Keto Diet 101: Bowel Trouble. Too Fast or Too Slow

Transition your eating from Standard American Diet to Keto and you can find POO the focus of your conversation. Some patients have their stools slow WAY down, Others find that every time they eat a high-fat meal, they have a date with the toilet.


THIS PROBLEM LASTS UNTIL: your bowels adapt to your new diet.

Drinking salted water prevents the keto flu and also helps with changes happening in your guts. I’m referring specifically to your stool. Constipation and hard bowel movements occur naturally as part of the keto transition process.

With less water, your stools become dehydrated and harder. Drinking salty water helps lessen this problem.

For the first couple of weeks, patients struggle with what to eat. My salesmanship for high-fat meat must work very well because they do a great job of loading up on fatty, greasy meat.

They produce ketones, but they also get constipated. A few minutes studying the number of carbs found in fruits and vegetables teach you that corn, cantaloupe, peas, bananas, and are all no-nos.

My new keto patients usually aren’t that familiar with many keto-friendly vegetables. For example, cabbage, Brussels sprouts, and fresh spinach are all great additions to a keto diet.

Sadly, many patients look at me bewildered that others actually eat that stuff. They ate yummy fatty meats, successfully peed ketones and did a little dance. Everything’s awesome until day 4 when they couldn’t poop.

Some patients got so constipated they gave up. Be prepared for this constipation challenge. Drink salt water. Add cabbage early.

Ingest a spoonful of dry chia seeds with some water every 2-4 hours. These little seeds swell up into a gelatinous substance and have helped many patients transition. This trick is tried and tested. One tablespoon every 2 hours followed by two cups of water has yet to fail my patients with this problem.

Several said they could not keep up with the spoonful of seeds that often and only made it to six tablespoons before they quit. However, the next day: success!!

If you’re still having a tough time with constipation, try Milk of Magnesia. This over-the-counter medication is the perfect fit for this problem. In the first weeks of keto, magnesium is the most common salt your body will lose. This magnesium-filled liquid medication helps replenish your missing magnesium while boosting your stools to soften up and move along.


THIS PROBLEM LASTS UNTIL: we figure out the cause of the loose stools.

Most people on a keto program experience bowel problems in the form of constipation. Sometimes, people experience the other extreme: diarrhea. This is usually due to a pre-existing problem with their system.

Over the years, the US government and corporations have spent millions of dollars researching ways to help people suffering from all sorts of bowel ailments. These range from irritable bowel to bacterial overgrowth, to leaky gut syndrome. One 1970s study treated irritable bowel syndrome with a high-fat diet.

It took six months for the study’s subjects to become regular. Still, the study showed that a high-fat low-carb diet is one of the cheapest and most effective ways to regulate runny stools and other bowel problems.

Unfortunately, the study was small and was not funded by a big pharmaceutical company. The study did not promote any medication. The outcomes from that old trial were so promising for this taxing problem that it led me to change how I approached my patients with bowel problems.

My experience with patients suffering from irritable bowel has taught me to stick to the plan of peeing ketones for three to four months before they turn the corner.

Did you know your small bowel or small intestines are supposed to be sterile? Sterile-as in no bacteria. Your large intestines are packed with bacteria. But your small intestines are supposed to be sterile. Anxiety, stress and chronic illness all lead to poorly functioning bowels.

Your small intestines can get so messed up that the bacteria normally found at the end of your intestines, in the large colon, wiggle their way into the upper portion of your digestive tract.

The bacteria in the small intestine reproduce without much resistance and grow rapidly. This is called small bowel overgrowth.

When patients have small bowel overgrowth, it is not uncommon for them to lose out on fatty vitamins normally absorbed there. Because their small bowel gurgles with abundant, unwanted bacteria, they can’t absorb any fat-based nutrients.

I’ve started patients on a ketogenic lifestyle not knowing that they had small bowel overgrowth. A week into the change and they are miserable with uncontrolled diarrhea. They call the clinic upset and declare, “This just is NOT the diet for me!”

After checking their lab results as well as a detailed history, it turns out they often have had loose stools after eating fat for the better part of a decade. These patients report avoiding all fat because it always gives them explosive diarrhea.

Such eruptions after each greasy meal kept them malnourished from their avoidance of fat. They go on for years without understanding what was truly happening to their system. One day, they happen to have their Vitamin D checked. Their results were so low that it could only mean they have not been absorbing any fat for years.

Fat absorption failure means you absorb no fat-based vitamins. Vitamin D is one of those vitamins.

I advise patients of mine who suffer diarrhea after switching to a high-fat diet not to give up. Why? They need this anti-inflammatory diet more than most of my other patients. If you suffer from loose stools or explosive diarrhea after going keto, give your body time to adjust.

Don’t give up! Your bowel has grown used to the low-fat life you used to lead. The mechanism to absorb fats has been sleepy or even shut down altogether. Turning these cells back on takes time. A few months!

The health of your brain and bowels depend on your ability to persevere. If your bowels flare up when switching to high fat, please know that it is more than just an annoyance. Something more is going on. See a gastro specialist. Extreme intestinal inflammation mentioned above can last weeks.

The lack of adequate fat enzymes also takes times to correct. Give your body time to adjust. Years of this hidden problem led to the chronic swelling of your bowels’ inner lining. It takes time to mend that chronic wound inside your guts.

Keto Diet 101: Solutions Available
If you get diarrhea within days of switching to keto, you have a problem with inflammation or absorption. Don’t quit. Fix it. To tide you over, I recommend the following:

Loperamide: (Also called Imodium) This over the counter medication slows down bowel movements. Most people cannot put their life on hold to deal with intense diarrhea. It takes time to fix this problem. In the meantime, don’t take all this suffering lying down. Control your symptoms. Take Loperamide. It will settle the symptoms down while we work through the problem without hurting you.

Kombucha Tea: This ancient drink is bubbly and fermented with healthy live bacteria in it. Most of my diarrhea patients reversed their bowel problems when they repopulated their gut bacteria. Many patients spend thousands of dollars on this process. Save your money.

Drink 1/4 cup of this tea a day until the diarrhea is resolved. Notice that I said ONE-FOURTH OF A CUP. Too much of that bacteria is often not tolerated by those struggling with bowel problems.

For my friend’s recipe on BONE BROTH that wins the BEST BROTH award – see the image below.

Finally, the surefire antidote that transitions my diarrhea patients through the roughest part can be unsettling for patients to hear: intermittent fasting. Yes, I am referring to the term for NO EATING. Before you transition your body chemistry to keto, any kind of fasting sounds like a strange idea.

Once you produce ketones, your appetite decreases. My diarrhea patients have an unknown injury inside their guts. That lining needs to heal. The answer? Rest. In other words, intermittent fasting. Fasting is a universal remedy for many medical problems.

When I suggest this to patients, they often resist due to fear of going without food. To help them begin to consider the option, I remind them that animals instinctively fast when they are ill. Rest your guts to allow time for healing. Stop eating.

The ancient Greek physician Hippocrates, regarded as the father of medicine, said this about fasting, “Everyone has a doctor in him; we just have to help him in his work. The natural healing force within each one of us is the greatest force in getting well. To eat when you are sick is to feed your sickness.”

If you want to learn more about understanding the ketogenic diet, check out the book ANYWAY YOU CAN on Amazon or Audible by Annette Bosworth, MD.

Mavropoulos, J. C., et al. “The Effects of Varying Dietary Carbohydrate and Fat Content on Survival in a Murine LNCaP Prostate Cancer Xenograft Model.” Cancer Prevention Research, vol. 2, no. 6, 2009, pp. 557–565., doi:10.1158/1940-6207.capr-08-0188
Nikaki K, Gupte GL.; Assessment of intestinal malabsorption; Best Pract Res Clin Gastroenterol. 2016 Apr;30(2):225-35. doi: 10.1016/j.bpg.2016.03.003.

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