I’m getting people complaining to me that when they did a keto diet, they had an upset stomach. I got into this area based on research. Two of my patients did a low-carb diet back in 1998 and I was curious about whether or not it was safe. I visited doctors who were using low-carb keto diets for their whole careers from 1970 to 2000. Dr Atkins is one example. What I learned is that if you teach a real food-based type of program, it’s really smooth; there are very few side effects, maybe a headache and fatigue during the first few days – that’s called “keto-adaptation,” but there shouldn’t be any nausea or diarrhea if you’re eating real foods.
Adding unnecessary oils
We did our research here at Duke University and published research papers over the last 20 years. I have been using this type of diet for 20 years, but people have only recently started coming to me saying that they’re having all of these side effects, the most common one being nausea or stomach upset. I never saw this when I was teaching using a real food-based diet and learning how to use a diet like this from the doctors who used it from 1970 to 2000. I started asking, “What did you do?” All of these weird things started coming up that I’d never heard of: medium chain triglyceride (MCT) oil, Bulletproof coffee, coconut oil, having apple cider vinegar, consuming bone broth that you make yourself, sitting in ice water baths, or using infrared saunas. This was all news to me, so I started to be a detective about what could possibly be different from what these people were doing to what I was teaching.
I have a pretty good sense through thousands of people in terms of what to expect when I teach the approach that I teach. Nausea and stomach upset go away almost 100 percent, and so does heartburn. I take people off heartburn medicines – they don’t need them anymore! “Internet keto” was the problem. Internet keto was teaching that you had to add oils and use exogenous ketones and have all these butters and medium-chain triglycerides to get into ketosis. This was causing heartburn, indigestion, stomach upset, and nausea. If you’re feeling nauseated after having any of these oils, suspect that it’s the oils. I’ve never prescribed anyone a ketone pill or ketone oil in my life. You don’t need those things, because when you do a low-carb keto diet for obesity and diabetes treatment, your ketones come from your own body fat. That’s an important lesson to learn: you don’t have to drink ketones to be in ketosis. You don’t have to have these added oils and things to be in ketosis. If you’re burning your body fat really well, your body makes its own ketones and you go into ketosis from your own body’s metabolism. This is called nutritional ketosis. It’s also known as fasting. What I teach is really “fed fasting,” because you get the benefits of the fat burning from fasting while you’re still eating food. (Ketogenic diets are sometimes called “fasting-mimicking diets” for this reason.) A properly formulated keto diet begins with protein – meat, poultry, fish, shellfish, and eggs. That’s where your nutrition should come from as you start this and your ketones come from within. If you have nausea or diarrhea, stop adding oils; you’ll know within a week if that was the problem.
Reacting to medications
The other thing I’ve noticed is that certain medications that are commonly used for diabetes, prediabetes, and PCOS, can cause nausea and stomach upset. You might experience these effects even if the medication didn’t cause those side effects before you started a low-carb/keto diet. I don’t fully understand why, but eating this way can change the side-effects of medications – possibly because of the way your hormones and metabolism change on a keto diet, including the way your body metabolizes certain drugs. If you have nausea on a keto diet, it’s not normal, so try eliminating extra oils or looking at your medications to resolve the problem.
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