ryumin/Moment/
Chief Development Officer John Zieser
Getty Images
Chief Strategy Officer Daphne Kwon
PP. 90–94 Jennifer Causey (4)
President, Meredith Local Media Group Patrick McCreery
P. 96 Tetra Images/Getty Images (2)
Senior Vice President, Human Resources Dina Nathanson
Chairman Stephen M. Lacy
Vice Chairman Mell Meredith Frazier

Copyright © 2019 Meredith Corporation.

Published by Meredith Corporation. 225 Liberty Street • New York, NY 10281
All rights reserved. No part of this book may be reproduced in any form or by any electronic
or mechanical means, including information storage and retrieval systems, without permission
in writing from the publisher, except by a reviewer, who may quote brief passages in a review.
For syndication requests or international licensing requests or reprint and reuse
permission, email syndication@meredith.com.
Printed in the USA.

H E A LT H 95
 Last Word

GUT-HEALTHY YOGA
WHETHER YOU’VE OVERINDULGED in certain foods or one too many
drinks, you’re feeling stressed from a long week, or you’re just generally
backed up, rolling out the yoga mat may help alleviate digestive distress.
OPEN TRIANGLE
From squats to twists to lunges, yoga stretches and tones abdominal POSE
muscles, and it stimulates endocrine glands to help them work smoothly. Stand at the top of the
Getting in touch with your mindful side can also lower stress levels mat and take a step
causing tummy troubles. Here are two gut-healthy poses to try. back with your right
foot. Turn it to the side
of the mat. Spread
your arms out. Lean
forward at the hip and
lower your left hand
down to the floor.
Raise your right arm,
keeping your arms
spread out. Look up at
your right hand.

CHILD’S POSE
Sit on your knees and
feet with your legs
widely apart. Lean
forward and stretch
your arms out in front
of you. Keep your back
straight and place
your forehead on
the floor.

96 H E A LT H
 Living Well, Inside and Out
The connection between our guts and our brains is affected by what we eat, how much
we sleep, our stress levels, and our genetics. The latest science shows that the right food,
fitness, and lifestyle choices can have a lasting impact on our digestive health.