Given that the standard American diet is high in carbohydrates, switching to a keto diet puts you at the opposite end of the spectrum. Based on a typical keto diet food list, this approach is high in fat (70 to 80 percent), moderate in protein, and very low in carbs — many people stick to 20 to 50 grams (g) of net carbs (total carbs minus fiber and sugar alcohols) daily. What’s more, everyone’s colon is unique, which is why some people may be stricken with constipation, others with diarrhea, and some may not notice a change at all, says Dr. Riopelle.

The biggest issue? “When it comes to gastrointestinal symptoms on a keto diet, I worry most about the lack of fiber in the diet, which can lead to constipation,” explains Lindsey Albenberg, DO, gastroenterologist at the Children’s Hospital of Philadelphia in Pennsylvania. And when you’re allotted so few carbs in your diet, you’re leaving out fiber-rich sources like fruit, vegetables, whole grains, and legumes.

In fact, even without restricting carbs, Americans on average already fall short of their daily fiber quota. According to Harvard Health Publishing, American adults consume an average of 10 to 15 grams of fiber per day, and yet the goal for people up to age 50 is 25 grams of fiber for women and 38 grams of fiber for men each day.

Here’s why that matters: “Fiber is important for colonic health,” says Riopelle. The organ simply functions better when it has plenty of fiber. “I explain to patients that the primary job of the colon is to be a sponge and absorb all the water you’ve consumed and fluids secreted during the digestive process. Fiber adds bulk to the stool and helps the colon work like a muscle to move things through more easily,” he says.

But instead of constipation, perhaps things are moving through a little too fast, and now you’re constantly running to the bathroom. While diarrhea may not be as common a reaction to the keto diet, it is possible. “There may be a delay in enzymes that digest fat to respond to the increasing amount of fat in your diet. If fat doesn’t get broken down in your small intestine the way it’s meant to, it travels into your colon and gets digested by bacteria that can lead to gas, bloating, and fat in the stool,” he says. Extra fat in the stool causes a looser stool.

Another potential problem is acid reflux. “Fats take the longest to empty out of the stomach, so they keep people fuller, longer. On keto, delayed stomach emptying may leave your stomach full all the time, triggering abdominal discomfort and an increase risk of regurgitation and heartburn,” says Dr. Albenberg.

That said, these effects are often short lived. Your gastrointestinal (GI) tract will likely adjust, but the time it takes to do that differs for every person, says Riopelle. Still, there are warning signs that you should see a doctor, which we will discuss in a minute.

Is Keto Dangerous for Digestive Health?
Everyone knows that constipation is uncomfortable for sure, but can it harm your health? Aside from the risk of hemorrhoids due to constipation, the issue is that constipation is simply a sign that something’s off in your body, says Albenberg.

Then there’s the potential issue that changing your diet may affect your gut microbiome, the vast network of microorganisms in your digestive tract, which has been linked to immune and metabolic function. The gut microbiome may also play a role in disease prevention and progression, according to research. “Research in animals, and some human data, shows that high fat diets lead to fairly rapid and significant changes in the microbiome. Yet we don’t necessarily know what that means for long-term health,” says Albenberg. (It’s also important to note that the high-fat diets used in these studies are often Western-type diets that are high in both fat and sugar, so they don’t perfectly replicate the keto diet.) There is also an indication that these changes may be associated with increased inflammation, though it hasn’t been found to directly cause inflammation, she adds.

Adding to the complexity is that, in the context of epilepsy, it may be because of these alterations in the microbiome that keto can potentially help reduce the frequency of seizures, notes a preliminary study that observed these effects on mice. That means that in certain contexts, when medically appropriate, these changes can actually be helpful, says Albenberg. But many people today who are trying keto aren’t doing it as part of a seizure disorder treatment.

For those new to keto, it’s the lack of fiber to watch out for. “We know a high-fiber diet promotes diversity in the gut microbiome that’s been associated with health,” says Albenberg. Fiber travels through the colon and provides food for gut bacteria, which then produce short-chain fatty acids that nourish colon cells and are thought to be anti-inflammatory, she says.

It’s those short-chain fatty acids that have been shown to improve blood glucose regulation in people with diabetes, per a preliminary study. What’s more, a certain type of fiber, called insoluble fiber, may help control blood sugar and improve insulin sensitivity, according to the Centers for Disease Control and Prevention, which can be important for those who have prediabetes or type 2 diabetes.

Then there’s cancer prevention. People who consume just 10 g of fiber daily have a 10 percent lower risk of colorectal cancer than those who consumed none; eating three servings of whole grains daily dropped that risk by another 17 percent, according to a review.

And finally, fiber aids weight regulation. Not only does it increase feelings of fullness (leading to lower caloric intake), it also promotes the growth of good bacteria, which may help protect against obesity, as noted in animal research. Of course, you’re not a mouse, but a human study found that people who made the sole change of adding more fiber to their diets were able to successfully lose weight.

On the flip side, it’s worth noting that while keto may take away many fiber-rich carbohydrates, it also eliminates the highly processed and refined carbohydrates (crackers, snack mixes, desserts). The potential health risks all come down to the individual. For instance, for an obese person who has an unhealthy diet and has been advised to jump-start weight loss quickly, a short course of the keto diet under doctor supervision may be appropriate, says Albenberg. Beyond that though, she says, “I don’t see keto as being a great long-term solution, simply because it is just too low in fiber.” 

When to Worry if You’re Having Tummy Trouble on the Keto Diet
If you’re new to the keto diet, it’s not abnormal that an intense dietary swing would change your bowel habits, so you may need to give your GI system time to adjust, says Amar Naik, MD, a gastroenterologist at Loyola in Chicago. You can do that safely, as long as you don’t have any red flags, like blood in your stool.

Also watch out for severe or constant abdominal pain, or diarrhea that happens more than six times a day or wakes you up at night, says Riopelle. If symptoms persist more than two or three weeks, see your doctor to make sure that things are okay.

Your Gut-Friendly Action Plan for Following Keto
If you’re committed to the keto diet, here’s how to work through GI symptoms and help prevent them in the first place:

Choose keto-friendly high-fiber foods. Many people on a keto diet count so-called net carbs, which are grams of total carbs minus grams of fiber and sugar alcohols. That’s great news for people who are looking to get more fiber in their diet, as it will give you more wiggle room to meet or get close to your quota. High-fiber, keto-friendly foods include nonstarchy vegetables, like broccoli (1 g fiber, 2 g net carbs per ½ cup), artichokes (7 g fiber, 6.5 g net carbs per medium-sized artichoke), and collard greens (1 cup of cooked greens has 5.6 g of fiber and 2 g net carbs). Some fat sources also have a lot of fiber, like avocado (1 whole avocado has 13.5 g of fiber and 3.6 g of net carbs) and nuts (1 ounce [oz] of almonds has 3.5 g of fiber and 2.6 g of net carbs).

Load up on fermented foods. These contain natural probiotics to support gut health, and they are handy if you’re on a restricted diet, says Albenberg. A couple of keto-compliant choices are cabbage-based: sauerkraut (1 cup has 4 g of fiber and 2 g net carbs) and kimchi (1 cup has about 2.4 g of fiber and 1.2 g net carb).

Take a fiber supplement. First, a warning: It’s difficult to get all the fiber you need from supplements alone, says Albenberg. So, make sure your keto diet is well planned so that it includes high-fiber foods too. That said, go ahead and try a fiber supplement. Experiment with different types, as people have varying responses to each, says Riopelle.

Try a whole-food “supplement.” Some foods have so much fiber that they’re basically a supplement. That includes 1 oz of chia seeds (10 g fiber, 2 g net carbs) and 2 tablespoons of ground flaxseed (3.8 g fiber, less than ¼ g net carbs).

Stay hydrated. Adequate water intake is key to moving things along. The Institute of recommends that women get 91 oz of total fluid from beverages and foods daily and men get 125 oz. Twenty percent of that can come from food, such as veggies.

Ask your doc about using a short-term laxative. Normal bowel frequency ranges from three movements daily to one every three days, says Riopelle. If you’ve gone beyond what’s normal for you, you can talk to your primary care physician about whether a stool softener or stimulant laxative on a short-term basis might be right for you.

Don’t count on probiotics. It may be tempting to pop a probiotic supplement and count on it to sort out your digestive health. But there’s not much evidence that commercial probiotics impact GI health in a meaningful way — and many do nothing at all — says Albenberg. For this reason, focus your efforts on fiber.

Don’t count on coffee either. For some people, a cup of coffee does stimulate a bowel movement when things are stopped up, but that’s not true for everyone, says Riopelle. It’s okay if coffee has that effect on you, but the point is that it isn’t always a reliable go-to fix.