EP.355/ My experience with mBiota elemental diet for sibo treatment
Some of you may know that I recently completed the elemental diet for SIBO treatment, and today, I wanted to share my experience with the particular formula I used.
So, before we begin, I need to give you a bit of context and some explanations, and disclaimers!
First up is - what is the elemental diet? The elemental diet is a liquid formula that contains all of our macro and micronutrients in a predigested state, meaning these nutrients absorb incredibly quickly, in fact, in the first two to four feet of the small intestine. This allows the gut to rest and heal, which is why the elemental diet is used in severe cases of gastrointestinal conditions like coeliac disease and Crohn’s. However, because it is digested so quickly, it’s also a treatment for small intestine bacterial overgrowth, because when we eat, SIBO bacteria eat by fermenting our food, however the elemental diet starves them of food because it’s absorbed so rapidly and there’s no residual fibres, etc. for them to eat, as it’s all predigested. So, the elemental diet is a studied and tested treatment for SIBO.
In fact, the elemental diet has a high success rate for SIBO clearance. A two week course of the elemental diet is 80-85% effective at clearing SIBO, in contrast to antibiotics and antimicrobials, which have an average success rate of 70-73% and take much longer and tend to require multiple rounds. Additionally, the elemental diet on average reduces SIBO levels by 70ppm, whereas antibiotics and antimicrobials reduce by about 30ppm on average.
Secondly, I have used and worked with the elemental diet for a number of years. As you probably know, because of the prevalence of SIBO amongst endo patients, and the continued emerging research on the connection between the two, I specialised in SIBO pretty much immediately after I specialised in endometriosis, so I support my clients with their SIBO treatments, including the elemental diet if that’s the right choice for them.
I have also done the elemental diet myself, twice. One of the reasons why I trained in SIBO is because I suspected I had it, once I got the confirmed test, I took myself through treatment. I deliberately took the longer route of multiple rounds of antimicrobials and antibiotics, in order to experience as many treatments as I could, so I could share my experiences of them with clients and you guys.
Now, what’s important to know about SIBO is that it’s often hard to treat. Treatment takes on average at least three rounds (if you’re not doing the elemental diet, because that can often kill all the SIBO in one go) and a minimum of three months, but can be up to a year or more in tough cases. Additionally, people respond differently to the different types of treatment - for some, antibiotics are great, for others, they don’t work at all, for some, antimicrobials move the needle, for others they don’t make a huge amount of difference. It often takes rotating through treatments and trying different ones, to see full effects and success.
So, this brings back to my story. The herbs were taking a long time to shift my SIBO, they were doing it, but very slowly, and I was almost a year into treatment and had rotated through all the herbs and so it was time to test antibiotics and the elemental diet, which was fine, because it was my intention, as I said, to hopefully be able to try all the treatments.
So, I did the elemental diet and it did shift my SIBO by about 30ppm, so not as much as I had hoped and I was still positive. I then did a round of antibiotics, and they helped, but I was still positive, so I went in with one more round of the elemental diet, this time at three weeks rather than two, which you can do when you have high levels or tough cases, and it cleared it, and I was negative!
If you want to listen to my experience of those, I recorded episodes of those at the time, and I’ll link to those in the show notes.
Now, after I cleared the SIBO, I felt I rapidly relapsed - which is a term we use for SIBO patients whose SIBO comes back very quickly. Now, to be clear, two thirds of SIBO-ers will be chronic, that means at some point, they will relapse and our goal is to keep them in remission for as long as possible, though it is common for those people to relapse between two months to a year post treatment. The other third are what we call the “one and done” group, we treat and they clear the SIBO, and it doesn’t come back.
So, why are there two thirds who it comes back for? That’s because SIBO is caused by various root causes, some of which can be fully solved, some of which can be partially, and some not at all. The key cause of SIBO is dysfunction of the migrating motor complex. The migrating motor complex is a wave like motion that cleans the small intestine of bacteria and food debris between meals and overnight. It can be damaged or slowed down, or it can be obstructed by a structural issue in the intestines. The number one cause of damage to the migrating motor complex (at least in SIBO cases) is food poisoning or gastroenteritis, and that damage is very difficult to completely recover from. For others, it’s the presence of a condition that slows the migrating motor complex down, such as diabetes or hypothyroidism, and whilst we can improve those conditions and improve the function of the MMC, we may not be able to fully resolve it. This means that the patients may relapse at another time, or may have to live with SIBO long-term. The good news is, there’s lots that we can do to keep SIBO at bay and well managed, so you can still live well if you are someone living with chronic SIBO.
Now, as I mentioned, I felt I had relapsed quicker than two months post-treatment, which is the average, minimum amount of time we see in remission before relapses can start to occur, so this is what we call rapid relapse. In cases of rapid relapse, there’s normally something else going on, like SIFO - small intestine fungal overgrowth, mould, or something structurally that is physically obstructing the MMC, like adhesions.
At the time, I was pretty sure I had an obstruction in my small intestine, because I could feel it whenever I took prokinetics, which are natural or pharmaceutical treatments to speed up the MMC and getting working better. I also suspected I had SIFO.
I had intended to treat the SIFO at the time, but upon reflection, my body and finances were exhausted from over a year of SIBO treatment, so I decided to focus on managing my SIBO for the time being. Since then, as my experience in SIBO has grown, I actually don’t think I rapidly relapsed then - I think I was suffering from gut dysbiosis (so an imbalance of the microbiome) from a year’s worth of treatment, and this was creating SIBO-like symptoms, and I just needed to work on my microbiome and digestive function to bring back balance and harmony.
As part of my approach to managing chronic SIBO, I ended up doing that anyway, and the need to treat SIBO again has been low on my priority list as the symptoms haven’t been severe or too bothersome. I no longer have chronic diarrhoea, and severe bloating only really happens when I eat trigger meals. Other than that, I am pretty much asymptomatic. However, my mast cell activation syndrome, which is a condition where our mast cells fire out too much histamine, is still very difficult to live with, and one of the causes and aggravators of it is SIBO, so I knew at some stage I would need to address it. Additionally, the toxins released from SIBO bacteria, called lipopolyscharrdies, are key drivers of endo growth, so I knew it was best for me to address the SIBO again at some stage.
The past few years however, have been dedicated to investigating and diagnosing my dysautonomia, mast cell activation syndrome and kounis syndrome, and because, just like endo, these conditions are dismissed, under diagnosed and misunderstood, I ended up going the private route, so it’s taking me literally years to slowly go through each investigation as of course, I am self employed, so going private was very difficult for me to do financially and I had to stagger the payments.
Towards the end of these investigations, I started developing a specific abdominal pain when eating, which escalated into obstruction of food going through my intestines and resulted in me having a couple of vomiting episodes. This pain was directly behind my scars and stretched between them, and you can actually trace a line of what feels like elastic bands underneath my skin. I was and am still convinced this is an adhesion, and we know that adhesions develop in roughly 60% to 100% of abdominal surgery patients, and I’ve had two surgeries for endo. Now, I think this adhesion, and the other one which is higher up, are one of the reasons why I did at some stage, eventually relapse with SIBO (though I do not think it happened as early as I once thought it did, as I just explained). Again, I went down private investigation routes, and due to a very frustrating series of not being listened to, ended up having the wrong investigations, and now need others to confirm the presence of these adhesions on the outside of my small intestine. Once I know for sure that these are adhesions on my intestine, I can look at getting them manually manipulated as much as possible, to free up my intestines. I haven’t gone down that route sooner as I travel full time, and am never in one place long enough to go through course of visceral manipulation. I did pursue it when we were in the UK, but the only lady who was near me at the time, ended up putting me in hospital because she went in far too hard, so I ceased that treatment at the time.
Now, fast forward to today. A year or so ago, a new elemental diet formula came to the market that I was very excited about, called mBiota. Typically with clients I used Dr Ruscio’s formula or Absorb Plus, but these are both semi-elemental diets and so I was incredibly excited to see that mBiota was a full elemental, which are typically harder to get hold of and much less palatable.
For those of you who don’t know the difference, a semi elemental contains short chains of amino acids, known as peptides, as the protein source, whereas a full elemental contains protein in its simplest form, amino acids. That means a semi elemental does require a small amount of digestion, so is less restful on the gut. It also hasn’t been tested for SIBO, whereas a full elemental has, however, clinically, we see both types work well, but I loved that a full elemental was now on the market and easy to get hold of.
The other thing I was super excited about with mBiota is that they had actually clinically studied it for SIBO, and found some incredible results. Now, before I share the results, I just want to make something clear, I have shared this before in my previous episodes on SIBO, but what we used to call methane SIBO is no longer methane SIBO, it’s now Intestinal Methanogen Overgrowth. This is because SIBO is an overgrowth of bacteria in the small intestine, whereas methane producers can overgrow in both the small and large intestine, so the new name reflects that - but the treatments remain the same. So, we have three gases - hydrogen, hydrogen sulphide and methane. Hydrogen and hydrogen sulphide are classified as SIBO, and methane is classified as Intestinal Methanogen Overgrowth. However, a lot of practitioners, including myself, may still references methane as methane SIBO, just for ease, but really, we should be calling it IMO - it’s just a mouthful, especially when a client has both!
Okay, so now I’ve explained that, it should make the following results clearer:
100% of patients with SIBO only (remember, that’s hydrogen and/or hydrogen sulphide) experienced complete eradication of SIBO.
75% of patients with both SIBO and Intestinal Methanogen Overgrowth experienced complete eradication.
58% of patients with Intestinal Methanogen Overgrowth experienced complete eradication.
Overall, so the average of both SIBO and IMO, there was an 83% eradication rate.
I am sure you’re also wondering about the symptoms…
At end of study, even with a reintroduction of normal foods, there was:
40% reduction of bloating
37% reduction of distention
34% reduction of flatulence
50% reduction of constipation
82% reduction of diarrhea
68% reduction of brain fog
Stool consistency normalised in 71% of patients, and sensation of complete evacuation increased from 38%-69%.
Of course, these results adds a layer of confidence to my client’s decision to go ahead with the elemental diet, when they know that brand is backed by science.
So, I started using mBiota with clients, and knew at some stage when I had the time and budget, I wanted to try it myself, so I could speak from experience with my clients.
Then, mBiota reached out, and in all transparency, they offered me the formula to review. Now, they didn’t pay me to be clear, they offered me a sample - I think of two days - to test the palatability, etc. and I actually went back to them and said “look, it would be more helpful to me and my clients/listeners if I did the full two weeks” and reviewed my results. And amazingly, they agreed. So, I tested the formula In exchange for a review, and this is it!
So, my experience wasn’t straight forward…
Palatability
Let’s start with the easy bit, I went for the original flavour as I was worried the orange flavour would flare up my interstitial cystitis, which can be irritated by citrus. Oddly enough, when the original arrived, it still tasted a bit citrus to me - my client described it well, like a pina colada, but thankfully, it didn’t cause me any worsening bladder pain. I think it did increase frequency, but that’s very likely just down to the fact that I was now drinking extra liquid on top of water, because the elemental diet is a liquid formula.
Now, we have always been taught to blend the elemental diet with ice and pour over ice to improve palatability and the team at mBiota also recommended this approach, and with ice, I actually found it enjoyable. The times I went out and about and had to make it on the go, so didn’t have ice, I did struggle with the flavour, but this has always been my experience (and the general experience) of all elemental diet formulas - they do best when ice cold.
The instructions recommend to use 300ml of water for one satchet, which is one ‘meal’ or serving. When I last did the elemental diet, I found my blood sugar did best when I diluted one sachet further, in more water than recommended, and so I actually began straight away with this approach, and so diluted one sachet in 600ml of water, plus ice, and I found that quite enjoyable flavour wise. I did experiment so I could report back to you guys, and tried it with 300ml, and I found it a bit too sweet for my liking, but I enjoyed the texture because it was bit more creamy (I don’t mean creamy like a milkshake, more so like an ice cream soda).
Now, in my training with Dr Siebecker, she recommends we add a fat source, because most formulations don’t offer that. Typically we use MCT oil, but I was travelling in France and couldn’t find it, so I actually used flaxseed oil and I actually really enjoyed the added richness of texture and flavour it added, and I once forgot to bring the oil out with me, so tried the formula on its own, and I much preferred it with the oil, so I do recommend that. The flax also added a nice omega 3 boost. To be clear, you can use any oil source you’d like with an elemental diet, you just have to find one that best suits you, but typically MCT is the go-to.
Blood sugar
So, here’s where it got tricky.
The first time I ever did the elemental diet years ago, I had real trouble stabilising my blood sugar levels and this is very common. The reason why this is an issue is because all the macronutrients are in their simplest form, which means the carbohydrates are in the form of simple sugars, and as I have shared with you, the idea is that the elemental diet is absorbed rapidly. Now, if you follow this podcast, you’ll know that for blood sugar, we definitely do not want a rapid absorption of glucose, as it’ll create high blood sugar levels followed by a crash. Instead, we want a gradual drip effect to the blood stream, and this is made possible by consuming fibre rich, whole food sources of carbohydrates, like veggies, beans and whole grains. So the elemental diet is pretty much the opposite of that, hence why I struggled the first time.
But, by the last week, I had found a way to stabilise it and that worked really well for me, and I actually felt amazing and didn’t want to come off it! What I found worked well for me was:
To drink slowly over two hours, not one, which is the typical recommendation, so I was having more of a drip affect to the blood stream.
To dilute the formula in more water than is standardly recommended, so the glucose was less concentrated.
To add a fat source, which helps to slightly delay uptake of glucose.
To halve the serving sizes, so I was drinking half the amount suggested in one serving. Typically, one serving is 60g of carbohydrates, and so the suggestion is normally to drink that 60g of carbs across one hour, slowly, but that still caused my blood sugar to spike and crash, and so I found 30g carbohydrates, drank over two hours, was best for me. Now, that meant is that to get in enough calories and nutrients, I was pretty much sipping all day, and that’s not unusual with the elemental diet.
So, the second time I did the diet, I replicated this pattern and again, I felt great, I honestly felt amazing and again, was reluctant to come off it, though of course I had to!
So, I went into this elemental diet pretty much raring to go. However, I was shocked to find my blood sugar really, really struggled.
I was having big blood sugar spikes which was causing blurry vision and dizziness, followed by extreme crashes that were making me incredibly sleepy, literally the first afternoon I was in bed and for about three hours, I didn’t even move position because I didn’t have the energy.
I quickly identified that my old ways of managing my blood sugar on the elemental diet were going to have to be adapted. I tried various changes, more fat, more water, timing the sips, etc. but I unfortunately, the only thing I found that really worked, was splitting a sachet in half, and adding 600ml of water to one half, and drinking that half across three to four hours. I tried again and again to drink quicker, in say two hours, and I literally couldn’t do it - I was genuinely concerned about how high my blood sugar was getting, and was unwilling to keep risking it getting to such damaging levels.
Of course, the result was, I couldn’t get through many satchets, and so was not getting in enough calories or nutrients. Now, if this was a client, I would have told them to cease the protocol, in fact, I would have said this earlier into the process due to the extreme blood sugar spikes, but of course, I am a coach and I really wanted to be able to share my experience with both listeners and clients, and to find a way to make the formulation work for me and trouble shoot as much as possible.
So I took another step to improve my blood sugar and also to get in more calories and nutrients, and that’s to add a lean protein. So, this hasn’t been studied, so we have no evidenced that this approach works, but clinically, we see some people do well and still clear their SIBO on the elemental diet, with one piece of lean protein a day. And when I say lean protein, it needs to be a type that SIBO won’t feed on, so unfortunately, that’s not plant proteins, that’s meat and fish, as typically, SIBO doesn’t eat these foods. It’s important if doing this, to remove all skin and any visible fat, and to go for lean cuts, because SIBO can eat the collagen found in fat and skin, so we want to reduce those chances.
I actually saw this as a great opportunity, because I always share with my clients that eating one piece of protein a day is an option, but a risk, and so it’s helpful to be able to share my experience of it.
So, I did go ahead with eating one piece of chicken or fish a day, and I was able to increase my sachets a little bit, but not enough to get in the recommended daily allowance of calories and nutrients, and this led me to another problem.
About a week in, I started developing back pain, sort of around my waist. It almost felt like I couldn’t hold myself up, and the more I stood up, walked or was holding myself up right in a chair, the worst the pain got. It would improve with lying down or massage.
At first, I thought it was to do with having been in the car for ten hours, because as you may know, we travel full time, and so tend to cover long distances in the car when we’re driving from country to country. However, as the week went on, the pain got worse, and I started having a worsening of my POTS symptoms, which are typically for me, a racing heart, palpitations and dizziness. Once these kicked in, and the back pain worsened, I connected the dots and realised my muscles were beginning to cramp and struggle without sufficient salt and electrolytes, because of my low nutrient intake, but high water intake, which was further diluting my mineral status. This was as a result, worsening my POTS symptoms, because those of us with POTS tend to need more sodium and electrolytes to improve our symptoms. Once I made this connection, I started adding extra salt to my protein, but was careful about this because I knew I wasn’t having enough of the other electrolytes to balance my salt intake, so I couldn’t go too far with this. I also upped my sachet intake by about a half or so, to try and get more in. Thankfully, by the time I had worked this out, I was only two days away from finishing, otherwise, I honestly do not think I could have continued or that it was safe to continue, because my body was clearing showing me that my mineral status was too low. Again, there’s no way I would have encouraged a client to have continued to do this with these symptoms, but I really wanted to trouble shoot and be able to report back so that those of you who may encounter the same, can learn from my experience, know what the warning signs are, etc.
So, why did I react so badly to this formula?
I think there were a few things going on. As many of you know, I have PCOS and dysautonomia which predisposes me to blood sugar challenges and research has also shown that endo is associated with blood sugar deregulation. So, I work very hard to control my blood sugar, and before I knew what blood sugar was and how to manage it, my levels were very unstable.
Before starting the elemental diet, I had felt my blood sugar wasn’t doing to well following a dysautonomia flare, a lot of stress, travelling and food changes with being on the move on long car journeys. I was under some pressure to go ahead with the diet because I wasn’t going to be able to get the formula on the plane, because the package was extremely heavy, so I needed to complete it before our next trip, which was in a few weeks. If I didn’t have that time restriction, I would have let my blood sugar levels stabilise more, and my POTS to calm down, before proceeding with the diet.
The other thing I considered is the difference between the semi elemental and full. Even though the amount of digestion is minor, I do wonder whether that slight need to digest some of the peptides, was enough to help me stabilise my blood sugar a bit easier with the semi, in contrast to the full.
In fact, mBiota clearly state on their sales page that they do not recommend the formula to those with diabetes or active blood sugar issues, but again, as I shared, I really wanted to be able to trial the formula so that I could tailor the experience for clients.
I’ll never know for sure why my reactions were so severe this time around, but I think had I done the diet at a different time in my life when my body was more regulated, that my experience would have been different.
Energy and cognitive function
Now, despite the struggles I had, once I was in the routine of drinking half a sachet over a few hours, and I was eating a protein source, that laser sharp focus kicked in. This is a very common occurrence with the elemental diet, and it’s likely to do with a few things:
Reduced systemic inflammation because the gut and local immune system is not being irritated by SIBO or IBS issues.
A reduction in gases which can influence cognitive function - so for example, in cases with hydrogen sulphide, which you may remember from earlier podcasts, I am certain I have, the hydrogen sulphide can actually affect cognitive function because it’s a neurotoxin.
Finally, complete absorption of key nutrients, which many people with SIBO do not experience, because their digestion is so poor and their small intestine is often damaged from the SIBO, and the small intestine is where the majority of our nutrients are absorbed from.
Results
So, my results unfortunately, weren’t negative, but they are promising, despite initial appearances.
So, just before the elemental diet, I tested my levels and they were:
Methane: 11ppm
Hydrogen: 69ppm
So, to be clear, I was positive for both. A positive for methane is above 10ppm in patients without constipation, but in a patient with constipation, it’s positive at 3-9ppm. And for hydrogen, the North American Consensus classifies a positive as a rise of 20ppm from the baseline (that’s the first number on the tests), within 90 minutes. However, after seeing thousands of test results, Dr Siebecker sees above 20ppm, no rise required, within 120 minutes, as a positive, and if you want to learn more about that, I’ve linked to several articles and podcast episodes I’ve done on the topic, or you can take one of my courses, where I teach you how to diagnose and treat SIBO. I also have a SIBO class coming up, where I will help you all on your individual SIBO cases, including understanding your test results, or pursuing testing, if you haven’t done it yet.
So, after the elemental diet, my levels were:
Methane: 2ppm, so you can see I am negative for that.
Hydrogen: 96ppm
So, you can see my levels of hydrogen have gone up, but my methane is negative. So, what does this mean? This is likely what we dub as ‘pissed off methanogen syndrome’. Methane is typically harder to treat than hydrogen, and Dr Siebecker explains she sees two patterns with methane, normally one after the other; the methane numbers may rise at first, followed by them falling and hydrogen levels going up, before they start to fall. This is because the bacteria that make methane (which are actually called archaea, they are single celled organisms that are like bacteria) used hydrogen atoms to make methane gas - so some of the hydrogen that the hydrogen producers are making, is being absorbed and used by methane producers. So, when these methane producers start to die, we see the true numbers of hydrogen. This is what I have commonly observed in my clients, and I actually had two clients who had higher levels of hydrogen following their rounds of mBiota, and in both cases, we continued to treat with other options, and they are now negative (well, one is negative, the other is almost, we have about one more round). So, in these cases, what likely happened was that during the elemental diet, the methane fought hard and rose, then started to die, and as a result, the hydrogen numbers went up, and we just needed to continue to treat - and I actually spoke to Dr Siebecker herself about this, and she agreed.
So, this is very likely what has happened with me, but unfortunately, due to financial restrictions and constantly being on the move with travelling (so I cannot get hold of antimicrobials or antibiotics), continuing with treatment is not something I can do right now. I had hoped I’d maybe just be able to clear it with this one round of the elemental diet, but this wasn’t the case, so for the time being, until I am settled somewhere for a period of time, I am just going to continue to manage the SIBO well, as I have been.
Now, to be clear, ‘pissed off methanogen syndrome’ is a theory at present, that is still undergoing research, but is one my colleagues and I consistently see to be true, so at this stage, I really believe this is what occurred for me.
So, that sums up my review of mBiota and my latest SIBO escapade.
Show notes
Endometriosis, SIBO, LPS and the microbiome connection
https://pubmed.ncbi.nlm.nih.gov/9660426/
https://pubmed.ncbi.nlm.nih.gov/39959963/
https://pmc.ncbi.nlm.nih.gov/articles/PMC5902457/
https://pmc.ncbi.nlm.nih.gov/articles/PMC4519769/
https://www.mdpi.com/1424-8247/16/12/1696
https://www.fertstert.org/article/S0015-0282(14)00666-9/fulltext
Adhesions and surgery
https://www.theendobellycoach.com/podcast/endo-belly-after-endometriosis-surgery?rq=adhesions surgery
SIBO test results interpretation
https://pubmed.ncbi.nlm.nih.gov/28323273/
https://endometriosisnews.com/2020/08/06/how-to-interpret-results-sibo-breath-test/
SIBO treatment options
https://endometriosisnews.com/2020/12/17/elemental-diet-sibo-treatment/
https://endometriosisnews.com/2020/11/05/antimicrobial-herbs-treat-sibo-right-for-me/
https://endometriosisnews.com/2020/10/08/antibiotics-treat-sibo-guide/
https://endometriosisnews.com/2020/09/24/sibo-treatment-what-to-know/
Elemental diet
https://endometriosisnews.com/2020/12/17/elemental-diet-sibo-treatment/
https://pubmed.ncbi.nlm.nih.gov/14992438/
mBiota
https://mbiota.com/pages/mbiota-clinical-trial-results
https://www.cghjournal.org/article/S1542-3565(25)00241-1/fulltext
SIBO relapse, prevention and root causes
https://www.theendobellycoach.com/podcast/sibo-relapse-endometriosis?rq=adhesions surgery
https://www.siboinfo.com/prevention-of-relapse.html
How to test for SIBO
https://www.theendobellycoach.com/podcast/how-to-test-for-sibo?rq=SIBO
My past SIBO treatments
https://www.theendobellycoach.com/podcast/elemental-diet-sibo?rq=SIBO
https://www.theendobellycoach.com/podcast/endometriosis-sibo-treatment?rq=SIBO
Kuonis syndrome
https://pmc.ncbi.nlm.nih.gov/articles/PMC6791094/
https://www.mdpi.com/2077-0383/14/3/768
https://www.ejinme.com/article/S0953-6205(15)00432-X/abstract
Endo and blood sugar research
https://pmc.ncbi.nlm.nih.gov/articles/PMC10967113/
https://eurjmedres.biomedcentral.com/articles/10.1186/s40001-023-01280-7
https://pmc.ncbi.nlm.nih.gov/articles/PMC8609862/
https://www.nature.com/articles/s41598-023-35236-y
https://www.sciencedirect.com/science/article/abs/pii/S0378512223004115
https://pubmed.ncbi.nlm.nih.gov/37673102/
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