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Jeffrey Bland, Ph.D

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

Posted: 09/10/09 09:52 AM ET

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 (www.jeffreybland.com), 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 (www.functionalmedicine.org) 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.

 
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...
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...
 
 
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HUFFPOST SUPER USER
jennyjen
01:14 PM on 09/30/2009
I also want to thank you for being so generous with your knowledge and experience.

We are lucky to have you, Dr Weil, Dr Hyman, and so many others giving us such great information and here at Huffpost.
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ReealOne
Don't sweat the small Stuff, life is way too short
08:05 PM on 09/13/2009
Thank you Dr. Bland for all of the great information, and your help!
12:55 PM on 09/12/2009
I have a friend who's detoxing & readying himself & some friends to ingest white powder gold. He knew a guy named David Hudson who gave him video years ago that gave him the recipe to make the product.

Here's a company that makes the powder;

http://www.whitepowdergold.com/

Here's testimonials;

http://www.whitepowdergold.com/testimonials.sht

I'd also like your opinion for this most extraordinary, if true, matter.

Suppressed Medical Discovery that cures most chronic disease, even some cancer by Dr. Robert C. Beck:

http://video.google.ca/videoplay?docid=-3383948315844437935&q

My friend also ordered some of these electric boxes for testing. The phone number to order is in the video & so are schematics to make your own which I think adds credibility.

I hope all this is real. If it's not, it's very convincing.

I asked Sermo & AMA doctors who were posting here at HuffPo about this but not one had a thing to say positive or negative. In fact both blogs stopped dead in their tracks as you can see;

http://www.huffingtonpost.com/dr.-daniel-palestrant/the-biggest-risk-to-us-ph_b_229068.html?show_comment_id=27532204#comment_27532204

&

http://www.huffingtonpost.com/dr.-daniel-palestrant/why-physicians-always-get_b_238138.html

What do you people reading here think?
01:09 PM on 09/12/2009
All I can say is, remember the man who took Colloidal Silver for whatever reason and his skin is now dark blue and has been that way for a long time. He looks like a Smurf.
01:48 PM on 09/12/2009
I know, I saw that years ago, but everything in moderation, you know, & he did admit to taking high doses.

I heard the history of silver colloidal is that before they invented penicillin, silver colloidal was what they used. I know many people that swear by it & use it for all kinds of ailments & benefit. They say it's simple to make your own & kind of expensive to buy it in the health stores.
10:03 AM on 09/13/2009
This guy over did it & that's why he turned blue.

http://www.huffingtonpost.com/2009/09/10/paul-karason-bule-man-sti_n_281797.html
01:14 PM on 09/12/2009
I forgot to say, my friend even got online & showed me the scientific process of this zapper getting rid of parasites & such. It was amazing & very believable.

I always said, "Science fact would have to be stranger than any science fiction we could imagine"
10:04 PM on 09/12/2009
I just found this video on David Hudson & the white powder gold. There are seven small parts;

http://www.youtube.com/watch?v=_epz_b3tkMM&feature=related

Jim Marrs is the speaker & this is who he is;

http://en.wikipedia.org/wiki/Jim_Marrs
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StThomas
Not until I see the holes of the nails....
06:26 AM on 09/13/2009
The zapper thing is a fraud.
http://www.quackwatch.org/01QuackeryRelatedTopics/Cancer/clark.html
I don't doubt amazing and belivable, but not true. I don't know about the gold, but ingesting heavy metals is in general bad for you.
06:10 PM on 09/11/2009
All those listed and some more made up illnesses to bulge the already huge bottom line of the drug companies.
09:06 PM on 09/11/2009
See how many of the claimed disease's are listed at the links below. The individual who posted this blog has his own remedies that he sells. With a racket like that who needs the drug companies?

http://www.mayoclinic.com/health/DiseasesIndex/DiseasesIndex

http://www.cdc.gov/diseasesConditions/
01:58 AM on 09/12/2009
Why bother?

"They" used to say MS was all in the mind of those afflicted. Epilepsy wasn't a "real" medical condition. Etc. Etc.
02:01 AM on 09/12/2009
Some chronic conditions are the result of "syndromes" affecting more than one system of the body, but aren't "diseases".
03:47 PM on 09/11/2009
"The exposure to toxic chemicals and toxic metals such as mercury is also eliminated."

Considering 50% of dental amalgam, the so called dental "silver fillings" is mercury it is inconceivable that the FDA does not ban the use of it. A true risk analysis might prompt the truth to the front pages and raise public awareness about the harm caused by" silver fillings". The FDA feigns few reports on record reporting harm caused by these fillings; yet how many health care professionals actually consider the exposure as a source of harm and report the reaction as mercury exposure from dental amalgam?
06:11 PM on 09/11/2009
Try to catch up.
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HUFFPOST SUPER USER
kkdc
chiropractor, functional medicine approach, therap
03:01 PM on 09/11/2009
Hey Dr. Bland, so excited to see you here on Huffington Post. Now all my patients from stopchronicdisease.com have a new place to look for excellent cutting edge information about Functional Medicine. Also all my patients who are getting well with the 4 R protocols, personally tailored to their specific needs have a new place to learn more about what we're talking about here in my clinic. The 4 R program just did fabulous things for a patient of mine who has had a lifelong problem with psoriasis. Our object was just to reduce his cardiac risk, so I put him on a body composition change program, after thorough lab testing. We found he was lacking in numerous anti-oxidants and woefully low in vitamin D...as have been all the patients I've tested. Within 2 weeks of changing his diet, using specific set of nutrients and a medical food, he stopped taking his anti-inflammatories and had no more joint pain, swelling or skin lesions. His medical doctor had had him on this medication for years. The surprise of this case was the huge surge in energy he experienced. I have this patient's permission to share the information, or I could not have shared it, it's on my website.

I have enjoyed working with you over the last 15 + years. Your work has helped me help so many others. Now my patients have a new resource!
Dr. Krahl, D.C.
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StThomas
Not until I see the holes of the nails....
03:32 PM on 09/11/2009
Anecdote, and some mildly nauseating grovelling. Do you have any _evidence_ that any of this is more than an expensive (and from one post below uncomfortable) waste of time
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StThomas
Not until I see the holes of the nails....
02:03 PM on 09/11/2009
Starts with three paragraphs of hype, followed by a list of several conditions which are typicially difficult to diagnose and treat, then lists various "treatments". He does not go into any details about the evidence that he and his colleagues have hopefully amassed, to justify putting human beings through all of this.

How changing the diet, eating bacteria then dosing oneself up with an unappetising list of chemicals will make you better is unexplained, but the science-y feel might slip that under your radar

All of this I could happily ignore if there were some kind of measurement of outcomes, but if patients are ever objectively cured forever (one potential outcome measure!), then Dr Bland doesn't say. I think he _may_ have this data for $60 on his webpage http://www.jeffreybland.com//Products.aspx?Category=8
Not a sniff of a peer reviewed journal here ...
02:56 PM on 09/11/2009
Facts
Most people here don't need no stinking facts. LOL
01:38 AM on 09/12/2009
You don't know that. I'm extremely skeptical of everything I read. I'm sure others are, too.
12:59 PM on 09/11/2009
As to diet, I'll add this: back in the '80s, I went to a medical doctor who had spent time in India to study Ayurveda and had taken it up full time. Desperate for help with my health problems, I changed to an Ayurvedic way of eating and used the herbs that were supposed to help my "type". I stopped eating everything that wasn't included in the plan. I did this for many months and saw NO improvement in any of my symptoms.

Remembering this, I'm reminded how skeptical I am about dietary causes of some health problems. Surely, there are food allergies in some cases, but I don't believe diet it the answer to everything.

Back in that decade, I also tried Chinese medicine, acupuncture, and whatever else offered hope. Now I simply try to eat healthfully and use the few medications that alleviate the various symptoms better than others. I've been on SSDisability for over a decade now and am trying to exist well below the poverty level. It is not easy and is a cause of great stress -- which of course, does not help at all.

If there is an answer, I'd be happy to learn of it.
02:49 PM on 09/11/2009
I suffer from chronic back pain due to wounds and injury. Had a job that required over an hours drive each way (when the traffic wasn't backed up) and flew a desk. Relied on takeout and heavily processed foods due to time considerations. A little after leaving my job I started to exercise more and took up cooking more for myself. I lost a little over 20lbs, lowered my blood pressure, cholesterol level. Exercise (any exercise) has been shown to reduce pain and improve overall health. Personally the biggest surprise was I turned out to be a pretty damned good cook.
01:36 AM on 09/12/2009
Glad you had improvement in your condition.

Have any cooking tips?
11:38 AM on 09/11/2009
Dr. Bland -

It is always a pleasure to see anyone talking about functional foods and nutrition's role in overall health.

It is even better to see you recommending a prebiotic to ensure/enhance probiotics. At Prebiotin.com, we like to say taking a probiotic without a prebiotic is rather like putting down grass seed, then not watering it!

One minor issue: I'm pretty sure you mean "inulin" not "insulin" when you give examples of some prebiotics. I should hate to think someone would interpret that literally and take insulin for digestive health benefits!

Regards,

Kristian Chronister
01:27 PM on 09/11/2009
Good looking out Mr. CEO of nutraceuticals. Thank you & welcome to Huffington Post. I read that & being the layman in this matter I am, I had no idea.
03:03 PM on 09/11/2009
What a large number of people don't realize is that the supplement industry is largely unregulated.
07:08 AM on 09/11/2009
I am retired and live alone. Cooking is a chore and I rarely have the energy anyway. My solution is to toss everything into the pot. Rice or noodles. No pasta or wheat based carbs (gluten). A chunk of lean boneless meat. Leafy veggies. No peas, legumes or potatoes (bloating and constipation). Minimal salt and no sauces. Its bland but works well. Once or twice a week I hit the Chinese noodle shop to get my MSG fix. I then happily go back to my bland meals that are very easy to prepare and to clean up. I take an alphabet soup of vitamins a week or in two in case I am missing some dietary component. On occasion I will eat everything at a restaurant meal. Any food problem will clear itself in a day or two on my normal diet. I sleep like a log and have no health problems. I am no live wire but after a life-time of chronic problems this is like living in heaven.
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10:07 AM on 09/11/2009
Noodles have gluten, too. And MSG is not good for you. Did you know you can ask for your food to be prepared without it?
07:03 AM on 09/11/2009
On the 15 types of Chronic illness I score on 13. I never even knew I was sick until I was 50 (I'm 67 now). My problems were never severe enough to disable me but they upset my wellness to cause serious problems at work and in my libido (divorced.) To cut a long story short my chronic illness is brought about by food intolerance. These are the same foods that cause allergic reactions in others but in my case the symptoms are milder and do not show up in clinical tests (no rash or IgE signals.) By avoiding them (self reporting and therefore a victim has to work out what his/her intolerance foods are) the most important result is the ability to get restful sleep. With restful sleep practically all the other chronic symptoms disappear. My explanation is that intolerance foods trigger the innate immune system (therefore no IgE signal.) Since this metabolic activity consumes ATP my body never achieved the basal metabolic level as one should in REM sleep. This severe sleep debt can be cleared only by restful sleep, a state rarely if ever achieved if there is no change in diet. Therefore I suffered long term chronic illness. I'll write up a detailed paper some day on this. Do note that there is a rich store of food based health related lore in every culture but none are unable to provide a scientifically testable hypothesis why it is so. (more)

.
12:30 PM on 09/11/2009
Lack of sleep is a severe problem. More like a curse. But which comes first, the chicken or the egg?
03:27 AM on 09/11/2009
Great to see Jeff Bland on HuffPo. I owe him a debt of gratitude for his cutting edge research and breakthrough products, that have helped me so much over the years.

And the FIFTH R is RELAX!! Breathing diaphragmatically to up regulate the parasympathetic nervous system is an important R to include.
03:00 AM on 09/11/2009
You forgot Chronic Lyme Disease.
11:12 PM on 09/10/2009
I am thrilled to see Dr. Bland on HuffPo! He is an awesome health researcher, lecturer, practitioner! I've heard him talk many times - what an inspiration - the info he shares is cutting edge effective. Yes, it is a drag that it's not part of standard medical practice so often it's not covered by insurance. But I'm grateful this info is out there it's helped many people I know, myself included.
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HUFFPOST BLOGGER
Angie Cordeiro
We do all things through Grace which empowers us.
08:17 PM on 09/10/2009
Thank you Dr. Bland, your article works for me, and has for a while now.

BTW I support The American Association of Naturopathic Physicians: Physicians Who Listen

http://www.naturopathic.org/
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HUFFPOST SUPER USER
FrankKalder
01:04 AM on 09/11/2009
Yes, indeed, there's an innate healing ability, and the “natural” methods offered work at treating diseases as well as restoring overall health. :)