Nutritional Consulting for a Hypothetical Client with GI Issues

Nutritional Consulting for a Hypothetical Client with GI Issues

By Laura Sheehan

March 19, 2018
My client Mrs. Green has come to me for help with her GI issues. Her symptoms include diarrhea, constipation, and recent unintended weight loss. She works full-time as a social worker and is also working on her master’s degree. She and her husband cook some of their meals and she also buys ready-made food at a gourmet shop.
Mrs. Green is wondering whether she might have IBS but based on her food record it appears she has already determined that she has it. Her consumption of fiber is very high. Fiber is a commonly recommended treatment for IBS by physicians1. But Mrs. Green may be consuming too much, or the wrong types of fiber2. I would suggest that she start to limit all types of fiber in her diet (i.e. beans, wheat berries), at least until her symptoms improve. I would also have her examine her continuing consumption of Metamucil and Colace, especially since she is currently not constipated. If she would agree to cutting them out or at least reducing them, we could see how that would affect her symptoms.
Another possible cause of her bowel issues is Lexapro. I do not know how long she has been taking it and I would attempt to get this information from her, especially because both diarrhea and constipation are listed as “common side-effects” of the drug3. If the bowel issues seem to have begun relatively concurrent or subsequent to her taking Lexapro, I would suggest that she talk to her doctor about potentially switching medications for her depression and anxiety.
My biggest concern about Mrs. Green is that she might be gluten-intolerant. Her reliance on gluten-containing foods is evident from her Food Frequency Questionnaire and 24 Hour Recall. Considering that cutting out gluten could help her IBS symptoms4, I will focus on this in the next section.
Mrs. Green appears to be an overall health-conscious eater. Among her favorite foods, she lists fish, salads, vegetables and fruits. Most of her foods appear to be fresh and not processed. Even the foods she buys pre-prepared at the gourmet shop look like they are made from scratch. This is good.
I am recommending that Mrs. Green do a trial of a gluten-free diet. I do not think this will be difficult for her as she will not have to change her current food selection habits very much. She will need to learn to replace gluten-containing foods in her diet with gluten-free options. It is likely that her gourmet food shop has gluten-free food selections that are prepared fresh and not processed. For example, instead of buying wheatberry salad, she could buy quinoa or buckwheat salad (although it would be better to buy tuna salad since I would like her to cut back on the fiber). Gluten-free foods are usually more expensive but this will likely not be an issue for her considering her demographic.
In order to increase the chance of compliance, I will try to transition Mrs. Green slowly to gluten-free. From her 24 Hour Recall, it looks like she consumes a gluten-containing food three times daily. I will work with her over time to reduce this to two servings a day and then gradually to zero servings. This should be relatively easy to do since she is motivated to make the necessary changes, and will be especially motivating for her if she sees changes in her symptoms.
The seed pizza is a favorite of Mrs. Green’s and for this reason I will provide an alternative gluten-free recipe for her. Here is the original recipe:
Seed Pizza
1 13- to 14-oz. pkg. refrigerated whole-wheat pizza dough
2 Tablespoons shelled pumpkin seeds, plain sesame seeds, and black sesame seeds
2 Tablespoons toasted pine nuts
3 cloves of roasted garlic
3 ounces of fresh mozzarella, cubed
½ tsp. red pepper flakes
1 tsp. olive oil
Preheat oven to 425 degrees. Lightly grease a large baking sheet. Unroll pizza dough onto a lightly floured surface. Using your hands, shape dough into a 12×9-inch rectangle. Brush the pizza dough with the roasted garlic. Sprinkle with seeds and pine nuts and lightly sprinkle with salt and red pepper flakes. Sprinkle cubed mozzarella evenly over pizza. Drizzle olive oil over pizza. Bake for 8 to 10 minutes or until cheese is completely melted. Cut and serve.
Gluten-free modification:
Substitute a pre-packaged gluten-free pizza dough for the whole-wheat pizza dough in the recipe.
The gluten-free pizza dough should taste similar to the whole wheat pizza dough. In keeping with my philosophy of not changing too many things at once, I am making a relatively simple change in the recipe. I love the idea of a homemade cauliflower crust, but that would be a lot more work and Mrs. Green is already busy and stressed. Keeping the changes simple and straightforward will increase compliance. Plus Mrs. Green will get to keep the “crunch” she enjoys in her pizza.
Nutritionally, the whole-wheat and gluten-free pizza crusts are quite similar, at least from a macro-nutrient perspective5,6. According to the nutrition information supplied by the manufacturer5,6, each crust has about 150 kcal per serving and comparable amounts of carbohydrate (about 31 g/serving). Both recipes are low in fat and protein. There is only a small amount of fiber (2g) in each pizza crust.
Once I’ve made headway with Mrs. Green in cutting out dietary gluten, I would then assist her in eliminating refined sugars from her diet in the context of her overall carbohydrate consumption7. The degree to which I would eliminate the sugars depends on her response to the changes she will have made thus far.
In conclusion, I will work with Mrs. Green over a series of consultations to systematically identify and alter potential issues with her diet that are contributing to her symptoms. I will help her transition to a gluten-free diet and rule out issues with her fiber and laxative intake. I will also encourage her to examine potential unwanted side-effects of the Lexapro she is taking with her doctor.
1. El-Salhy M, Ystad SO, Mazzawi T, Gundersen D. Dietary fiber in irritable bowel syndrome (Review). International Journal of Molecular Medicine. 2017;40(3):607-613. doi:10.3892/ijmm.2017.3072.
2. Talley N. Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. Yearbook of Gastroenterology. 2010;2010:46-47. doi:10.1016/s0739-5930(10)79444-7.
3. Lexapro Side Effects by Likelihood and Severity. WebMD Web Site. Accessed March 18, 2018
4. Vazquez–Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, Oneill J, Carlson P, Lamsam J, Janzow D, Eckert D, Burton D, Zinsmeister AR. A Controlled Trial of Gluten-Free Diet in Patients With Irritable Bowel Syndrome-Diarrhea: Effects on Bowel Frequency and Intestinal Function. Gastroenterology. 2013;144(5). doi:10.1053/j.gastro.2013.01.049.
5. Whole Wheat Pizza Dough. Web Site.
Accessed March 18, 2018.

6. Schar Gluten-Free Pizza Crusts. Thrive Market Web Site. Accessed March 18, 2018.
7. Goldstein R, Braverman D, Stankiewicz H. Carbohydrate malabsorption and the effect of dietary restriction on symptoms of irritable bowel syndrome and functional bowel complaints. IMAJ. 2000; 2(8): 583-587.

Carbohydrate Diets in Clinical Nutritional Practice

Carbohydrate Diets in Clinical Nutritional Practice

By Laura Sheehan

I have been using low-carbohydrate diets in my nutritional consulting practice for three years. The results have typically been very good. For the most part, people lose weight, reduce inflammation, improve their digestive function and have better energy. I don’t have a one-size-fits-all diet that I recommend but help people to reduce their carbs to a reasonable level where they start to feel better. This level is different for everyone. People that have severe metabolic issues such as diabetes, heart disease, or obesity, I would recommend that they go even lower carbohydrate. When these people follow a ketogenic diet, they have reversed diabetes and lowered inflammatory blood markers. I do not believe everyone needs to go keto to be healthy however (many nutritionists are espousing this right now).

Some of the most dramatic “low-carb successes” I have witnessed have been Alzheimer’s clients. There have not been very many of them, I admit. But when they do choose to agree to follow a very low carbohydrate (no more than 30 grams of carbohydrates a day) and high fat diet, I have observed amazing results. People that didn’t seem quite “all-there” in the room with you suddenly begin to look you in the eye and engage you in meaningful conversation. It stays that way as long as people are willing to keep the ketogenic diet going. I can immediately tell if they have indulged in sugar when I meet with them.

What would account for this observed effect? A study1 showed that ketone bodies are protective of hippocampal neurons in vitro that have been exposed to a a fragment of amyloid protein, Aβ1–42, a substance found to produce a deficit similar to Alzheimer’s disease.

I have come across many different viewpoints on low carbohydrate diets and their effect on health. The scientific data are mixed2. I personally believe that human beings can be healthy and eat a vast array of different types of diets. What I am looking to do in my practice is to balance out the incredible over-consumption of sugar that most of my clients are guilty of. To this end, a continuum of different lower-carbohydrate diets appears to be useful. Even though the scientific debate is clearly not settled, I believe I have been helping people get healthier, lose weight, and feel better on lower-carbohydrate diets.

Click here to read more posts on Nutrition.

1. Kashiwaya Y, Takeshima T. d-β-Hydroxybutyrate protects neurons in models of Alzheimer’s and Parkinson’s disease. Proc Natl Acad Sci U S A. 2000 May 9; 97(10): 5440–5444.
2. Nordmann AJ, Nordmann A. Effects of Low-Carbohydrate vs Low-Fat Diets on Weight Loss and Cardiovascular Risk Factors. Archives of Internal Medicine. 2006;166(3):285. doi:10.1001/archinte.166.3.285.

Effect of Carbohydrate Intake on Depression

Effect of Carbohydrate Intake on Depression

By Laura Sheehan

I was never formally diagnosed with depression and I have never taken depression medication, but I can attest to the effect that altering my carbohydrate intake had on my depression symptoms. In short, I am cured of my symptoms when I avoid refined white sugar, and my symptoms return when I begin to consume refined white sugar again.

Research by Akbaraly et al.1 concluded that a processed-food based diet is associated with increased risk for depression while a whole food based diet is protective. In another older study 2, nondepressed individuals were found to consume more protein relative to carbohydrates, but in depressed individuals it was the other way around.

So does this mean that high carbohydrate diets are associated in general with increased risk for depression? Recent research has revealed that depression is more a result of systemic inflammation than a chemical deficiency in the brain.3 Because of the inflammatory effect of high blood glucose 4, one can conclude that eating too much sugar and carbohydrates causes depression.

Many nutrition textbooks state that carbohydrate intake should be no lower than 50-100 grams per day. 5 It is my clinical experience that lowering carbohydrate intake in general to these levels can have a positive impact on mood and help individuals with depression.


    • 1. Akbaraly TN, Brunner EJ. Dietary pattern and depressive symptoms in middle age. British Journal of Psychiatry. 2009;195(05):408-413. doi:10.1192/bjp.bp.108.058925.
    2. Christensen L, Somers S. Comparison of nutrient intake among depressed and nondepressed individuals. International Journal of Eating Disorders. 1996;20(1):105-109. doi:10.1002/(sici)1098-108x(199607)20:1<105::aid-eat12>;2-3.
    3. Leonard B, Maes M. Mechanistic explanations how cell-mediated immune activation, inflammation and oxidative and nitrosative stress pathways and their sequels and concomitants play a role in the pathophysiology of unipolar depression. Neuroscience & Biobehavioral Reviews. 2012;36(2):764-785. doi:10.1016/j.neubiorev.2011.12.005.
    4. Dandona P, Ghanim H. A. Insulin infusion suppresses while glucose infusion induces Toll-like receptors and high-mobility group-B1 protein expression in mononuclear cells of type 1 diabetes patients. American Journal of Physiology-Endocrinology and Metabolism. 2013;304(8). doi:10.1152/ajpendo.00566.2012.
    5. Insel P, Ross D. Carbohydrates. In: Nutrition. 6th ed. Burlington, MA. Jones & Bartlett Learning; 2016: 138-171.

Types of Carbohydrates (from a blood sugar point of view)

When people come in to my office, and we start talking about diet, and we start talking about carbs, they invariably say “are all carbs bad for you?”  This is a difficult question to answer, because it’s not about bad or good, it’s about what carbs your body need and can handle, and how much of each.  Every person is different, but there’s some good rules to follow.  Now keep in mind, this is not the article about simple vs complex carbs, or refined vs unrefined, or something else like that.  It’s literally what myself and other nutritional specialists have observed after treating thousands upon thousands of new patients.  It’s more about how to practically apply knowledge of carbohydrates vs theoretical what they’re made of, and how they work in the body (although there’s a place for that, most people just want to know what they should and shouldn’t eat.  So here it is).

  1. White Trash, or White Death, as Arnold Schwarzenegger would call it. Yup, the worst of the worst, white sugar, and white flour and all of its family. I would include in this any refined sugar, and any refined flour, and all its family, cousins, and extended family.  Here you’ll find candy, cakes, soft drinks, juice drinks and fruit juices (even though fruit juices are from fruit, they are still concentrated sugars. I’ve seen them be responsible for serious health problems like high cholesterol, high triglycerides, weight gain, obesity, high blood pressure, suppressed immune function, etc.), cookies, pies, bagels, bread, pasta, doughnuts, rice, rice cakes, pastries, I think you get the point.  These are bad.  No one does well with them.  They might get away with them for a while, but eat enough of them, and they will catch up to you.  Remember the insulin surge caused by these foods may not cause weight gain, high blood sugar, and or triglycerides, it might just cause high cholesterol, blood pressure, or they may just be causing hormonal problems or tumor growth.  Avoid them at all costs.
  2. Whole grains. People are often surprised that I tell most of my patients to avoid them. Why would I do that?  Aren’t they supposed to be “good carbs?”  Don’t they have B vitamins and fiber?  Well, here’s the rub.  A lot of people have digestive sensitivities to them, and they aggravate any health condition they have.  You get more B vitamins from certain veggies, and definitely meat.  You can get plenty of fiber once again from veggies.  Also, it’s very easy to overdo it with these. Take for instance brown rice.  One cup has 45 carbs (ok, so only 41.5 net carbs, since it has 3.5 grams of fiber)!  Considering that most people can only handle 70-100 grams of carbs per day for optimum sugar balancing, having whole grains once per day can severely limit the amount of vitamins and minerals you can get from other carbs, like fibrous veggies.  In this category I’d put brown rice, whole wheat (although I’d avoid this altogether because almost all of my patients with symptoms are sensitive to it, some severely), quinoa (although it’s not as high in carbs as other grains), corn, barley, spelt, and other grains.  The low down on grains is that you are not looking to lose weight, and that you don’t have health problems, you can eat them sparingly. If you’re looking to lose weight, balance blood sugars, inflammation, or reverse an illness, avoid them.  They have a sneaky way of getting in to your diet.
  3. High carb veggies-In here are things like potatoes, sweet potatoes, beans, certain squashes, beets, and some others. They are packed with vitamins, minerals, and fiber, and some are especially high in potassium (extremely important for liver health, especially in how it processes sugars and fats).  They are good for you, but depending on how well you handle carbs, you may need to limit these.  For example, for someone with diabetes or pre-diabetes, or some kind of inflammatory condition, I’d only eat them sparingly.  Basically, this is a grey area, and you’ll have to use some judgement.
  4. High carb fruits-In here are bananas, pineapple, mango, and of course dried fruit. Once again, it’s not that they are bad for you, they are actually good for you if you can handle sugar.  For someone with diabetes or prediabetes, or some kind of inflammatory condition, I’d only eat them sparingly.
  5. Medium carb fruits-In here you’ll find apples, oranges, pears, cherries, blueberries, grapefruit, etc. You can eat more of these, even if you’re a little carb sensitive.  But not too much, or you’ll blow your carb count, and aggravate any condition you have.
  6. Low carb fruits-In here are strawberries, raspberries, and blackberries. You can eat almost as much of these as you want.  Eating a little here and these won’t even bring someone out of ketosis if they are in a ketogenic diet usually!  I put them in my shakes if I’m trying to lose weight, I love fruit.
  7. Low carb, or fibrous veggies-There are a huge number of fibrous, low-carb veggies. There loaded with fiber, vitamins, and minerals.  You can, and should eat a ton of these.  I try and eat at least 10 cups of leafy greens per day (yup, 10 cups).  You need a lot to support liver detoxification, and balance blood sugar.  Some favorites (but I’m not listing them all) are broccoli, cauliflower, kale, Brussel sprouts, spinach, salad greens, peppers, squash, zucchini, onions (a little on the high side of carbs, but not bad), and the list goes on and on.  Unless you’re on a strict ketogenic diet, you can eat pretty much as much of these as you can handle.

Here’s a pictorial representation of the carbs.  As you can see, we should eat plenty of the ones on the bottom.  The ones at the top, everyone should avoid.  In the middle is the “grey” area.  The better your blood sugar metabolism is, the more you can eat. Hope this helps.

Click here to read more posts on Nutrition.

The Best Breakfast for Health and Weight Loss

A holistic approach to weight loss

As a holistic doctor, one of the most common questions I get from people about diet is “what do I eat for breakfast?” About 4 years ago, I learned from a world famous trainer named Charles Poliquin, that you should basically be eating meat and nuts for breakfast.  This is the best breakfast for weight loss and to feel better. The reasons for this are very basic-it will:

  1. lower blood sugar fluctuations, and
  2. subsequent insulin surges.

This is important for five reasons. Lowering blood sugar fluctuations and insulin surges will help:

  1. Lower cortisol levels (the primary stress hormone)
  2. Lower inflammation (the primary factor in most chronic diseases)
  3. Reduce food cravings
  4. Strengthen the immune system
  5. Build muscle and lose fat
  6. Balance hormones (including estrogen, progesterone, testosterone, and thyroid hormones)
  7. Help you lose weight

So, basically, you need to cut your carbs, ESPECIALLY in the morning, in order to be healthy. The problem is, most people don’t want a piece of fish or a hamburger for breakfast. But there are other solutions. What I tell people to eat is protein and nuts, not necessarily meat and nuts, for breakfast. If you absolutely CANNOT eat in the morning, you can substitute a low carb protein shake (recipe below). The reason I say this is that back in the day, I took a whole lot of body fat measurements on my patients (I would still do it, but it took too much time, and I had to charge accordingly). People consistently lost a lot more fat if they ate protein rather than drank it. So that’s why drinking your protein is a distant second. Here’s some choices of what to have for breakfast:

  • Eggs
  • Bacon
  • Sausage
  • Burgers
  • Fish

Feel free to mix and match these, don’t eat the same thing every day. Along with your protein, eat a handful of nuts. I recommend going easy on the peanuts, though, because they’re actually a legume, and some people don’t handle them well. Also, it goes without saying, that organic, local sausage, bacon, and eggs are much better than commercial. But like the saying goes, get the quality of food up after you’ve cut down the quantity of poison you put into your body (sugars and refined carbs).

If you must, must have a protein shake, here’s what I recommend. One, use my protein, Sheehan Whey, and/or Standard Process SP Complete. These proteins are the best ones I’ve come across, have no artificial sweeteners, and have no sugar. Two, mix these with water, sugar free coconut milk, almond milk, hemp milk, cashew milk. NO soy milk, as soy is a major food allergen, may be a hormonal disruptor, amongst other problems. There are better options, so use them instead. Three, if you like your shake creamier, add ½ to 1 avocado. If you must put a fruit in there, you can add berries, just not cherries, as they are high in sugar. Four, if you’re feeling really adventurous and healthy, add some greens, in the form of baby spinach, kale, whatever. It’s actually not bad. So here’s a shake synopsis:

  • Liquid (water, sugar free coconut milk, almond milk, hemp milk, cashew milk)
  • Sheehan Whey and/or SP Complete
  • Avocado (optional)
  • Greens (kale, baby spinach-just add a little, don’t want to overpower the rest of the shake)
  • Berries (raspberries, red or black, blueberries, etc.)
  • Essential Balance Oil (a properly balanced oil that has omega 3, 6, and 9 in the right proportions). You should definitely add this for the healthy fat; protein by itself won’t hold you.
  • Other spices of you like-like organic cocoa, cinnamon, cardamom, turmeric, stevia, you can get creative here.

Use these guidelines to create your own unique shake. Just make sure that it has protein, fat, and low carb. Go crazy!

So there you have it, what to eat for breakfast. This should satisfy everyone. And remember, breakfast is the most important meal of the day! So let’s get healthy with a healthy breakfast each and every day!

Click here to read more posts on Nutrition.