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Chronic Illness: What Works? Part One: The Four 'R' Program

I have come to recognize that there are three therapies that stand above others in helping to reduce the burden of many chronic illnesses.
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Over the past 35 years that I have worked in the health field (as a biochemistry and medical school professor, researcher, lecturer, founder of the Institute for Functional Medicine in 1991 along with my wife Susan, and most recently as President and Chief Science Officer of a global nutritional products company), one of the questions I most often hear is: "If you only had one therapy for improving health what would it be?"

Over the past three decades, I have had the privilege of knowing and learning from some of the most innovative leaders in the medicine and biological sciences. In fact, as I review the researchers and clinicians that I have interviewed over the past 27 years as part of my monthly audio newsletter Functional Medicine Update (, I have come to recognize the incredible gift that I have received from knowing these leaders in the field, and how much impact they have had on my thinking about the future of our health care system. I have learned of many breakthrough approaches to the management of various chronic illnesses, so picking "one therapy" seems impossible.

But as I have thought about this question at greater length, and particularly in light of the present debate about the future of health care in the United States, I have come to recognize that there is not one, but rather three therapies that stand above the others in helping to reduce the burden of many chronic illnesses.

The criteria I used for selection of these three therapies are based upon the management of the most common signs and symptoms of chronic health problems. These are pain, inflammation and fatigue. The medical names of the disorders associated with these signs and symptoms include the following as examples:

  • Chronic fatigue syndrome
  • Fibromyalgia (muscle pain and fatigue)
  • Irritable bowel syndrome
  • Chronic headache
  • Arthralgias (arthritis symptoms)
  • Metabolic Syndrome (pre-diabetes)
  • Allergies
  • Environmental/Chemical Sensitivities
  • Hypertension (high blood pressure)
  • Dyslipidemias (elevated cholesterol)
  • Prostatitis (prostate irritation)
  • Fibrocystic breast disease
  • Dyspepsia and gastrointestinal reflux disorder (digestive problems)
  • Sleep apnea
  • Cognitive impairment (short term memory)
  • Eczema and rosacea

Although none of these conditions are immediately "life threatening," they are common chronic problems that become more troublesome over time if not corrected. These are also conditions that can progress to more serious diseases if not corrected early.

In a pharmacological model each of these conditions would be treated with its own family of medications to manage the symptoms. This often results in people taking several medications, all of which have the potential for adverse side-effects and drug-drug interactions.

In the Functional Medicine model, the clinical approach treats the underlying cause of the signs and symptoms. I have come to recognize that the three principle Functional Medicine therapies that I will summarize are very successful in managing this wide-variety of diagnoses.

These three therapies are:

  • The Four R Program
  • Metabolic Detoxification Program
  • Therapeutic Lifestyle Change (TLC) Program

Given that each of these therapies requires a different set of skills and tools, I want to discuss each of them separately. The first of the three critically important therapies was titled the "Four R Program" for gastrointestinal restoration by our group in 1995.

If I had only one clinical tool to teach doctors how to become successful with, it would be this therapy. Any person who suffers from symptoms such as chronic fatigue, pain and low energy that is accompanied by digestive problems is a candidate for a twelve week application of the Four R Program. We have found that in most people with chronic symptoms twelve weeks is a good target for the time it takes to restore proper physiological function.

The Four R Program stands for the four steps in the management of the patient: These steps are:

  1. Remove
  2. Replace
  3. Reinoculate
  4. Repair

So how is the Four R Program applied?

Remove Phase: In this phase the patient removes the common allergy-producing foods including grains containing gluten and dairy products. A low allergy potential diet utilizing rice-based products, legumes, fruits, vegetables, fish and poultry is prescribed. If the patient is suffering from chronic infections of the sinus, oral cavity or intestinal tract, these are treated. The exposure to toxic chemicals and toxic metals such as mercury is also eliminated.

Replace Phase: While removing the substances that might disrupt the function of the immune system, the patient is evaluated for their sufficiency of digestive enzymes and proper stomach acid. The best "test" is whether the person can properly digest a normal meal without complaints of bloating, gas formation, or reflux. If this is a problem the Functional Medicine doctor will recommend the use of digestive aids such as digestive enzymes to be taken along with meals.

Reinoculate Phase: In order to improve intestinal immune function and thereby improve whole body function, the patient will be prescribed a combination of a therapeutic dose of a well researched and medically documented probiotic (3-5 billion live organisms). The most well-researched probiotics are specific strains of acidophilus and bifidus bacteria that are normal inhabitants of a healthy intestinal tract. The probiotics are recommended to be taken along with a prebiotic supplement such as inulin, fructooligosaccharides or arabinogalactans. Prebiotics are specific food fibers that are used by the friendly probiotic organisms as their 'food" in the intestinal tract to improve their therapeutic value. This reinoculation phase of the Four R Program should be done in escalating doses over a two week period to allow the intestinal tract to adjust. If the dose of the probiotics and prebiotic is increased too quickly it can result in excessive intestinal gas formation and discomfort.

Repair Phase: After two weeks on the reinoculate probiotics and probiotics supplement, the patient then adds additional nutrient supplements to promote proper repair of the intestinal lining. These supplements include the amino acid L-glutamine (6-10 grams per day), pantothenic acid (500-1000 mg per day), zinc citrate (10 mg per day), omega 3 EPA/fish oil (1-3 grams per day), vitamin E as mixed tocopherols (400 mg per day), and the amino acid glycine (6-10 grams per day).

This regimen is followed for a total of 12 weeks during which time signs and symptoms are evaluated weekly. A practitioner that is skilled in the application of the Four R Program will modify the specifics of the program to meet the needs of the specific patient. Over the past 15 years that we have been applying this program and teaching it to doctors around the world through the training programs of the Institute for Functional Medicine ( it has resulted in tens of thousands of positive outcomes in patients who suffer from many health problems that have resulted from alterations of immune system function and increased inflammation. More detailed information about the specific application of this program can be gotten from The Textbook of Functional Medicine available from the Institute for Functional Medicine.

In my next blog, I will discuss my other two "favorite" therapies for managing chronic health complaints.

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