If you deal with irritable bowel syndrome (IBS), you’re not alone. This common condition causes bloating, gas, stomach pain, constipation, and diarrhea. IBS affects 14% of the world’s population.
To manage IBS, your healthcare provider may recommend that you change your diet, improve your lifestyle quality, and limit your intake of certain fermentable carbs called FODMAPs. You may have also heard that the high fat, very low carb ketogenic helps treat IBS symptoms. Yet, you may wonder whether this claim is backed by scientific evidence - and whether you should try out keto if you have IBS.
Understanding IBS
Irritable bowel syndrome (IBS) is a heterogeneous disorder, and sub-classifications of diarrhea-predominant IBS (IBS-D) and constipation-predominant IBS (IBS-C) have been identified. Its symptoms include stomach pain, bloating, cramping, constipation, and diarrhea. There’s no one identifiable cause of IBS. Instead, it likely involves a number of processes that may be unique to each individual.
Possible causes include increased digestive sensitivity, chemical signals from your gut to your nervous system, psychological and social stress, immune system activity, changes in your gut bacteria, genetics, diet, infections, certain drugs, and antibiotic use. Functional alterations in irritable bowel syndrome have been associated with defects in bioenergetics and the mitochondrial network.
Common IBS Triggers
While the cause of IBS remains unknown, it can be triggered in different ways depending on each individual. The most common triggers are processed foods, certain fruits and vegetables, most sugar alcohols, caffeine, and alcohol.
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Conventional IBS Treatments
IBS treatment focuses on managing symptoms via medications, diet, and lifestyle adjustments. Many individuals find that food is a trigger for specific symptoms, so 70-90% of people with IBS limit certain foods to try to decrease negative effects.
Experts often recommend a diet that includes regular meals, as well as adequate fiber and fluids. You should limit alcohol, caffeine, and spicy or fatty foods if they trigger symptoms.
Currently, a common treatment for IBS is a low FODMAP diet, which limits short-chain, fermentable carbs that are poorly absorbed by your body. FODMAPs are found in wheat, onions, some dairy, and some fruits and vegetables. These carbs cause increased water secretion and fermentation in your gut, which produces gas. Although this doesn’t negatively affect healthy people, it may trigger symptoms in people with IBS.
Diets low in FODMAPs have been shown to reduce the severity of IBS symptoms, particularly pain and bloating. Very low carb, gluten-free, paleo, and immune-modulating diets are likewise used to treat IBS, though evidence on their effectiveness is mixed.
The Role of Diet
As we’ve seen, the best medicine for IBS is your diet. A change in your eating habits can help you a lot with the symptoms. Usually, the foods that will make you feel better are keto-friendly, gluten-free, and low-FODMAP. But, since everyone is different and every individual has their triggers, it would be good if you could keep a food journal. You could use a simple notebook or app on your phone where you can track everything you eat and drink daily.
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Here’s a list of foods you should avoid since they increase and worsen gas, bloating, pain, and other symptoms mentioned above. Most foods on the list are high in carbs. As we’ve mentioned, going on a keto diet can help ease IBS, inflammation, and bloating symptoms. But, as we’ve also seen, it’s important to watch out for some sources of FODMAPs that, despite being keto-friendly, can harm you.
The Ketogenic Diet Explained
The ketogenic diet is a high fat, low carb eating pattern that’s similar to the Atkins diet. Originally developed in the 1920s to treat children with severe epilepsy, it’s commonly used for weight loss and other health conditions like blood sugar control.
Its exact macronutrient ratio may differ based on individual needs, but it’s usually 75% fat, 20% protein, and 5% carbs. Keto limits bread, pasta, grains, beans, legumes, alcohol, sugar, and starchy fruits and vegetables while increasing your intake of high fat foods like nuts, seeds, oils, cream, cheese, meat, fatty fish, eggs, and avocados.
By restricting carbs to 50 grams or fewer per day, you enter a metabolic state in which your body burns fat for energy instead of carbs. This is known as ketosis.
Potential Benefits of Keto for IBS
Despite keto’s popularity, very few studies investigate its effectiveness for treating IBS. A 4-week study in 13 people with diarrhea-predominant IBS found that the keto diet helped reduce pain and improve the frequency and consistency of stools.
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This may be due to the diet’s influences on your gut microbiome, or the collection of bacteria in your gut. Interestingly, people with IBS often have an imbalance in their types and numbers of gut bacteria, which may contribute to symptoms.
Furthermore, animal and human studies reveal that very low carb diets deplete the bacteria in your gut that produce energy from carbs while boosting the number of beneficial bacteria. However, some research also suggests that low carb diets like keto decrease the overall diversity of gut bacteria and increase the number of inflammatory bacteria, which may have negative effects.
Applying a feasible and straightforward study model to the pathophysiology of functional gastrointestinal disorders (FGIDs) is still challenging since FGIDs result from the complex interplay between several putative factors including genetics, biology, and psychological attitude. Among FGIDs, irritable bowel syndrome (IBS) is a highly prevalent disorder affecting an estimated 10-15% of the worldwide population . An inflammatory component has been suggested to contribute to the etiology of this syndrome , and miscommunication between the ENS and CNS has been evoked for the onset of several symptoms apart from the classical and major gastrointestinal (GI) ones (e.g., abdominal pain, diarrhea, and constipation). These functional GI and extra-GI alterations have recently been associated with low cellular energy metabolism, driven by defects in the bioenergetics supply and the intracellular mitochondrial network. Emerging evidence supports a broader role of mitochondria in several GI disorders of both inflammatory and malignant nature.
There is an increased interest in using low carbohydrate diets like the ketogenic diet (KD) in IBS treatment , even if the reports are still few and lack firm conclusions. The high fat, adequate-protein, low carbohydrate KD reprograms metabolism, forcing the body to utilize fat as a source of energy as it occurs during the fasting state. Through ketogenesis, fatty acids are oxidized to ketone bodies in the liver mitochondria and then distributed via the blood to the other organs to be consumed as fuel. Limited research has explored the effects of chronic psychosocial stress or early-life stress (ELS) on gut mitochondria , leading to the conclusion that mitochondrial activity was disturbed.
Study on Very Low-Carbohydrate Diet (VLCD) and IBS-D
Patients with diarrhea-predominant IBS (IBS-D) anecdotally report symptom improvement after initiating a very low-carbohydrate diet (VLCD). Participants with moderate to severe IBS-D were provided a 2-week standard diet, then 4 weeks of a VLCD (20 grams of carbohydrates/day). A responder was defined as having adequate relief (AR) of gastrointestinal symptoms for 2 or more weeks during the VLCD. Of the 17 participants enrolled, 13 completed the study and all met the responder definition, with 10 (77%) reporting AR for all 4 VLCD weeks. Stool frequency decreased (2.6 ± 0.8/day to 1.4 ± 0.6/day; p<0.001). Stool consistency improved from diarrheal to normal form (Bristol Stool Score: 5.3 ± 0.7 to 3.8 ± 1.2; p<0.001). Pain scores and QOL measures significantly improved.
The purpose of this prospective trial was to assess the effect of a VLCD in IBS-D. The results provide preliminary evidence that a VLCD provides adequate relief of IBS-D symptoms, decreases abdominal pain, improves stool frequency and consistency, and improves quality of life. All 13 participants who completed the 6-week study reported adequate relief of their IBS-D symptoms for at least two of the four weeks. This is the first study to assess the effect of a low-carbohydrate diet in individuals with IBS-D, though previous research has investigated the role of carbohydrates in IBS. One study of 239 individuals with either IBS or non-specific functional bowel complaints showed an improvement in symptoms after elimination of some combination of sorbitol, lactose, or fructose for one month. Additionally, King et al found that individuals with IBS have abnormal colonic fermentation of carbohydrates. They found that an exclusion diet that reduced the load of potential offending carbohydrates improved IBS symptoms.
Additional Potential Benefits
- Reduced Carbohydrate Intake: The keto diet drastically limits carb intake, potentially reducing exposure to FODMAPs and eliminating most symptom triggers.
- Improved Gut Microbiome: The keto diet might positively influence the gut microbiome composition, which could alleviate IBS symptoms.
- Stabilized Blood Sugar Levels: The keto diet's focus on fats and proteins can help stabilize blood sugar, potentially reducing the symptoms that are related to excess sugar.
Potential Downsides and Considerations
Despite some promising results, evidence for using keto to treat IBS remains limited. It’s unclear whether positive effects can be attributed to the diet itself or rather the incidental elimination of trigger foods, such as FODMAPs or gluten.
Therefore, people with IBS shouldn’t use the keto diet as a primary treatment for IBS. Many people may find keto too restrictive in nature, as it eliminates food groups like grains, beans, and legumes. That said, if this diet can fit into your lifestyle, and you are interested in how it could change your symptoms, please talk to a medical professional to learn more.
It’s important to remember that the keto diet may have a few downsides. For example, fatty foods trigger symptoms in some people with IBS. Because the keto diet is very high in fat, it may worsen symptoms instead of improving them.
Furthermore, the keto diet can be low in soluble fiber, a nutrient that may alleviate some IBS symptoms. Thus, it’s important to eat plenty of leafy green vegetables and seeds to boost your intake of soluble fiber if you have IBS and decide to try keto. Alternatively, you can take a fiber supplement.
Finally, people with diabetes should consult a health professional before starting keto, as the low carb intake could cause dangerously low blood sugar levels.
Considerations from Research Studies
- This study has a few limitations. Our study represents the experience of 17 individuals, with 13 participants completing all 6 weeks. The results must be confirmed in larger numbers.
- Three participants who dropped out did so primarily because of difficulty following a restrictive diet. There is no a priori reason why the drop out group would be different from those who completed the study with regard to treatment benefit.
- The other main limitation is the lack of a standard control group. Although participants served as their own control for several outcomes, a placebo effect may explain the positive findings, particularly for subjective outcomes such as abdominal pain. However, the use of daily diary cards helps to obviate subjective interpretation or recall bias by providing a systematic and objective measure of daily bowel habits.
- Despite these limitations, this study found objective evidence that overweight and obese individuals initiating a VLCD had a profound clinical response in their IBS-D symptoms. This finding requires further investigation to identify mechanisms by which a VLCD affects the symptoms of IBS-D.
Incorporating Keto Safely for IBS
Before making dietary changes, it’s always a good idea to consult your own healthcare provider, especially if you have other underlying health conditions. They can guide you on whether the keto diet is suitable for you.
Once you get the go-ahead, ease into the keto diet slowly to allow your body to adapt. Drastic changes can sometimes trigger digestive discomfort. When eating a keto diet, opt for low-FODMAP foods within the keto framework. Examples include meats, fish, eggs, non-starchy vegetables, and certain nuts and seeds. Keep in mind, you are taking carbs out and adding fats in. If you have questions about the FODMAPs in any food, I recommend using the Monash University FODMAP app. It’s the gold standard when it comes to food and FODMAPs.
Keep yourself hydrated. This, of course, applies to all diets but in particular, the keto diet that can cause increased water and electrolyte loss. If you have trouble maintaining your electrolyte balance as a result of fluid loss, I recommend using Trace Minerals 40,000 Volts drops (up to 1 teaspoon per day) to maintain electrolyte balance without adding sugar or other FODMAP-containing ingredients to your diet. While the keto diet is low in carbs, incorporating low-carb, non-starchy vegetables can provide essential fiber to support gut health. (If you find you need more fiber, I recommend adding up to one scoop of Paleo Fiber Resistant Starch Fiber to your daily routine.)
Finally, mindful eating is more important than you might think no matter what diet you may be on. Pay attention to serving sizes and listen to your body's cues for fullness and satiation. Overeating on anything, even on keto-friendly foods, can exacerbate IBS symptoms.
Getting Started with Keto for IBS
Getting started on a keto diet requires some planning and preparation. Here's a step-by-step guide to help you get started:
- Review the list of basic keto-friendly foods below.
- Stock your kitchen. Clean out your pantry and stock up on keto-friendly ingredients. Focus on foods like avocados, olive oil, nuts, seeds, eggs, fatty fish, and non-starchy vegetables. Having these items readily available will make cooking keto meals much easier.
- Plan your meals. Start by creating a meal plan that includes a variety of keto-friendly foods. Incorporate low-carb vegetables, lean proteins, healthy fats, and small portions of low FODMAP options. Planning your meals ahead of time will help you stick to the diet and avoid last-minute temptations.
- Listen to your body. Every individual's response to the keto diet is unique. Pay attention to how your body reacts, and adjust your dietary choices accordingly. If you encounter persistent discomfort or adverse effects, consult your healthcare provider.
Keto-Friendly Food Options
On a keto diet, you'll primarily focus on consuming foods that are high in healthy fats, moderate in protein, and low in carbohydrates. Here's a list of basic foods that are typically included in a keto diet:
Healthy Fats:
- Avocado (keep to 1/8 per sitting for low FODMAP) and avocado oil
- Coconut oil and coconut products
- Olive oil
- Butter and ghee
- Nuts and seeds (e.g., almonds, walnuts, chia seeds)
- Fatty fish (e.g., salmon, mackerel)
- Cheese (in moderation)
- Heavy cream
Protein Sources:
- Lean meats (e.g., chicken, turkey, beef, pork)
- Fatty cuts of meat (e.g., bacon and sausage but watch for onions/garlic in the ingredients)
- Eggs
- Fish and seafood
- Tofu (firm tofu is low FODMAP) and tempeh (for vegetarians)
Low-Carb Vegetables:
- Leafy greens (e.g., spinach, kale, lettuce)
- Cruciferous vegetables (e.g., broccoli tops are low FODMAP, and Arugula too)
- Zucchini
- Bell peppers
- Cucumber
Berries (in Moderation):
- Strawberries
- Blueberries
- Raspberries
Dairy Alternatives (if you don’t tolerate dairy well):
- Unsweetened almond milk, coconut milk, or other plant-based milk (but watch for FODMAP ingredients)
- Dairy-free cheese alternatives (check labels for carbohydrate content)
Herbs, Spices, and Condiments:
- Herbs and spices (e.g., basil, oregano, etc.)
- Salt and pepper
- Vinegar
- Mustard
- Hot sauce
Beverages:
- Water
- Herbal tea (without added sugar)
- Black coffee (decaf is best for those with IBS and in moderation)
Additional Strategies for Managing IBS
- Stress reduction: Mindfulness-based stress reduction, which combines meditation and yoga, greatly improves IBS symptoms. You can also do deep breathing to calm down. Slow down and remember to take time off for yourself.
- Probiotic supplements: These are live microorganisms that prevent the overgrowth of harmful gut bacteria and regulate your bowel movements. When choosing a probiotic supplement, pick one that’s keto-friendly and designed for your type of IBS (IBS with diarrhea, IBS with constipation, or IBS with mixed bowel habits).
- Regular exercise: Working out not only enhances your body’s fat-burning potential and transition to ketosis, but it also reduces IBS symptoms and helps you to feel more in control over the disease.