How can I improve bloating?

How to Improve Bloating

Start with a 2-week dietary elimination trial to identify trigger foods (fructose, lactose, sorbitol, artificial sweeteners), combined with diaphragmatic breathing exercises for immediate symptom relief, then advance to a supervised low-FODMAP diet if initial measures fail. 1, 2

Initial Dietary Modifications (First 2 Weeks)

Begin by eliminating common trigger foods for a 2-week trial period: 1, 2

• Eliminate fructose-containing foods (high-fructose corn syrup, foods with added fructose as sweeteners) - approximately 60% of patients with digestive disorders have fructose intolerance, and dietary restriction improves symptoms in >80% at 1 month 1, 3
• Remove lactose-containing products - 51% of patients with bloating have lactose intolerance 2
• Avoid sorbitol and artificial sweeteners found in sugar-free products 4
• Limit fresh fruit to 3 portions per day (approximately 80g per portion) 4
• Reduce carbonated beverages, limit tea/coffee to 3 cups daily, and minimize alcohol 4

Immediate Symptom Relief Techniques

Practice diaphragmatic breathing exercises to reduce symptoms immediately by increasing gastroesophageal tone and decreasing stress response 2

• Lie down for 30 minutes after meals to slow gastric emptying 2
• Avoid drinking water until at least 30 minutes after eating 2

Second-Line Intervention: Low-FODMAP Diet

If initial dietary modifications fail after 2 weeks, implement a structured low-FODMAP diet under supervision of a trained gastroenterology dietitian: 1, 4

• Restriction phase (4-6 weeks maximum) - eliminates fermentable oligosaccharides, disaccharides, monosaccharides, and polyols 1, 4
• Reintroduction phase - systematically reintroduce foods to identify specific triggers 4
• Personalization phase - create individualized long-term diet based on tolerance 4

Critical caveat: The low-FODMAP diet decreases beneficial Bifidobacterium species and risks malnutrition, so it must be implemented with planned reintroduction by a trained gastroenterology dietitian exclusively 1

Fiber Management

Use soluble fiber cautiously, starting at 3-4g/day: 2

• Avoid insoluble fiber as it worsens bloating 2
• Consider oats and linseeds (up to 1 tablespoon per day) for constipation-predominant bloating 4

Pharmacologic Options Based on Underlying Cause

For bloating with constipation: 2

• Secretagogues (lubiprostone, linaclotide) are superior to placebo for bloating and constipation 2
• Polyethylene glycol is effective and cost-efficient for chronic constipation 2
• Prucalopride may help both constipation and abdominal pain 2
• Avoid anticholinergic antispasmodics as they worsen constipation 2

For acute symptomatic relief: 2

• Antispasmodics reduce abdominal pain and global symptoms (RR 0.65; 95% CI 0.56-0.76) 2
• Simethicone for relief of pressure and bloating commonly referred to as gas 5

For suspected small intestinal bacterial overgrowth (SIBO) or dysbiosis: 2

• Rifaximin is first-line antibiotic 2
• Alternative antibiotics: amoxicillin, fluoroquinolones, metronidazole 2

Central Neuromodulators for Refractory Cases

For bloating related to visceral hypersensitivity or psychological comorbidities: 1

• Tricyclic antidepressants (amitriptyline) or serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine) show greatest benefit in reducing visceral sensations 1
• Pregabalin has shown improvements in bloating in IBS patients 1

Biofeedback Therapy for Constipation-Related Bloating

For patients with bloating and constipation who fail dietary interventions, consider anorectal biofeedback therapy: 1, 2

• 54% responder rate for 50% reduction in bloating scores in patients with diet-refractory bloating and disordered defecation 1
• Long-lasting improvements in abdominal distention, rectal hypersensitivity, and bloating based on RCTs 1
• Home-based alternatives available when motility specialists are not accessible 1

Psychological Interventions

Cognitive behavioral therapy and gut-directed hypnotherapy have strong evidence for improving bloating symptoms, particularly when psychological factors amplify visceral sensations 2

What NOT to Use

Probiotics are NOT recommended for bloating or distention: 1, 2

• No studies have examined efficacy specifically for bloating 1
• British, European, and American guidelines do not endorse probiotics for IBS or functional dyspepsia 1
• May cause brain fogginess, worsening bloating, and lactic acidosis 1

Peppermint oil showed no improvement in bloating at 6-week endpoint in recent placebo-controlled RCT 1

Critical Safety Considerations

Screen for eating disorders before implementing restrictive diets - work with gastroenterology psychologist to avoid avoidant/restrictive food intake disorder 1, 4

Discontinue elimination diets if not beneficial to prevent malnutrition 1, 2

Consider breath testing (hydrogen, methane, CO2) for patients refractory to dietary restrictions to identify carbohydrate malabsorption or SIBO 3, 2