Written by Christopher Kelly
June 6, 2018
Christopher: Dr. Sunjya Schweig, Dr. Tommy Wood. I'm here live in Berkeley at Mission Heirloom, a truly fantastic place to get together with other like-minded people and consume some amazing food. It's sunny, everything we love about California is right here. We're going to be talking about chronic infections in Lyme, a very interesting topic. But before we get into that, Dr. Schweig, can we talk about how you became interested in alternative medicine because you are a traditionally trained medical doctor. Why do anything alternative?
Sunjya: Yes. So, first of all, thanks so much for making this opportunity. A beautiful day here. It's great to be spending time with you guys and really excited to talk with you and your audience about this really important topic. My background story, I had a very alternative upbringing. I grew up here in Northern California. My first name is actually my birth name, my given name. Somebody will ask, "Did you change your name, et cetera?" But, no, I had a, again, very alternative -- My parents were very focused on meditation and alternative medicine and healthy food, organic lifestyle.
I lived here in Northern California and I spent six years of my childhood also in India. And so the healing options that were available to us as kids and growing up and all the way through were a lot of complementary alternative medicine possibilities. And then in India, a lot of exposure to ayurvedic medicine, to homeopathy, to herbs, et cetera.
And so that was really -- That's who I am. That's part of the fabric of my existence and at the same time who I am is also made up of western medicine and science and biology and physiology and that was also very exciting to me. I've always really love science. And so coming up through high school, I started to get this sense that I wanted to be a doctor through that process.
I was always exploring the opportunities that were available to me and I looked at naturopathic schools. I looked at osteopathic schools. I sometimes think that I'm kind of a DO wannabe in a way because of the holistic education they get and because they have this amazing treatment modality with their hands. And I had just this opportunity when it came down to deciding which school to go to, to attend UC Irvine.
They offered me a full scholarship, so that was a great opportunity. They were also starting an integrative complementary alternative medicine center there so I got to be involved with that. So, it's some exciting possibilities there. The question wasn't so much how did I decide to be alternative but, again, that was my focus. I knew that I wanted to do that and I decided to go into the traditional scientific MD program but at the same time I was always kind of hoping and praying that my plan work out, that I would be able to exit and end up on the proper side of things, in my opinion, because I couldn't really see myself doing mainstream medicine.
Christopher: Right. So, why not go a different route then? Why not be an ayurvedic doctor instead?
Sunjya: Yes. And I have a lot of respect for all forms of complementary alternative integrative functional medicine, but I also knew that I wanted to do something bigger. I wanted to be involved with patient care but also research and teaching and writing and I felt that having a solid degree, that there wasn't any question. I felt like there was going to be some questions about the work of other. What are you doing and why are you doing that?
People might be asking like, "What does this all mean? How do you put this all together? Is it evidence-based? Is it not evidence-based, et cetera?" I felt that having the degree, having the MD would put me in the situation where I would have that extra credibility on the face of it and that more doors would be open.
Christopher: And do you feel like you've been successful in keeping a foot in both of those worlds? Is it possible to integrate them and take the best of both worlds?
Sunjya: Yeah, absolutely. That's the thing that really gets me jazzed up, is my partner, Chris Kresser and I are running this really fun, really exciting clinic. I think that functional medicine is really where that comes together now in our current society and our current medical field because functional medicine is so broad and offers the opportunity to bring in these other modalities, the other tools in our tool kit, but it's very science based and knowing the science and knowing the biochemistry and knowing the physiology and understanding all that really, as you guys know, puts you in the position where you're able to bring those pieces together.
Tommy: So, I do want to talk -- Well, now that we're talking about it, I'll ask you about the potential branding problem that we have in functional medicine. So, to start with, many functional medicine practitioners don't have a medical background so that immediately makes more mainstream scientists, doctors more wary of it. And then also just the name. Whoever chose it, obviously, didn't think about the fact that a functional disorder in medicine basically is code for the patient is making it up.
So, as soon as a medicine is functional, you automatically start to have questions about what this actually is. Is it science based? Because just the name implies some sort of disconnect there. How do you kind of see that playing out and how can we maybe change that?
Sunjya: Yeah. Functional problem, functional bowel disorder, et cetera, like you say, maybe the doctor is implying the patient is making it up or also just that we don't know why.
They're saying, "Okay. I don't really know why this is happening to you." But at the same time that's where functional medicine shines. I agree the term functional medicine is a bit clunky, is a little awkward and people don't understand it. I always bring it back to the underlying structure and function of the body and then pivot to a root cause. But it is. It requires an explanation each time.
I agree that we need to kind of think about ways to make that more household word. But I think it's happening. Cleveland Clinic for Functional Medicine, Center for Functional Medicine, they're doing some amazing work. Mark Hyman, Patrick Hanaway, Institute for functional Medicine offer the opportunity to go in there and build basically their dream clinic and they took over this huge facility and putting into place steps there that is going to turn out some really amazing research on short order here.
I think that we'll be getting more credibility and the term will become better known. I think it has stuck and I think it will become better known. But there's also this -- I was reading an article last night by Eric Topol talking about personalized medicine or precision medicine. Neither of those are really great terms. Maybe then talking about individualized medicine, something that really looks at all the different factors that are in play for you as the patient or the interested party. Yeah, there's a number of different terms being bounced around that we have to think about.
Christopher: And did you think about those when you named your clinic the California Center for Functional Medicine? Did you think about calling it something else?
Sunjya: Yes, absolutely. And Chris agreed we wanted the word functional medicine in there and bounced it around with idea with friends like naming a child. People give their, "Oh, love it," "Oh, I'm not so sure." And then after a while you stop telling people because you don't really want their opinion. Because once you name it and you say, "This is what it is," then people are going to say, "Oh, that's great. I love it."
I felt strongly that we are either at or a little past the tipping point of a functional medicine becoming mainstream and becoming the answer for chronic illness. So, I really wanted functional medicine in there. I'm pretty happy with the name, the California Center. I think it just gives us a good mix of this beautiful pace we live in plus forward thinking kind of leading the standard in terms of our nation and even the world in a lot of ways as well as functional medicine.
Tommy: Yes, just the naming aspect is just part of what, I think, I want to do and what we tried to do and it's obviously the same thing that you tried to do is make it more mainstream, make this approach more mainstream. So, creating a language or a discourse that will be more likely for more traditional doctors, physicians to understand that because for it to become mainstream we have to do that.
That's just one of the things that I always think about, is part of the way, first of all, the people who are doing it and, obviously, there are some functional medicine practitioners just like there are some doctors who just aren't very good at what they do. [0:07:47] [Indiscernible] and it's just trying to make sure that we have a way to really start that conversation because that's what we really want for that, just sort of push this out into the mainstream.
Sunjya: Yeah, it's interesting as this does grow bigger and become better known and more popular. Like you mentioned, more and more practitioners are pulling that name and adding it to their brand and there is a big stratification in terms of the quality. I think that the Institute for Functional Medicine, my friend Dan Kalish has an education program and especially Chris Kresser, my partner, with his ADAPT program and now coming out with a health coach training.
Those people who go through his program and those programs are the people we want to lean on and use as our foundation. And then it's a matter of experience over time and some idea of how to understand sort of outcomes. That's one thing I'm really passionate about. I have colleagues, I have friends, I am part of a functional medicine doctors group and it's really the case that I have no idea and they don't know what's happening inside my practice, I don't know what's happening inside their practice, I don't know what their outcomes are.
If I see a patient for Lyme disease who saw Ray Stricker in San Francisco or Richard Horowitz back east or some other really well known person, the fact is I'm really only usually going to see the people who failed out of that person's practice. You're not going to see the people who got better because they're not going to be seeking care still. And so it's really difficult to know what's happening. That's one area I'm really passionate about and that we're trying to do a really good job in our practice is generate data, use standardized questionnaires.
We're using the NIH PROMIS scale, we're using the fatigue severity scale. Patient questionnaires that gather data and so we can track them over time, see what's happening to them, and then I'm also working with another company called Clymb Health to build out a symptom tracking dashboard. Basically, I want to have a more of a real time experience of what the patient is experiencing, of what their symptom fluctuations are, which is really key. We'll get into that later with the chronic infections in terms of diagnosis and treatment.
But also, are things working? Are they not working? What parameters are affecting them? Does the weather -- does their joint pain or fatigue flare with that? Or sleep quality, tracking them with wearables like the Oura ring which I'm super passionate about, and having all that dumped into one big data sump and then we can kind of start to ask questions like you guys are doing with machine learning and artificial intelligence, et cetera.
Christopher: Are you having much luck being able to track patient symptoms using those types of apps? We found the health assessment questionnaire, you can get someone to do it once or maybe twice or maybe three times but probably not four times even if it only takes seven minutes of clicking on radio buttons. People are not going to keep doing that especially if they're feeling better. The original reason for them to do it has kind of gone away. Is that what you're finding or maybe you found a more intelligent way of tracking that data?
Sunjya: Yeah. So, we are trying to hack that problem. Our patients are very motivated. The adage from Mark Hyman is that holistic doctors see the people with the whole list of medical problems. We see people who have routinely seen ten to 15 to 20 other doctors who are have gotten better, not gotten the help they needed or still struggling, have symptom scores of 150 plus on the MSQ fatigue severity scale, scores in the six and seven range, really severe limitations.
And so they're very willing usually to do whatever we ask them to do which is such a blessing on my end, on our end, which just makes our job so much more fun. It's not about did you do it? It's about, okay, you did it now what happened? So, they do fill out a lot of data for us and right now, for the most part, they fill out those questionnaires prior to each visit. So, it's sort of time limited in that regard but we get a good return on those.
But in terms of the more longitudinal daily symptom tracking, that's something which we're definitely trying to break the code on with this Clymb Health platform because -- And we're using a lot of really trying to dive deep into the -- We've talked with a lot of colleagues of mine in general and the quantified self movement. You guys would be, I think, really helpful for us to ping some ideas off of as well. But what does it take to get that buy in and what does it take to avoid sort of reminder fatigue on your phone? People are just like, "Do that later." Later is too late.
Basically, what we're looking at is if we have a narrowing down on a certain patient to what's their core symptom list, and instead of saying, "Okay, please run through this 15 or 20 item list every day," no, we're saying, "Okay, answer these two or three questions right now and do it three to five times a day," and so we might over two or three days get a snapshot of what their symptoms are.
Pieces like that incentivizing, gamifying, bringing social interplay, social network aspect to it so that they can kind of invite other people to their care team and as more people are kind of watching this, more accountability. So, we are trying to play with that and see what we can come up with.
Tommy: So, I feel like we've kind of derailed the conversation slightly.
Sunjya: Yes. This is all leading into. This is all important.
Christopher: It's a two-part interview.
Tommy: Maybe we can go back. You're in the middle of your genesis story and we kind of jumped in, so maybe you can continue with that and then we could get into why you got interested in chronic Lyme and coinfections and go from there.
Sunjya: Yeah. So, I went through undergrad at UC Berkeley, focused on this, went through medical school at UC Irvine, focused on integrative medicine and then went to UCSF Santa Rosa family practice residency program up in Santa Rosa, affiliate with UCSF, really wonderful program, very forward thinking, some of the brightest minds. And people were very smart, very into healthy diet, yoga, meditation, mind body, the whole connection.
And then when I was there in Santa Rosa -- So, basically, any time I had the opportunity to have an elective or do work outside of the mainstream hospital or clinic, I would always do it with functional medicine provider, colleague or a friend and just go spend time in their office. That served may purposes. It rejuvenated me, reminded me where I'm going if I ever lost track, which is easy to do when working 120 hours a week.
And also it set me up with contacts so that as soon as I finished my residency I immediately started work in the functional medicine practice and never looked back. But right then, at that point, that time point, 2007, was also where my personal life took a turn because right there when I graduated residency, was just starting to work at Hillpark Medical Center with my friend, colleague and mentor Brian Bouch, my wife was diagnosed with Lyme disease.
And so right there my idea of sort of what my practice was going to be in terms of I'm going to do integrative and functional medicine, it's going to be great, we're going to be helping people live better easier lives and avoid nasty drug like antibiotics, et cetera, I went down this other rabbit hole which I didn't even know existed because they don't teach us about it in med school and residency.
I had some inkling because I had seen some patients here and there who were seeing other providers but I ended up doing this much more intense work and I think of it like the frog and the pot of water where I would keep having these moments of like, "Oh my gosh, this is insane. Can I keep doing this?" You kind of adjust to that phase and you keep going on to the next and, like many people like myself would get into treating Lyme disease and chronic infections because it's so complicated and so intense and so multilayered. It's like the ultimate functional medicine problem.
Because of that, many of us who were doing this have personal reasons to be doing it either our own health or a family member or a close friend or some reason that you kind of had to go down that rabbit hole.
And once I did and once I started going to conferences and reading, just spending all my free time doing this, people started coming out of the woodwork to find me and very quickly my practice transitioned. Again, that frog in the pot of water feeling, like there were moments when I was feeling the weight of it but, knock on wood, if I feel like I've come to a nice balance with it and I can't really imagine doing anything else now, because all the rest of it just seems too simple. Where's the meat?
Christopher: Oh, SIBO, how trivial.
Sunjya: No, we do a lot of SIBO. SIBO is not so trivial. SIBO is complicated.
Tommy: You say that. I remember speaking to a client a week or two ago and right after the conversation started this person hadn't really thought about their sleep or their diet or their exercise and I was like, "This is great. I've got so many things that I [0:15:48] [Indiscernible]. This is going to be amazing because there's so many easy wins here."
Sunjya: It used to be like, "I think you should go gluten free." "You what? Oh, no." "Okay, did it." "Oh my god, it's so much better." And I was like, "No, that one's even taken care of."
Christopher: Can you expand on your wife's story? Where was she when she got the diagnosis? How did she get the diagnosis? Were you involved in that at all? Can you expand on that some more?
Sunjya: It's not uncommon for people with these infections, with Lyme disease, to have it be missed and have seen literally ten to 15 doctors or more over the course of five to ten to 15 years before they finally get diagnosis. In her case, it's actually a hybrid of that. Before we were married, she went to graduate school in upstate New York, Ithaca at Cornell University. She was in the natural resources department working on ethnobotany. So, medicinal plants.
She would go out and do field work in the forest and lead undergraduate courses and take them out for field work and it was never discussed that you should be aware of Lyme disease or you should check for ticks and she never knew about a tick bite but one point during our time there, I was splitting my time between upstate New York, and I was also working with a medical exchange program in Ecuador, so I was going back and forth, but when I moved there with her she had this acute onset, sudden onset of heart palpitations, severe anxiety, difficulty catching her breath, shortness of breath, night sweats, et cetera.
So, multiple doctors from, starting at the student health center, they listened to her heart and said, "You have two out of six systolic ejection murmur," which she had never had before. Okay, let's have you go see the cardiologist. And so she did that. Cardiologist did their whole work up and documented that, documented some mitral valve regurge and some premature atrial contractions, et cetera.
But basically said, "We don't know why." Nobody said, "Let's test you for Lyme or babesia,"which is the coinfection which she did in fact have. And so things kind of simmered along like that over the course of ten years. She got a little bit better but still was having symptoms off and on. She was followed by a cardiologist through both pregnancies and, same story, "Yeah, things are a little weird but not really that weird and we'll just keep going."
Christopher: She never saw the tick? There was no bull's eye rash, any of that stuff that people talk about?
Tommy: The problem is the patients present as they are in the textbook. Like they always look slightly different than what you've read in terms of the--
Sunjya: Yeah, those points you bring up are super important in this discussion because knowing about the tick bite, less than 50% of the time do people know about the tick bite, maybe even less than 25% at a time. And the classic erythema migrans, bull's eye rash," which can look a variety of different ways, not just the bull's eye. That also occurs in less than 50% of people. So, those things that we think of pathognomonic should be there for the diagnosis are less common than not.
And again, so back to her case, she was kind of simmering along with this chronic but functional symptomatology and then it was actually summer of 2007 when we had a camp out music festival in Mendocino, which is a hot bed of Lyme disease and it's these hot areas in California that we could talk about Mendocino. It's one of the probably over 40% of the ticks up there are carrying their borrelia bacteria.
Again, did not see a tick bite but have this little red rash, was not large, it was not bull's eye, and then about six weeks after that she developed this really acute much more severe more classic presentation, severe neck pain, couldn't turn her neck, sort of meningeal swelling, severe joint pain, elbows, wrists, knees, now it's moving around, migratory joint paint which is pretty classic for Lyme disease, worse anxiety, more uptick in the night sweats, et cetera.
At that point I was starting to work in practices with colleagues who knew about this and I ran it by a friend of mine and he came over to our house. It was very nice of him to evaluate her and basically said, "You have Lyme disease. There's very little else that can do this."
Christopher: That was purely on the symptoms? You didn't do any testing?
Sunjya: Clinical diagnosis, yes, symptoms. So, we did do testing. That's when the testing showed, yes, she was CDC positive on the western blood which for a variety of reasons can be tricky to find that on testing, but she was positive and she had markers all also. She had markers that were indicating that this has been around longer than we knew in terms of both the types of bands that were present as well as things like the CD57 cell count which is the white blood cell marker which tends to go low when it's a longer term infection showing immune dysregulation from the infection.
And so at that point we put all the pieces of the puzzle together and understood, okay, wow. The babesia picture too. That explains exactly what happened to her in Ithaca in Cornell and so we understand now that it was a double exposure, one there and then she kind of kept that somewhat in check but having symptoms and then another exposure here which sort of opened the floodgates, in a way.
And she responded very well to treatment and almost all those really difficult scary symptoms that had been plaguing her for years layered off. And she did a hybrid treatment a lot like we do in our practice. She took a lot of antibiotics both oral as well as for many months had to do injections in her buttocks by someone. She took Mepron. She has this liquid $800 a bottle anti-babesia and anti malaria type treatment. That was her best friend.
She's like, "This is amazing. I feel so much better." And she did Myers Cocktails, vitamin IVs, tens and tens of supplements, massage, acupuncture, cleanses. It's an interesting story, actually. She had gotten better and then had gotten worse and her doctor actually wanted to put her onto IV antibiotics. I was sort of, "Okay, things aren't going the way we want to, let's up the ante a little bit." She's like, "No, I don't want to do that. That doesn't sound like the right move for me."
She left and did a week at the Optimum Health Institute in San Diego, and did this really intensive cleanse in wheatgrass enemas and that actually totally reset her. That was like sort of the final thing that got her over the hump. We credit that to a lot. Again, just like these infections are so complicated and so multilayered and it's really a matter of harmonizing the body, balancing the body, dealing with any and all triggers that are going to drain or distract or confuse the inflammatory processes, the cytokines, the immune balance, the detoxification balance, the hormone balance, dealing with all those pieces and also trying to fight the infections directly. It's very much a functional medicine, ancestral health, evolutionary health problem. There's so many different lenses that we can look at it from.
Christopher: And she remains well to this day.
Sunjya: Yes, thankfully.
Christopher: So, what do you think made it the term chronic Lyme? The ten years is chronic, isn't it really?
Sunjya: As you probably know, there is a major divide in the medical system and in society as to what is or is not going on with borrelia infections, with coinfections, et cetera. There's no dispute that Lyme disease exists but the CDC and the IDSA, Center for Disease Control and the Infectious Disease Society of America, their position is that Lyme is relatively hard to get and relatively easy to treat and if you do get Lyme, and again they want you to have documented tick bite for greater than 48 to 72 hours of attachment, they want you to have the bull's eye rash, which is pathognomonic, and/or they want you to test positive by two-tier testing which is very fraught with problems.
So then if you do meet those criteria you get your two to three weeks, maybe if they're feeling somewhat, the doctors are feeling a little generous, maybe four weeks of antibiotics, and then whatever happens after that, if you have persistent symptoms, they would argue is not from an ongoing infection. It's from what they call post treatment Lyme disease.
Sunjya: Yes. So, either it's inflammatory or it's autoimmune now but it's not to be treated with more antibiotics.
Christopher: You can get into trouble as a primary care doctor if you do continue to use antibiotics.
Sunjya: In some places you can. Yeah, we have some protections here in California that I feel decent about and there's some new laws coming on online, in Massachusetts, for example, that doctors are now allowed to treat for longer term. But, yeah, it's been a very controversial and very hot topic. That's their opinion that this thing, yes, you can get Lyme but it's easier to take care of. And if you have prolonged symptoms afterwards, which many, many people do, which we have some good data on that now. We're looking at anywhere from 15% to 30% of people with known Lyme disease who go on to have chronic symptoms of marked disability, they would say that's not from a persistent infection.
However, on the other side, there's those of us who do acknowledge that this bacteria, the borrelia burgdorferi bacteria is extremely smart. It's one of the smartest bacterias that we know of. It has this huge genomic library, plasmid library where it can find ways to hide out and to evade the immune system, to shift its surface protein so our immune system can't find it, can't attack it, et cetera.
There's over 200 plus studies looking at this question of can it persist long term and the answer is unequivocally yes, it can. In fact, even with prolonged antibiotic treatment, in some cases, of up to four months, if shown that you can still isolate viable spirochete bacteria from these animals.
And they've done this in a variety of different animal models, mice, dogs, cats, horses, and then most recently and most compellingly in monkeys, rhesus macaque monkeys showing that here's this animal, we've treated it extensively and now we can isolate these borrelia spirochete six, nine, 12 months later. But they've changed. They've shifted their physiology. The spirochetes haven't. They've become, in some cases, slower, more of a persister cell phenotype.
So, that's really the model of the persister now which is very interesting and very compelling. And there's some great work being done on this at Johns Hopkins with Dr. Zhang, Northeastern University with Dr. Lewis, Monica Embers at Tulane. She's doing the monkey studies. Because that's a model actually which could potentially unite these two sides and give the naysayers who are possibly still holding on to that because of ego and they don't want to be shown to be wrong but now they can maybe say, "Well, look, we didn't know about this before."
It's still a slow process but I'm hopeful that we can try/start to put aside some of the disagreement and move toward answering the questions which are still very, very difficult of how to diagnose and how to treat.
Christopher: And is it the straight shifting nature of the bacteria that makes it difficult to detect. Can you elaborate more on the two-tier process for testing?
Sunjya: Yes. So, the two-tier test as laid out by the CDC and IDSA involves, step one, is to do an ELISA test, take the blood from the patient and put it into the test system and check and see if the patient is making antibodies to this bacteria. And that test, if it's positive, is supposed to reflect over to the western blot test. And the reason they're doing that is [0:26:45] [Indiscernible] western blot has a higher chance of "false positives." They want to make sure that they only do it in cases.
So, basically, the sensitivity specificity argument that they're trying to answer, there are many, many problems with it which we could spend a long time talking about but the nature of the bacteria is a problem. All these tests use a single laboratory raised strain of borrelia. So, first of all, there's many, many different strains. There's at least 60 here in the US. There's probably over 300 worldwide. And so different strains are going to have the host produce different antibodies.
There's also the problem that when you take a laboratory raised strain and you build your test off of that, the surface proteins which that bacteria is exhibiting are going to be totally different than the surface proteins that that bacteria expresses now that it's inside of a host. And that those surface proteins are going to be different when it's inside of a human, different from when it's inside of a horse and inside of monkey, et cetera, because of the physiology and the biology of that organism.
So, the bacteria is capable of down regulating and up regulating different proteins at different times, again because of its ability to evade. That's more of its main mechanisms. I think about it as like you have somebody who's been arrested for doing a crime and you have this mug shot of them and here's this mug shot of this person and they're clean shaven and there's really good lightning and he's who we're looking for and they're showing this picture around to everyone saying, "Hey, we had to find this guy or girl."
But now the person that we're actually looking for has sunglasses on and a beard and a hat and they have a hood on or maybe even like a full ski helmet with goggles and their neck warmer up. So, you can't find him. The body can't see him. The testing has very high chance of missing cases. And on the flipside, it's an antibody test and so anyone who's been exposed, which I think is many, many people, they could potentially show some production of antibodies. And so that was just missing on both ends.
The CDC also at one point tried to develop a vaccine and they took out some very specific antibody bands from the test because anyone who had been vaccinated could potentially show positive. But then after about a year or two they nixed the production of that vaccine because of some complications and controversy but they never put those bands back in. It's just a whole stack of problems.
Tommy: Can you talk about alternative testing methods, the test that you do? Because, I mean, already you described the nature of the bacteria, how it changes, plus the different strains. So, I imagine no test could cover all of that. Even if you increase the sensitivity the specificity is almost certainly going to drop and you're going to end up with a lot of false positives. So, can you talk about how you currently approach testing or people are currently approaching testing and sort of the pros and cons of that?
Sunjya: Yeah, absolutely. So, what we try to do, and there are a variety of other labs who are trying to crack this and there's no great solution at this point, there's T cell activation testing or ELISPOT testing, which instead of looking at the antibody production now it looks at how activated your T cells get, and if you're on gamma release when they are exposed to this bacteria.
And because of the lifespan of the T cells, about 60 days, we think that might be indicating more of a current infection issue as opposed to more of a nebulous. But these are still all what we call indirect tests. Looking for some trace of the immune system and its response to the bacteria culture has been very difficult. It's a difficult bacteria to grow.
So, there was one company trying to make a go of that but they last year shut down, I think they're trying to retool.
Christopher: I saw this 2014 CDC thing where they were complaining about a blood culture. Is that the--?
Sunjya: Yes. The CDC came down hard on them and the problem is that we're in this situation where there's this thing called Lyme wars. It's a war. It is a war. It is like a combination of a fight on the medical side. It's almost like I think of a religious battle, like they're extremely entrenched camps and they don't listen to each other. They don't want to talk to each other.
So, the fact that the CDC came in and shut down Advanced Laboratory Company is not necessarily an indication that they were doing anything wrong, in my opinion, because the vested interest are strong. However, what I really want to see, and I was using that test for a while, and I found 90 plus percent of the people who I tested were positive. And that's a red flag for me.
Christopher: There's a huge selection bias, right?
Christopher: I heard Dr. Schweig talk about Lyme, and I came from the other side of the country to find it.
Sunjya: Absolutely. But still, not 90 plus percent of my patients would have this thing, maybe 50-60. I don't know. I do have a pre-test probability, in my practice it's very high. But still that was too high for me given how I know these bugs are so hard to find. So, I was talking with a lab at that time and they had done a study which was interesting and then the CDC came down on them and there was a sense, okay, let's verify this. Let's repeat the study at an independent university and ask some questions that way.
And I kept waiting and waiting and waiting for them to do that. They kept saying we're going to, we're going to, we're going to but then it never happened. And that also raised suspicion for me. And so it became a situation where I stopped doing the test because I couldn't in good conscience have my patients a lot of money on this test for us to then sit and they still tell them, "Well, we're not exactly sure what this means or doesn't mean and is it or isn't?"
So, I stopped using it. That one fell to the wayside. But we do at this point testing. It has to be understood that testing is still a major problem on any level, any of the tests that we have available. And the most important story is the patient's clinical situation and do they have symptoms which don't fit into any box which don't, haven't been diagnosed with atypical depression or atypical anxiety or atypical rheumatoid arthritis or atypical MS or ALS or Alzheimer's or Parkinson's or whatever the diagnosis is.
Do they defy categories? Do they have multiple doctors scratching their head? Multiple specialty centers? Do they have symptoms that come and go, wax and wane, pain that moves around? Paresthesias that move around, the numbness and tingling? Is it across almost any different body system?
Borrelia burgdorferi spirochete is related to syphilis and it was said to know syphilis is to know all of medicine because of how it can affect the antibody system. Lyme is the same way except for exponentially more genetically complex. So, is that the clinical picture? And if so, your index of suspicion should be very high. In that situation, what we do is we send out this pretty ridiculously large list of tests. We'll test at Quest, we'll test at Lab Corp, we'll send test to ARUP. They have one of the better C6 antigen tests that are available. I'll send tests back east to Stony Brook University. They have a Lyme disease lab. I'll send tests to Hygenix company. I'll send tests to Armin in Europe. And so we cast this huge fisherman's net, fisherwoman's net, drag it in, see what we can read in the tea leaves and basically try to put some evidence from the lab studies onto what the patient is experiencing.
But a lot of it is the clinical story and that's where you have to get good, you have to get experienced at understanding not just what borrelia/Lyme can do but what babesia can do, what bartonella can do, what ehrlichia can do, what role mold has, what role gut disruption and SIBO has and what's their ACE score, how much trauma do they have as a kid and do they need to be doing trauma work and DNRS, dynamic neural retraining system, work to balance their limbic system and quiet down the immune system.
We looked at any and all options that way but the answer really there is just by dragging that net, sifting through looking for patterns and matching that to the patient's experience and symptoms.
Christopher: Well, that's what I was going to ask you next is how much does all the other stuff that we know about muddy the waters? So, you have some patients come and present with a whole bunch of symptoms. Like how much of that is their food choices, how much they prioritize sleep, how they manage stress, are they part of the strong social support group, all of that stuff?
When I've read the Horowitz book in particular, he talks very little about the role of diet and social support and sleep. I mean, he does mention them but it's definitely not the core of what he does. Or maybe I'm wrong about that. Maybe that's not your interpretation. But I just wonder how much you see that in your practice. So, if someone turns up, they think they've got Lyme. Actually, you need to prioritize sleep and fix your diet.
Sunjya: Yeah. No, it's a huge part of it, and those are really what we think of as the core foundational pieces of functional medicine.
And so almost any case that comes in the door, no matter what the "actual diagnosis" is, those measures are going to help them. And it's very interesting to me. So, basically, we're trying to flip things around a little bit because patients will come and say either -- They'll come to me saying, "I think I have Lyme," or "I've been treated for Lyme and I'm not better."
Assuming that they are stable, I will always go back to that foundation layer of interventions and trial to dial in as much of that as I can. And even to the point now where we're asking patients, assuming they're not unstable/getting worse or have a recent tick bite which needs to be addressed right away, assuming they're sort of been simmering along in their normal state of unhealth or imbalance from where they are, we're asking them to first see our coach and then basically the first visit is health intake, history taking, order all the functional medicine testing, look at adrenal gland function.
We do split sample double testing on stool right away. We do SIBO testing, maybe organic acid, maybe heavy metals, et cetera, get all that stuff on the deck at that first visit before I even see them get their diet started, dialed in, put them in a reset Paleo template diet, get them meditating, get them sleeping well, get them exercising.
And then once that first round of labs come back they'll come and see me or one of the other practitioners in our practice. At that point it's super interesting to me because a lot of what they were experiencing will have layered off. Not because they don't have Lyme disease. They could. Maybe they do. Or maybe they have some other infection. But just like that work harmonizes the immune system and gets the information down--
Christopher: Just to say now your immune system can do what it needs to do.
Sunjya: Right. And then what's so cool is you show them the power that they have to change and to improve their health and maybe they went from a 40% function up to 70% of 60% in a good case. We still have a lot of work to do but at least they understand the importance of things that they can control. And the other thing that we really, I just get so excited about, is that I cringe that there's a lot of practitioners who just have their main tool is antibiotics and they say, "Okay, I think you have these infections, boom, here's your antibiotic dunk tank. We'll dunk you in it and pull you out from time to time and see if you're still alive and dunk you back in it."
Christopher: [0:37:11] [Indiscernible].
Sunjya: Using treatment approaches whether it's antibiotic or herbs or whatever it's going to be to try to directly go after the bugs, our job and our ability of us to do that is so much better when you've layered off all those confounding factors. That is just they respond quicker to treatment. They respond more profoundly. And then when you do get the patient to a point where you're going to try to stop treatment because they're a lot better, the chances of relapse are a lot less. That's the thing I get really passionate about.
Christopher: Do you have an order about which you go through things? So, if I turn up and I got SIBO and heavy metal toxicity and three gut infections and I come back positive for Lyme, where do you start?
Sunjya: We're always looking at this trying to figure out what is the best but I'm fairly convinced at this point, in most cases, that it makes sense to really dial in the adrenal/hormone thyroid piece and the gut piece. Because of the fact that, as you guys know, as most of your listeners know that 70 plus percent of our immune system is in the gut.
If they have H. pylori or Cryptosporidium or even some of the other players like Blastocystis, et cetera, or they have dysbiosis or if they have SIBO I will try to go after those first. SIBO is a little tricky because we're always just kind of playing with SIBO and trying to understand is that the driver or is it the passenger? And we know in particular borrelia, which is Lyme disease, Borrelia burgdorferi and also Bartonella henselae, which is another coinfection, can also be passed by other biting insects including fleas, et cetera.
Those two bugs have a major tropism for the gut. And so those guys plus mold and heavy metals, really we feel like those could be big triggers for SIBO. And so in those cases, we see a lot of SIBOs that doesn't get better which is normal SIBO treatment and they were kind of looping back and say, "Okay, do we actually need to deal with the Lyme or the mold or whatever is first." We're still playing on that.
Tommy: You mentioned the hormones as well. How often do you find yourself replacing versus trying to find out what it was that caused issue in the first place? Do you use a lot of thyroid replacement or hormone replacement or do you find that with lifestyle interventions or, say, eliminating heavy metals or something else you might be able to restore normal hormone function and where does that lie I terms of the response to treatment for something like Lyme?
Sunjya: It's very individual except for on the adrenal side. I am very low bar to get people onto support whether it's just a good multi or a good pharma like it has good levels of vitamin B, vitamin C, et cetera, adrenal cofactors. Virtually always we'll ask people to start taking adaptogenic herbal formula and also if warranted by the testing things like DHEA and pregnenolone to support the cortisol cascade and the anti-inflammatory hormones.
And then in some cases if fatigue is a big issue or if the cortisol is really bottomed out I will also give people low doses of Cortef hydrocortisone. And in some cases it's magic. Because they’re just so bottomed out from the ability of their immune system and their hormonal system to deal with the inflammation that they just need that foundation to move forward.
I'll deal with those things first. Thyroid is very testing dependent and we won't just look at the lab testing. We'll also look at basal body temperatures and then the whole symptoms related to low thyroid function. But I'm not at all unwilling also to give people treatment trial and see if that helps. I think that it's really a matter of propping as many legs of the stool up that you can help the organism because, again, these infections are so dysregulating that you get better traction on treating them if you support all these other pieces.
Christopher: So, what do we do about prevention? I wonder about that. Living in northern California, I'm out in the woods all the time. I pull five ticks off of my dog every single day. I'd been bitten probably three or four times this year already. There's a lot of ticks in Santa Cruz especially there's a lot of rain and then the grass comes up and I feel like a little bug is just waiting for me to brush my leg by as I go pass on the bike.
Sunjya: Absolutely, they are literally.
Christopher: Yeah. So, there's a lot of people listening to this podcast that are people like that, they're trail runners, they're mountain bikers. There are other people that spend a lot of time outdoors in nature. I don't think the recommendation should be, "Oh, don't go outside in nature." The benefits outweigh the downside.
Christopher: What's reasonable for someone to do about prevention?
Sunjya: Yeah, and there's a lot that could be done. Awareness is the number one first step. That's a battle still because a lot of the mainstream medical field here in California does not understand how prevalent Lyme is and so you might get a tick bite and go to your doctor and they'll say, "Oh, we don't really have Lyme in California. That's more of like an east coast problem."
But it's really important, really, really important to understand that there absolutely is Lyme disease and coinfections here in California. 56 out of 58 of the counties in California have been found to have the Ixodes pacificus tick which carries the Lyme bacteria and the actual Lyme bacteria has been found inside of those ticks in 46 out of 58 of the counties.
So, it's all over California. But that being said, there's sort of hotspots like we alluded to. The Mendocino ridge coming down through Santa Rosa and Adel Park is a hotbed, Occidental coming down through the--
Christopher: The best mountain bike places absolutely.
Sunjya: Marin Headlands, up here in Tilden is a big hotspot down through Santa Cruz. You can look on the California Department of Public Health website. They've done tick studies, tick drugs and anywhere from up to five, six, seven percent of those ticks have been found to be carrying Lyme bacteria up to like 40% in Mendocino, parts of Mendocino. The other thing that's really important to understand for prevention and risk is that most risky ticks out here in California are the smallest ones.
And so there are actually literally the size of poppy seed or the period at the end of the sentence. It's difficult to actually identify them even with a magnifying glass. And so really what people need to know is where are the ticks, how do ticks behave, how do ticks quest for a blood meal, and basically that's on the outer edges of the grasses. They'll climb up to the edge of the grass and turn themselves around and stick their legs out. It's called questing.
Basically, their legs are sticky and they'll just kind of grip on to something as it passes by. So, when you're hiking or mountain biking, if possible, staying to the center of a trail, avoiding trails that are really overgrown, understanding that when you're going to sit down and have a rest, that takes like leaf litter, that takes like cool moist places like under a log which is exactly where we might want to go to take a cool rest on a hot day, so avoiding going and sitting in those areas.
We're out in nature a lot. It's a huge part of my life. I'm not going to give that up. But you can spray your clothing with either natural lemon, eucalyptus oil, as a repellant or you can also treat your clothes with permethrin, which is derived from chrysanthemum, which is a good deterrent. It's not perfect but it does help prevent those ticks from climbing up.
Christopher: What about DEET?
Sunjya: DEET is very effective. It's just very toxic.
Christopher: So, I wondered about this. I looked into it on the environmental working group website and it seems like there wasn't a lot of evidence as to the toxicity. And when you discussed your wife's story, I'm thinking DEET or Lyme? I think I'll take the DEET. I don't use it personally at the moment but I'm wondering whether I should.
Sunjya: Again, it's effective as a repellant but it is just not something that we've chosen to use on a regular basis. We will sometimes for more intensive, if we're really out somewhere where -- I really don't recommend applying DEET directly to skin. So, permethrin is my personal preference. But again, not the skin. Permethrin is really for treating your clothes. There's actually clothing lines now where they've been prê-treated.
We have a colleague actually who has convinced the Harvard golf team to use permethrin treated clothing as well because it's a big Lyme epidemic that they've experiencing as well.
Christopher: On the golf course.
Sunjya: Yeah. Out on the golf course.
Christopher: Okay, go into the rough, I suppose. [0:45:04] [Indiscernible].
Sunjya: Yeah, totally. So, awareness, avoiding a tick bite and then also understanding that if you've been in an area where there are ticks then when you get home, take off your clothes, you put your clothes in the dryer on high setting for 15 to 20 minutes to kill the ticks and you check yourself and you take a shower. And you understand that when you're checking yourself you're looking -- You have to have a partner check you. It's really important to look under your armpits and the back of your head, your hairline, in your hair even.
Christopher: They always get my daughter on her scalp every time in her hair.
Sunjya: By design they have a number of different ways of finding a good blood meal and they'll sense carbon dioxide, so they'll find you where you have the most [0:45:41] [Indiscernible]. And they also sense temperature so they'll go for the warmest places. So, scalp, under your armpits, groin.
Christopher: Fleas do that as well. The dog, like they know.
Sunjya: Yeah. They know where to get the best meal. They're very smart. Smart little guys. So, coming home, checking, changing. I think it's just that awareness piece.
Christopher: And then if you do get bit which I get bit all the time, even my three-month old baby has been bit already. What do you do? What do you look for? Is there anything?
Sunjya: One of the most important questions that I'll always ask if somebody says they have a tick bite is I want to know what kind of a tick is it.
Christopher: There's lots of different types. You notice that some of them, they bite you and it hurts like crazy and then some of them it doesn't at all.
Sunjya: Yeah, it's interesting. I mean, I don't know the answer to it. A lot of ticks have anesthesia they'll inject also so you frequently will not feel a tick bite. So it's, I guess, if they bite someone that's more sensitive or there's a catch in their skin a certain way you might be more likely to feel we're also the size of the tick or the bigger one. So, yeah, I always ask if people do get a tick bite, remove it, save the tick and then try to identify. Definitely save the ticks. Always save the ticks.
Tommy: What's like spider bites? Save the spider.
Tommy: Or snake.
Sunjya: I want to know is it ixodes out there? Is it an ixodes specific, if you're back east is that the ixodes scapularus, type of tick which is the one which is more likely to transmit Lyme disease. And then also, if possible, like to know the stage. It's hard for the lay public to be able to differentiate nymph or adult or male/female. For the ixodes ticks it's usually just a female, that seek a blood meal in order to lay their eggs. But for the nymphs there could be either.
So, again, I want to know the type of tick. I want to know how long it was attached. That's important for understanding what the risk potentially. And then I want to know where you live, where you where when you got the bite. Because, again, those hot spots versus cooler spots. And then theres' a great, in terms of identifying ticks, one of my favorite resources is website called Rhode Island Tick Encouter. It's a university run web page that really great images top bottom of the ticks, what they look like as in the different life stages and also what they look like from being non-engorged, non-fed tick all the way up to very engorged.
At which point, their characteristics completely change. It becomes more difficult to identify. So then if it's a tick I'm concerned about for one of my family members and then we've dealt with the same thing, we pull out multiple ticks, we pull them off from our dog, I think we're going through this crazy boom right now. I pulled off three ticks from my dog who in the last three days, four days. And we don't let her go hiking.
We don't take her hiking. We take her only for her poop and pee walks just on the side of our urban streets but she's still picking up all these ticks. It's really like a lot of ticks out right now. If it was one of us we'll send it back east to tick companies for testing. Tickreport.com, which is run by the University of Massachusetts, so in three days, they'll turn it around. They'll tell you the type of the tick, how engorged it was and also what pathogens it is carrying.
Christopher: I thought I bumped into one organization like that at a local bike race in Mendocino which I feel like it was the Bay Area Lyme Foundation. And they were saying that they would do DNA analysis on ticks that you sent in.
Sunjya: Bay Area Lyme Foundation, wonderful organization. My wife Leah works for them. I'm also on the scientific advisory board, great organization, and really good and bad news. They are the number one funder of Lyme disease research probably in the world. So, great news. Wonderful for them. We're thankful. On the other hand, pretty dismal from the government point of view, which is like they really should be out there funding this disease more. Their amount of funding is tragic, that they give.
But Bay Area Lyme has raised probably over $18 million and they give it directly to the scientists trying to identify -- Their mission is basically to make Lyme easy to diagnose and simple to cure, to flip everything on a tit as it is now. But they were running free tick testing program.
Christopher: I think that's what I saw.
Sunjya: Yeah. Unfortunately they got completely inundated. They thought, okay, we'll get few hundred ticks from here and there and I think they had to cut it off at like 8000 ticks or something. But it's a cool project because basically there were running it for the science side. They want to bring awareness to where the ticks are, what they're carrying. Those are the guys, research funded by them and done by other friends of mine, Nate Nieto out of Arizona and Dan Salkeld.
They broke the story that Borrelia miyamotoi, this relapsing fever borrelia, was here in the US here in California. And that came out a year or two ago and that was previously thought not to even be on the continent of the US. Again, different strain problems. But, yeah, Bay Area Lyme is not able to accept ticks at this point. Hopefully they it will come back. And even when they were it was more of a surveillance program as opposed to -- You didn't get a quick turnaround. You got like a two or three week turnaround.
Christopher: Right. You don't have expectation of--
Sunjya: So, it can't guide treatment decisions, but the tick report is great. Again, three day turnaround so we can get answers back. I've done it both ways which is like, okay, let's wait for the report to come back before starting treatment or let's start treatment, if it comes back negative, stop.
Tommy: And so what would -- Multiple questions there. So, first of all, what's the threshold? Obviously, we talked about northeast, we talked California. What about the other 90% of the country in between? What's your threshold for sending a tick off? What's your threshold for say starting prophylactic treatment until we get the results back and what would you do in that case?
Sunjya: Yeah. So, Lyme has been found in almost all of the states in the US. So, my threshold really is, again, the type of the tick. If it was an ixodes and we're dealing with possible Lyme disease, if it's on me and my family members I will always test the tick. I'll always send the tick for testing. Again, for my wife, she had a nymph tick bite which I had to take tick and put it under the microscope at home and then kind of say, "Okay, yes this is an ixodes. It's higher risk for Lyme." And I put her on antibiotics for those few days while we're waiting. The tick tested came back negative so we stopped.
Tommy: And what antibiotics would you use?
Sunjya: There's a variety of options, again, individualized depending on the case but amoxicillin can be a good option, cephalosporin type medicine like Ceftin or Omnicef. Depending on duration and also risk, we sometimes will add a second medicine like azithromycin, so stuck up together. If I'm worried about other infections like bartonella or babesia, that changes the story a little bit. I also will use herbs at that point. I do have some colleagues who will only use herbs as prophylaxis that makes me a little nervous.
Not that I don't love and believe in the herbs but I also want to go hard. You completely avoid and cure a Lyme disease infection if it's caught early. So I always just give them what I see on a regular basis. In fact, I always like to -- It's like go in guns blaring if there's a chance I can knock the thing out quick. But for the more chronic cases I'm against that being back and doing more of the functional medicine approach.
Christopher: And then maybe, finally, then, can you put this problem into perspective? I worry that -- We've worked with some people like they will hear something on a podcast and they'll say, "Well, that's definitely me. That's definitely what I've got. That's definitely my problem. You should really look at this." So, all of the things, mold, you talked about SIBO, you talked about heavy metal toxicity, you talked about these gut infections.
There's all these things that potentially could be a problem. And then what's really going on for people that we could just pull off the street here in Berkeley? How big of a slice of the pie is that in the general scheme of things? How worried should people be in general versus all the other things, the boring stuff that we talk about in the podcast?
Sunjya: Yeah. I think that comes down to what is your symptom load? What are you looking at on a day to day minute to minute hour to hour basis in terms of your life? My friend and colleague Rich Horowitz has published a recent study providing some scientific validation to a questionnaire which he didn't fully develop a tweak. It's like a questionnaire that we all use and we structure the questionnaire and ran it in a huge number of his patients and then ran a bunch of statistics on it. It's basically trying to develop statically validated questionnaire for the diagnosis. And so there' cut off, yeah, right?
Christopher: Let's do a questionnaire and I can tell you whether you got it or not.
Sunjya: Right. So there's cutoffs on there. It's like less than 22 or 23 and this low risk and 23 to 45 and you should maybe consider this, and above 46 it's likely and that you should seek more advice. I think having people do that ,search on the internet for the HMQ or Horowitz Medical Questionnaire.
Christopher: I think it comes with the book, isn't it?
Sunjya: Yeah, it's in the book.
Christopher: Okay. I'll link to the book in the show notes.
Sunjya: Cool. So we have that. And I envision actually putting up onto our website with a self-scoring system so that people can just kind of get a quick snapshot. Because you have to sort of make some calculations on it. There are certain questions that weigh differently and you have to sort of multiply by this or that or you have this, this and this then you add five points kind of thing.
Tommy: So you want to automate it ideally rather than--
Sunjya: Yeah. So we have the automated in our EMR system right now so they can just fill it out, I get that score along with the other standardized questionnaires that we're using. That's super helpful because you can kind of put them into -- It's not definitive but it's pretty helpful tool in that realm. If you have these multilayered complicated multi system symptoms that are not responding linearly to some of the other treatments then this is something that should be on your check it out list.
That being said, it's a tricky thing because I think that it's really common to get exposed to these bugs and I think that that's why another reason why this standard testing is so crummy is because many people who are asymptomatic were going to show some degree of positivity on these tests.
And so you pull them off the street and test them. It doesn't mean or break the diagnosis one way or the other. Having people track those symptoms and provide that data does become a key element but also all these other pieces like mold and SIBO. I think the infections are really common but many people are just keeping them in check or they're an old exposure. I think that you start to stack things, like get really stressed and you get some mold exposure, your hormones get depleted, you're eating the wrong diet, you already take, of course, a steroids or antibiotics or end up having a surgery.
Something happens that you start to stack things and then over time -- Or you have -- My wife did one exposure and then another exposure later or a few exposures. It's almost like the bug stack up and gets this, the weight of it gets too heavy. And the people become symptomatic.
Christopher: Well, the final $64,000 question: Are you seeing patients? Have you got room in your practice for people who are listening to this and are interesting in seeing you?
Sunjya: We'd be happy to help them, yes.
Christopher: That's amazing. I didn’t expect you to say that.
Sunjya: I have a super long waiting list. We are doing our best to work our way through it we're restructuring our practice. We really believe that this new model of bringing in health coaches, bringing in a support team, or doing group visits and we have amazing group of practitioners in our practice right now and I just feel really blessed to be working with this group of people.
It might be that patients can come see me for a visit or for all their care. It might be that they see me once and then see other practitioners and follow up. It might be that they see other practitioners just start with and then I'm consulting on the case. But we all work very, very closely with each other. We're in constant discussion via Slack and kind of running cases by each other as well as having meetings on the phone, et cetera, in person.
So it's a team approach and the problem is so big and so pervasive that we're also dedicated towards training other practitioners. Chris has this ADAPT training program. I'm working on writing a chronic infection module for that program so that we can train additional practitioners and get them up to speed on what we're seeing in terms of the optimal way of doing this.
Tommy: For people elsewhere, do you have any tips on how to find a literate physician who's going to do a good job with this kind of thing?
Sunjya: Yeah. At least in the functional medicine realm, I think you're more likely to find someone who's somewhat knowledgeable but it's also the case that many of my functional medicine colleagues will do everything but not Lyme. "Yeah, I don't do Lyme. It's too complicated." A lot of them will. So, functional medicine, to start with, and then there's another group called ILADS, the International Lyme and Associated Diseases Society. They do maintain a registry of doctors who are willing to treat however they are a little bit more on the antibiotic focused side. But there's a lot of great forward thinking doctors who are friends of mine who are part of that organization. Another group is lymedisease.org. They maintain a doctor registry.
Christopher: And what is the best place to find you online?
Sunjya: Yes. So, our website is ccfmed, California Center for Functional Medicine, ccfmed.com, and I also have my own website, drschweig,com. I'm on Twitter @drschweig.
Christopher: Awesome. That's fantastic. I will link to all of those things in the show notes. Thank you very much for your time. We very much appreciate you.
Sunjya: You're welcome. Yeah, that's fun.
[0:58:30] End of Audio