Nirala Jacobi:

Welcome to another episode of the SIBO Doctor podcast. Very exciting to start 2022 off with another great episode of this podcast. I'm interviewing a SIBO expert, Dr. Ami Kapadia and this really marks the completion of five years of the SIBO Doctor podcast and moving into our sixth season, which is just mind blowing to see how many amazing practitioners and researchers and specialists I've been talking to over the years. So, Ami is no exception. She's practiced as a family medicine and integrative medicine physician since 2005, and has pursued training 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. She has been practicing integrative and functional medicine at Kwan-Yin Healing Arts Center in Portland since 2015. And she focuses on digestive health and autoimmune disease and with a special focus on chronic infections, allergic disease and environmental exposure in illness.

Nirala Jacobi:

I've heard Dr. Kapadia speak at various functions or conferences and have found her to be really succinct with her approach to candida. I know I've had several other specialists here on the podcast covering this topic, but I think she has a really great approach to candida and a lot of similarities with how I approach candida. So, I thought she'd be a great guest. Welcome to the podcast, Dr. Kapadia. It's so wonderful to finally have you on an episode of the SIBO doctor podcast.

Ami Kapadia:

Thank you. It's great to be here and please call me Ami and I'm happy to talk with you today.

Nirala Jacobi:

Fantastic. Well, yeast is such a huge topic and we get a lot of questions about SIFO and fungal overgrowth in general. So, it's always wonderful to have another expert from a different angle on the show. So, we'll sort of talk about different approaches that you have, and also just for listeners, Dr. Kapadia has a course that's coming out very soon, so stay tuned. I will let you know more about it as soon as we have more information about that. And I know how hard it is to work on courses. So, hat's off to you. So first up, tell us a little bit more about your practice and how you got into becoming a yeast expert.

Ami Kapadia:

Yeah. So, I was trained as a family medicine doctor from Philadelphia and that's where I did my training. So, I had a wonderful regular medical training in allopathic medicine. And I also was fortunate that one of my mentors in medical school was the head of our Integrated Medicine Center. So, he was treating SIBO and yeast dysbiosis and all of these things many years when I was shadowing him. I'm in Portland, Oregon now. And I have a private practice here where I see patients with a lot of different things, but I do focus a lot on digestive health and it's links to many other conditions like autoimmune issues, skin issues, brain issues, just because we know how important the digestive tract is. And I really try to look at all the research behind many different areas of dysbiosis and the microbiome and our friend, Dr. Dr Siebecker is in town. So, many people know about SIBO and treat SIBO here, but there's been less information on the microbiome and the yeast balance in our GI tract and how that can affect overall health.

Ami Kapadia:

So, I had all of this information from about 20 years at looking at the microbiome and mycobiome. And I've tried to integrate all of that into my work specifically again, because a lot of the patients I see, have already been treated for SIBO and I usually find that there's some combination of SIBO, CIFO and protozoa along with food sensitivities and that nervous system component to patients with GI disorders. And I know you said Nirala, we probably overlap a lot in what we see and that's how I talk to patients and the areas I focus on when we're trying to get to the bottom of these chronic GI issues.

Nirala Jacobi:

Yeah, definitely. I think that just listening to previous podcasts you've done and some of the presentations that you've done, I think that there often is a lot of overlap with what we do and how we approach things. But yeah, I find that really fascinating how you've come to be such a yeast expert now. My experience with yeast goes back over 20 years when I practiced in Montana and I had Dr. Margaret Beeson on the show as well, who has taught me a lot of the fundamentals of Candida. And back then, we had The Yeast Connection by William Crook and Orion Truss, The Missing Diagnosis. So, that was over 50 years ago that these books came out and still to this day, there is such a hesitancy from the conventional medical system to really accept candida overgrowth and fungal overgrowth in general as a legitimate diagnosis. What are your thoughts on that? Because I still am sort of flabbergasted that this has not been really addressed in mainstream medicine.

Ami Kapadia:

Right. I think it probably has to do with the lack of a definitive non-invasive test for the problem. And so a lot of practitioners that have trained in more traditional forms of medicine, like I read that Chinese medicine, probably some of the doctors you trained with Nirala, they were aware of these imbalances in the GI tract. And when we use natural medicines and herbs, we don't have to know exactly what's out of balance. We have things that we know have worked to help rebalance the whole system. And so, it wasn't as important to have a specific diagnosis, but in Western medicine, it's often we're trying to find that diagnosis because there's often a prescription that we're looking to use and there are some lab tests that we'll talk about that I find very helpful. But before Dr. Rao did his few publications in the last five, six years, looking at duodenal aspirates and CIFO and clinical correlates, there really wasn't any published data on "acceptable scientific research" showing that this is a problem.

Ami Kapadia:

It was more based on the experience of those practitioners you talked about that wrote those books that, Orion Truss, I believe was an allergist. And so, he figured it out through his allergy practice, treating these patients with immunotherapy and which is like allergy shots and things like that would be helpful along with dietary interventions. But I think the lack of a consistently accurate non-invasive test is probably part of the reason there's been hesitation, but I have found the last few years since Dr. Rao's publications, now that we have some research, I think it's probably going to become more acceptable as far as treating it, as far as GI doctor is being open to even doing trials of anti-fungal therapy and that type of thing.

Nirala Jacobi:

Yeah. I would definitely want to discuss the diagnosis aspect of it more, but just for our listeners who are a little lost right now, we're talking about fungal overgrowth that's very common in digestive disorders. And fungus is part of the normal microbiome. It is not "pathogen" per se, if it's just a normal amount, if we're talking about Candida species and the aim of treatment really is to reduce it to a level where it's not causing a problem, where the immune system can really recognize it and keep it in check. Would you agree with that in general?

Ami Kapadia:

I definitely agree with that. And that's how I explain it to patients. Like you said, it's not a pathogen, it's a normal commensal organism. It's just, when patients get at exposure to antibiotics, stress, excessive sugars in the diet, the balance can shift unfavorably and these organisms can grow more than we would like them to, and cause potential issues with GI health and systemic symptoms.

Nirala Jacobi:

Right. So let's talk about those symptoms both from a digestive perspective. And we've talked about this before that those symptoms very often mimic SIBO symptoms. So, we see a lot of IBS type symptoms in terms of bloating, constipation, or diarrhea, but I think more constipation in my experience. Let's talk about systemic symptoms in terms of what you tend to see.

Ami Kapadia:

Right. So, in addition to the IBS type symptoms, systemically, a lot of people have fatigue. A lot of people have brain fog, and that can change dramatically when we start to treat it. And part of that might be from the metabolites that yeast produces and acetaldehyde and other toxins that can affect cognitive function. And the other alcohols that can be produced as part of their metabolism. So, those are probably the two main ones, but I have had patients where they have joint pains that mimic rheumatoid arthritis that improve with treatment of this, other autoimmune conditions involving pain, joint issues, muscle pain, that type of thing can also improve. So, it's always hard to say when someone comes in, which of their symptoms might be related, but we follow that as we treat them. And we're sometimes surprised at the symptoms that might shift.

Ami Kapadia:

I've had patients with Dr. Vincent that will talk about, who's the founder of low dose immunotherapy, he often says endometriosis and interstitial cystitis are often related to yeast microbiome imbalance just because again of the effect of the GI microbiome on other organ systems. So, those are a few of the systemic symptoms we see with it.

Nirala Jacobi:

I'd also add to that histamine issues or intolerances, skin issues, migraines, or headaches, I often see. So, it's a very diverse set of symptoms and joint pain I definitely see a lot and of course, brain fog, but this kind of weird, wondering joint pain and very sharp and then next day it's gone, very interesting type of symptom. But let's move into the diagnosis of it because this is also a very diverse, lot of people have different favorites. I, for one, don't feel the stool tests are very accurate, but I use more the organic acid tests. What are your favorite approaches to diagnosing fungal overgrowth?

Ami Kapadia:

Right. So, as you know already Nirala, gold standard is a duodenal aspirate, but that's not readily available and that's an invasive test. So, we don't necessarily want to do an endoscopy on patients just to see if this is an issue. So, as far as the non-invasive tests go, I always tell patients, we don't have just one test that's going to tell us a yes or a no, but we can get clues from a couple different tests. So, what I always start with is candida antibodies and immune complex, which are standard in the US. These standard tests that are covered by Quest or LabCorp. And it looks at IgA, IgM and IgG antibodies to candida, and then something called candida immune complex, which is an antigen antibody compliment molecule that can form when there's an overgrowth in the GI tract.

Ami Kapadia:

So, as far as research goes, there was one study showing elevation of the IgG antibodies in particular correlated with patients who responded to antifungal treatment. For the IgA and IgM, we know that those can reflect a mucosal issue with that organism or "infection", but I also find them helpful in just determining if there might be an overgrowth. The immune complex sometimes is elevated even when the antibodies aren't. So, any of those being elevated gives me a clue. The way I describe it to patients is that their body might be having an issue with immune tolerance and or overgrowth with candida. And it would be worth exploring that as part of their treatment. So, I always start there. Other tests that I use, I agree with you, I don't find stool testing helpful for a couple different reasons, because we know everyone has candida in the GI tract. So, we don't have any known definitions of what concentration would tip us off that there's actually an overgrowth versus normal commensal organisms.

Ami Kapadia:

And, there's actually a couple other caveats where I learned from Dr. Vincent that actually, if someone does not have candida show up on a stool culture, it could be a tip off that they have a problem with that organism because their body's fighting so hard to eliminate it, it's not growing on a culture even though we know that most of us should have it as a commensal organisms. So, we sometimes think if it doesn't show up on a culture, it actually may indicate that there's a problem, as opposed to the opposite conclusion where it's showing in normal or excessive amounts. So, I agree with you there. I think organic acid testing is helpful.

Ami Kapadia:

I have an insurance space practice in, in Portland. So, I tend to start with those tests, but organic acid testing we do sometimes use, and I do find it correlates with the patients where I think they have a fungal overgrowth with the caveat that most people have an elevation of the arabinose marker, it seems. And so, I still think that could be helpful. I don't know if that means just that so many people are affected by this problem, or if the reference ranges are maybe shifted a little bit. But, I do find that one elevated a lot when we do run it. And I do find it helpful as another clue that the patient might have an issue with yeast. And if we do a organic acid test, if oxalates show up that sometimes can be from yeast as well. So, that could be another clue that they have a problem with this organism in the GI tract.

Nirala Jacobi:

Oh gosh. There's so many things you said there that I want to comment on. The one, it's interesting, this thought that if candida doesn't show up in a stool test, that may be a problem. I have a really hard time with that one because I have plenty of people who, it's actually the norm, that it doesn't show up. And sometimes when we're monitoring it and I use a different type of stool test perhaps, but I use almost on every patient, some microbiome assessment, and even in healthy people, we rarely, rarely ever see it and people that are very immunocompromised, I will see these organisms. And I had a conversation about this very test with Dr. Rahbar, who is a gastroenterologist in LA, who does a lot of looking at yeast and intestinal methanogen overgrowth combinations. He says, anytime, even plus one candida in a stool would indicate for him more of an immunocompromised individual.

Nirala Jacobi:

So, it's interesting that we have totally complete opposite assessments of stool tests. But suffice it to say, it's just not a really a great test to rely on whether or not a person does or does not have yeast in my experience also. The other thing I wanted to say, because I do a lot of organic acid testing and maybe it's selection bias, I do find the arabinose elevated in many, but those are the people that I suspect have Candida. And one of the things I really like about that test is that I find it very accurate in monitoring progress and using it more as treatment progress. So, seeing if they're still have it after months of yeast treatments, I find that really useful. So, interesting conversation, but I don't do a lot of the blood tests that you talk about. So, I'll definitely look more into that. It's less readily available where I am, but that's a great tip to investigate a bit more.

Ami Kapadia:

Right. Yeah. And with the stool testing, I should clarify. So, the GI test in the US, lot of them do a microscopic evaluation and yeast may show up there, but then not culture out. So, the clinical pearls I had learned from Dr. Vincent, and one of the other founders of functional medicine was that sometimes if you see it on micro, but it doesn't culture out, that was kind of the situation they were talking about. But I agree Nirala, I can't say found consistent findings with that and learning from Dr. Rahbar from your interview with him, it makes sense and the people that are coming to see us probably do have these imbalances. Like I find protozoa on 90% of my patients, that's probably a selection bias. So, I think that's important to note too, that we're not seeing the average person who's not having significant systemic and GI symptoms.

Nirala Jacobi:

Let's dive right into the connection that you discuss the Candida protozoan connection. Because, I talked to Dr. Jason Hawrelak, who we had a whole podcast on how many protozoans are actually totally normal commensal don't cause a problem. And every now and then, I do see people have a big issue, but I'm fascinated with your take on this now, fungal protozoan connection. Can you elaborate on that a little more?

Ami Kapadia:

Right. So, I had read a publication that Dr. Crinnion, one of the founders of environmental medicine in the US, he's since passed away, but wonderful teacher. And he had written this document up many years ago that I was looking over as one of his anti-yeast protocols. And it mentioned, I remember to rule out Giardia and protozoa if the symptoms just kept coming back. And at the time I wasn't doing a lot of testing for that, but now I do. And I find a lot of the patients that have these symptoms that we think are only SIBO or maybe only fungal related, often there's protozoa too if their symptoms keep coming back. And part of that, all of these organisms create the same symptoms. So, the patient tends to have trouble digesting carbohydrates.

Ami Kapadia:

And I think all these organisms probably ferment carbohydrates to some extent. And so, the symptoms just mimic again, CIFO and SIBO pretty much the same with protozoa often with long term protozoa, they'll have constipation as opposed to diarrhea from a more recent exposure. They'll often have bloating, maybe some reflux, the typical symptoms we see with IBS. And so, now that I test more for that, it's probably the most common combination I see. My selection bias is that most of the Portland, Oregon doctors have treated the patient for SIBO. So, when I see them, they have some combination of protozoa and yeast left and bacteria not so much at that point, but I think because it's been at least partially addressed. So, I find it very frequent to have some combination of cryptosporidium, Giardia, Blastocystis hominis as part of what's causing their digestive symptoms.

Ami Kapadia:

When I did research on protozoa, it was very interesting that it was up to 50% of patients with Giardia were asymptomatic. And so, we go back to, is it the bug or the terrain? And I would love if we could just fix enough other things where we didn't have to use pharmaceuticals regularly for some of these things, but for protozoa, I found some patients have dramatic results when we use anti-protozoa medications. Herbals work grade and they're my go-to for most things outside of protozoa, but it's hard to predict who's going to have that response, but I've had patients that have pretty significant changes when we treat those couple organisms that I just mentioned with the crypto, Giardia and Blastocystis. Sometimes entamoeba histolytica and other ones are in there too.

Ami Kapadia:

So, I do continue to treat it. I'm always looking for ways, always modifying, can we work on the [inaudible 00:21:52] more? So, we don't have to be as aggressive in eradication because ideally, like we do with yeast, if we could coexist and reestablish that immune tolerance, that would be great. I can't say I've found a way to do that in my very symptomatic patients with protozoa without trying to eradicate the organism. And a key part of that treatment is to then have them filter their water depending on, we have them check their city and if it's being filtered or not in that type of thing. So, that's important. So, we prevent re-exposure to these organisms until we get their GI tract in better shape.

Nirala Jacobi:

Maybe it's because I live in such a Blastocystis hominis endemic area, I myself have it. I say it all the time. It's just par for the course when you live in the Northern rivers up here to have Blastocystis hominis. So, we don't tend to really focus on that so much anymore, unless somebody is super symptomatic, as you say. So, that's, that's a good thing. And, do you mostly use Alinia or nitazoxanide for your preferred treatment of protozoan?

Ami Kapadia:

Yeah. So for Giardia, Alinia has very good efficacy, probably around 80%. Tinidazole also works really well for Giardia. For cryptosporidium, we primarily use Alinia and then for Blastocystis hominis, Alinia works well too. And there's a couple publications, one with a very aggressive protocol. Dr. [inaudible 00:23:18] had published where if it's just a resistant case, it did show very high improvement in IBS symptoms. But it's an aggressive protocol for two weeks. So, I tend to do the less aggressive ones at this point were we do a couple days of Alinia and we may repeat that two weeks later and that works pretty well. I would prefer again, not to treat patients with Blastocystis hominis, but I've had patients with resistant pruritus ani, resistant IBS where we've done all the other things. So, I think collectively treating it. But I agree, I think it's probably pretty ubiquitous and I would prefer not to have eradication as the goal in most people, if we don't have to.

Nirala Jacobi:

I think this is a really important point also for listeners is that, many times when we see patients that are very complicated or have ongoing symptoms, we tend to think more holistically. Like as you say about the terrain, rather than just this is the one thing we're going to go after, because a lot of people just fixate on this one bug or this one pathogen. And very often I find that is, not going to be as successful as really a much more holistic approach of, yeah, somebody may have blasto that may be causing their symptoms and that's another person may be totally asymptomatic. So, it's really important to remember that it's not ever just about this one thing. It's rarely just about this one thing. Right? Maybe it's because we see very complicated patients and we've learned to broaden our horizons with a variety of treatments rather than just going after one bug. Anyways, I find that, I don't know if you find the same thing.

Ami Kapadia:

I do. I remember several years ago I had a patient, she was an athlete, she was super healthy. And then she had acute digestive symptoms that started a year before and she had Giardia and a few things and we just treated her with the medication and I never saw her again. She came back once and said she was fine. So, it's almost like this. It's just unfortunate thing where if the patients that are more complicated, the simple interventions don't work, but for someone who was previously quite healthy and just maybe had a recent change, it can be the case.

Nirala Jacobi:

Yeah. We don't see those patients anymore or rarely do we see them, but anyways, I should speak only for myself. It's been a little bit more involved with some people. Now let's talk about, I want to dive into a couple of things. The one thing that I didn't really talk with other yeast specialists on this podcast yet, is this gluten connection. Can you talk about this issue of people developing non-celiac gluten sensitivity when they have a big yeast overgrowth and the mechanism behind that?

Ami Kapadia:

Right. So, there's a protein in the yeast cell wall called hyphal wall protein 1 that is similar in structure to one of the gliadin proteins. And so, there's a theory that's been published in a couple different studies that there may be this potential reason for why more people have a gluten gliadin sensitivity related to a molecular mimicry sort of phenomenon from their body making antibodies to yeast and that one hyphal wall protein and that antibody can then cross-react with gliadin and cause a gluten gliadin sensitivity. I don't know if that can be reversed once we treat the patient, I haven't done. We typically do quite a bit of gluten sensitivity testing initially to figure out if it's a problem or not. But I can't say I've retested patients several years later.

Ami Kapadia:

Usually if they're sensitive, they say, "I'll just stay off." Just because they've got so many other things going on, but I think theoretically, if you got the yeast candida problem under control, it could reverse the gluten sensitivity. And I know Dr. Shoemaker, who's one of the doctors who teaches a lot of about mold, he had talked about at some point, gluten sensitivity, that reversed when patients no longer had sort of a fungal issue per se.

Nirala Jacobi:

And yeah, you brought up a really important point about mold toxicity and mold exposure. And at what point, let's say you are treating somebody for yeast and they are not improving. At what point, do you consider testing for potential mold exposure? And do you wait then to remediate the mold before you resume yeast treatment or initiate yeast treatment?

Ami Kapadia:

Right. So, I ask all of my patients in the initial history. I asked them several questions about exposure to water damage buildings, just because it's so common, probably 50% or more of buildings have had water damage that hasn't been properly remediated. So, it's always on my radar cause it's super common, especially if someone's been sick for a long time and isn't responding to normal treatments, but if it's not very suspicious initially and they continue to have problems with recurrent dysbiosis and potential yeast overgrowth, the way I explain it is that, yeast and molds are in the same kingdom of fungi. And so if their bodies having this constant environmental exposure, they're going to have trouble keeping the yeast internally in check.

Ami Kapadia:

So, it's something where if we've treated for a couple cycle and they're just not making any progress, or if I have a tip off from their history that there's potential exposure, basements and crawl spaces here in the US are a common problem as far as causing water damage issues in the home, then I'll recommend we get a home evaluation and I don't find any of the tests for the person to be helpful in telling me whether they have current exposure or not. So, I really encourage them to get an environmental evaluation. And that's part of the struggle, because it's like opening up a Pandora's box and it's not always well received. But I also feel like as physicians, like I know many of your listeners are physicians, it's a difficult a problem to work with patients on because I feel it's primarily an environmental professional who we need to help us with that.

Ami Kapadia:

As doctors, we cannot accurately figure out if someone has a problem, because we're not going to their house. So, it would be like trying to treat a patient without ever examining them or talking to them, just getting a couple questions answered as their doctor. I used to do more with home testing and such and I found it led to a lot of false conclusions. So, I really encourage physicians to get to know their environmental professionals in the area. And I heavily rely on them to help me figure out if a patient's having exposure.

Nirala Jacobi:

Really good points there. It's such a tough situation when you're dealing with somebody that is mold toxic. It's just like you say, it's a Pandora's box in many ways. So, let's not focus on that. Let's just keep back [crosstalk 00:30:18]

Ami Kapadia:

I will mention, I think it's worth treating a person for whatever you can treat them with, even if they have exposure, if they can tolerate things. And because as much as we can get the load down, is helpful. And, it's also one of the times I'll recommend some limbic system retraining because often their nervous system is an overdrive. So, those are some things you can do while you're working on an environmental eval.

Nirala Jacobi:

A really good point. The more I treat gut patients, which I've done now exclusively for the last 10 years of my long naturopathic career, but the more I just think everybody needs brain retraining to some extent, especially after this COVID nightmare and stress and isolation and I think lot of people are dealing with much, much more than just some overgrowth. And, there are a lot of different mechanism that really entrenched different cases. And I find that brain retraining is wonderful. So, for your listeners, I didn't an interview with Ashok Gupta, who did the Gupta Program, which is a program on brain retraining, wonderful to get out of the fight or flight.

Nirala Jacobi:

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