HARNESSING THE POWER OF THE 5 R’S

FOR OPTIMAL GUT HEALTH

Dana M. Elia, MS, RDN, LDN, FAND

Owner, Fusion Integrative Health & Wellness, LLC
Adjunct Faculty, Pennsylvania College of Health Sciences
Lancaster, PA

2018-19 DIFM DPG Chair-Elect

 Speaker Disclosures

• Dana M. Elia, MS, RDN, LDN, FAND has indicated

no relevant affiliations or financial interests
• Speaker has not presented any promotional talks
for, or consulted with, industry within the past 12
months
 Objectives
• Review the factors contributing to poor GI
health
• Identify patients at risk for increased intestinal
permeability
• Describe patients may that benefit from a 5R
program
• State the 5R process and the tools to aide both
patient and clinician in the process
 Learning Need Codes

• 3000 Nutrition Assessment & Diagnosis

• 5000 Medical Nutrition Therapy
• 5420 Complementary care, alternative therapies*
*DIFM submitted to a CDR a proposed modification of this
code to integrative and functional medicine
“Functional Medicine
asks how and why
illness occurs and
restores health by
addressing the root
causes of disease for
each individual.”

Jones, D. S., & Quinn, S. (2017). Reversing

the Chronic Disease Trend: Six Steps to
Better Wellness. The Institute for
Functional Medicine.
When in
doubt –
start
with the
gut!
 Widespread digestive issues in the US

35 visits to a doctor for every 100 people

are for digestive concerns
8% of Americans have chronic digestive
diseases
6% have acute digestive episodes
43% have intermittent digestive issues
70% of Americans report having
digestive related symptoms or diseases
Everhart JE, editor. The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of
Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 2008; NIH Publication No. 09-6443 [pp. – ].
 Why address gut health first?
Dysfunction of one’s GI system can have a
downward spiral effect on overall health.
From a functional lens we recognize the
interconnectedness between:
Digestion/Absorption
Intestinal Permeability
Gastrointestinal Flora – balance vs dysbiosis
Immune Regulation & Inflammation
Enteric Nervous System
Gut – brain axis
Beyond
digestion – 1 2 3 4 5

wonders of the
gut! produces
3/4 of the
contains
2/3 + of the
contains 10
times more
houses a
genome
has a
metabolic
neurotrans immune cells than 100 times activity
mitters tissue the rest of larger than greater

Body’s 2nd Brain

the body the human than the
combined genome liver

Immune System
Ground Zero
Awareness of the
digestive process. Eat/Chew
• Digest
Is there a breakdown • Absorption
or barrier in the
• Assimilation
cycle?
• Excretion
Food is information!
 Gut Microbiota/Dysbiosis

Healthy gut ecology, biofilms, prebiotics, and probiotics

Involved in:
- digestion of lactose and proteins
- balance intestinal pH
- benefits to bowel habits
- reduce intestinal inflammation
- EFA’s and SCFA production
- conversion of flavonoids
- protection against pathogens
- activate mucosal-associated lymphoid tissue (MALT)
- protect and modulate autoimmune diseases
El Hage, R., Hernandez-Sanabria, E., & Van de Wiele, T. (2017). Emerging Trends in "Smart Probiotics": Functional Consideration for the Development of Novel Health and Industrial Applications. Frontiers in microbiology, 8, 1889.
doi:10.3389/fmicb.2017.01889

Hemarajata, P., & Versalovic, J. (2013). Effects of probiotics on gut microbiota: mechanisms of intestinal immunomodulation and neuromodulation. Therapeutic advances in gastroenterology, 6(1), 39-51.

Lipski, Elizabeth. Digestive Wellness: Strengthen the Immune System and Prevent Disease Through Healthy Digestion, Fourth Edition . McGraw-Hill Education. Kindle Edition.
 The Unhealthy Gut

INVASION
OF BAD
DAMAGE TO BACTERIA
GOOD COMPROMISED
BACTERIA IMMUNE SYSTEM

POOR DIET FOOD ALLERGY

ALCOHOL
IMPAIRED
CHEMICALS DIGESTION
STRESS AND
ELIMINATION
INFECTION
LACK OF LOSS OF
NUTRIENTS DISEASE
CELL
FOR CELL INTEGRITY
REPAIR LEAKY GUT
 Alteration of commensals
High antibiotic use, High animal Intestinal surgeries:
especially in C-sections protein and dairy ileocolic resection
children diet (ICR), bariatric

Inflammatory
Motility disorders: Post infectious IBS:
Celiac disease Bowel Disease
gastroparesis gastroenteritis
(IBD)

Small Intestinal
Bacterial
Overgrowth (SIBO)
 Remove
Replace
Re-inoculate The Five
Repair R’s
Rebalance
 The 5 R’s

PROCESS TO HELP REDUCE TARGETED, INDIVIDUALIZED PROCESS TO NORMALIZE

INFLAMMATION AND HELP INTERVENTION CRITICAL GASTROINTESTINAL
TO HEAL THE GUT FUNCTIONS
 Critical Thinking
What does this individual need to have Removed?

What does this individual need to have Replaced?

What does this individual need in terms of support to achieve a

healthy balance of microflora? What does the client need to
Re-inoculate their gut?

What does this individual need to support healing and Repair of

their GI barrier function?

What does this individual need to do to Rebalance their lifestyle?

 Remove

What factors are we asking the client to eliminate or remove:

• Foods to which an individual is sensitive, intolerant, or allergic
• Poor quality, processed foods
• Pathogenic microflora (bacteria, fungi, parasites)
• Toxins, chemicals, environmental stressors such as pollutants
• Chronic stress
Personalized approaches may include:
• Elimination diet
– reduce intake of foods that can trigger systemic reactions in order to reduce inflammation, lower
the allergenic load, and provide the gut with a dietary base to allow for restoration
• Botanical antimicrobials or bacteriostatic/bacteriocidal phytonutrients
• Referral to PCP for antibiotics/antifungal medications
 Replace

Providing replacement of or support for factors that may be inadequate or

lacking.
Personalized interventions may include:
– Digestive support
• Hydrochloric acid
• Pancreatic enzymes
• Bile salts
– Adequate fiber intake to support GI function – transit and elimination
 Assessment of need for
digestive support:

Critical
Thinking - Hypochlorhydria

Replace
Pancreatic
enzyme
insufficiency
 Replace

Causes of maldigestion
• Insufficient HCL
• Insufficient intestinal brush border enzymes
– Decreased CCK stimulation of pancreas
• Insufficient pancreatic enzymes
• Insufficient bile acids
 Replace
• Betaine HCL tablets (350–
3500 mg) taken with protein-
Providing containing meals
• Umeboshi plums
Support
Institute for Functional Medicine (2010). Textbook of
Functional Medicine

Kines, K., & Krupczak, T. (2016). Nutritional Interventions • Digestive enzymes with acid
for Gastroesophageal Reflux, Irritable Bowel Syndrome,
and Hypochlorhydria: A Case Report. Integrative Medicine
(Encinitas, Calif.), 15(4), 49–53.
for pH range
Lipski, E.(2011) Digestive Wellness, 4th ed. NY, NY:
McGraw-Hill
Proper • Swedish/digestive bitters
• Gentian root
Mullin, G. (2011). Integrative Gastroenterology (Weil
Integrative Medicine Library) Oxford University Press,
Gastric • Vinegar (ACV)
USA. Kindle Edition.

Rakel, D. (2018). Integrative medicine (4th ed.).

Acidity • Lifestyle factors - reduce
Philadelphia, PA: Elsevier Saunders. stress, increase exercise, sleep
Yago, M. A. R., Frymoyer, A. R., Smelick, G. S., Frassetto, L.
A., Budha, N. R., Dresser, M. J., … Benet, L. Z. (2013).
Gastric Re-acidification with Betaine HCl in Healthy
Volunteers with Rabeprazole-Induced
Hypochlorhydria. Molecular Pharmaceutics, 10(11), 4032–
4037
 Re-inoculate

Supportive reintroduction of beneficial GI microflora (prebiotics, probiotics,

synbiotics) to achieve a more desirable balance to the intestinal microbiome.
Personalized interventions may include:

Cultured and fermented foods Prebiotics:

– Inulin or fructooligosaccharides
Probiotics: (FOS)
– Bifidobacteria strains – Soluble fibers
– Lactobacillus strains Synbiotics:
– Saccharomyces boulardii – Bifidobacteria and FOS
– Lactobacillus and inulin
 Determining the need for probiotics?
What if you have a stool test?
Potentially Potentially
Stool culture Pathogenic Pathogenic
Microbiology Bacteria/Yeast: Bacteria/Yeast:
NORMAL EXCESS

Probiotics not needed. Consider prebiotics and

Beneficial Bacteria: Encourage continued probiotics.
NORMAL support of microbial Antimicrobials*
balance.
(botanical vs rx)

Supportive Consider prebiotics and

Beneficial Bacteria: supplementation with probiotics.
DEFICIENT prebiotics and probiotics Consider
is needed Antimicrobials*
 Re-inoculate

• Jerusalem artichokes • Legumes

• Onions • Eggplant
• Chicory • Honey
• Garlic • Green Tea
• Leeks • Yogurt, cottage cheese, kefir
• Bananas • Sugar maple
• Fruit • Chinese chives
• Soybeans • Peas
• Burdock root • Asparagus
 Repair

Nutritional support for healing and regeneration of the GI mucosa.

Setting the stage for an anti-inflammatory foundation.
Personalized interventions may include a combination of the following:

– Glutamine, arginine, vitamin A, vitamin D, vitamin C, zinc, pantothenic acid,

vitamin E, carotenoids, quercetin Institute for Functional Medicine (2010). Textbook
of Functional Medicine
Mucosal support – phosphatidylcholine, slippery elm, DGL licorice, Lipski, E.(2011) Digestive Wellness, 4th ed. NY, NY:
marshmallow root McGraw-Hill

GALT function - lactoferrin, lactoperoxidase, whey immunoglobulins, Gaby, A. (2017). Nutritional Medicine, 2nd ed.
Concord, NH: Fritz Perlberg Publishing
colostrum Mullin, G. (2011). Integrative
Gastroenterology (Weil Integrative Medicine
Phytonutrient anti-inflammatories - curcumin, EPA, and DHA Library) Oxford University Press, USA. Kindle
Edition.

Rakel, D. (2018). Integrative medicine (4th ed.).

Philadelphia, PA: Elsevier Saunders.
 Personalized lifestyle interventions may include:

‘Scheduling’ and relaxation

Mindful eating and better choices

Rebalance Heart rate variability/ biofeedback

Yoga, meditation, prayer, breathing, or other

centering practices

Psychotherapy
 Elimination Diet
Foundational
Gut Healthy Probiotics
Plan
Institute for Functional Medicine (2010). Textbook of Functional
Medicine Vitamin D
Lipski, E.(2011) Digestive Wellness, 4th ed. NY, NY: McGraw-Hill

Gaby, A. (2017). Nutritional Medicine, 2nd ed. Concord, NH: Fritz

Perlberg Publishing

Mullin, G. (2011). Integrative Gastroenterology (Weil

Integrative Medicine Library) Oxford University Press, USA.
Omega-3 Fatty Acids
Kindle Edition.

Rakel, D. (2018). Integrative medicine (4th ed.). Philadelphia,

PA: Elsevier Saunders.

L-Glutamine
 The 5R Framework for Gut Restoration

A properly functioning digestive system is critical to good health. In fact, problems with the gastrointestinal (GI) tract
can cause more than just stomach aches, gas and bloating or diarrhea. GI issues may underlie chronic health problems
that seem unrelated to digestive health, including autoimmune diseases such as rheumatoid arthritis and type 1
diabetes, skin problems such as eczema and acne rosacea, and heart disease (just to name a few). So in the bigger
picture, how can we deal with all that can go wrong “down there”? In Functional Medicine we use a program that
goes by the simple acronym of the ‘5Rs’: remove, replace, reinoculate, repair, and rebalance. When applied to various
chronic health issues, the 5R program can lead to dramatic improvement in symptoms, and sometimes even complete
resolution. The elements of the 5R program are described briefly below.

The 5R Framework
1. Remove
Remove stressors: get rid of things that negatively affect the environment of the GI tract including allergic foods,
parasites and potential problematic bacteria or yeast.

• A useful tool to help

n This might involve using an allergy “elimination diet” to find out what foods are causing GI symptoms or it may
involve taking medications or herbs to eradicate a particular bug
2. Replace
Replace digestive secretions: add back things like digestive enzymes, hydrochloric acid, and bile acids that are
required for proper digestion and that may be compromised by diet, medications, diseases, aging, or other factors.
3. Reinoculate
develop targeted
Help beneficial bacteria flourish by ingesting probiotic foods or supplements that contain the “good” GI bacteria
such as bifidobacteria and lactobacillus species, and by consuming the high soluble fiber foods that good bugs like to eat,
called prebiotics.
interventions to assist
n Probiotics are beneficial microorganisms found in the gut that are also called “friendly bacteria.” Use of

antibiotics kills both good and bad bacteria. Probiotics in the form of supplements or food are often needed to
help reestablish a balanced gut flora. Fermented foods, such as yogurt, miso, and tempeh are food sources
clients with normalizing
n
of probiotics.
Prebiotics are food ingredients that selectively stimulate the growth of beneficial microorganisms already in
the colon. In other words, prebiotics feed probiotics. Prebiotics are available in many foods that contain a fiber
gut health
called inulin, including artichokes, garlic, leeks, onion, chicory, tofu, and other soy products. Grains such as barley,
flax, oats, and wheat are also good sources of prebiotics. Another good prebiotic source is a supplement called
“fructo-oligosaccharide” or FOS.
4. Repair
Help the lining of the GI tract repair itself by supplying key nutrients that can often be in short supply in a
compromised gut, such as zinc, antioxidants (e.g. vitamins A, C, and E), fish oil, and the amino acid glutamine.
5. Rebalance
It is important to pay attention to lifestyle choices. Sleep, exercise, and stress can all affect the GI tract. Balancing
those activities is important to an optimal digestive tract.

Version 3 © 2016 The Institute for Functional Medicine

 Thank-you!

Speaker Contact info:

Dana Elia, MS, RDN, LDN, FAND
Fusion Integrative Health & Wellness, LLC
270 Granite Run Dr.
Lancaster, PA 17601
[email protected]
 References:

El Hage, R., Hernandez-Sanabria, E., & Van de Wiele, T. (2017). Emerging Trends in "Smart Probiotics": Functional Consideration for the Development of Novel Health and Industrial Applications. Frontiers in
microbiology, 8, 1889. doi:10.3389/fmicb.2017.01889

Everhart JE,. (2008). The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, NIH Publication No. 09-6443.

Gaby, A. (2017). Nutritional Medicine, 2nd ed. Concord, NH: Fritz Perlberg Publishing

Hemarajata, P., & Versalovic, J. (2013). Effects of probiotics on gut microbiota: mechanisms of intestinal immunomodulation and neuromodulation. Therapeutic advances in gastroenterology, 6(1), 39-51.

Ianiro, G., Pecere, S., Giorgio, V., Gasbarrini, A., & Cammarota, G. (2016). Digestive Enzyme Supplementation in Gastrointestinal Diseases. Current Drug Metabolism, 17(2), 187-193.
doi:10.2174/138920021702160114150137

Institute for Functional Medicine (2010). Textbook of Functional Medicine

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.

Lipski, E.(2011) Digestive Wellness, 4th ed. NY, NY: McGraw-Hill

Mullin, G. (2011). Integrative Gastroenterology (Weil Integrative Medicine Library) Oxford University Press, USA. Kindle Edition.

Rakel, D. (2018). Integrative medicine (4th ed.). Philadelphia, PA: Elsevier Saunders.

Yago, M. A. R., Frymoyer, A. R., Smelick, G. S., Frassetto, L. A., Budha, N. R., Dresser, M. J., … Benet, L. Z. (2013). Gastric Re-acidification with Betaine HCl in Healthy Volunteers with Rabeprazole-Induced
Hypochlorhydria. Molecular Pharmaceutics, 10(11), 4032–4037.