digest
Short Summary
Main recommendation: Do not treat a lower bowel movement frequency as constipation; constipation is defined by hard or hard-to-pass stools, and if stools are soft and pass comfortably, less frequent bowel movements are not a medical problem. Dr. Westman says most people switching to a low-carb, keto-type diet have fewer bowel movements, and he suggests that if hard stools do occur, the first thing to check is adequate water and salt, with milk of magnesia as a gentle option he recommends.
Key Points
- Constipation means hard stools, hard-to-pass stools, or uncomfortable bloating or straining; how often you go is not the criterion.
- Changing to a low-carb, keto-type diet typically reduces bowel movement frequency, which Westman frames as the body being more efficient with less waste to eliminate.
- Westman rejects the idea that bowel movements are detoxification, comparing them to taking out the trash: you don't need to do it every day.
- Westman says that in his experience, roughly a quarter to a third of people switching to a real-food diet get hard stools, and he recommends first checking water and salt intake, since he explains the colon reabsorbs water when the body is low on fluid.
- He says he doesn't ask people to add oils and medium-chain triglycerides, noting that in his experience these can tend toward diarrhea for some people.
- Westman says he tells patients to stay on prescribed laxatives from their doctor as they get started, but he personally prefers electrolyte supplementation such as magnesium because he says some laxatives can be habit-forming.
Details Worth Noting
- Concrete instructions:
- If stools are hard or hard to pass, first check water and salt intake. Drink enough fluid and get plenty of salt, unless you have high blood pressure being treated with medication. Consider that you may be drinking less than you think, especially in summer when water vapor loss is higher.
- If you need an electrolyte supplement, magnesium is the main one to consider. Milk of magnesia (liquid magnesium, available without prescription at pharmacies) can be taken as one teaspoon at bedtime for about one to two weeks until hard stools resolve, or used at that dose as a preventative.
- Do not confuse dosage: a capful of milk of magnesia is about two to four tablespoons and acts as a stronger overnight remedy, so reserve that for when more is needed.
- Practice proper stool hygiene: sit up straight, take deep diaphragmatic breaths to push down the diaphragm, and vocalize.
- Raise the feet while on the toilet, because humans are designed to squat; raised feet can straighten the intestines and ease elimination. Westman mentions a stool sold by a company for this purpose.
- Minimize external irritation, for example with a bidet.
- Westman cites a physical therapist's video in Australia called "Move to Poo" as a resource for stool hygiene detail.
- He notes that most people do not develop constipation on a low-carb keto diet, and the speaker's estimate for those who do is roughly 25 percent in his experience.
- Over-the-counter suppositories and enemas exist but are not needed frequently, according to Westman.
Bottom Line
Infrequent bowel movements alone are not constipation; focus on whether stools are hard or hard to pass, and if they are, address water, salt, and magnesium before reaching for stronger remedies.
