What you need to know to manage keto diarrhea
Martha Carlin
| May 09, 2023 |
3 minutes read
- Is there a link between keto diet and diarrhea?
- Fat digestion and diarrhea
- Where does fat digestion start and end?
- Why you might get diarrhea after starting keto
- Other potential reasons that can lead to keto diarrhea
- Too much MCT
- Hidden laxatives in your diet: caffeine and artificial sweeteners
- Carbohydrate withdrawal and electrolyte supplementation
- Changes in your gut flora
- Too much protein and lactose intolerance
- Digestive enzymes and too much bile
- Frequently asked questions
- Keto diarrhea - what to do?
Over the last few years, keto diet has become one of the most searched1 terms on Google. With millions of people trying out the diet annually, the number of people looking for answers about how to manage keto diarrhea is on the rise.
For most keto dieters, keto diarrhea or the runs are a common symptom associated2 with the first week of the diet. If you’ve found yourself searching for ‘Why do I have keto diarrhea’ or ‘keto flu’, keep reading to learn more about keto diarrhea and how you might navigate it.
Recent research suggests3 that diarrhea is one of the most common gastrointestinal (GI) symptoms associated with the consumption of a high-fat, low-carb diet such as the ketogenic diet.
Fat digestion is energy intensive4 and can be taxing for your digestive system. When you start consuming higher than normal (for you) amounts of fat and protein, it might lead to undigested food reaching your large intestine causing diarrhea and bloating5.
Fat digestion and diarrhea
As you begin your keto journey, you’ll possibly try out different combinations and sources of fat. Digesting some types of fats takes longer6 than others. For example, LCTs (long-chain triglycerides) found7 in foods such as nuts, seeds, avocado, fish and meat take longer to digest and be absorbed than MCTs (medium-chain triglycerides) found in dairy (milk, ghee) and coconut oil.
To understand why some keto dieters might have to deal with diarrhea, let’s break down what typical fat digestion looks like and what might happen when this process goes out of sync.
Where does fat digestion start and end?
Fat digestion starts8 in the mouth and finishes in the small intestine with the absorption of free fatty acids and monoglycerides through the lymphatic system.
Your saliva and gastric juices contain special enzymes such as lingual and gastric lipase that emulsify the fat present in the meal and make it ready for digestion further down the digestive system.
Although the actions of lingual and gastric lipase begin the process of fat emulsification and digestion, the majority of fat breakdown happens in the small intestine.
Once the partially digested meal reaches the small intestine, bile acids produced in the liver and released into the small intestine work to further emulsify fats and increase their surface area so that pancreatic lipase can break down fats into free fatty acids and monoglycerides.
For absorption, medium-chain fatty acids (derived from medium chain triglycerides) directly travel to the liver via the hepatic portal vein whereas long-chain free fatty acids (derived from long chain triglycerides) pass through the mucus barrier and into the epithelial cells with the help of bile acids.
Once in the epithelial cells, fatty acids, monoglycerides, cholesterol, and phospholipids combine to form chylomicrons. Chylomicrons travel through the lymphatic system and enter the bloodstream from the jugular vein in the throat.
As chylomicrons come in contact with cells across the body, they are broken down into fatty acids which can either be used for energy or stored for later use.
Why you might get diarrhea after starting keto
So, what happens when your fat metabolism isn’t working as well as it should? Or your fat consumption is simply higher than your digestive system can effectively break down?
Ideally, all fat would be broken down and absorbed in the small intestine but when undigested fat9 reaches the large intestine, it might lead to diarrhea.
Undigested fat in the large intestine has been associated with steatorrhea9 which is characterized by fatty loose stools that might float in the toilet and may be difficult to flush down.
Undigested fat in the gut might either be due to low bile acid production resulting in incomplete fat digestion or due to a lack of fat digesting microbes in the gut. If you’re struggling with floating stools, then it’s advised to consult your healthcare provider to identify any underlying causes for undigested fat.
If you’re at the beginning stages of keto induction, you might consider taking an ox bile supplement to help with insufficient bile acids as your body ratchets up its own bile production.
Keto adaptation can take a few months10 as all organs adapt to primarily using ketones as the primary source of energy, and as you adapt to the high fat diet, your keto flu symptoms should resolve on their own.
But undigested or malabsorbed fat might not be the only reason behind keto diarrhea.
(Figure 1, S. Bostock et al., 2020)
Other potential reasons that can lead to keto diarrhea
Any shift in your diet can lead to a cascade of changes in how your digestive system responds to it. Here are some potential reasons for why you might be dealing with keto diarrhea.
Too much MCT
Medium-chain triglycerides (MCTs) are ketogenic and have been associated11 with increasing tolerability to low-carb diets. While supplementing with MCTs can be a great way to advance your way to keto-adaptation, too much MCT might make that progress difficult.
Once in the small intestine, MCTs can travel directly11 to the liver through the hepatic portal vein and be preferentially utilized for ketones. But one of the most common side effects12 of excessive consumption of MCT is diarrhea.
Starting with small amounts of MCT and gradually increasing its dosage might be helpful in decreasing the incidence of diarrhea.
Hidden laxatives in your diet: caffeine and artificial sweeteners
Caffeine has been associated13 with increasing the rate of ketosis along with MCT. It can also be helpful in the initial period of keto induction as it suppresses appetite and helps with fat burning. But too much caffeine might add to your troubles too.
Coffee might have14 a mild laxative effect and as such might increase gut motility. When you combine that with the possibility of undigested fats in your gut or MCT in your coffee, it might be adding to your tummy troubles.
Additionally, caffeine is a mild diuretic15 - meaning it makes you pee more than usual. If you aren’t keeping up with your hydration, it might add onto an electrolyte imbalance while you’re already working on adapting to a high-fat diet.
Scaling back on your coffee consumption and altering the amount of butter or MCT oil in your bullet coffee might help ease some of your GI distress at this stage.
Carbohydrate withdrawal and electrolyte supplementation
In a carbohydrate-rich diet, your body secretes more insulin and as a result, retains more water and electrolytes. But as you switch to a low-carb, high-fat diet, your insulin levels drop16 and as a result, so do your electrolyte levels.
In response to this initial electrolyte dumping and associated symptoms such as fatigue and muscle cramps, keto dieters tend to turn towards mineral supplements to increase their mineral intake. But consumption of high doses of some mineral supplements such as magnesium might lead17 to diarrhea.
If you’re taking a magnesium citrate supplement, try switching it with magnesium glycinate or magnesium malate as well as consider adding keto-friendly and mineral-rich whole food sources to your keto diet.
As your keto diet and digestion stabilizes, you might want to consider adding epsom salt (magnesium sulfate) to your diet or drinks since it's a great way to have additional magnesium. But be mindful that epsom salt can have a laxative effect and it isn’t advisable to take it while you’re dealing with diarrhea induced dehydration.
Some magnesium and potassium-rich foods to add to your diet are avocados, almonds, spinach, nuts, seeds, and citruses such as lime, oranges, grapefruit, etc. When selecting foods make sure you are getting organic as much as possible, as chemicals in the food supply impact the microbiome and its ability to help you digest foods, including fats.
Changes in your gut flora
Changes in your diet lead to changes in your gut flora and any initial shifts in the gut microbiome have been associated with GI issues such as diarrhea and constipation.
Levels18 of certain carb-dependent species such as Bifidobacterium go down, whereas other beneficial species such as F. prausnitzii stay stable as you begin eating keto.
Enzymes produced by microbes in your gut work together with pancreatic enzymes to digest and absorb your meals. Probiotics containing lactase-positive strains such as B. longum and B. animalis might help relieve19 symptoms of lactase intolerance related diarrhea.
Additionally, strains such as B. subtilis20, B. longum and L. rhamnosus have been associated21 with potential lipase - a fat digesting enzyme - activity in the gut. Microbial lipase in the gut might further help in fat digestion as your gut readjusts to the keto diet.
(Figure 5, Zhou et al., 2022)
Too much protein and lactose intolerance
Starting the keto diet not only alters how much fat you eat, but it also alters how much and which type of protein you eat. For most keto dieters, their keto protein intake might be more than they’re used to and a sudden shift in their protein intake might lead to diarrhea.
Not everyone digests protein equally. The source of protein (animal or plant), whether you’re lactose intolerant, and your own capacity for protein digestion (depending on the diversity of your gut microbiome) will determine22 how well you respond to an increased consumption of protein.
Additionally, if you’re consuming a protein powder to meet your daily protein intake, check the ingredients list to ensure it's not adding to your GI troubles.
Protein powders might have fillers such as fibers like psyllium husk and coconut flour, dairy protein sources such as WPC23 (whey protein concentrate) and casein protein, artificial sweeteners24, and sweetening agents such as dextrose and milk solids, any of which might add additional stress to your already reactive belly.
Overall, slowly increasing the consumption of whole foods such as wild game to fulfill your protein needs will be a more sustainable way to improve your own protein digestion capacity as well as give your gut flora a chance to diversify to break down a more fat and protein dominant diet.
(Figure 1, DALLAS et al., 2017)
Digestive enzymes and too much bile
You may respond to a high-fat diet in one of two ways, one by needing supplemental digestive enzymes to digest and break down fat and protein, or two, by releasing excessive bile into the small intestine to digest the increased intake of fats.
Bile is a natural laxative and too much bile25 in your colon might cause diarrhea. Similarly, some digestive enzyme supplements might also lead to diarrhea.
A gradual increase in fat consumption and any additional digestive supplements might be the way toward a more sustainable keto journey.
Frequently asked questions
Does keto diarrhea go away? How long does diarrhea last in ketosis?
According to this2 study, keto dieters reported symptoms of keto flu subsiding within a few weeks and up to a month.
Is diarrhea a symptom of keto flu?
Diarrhea and constipation are common2 side effects and are a part of keto flu.
What color is your poop in ketosis?
Your poop might go through a few color, consistency and frequency variations from light tan to dark brown, from very runny or floaty to well formed and from having to go everyday to only once every few days as you progress further in your keto diet.
The color of your poop will change depending on how well-hydrated you are, bile production, and amount of fat and fiber consumption. If you find your poop to have an unexpected color such as green or a very pale clay then it might be a good idea to talk to your healthcare provider as it might represent an underlying health issue. Want to learn more about what your poop might be telling you? Check this out!
Keto diarrhea - what to do?
For now, rest. Load up on water and electrolytes - mix up an adrenal cocktail with a whole food source of Vitamin C such as lemons or oranges, a bit of cream of tartar (for potassium) and some sea salt - and give your body a chance to adjust and adapt. Slowly incorporate changes in your diet rather than going all in at once.
When you’re further along on your diet, consider sprinkling your foods with spices such as turmeric and black pepper which help with fat digestion and adding probiotic foods such as sauerkraut and kimchi to enhance your gut microbial diversity.
Adding dietary supplements such as keto digestive enzymes (lipase and protease) and probiotics such as Sugar Shift formulated with B. subtilis and B. longum might help enhance your keto diet in the long run.
Feeling the rumblings of keto bloat? Here are 10 reasons why keto bloat won’t leave you alone!
References
- Simon, J. (2022, March 9). Global Keto Diet Trends | Statistics & Market size of the ketogenic diet. Bolst Global.
- Bostock, E. C., Kirkby, K. C., Taylor, B. V., & Hawrelak, J. A. (2020). Consumer Reports of “Keto Flu” Associated With the Ketogenic Diet. Frontiers in Nutrition, 7, 511082. https://doi.org/10.3389/fnut.2020.00020
- Kirkpatrick, C. F., Bolick, J. P., Kris-Etherton, P. M., Sikand, G., Aspry, K. E., Soffer, D. E., Willard, K., & Maki, K. C. (2019). Review of current evidence and clinical recommendations on the effects of low-carbohydrate and very-low-carbohydrate (including ketogenic) diets for the management of body weight and other cardiometabolic risk factors: A scientific statement from the National Lipid Association Nutrition and Lifestyle Task Force. Journal of Clinical Lipidology, 13(5), 689-711.e1. https://doi.org/10.1016/j.jacl.2019.08.003
- Field, C. J., & Robinson, L. (2019). Dietary Fats. Advances in Nutrition, 10(4), 722-724. https://doi.org/10.1093/advances/nmz052
- Libretexts. (2020, August 14). 5.4: Protein Digestion, Absorption and Metabolism. Medicine LibreTexts.https://med.libretexts.org/Courses/American_Public_University/APUS%3A_An_Introduction_to_Nutrition_(Byerley)/APUS%3A_An_Introduction_to_Nutrition_1st_Edition/05%3A_Proteins/5.04%3A_Protein_Digestion_Absorption_and_Metabolism
- Watanabe, S., & Tsujino, S. (2022). Applications of Medium-Chain Triglycerides in Foods. Frontiers in Nutrition, 9. https://doi.org/10.3389/fnut.2022.802805
- Volpe, S. L. (2020). Medium-chain triglycerides and health. ACSMʼs Health & Fitness Journal, 24(1), 35–36. https://doi.org/10.1249/fit.0000000000000537
- Medicine LibreTexts. (2017, June 14). 5.4: Protein Digestion, Absorption and Metabolism. https://med.libretexts.org/Courses/American_Public_University/APUS%3A_An_Introduction_to_Nutrition_(Byerley)/APUS%3A_An_Introduction_to_Nutrition_1st_Edition/05%3A_Proteins/5.04%3A_Protein_Digestion_Absorption_and_Metabolism
- Azer, S. A., & Sankararaman, S. (2024). Steatorrhea. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK541055/
- S. Bostock, E. C., Kirkby, K. C., Taylor, B. V., & Hawrelak, J. A. (2020). Consumer Reports of “Keto Flu” Associated With the Ketogenic Diet. Frontiers in Nutrition, 7. https://doi.org/10.3389/fnut.2020.00020
- Harvey, C., Schofield, G. M., Williden, M., & McQuillan, J. A. (2018). The Effect of Medium Chain Triglycerides on Time to Nutritional Ketosis and Symptoms of Keto-Induction in Healthy Adults: A Randomised Controlled Clinical Trial. Journal of Nutrition and Metabolism, 2018. https://doi.org/10.1155/2018/2630565
- Courchesne-Loyer, A., Lowry, M., St-Pierre, V., Vandenberghe, C., Fortier, M., Castellano, A., Wagner, J. R., & Cunnane, S. C. (2017). Emulsification Increases the Acute Ketogenic Effect and Bioavailability of Medium-Chain Triglycerides in Humans: Protein, Carbohydrate, and Fat Metabolism. Current Developments in Nutrition, 1(7). https://doi.org/10.3945/cdn.117.000851
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- DALLAS, D. C., SANCTUARY, M. R., QU, Y., KHAJAVI, S. H., VAN ZANDT, A. E., DYANDRA, M., FRESE, S. A., BARILE, D., & GERMAN, J. B. (2017). Personalizing Protein Nourishment. Critical Reviews in Food Science and Nutrition, 57(15), 3313. https://doi.org/10.1080/10408398.2015.1117412
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- Farrugia, A., & Arasaradnam, R. (2021). Review: Bile acid diarrhoea: Pathophysiology, diagnosis and management. Frontline Gastroenterology, 12(6), 500-507. https://doi.org/10.1136/flgastro-2020-101436
With gratitude,
Martha Carlin, is a “Citizen Scientist”,
systems thinker, wife of Parkinson’s warrior, John Carlin, and founder of The BioCollective , a microbiome company expanding
the reach of science and BiotiQuest, the first of it’s kind probiotic line. Since John’s diagnosis in 2002,
Martha began learning the science of agriculture, nutrition, environment, infectious disease, Parkinson’s
pathology and much more. In 2014, when the first research was published showing a connection between the gut
bacteria and the two phenotypes of Parkinson’s, Martha quit her former career as a business turnaround expert
and founded The BioCollective to accelerate the discovery of the impact of gut health on all human disease. Martha was a speaker at the White House 2016 Microbiome Initiative launch, challenging the scientific
community to “think in a broader context”. Her systems thinking background and experience has led to collaborations
across the scientific spectrum from neuroscience to engineering to infectious disease. She is a respected out of the
box problem solver in the microbiome field and brings a unique perspective to helping others understand the
connections from the soil to the food to our guts and our brains.
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