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.

Ready to cook and clean


The key to getting healthy is feeding yourself right. And the key to feeding yourself right is successful food prep.

And what is the key for successful food prep? You might be able to guess.

Why, planning ahead, of course!

There are many different ways to plan, but in general it is making sure you have the food you need when you need it, ahead of time.

For example, Dr. Sheehan makes a humongous shake every day so he has it to snack on throughout the day. I make 2-3 meals worth of food at one time so the next meal just needs to be heated up. Plus I cook from scratch, and it’s time consuming to do that three times a day! Once a day is more do-able. We also make sure we are always stocked on bananas and apples, nuts, seeds, and organic lunch meat or jerky for snacks.

Some people prep all their meals for the week on the weekend or day off.

If you like crock pot cooking (I do!) here is a great idea, with others like it easily searchable on the internet.

Other people are strategic about getting to the store or having healthy restaurant options available for something quick and easy.

So plan ahead, feed yourself right, and your body will repay you with abundant good health and happiness!


Here is my food journal for the last several days:

Saturday 2-20-16

6 AM: coffee with butter, ayurvedic breakfast (1 apple cut up and cooked with a little bit of raisins and clove)

8:30 AM: 2 cooked beets, chicken meat balls

1:00 PM: tuna salad on a salad with provolone from Pasquale’s

5:00 PM: salted mixed nuts, grass feed whey in water

8:00 PM: Indian food: a mango lassi (8 oz-OH NO IT HAD SUGAR), chick peas with onion, veggie samosa with chutneys, chicken

12:00 AM: 1 piece low-carb fudge, 1 stone dry angry orchard

Sunday 2-21-16

8:00 AM: coffee with butter

11:00 AM: banana fritter mash with beef protein, banana, eggs, pork rinds, and coconut milk

12:30 PM: black tea, pecans, herb tea

5:00 PM: whole milk Greek yogurt (1 cup), puffy carb snacks (gluten-free) dipped in hummus, sip of green juice

6:00 PM: chili beef stew with tomato and onion

Not bad for the weekend!

Monday 2-22-16

6 AM: coffee – black, ayurvedic breakfast

8:45 AM: mixed salted nuts, leftover beef stew

9:30 AM: herb tea

12:00 PM: PB meal bar

2:00 PM: 1 cup Greek yogurt (whole milk) with 1 scoop grass-fed whey protein, 2 mini cucumbers, hummus

3:00 PM: more nuts

Supper – ? Not sure yet, probably leftover beef stew.

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Turkey Pot Pie

This turkey pot pie is an interesting concoction I made this morning for breakfast. I have been wanting to get more organ meats into my diet, except that I actively dislike most organ meats. So I saved some beef heart broth (yes, I cooked a beef heart in the crock pot last week for Dr. Sheehan) in hopes that I could add it secretly to some other recipe. So here’s what I made this morning for breakfast (the recipe is loosely adapted from Elana Amsterdam’s Cookbook The Gluten Free Almond Flour Cookbook which, by the way, I highly recommend).


1 large onion, coarsely chopped

3 stalks celery, cut into 1 inch long pieces

1 monster sized carrot, sliced

1 lb. organic ground turkey

1 cup or so beef heart broth

2 Tablespoons arrowroot powder

1 teaspoon sea salt

1/2 cup or so fresh tarragon, chopped

freshly ground black pepper to taste


Sautee the onion, celery and carrot in butter (or coconut oil or lard), over medium heat until slightly soft, about 10 minutes. Add the ground turkey and mix well. Cover and cook a few more minutes. Meanwhile, mix the beef heart broth and the arrowroot and whisk until the arrowroot is thoroughly combined. Add to the turkey mixture, lower the heat slightly, and cook until the turkey is fully cooked through, about 5-10 more minutes. Add the sea salt and fresh tarragon and remove from the heat. Add the freshly ground black pepper.

It’s delicious! Hitting the spot for breakfast on this 18 degree morning. The heart broth actually tastes delicious with the tarragon. Honestly it’s the fresh tarragon and black pepper that made this dish.

I hope you try it and enjoy!

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