The 4R Approach to Treating Chronic Digestive Issues


This year marks my 35th year in clinical practice, and one thing I have learned over the years is to find ways to organize the clinical information I receive when working with my patients in order to make the most accurate diagnosis and chose the most effective and focused treatment plans to get the best results. This involves taking a careful history, doing a problem-focused examination, ordering objective tests and putting it all together to understand causes of conditions that bring people to my practice. Frequently new patients come to me after having seen many doctors and have run numerous tests for me to review and interpret.

These days greater than 50% of my practice involves treating people with chronic digestive conditions in an integrative way. From SIBO to leaky gut to chronic constipation or diarrhea to irritable bowel syndrome and inflammatory bowel disease, I am working with many people to help them resolve or better manage their chronic symptoms and lead more comfortable and less restrictive lives. When it comes to digestive issues, I follow the 4R approach in my treatment plans.

The 4R approach

  • Remove

  • Replace

  • Reinoculate

  • Repair

The 4R approach allows me to chose my therapies in an orderly fashion to get the best results. While these may overlap somewhat, following the order helps keep the process more simple and effective by making changes that lead to next steps.

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Here’s an example. Let’s imagine you have inflammation in your intestinal tract. Following the 4R approach, we would focus first on therapies to reduce that inflammation by removing factors that promote the inflammation and adding factors to help lower inflammation before doing therapies to repair the damaged intestinal lining. By doing so, the job of repairing the gut lining becomes easier and more effective. Otherwise it would be like replacing boards on a burning building before the fire is out!

Let’s go a little deeper and review some possible approaches with each step.


This may include foods that you are allergic, sensitive or otherwise reactive to, overgrowth of normal bacteria or the presence of pathogenic or otherwise irritating microbial organisms. Removing pathogens or inflammatory triggers can help reduce leaky gut as well as improve digestive comfort.


This step involves adding things to help lower inflammation, replace missing elements that are needed for proper digestion, and otherwise supporting healthy digestion. This may include adding high-fiber foods, healthy protein sources, and anti-inflammatory herbs and spices. If digestive enzymes or hydrochloric acid are deficient, these would be supplemented at this point. If malabsorption is present we may add a multivitamin/mineral formula or in severe cases use IV nutrition. This is where I also may use Traditional Chinese Medicine formulas that have been shown to improve the tone and function of the digestive system.

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Did you know that the average person has 2-3 pounds of bacteria in their gut? This step aims at supporting gut and microbiome health by supplementing/reinoculating probiotics and fermented foods aimed at restoring balance to the large intestinal microbiome.


If the first three steps are done well, repair becomes easier. Our body knows how to fix things once irritants are removed as well as other obstacles to cure. Repair aims at keeping inflammation at bay and supporting a healthy gut lining with normal membrane permeability. Certain vitamins, amino acids and herbs are most often used to help with the repair phase in the 4R approach.

The 4R approach helps organize the process for successfully treating, managing or resolving many chronic digestive issues. By following the principles of this functional approach, I have found my protocols to be more effective as well as more focused, easier for my patients to comply with, and less expensive in the long term.

Carl+mini+steth.jpgDr. Carl Hangee-Bauer is SFNM’s founder and Clinic Director and a member of the Gastroenterology Association of Naturopathic Physicians. He has a general naturopathic medical practice and specializes in immune support for allergies, autoimmunity and cancer support, functional gastroenterology and pain management. He has over 30 years of clinical experience using individualized care and treatment plans to provide effective naturopathic based care.

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