Guest post by: Dr. Lauryn Lax
Keto constipation is real.
Despite the hype about low carb ketogenic diets being good for everything from brain health to metabolic boost, there is a dark side no one is really talking about: Constipation.
Constipation is defined as “difficulty relieving the bowels.”
Although chronic constipation technically happens when you “don’t go” for three or more days in a row, in functional medicine, nutrition and general health world, constipation is a REAL DEAL if you aren’t going #2 every day.
And not just any doo—but a nice sausage-like, well-formed brown turd (like the Bristol Stool Chart below) and a feeling of complete elimination (like you can do a happy doggy dance!).
Unfortunately, low carb diets are notorious for impairing your natural-born abilities to “do the doo” like a normal human.
Here are 6 Reasons Why Keto Constipation Happens (plus 3 things you can do about it—now)
6 Reasons Why Keto Constipation Happens
- Decreased Healthy Gut Bacteria
Your gut is home to upwards of 15-30,000 different species of bacteria and trillions of individual bacteria critters.
Gut bacteria DIVERSITY (different strains of bacteria) is associated with better health overall.
Ketogenic diets have been shown to improve gut bacteria diversity in the presence of disease as a “therapeutic” diet (such as Autism, Diabetes, and Epilepsy).
However, in healthier individuals and long-term dietary implementation, gut bacteria diversity appears to diminish , as well as increase systemic inflammation (1 Short-term impact of a classical ketogenic diet on gut microbiota, 2 Low-carbohydrate ketogenic diets, glucose homeostasis, and nonalcoholic fatty liver disease) in the body—particularly without enough butyrate (prebiotic fiber) present.
Low carb, high fat, and higher protein diets can also decrease beneficial bacteria, while spiking overgrowth of negative bacteria in the gut, when dietary “balance” is lacking—particularly DIVERSITY of healthy fats (Influence of diet on the gut microbiome and implications for human health).
In addition, while many people believe that carbohydrates and sugars alone are the culprits for breeding “bad” gut bacteria, “bad” gut bacteria can EQUALLY breed from ketone bodies (the substances formed in the body from fatty acids to replace glucose—sugar—on a keto diet). Excess ketone bodies (such as from long term ketosis) have been linked to symptoms of IBS—explaining close ties for some who experience constipation or other gut symptoms (loose stools, bloating, diarrhea) when following a Ketogenic diet. (Campbell et al, 2010).
The Bottom Line: Keto diets improve gut bacteria diversity in unhealthy, disease state individuals. For those who no longer have a disease or adhere to a long-term Keto diet however, healthy gut bacteria and diversity may lessen.
- Lack of Prebiotic Fiber
By default, people on low carb diets aren’t eating a lot of color and plants—where most of the “push” for your food lies.
Each macronutrient we eat plays a unique role in your body and digestion:
- Fat= The “slippery slope” to help ease food down through the “tubes” of digestion.
- Carbohydrates= The “bulk” to carry food through (and ride the slippery slope from fatty acids).
- Protein= The “building block” of your cells and muscles—essential for healthy cell metabolism and body structures/organs, as well as helps stimulate stomach acid and enzyme production (to break down food).
Ultimately, a healthy body desires balance from all food groups—and although it CAN create glucose-like energy from fats or proteins, or protein support from broccoli and mushrooms, or extract fat from your chicken breast. Ideally, your body just wants the real deal so each macronutrient can stay in its lane and do their job—ESPECIALLY prebiotic foods (resistant starch carbs) to maximize healthy digestion.
Prebiotic foods are foods with fiber that feed healthy gut bacteria (probiotics), helping them populate the gut. Ketogenic diets, bent on keeping carbs to less than 25-net carbs each day often neglect many of these prebiotic fibers—found in starchier foods like cooked and cooled sweet potatoes/potatoes, Jasmine white rice, green tipped bananas and plantains, taro, onions, leeks, jicama and other starchy tubers. Resistant starches also help “push food through” your GI tract, and cleanse your system.
Prebiotic fiber has long been touted for promoting a healthier gut microbiome (Saha & Reimer, 2014). Unlike other low-starchy carbs, like greens, cucumbers, and celery (wonderful in their own right), prebiotics help make our probiotics (healthy gut bacteria) STICK in our gut for the long term. Studies have also shown that prebiotic fiber significantly increases ketone production (body’s ability to burn fat for fuel) and boost metabolism (Vetali et al, 2010).
The Bottom Line: Resistant starch, prebiotic foods support healthy digestion.
- Bulletproof Coffee, Bars, Shakes, Cheese & Dry Foods
Aside from running low on starchy fibers, many people on a keto or Atkins style diet fail to eat enough color and green things in general—hydrating foods that support elimination (poop)—NEGLECTING carbohydrates and fiber altogether.
Bring on the butter, bacon, eggs, nut butters, shakes and coffee! Opting for more white, brown and tan colors on their plate (instead of rich greens, reds, oranges, yellows, blues and purples) can keep you clogged! While bacon, butter and eggs are NOT bad things by any means, when we keep putting these dry foods down the hatch—without some hydrating foods from leafy and colorful things—we run “dry” ourselves (i.e. constipation).
Not to mention, many of the supplemental products like (exogenous ketones, shakes, bars, nut butter packets) people turn to when they “go keto” are filled with fillers, additives, soy, artificial sweeteners and chemicals—equally havoc-wreaking for your digestion.
Food quality also matters. Is your dinner from Tyson Farm’s conventional chicken farm? Your “butter coffee” made from Keurig or Starbucks’ finest grounds (and highly cross-contaminated with gluten)? Your cheese from a high-pasteurized, hormone-infused dairy source? Chances are, your gut knows the difference.
The Bottom Line: Food quality matters. If you’re eating conventional meats and dairy, bars, shakes and processed keto products, your bod (digestion) is naturally going to struggle.
- Liver/Gallbladder Congestion
Do you ever get gas or a tummy ache after eating lots of healthy fats with your meal? Greasy stools or clay-colored stools? Pellets or rocks? You may have a sluggish or congested liver and/or gall-bladder—the organs essential for creating waste. When our detoxifying organs can’t do their job efficiently, “backup” (i.e. constipation) happens.
In addition, your gallbladder is SPECIFICALLY responsible for digesting your fats and forming bile salts. If queasiness hits you when you eat a little too much coconut oil or dig into a fatty steak, this could be because your gallbladder is not strong enough to break those fats down.
How do your liver or gallbladder go “bad?”
Common triggers to liver/gallbladder congestion include:
History of low-fat diet
Lack of (real food) fiber
Low stomach acid
History alcohol/processed food diet
Toxin exposure (conventional beauty/cleaning products, tap water, plastics)
Long term medication/NSAID use
Poor quality meat/dairy
The Bottom Line: Fats cause digestive distress if your liver/gallbladder is sluggish.
- Feast & Fast
All or nothing. Many people on a keto diet dabble with IF (intermittent fasting), fasting and intermittent feasting—going from 16-hours to days without food, then “feasting” on everything in sight (within their dietary constraints of course). Sure, this all or nothing style of eating can mimic the way humans DID eat for centuries (times of “feast” and times of “famine”) and serve many well…however, from a biological perspective, this “food dump” into your system with all of your daily calories at once (or within a shortened time frame) can also be A LOT of information for your body to process at once.
Couple this food dump (or feast) with gut issues (such as underlying bacterial overgrowth, low stomach acid or slow motility) and your ketogenic diet PLUS intermittent fasting may be a better thought than actual enhancement for your digestion.
The Bottom Line: Consider how well you digest your food and feel during your feeding periods. Bloated? Gassy? Constipated after a large meal post-fast, or trying to get all your energy needs in to a shortened time frame? Your digestion may not be able to handle larger meals at once and can benefit from smaller. Experiment.
- The Elephant in the Room: Stress
Face it, it takes a fairly rigid person to be able to stick with any diet for the long haul (in fact, 97% of diets fail). For those who can stick with it, there’s often more to the story than just food—particularly for the constipation conundrum.
From a human psychology perspective, oftentimes, individuals who are able to stick with keto for the long haul, are also those who are able to:
(1.) Wake up at 5 a.m. for their 5:30 a.m. CrossFit workout
(2.) Squeeze 80-hour work weeks into “40-hours”
(3.) Spin three plates at once…you get the picture. They often can “bite off more” than they can chew.
Challenge: Clench your fists—really tightly—for a moment….What happens? Fists swell? Get red? Palms sweat? Hands grow tired?—Stress.
Well, the same thing happens in your gut when your body is stressed—from staring at screens for hours on end, lack of sleep, low water intake, overtraining, under-training, lack of passion and connection in your life, burning a candle at both ends, running off coffee, etc. Your body (and gut) “clenches” on to that stress—giving way to constipation.
The Bottom Line: Stress is the #1 constipation cause.
What to Do About It
7 quick-hit tips to bust constipation on a Keto diet:
- Prebiotic & Probiotic Up. Reach for a soil-based probiotic and partially hydrolyzed guar gum prebiotic fiber as part of your supplement routine.’
- Swig 1-2 tbsp. apple cider vinegar in water around meals.
- Incorporate at least three different colors at each meal of real foods. Consider a serving of prebiotic fiber each day (cooked and cooled sweet potatoes/potatoes, winter squashes and starchy tubers – carrots, taro, etc.)
- Drink LOTS of clean, filtered water (aim for half your bodyweight in ounces)
- Replace coffee with herbal tea, like ginger, licorice or Dandelion
- Consider taking Ox Bile supplement if you feel queasy after eating fats
- Check in with your stress—be real. How’s your sleep? Are you pushing it too hard at the gym? Saying yes to everything? Neglecting your body cues in the name of keto perfection? Permission to stop one stressor wreaking havoc on your health.
Be sure to check out Part 2.
Resources
Campbell, A., Matthews, S., Vassel, N., Cox, C., Naseem, R., Chaichi, J., & … Wann, K. (2010). Bacterial metabolic ‘toxins’: A new mechanism for lactose and food intolerance, and irritable bowel syndrome. Toxicology, 278(3), 268-276. doi:10.1016/j.tox.2010.09.001
Vitali, B., Ndagijimana, M., Cruciani, F., Carnevali, P., Candela, M., Guerzoni, M. E., & Brigid, P. (2010). Impact of a synbiotic food on the gut microbial ecology and metabolic profiles. BMC Microbiology, 101-13. doi:10.1186/1471-2180-10-4
ABOUT THE AUTHOR
Dr. Lauryn Lax is a Doctor of Occupational Therapy, Nutritional Therapy Practitioner, Functional Medicine Practitioner, author and speaker, with over 20 years of clinical and personal experience specializing in gut health, intuitive eating, disordered eating, anxiety, hormone balance and women’s health. She’s based in Austin, Texas, and operates a virtual Nutrition & Functional Medicine practice, Thrive Wellness & Recovery, LLC. In addition, Dr. Lauryn is a published journalist and speaker, and her work has been featured in Oxygen Magazine, Women’s Health, Paleo Magazine, Breaking Muscle, CrossFit Inc, USA Today, ABC and CBS News. She loves nothing more than helping others “quiet the noise” in the health food and fitness world.
Great info here! I consider myself “borderline keto.” Don’t actually track anything, but stick pretty high fat/low carb. As long as I eat a variety of non-starchy veggies I’m fine. I try to include veggies with every meal. For example, this morning I threw some spinach into my scrambled eggs. Lunch was sardines over some roasted broccoli. Probiotic foods like sauerkraut or a shot of kombucha (you don’t need to drink the whole bottle all at once) are helpful too.
As long as you’re eating plenty of low-carb vegetables and healthy fats, staying hydrated all day, and utilizing high-quality supplements occasionally, a healthy digestion on keto shouldn’t be a problem for long.
Curious if this is an issue that affects those on carnivore. That diet basically says the opposite of much of what is written here, but people seem to be doing fine. Although I do wonder if the diversity in the gut becomes a bad thing after many years.
This has been a concern of mine even with taking magnesium and vitamin c. I love the diet for sure but wonder if I am missing this element. Probiotics don’t work for me but I do have some prebiotic fiber I can add and have no problem adding in some carrots. For those of us with a history of gut issues, it’s really important to look at the whole picture… stress is huge and diet alone won’t necessarily fix everything. I fully believe that keto has more merit than its given credit for but that we need to adjust ALL nutritional approaches to suit our specific needs. I will try the probiotics and add back a wee bit of starchy carbs. Constipation is a symptom of a much deeper not so obvious issue. We need to address the whole picture not just the symptom itself. Great article
A better framework for understanding fibers is to categorize them based on mechanisms – (1) bulking, (2), viscous, and (3) fermentable. Bulking fibers hold a lot of water and push things through but are not fermented. Viscous fibers thicken the contents of the intestinal tract and thereby slow down absorption of glucose and cholesterol. (4) fermentable fibers feed the microbiome and produces short-chain fatty acids (SCFAs) and other beneficial metabolites. This fermentation changes the expression of >200 genes in the large intestine that control metabolism. Fermentable fibers mildly increase bulk (about 1 gram of increased bulk for every 1 gram of fiber) but it is not through water holding – it is increased bacterial mass. In contrast, bulking fibers increase bulk by about 4-5 grams of bulk for every 1 gram of fiber.
Guar gum is very viscous – you cannot eat a lot of it and its prebiotic effects are limited. Resistant starch, inulin, fructooligosaccharides and galactooligosaccharides are fully fermented. Inulin, FOS and GOS are generally soluble and fermented very quickly, which gives most people a lot of gas, so you cannot eat a lot. Resistant starch is insoluble, it ferments slowly and you can eat a lot of it. Human clinical studies showing health benefits of resistant starch show improved insulin sensitivity, satiety, fat burning, pancreatic release of insulin, kidney function, liver health. Animal studies with resistant starch are showing healing the leaky gut, improvements in autoimmune diseases, and reduced risk of advanced macular degeneration. People should understand the specifics of dietary fibers and how they work in order to make better choices about which benefits they will see.
Great article. I like the fact that you included prebiotic fiber in your article. That might be the key because those of us on keto aren’t getting enough. A lot of the prebiotic fiber is in starches. Fermented foods also helps.