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keto diet
What is constipation? Prevalence on a keto diet Why constipation occurs
Have you become more constipated since starting a low-carb or keto diet? Or
are you hesitant to try a low-carb diet after learning constipation may be a side
effect?
If so, this guide will help explain all things related to low carb and
constipation.
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What is constipation?
Before exploring how low-carb eating and constipation are related, we first
need to define what constipation is.
Here is possibly the most important take-home point of this entire guide: If
your bowel movements decrease, but you have no other symptoms or
changes, you are not suffering from constipation.
How prevalent is constipation on a keto diet?
The prevalence of constipation on a low-carb or keto diet can be as high as
50% according to some studies. 1 Clinicians familiar with low-carb
diets, however, feel it is closer to 25%. 2 The good news is that
clinicians also agree that constipation is usually mild and self-resolves over
time, or it is easily treated with home and over-the-counter remedies.
The first is an acute decrease in fiber. While it is debatable if you need fiber for
healthy bowel movements, many believe that your body needs time to adjust
to a sudden decrease in fiber content. Therefore, if someone was getting a lot
of fiber from whole grains, fruit, and beans — and suddenly stopped eating
those foods — that may temporarily result in constipation. 3 Of course,
some people may actually increase their fiber intake on a low-carb diet if they
replace processed sugars and starches with vegetables.
Keep in mind that low-carb diets don’t have to be low in fiber. Above-ground
veggies and seeds can still provide plenty of fiber for most people. Read more
in our guide about the best low-carb high-fiber foods.
Along these same lines, some believe a change in body electrolytes can alter
stool frequency.
Last, low-carb diets often result in a natural caloric decrease. 5
2. Get adequate salt: Just like with hydration, this hasn’t been studied in clinical
trials, but the idea is that increasing salt intake can help with fluid retention
and preventing dehydration. What is “adequate salt?” This may vary for each
individual, but a good starting point is between four and six grams of sodium
per day (that’s about 2.5 teaspoons per day). To learn more you can read our
evidence-based guide on salt.
3. Eat more fiber: Maintaining adequate fiber intake may be the most effective
approach for preventing low-carb induced constipation. 8 We
recommend getting fiber from whole foods whenever possible. Above-ground
veggies, nuts, and seeds all are good sources of low-carb fiber. Learn more in
our visual guide to low-carb veggies.
How much fiber is enough? The Academy of Nutrition and Dietetics
recommends 25 grams per day for women and 38 grams for men from food
sources. 9 However, these are best estimates for a population, and may
not apply to those on a low-carb diet or those suffering from constipation. You
can use this as a starting point and adjust as needed.
To get 25 grams of fiber, you can combine one avocado, one cup of broccoli,
and ten spears of asparagus. For 38 grams, you can add an additional one-half
cup of macadamia nuts and two tablespoons of chia seeds. You can find
more fiber-filled foods in our guide on low-carb, high-fiber foods.
If you still feel you need more fiber, supplementing with insoluble fiber like
psyllium husk can also help. 10 The starting dose of psyllium husk is
usually 5 grams per day, increasing to 10 grams if needed.
5. Add MCT oil: Another solution is adding medium-chain triglyceride (MCT) oil.
MCT oil can help promote ketosis and can also stimulate gut motility and
bowel movements. Consider starting with one to two tablespoons (0.5 to 1
ounce) and slowly increase if needed. 12
Just be aware that one tablespoon has 115 calories. These calories can add
up quickly if you take multiple tablespoons per day.
For those who continue to suffer from infrequent bowel movements, there are
several potential interventions, as we described in this guide. These
interventions are all compatible with a low-carb lifestyle to help you maintain
the benefits of low carb while getting back on track with your normal bowel
habits.
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1. In a study of people with type 2 diabetes, who ate 20 or fewer grams of carbs per day,
slightly more than half complained of constipation at some point during the trial:
Nutrition & Metabolism 2008: The effect of a low-carbohydrate, ketogenic diet versus
a low-glycemic index diet on glycemic control in type 2 diabetes mellitus [randomized
↩
trial; moderate evidence]
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2. This is based on consistent clinical experience of low-carb practitioners. [weak
evidence]
3. Most of the data on fiber and bowel frequency comes from lower-quality observational
studies, such as the following.
But there are higher-quality studies, such as the following meta-analysis of RCTs, which
showed a small improvement in stool frequency with increasing fiber. Granted, that is
not the same as proving that removing fiber causes constipation. However, this
evidence combined with clinical experience has led many to believe the removal of
fiber causes constipation.
Interestingly, not all studies agree, and there may be a threshold effect where too much
fiber can worsen constipation. the following nonrandomized trial showed improvement
of constipation after subjects decreased fiber intake
The conflicting data may relate the individual variations in the baseline diet, although
this has not been adequately studied.
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4. It’s known that when insulin levels drop — as they do when carb intake is very low— the
kidneys excrete more sodium and water, although the exact mechanism isn’t clear:
↩
Diabetalogia 1981: The effect of insulin on renal sodium metabolism [overview article;
ungraded]
5. Several studies have reported that calorie intake spontaneously decreases when very
few carbs are consumed:
In one small study, 10 obese adults with type 2 diabetes who followed a non-calorie-
restricted, very-low-carb diet ended up eating about 1,000 calories less, on average —
even though they were permitted unrestricted intake of fat and protein foods:
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glucose levels, and insulin resistance in obese patients with type 2 diabetes [non-
controlled study; weak evidence]
6. Journal of Pediatrics 2017: Water and fluid intake in the prevention and treatment of
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functional constipation in children and adolescents: is there evidence? [review of
observational and interventional studies, weak evidence]
7. In the following study, lower doses of caffeine, 3mg/kg, did not cause dehydration,
whereas higher doses, 6mg/kg, did cause dehydration.
↩
Frontiers in Nutrition 2017: Coffee with high but bot low caffeine content augments
fluid and electrolyte excretion at rest [nonrandomized study, weak evidence]
It is important to note that not all fibers act the same way in gastrointestinal motility.
As the following review summarizes, fermentable fibers generally do not stimulate
bowel movements as do large particle insoluble fibers and gel-forming soluble fibers.
Journal of the Academy of Nutrition and Dietetics 2017: Understanding the Physics of
Functional Fibers in the Gastrointestinal Tract: An Evidence-Based Approach to
Resolving Enduring Misconceptions about Insoluble and Soluble Fiber
[overview article; ungraded]
9. Journal of the The Academy of Nutrition and Dietetics 2015: Position of the Academy
↩
of Nutrition and Dietetics: Health implications of dietary fiber [overview article;
ungraded]
10. Clinical Nutrition ESPEN 2019: Effect of flaxseed or psyllium vs. placebo on
management of constipation, weight, glycemia, and lipids: a randomized trial in
11. Clinics in Colon and Rectal Surgery 2010: Medical management of constipation
↩[overview article; ungraded]
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12. This is based on consistent clinical experience of low-carb practitioners. [weak
evidence]
13. Diabetes Metabolic Syndrome and Obesity 2017: Effects of a proposed physical
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activity and diet control to manage constipation in middle-aged obese women
[randomized trial; moderate evidence]