Fungus occurs in the body in several ways. Some are pathogenic and others are not. Why is this?
Fungi and yeast are common inhabitants of the GI tract, birth canal, mouth, skin, and lungs. Three quarters of women will have a yeast infection during their child bearing years. This doesn’t mean there is a systemic problem. Fungal overgrowth has been over-diagnosed in alternative care and under-diagnosed in conventional medicine. Part of the problem is that it doesn’t always show up on testing.
Antibiotics, Sugar & Stress
The normal balance between healthy bugs in the gut (lactobacillus, bifidobacter, e. coli) and other potentially dangerous bugs, including yeasts, bacteria, and parasites is disrupted by multiple rounds of antibiotics. The bad bugs are usually present in small numbers in the digestive system except when the good bugs are killed by antibiotics or not fed with adequate prebiotics and fibres. A contributing factor is refined sugar and processed foods fuel the overgrowth. The gut is damaged by too much stress which can’t be underestimated.
Iron Deficiency & Fatigue
Low iron levels can lead to chronic insomnia, depression, anxiety and restless legs. Treating fungal overgrowth has helped patients who have been unresponsive to iron therapy. B12 and iron are both absorbed at the terminal end of the small bowel. A compromised ileocecal valve allows the migration of bacteria and fungus from the colon upwards. This is why it is not uncommon to see gut dysbiosis resulting in low iron and B12. Keep in mind that low B12 can have irreversible effects including neurological disorders.
Back to Why?
Some people can have fungal overgrowth with no symptoms at all, whereas it severely impacts another persons health causing chronic illness. Symptoms include allergies, inflammation, joint problems, mood and brain disorders, digestive symptoms, and more.
One reason some are affected while others are not is due to the shape of the organism. A sphere-shaped candida isn’t pathogenic and the immune system ignores it. The other form of candida is a hyphae (shaped like a spear) and it can puncture the walls of cells. Zinc and iron are then stolen from these cells. The host’s immune response also goes into attack mode and autoimmune diseases begin to pop up.
Estrogens & Metabolic Issues
The majority of cases are not linked to immunocompromised people as is taught in conventional medicine. Most are people who underwent surgery or had long-term antibiotic use. A disrupted gut is implicated in both estrogen metabolism (the estrobiome) and metabolic diseases like diabetes.
Diabetes and high estrogen levels can enhance yeast colonization. Elevated estrogen triggers a decrease in the ability for the immune system to recognize and fight an invading pathogen.
Candida overgrowth becomes pathogenic under these circumstances:
- Immune-suppressing drugs
- HIV Infections
- Abdominal Surgeries
- Medical implants such as pacemakers, joint replacements, catheters, etc.
- Oral contraceptives and Estrogen HRT
- Chronic fatigue
- Loss of energy
- General malaise
- Decreased libido
- Bloating and gas
- Intestinal cramps
- Rectal itching
- Altered bowel function such as diarrhea (iv) or constipation
- Yeast infections
- Frequent bladder infections
- Interstitial cystitis (irritable bladder)
- Menstrual irregularities like pain, bleeding, etc.
- Premenstrual syndrome
- Thyroid dysfunction
Nervous System Complaints
- Inability to concentrate
Immune System Complaints
- Chemical sensitivities
- Low immune function
- Chronic yeast infections
- Chronic antibiotic use for infections or acne
- Oral birth control pill usage
- Oral steroid hormone usage
- Sensitivity to foods, chemicals, or other allergens
- Irritable bowel syndrome
- Craving for foods rich in carbohydrates or yeast
- Toenail fungus
Within 24 hours of the fungal invastion, the epithelial cells start to develop a biofilm. Biofilms create a protective barrier that are resistant to both anti-fungal therapy and the immune system. They are a safe haven for bacteria like E. Coli, Klebsiella pneumonia, Enterococcus faecalis, bacteroides fragilis, and Clostridium perfringens. Staphylococcus can also be problematic.
Testing & Treatment
Garlic, tannins and polyphenals from black tea, oregano oil, saccharomyces boulardii,along with n-actyl cysteine or another biofilm disruptor are all effective. Undecylenate is another potent antifungal. Isatis tinctoria is a Chinese herb that can be a useful adjunct to treating intestinal imbalances. Citrus seed extract is full of phytochemicals with potent antimicrobial properties. Also, berberines which come from goldenseal and barberry are effective in metabolic disease. A pharmaceutical called nystatin is a safe option as well because it doesn’t damage the liver or disrupt the microbiome.
Botanicals need to be rotated and used in the right therapeutic dose. Also, supplementation with zinc and iron may be necessary. There are formulas I use depending on the presentation.
Testing for fungal infection has proven to be difficult. Often it won’t show up in blood or stool in any remarkable amount. A urine organic acids test can show patterns of dysbiosis and infection which seems to be more accurate when cross-referencing symptoms.
In Functional Medicine, we look for patterns. When using the urine organic acids test I often see an indication of oxidative stress along with a fungal infection. Glutathione is the body’s major antioxidant. Similarly, that cells are attacked and depleted of zinc and iron, glutathione can also be depleted. I often use the precursor to glutathione while treating the infection. Interestingly, n-acetyl cysteine has a dual function of being this precursor and disrupting the biofilm. Gosh, the science of medicine is cool! Using fewer supplements is ideal and layering treatment for the best long-term outcome is always my goal.
What’s the Difference?
Symptoms like chronic yeast infections, brain fog and sugar cravings can indicate dysbiosis or an imbalance in the gut microbiome. About 20 years ago candida albicans began receiving a lot of attention. Some said to cause a long list of ailments. We’ve learned a lot since then and continue to learn more all the time. Endoscopies are not perfect but can show fungal overgrowth occurring in the small intestine. (SIFO). In out patient settings, we test the gut using stool and breath tests.
Candida albicans is one strain of bacteria residing in the colon and is part of a healthy colon when in balance. It can get out of balance. This can happen when there is a dybiosis of insufficiency meaning a lack of other bacteria. Often it occurs after antibiotics used especially if several rounds were used.
Keep in mind that high stress, poor diet and reactions to foods also trigger an imbalance in gut flora. Similarly a parasitic infection like giardia can trigger the onset of Celiac disease and non-celiac gluten sensitivity. This is why people go traveling and say their gut was never the same afterwards.
So what causes SIFO?
If you are on a very limited diet to manage symptoms that appear to be fungal overgrowth but your labs come out looking good we have to consider SIFO. There isn’t a breath test available for SIFO and it won’t show on stool tests. Certain antibodies can be used to detect it but this is not yet widely used. An organic acids test has markers that are more telling. This is what I end up using because it has a variety of other markers that are helpful for assessing the patient’s health status in general. Knowing what triggered the symptoms is important so reinfection can be avoided. There is a strong correlation between long-term use of proton pump inhibitors and SIFO. Low stomach acid means more pathogens make it into the small intestine.
Treatment can include both pharmaceuticals and botanicals. As far as botanicals go I use monolaurin, a concentrate of coconut oil, oregon grape root, berberines, caprylic acid or allicin and biofilm disruptors like NAC or Interfase Plus. Cycling antibiotics followed antifungals is what gastroenterologist Dr. Satish Rao suggests. This is because onset of fungal infection occurs after the good bacteria is killed off whether its in the small intestine or the colon.
Can diet help?
A lower carb diet rich in nutrients is a good starting place. There is some indication in the research that ketones can feed the overgrowth so use caution with this approach. Often people will know what triggers symptoms and these need to be avoided. Following treatment a period of rebuilding is key to ensure that the colon is functioning optimally. A prokinectic like 5-HTP or bitters encourage the migrating motor complex to prevent reinfection in the small intestine. If the ileocecal valve between the two bowels is inflamed we want to address this. Bacteria collect around these valves and take up residence where they shouldn’t. So inflammation and any immune issues also need to be addressed.
Keep in mind that candida albicans is different than candidiasis, which is a serious condition occurring in immune compromised people. Candidiasis requires immediate medical intervention.
People ask me as many questions about leaky gut as candida. Candida is fairly simple. It is just one of many microorganisms that can be causing problems. Candida received enough attention in the last 20 years that people associate any gut imbalance, overgrowth or infection with it.
Now onto leaky gut. The gut barrier is made up of cells and tight junctions that, in a healthy state, regenerate rapidly. As our first line of defense against pathogens its primary job is to regulate what comes into our body and what doesn’t. When this isn’t functioning properly leaky gut is the result.
5 Causes of Leaky Gut
1. An inflammatory diet. Processed food lacks microbiota accessible carbohydrates. These feed the good bacteria. The regeneration of the gut lining requires 40% of our overall energy. Eating a nutrient dense diet and removing foods that cause reactions supports this repair cycle.
2. Gut infections. These include a wide variety of pathogenic bacteria, parasites, overgrowth or undergrowth of various strains including yeasts and fungi. It can also be bacteria that has migrated to the small intestine where it doesn’t belong. Resolving these and restoring a healthy microbiota is key.
3. Medication. Proton-pump inhibitors and antacids are major contributors to chronic leaky gut. Chronic use of NSAIDs irritate the gut lining. Multiple doses of antibiotics destroy good bacteria. These medications often mask symptoms and create more problems.
4. Stress including lifestyle factors like chronic sleep deprivation, too little or too much exercise. These all affect the tight junctions of the gut barrier. Chronic stress both the perceived and invisible stressors need to be addressed to recover fully. (1)
5. Trauma and environmental exposure. Intestinal permeability is known to develop after traumatic events including minor surgery or exposure to heavy metals and mold. A full health history and screening tools for exposure can help with treatment.
Tight Junctions and the Immune Response
When the tight junctions of the gut barrier aren’t functioning, higher levels of endotoxins, like lipopolysaccharide (LPS), accumulate. A strong immune response is mobilized results. This can go on indefinitely causing a wide range of symptoms. The connection between leaky gut and autoimmune disease is well established. An overworked and confused immune system will attack healthy cells.
Research confirms that over 90% of those with a genetic susceptibility to autoimmunity will not develop into full blown disease without a trigger. This means chronic infection, certain dietary proteins or an environmental toxin must be present for disease to progress. What this also means is we have a lot of say over whether it does or not.
The Hygiene Hypothesis
Although autoimmunity is growing rapidly in the developed world it has yet to take hold in developing countries. The hygiene hypothesis provides clues as to why this is. Cleanliness is arguably the most important factor in creating a healthier population. However it looks like we may have gone too far. Too clean of an environment leads to an immune system that does not develop properly. Lack of stimulation for a child results in problems and this is the same for a child’s immune system.
A few key nutrients
Vitamin A regulates the growth and differentiation of intestinal cells. A deficiency causes changes in non-pathogenic bacteria and the expression of the immune molecules MUC-2 and defensin.
Vitamin D plays a role in barrier function, and a deficiency is related to inflammatory bowel disease characterized by intestinal permeability. Experiments with mice show a deficiency is linked mucosal damage and compromised barrier function.
High doses of zinc can improve mucosal repair especially where diarrhea is predominant. When 110 milligrams is taken three times a day for eight weeks results were seen. Lower doses aren’t effective. This amount should only be taken in a short term therapeutic dose as copper deficiency can result otherwise.
Short chain fatty acids that are non-digestible by colonic bacteria are also indicated. Butyrate is an example and regulates barrier function. When butyrate is low the tight junction are impaired and intestinal permeability results. Use the sodium potassium form if supplementing. In the long term increase consumption of fermentable fibres and prebiotics.
What lab tests are available? Are they necessary?
In clinical practice labs for intestinal permeability or leaky gut are not the first step. Focusing on the foundations of managing stress and resolving gut issues come first. Often these steps are enough as the gut lining repairs itself once the pathogenic factors are removed. The most difficult part can be finding the optimum diet and sticking to it.
My son had an autoimmune response last winter. He developed severe eczema and a chronic cough. It wasn’t until I addressed a reaction to egg white that his skin recovered. Loose stools resolved once I removed gluten. We did do a blood test to confirm that he was reacting to these but started with an elimination diet first.
Each social situation and every activity he attends requires creativity. He knows egg whites make him itchy. However it can be difficult to limit ones diet whether you are 4 or 40. Being strict actually makes it easier. The slippery slope of ‘maybe’ becomes confusing.
Lab tests for intestinal permeability:
1. Lactulose mannitol uses long chain sugars called oligosaccharides.
2. Antigenic permeability screen: tests for antibodies to antigens of LPS and antibodies to endogenous to proteins that regulate tight junction permeability. Proteins like occludin, zonulin and actomyosin.
3. D-lactate is product of bacterial metabolism that is produced in the gut. Its part of an organic acids test. A high result can indicate leaky gut.
4 Butyrate levels that are low can equal leaky gut.
5. Zonulin is also being explored more as a way to test. Its found in gluten and contributes to leaky gut.
The first test measures sugars in urine. The ratio of the two markers show if any is getting through the gut barrier. However motility, NSAIDS, surface area, gastric emptying can all affect the result. Only very large molecules (over 500 daltons) cause inflammation and create an immune response. These sugars are smaller. So this lab shouldn’t be used without other testing which is also true of the third test. Organic acids need to be cross referenced with other markers.
The best test is likely the antigenic screen. Blood samples of LPS (including IgA, IgM, IgA antibodies) prove a positive indicator for gut permeability. Lipopolysccharide is produced by very small bacteria (gram negative in fact). In general these are also the bacteria that create dysbiosis and are pathogenic. Actomyosin is part of this test which indicates epithelial cell damage and permeability. Occludin and zonulin are two proteins which regulate the tight junctions so these markers show if these have been damaged. So this test is the most extensive and accurate.
Recovering from leaky gut can be as simple as beginning an elimination diet, focusing on nutrients dense food and lowering stress. I always start with these in my clinical practice as they are the lowest cost and longest lasting interventions.