Gut Healing with the 5’R’ approach

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When it comes to healing the gut, have you ever wondered how the professionals approach this issue?  Nutritional therapists and functional medicine practitioners use what is known in the industry as the 5R programme – a comprehensive framework that can have a profound impact on gut health restoration and associated chronic health problems. This process addresses fundamental imbalances in the gut which can underlie chronic health problems.  Broadly speaking, the 5 R steps are as follows:

  • Remove the source of gut inflammation or hyperpermeability (or ‘leaky gut’)
  • Replace digestive juices that may be lacking or sub-optimal
  • Re-inoculate the gut with beneficial bacteria, whilst bolstering existing beneficial ecology
  • Repair the gut with gut healing nutrients
  • Rebalance lifestyle factors to help maintain optimal gut function

Remove

This step is all about identifying the external factors that inflame and irritate the gut and removing them. Identifying and removing any environmentally derived sources of gut inflammation, irritation and hyperpermeability is an important first step to healing the gut.  The main culprits include:

  • non-steroidal anti-inflammatory drugs1,
  • pathogenic bacteria2,3(i.e. bacteria that causes harm in our system)
  • viruses3,
  • fungi3,
  • parasites4; or
  • foods that cause an allergic, sensitivity or intolerant response4

The most common food triggers include milk, egg, peanut, shellfish, fish, wheat and soy5.  Wheat (and other cereal grains) has also been shown to cause leaky gut – contributing to chronic inflammation and autoimmune diseases6. (LINK to our article and video on leaky gut)

Laboratory tests such as stool tests can confirm and identify troublesome bugs (e.g. bacteria, parasites and yeasts).  However, the most effective and accurate way of determining food triggers is to eliminate common aggravators and slowly re-introduce them7. Working with a nutritional therapist is recommended to pursue this properly..

Replace

Different digestive enzymes break different foods down into their smaller, absorbable component parts.  Enzyme deficiency such as lactase results in lactose intolerance8; whilst enzyme insufficiency such as pepsin and other proteases will lead to poor protein digestion, which has been linked to food allergies9.

Gastric juice in the stomach contains acid responsible for destroying invading pathogens(as well as facilitating protein breakdown, and the absorption of several vitamins and minerals)10.  Sub-optimal levels have been associated with yeast infections11 and small intestine bacterial overgrowth (SIBO)12.

Verifying the status of digestive enzymes and stomach acid through laboratory tests, and replacing any that are deficient or insufficient is important to help with the proper breakdown of foods, absorption of nutrientsand prevention of stomach and intestinal infections. 

Re-inoculate

Dysbiosis (gut microflora imbalance) caused by antibiotic use, gut infections, poor diet13 and exposure to toxins such as pesticides and heavy metals14 is associated with the development of a variety of disorders including inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), coeliac disease, allergy, asthma, cardiovascular disease and obesity13.  Re-establishing a healthy balance of gut microflora is therefore pivotal to gut and general health status.

This phase takes a two-pronged approach if dysbiosis is confirmed.  The first is re-inoculating the gut with beneficial gut bacteria (probiotics).  Probiotics from supplements and fermented foods15 act by displacing pathogenic bacteria, inducing anti-microbial secretion, and protecting the barrier function of the gut lining16.    

The second approach involves stimulating the growth of existing beneficial microflora by feeding them with prebiotics.  Prebiotics are a class of dietary fibre that are non-digestible by digestive enzymes but selectively fermented by beneficial bacteria; and are found in foods such as leeks, asparagus, chicory, Jerusalem artichokes, garlic, onions, oats and soybeans17.  They have been shown to promote gut wall regeneration, improve gut barrier function and immunity, and reduce pathogenic bacteria populations18.

Repair

As discussed, the gut can be damaged due to insults from food allergen and toxic exposure, drugs, chronic nutritional insufficiency, pathological intestinal infections, dysbiosis and chronic inflammation (such as IBD).  Once the relevant remedial phases of remove, replace and re-inoculate have been achieved, supporting gut repair maybe required.   

The gut is the most highly regenerative organ in the body, regenerating its lining every five to seven days. To do this, it is highly dependent on nutrients including the amino acid glutamine19, essential fatty acids, zinc and quercetin20,21.  This phase therefore involves providing the gut with vital nutritional support, so that it can effectively heal itself. 

Rebalance

Lifestyle factors such as sleep, stress and exercise all impact gut health.  The line of communication between the gut and brain (the microbiota-gut-brain axis) means that alteration in the circadian rhythm and sleep loss has been shown to alter gut flora balance and vice versa22,23.  Similarly, stress can also result in dysbiosis, which in turn, can induce anxiety and depression23.

Exercise on the other hand, has a protective effect on the gut by reducing the transient stool time and therefore the contact time between pathogens and the gut.  This has been shown to reduce the risk of colon cancer, diverticulosis and inflammatory bowel disease.  Exercise can also increase beneficial gut bacteria diversity (regardless of diet!)24.

Rebalancing these activities is therefore important in maintaining gut health once all the hard work of restoration has been done. 

5’R’s in Practice

In clinical practice, the 5R programme usually takes a minimum of 12 weeks and can last for up to 24 months, depending on each case.  Each phase is not necessarily sequential i.e., the remove and replace phases can often happen simultaneously.  Furthermore jumps between phases are not uncommon, as gut function assessment (with the aid of laboratory tests) based on the 5R framework will determine what is relevant for each individual. 

References:

  1. Sigthorsson, G., Tibble, J., Hayllar, J., Menzies, I., Macpherson, A., Moots, R., Scott, D., Gumpel, M. J., … Bjarnason, I. (1998). Intestinal permeability and inflammation in patients on NSAIDs. Gut, 43(4), 506-11.
  2. Bodger, K. and Crabtree, J.E., 1998. Helicobacter pylori and gastric inflammation. British medical bulletin, 54(1), pp.139-150.
  3. Sartor, R.B. and Wu, G.D., 2017. Roles for intestinal bacteria, viruses, and fungi in pathogenesis of inflammatory bowel diseases and therapeutic approaches. Gastroenterology, 152(2), pp.327-339.
  4. Katz, D.E. and Taylor, D.N., 2001. Parasitic infections of the gastrointestinal tract. Gastroenterology Clinics, 30(3), pp.797-815.
  5. Taylor, S.L. and Hefle, S.L., 2001. Food allergies and other food sensitivities. FOOD TECHNOLOGY-CHAMPAIGN THEN CHICAGO-, 55(9), pp.68-84.
  6. De Punder, K. and Pruimboom, L., 2013. The dietary intake of wheat and other cereal grains and their role in inflammation. Nutrients, 5(3), pp.771-787.
  7. Sicherer, S.H. and Sampson, H.A., 2010. Food allergy. Journal of allergy and clinical immunology, 125(2), pp.S116-S125.
  8. Lomer, M.C.E., Parkes, G.C. and Sanderson, J.D., 2008. lactose intolerance in clinical practice–myths and realities. Alimentary pharmacology & therapeutics, 27(2), pp.93-103.
  9. Untersmayr, E. and Jensen-Jarolim, E., 2008. The role of protein digestibility and antacids on food allergy outcomes. Journal of Allergy and Clinical Immunology, 121(6), pp.1301-1308.
  10. O’Connor, A. and O’Moráin, C., 2014. Digestive function of the stomach. Digestive diseases, 32(3), pp.186-191.
  11. Massarrat, S., Saniee, P., Siavoshi, F., Mokhtari, R., Mansour-Ghanaei, F. and Khalili-Samani, S., 2016. The effect of Helicobacter pylori infection, aging, and consumption of proton pump inhibitor on fungal colonization in the stomach of dyspeptic patients. Frontiers in microbiology, 7, p.801.
  12. Kines, K., & Krupczak, T. (2016). Nutritional Interventions for Gastroesophageal Reflux, Irritable Bowel Syndrome, and Hypochlorhydria: A Case Report. Integrative medicine (Encinitas, Calif.), 15(4), 49-53.
  13. Carding, S., Verbeke, K., Vipond, D.T., Corfe, B.M. and Owen, L.J., 2015. Dysbiosis of the gut microbiota in disease. Microbial ecology in health and disease, 26(1), p.26191.
  14. Lu, K., Mahbub, R. and Fox, J.G., 2015. Xenobiotics: interaction with the intestinal microflora. ILAR journal, 56(2), pp.218-227.
  15. Parvez, S., Malik, K.A., Ah Kang, S. and Kim, H.Y., 2006. Probiotics and their fermented food products are beneficial for health. Journal of applied microbiology, 100(6), pp.1171-1185.
  16. L Madsen, K., 2012. Enhancement of epithelial barrier function by probiotics. Journal of Epithelial Biology and Pharmacology, 5(1).
  17. Al-Sheraji, S.H., Ismail, A., Manap, M.Y., Mustafa, S., Yusof, R.M. and Hassan, F.A., 2013. Prebiotics as functional foods: A review. Journal of functional foods, 5(4), pp.1542-1553.
  18. Slavin, J., 2013. Fiber and prebiotics: mechanisms and health benefits. Nutrients, 5(4), pp.1417-1435.
  19. Krishna Rao, R. (2012). Role of Glutamine in Protection of Intestinal Epithelial Tight Junctions. Journal of Epithelial Biology and Pharmacology, 5(1), pp.47-54.
  20. Dulantha Ulluwishewa, Rachel C. Anderson, Warren C. McNabb, Paul J. Moughan, Jerry M. Wells, Nicole C. Roy., 2011. Regulation of Tight Junction Permeability by Intestinal Bacteria and Dietary Components, The Journal of Nutrition, Volume 141, Issue 5, Pages 769–776, https://doi.org/10.3945/jn.110.135657
  21. Lan, A., Blachier, F., Benamouzig, R., Beaumont, M., Barrat, C., Coelho, D., Lancha Jr, A., Kong, X., Yin, Y., Marie, J.C. and Tomé, D., 2014. Mucosal healing in inflammatory bowel diseases: is there a place for nutritional supplementation?. Inflammatory bowel diseases, 21(1), pp.198-207.
  22. Li, Y., Hao, Y., Fan, F., & Zhang, B. (2018). The Role of Microbiome in Insomnia, Circadian Disturbance and Depression. Frontiers in psychiatry, 9, 669. doi:10.3389/fpsyt.2018.00669
  23. De Palma, G., Collins, S.M., Bercik, P. and Verdu, E.F., 2014. The microbiota–gut–brain axis in gastrointestinal disorders: stressed bugs, stressed brain or both?. The Journal of physiology, 592(14), pp.2989-2997.
  24. Monda, V., Villano, I., Messina, A., Valenzano, A., Esposito, T., Moscatelli, F., Viggiano, A., Cibelli, G., Chieffi, S., Monda, M. and Messina, G., 2017. Exercise modifies the gut microbiota with positive health effects. Oxidative medicine and cellular longevity, 2017.