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.

The 5R Approach

 Broadly speaking, the 5R steps are as follows:

• Remove the source of gut inflammation or hyper-permeability (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 bacteria^2,3(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 soy.⁵ Wheat (and other cereal grains) has also been shown to cause leaky gut – contributing to chronic inflammation and autoimmune diseases.⁶ 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, such as one of our Gutologists, 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 obesity.¹³ 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 lining.¹⁶ 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 soybeans.¹⁷ They have been shown to promote gut wall regeneration, improve gut barrier function and immunity, and reduce pathogenic bacteria populations.¹⁸

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, glutamine,¹⁹ essential fatty acids, zinc and quercetin.^20,21 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 versa.^22,23 Similarly, stress can also result in dysbiosis, which in turn, can induce anxiety and depression.²³ 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.

5R’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.

Where does microbiome testing come in? 

We often use the latest microbiome testing at the beginning of a clients journey. Having the data means we can start pin pointing the root issues faster and allows the practitioner to be more specific with their protocols. 

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