Candida—Hidden Epidemic or Fad Diagnosis?

Note: The Prescript-Assist supplements discussed in this article are no longer available. Please click here to learn more about a substitute, the Daily Synbiotic from Seed.

In this episode we discuss:

• Overdiagnosis for non-specific symptoms
• Small intestinal fungal overgrowth
• Testing for fungal overgrowth
• Treating fungal overgrowth

Chris Kresser: Hey, everybody. Welcome to another episode of Revolution Health Radio. I’m Chris Kresser, and this week we have a question from Jacquel. I think I’m pronouncing that right, so let’s give it a listen.

Jacquel: Hi, Chris. I’m an 80-year-old male in Guyana suffering from what I believe to be as a candida. I’ve been feeling symptoms for at least a year and a half now, but I’ve noticed some slight symptoms which could be related to candida. My symptoms are an infection in the groin, jock itch, severe fatigue, severe lack of concentration, severe sweets craving. I also noticed one of those in the neck on the right side as well as over the groin, in general, in the lymph nodes. Since I already said I have jock itch in the groin. Well, where I live, my family in this country near South America, Guyana, the diet is mostly, say, Creole, but my family makes a lot of sugary foods, starchy foods, and I had a bad diet during high school. And I think it’s going to contribute to what I’m feeling now, but it’s been overbearing, like I have some days I can barely walk or even function. So I don’t know what to do. And more symptoms I forgot to mention, constipation, upon just smelling gas I’m not sure if it’s candida or something else going on. I’m not sure and the doctors in my country, they’re not really that good. I went to the doctor for a fungal infection and he gave me antibiotics. I took antibiotics, I vomited, so I stopped taking them. So I don’t really know, and I need your insight. I really appreciate it.

Chris: Okay. Sorry if you weren’t able to make out some of Jacquel’s question. The audio wasn’t great, probably because he’s dialing in from South America, but here’s the gist. He’s suffering from a number of symptoms which he suspects may be related to candida and is wondering what to do about it.

This turns out to be a controversial and somewhat complicated question. Let’s start with the basics. Candida is a genus of yeast that is the most common cause of fungal infections worldwide. A lot of species have candida, like Candida albicans, which is probably the best known that are found in the gut flora and systemic infections of the bloodstream and major organs, which is referred to as candidemia, or invasive candidiasis, particularly in immunocompromised patients, in fact over 90,000 people a year in the U.S. There’s nothing controversial about that, that’s just a fact. Candidiasis is well established and recognized in conventional medicine. There’s really no issue there. However, the idea that that candida can cause a problem in immune-competent people, people without severe immune dysregulation like HIV and AIDS and other things that impact the immune system in a similar way, it is where the controversy comes in.

Overdiagnosis for Non-Specific Symptoms

On the one hand, you have the conventional medical establishment’s perspective, which is that we all have yeast in the digestive tract, which is true, and that candida only really becomes a problem in people with severe immune dysfunction, as I just mentioned. On the other hand, you’ve got a subset of the alternative medicine world that blames candida for everything and suggests that you don’t need anything more than a list of symptoms to diagnose candida infection or a problem, and as I’m sure many listeners will know, back in the ’90s, candida, and maybe into the aughts, candida really was kind of a fad diagnosis that was a label that was thrown on just about any collection of signs and symptoms that hadn’t yet been properly diagnosed.

A wide range of symptoms has been blamed on candida—is it a legitimate diagnosis?

But even now, although I think that trend has shifted a bit, we still have articles on popular websites like one that had a headline, “Five signs you may have a candida problem” or something like that. The article begins with the question, “Do you ever experience any of these health issues? Exhaustion, cravings for sweets, bad breath, white coat on the tongue, brain fog, hormone imbalance, joint pain, loss of sex drive, chronic sinus issues, digestive problems, gas and bloating, weak immune system, or UTI.” And then it follows that list with, “If so, these are just some of the signs that you might have candida.” Well, the problem with this, of course, is that it’s not scientific at all. These symptoms are extremely nonspecific, which means they cannot be attributed to only one problem. They could be caused by any number of problems. I can think off the top of my head of about 10 different possible diagnoses that could cause all of the symptoms that are not candida.

Candida is a normal resident of the digestive tract. We all have candida in our gut, and that’s not abnormal. That’s a fact that often eludes a lot of people in the alternative medicine world. And having candida in your gut is not necessarily a problem. It’s also true that in many cases, especially where no lab testing is used, candida is overdiagnosed, and the issue there is that it might mask another problem that needs to be addressed. For example, if a patient is convinced they have candida, they may not seek proper attention to get a diagnosis of SIBO, a parasite infection, or more seriously, something like inflammatory bowel disease, ulcerative colitis, or Crohn’s that would require a different treatment approach than a presumed candida overgrowth. In Functional Medicine, we often say, “test don’t guess,” and the reason for that is that getting the correct diagnosis is the starting place for an effective treatment.

All of that said I don’t agree with the conventional assessment that yeast is only a problem in immunocompromised individuals. Yeast is a normal resident of the GI tract, but that doesn’t mean that it can’t become overrepresented or imbalanced. The gut flora is an ecosystem, and like all ecosystems, it can get thrown out of whack. Many aspects of the modern lifestyle, like poor diet, excessive antibiotic use, birth via cesarean section, etc., reduce levels of beneficial bacteria in our gut, and that in turn creates a more hospitable environment in which yeast can proliferate. Not surprisingly, several recent studies have highlighted that candida can be a problem even in people without HIV or AIDS or another similar condition.

Small Intestinal Fungal Overgrowth

One was a recent review paper on SIFO, or small intestinal fungal overgrowth. Yes, you did hear that correctly. This is just like SIBO, but instead of overgrowth of bacteria in the small intestine, it’s an overgrowth of yeast, and for quite a long time I’ve suggested that some of our patients with SIBO who don’t respond to treatment, don’t improve with treatment, either their symptoms don’t really improve, or their breath test results don’t really improve, or neither improves actually may be suffering from SIFO, perhaps in addition to SIBO, or just SIFO is the main underlying problem, and SIBO is kind of a red herring. This review paper looked at two studies that showed that 26 percent in one paper and 25.3 percent in another paper, which are remarkably similar incidents of patients with unexplained GI symptoms, had SIFO. That’s pretty substantial. That’s a quarter of people with unexplained GI symptoms had SIFO in both of these studies when they tested for it. That means we may be misdiagnosing or missing up to a quarter of patients with gut problems with something else like SIBO or some other gut problem, when the problem is really yeast overgrowth in the small intestine.

Another study found that a yeast that is commonly located in the GI tract worsened the symptoms of inflammatory bowel disease in mice, and then a third study out of UCSD found that intestinal fungi or yeast can worsen alcoholic liver disease. When you put all this together, it’s still pretty preliminary, but these studies do indicate that even normal intestinal yeast can become problematic in certain situations.

Testing for Fungal Overgrowth

The challenge is that because the conventional paradigm has denied this for so long, we have very few studies to guide us, and the testing is extremely limited. We can use stool testing from specialty labs like Doctor’s Data or BioHealth to diagnose fungal overgrowth in stool. There are also urine organic acid markers like d-arabinitol which can detect fungal overgrowth. D-arabinitol is actually used in some settings in hospitals and other settings as a marker for invasive candidiasis, so there’s peer-reviewed research behind that.

In some cases, testing antibodies against candida in the blood can be helpful, but the problem there is that those antibodies don’t tell you whether there is a current problem or whether it’s just picking up on a past problem. The stool testing and the urine testing, I think, can be helpful, but they have issues as well. There’s no perfect test that we have for diagnosing fungal overgrowth. It’s even worse with SIFO because although we have lactulose and glucose breath testing available to us for testing for SIBO, there are no tests for SIFO outside of a research setting that I’m aware of yet. Even if you came to see me or another Functional Medicine clinician and you wanted to get tested for SIFO, there’s nothing that we could do about it because we don’t have any tests available.

Treating Fungal Overgrowth

The question then becomes, “What do you do if you do have fungal overgrowth on one of these stool tests?”

Diet. Well, the diet that I found to be most helpful in practice is low-carb Paleo or even keto-type of diet. There is some research suggesting that yeast can thrive on ketones, which I’ve talked about before, but empirically I question that because what I see in practice is people responding very well to these lower carb and even ketogenic diets when they have a fungal overgrowth problem.

Antifungal botanicals. Then there are a lot of herbs and nutrients that are antifungal, like:

• undecylenic acid, which is an organic type of fatty acid
• lauric acid, which is found in coconut products, and also monolaurin in products like Lauricidin
• caprylic acid
• uva ursi
• cat’s claw
• pau d’arco
• spice oils like thyme and oregano, which are extremely potent and should really be used with caution and preferably under the supervision of a practitioner, in my opinion
• coptis
• Oregon grape
• Chinese skullcap
• berberine

These are all time-tested botanical remedies that are antifungals. Some of them are also antibacterial and antiparasitic, so they can be useful in situations like that. But this despite the fact that these botanicals don’t have the same kind of impact on the gut flora as prescription antibiotics or antifungals, and far, far fewer side effects and risks, they still can be quite potent, and especially when used over the long term, I think they can actually deplete the gut flora, so best to work with a practitioner if possible and definitely be judicious with your use of them.

Biofilm disruptors. You also might want to consider biofilm disruptors like:

• N-acetylcysteine
• nattokinase
• products like Biofilm Defense

Yeast can form biofilm, which is an extracellular matrix that they can live in that makes it harder for the immune system and for any external antimicrobials that you might take to be effective, so disrupting the biofilm can be helpful.

Probiotics. There are probiotics:

• soil-based organisms like Prescript-Assist
• transient commensals like MegaSporeBiotic
• beneficial yeast Saccharomyces boulardii
• prebiotics to support the growth of beneficial bacteria

If you think about it, you might question the use of prebiotics because maybe that provides substrate fiber that the yeast can thrive on, but in practice and actually in the research, prebiotics mostly have been shown to be beneficial in these kinds of situations. When you think about the diet that is effective, like a lower-carb Paleo or keto-type of diet, that’s a diet that can be very high in fiber because you’re eating a lot of non-starchy vegetables. I don’t think it’s fiber per se that is problematic. I think it’s the sugars that make the biggest difference, and the prebiotics of course also support the growth of beneficial bacteria in your gut and any probiotics that you might be taking. I think for those reasons they’re going to be beneficial for most people.

Prescription antifungals. Sometimes stronger remedies are required all the way up to prescription antifungals, but I think that these are used too liberally and freely, so you need to watch out. Some of the antifungals like Sporanox have pretty severe side effects all the way up to death and liver damage. You have to have your liver function monitored while you’re taking them. Others like nystatin are typically much better tolerated because nystatin is sort of like the rifaximin of antifungals in that it’s not absorbed systemically and thus it’s less likely to cause problems, but I think caution is warranted there as well.

This is a big subject, and I just wanted to give you an overview of the considerations, and I hope this is helpful to you, Jacquel, and any others that might be dealing with this stuff. I realize not everyone has access to the kind of testing that can help clarify this, so a prudent approach might be to do the [low-carb Paleo] diet, choose some of the fatty acids like undecylenic acid (Thorne SF722 is a good product there) or lauric acid (like monolaurin or Lauricidin), maybe one or two of the herbs, a biofilm disruptor, and see how that goes. It’s always better to do it under the supervision of a practitioner, but I realize that’s not always possible.

Again, I hope this is helpful, and please keep sending in your questions at chriskresser.com/podcastquestion, and I look forward to talking to you next time. Thanks, everybody.