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Episode 76: Are You Doing Everything "Right" And Still Sick?

Episode 76: Are You Doing Everything "Right" And Still Sick?

It can be frustrating when you feel like you’re “doing everything right” and still not improving. 

On this episode, Dr. Ami Kapadia joins Andrea to talk about persistent yeast overgrowth when all obvious factors have been ruled out. 

Dr. Kapadia is a family medicine and integrative medicine physician. In practice since 2005, she trained at the Institute for Functional Medicine and the American Academy of Environmental Medicine. She is also qualified by the American Board of Integrative and Holistic Medicine. 

Her practice focuses on digestive health and IBS, with an emphasis on the impact of chronic infections, allergies, and environmental exposure in illness. 

We'll discuss why stool testing isn't a good depiction of Candida overgrowth and what to do if you're doing everything properly but still have a fungal infection and yeast overgrowth.

To sign up for Dr. Kapadia’s newsletter, visit her website at www.amikapadia.com

Questions? Ideas? Email us at themicrobiomereport@biohmhealth.com or reach out on Instagram @DreEats or @BIOHMHealth

On This Episode, You’ll Learn: 

  • What is SIFO? [2:15]
  • The formal definition is from Dr. Rao's work. He's a gastroenterologist and in Atlanta who's done most of the published research on this, and he defines it as an abnormal number of fungal organisms in the small intestine associated with irritable bowel syndrome.

  • Can you have an overgrowth of other fungal communities in the gut that would also contribute? [2:59]
  • Sometimes yeast species such as Rhodotorula and a couple of others can occasionally show up. But generally, Candida is the most common organism. That's a commensal. And that can be prone to overgrowth.

  • Do SIBO and SIFO show up at the same time? [3:28] 
  • According to Dr. Rao’s work, for patients with irritable bowel syndrome, these can certainly overlap. They can definitely coexist. But someone doesn't necessarily have both or just one or the other. It's not possible to determine that from clinical symptoms alone.

    [4:18]

    There are some overlap and risk factors between SIBO and SIFO. Motility disorders as well as acid-suppressing medications can predispose to both SIFO and SIBO. Pancreatic enzyme deficiency can predispose to both, and antibiotic usage is common to both of them as well. One of the common risk factors for a yeast imbalance that doesn't really affect SIBO is having an allergic or hypersensitivity response to these commensal yeasts organisms that live in our GI tract. 

  • Common Symptoms [5:22]
  • The common symptoms are belching, bloating, indigestion, nausea, diarrhea, typical IBS symptoms. There’s also constipation, if not just as much more common than diarrhea is one of the symptoms. Some of the other things that Dr. Kapadia sees clinically with the gut-brain connection, sometimes there can be significant brain fog because of some of the metabolites of yeast fermentation that can affect the brain, particularly acetaldehyde. Significant fatigue can be a common problem. Intolerance to starches and sugars, generally feeling the unwell history of recurrent infections that are fungal in other areas of the body, such as recurrent vulvo-vaginal candidiasis, yeast issues, as well as other skin problems.

  • Helpful testing modalities [7:19]
  • With stool testing, the problem with yeast and Candida is that commensal organisms live in harmony on most of our mucous membranes. There's not a good way to tell from a stool test whether or not someone has an overgrowth of yeast or Candida. The gold standard is a duodenal aspirate, which is where they can remove some fluid from the small intestine during endoscopy and analyze it for the number of fungal organisms.

    [8:31]

    Dr. Kapadia orders a Candida immune complex and Candida antibodies on most of her patients.

    [9:44]

    There's an organic acid test, where it's a simple urine collection. They measure about nine metabolites of yeast in the urine. 

  • Other things you should be paying attention to [12:51]
  • Dr. Kapadia says that a lot of us and a lot of her patients need to focus on current lifestyle practices. That's a really important piece of the puzzle. If they don't address that component, it's hard for any of the protocols to work because the body's in a constant state of fight-or-flight. You don't really have time to digest your food, you don't have time to detoxify anything, so you could be taking the best supplements and eating the best food, but your body still thinks you're running from that tiger. So you need the cooperation of your normal immune system function, even when you're using all the other tools. 

    [13:55]

    A lot of people aren't even breathing correctly. They're breathing with their upper chest instead of their diaphragm, which is going to keep them in this sympathetic overdrive. Some of Dr. Kapadia’s favorite tools are some home-directed limbic system retraining programs.  

  • Yeast connection to IBS and gluten sensitivity [16:59] 
  • Dr. Rao published studies showing a connection between SIFO and IBS. You cannot differentiate between SIFO and SIBO based on symptoms alone. There are also studies dating back to earlier in the 2000s that show patients who develop an abnormal immune system response to yeast and Candida in the gut can cause IBS.   

    [17:54]

    One idea is that if someone is infected with Candida or has an overgrowth from antibiotics or something similar, they may develop gluten sensitivity if the body has started manufacturing antibodies against Candida that subsequently cross-react to gluten.

  • Checking for an optimized that might be causing underlying infection [19:56]
  • Ferritin, which measures iron reserves, is one that Dr. Kapadia frequently checks lab levels for. She measured plasma zinc serum copper levels, which is the most accurate approach to test for zinc. It's a sort of a Goldilocks situation for those nutrients containing iron or ferritin, since they don't want iron to be too high or too low. When it is too low, it can undoubtedly harm red blood cells and white blood cells, as well as the overall immune system functioning against a variety of bacteria.

  • An allergy that predisposes to a recurrent infection [24:01]
  • Dr. Marjorie Crandall wrote this manual called the Candida information packet, though percentage of the population is just predisposed to allergies, as there is a genetic component to allergies. There are environmental factors that can make someone manifest that allergic predisposition more. Dr. Marjorie talks in her booklet about this potential issue where if someone is allergic to the organism, it actually impairs the immune system's ability to keep that organism in check. That's because histamine and other mediators are released that can impair our immune system response. 

    [25:19]

    There are various ways to determine if someone has this response. Some integrative environmental medicine doctors are able to test patients for this through the American Academy of Environmental Medicine.

    [27:18]

    Dr. Vincent teaches that if someone tends to have recurrent symptoms within a couple of days of stopping your therapy, whether it's herbal or pharmaceutical for this potential yeast imbalance, that's a clue that they might have this yeast hypersensitivity.

  • Diet Components [28:35]
  • What Dr. Kapadia has patients do is based on the five-day yeast mold avoidance challenge. That typically involves removing yeast, alcohol, dried fruit, sugar for about five days. On the sixth day, they challenge some food - typically a good one to challenge is vinegar - and see how they feel for the next 24 to 72 hours. If they notice a problem, they stay off of it during the treatment where they're reducing the load of yeast in the gut. If they don't cause a problem, there's no need to avoid those foods, except for the refined sugars.   

    [30:29]

    Moldy peanuts are common. As far as nuts go, if it tastes moldy, don't eat it. Dr. Kapadia, on the other hand, does not usually have folks go wild trying to locate something specific. She only buys them in whole nuts. In terms of nut butter, she doesn't usually have an issue with them. Peanuts, in general, can be moldy just because of the way they're processed and handled. While she doesn’t specifically remove them, she probably should add them to the list for the Elimination portion.

    [31:46]

    Fruit, fresh or frozen fruit is fine. Grains are fine, as long as the person tolerates them. Dr. Kapadia doesn’t like to limit the diet too much. She has found over the years that it's not necessary if they're targeting the organisms correctly. It can also create some disordered eating patterns.

  • Treatment [32:58]
  • Dr. Kapadia prefers to use natural agents for many reasons. One, she feels like there's a really good safety profile, they can be safe to use on a longer-term basis. Her general approach is to start with herbs that have antifungal properties. She uses a lot of herbs from Dr. Liebowitz’s company. They're generally broad-spectrum herbs. She usually starts with herbal treatments and uses prescriptions sometimes.

    treatment: a multi-pronged approach

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    Transcript: 

    Andrea Wien: Hey, everyone. Just a quick housekeeping item before we get started today. The show is going to be moving to once monthly episodes again for the next few months. We have some exciting projects in the works that are going to take some resources to get off the ground. So we are moving the show to once a month for the time being and shows will still be on Thursdays. So you will have a new Microbiome Report every Thursday of each month.

    Welcome to The Microbiome Report powered by BIOHM Health. I am your host, Andrea Wien, and today I'm talking to Dr. Ami Kapadia. Dr Kapadia is a family medicine and integrative medicine physician, and she's been in practice since 2005. She's trained with the Institute for Functional Medicine and the American Academy of Environmental Medicine, and is certified by the American Board of Integrative and Holistic Medicine. Her practice focuses on digestive health and IBS, and she pays particular attention to the role of chronic infections, allergic disease and environmental exposure in illness.

    On this show, we talk about SIFO, that's SIBO's fungal sibling. Why stool testing isn't an accurate representation of Candida overgrowth. This was news to me. And we talked about what to do when you're doing "all the right things" and still show up with a fungal infection and yeast overgrowth. I learned a lot on this episode and I think you'll walk away with some new understandings and a whole lot of respect for Dr. Kapadia. Enjoy the show. Dr. Kapadia, welcome to the show. Thanks so much for being here.

    Dr. Ami Kapadia: Thanks, Andrea. Happy to be here. Thanks for inviting me.

    Andrea Wien: So I want to set the groundwork a little bit because we have done some episodes on Candida, and longtime listeners will know it's Dr. Ghannoum's favorite microbe, which is so funny to even say that researchers have their favorites, but that is the case. But we haven't specifically talked about SIFO, and really the underlying issues that could be causing it. And so we can get into what I'm talking about. I'm being a little bit intentionally vague, but let's just set the groundwork with what is SIFO?

    Dr. Ami Kapadia: Yes. So, good question. So you know the formal definition is from Dr. Rao work, and he defines it…He's a gastroenterologist in Atlanta who's done most of the published research on this, and he defines it as an abnormal number of fungal organisms in the small intestine associated with irritable bowel syndrome. So I think of it like SIBO, it's just fungal organisms instead of bacteria that are in a larger amount than we would like more approximately in the digestive tract.

    Andrea Wien: And so when people talk about candida overgrowth, are they actually talking about SIFO? Or can we have overgrowth of other fungal communities in the gut that would also contribute?

    Dr. Ami Kapadia: That's a good question. In general, we're talking about Candida. When we do certain tests, stool testing and otherwise, sometimes yeast, such as rhodotorula, I don't know if I'm pronouncing that one right, actually, and a couple others can occasionally show up. But generally, Candida is the most common organism that's a commensal and that can be prone to overgrowth. So that's usually what we're talking about.

    Andrea Wien: Okay. And then I was curious about this aspect of it. So we have SIBO, small intestinal bacterial overgrowth, we have SIFO, do they often show up at the same time? Or is someone usually dealing with one or the other?

    Dr. Ami Kapadia: Again, from Dr. Rao work, he found that for patients with irritable bowel syndrome, these can certainly overlap. But there was a percentage of patients that had just SIBO, there was a percentage that just had SIFO, and then there was overlapping some patients that had both, and so they can definitely coexist. But someone doesn't necessarily have both or just one or the other. It's not possible to determine that from clinical symptoms alone.

    Andrea Wien: I guess this whole show we'll kind of get into why someone might have SIFO and not SIBO because SIBO we've done a couple shows and we have a mutual friend, Phoebe Lapine, she came on and talked about her work with SIBO. And really, that can be caused by food poisoning, slow motility, like there's a couple of really big risk factors. And it seems like maybe the risk factors and underlying conditions for SIFO are different. Is that accurate?

    Dr. Ami Kapadia: That's accurate, but there's also…So there is some overlap and risk factors between SIBO and SIFO. And so, motility disorders as well as acid suppressing medications can predispose to both SIFO and SIBO, pancreatic enzyme deficiency also can predispose to both, antibiotics common to both of them as well. And so there are common risk factors. There are some additional risk factors with SIFO and sort of general yeast dysbiosis is sometimes the way I think about it, and we can get into those. One of the common ones I find that can be a risk factor for a yeast imbalance that doesn't really affect SIBO is having an allergic or hypersensitivity sort of response to these commensal yeast organisms that live in our GI tract.

    Andrea Wien: Yes, that was so interesting. And it's not something that I've heard before. But before we jump into some of these reasons, can we talk just about common symptoms?

    Dr. Ami Kapadia: Sure. So again, some of these do overlap with SIBO. Clinically, we do find some symptoms that that can be quite different. But in the clinical, sort of the published research, the common symptoms are belching, bloating, indigestion, nausea, diarrhea, somewhat typical IBS symptoms. In clinical practice, a lot of us that work with this condition also see constipation, if not just as much more commonly than diarrhea is one of the symptoms. Some of the other things that I see clinically with the gut brain connection, sometimes there can be significant brain fog because of some of the metabolites of yeast fermentation that can affect the brain, particularly acetaldehyde.

    Other symptoms, significant fatigue can be a common problem, intolerance to starches and sugars, generally feeling unwell, history of recurrent infections that are fungal in other areas of the body, such as recurrent vulvovaginal candidiasis, yeast issues, as far as other skin problems, that type of thing we can see as well as far as some of the symptoms we would see in someone who has this.

    Andrea Wien: So we talked about my son briefly on our pre-call and offline, but just to kind of give people a background. So I have a very vested interest in this at the moment. And I do want to talk about the testing piece, because you also said something really interesting in email that I want to get into. But my son who's two has some eczema that has been difficult to figure out. I'll say it that way. And we've kind of gone through the gamut of all of these different things. And I thought we've landed on Candida and yeast overgrowth. And so he had a stool testing done and Candida came back sky high.

    And you mentioned in email that that actually might not be the best testing to figure out if someone is actually dealing with yeast overgrowth or SIFO. So I'm curious about the testing component, what is it in traditional stool testing that isn't so helpful as a diagnostic tool? And then what are some of the different testing modalities that are shown to be more helpful?

    Dr. Ami Kapadia: That's a good question. So generally, with stool testing, the problem is yeast and Candida is that commensal organisms, so it's really living in harmony, or ideally, it's living in harmony on most of our mucous membranes. And so we don't really have any clinical data that would define, "an overgrowth" versus normal colonization in a stool culture. And so there's not a good way examining stool that I know of. I would love to be wrong if someone has some information on this. But as far as I know, there's not a good way to tell from a stool test whether or not someone has an overgrowth of yeast or Candida.

    Part of the problem with this is that we don't have a perfect non-invasive test to tell if someone has this problem. And so, the gold standard is a duodenal aspirate, which is where they can remove some fluid from the small intestine during an endoscopy and analyze it for the number of fungal organisms, but that's obviously invasive and not readily available. So there are tests that I find helpful. None of them are completely diagnostic, but they definitely give us clues about if someone is having a problem with yeast imbalance. And some of those tests…I have an insurance based practice in Portland. And so I tend to start with things that are covered by insurance.

    So I ordered a Candida immune complex and Candida antibodies, IgG, IgM and IgA on most of my patients where I suspect this, and you can get those through request. I believe Labcorp also does the antibodies. And the way I explained it to patients is it's not diagnostic of a problem. But if those are elevated, based on clinical experience, that helps to give me clues that that person's body is having some issues with dealing with yeast, and there might be a component of overgrowth or hypersensitivity that's contributing to their symptoms. I can stop there for a moment. There are some other tests that may be helpful if we want to go into those.

    Andrea Wien: Yeah, I think it's helpful for people just to hear what the options are. Because I think this is something that, one, might be relatively new for people. They might have said, I got tests back and did show high Candida. And so what are some of the other options that I could maybe dig into to see if that really is an issue?

    Dr. Ami Kapadia: Right. So I'll mention one more thing about the stool test. So if it does show Candida, and if the particular lab you used does sensitivities as far as which medications or herbal options that particular strain of yeast is sensitive to, I do think that can be useful to help choose what agents to try for that patient. But getting back to some of the other testing. So there's an organic acid test. I've mostly used Great Plains Lab when I've done that, and so that's a test where it's a simple urine collection so it's easy to do with kids as well. And they measure about nine metabolites of yeast in the urine. The most commonly cited one that I've seen is Arabinose, as far as the one that may help determine if there's a yeast overgrowth, but they'd measure several of them. So that's an option to get some more clues about if this might be an issue.

    I also sometimes if I'm doing food sensitivity testing, as far as IgG testing with patients, I've used [ALE 00:10:18] Test Labs, as well as Great Plains lab. And they have a test that looks at basically antibodies, two saccharomyces, brewer's yeast and baker's yeast. And sometimes there's a cross reactivity that develops to yeast in food when someone has a yeast imbalance in the gut. So if those are positive, that gives me some clues as well. And then sometimes I'll do a clinical sort of empirical trial to see if the person responds to a trial of antifungal herbs or medications as another approach.

    Andrea Wien: Okay. That's really helpful. I think a lot of people, and the same is true with SIBO, there's kind of so many angles and ways to come at these things. And so having all of the information is helpful when people are trying to decipher what step to take next. I think what I'm most interested in this discussion is talking about these underlying reasons that a yeast overgrowth might exist. So we've done some shows in the past where we focused on kind of those big reasons that we talked about, antibiotics, a diet high in refined starches and sugars, chronic stress being a big one, which I know we can get into. But people are kind of aware of those, at least the people who are listening to this show.

    So for someone who's "doing everything right" and still this testing is coming back and saying, hey, there's an issue here. And that's really kind of what's happening with Miles, my son, too, is I feel like we've "done everything right". We did the home birth, he's breastfed, he's never had antibiotics, he doesn't have packaged foods and sugars. There's all great things. And so I'm curious when we're starting to dig under the hood of some of these, what else is there that we should be paying attention to when someone has done all of the things that they should be doing?

    Dr. Ami Kapadia: Good question. So just sort of a side note with, eczema, certainly there can be a yeast imbalance or dysbiosis in general, as a piece of it. We also often see, I'm not sure if you're familiar with LDI or LDA, low dose immunotherapy and low dose allergen therapy. Dr. Ty Vincent and Dr. Butch Schrader are the main doctors that teach about those. It's a way to sort of retrain the body to not react to foods and environmental exposures. And so we do often see with eczema that there can be a food sensitivity or environmental sensitivity component. So that's something I sometimes explore with patients if we're not making progress, just working on digestive function, as a side note. But kind of getting back to underlying risk factors if someone's doing everything right.

    So there's some common ones I see. I think one is the common sort of sympathetic overdrive that a lot of us are in and a lot of our patients are in just from sort of current lifestyle practices. And so I think that's a really important piece of the puzzle. Just said, if we don't address that component, it's hard for any of our protocols to work just because the body's in a constant state of we're running from a tiger, we don't really have time to digest our food, we don't really have time to detoxify anything. We could be taking the best supplements, eating the best food, and our body thinks we're constantly running from that tiger. So it just really can't…We need the cooperation of our normal immune system function, even when we're using all the other tools. So I do find that addressing that piece.

    At this point, I can usually tell if someone's in sympathetic overdrive, just when they come into the office. It's often someone that has a hard time sort of sitting still, their speech is somewhat hurried, I'll be talking to them, and they'll respond very quickly. There's some obvious things that you'll notice when you become more aware of it. And so a lot of people aren't even breathing correctly. And so they're breathing with their upper chest instead of their diaphragm, which is going to keep them in this sort of sympathetic overdrive. So it's something that definitely should be addressed in some way and there's many, many ways to address it.

    Some of my favorite tools are some home directed limbic system retraining programs. And so in the last several years, the last decade or so, there's been two programs. One is called Dynamic Neural Retraining System. The other is called The Gupta Program. And they're are programs that you can buy and do on your own at home, and they have coaches that help guide you. And basically, it's a way to retrain a primitive area of the brain that gets sort of stuck in fight or flight. And so I found that really, really useful if we think that sympathetic overdrive is a piece of the puzzle for patients.

    Andrea Wien: I love that and I actually just finished reading a book called Breath by James Nestor. I don't know if you've seen this.

    Dr. Ami Kapadia: Yes.

    Andrea Wien: I feel like this should be a required reading for every single human. So I've told everyone I know about it. I knew that breath was important before I read it, but reading it really has solidified so many different things for me. We'll link to that in the show notes. We'll also link to those two courses that you mentioned. Because yeah, breath is such a critical piece of this wellness puzzle that we're just not talking about enough.

    Dr. Ami Kapadia: I agree. I have a bunch of my patients trying mouth taping I started the last couple years.

    Andrea Wien: I'm on it.

    Dr. Ami Kapadia: Our dentist recommends it now. So yeah, I think that's really important to get our breathing in order, including nighttime breathing as well as the sympathetic/parasympathetic piece.

    Andrea Wien: Yeah. We did an episode actually with Dr. Matt Kogan, who is a dentist and we did a lot of talking about mouth breathing. So if people are interested, they can go back and check that one out. Have you ever thought about getting your gut tested and stopped yourself because it's either too expensive, too inconvenient, or you're not sure about its accuracy? Listen up. BIOHM has recently launched guttesting.com. This is a website where you can go and get got results in under two minutes for free. Let me just repeat that. You can get a good sense of where your gut health is for free in two minutes. Now, how is this possible?

    As you might know, BIOHM has a gut test where you can go, send in your stool sample and get the contents of your microbiome back. They also ask a series of questions when you send in your stool sample. And what the brilliant minds on the data side have figured out is that they can fairly accurately predict if someone is going to have that imbalance or gut dysbiosis or be imbalanced based on how they answer these questions. So they've made these questions available to you to be able to analyze your gut for free in under two minutes. Go to guttesting.com, G-U-T-T-S-T-I-N-G.com, no strings attached, get your gut analyzed under two minutes for free. You're welcome. So one of the other pieces that you mentioned was this yeast connection to IBS and gluten sensitivity. So I would love to dive into that piece.

    Dr. Ami Kapadia: Sure. So again, Dr. Rao is the main researcher physician who's published on this recently, and so he's published studies showing a connection between SIFO and IBS. And basically what he's shown is a little bit of what we touched on where clinically, the symptoms are quite similar to SIBO. And so you cannot differentiate between SIFO and SIBO based on symptoms alone. So that's where kind of some of the clinical history and the other testing that we talked about would come into play. So that's the more recent studies on that. There's also studies dating back to earlier in the 2000s that show patients who develop a sort of abnormal immune system response to yeast and Candida in the gut, it can cause IBS-like symptoms. And so I think it's another piece of the puzzle.

    I think, like I mentioned, it's a bit trickier to navigate since we do not have a simple non-invasive test like we do at SIBO. But for anyone with irritable bowel syndrome, I think it's definitely worth exploring. And with the gluten sensitivity piece, there's a very interesting theory. There's a protein from the Candida cell wall called hyphal wall protein 1, and it was found to be similar to the gliadin protein. So one theory is that there could be this cross-reactivity where if someone is colonized with Candida or has an overgrowth from antibiotics, or something similar, that may trigger a gluten sensitivity if the body has started making antibodies to Candida that then cross react to gluten. And I do check gluten antibodies on all of my patients as well and it's not uncommon to find that to be positive.

    Andrea Wien: That's so interesting. So similar, so I have celiac disease. And I know a lot of people who have celiac also have issues with thyroid, even people who don't have issues still have gluten and thyroid connection issues. Hashimoto's comes to mind. So we're saying now that this kind of that bio-mimicry thing that's happening in that case is also happening here.

    Dr. Ami Kapadia: It could be. It's a theory as to why we may be seeing more gluten sensitivity in recent decades since we've been using antibiotics since the middle of the last century. It could be a piece of the puzzle as far as why more people are reacting to gluten as well.

    Andrea Wien: Now, can it go the other way? So if someone has celiac are they may be perhaps more likely to have SIFO?

    Dr. Ami Kapadia: That would make sense since the protein is similar. I haven't seen research on it that way. But it makes sense.

    Andrea Wien: Something to watch out for. This is also exciting. Every time we do a show, I'm like, man, there's so many interconnectedness things and the research is just not there. Right? It doesn't have all the answers that we need yet. But it's getting there. And it's so interesting to watch it unfold.

    Dr. Ami Kapadia: I agree.

    Andrea Wien: Okay. So one of the biggest ones, and this is something that I've been focusing on with Miles, is the nutrients to check for and optimized for that might be causing some underlying infection. So I would love to hear your perspective. I can certainly talk about my personal experience, but all research is me search, as they say, so I'll let you go first.

    Dr. Ami Kapadia: Right. No, that makes sense. So as far as nutrients, so the ones that I check lab values for commonly would be ferritin to measure iron stores, I check plasma, zinc, serum, copper levels. That's the best way to check for zinc. I learned that from some podcast with Dr. [Gallin 00:20:11] where intracellular levels of zinc are not as accurate. So I just do those blood levels. I also check B12s on most of my patients, sometimes methylmalonic acid but B12 has actually been very reliable for checking for a lot of my patients. And so specifically for those nutrients with iron ore or ferritin, it's a bit of a Goldilocks type of thing where we don't want iron to be too high or too low.

    If it's too low, it can definitely impair red blood cells and white blood cells, our general immune system function against a whole host of microbes, but Candida and yeast as well. So I typically shoot for around 50 for a ferritin. If someone's less than 20, I definitely try to replete it. There's some great information on iron infusions for especially a lot of our female patients who have continuous iron loss through their cycles. We've been ordering more iron infusions because it's hard to get to the right amount of oral iron, as far as tolerance levels, to get to the level where we want that ferritin to be.

    For zinc, I usually shoot for 80 to 100, at least. A lot of my patients, they'll be either outright low on the lab values or kind of in the 70s range or so. And then B12 is frequently low. And we use slightly different values to say it's low. Certainly I have a whole host of patients where it's in the 200 to 400 range which even mainstream medicine, they make a note on the lab report that it's worth considering repletion there. But if it's less than 600, it gives me some clues about potential issues with digestion and absorption.

    I don't check vitamin A Levels very often, but it is important for T cell and immune function. And so the way I tend to cover that is for kids or sometimes even adults, if they tolerate cod liver oil, and they're already taking some form like that, it would have some amounts of vitamin A, and then I use a couple of products. Vitamin D complete is a product that contains vitamin D, K and A, so that's an easy way to cover our bases to get some repletion of that in case it's low without going to any sort of dangerous level because you want to be careful with vitamin A, especially with pregnancy. So those are the main nutrients that I check in that are often low in a lot of the patients we see.

    Andrea Wien: Now, is the SIFO causing those deficiencies? Or is it the deficiencies are giving rise to the environment that allows the SIFO to flourish?

    Dr. Ami Kapadia: That's a good question. I don't have a definitive answer for that. I suspect it's similar to what we find with SIBO, where there's some impaired digestion and absorption of those nutrients. I suspect there could be a common underlying factor that would predispose to both of those issues as far as having some nutrients depleted as well as having a problem with a yeast dysbiosis. But my current thought process is that probably the dysbiosis leads to some impaired absorption.

    Andrea Wien: Yeah, I think that's an important piece to focus on. Because just repeating those nutrients, if someone's like, my B12 did come back low or my ferritin is quite low, you have to fix the underlying reason. So working with someone who can help you with the gut health piece of it, and then in addition be repeating the nutrients because otherwise it's just going to continue to diminish.

    Dr. Ami Kapadia: I agree. Whenever I have someone, particularly B12 levels often come back low. I'll tell them, so there's two pieces to this puzzle. We need to replete it. But then why was it low in the first place? And that's sort of the puzzle that needs to be solved for that person.

    Andrea Wien: Yeah, absolutely. And then the last piece before we get into more of the options for treatment is this allergy component. So this is not something that I had heard before. I would love to just get some information on what you mean when we say there might be an allergy that predisposes to a recurrent infection. 

    Dr. Ami Kapadia: Yes. So there's this woman, Dr. Marjorie Crandall, who she wrote this manual called the Candida Information Packet. For anyone that's interested, you could Google it. She was a researcher for many years. And she kind of lays out all the details of this. And basically, if someone is allergic to the actual yeast ... To back up a little bit, a percentage of the population is just predisposed to allergies. And there is a genetic component to allergies. We do see it rising in general as far as seasonal allergies, food sensitivities, all of those in general. But there's a genetic predisposition, there's environmental factors that can make someone manifest that allergic predisposition more.

    And so she talks about in her booklet, and it's well researched that there is this potential issue where if someone is allergic to the organism, it actually impairs the immune system's ability to keep that organism in check. And that's because histamine and other mediators are released that can impair our immune system response. So, if you think about it again, if this microbe is part of our commensal Flora on most of our mucous membranes and someone becomes allergic or hypersensitive to it, it can predispose to having an overgrowth because their immune system isn't able to keep it in check to the level that we would want. And so there's various ways to determine if someone has this response.

    Some of the integrative environmental medicine doctors are able to test patients for this. And so that would be through the American Academy of Environmental Medicine. I'm not sure if regular allergist routinely would check for this or not. They definitely can check for typical environmental allergens, including molds and fungus. And so getting that checked and treated, I think can be very helpful. And so that's one way of getting it tested is through either an environmental medicine doctor or at least getting typical pollens, molds, et cetera, tested through an allergist. Other ways to kind of get clues if this might be an issue.

    Again, if I do a food panel on someone and they're showing antibodies to bakers and brewer's yeast, sometimes that will be a clue for me that it might be an issue. If someone is reacting to yeasts and molds in foods because there can be a cross-reactivity, that can be another clue. So some combination of those modalities to help determine if it's an issue. And then as far as treatment, again, some regular allergist, if they do allergy shots, they can treat for molds, pollens, et cetera, and that can be helpful to down regulate that overall immune response.

    And then through the American Academy of Environmental Medicine, they have specific ways they can help desensitize patients. And then finally, through the low dose immunotherapy that Dr. Ty Vincent teaches, there's a way through that, again, somewhat similar but different from homeopathy to help retrain the body's immune response to those organisms.

    Andrea Wien: It does seem like that approach and looking at this allergic component is probably a later stage. Is that accurate? Are you testing for this right away? Or is it with someone's not really responding to treatment that you would expect them to respond to?

    Dr. Ami Kapadia: Yes, I agree. That's a later step because it's more involved. And so typically, we'll first just try to see if doing the foundational therapies help someone. And Dr. Vincent teaches that if someone tends to have recurrent symptoms, within a couple of days of stopping your therapy, whether it's herbal or pharmaceutical for this potential yeast imbalance, that's a clue that they might have this yeast hypersensitivity. And the way he explains it is that yeast grows very slowly. So if you stop your therapy, and a couple of days later, someone's IBS symptoms are coming back, he says, that's more of an immune response to the small number of organisms that have come back as opposed to a recurrence over of the overgrowth.

    Andrea Wien: Okay, that's interesting. Okay, let's jump into some options for treatment. So maybe we can start from a diet perspective. I think one of the things that was always a little bit confusing to me is removing all yeasts from the diet when you're doing some type of treatment for a yeast overgrowth. So these are things like soy sauce, vinegars, et cetera, et cetera. I'm just going to leave it there. What are some of the diet components that we can look at?

    Dr. Ami Kapadia: Good question. So I learned about this from this little booklet that Dr. Sidney Baker wrote in the early 80s. And he allowed me to post it on my website because it's no longer in print. So it's available under my website under the resources section under Digestive, I believe. And basically, what I have patients do is based on his five-day yeast mold avoidance challenge. And so what we do is, these foods don't feed the yeast but because a hypersensitivity to molds and yeasts and foods can develop if you have this form of dysbiosis. We want to determine if that's an issue, because then we will temporarily remove those foods. And so that typically involves yeast, alcohol, dried fruit, sugar.

    Sugar is in a cross-reactivity that does feed the yeast but the rest are cross-reactive. And vinegar, except for distilled vinegar, which doesn't have mold, or yeast. Fermented vegetables, kombucha, aged meats, anything fermented or aged. Teas often can have mold residues. Coffee, I have people they can keep it in if they do organic and grinded at home, otherwise, that can also have mold residues. So we have them remove all that for about five days. And then on the sixth day, they challenge some of those. Typically, good ones to challenge would be vinegars, except for distilled vinegar, because again, that one's usually not an issue. But add back other vinegars or yeast and see how they feel for the next 24 to 72 hours.

    If they notice a problem, I have them stay off of it during the treatment where we're reducing the load of the yeast in the gut. If they don't cause a problem, there's no need to avoid those foods except for the refined sugars. So that's typically how we start with figuring out if yeast and mold related foods are a piece of the puzzle for that person. he goal is to add back those foods eventually as we rebalance things, but for the time being, it can help during treatment to take a load off of the immune system.

    Andrea Wien: I guess one of the other questions I had diet related was about nuts. Because we know, for example, peanuts have potentially high mold levels, kind of any nut that is out of the seed, pistachio, walnut, et cetera. Is that something that you're concerned with?

    Dr. Ami Kapadia: Good question. So peanuts do tend to be moldy. I mean, most nuts, I don't have people remove. We just tell them that the more sort of processed it is, the more surface area it has to potentially become moldy. I learned that from one of my mentors, Dr. Michael Lebowitz, who has been treating mold and yeast issues since the early 80s. And so typically, I just ask people to stay ... If it tastes moldy to not eat it as far as nuts go. But typically, I don't have people go crazy with trying to find anything in particular. I just have them by whole nuts. As far as nut butters go, I don't typically find them to be a problem. I agree, peanuts in general can be moldy just because of the way they're processed and handled. So while I don't specifically remove them, I probably should add it to the list for the elimination portion, at least.

    Andrea Wien: Okay. And then in terms of just regular carbs, so these are things sweet potatoes, kind of the starchy carbs that aren't refined carbs, are those causing an issue?

    Dr. Ami Kapadia: So I typically don't remove those. Again, from Dr. Lebowitz work since the early 80s, I use some of the initial principles he came up with. I have people remove processed sugars, including honey. I also had them remove of honey, maple syrup, any added sugars or sweeteners, because really, ultimately, they all can cause similar issues. But fruit, fresh or frozen fruit is fine, grains are fine as long as the person tolerates it. I do have some patients that just tell me they don't do well on grains. And that's fine. We don't have to include it.

    But I don't like to limit the diet too much. Because I found over the years, it's not necessary if we're targeting the organisms correctly, and it can create some disordered eating patterns. So there was a quote, I believe it was by Dr. Baker as well, where ideally, we don't put someone on an unhealthy diet in pursuit of helping them regain their health, something to that effect.

    Andrea Wien: I love that.

    Dr. Ami Kapadia: Yeah. And my parents are from India, I can't live without rice. Like I personally don't like to remove those foods. So unless someone tells me that they have a particular problem with whole grains or certain starches that are healthy, I prefer to not get overly restrictive with the diets.

    Andrea Wien: No. That's incredibly helpful because I did visit with a naturopath and they told me to do an AIP paleo diet with my son. And I was thinking, that doesn't sit right with me. So it's good to have a little bit of extra validation on that. Okay. Outside of diet, what are some of the things that we're looking at in terms of treatment?

    Dr. Ami Kapadia: Okay. So as far as treatments go, my personal biases, I prefer to use natural agents for many reasons. One, I just feel like there's a really good safety profile. I think they can be safe to use on a longer term basis. And often we have to treat this issue for at least several months and sometimes are currently. So my general approach is to start with herbs that have antifungal properties. And there's a couple ways you can do this. So there's certain herbs that we know work primarily on yeast and fungus. The main ones I use the ThorneSF722, which has been around for decades, a very safe natural antifungal I've used with hundreds of patients has really good results.

    We generally use three to five Gel Caps up to three times a day, which I think is the same dosing on the bottle. The other sort of yeast fungal specific herbs that I like is a company called Beyond Balance MYCOREGEN. It's a liquid, it can be used with kids, very safe. The fact that it's a liquid, we can titrate the dosing, so for someone that's prone to die off and such, you can start very slowly with the dosing. So I like those. I also use a lot of the herbs from Dr. Lebowitz company. I'm not affiliated with them, but they're just very clean. It's Supreme Nutrition products. So they are not yeast or fungal specific, they're generally a broad spectrum herbs.

    And some of the main ones I use from their company are Melia Supreme, which is neem. Morinda Supreme, which is noni. Golden Thread Supreme, which is coptis. Olive Leaf Supreme. And so there's pros and cons to that. One is because they're broad spectrum, they can work on many different organisms, which is great. The only challenge is, then if we someone feels better on it, we don't really know exactly what we were treating, which isn't really a problem, per se, but that's one challenge with that. Any of these if they're helping, I have someone do at least like a one to two month trial, usually a minimum of a month or so to see. And sometimes that can be sufficient. For other patients, we'll do it for three to four weeks and we'll stop it they'll have recurrent symptoms, and then we'll do a longer course with whichever one was helping them.

    If it continues to work for them, we may just do a three month course. If it's working and then it loses effect, we may take a break every four to six weeks because some of the yeast organisms may be resistant to it. And if you give the body a break for a week or so, those organisms can die off, and then it'll work again. So those are kind of a couple options for ways to work with it. So I usually start there with herbal treatments. I do use prescription sometimes. And we can get into that if you don't have any questions specifically about the herbal options.

    Andrea Wien: No. I guess my question that I was thinking of is, in the case of SIBO, for example, it's very common to have a recurrent or chronic SIBO infection. You might be fine for even a year or two and then those symptoms return. Obviously, we're always looking at root cause and trying to figure out what's causing that. But is that the case with this? Or is it common that people maybe have SIFO, they go through a round of treatment that's effective, and then they're not having issues?

    Dr. Ami Kapadia: I think it's kind of like what Dr. C. Becker told me, one of my friends here in Portland that teaches about SIBO. Initially, when I started my practice, I had more patients that would respond in a shorter timeframe and wouldn't have recurrence. But now, the majority of my patients don't fall into that category. And I don't know if it's just because the patients I see now have more complex issues where there's many more things going on that make them prone to recurrence. And so it is more common at this point for me to see patients where we have to unravel multiple factors before we can get some more permanent resolution. But it shouldn't be a forever issue if we identify all those factors.

    Some of the more common concurrent issues I see that prevent us from resolving this. One would be protozoa and parasites, which I find very commonly. And it's a bit tricky because we don't think we have those organisms in America. So we don't get great results from standard lab testing for that. I typically have patients use a couple specific labs, ParaWellness Research and parasitetesting.com where the practitioners are very well-trained in looking at the stool specimens, and they have better experience in finding the organisms. And so 90% of the time, when I think someone has something going on, they will find an organism for us to treat. So I think that can be a common concurrent issue.

    One of my mentors said his main thought on why we're finding this so much is, even though it may not be common in the American food supply and water supply, a lot of our food that we eat currently comes from other countries that may use sewage water and such for irrigation. The other possibility is that we've got a melting pot in America, and a lot of food handlers can be from other countries. And so there may be different ways that we're getting exposed more than we were, say, maybe 50+ years ago. So that's one piece of the puzzle I see frequently.

    The other pieces would be the stress or sympathetic overdrive that's somewhat a result of our current culture that can make this a recurrent issue. If someone has food sensitivities that we have not addressed that can cause this to come back. And then the yeast allergy hypersensitivity issue is the other. Those are kind of the common issues that I see as impeding our more permanent resolution.

    Andrea Wien: Okay, that's helpful. Yeah. Let's talk quickly about the antibiotic piece. And then I think we've covered quite a bit in this for people to digest.

    Dr. Ami Kapadia: Yes, we have. Okay. So for antifungals, there's a couple of prescription antifungals that we use. Basically, if I've used the herbal options and I'm still not clear if someone has a yeast dysbiosis as part of their problem, I'll do a trial of antifungal herbs because they're specific for yeast. And so if someone has a positive response or no response, I can have a little bit more confidence that their response either way is due to working on this yeast issue. And so I typically start with Nystat, and it's a very old, non-systemically absorbed antifungals. So there's no real potential for harm outside of a little bit of stomach irritation. Long term, it may induce some resistance, but we don't use it super long term.

    So I'll typically do a one to three month trial of Nystatin at a dose of one to two tablets three times a day. If someone doesn't tolerate it, there's a red dye on it. So we sometimes get it compounded. Some people get a die off reaction, which may be indicative of the yeast allergy issue, where they're reacting to the die off products. And then we just go really slow, start at a lower dose and work up gradually. And so we'll do a trial of that. If I still don't have a clear response as far as if they had improvement from that and we want to try something else, I'll do a couple week trial of fluconazole. You always have to check liver function tests before you start that. Typical dosing is 100 to 200 milligrams, once a day for a two to three week trial.

    So the idea with that is we need to identify which medication is specific to the strain of yeast that that person has. So there's the same issue with an herb or a prescription. If we give them something that is supposed to work for yeast, it may or may not work depending on if the organism they have is sensitive to it just like with an antibiotic and a bacteria. So I'll do a couple week trial of fluconazole, again, just to try to get a yes or a no whether this person is responding to more specific antifungal therapy, and I don't really use that long term at all. I do have some concerns about inducing some resistance if we use it long term. And it also that one does have drug interactions because it's systemically absorbed.

    Andrea Wien: Just anecdotally, what percentage would you say have to take more of the antibiotic route when you're working with them?

    Dr. Ami Kapadia: With the antifungals, so typically, most of my patients have responded better to the herbals. And for the people I have been unclear on a response and I've done a trial of antifungal prescriptions, very few of them have had a better response to that than the herbs that I've given them, it's maybe a handful. Again, my bias is towards herbal options, but I haven't seen a better response with the prescription. So I do use it more as that sort of trial and error process to troubleshoot if I'm unclear about what we're treating.

    Andrea Wien: Okay, that's helpful. Well, thank you so much for the time today. This has been incredible. If people want to find you, do you work virtually? Can they book an appointment with you or follow you online to see your work?

    Dr. Ami Kapadia: Yeah. So my website is just my name, amikapadia.com. I have a newsletter. Sign up on my homepage that I would love anyone interested, you could sign up. I'm putting together a course for patients and doctors on SIFO dysbiosis as well as mold environmental exposure, which I also do some lectures on for clinicians and patients and I'm going to send out a notice when that's ready. Currently, telemedicine laws for medical doctors are a bit tricky. So I see patients in Oregon and Washington. But as the laws change, I again will send out an email to anyone on my newsletter to let them know if and when I can work with patients in other states virtually.

    Andrea Wien: All right. Well, thank you so much for the time, again. We'll link to all of that in the show notes. It will be a biohmhealth.com/pages/podcast. Thank you. Have a great night.

    Dr. Ami Kapadia: Thanks, Andrea. Have a good night. Bye.

    Andrea Wien: Thanks so much for listening. I would encourage everyone to go sign up for Dr. Kapadia's newsletter on her website homepage. You can find that at amikapadia.com and we'll also link to that in the show notes at biohmhealth.com/pages/podcast. Again BIOHM is B-I-O-H-M. If you sign up for that newsletter, you will be alerted when Dr. Kapadia puts out her practitioner and patient SIFO course. So definitely go sign up there. We'll put it in the show notes. Thanks so much for listening. Have a good one. I'm Andrea Wien.

     

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