Written by Christopher Kelly
June 20, 2019
Christopher: Dr. Abbott, thank you so much for joining me this morning. I very much appreciate you.
Rob: Oh, thank you for having me back. I always feel lucky. I've been on a couple of podcasts now, a second or third time, and it's like I'm either tricking them or doing something right to be get back on these shows, so thank you for having me.
Christopher: Yeah. You are doing wonderful work. This morning on my morning walk, I listened to the episode that you recorded with Tommy on your genesis as a functional medicine practitioner and I have to say, you come across as an extremely grateful, courteous, compassionate, intelligent individual and I really enjoy that. I always love people -- Tommy is one of these people too -- that you have so much knowledge, so much formal education, and yet you're still listening to all of the podcasts, reading blogs, listening to audio books and reading real paper books, as well as all the stuff you find on PubMed, and I think that's quite incredible, so congratulations on everything you've achieved.
Rob: Thank you. I'm almost wordless with some of those words you've shared. I think I was very lucky to be able to walk that path. Obviously in medical school, as you said, I'm surrounded by academia, pursuing my own education, but being in a very compassionate environment from the nursing school that was adjacent to the medical school. I went to the University of Virginia, School of Medicine, and the nursing school next door, they understood resilience. They understood compassion. They had meditation classes. They had yoga classes. They had retreats. I can't remember if I spoke about that in the conversation with Tommy, but that was just so formative to me. I extend so much gratitude to some key people, Jonathan Bartels, Esther Lozano, these beautiful human beings who just gave me an ability to get through medical school without crazy cynicism and burnout.
Christopher: Last time you spoke with Tommy, you're a third of your way through your residency, I believe. Give us an update. Where are you now?
Rob: Oh, yeah, so a little bit different setting now. I basically got through about the first half of my three-year residency and just a lot of things came together that were pointing to go a different direction, one of the main ones being the research I was trying to perform. And a lot of things that I was trying to do, patients that were coming to the clinic seeking my care just wasn't -- I was a round peg trying to get into a square hole and it just wasn't the right place to be, and so I decided to move back home to grow a collaborative clinic with my partner, Ryan Hall, who's a nutritionist, and at the same time, dive back into the research I was trying to pursue with the AIP diet. That was back in November of 2018 and I haven't looked back. My life has just gone in a great, positive trajectory. I don't wake up at 2:00 a.m. anymore thinking, "Is someone dying?"
Christopher: Oh my God.
Rob: I still haven't fully recovered my HPA axis, but it's well on its way and I couldn't be happier, so yeah, I'm working in a growing clinic and continuing to do research. I was able to complete the research, the AIP research study that we'll talk about today and going to be a part of a couple more studies going forward, so yeah, my life is very different than it was by the time of that podcast, but in a very good way.
Christopher: That's excellent. That's really great news. I was privy to a conversation that Simon was having with a client recently and Simon said, "Never trust anything your brain tells you at two o'clock in the morning." It's always bad news, isn't it?
Christopher: I was like, oh yeah, I've never really thought about that. Your brain never really gives you a great idea at 2:00 a.m., doesn't it? Just discard -- just thank your mind and say, "Thank you, brain. I'm just going to go back to sleep now and I'll catch up with you in the morning. How does that sound?"
Rob: I totally agree with you. I think I was talking to someone else about that phenomenon of waking up at two o'clock and being asked to go do something medical and just being definitely afraid of making a mistake or not being able to function. I was only in residency 16 to 17 months to be able to even have any kind of experiences like that, let alone somebody who's been working for 30 years, but just having that shared fear, I don't know if that's fully the right word, but just this depredation to be able to care for the person and not make a mistake, that could be -- maybe not necessarily life-threatening, but just make a mistake at 2:30 in the morning because I shouldn't be awake right now.
Christopher: I don't think it's any better if you're being paid for some other reason like support engineers get paid to tell them that some server has crashed or somebody can't log in or something like that. Even though nobody's life is at stake probably or it's less likely to be at stake, it's still a catastrophe. Now, the chimp in your head doesn't know that, right? It's still going to be screaming bloody murder.
Rob: Yeah. I've talked to a couple of IT friends who did that and made some good money. I was like, that's not helping your health at all.
Christopher: Yeah, absolutely. Okay, so let's talk about your new study "Efficacy of the Autoimmune Protocol Diet as part of a multidisciplinary supported lifestyle intervention for Hashimoto's thyroiditis.” You managed to pack a great deal of information into that title. Congratulations on getting this published and also on the title, which is fantastic.
Rob: Yeah. One of my pet peeves is obviously, you can't put everything into the title, but put as much in there that's truly what you did into the title, so yeah, it's a bit of a mouthful, but I feel like it's pretty reflective of what we studied.
Christopher: I am very interested indeed in the autoimmune protocol diet as that's the diet that recovered my health. I got very much better. My gut symptoms massively improved when I switched to a Paleo-type diet, but really the only thing that saved me from the gastroenterologist and their recommendation of steroid anti-inflammatory drugs and surgery was this autoimmune Paleo diet, which my wife, Julie, found online.
At the time, there were barely any resources that would help you implement such a protocol, let alone scientific evidence to support that it might be helpful. So wow, things have come of age. This is fantastic. Tell us about how you got interested in the protocol and how you funded this study because that was interesting too.
Rob: Yeah. This whole process has been just remarkable, in my opinion. It started back at the 2017 Ancestral Health Symposium where I was presenting a poster and I was able to meet Mickey Trescott and talk a little bit about her work. At that point, I had been deep into the Paleo Ancestral AIP world. I think I was a third or fourth year student at the time and had been using recipes, resources from Autoimmune Wellness and different AIP blogs. I've been recommending books to patients during my medical school training.
I was able to finally meet Mickey Trescott at the time and then later got connected with her partner, Angie Alt, through Autoimmune Wellness and maintained a relationship with them in relation to the first AIP study on IBD coming out at the end of 2017. I actually started a formal relationship with them a little over a year ago on Facebook. It reminded me a couple of weeks ago that it's just been a year, but I started to have a formal relationship with them to bring a medical perspective to their work as they had done a survey of their audience asking, "What would you like from us?" The biggest thing they said was, "We would love more research. We would love more medical perspective on some of the things that we're doing."
That first study had been out at this time, and so I saw that and went to them and I was like, "I have no time. I'm a resident, but this is amazing. This is my passion. Let's jump in." The first thing I really wanted to do was "Can we do another study?" and I didn't have -- as I mentioned, I was a resident at the time. I didn't have grant funding. I didn't have crazy academic support to do it, but I wanted to design something that was meaningful using the structure from the first AIP IBD study and using the elements of Angie Alt's SAD to AIP in SIX, an online health coaching program. I wanted to use elements of that to design a new pilot study. We sat around, tossed around ideas of what disease state should we study and this and that, and decided, "Hey, let's see if we can replicate something on a similar scale, but actually add in layers of functional medicine and personalized care into the intervention that I would be able to provide folks."
We decided we wanted to work with Hashimoto's thyroiditis just because it's a huge epidemic, and depending on where you read, the number one autoimmune disease affecting our world. And outside of hormone replacement therapy, there's really nothing else that is helping. Even when I dug into the literature to look at the potential benefit from replacement therapy, I was underwhelmed. There are a lot of folks with autoimmune thyroid disease, hypothyroidism, with lots of symptoms that are going over every single system. They have GI symptoms. They're getting sick frequently. They have brain fog. Even for a functional provider, it might be like, where the heck do you start? So knowing that population was out there, we wanted to potentially be able to design a study that could help elucidate, does a multifaceted lifestyle intervention incorporating the AIP diet help those folks because we want to get folks feeling better and be able to hopefully allow them to use less medication.
So once we decided that was what we wanted to do, I had to make a budget to decide how much it's going to cost to do labs, and barebones budget for the study was just for the labs. This didn't include our time. Basically, I volunteered all my time for free. My study partner, Adam Sadowski, volunteered all his time for free, but just to get the labs in the HIPAA Compliant software covered, it was something like $10,000 or $11,000.
Rob: So I went to Mickey and Angie and was like, "Well, I definitely don't have that and I don't have a way to get that quickly" and they were like, "Well, we have social media and we have an audience and the ones who do the survey. People want this research to be done, so let's create a crowd-funding campaign to see if we can raise that money." So what we did, we made a video on Indiegogo, put together some things. Mickey did an amazing job with things and we were able to put it out there and share it with folks like yourself who graciously shared it with your audience. And within two and a half weeks, less than three weeks, we had $12,000 from over a hundred --
Christopher: That's amazing. Amazing.
Rob: Going back to what you said about the gratitude piece, I was so happy. Part of me was like, "Man, I should've asked for $25,000. Let's do more testing and have a controlled group," but I was just so happy to be able to get that money and be able to actually do this study, so yeah, this community is doing so much grassroots, amazing stuff. I hope people can hear that to recognize that research doesn't have to be dictated by big pharma's pocketbooks. We can, if we mobilize in these ways and use social media for good, direct health science that's being performed. It's not about doing bad science and showing what we want to see. It's about doing good science, but funding the appropriate investigations because a lot of -- Tommy and I talk about this all the time. A lot of biomedical research is just absolutely garbage and should never have been done in the first place. It's like associations between egg consumption and length of toenails.
How did they get past the IRB? I'm rambling a little bit here, but it was just such a great story to be able to even get the study off the ground in the first place.
Christopher: The people that Mickey and Angie surveys, were they practitioners? That's very interesting that the clients or patients or just human beings that are benefitting from the autoimmune Paleo protocol would want to have scientific evidence to support its efficacy. I know that I didn't care about that as a programmer. If you think that something is going to fix your gut and fix your health then you do it and you're not going to be looking at the nuances, look at some of the data on this paper and say, "Oh, did he use the median or did he use the mean? Where are the outliers?" No one's thinking like that. They're not thinking in that term, that type of scientific rigor that is really buying into a story that this diet might recover their health, so who were the people that Mickey asked?
Rob: Yeah. It was to my understanding just their audience, so they get on to their email list and it's over a hundred thousand folks. Most of them -- I'm a practitioner. I was on their email list before I met them, so a wide audience. They had thousands of responses. They would know more specifically the types of people that are -- I don't even know if they had any data, the specifics about the people, but it was their larger audience, so it wasn't targeted to just clinicians. I agree with you. I think there's a lot of people in this audience who say that exact thing like I don't need this level of evidence for this type of intervention for me to go and do it, and once I've seen the benefits, I don't need a study to prove my experience. I completely agree with those things, but I think there's a level of altruistic desire and recognition from citizen scientists that in order for this movement to grow, they don't need it to legitimize their experience. They want it so that maybe this will tip the bar over so that somebody else can find it or someone else's practitioner can find it and see some validity behind it in the scientific realm so that they'd go and recommend it for somebody.
That's where I see the reason to be doing this research is yes, I've seen it clinically. I work with Angie. I've seen it work. I didn't really need a study to show that it worked, but within the scientific realm and applying scientific rigor, these are the logical steps to take that hopefully through time in larger studies, we'll be able to change medical practice, and hopefully someone else who wouldn't have been exposed to it gets exposed to it because we have well-done studies supporting it.
Christopher: That's a really good point. I think it's true that I got lucky. I was in the system with the gastroenterologist who's not going to be getting that information from the blogosphere and podcast primarily. I just got really lucky that I just happen to be dating a woman who had just finished a Master's Degree in Nutritional Science and had been studying food allergies in the lab. She looked at the diet and she said, "Yeah, I could see how this would have great potential to help you. Why don't you give it a shot? It's a very low risk intervention." Had it not been for her then I'm not exactly sure where I'd be now. So I think you're doing important work there where you're just -- I mean it's not going to change the system overnight, but you're at least nudging in the right direction.
Rob: I talked about this with Adam Sadowski on another podcast with Guillermo Ruiz, his 30/30 Strong Podcast. We went through and we talked about that in depth about this is just a pilot study. We didn't go from this and made conclusions that every single person with autoimmune thyroid disease should be put on AIP, and that's not what the study could have shown to be to begin with, and so making proper conclusions, but recognizing the sequence because we also couldn't have gone and gotten or tried to get $100,000 and $500,000 to do a really large study in the beginning if we didn't have grounds to show that this study we were then eventually applying had any kind of efficacy.
Adam had the right terms of this is a rough draft. This is the first intervention to see where we're studying the right things, where we're able to even do it in a small population, could we scale it up to a larger population, and then to better inform the next study because not that I would want to waste anybody's money, but I would really hate to have done something off the get-go that was crowd-funded and it was just super poorly designed and we couldn't do it on that scale and that markers we looked at were not good markers. It would just be a waste, and so there's a natural progression of doing things like this pilot is a single arm and then scaling up to do randomized controlled studies, and do those studies over time of how you can make meta-analyses and systematic reviews about multiple studies, so there's a natural sequence.
I would love to just jump to this should change clinical practice overnight, but we have to be realistic. I also always apply out risk benefit analysis to things, and for me, the study luckily was a low risk intervention from an IRB standpoint and ethical standpoint, so I was able to go through that process pretty quickly, but as a clinician, if I'm going to apply a therapeutic such as a dietary intervention in a supported setting, it's a lot lower risk than putting someone on a certain supplement actually or certain drug regimen, so we have to apply the risk-benefit spectrum. It'll be a lot easier for me to with less technical scientific evidence recommend something like a dietary lifestyle change than a chemotherapeutic agent, so you have to apply things in context.
The last thing I just want to say here is that some of our study design, what people consider gold standard, is really designed for either drug or supplement studies. It's not designed for multifaceted lifestyle interventions because our study was multifactorial. It's inherently confounded. By the end of it, I have no idea for one person. Was it the dietary changes? Was it the recommendations on sleep? Was it being a part of a community? And yes, we can continually design studies in the future that can try to tease elements out of that, but they have to be super elegant. There's just a lot of complexity to them and as soon as you start adding some of that complexity, you also take out the real world application like did you put people in the metabolic ward to have them do this or did you have them do it on their own? For me as a clinician, I want to know what can be done in the real world, not like what you can find when you give everyone their food and they just sit in a controlled setting, so all those things are important as an outsider.
It's hard for a lay person like when you're reading a study, how is it the median and the mean, all these things, what is it really saying, and trying to do our due diligence as scientists to put out the right conclusions, to put out the right information so that we're not trying to mask things that really weren't there. And then of course, news media gets a hold of it and then after that, it's like oh gosh, you've lost control of what people's opinions and conclusions can be about the study. Yeah, I really do hope that one uses this as a springboard to do more rigorous study because we want to go through that process in a legitimate way.
Christopher: Talk about the study design. What specific questions did you set out to answer?
Rob: Yes. The main thing that I wanted to study was could we improve people's quality of life and symptoms? So you may be asking, "Well, that doesn't sound very scientific. That's not an objective marker." I would put back, yes, on paper, it's not an objective marker, but also as a clinician, I'm not interested in seeing something change, say a biomarker like Hemoglobin A1c, if the person themselves doesn't have improvements in symptoms and quality of life. We are even in traditional medicine moving towards a new era of medicine that's guided by what's called by patient-oriented evidence that matters, so looking at patient-oriented outcomes, things like mortality, things like symptom burdens, things like quality of life, and not just objective markers like IL6 and things that patients probably could care less about. So I wanted to ask as a primary question, could we improve people's quality of life with our multifaceted intervention? And then secondarily I wanted to look at because we had thyroid patients, yes, I wanted to look at could we decrease their need for the use of thyroid medication by seeing improvements in thyroid hormone markers and potentially decreases in thyroid antibody markers.
Another sort of secondary question I had before this study -- and this specific population have sort of a priori hypothesis about it because it's not a routine marker that's used in autoimmune thyroid disease -- but I wanted to find something that reflected the inflammatory state, so we ended up measuring high sensitivity CRP, which is more regularly used in cardiovascular disease and risk stratification, as well as IBD. They did use that marker in the original IBD AIP study and actually saw some clinical improvements. They just didn't see anything statistically because there was crazy range just because of the small population and the great variations in people, but I wanted to find something that potentially could be a marker of immune inflammation modulation in our population, so I put that in there as well.
Back to that original design question, essentially what I wanted to do was a single arm study. I would have loved to have a control group, but I just didn't think we could have the money. I wanted to do a single arm, which basically means everyone got the same treatments. We had a ten-week study, so they started the program utilizing Angie's SAD to AIP in SIX frameworks. Essentially, it was a graded, gradual, nutrient-dense elimination diet. Week one is not follow AIP. Week one is remove grains and alcohol because I've talked about before, you probably can count the number of -- maybe you did it because you're so motivated. There's very few people who unsupported could look at AIP and be like, "All right, I'm doing that tomorrow by myself."
Her program has so much great nuance that it walks people each week by eliminating the least nutrient-dense, most problematic foods at the beginning, and leaves the things like nuts and seeds, most nutrient-dense, and probably least problematic foods towards the end so that after six weeks, somebody is in full AIP, and then we added another four weeks to that of just maintenance AIP. So in total, it was a ten-week study, which was relatively short, but jammed into there was also guidance on sleep hygiene, guidance on incorporating stress management practices, guidance on engagement and relationships, and we have the community aspects. So everyone who's participating was in together so they're interacting with each other online and interacting with ourselves as clinicians, and I got to meet with folks individually as well as kind of a functional provider at the beginning, at week six, and at the end.
When I start to explain all these nuances, they're like, wow. That is definitely not just a diet study. That's not just hand people a book and say, "Do this" or just even one nutritional. This was lots of community, lots of personalized care, but it was all diets. As a functional provider, no one was going on a new supplement. No one was going on anything fancy in that realm. It was just dietary and AIP compliance tweaks, which to me is pretty awesome and pretty profound. So going back to the original outcomes, we specifically use the SF-36, which stands for Short Form 36 as a quality of life questionnaire.
It's one of the more routinely used questionnaires because it has multiple domains like physical health, emotional health, different parameters that you can tease out, but it gives you an easily quantifiable score. We also use -- it's not yet validated, but the Medical Symptoms Questionnaire, which is something that was developed by Jeffrey Bland of the Institute for Functional Medicine. The Cleveland Clinic uses it. I use it. A lot of functional practitioners use it because it gives a good breakdown objectively. It gives you a number, but a good breakdown of where people's symptoms are, and so we use those questionnaires to try to objectify that quality of life and symptom burden in our population, so those were the specific things. Then as I mentioned earlier, we looked at the full thyroid panel, so TSH, T4, T3, the free levels of those hormones, as well as two antibodies, the thyroid peroxidase antibody and thyroid globulin antibody, which are the two main antibodies used to either initially diagnose or track autoimmune thyroid disease or Hashimoto's.
Christopher: Who were the study participants? You said that it was Standard American Diet to AIP. Were those participants really eating a Standard American Diet before they embarked on the study?
Rob: Yeah. It's a really good question. The study participants came from 12 states, so they were across the country. They ended up being 17 women between the ages of 20 to 45 and they were either normal weights or just overweight, so BMI less than 29, so somewhat a narrow population, but also what I felt was very representative of the most commonly affected population with Hashimoto's. When I looked at their initial food frequency questionnaires, which I will certainly say we've probably talked about in your show when you look at our retrospective review like what did you eat over the last year, there's limited utility in getting a really great understanding of what that person ate, but when I spoke with them individually and I corroborated the food frequency questionnaire with folks, people were doing above average. They were not doing Standard American Diet.
Everyone was somewhat familiar with AIP because either a friend messaged them about the study or they had even tried it for like a day or two, but weren't able to sustain it, so almost everyone was aware of it and was doing -- some people were already gluten-free. Some people were already dairy-free. I try to put elements of that into the case studies and the study itself so you could see a deeper individual as a picture of who we studied, but yeah, these were not super sick, off the street people, but they also had probably a positive expectancy. You were talking about earlier there's a lot of information about the AIP diet now and there's lots of stories. Someone reads a story and like oh, I got --
Christopher: It sounds great.
Rob: -- on communications, so yeah, maybe someone does it and they get better just because they really believe in it. I think that that could be seen as a placebo, not real effect. When it comes to lifestyle change, dietary change, you have to believe that what you're doing is going to be helpful. It makes no sense to study people off the street and put them on a restrictive dietary plan that are like this is -- if you don't believe in it, it won't do it. So while in one sense, it's a targeted population and maybe there's an expectancy effect, in my opinion, it would be silly to just get a bunch of people who weren't familiar with it and just didn't want to do it. This would be a good study to be able to -- if you've got people who are motivated to change and people who aren't familiar with it do it and compare that to people who maybe had more familiarity and a greater expectancy, but yes, that base line, back to what your original question was, people were eating above average. They weren't eating the Standard American Diet.
Christopher: And how did you recruit these participants? It wasn't through Mickey's mailing list or anything like that.
Rob: It was also through social media. I can't remember if they put it out in an email, but it also was through social media because we wanted to get folks through different states. We didn't want to have --
Christopher: Right, but you see where I'm getting at here. We actually tried to do this recently and it's really hard, try and get ten people to participate in a study, but you're not allowed to use your social media account and you're not allowed to use your email list because the moment you do that, you've automatically introduced a bias, whereas if you talked to your mother-in-law and have her talk to some of her friends that she knows through her kid's school then you're going to get a very different person from the former way of recruiting.
Rob: I completely agree with you and I think that -- this might not be the right term, but one of the limitations of the study was yeah, we recruited from an already smaller pool because of that. I will say we had I think over 500 people submit an interest survey. A big fraction of them just off the get go didn't qualify because they were either pregnant or outside the age range, but yeah, that's definitely a very practical limitation of our study, was that we were already looking at a narrower pool because we use social media rather than practitioners, my practitioner network, or other means for recruitment, but from a practical standpoint, not really having a budget for that, if that makes sense.
Christopher: Right. Well, I think you've introduced a selection bias and you've made it much harder for yourself to find a positive outcome with the study because if people, as you said, already knew about the diet and had some expectation then I think it's going to make a difference to what you find when you do the trial.
Rob: Yeah, I completely agree.
Christopher: Okay. Tell me a bit more about how the support was delivered. You didn't just hand people a piece of A4 paper with foods they could eat and maybe on the back, there are some foods you can't eat, and just push it across the table. "There you go. I'll see you in ten days" or whatever it was.
Christopher: It was obviously a lot more support than that. So tell me about how the support was delivered.
Rob: Yeah. Angie, she's adapted a little bit now her education, but she has essentially a planned out six-week education program so that each day, there's new content. For our study, the way it was delivered was through a Facebook group, a closed, private Facebook group where the study participants got to interact with each other and interact with Angie as well as the other health coach nutritionists. She's now since made that content like a separate learning software and then had the Facebook community portion be different, but our study specifically, it was all embedded there. That's how people interacted with the content from their home. And since we had people across different time zones, everyone was kind of interacting with things slightly differently, but there was this core content that people would get and then the reflections so they would make comments on a post or say something, and then Angie might make a reflection back or some of the other participants will make a reflection, so there's this constant dynamic.
Then outside of that between Angie and myself, we met as a group a couple of times during it to help guide what I might discuss or talk about when I was meeting with the folks individually. In the beginning, I went over their initially thyroid labs and talked about if they were on too much, they needed to go back to their practitioner and get on less medication, or to review things. In the middle, we did a visit that was really guided towards just engendering further positive habit change that was really guided by some of the lab testing, but more of what Angie and Andrea, the other health coach, could provide. So it was really cool to be able to work with them outside behind-the-scenes. Then when I went into my individual visits, I could incorporate some of those things. I could also give some of my medical information to Angie then to then help enact in the health coaching world. There's both embedded personal individual care, but also that group dynamic. It's just incredibly unique. Angie has been doing this for five or six years now and really curating some awesome contents. I don't want to jump ahead to results and conclusions, but that honestly I think is making the difference.
For what you said somewhat jokingly like getting some of the recipe book or a sheet of paper, there's a huge element here going back to once again, we saw the folks at the beginning. People were aware of this. People were already starting from the higher starting point than they were in as sick on certain aspects on paper, so maybe it was going to take something just beyond the diet itself to allow them to either follow it or to add greater value. There's tremendous value, I think, in some of the education and community aspect that Angie provides in her program.
Christopher: And it wasn't just diet, right? You mentioned sleep and community support. Was there anything else that was part of the protocol?
Rob: Yeah. Those were the main elements. I'd have to go back and walk through. It really hit different lifestyle domains. I talk individually with different folks sometimes about their spiritual practice or how that embedded to a stress management practice and things. We're impacting them positively or negatively, so we really try to cover the gamut of what you might think about in sort of a naturopathic medicine context, the different lifestyle elements. Diet, movement, sleep are some pretty big ones, but some of the women were able to go for a movement around being fairly limited to not necessarily doing CrossFit workouts, but to start incorporating different movement practices or in some cases, even restrict your limit, maybe exercising too much in the beginning, so there was guidance there, but we really try to cover the gamut when it came to multiple lifestyle domains.
Christopher: How is the compliance? Did anyone drop out?
Rob: No one technically dropped out. We had to "kick" a woman out at the end because she got pregnant, which was her goal, which is pretty awesome.
Christopher: That's an upgraded problem. It's a better problem, right?
Rob: She'd been having some infertility issues. I think it was week eight or week nine. I sent a message to Angie and the group that she got pregnant, and so she didn't technically finish, but the other 16 women finished, which is remarkable given the restrictive nature of the dietary plan. Also, we asked them to do quite a lot. They performed blood testing at the beginning and the end. They also performed stool testing and organic acid testing, which is a pretty big burden to ask, and constant interactions with the group with no guarantees that things would get better. And so the fact that essentially nobody voluntarily dropped out and we had essentially everyone finished, it's pretty remarkable and speaks to I think the structure of the study.
I'm part of another study right now, a little bit differently designed, and I'm having dropout issues because it doesn't have that same kind of interaction and dynamic and there's much less of a "study burden" in this study. There's no testing involved in it, so it's helping me to see the elements that are key in order to help keep people maybe in a community or key part of a study because that's one of the biggest things. Tommy would agree too. When you start looking at some of the literature in different -- whether it's a drug therapy and things, you look at how many people followed up or dropped out. It's like massive amounts and maybe it's because of drug side effects or complexity of what was going on and that's a real world, an important thing to recognize because I don't want to do something that only -- so you start with 20 people and only five people can finish. That's probably missing the boat there if that's the number of people finishing.
Christopher: That's quite incredible, so 17 women in a ten-week program and no dropouts apart from that one woman that got pregnant. I think that might be a testimony to Mickey and Angie and also your self’s ability to coach these people is quite incredible. Is that typical for Mickey and Angie?
Rob: Angie has been -- I'd say in her group, she usually -- because of the community dynamic and what she's able to provide in her other health coaches, she has a pretty high retention rate because of that. I will certainly say that we in my growing clinic don't yet have contracted or employed health coaches. I do work alongside Angie to have people go through her program, but I certainly don't feel like we have the same rate of people -- I mean I don't stop being her patient, but following through with maybe some of their recommendations in the same structure that we would want them to because there's not that community engagement or that level of support, so I think she really has developed something that's quite unique.
I was having a conversation with somebody else that had a really good point. Could we design a study to maybe tease out the community aspect? Maybe you have a group that does this AIP versus AIP in this program and see what are the differences. I think that would be a really cool study because I don't see that once again as a weakness. We didn't study just the diet alone. We recognize the importance of community and I think -- I saw a post today. My good friend, James Maskell and Dr. Kelly Brogan, she's developing a new online community-based program for her clinic and her patients and clients, and James has been talking about from the beginning that community heals. You need this group setting. You don't see it as part of the placebo effect or something silly. This is incredibly critical, but yeah, it would be really fun to be able to do a study to tease out what was diet and what was the community aspect, not to devalue the diet, but to actually bring more credence and validity to the community aspect to further validate the role of community structures and group health coaching.
Christopher: Yeah. I don't see the problem with the top-down approach. Find the multidisciplinary approach that works and then once you've got something that works, sure, go ahead and dive down and figure out what all the different levers do in different combinations and all of that for different people, but in the beginning, you just want something that works, right?
Rob: Yeah, I totally agree. As a researcher, I want to know what element did it. As a clinician, I'm like, I don't particularly care, but people got better. I know there are elements in here that would have contributed. I just don't know to what degree for which person.
Christopher: Talk about the results.
Rob: Yeah, so going back to that primary outcome of quality of life, we saw at the group level a clinically and statistically significant change in the SF-36 quality of life, all eight in the total SF-36 as well as all eight sub-domains in the population. I took p-value with a bunch of zeroes. It was pretty robust. When we looked at the --
Christopher: Sorry. I'm laughing at your p-value with a bunch of zeroes take.
Rob: I know. Make fun of me.
Christopher: No, no, it's good. I like it. I know exactly what you mean.
Rob: Yeah. Tommy is probably giggling too. When I look at some of the sub-domains, a couple of the physical health parameters, physical role functioning, we saw some pretty big improvements. We also saw a pretty big improvement in vitality, which I'm not totally sure if that was -- we started pretty low.
Christopher: Can you define that? What is vitality?
Rob: It was basically energy and fatigue. It's that sub-scale, so when you look at the questions that are in the questionnaire, it's really getting at energy and fatigue and functional capacity from an energy standpoint. We also saw mental health parameters go up pretty significantly, and then a general health, which kind of incorporates multiple parameters. There were improvements across multiple domains, so it wasn't just like all physical or all emotional. There were elements across all of them, some more than others, but that was pretty amazing because in certain subscales, when I looked at previous studies and looked at other studies that use a healthy, controlled population, a lot of the subscales were either about the same as average or maybe a little bit better. Vitality was one that started out really low and it wasn't as high at the beginning as I would've expected, and so maybe the effect there was just getting people back to functioning barely or a little better than functioning barely, but the other ones are pretty robust.
Same thing for the MSQ, that symptom questionnaire, we saw a clinically and statistically significant decrease where the average in the beginning was around I think 90. It's like a golf score. You don't want a high score. It started around 90, which if people are familiar with the MSQ, that's a pretty big symptom burden. It's also somewhat reflective of some of the more complex function medicine patients. At the end of it, the average was something like 28 or 29. There was remarkable decrease, so those were the two most impressive results and findings. When we looked at the thyroid hormones across the group and the antibodies, we did not see a statistically or clinically significant change. I say that with a caveat, not to masquerade something, but we started off actually pretty good. The average TSH of the group was around two and the average TPO antibody, which is the main thyroid antibody used at Hashimoto's thyroiditis, was just a little bit more than 200. At least for me clinically, when I've seen someone in the literature, I just try to get people less than 500. Once you get down to these lower amounts, people's antibodies definitely don't correlate really well to their symptoms, so we were starting already with a group with the TPO antibodies.
I would've been really hard-pressed to see a change either way at that level over a short period of time, so while on the surface, you say, "Oh, we didn't see hormones change. We didn't see antibodies change," there wasn't much room to change. And so what actually I think is more representative of what happened, 6 of the 13 women who started the study on medication and finished actually were able to decrease their thyroid medication either once or twice during the course of the study. Three women who started at the beginning and finished actually started without the use of thyroid medication, and all three of them, by the end of the study, hadn't started any medication, so they had Hashimoto's with elevated antibodies. They just weren't hypothyroid and needing medication. When you look at it like that, it's actually pretty remarkable to see that people were able to use, even with that short period of time, start to use less medication and then associate that with the symptom improvements, the quality of life.
The last result I'll give you now until you reflect back some thoughts was we also saw -- and this is probably the stickiest marker. This is the one I had the toughest time how do we best represent this, was that high sensitivity CRP, the average in the beginning for the group that I was able to include in the analysis, so two people -- 2 of the 16 people were either acutely sick during one of the lab points, so I couldn't include then the analysis because they had appropriately elevated CRP because they were acutely sick, but of the 14 women who weren't sick, either blood draw or time point, the average there was something like 1.5 mg/L, which if you're not familiar with the range, less than three is considered normal, less than one is considered ideal. A lot of that risk stratification is still like in a cardiovascular risk.
Christopher: I was going to say we rarely see it above 0.5 even in elite athletes doing 20 to 30 hours a week of training.
Rob: Exactly. And so I give people the caveat, that point of like while I say less than one, if someone's not acutely sick, there is no good reason for that to be greater than 0.5. If it is and they're not acutely sick, it's a pretty good marker for telling you something's not quite right. If they are acutely sick, it's not helpful. It should be elevated or they have cancer or something that they're needing to respond to, but yeah. People who aren't acutely sick, it should've been definitely less than one, potentially less than 0.5, but our average was 1.5, so clearly something not quite right there, but also, we didn't start with an average of four of five. It wasn't crazy high like some of the folks in the IBD study if you go look at the stats because the inflammatory bowel disease process this. Some of those CRP markers were astronomical. And so when we looked at that same group at the end, the average was around 1.1, so almost a 30% decrease. The sticky point I got into was there was a pretty big outlier in that group of 14, and so I did a secondary analysis. I ended up doing the 14 in the original analysis and have all the data in the graph so you can see, oh wow, there's a pretty big --
Christopher: I like that graph actually.
Rob: I went back and forth. We had enough, that right size of data that it wasn't too overwhelming to show, and I wanted people to -- I didn't want a fake graph that didn't show what I wanted to show like the data so you could make your own judgments about it like yeah, that person is up here and here's the median and here's the mean. There was one person who's a pretty big outlier, so in a secondary post hoc analysis, we showed that the average at the beginning, if you didn't include that big outlier, would've been something like 1.2, and then afterwards, it was going to be like 0.8, so still a 30% decrease, but that actually got them under that less than one threshold.
What I've given as an analogy to this, it's a crude analogy, but I've given on a couple of other shows. Seeing that 30% change like oh, 30%, it doesn't seem like that much, it's more akin to like trying to lose the last five pounds versus losing the first seven pounds. The first seven pounds probably just melted off, so trying to get someone from five to three and a half probably won't take that much, but trying to get someone from less than ideal to less than one, what I consider ideal, is probably going to take a little bit different of an intervention. Yeah, there's a lot of stickiness with that CRP because if I didn't include the outlier then the p-value would have become not statistically significant, so do you not include it because it's not representative? Do you include it?
I try not to make a definitive conclusion in the study, but there was some clear effect going on that tells me as a clinician we should study this in a large population and find out, was it statistical noise or is there something going on here from an inflammatory immune modulation effect? Yeah, I tried in that graph to be able to help people look at -- I really encourage you -- the paper is open access. Look at the graph of the high sensitivity CRP, to look at the individual values to see because I think it does a good job of showing you -- there's clearly a downshift of where things were and you can see that one outlier. Yeah, that's I think the most interesting and curious thing for me, which someone who's a strictly objective person may be like, "Oh, I don't care about the quality of life thing. That's all subjective nonsense." Something was happening with the CRP I don't fully know, but it was going in the right direction and I would love to see in larger populations, could we replicate it or do we find that it was just this cool artifact because we had a small group?
Christopher: Elaine makes fantastic show notes that you can find over at nourishbalancethrive.com/podcast. I will, of course, link to -- I believe it's Figure 6 that you're talking about.
Christopher: Where you've got a bar chart for the pre and post group, and you've done something really nice and quite unusual in that you've plotted all of the data points, so you can see the outliers. It also highlights the fact that you could plot all the data points, so it hints to me that maybe this study was not sufficiently powered to show any effect at all, right? But to your point, it just means that you need to go out and do a larger study to see if you've got something or not.
Rob: That's the thing. It was a pilot study. If we had made some erroneous conclusion, yeah, we should change all clinical practice because 17 people, that would've been so silly. So yeah, if you can actually plot all the data points on a figure, you probably are empowered enough to make some robust conclusions.
One of my pet peeves -- and Tommy has been a great mentor for me through this process -- is I hate reading studies. I don't have the raw data or create some weird graph that you're trying to interpret or figure out, what was the raw data that they started with, so I put in the appendix, I put in all the raw data that we had. If you're a stats nerd, you go and do your own statistics and make your own conclusions and I wanted to -- because it wasn't too intense of a graph to show the raw data, so people can look at the graph and the figures and make their own judgments and not just think we made some silly erroneous conclusions because yeah, as a citizen scientist, I feel like when I read some of those papers, I'm trying to figure out what they did or what values they started with, and they have some crazy graph that I don't understand. This really bothers me, so I wanted there to be just an openness to be able to provide that so people don't just look at it and take my word for it or try to figure out what was going on and make a conclusion that was invalid.
Christopher: Were any of the results surprising? Did you see everything that you're expecting?
Rob: Honestly, in seeing some of the staggering improvements in the symptom questionnaire, having worked with folks clinically, I was expecting some improvement like maybe one person goes from a score of 100 to 6, but there was a remarkable number of those and I was just blown away, so the effect that we saw there, I was somewhat blown away by it. I was also not fully expecting that people were going to need less medication that quickly, even some of the folks that lost weights, and the main reason they needed less medication was from weight loss. There were a couple of people who I couldn't explain their need for less medication or their drop in TSH by weight loss alone, so pointing me to say something else was happening here, maybe they were better absorbing their medication in the gut. Maybe there are some other aspects of the trial intervention that was helping them from an HPA axis standpoint, so I was certainly surprised to see those changes and then some of the more subtle changes that yes, some people needed less medication and it wasn't just simply from weight loss.
The last thing would be maybe the CRP marker. I had no idea what it was going to be at the beginning. I think going back to your selection bias, I kept things very open, so I had no idea what the average antibody level was going to be at the beginning. I didn't recruit people only with antibodies over a thousand because I didn't want to see just statistical noise. If you get a bunch on paper who's sick, high antibody folks, and then you follow them for ten weeks then you see decreases to 700. Well, maybe that was just a decrease because it was really damn high at the beginning and it wasn't your intervention at all. I didn't know what the average level for these things were going to be at the beginning.
Back to the CRP, I was still really impressed to see that it started out less than ideal and get really either close to ideal or under it depending on the sub-population study. That pointed to me to say hey, maybe we should include this in a population and other studies even if it's not a marker that's routinely used like it is in IBD or in cardiovascular disease.
Christopher: Does that make you question at all whether we truly understand what the disease looks like in blood markers? If you know that you've got this improvement in subjective life experience and no doubt you're having the opportunity to talk to these women and know that they're getting better, it's obvious, right? When one gets pregnant then you know they're getting better, yet you see no change in the blood. Does that make you question at all what we know about the disease from doing blood tests?
Rob: Yeah. Well, I think in the functional medicine space, we've probably gone too far in the other direction. Putting too much stock in thyroid antibodies as an example, I think it's a great less invasive test than, say, thyroid biopsy. Even ultrasound is not as invasive, but it's a costly test that involves specific equipment, so it's a great way to screen and we found to be fairly specific, although there are folks with Hashimoto's who are antibody-negative. They would only be diagnosed by ultrasound or via biopsy, looking at the [0:44:45] [Indiscernible] infiltrate thyroid tissue, so you technically would miss those people if you just looked at antibodies, but back to some of my earlier points, I haven't seen the clinical correlation between someone's symptoms and the antibody level once you really get below 500. There are different studies that have looked at different aspects of quality of life and I think cognition is maybe less than 101 study as a small study, but I just haven't seen it pan out.
As an example, probably I wouldn't say the sickest, but one of the sickest women from a symptom burden standpoint and even her organic acid testing, which showed too from a nutritional standpoint, one of the sickest people, she actually -- at the beginning of our study, her thyroid antibodies were just within the normal range. She had had them elevated previously on the medical report that she submitted to be able to be in it, but when she started, she technically was just inside the normal range. They stayed normal by the end of it, but she started out with crazy symptoms, which her antibodies were normal. "Oh, your Hashimoto's is in remission." Well, she was doing really bad. So I don't want to put so much stock in these antibody levels especially when as you start treating antibodies and you start to feel better but then you re-test and maybe it hasn't changed or it's gone up, you get this nocebo effect. So someone starts to feel worse because oh, I haven't changed the disease progression. Well, maybe since we're just measuring antibodies, we don't know what's happening at the cellular level. We don't know what might have changed in your gut ecosystem because of other things that have been utilized in a treatment.
I think they're helpful for initial diagnosis potentially if they're really, really high and you want to track to get things done under a certain range. And then I think it's important to literature too for looking at antibodies in pregnant women or women trying to conceive. Outside of that, I think we get too overzealous with tracking antibodies especially when they're in these lower ranges because people want to say in the functional community, "Oh, that's evidence of autoimmunity." Well, I'm not going to argue with that, but from a clinical standpoint, is it going to change anything that you do beyond once you get the diagnosis? So for me, if I see someone who has those antibodies in the beginning, okay, you've got Hashimoto's. Let's maybe make these recommendations for AIP diet or other changes versus someone who doesn't. Yeah, I think we've maybe gone a little bit too far to start testing them every three months. When I see that, I'm like, we are not doing the right thing here. We're missing the boat and it can potentially take someone who's feeling better make them feel worse because they saw that their antibodies didn't change.
Christopher: Yeah, it's a difficult discussion that needs to be handled with great care. Now, I think that Tommy has written about this and maybe I can link to it in the show notes, but in essence, you're right. You don't want to nocebo someone that is obviously getting better, but at the same time, there's a risk of normalizing disease, right? So okay, you've got 500. That's normal. We've seen people doing really good with levels of 500, so you don't need to worry about that. That's clearly not the case and I'm pretty sure I can cite some studies in the show notes showing worse health outcomes with the higher levels of antibodies, but yeah, you're right. If you're working with someone and it was in the thousands and you put it down to 500 then clearly that's a clinical win.
Rob: Yeah. I would love to see more robustness there, I think, because once you get down to these lower amounts, yeah, there's an autoimmune process represented by that antibody, but as a clinician standpoint, does it make sense to be tracking someone once they're below 70 every three months? It probably doesn't. You're getting into a wasteland, and so being able to use it properly in context and I think it's going to be critical in helping to educate folks so we don't get overzealous with testing because that's the other thing that I think folks from medicine can do inappropriately, is you do all this testing. Well, then you find a bunch of stuff that looks wrong and it's like, well, all of this would've gotten better just because you did something.
One of my main conclusions from this study was folks got better in ten weeks with no supplement therapy and no drug therapy, and they came in pretty complex. So this could better inform how we should care for folks in the integrative functional space. If someone comes to you pretty complex, pretty sick with a lot of issues and you're drawing at straws like do I start with the gut, do I start with hormones, do I start with this, what tests do I order, maybe what we should be doing is putting them into a very supported community health coaching program that maybe walks them through something like AIP or walks them into Paleo and do that over 10 to 12 weeks and then see what falls away. Whatever is left after that, that's what you dig into.
As a clinician, I've been able to work with a couple of the women after the study. It knocked away so much noise so that I knew at the end, oh, yeah, we do the gut stuff now. Oh, female hormones, we need to explore that now. It made it so much clearer so that it's going to improve value for them. It's going to decrease total cost. I see it. Well, I'm not going to once again make a conclusion and say we need to really change clinical practice based off one small pilot. It should help inform us to say nutritionists and health coaches, this group dynamic, you guys matter a ton. If we employ this in more creative ways like Angie is doing, like Angie and I are doing together, we might start to move the dial in the right direction and start helping people at scale for a lower cost and be able to improve the value of care that we provide. Maybe that's what gets noticed by somebody else versus I just do all my fancy testing, find some stuff that's wrong, and do some complex treatments and maybe get the person at the same state, but they've gotten there by just doing a dietary lifestyle intervention with group health coaching.
Everyone's different, but I would encourage folks to think about that. It's not to say we should stop researching the gut and stop focusing on the gut, but let's use some of the basic principles that we have now in new, creative ways to help people in maybe a way that you couldn't before on your own, and maybe we start to move the dial that way rather than introducing some new fancy treatment or protocol or what have you.
Christopher: Could I have you speculate as to the importance of the autoimmune Paleo protocol as the specific dietary intervention in this study if you were to do everything else that you did? I'm sure Angie would be just as capable at coaching people on just a Paleo-type diet that didn't go as far as AIP or the specific carbohydrate, say. Would you expect to see very different results?
Rob: I would not. I would expect to see -- if we just basically insert a new dietary regimen within her program structure and the care that we provided, I would expect to see somewhat similar results. I think it also would come back too to the person's familiarity and expectancy and belief. Maybe we could've taken folks on a wider audience and if they believe that low FODMAP or SCD was the thing for them and we coach them through that, maybe see even greater benefits because I'm always wanting to hear what people have researched and believe in. I don't want them to do something that's completely detrimental, but if there's some potential efficacy behind it and they really believe in it more than say AIP then maybe that's what you should do, so I would really expect to see similar improvements whether it was a Paleo diet, an SCD diet, AIP.
I think some of the positivity, back to what I talked about earlier in the podcast, was because the people in this study believed in AIP specifically. So if we had gotten a group of people that really believed in low FODMAP or SCD, I would expect to see some similar things, and there's enough cross-pollination similarity between a basic Paleo template and AIP. And while the people in the study, a lot of them have already removed grains or removed dairy, there was enough still non-Paleo in their diet that could've been removed gradually in a similar structure that would've gotten them to just Paleo and probably would've gotten the same results. This is all, as you said, speculative, but definitely I'm not a dietary zealot. I've seen great power from nutrient-dense elimination diet. It's like AIP, but they have to be applied in the right context. It takes a lot of rigor to do it even in a group setting. If someone's got all sorts of stress going on in their life, they're a new mom and this and that, maybe it's not the right time to be doing something like strict AIP, so you have to apply things in context.
Christopher: If I'm listening to this and I would like to take part in the program, is that still possible even though there isn't a study ongoing?
Rob: Yes. Angie still does her -- it's like quarterly groups of the SAD to AIP in SIX Program. I think her next group is starting in September because we're going to be doing -- hopefully, as this comes out, I've just started the next AIP study for eczema and psoriasis. I'll be working with Lucy Mailing, who's a wonderful -- I think either just gotten her PhD or just about to get her PhD, really gut-centric researcher, just a beautiful human being. She'll be at the Ancestral Health Symposium this year too, so anyone who's interested, definitely come and meet her. We will be collaborating on the next study.
Angie's next program open to the public should be starting, I think, in early September. She usually opens enrollment a month early, so around August to participate. I cannot emphasize enough how amazing the program is. I've had personal patients go through it. I've worked alongside Angie in a program. I've observed the group even before all this started. It's a wonderful group, and so if you've ever had any hesitation or inability to follow through on things that you've wanted to do, this program is just -- and the value of it too is incredible, so yeah, I think early September.
Christopher: That's amazing. I will, of course, link to that in the show notes. I will of course link to the Ancestral Health Symposium in San Diego is this year in August, is that right?
Rob: Yes, mid-August.
Christopher: Are you going to be there, Rob?
Rob: I am. Angie, Mickey, we're going to be there talking about the study, so that's --
Christopher: That's great! That's fantastic. I think I saw Lucy talk at last year's symposium in Bozeman, in Montana.
Rob: My residency at the time was awful, so I could only come for a day --
Christopher: Oh, okay.
Rob: Even presenting, I wasn't able to get there to spend time. I was introduced to her, but I missed you guys, so --
Christopher: Oh, that's right, yeah. Don't worry. We're going to be there this year as well. I think Tommy is going to be talking and I'm going to be there with Megan and Zach and Clay. I believe Josh Turknett, our neurologist, is talking as well, and Mike T. Nelson as well is going to be with us. I'm sure he's talking too. I haven't checked the speaker lineup, but yeah, I will of course link to that in the show notes. I hope people can make it to San Diego.
Rob: It is the best value. I have a huge bias, but it's an awesome conference. It's such a great value. It's a very intimate experience and if you want to geek out, nerd out, it's a place to go, in my opinion.
Christopher: Yeah. It's just great to feel like a part of a group of friends for a while, right? I find this diet and lifestyle to be quite isolating, going and hanging out in the wild, and there are all these other humans that you don't relate to in any way, shape, or form.
You go to the Ancestral Health Symposium and you can almost guarantee that you'd have something in common with everybody there and there are hundreds of people there, so it's a great experience.
Well, Rob, can people work with you as a patient? Can I find your clinic online if people are interested in working with you? Is that a possibility at this time?
Rob: Yeah, it is. I'm in Charlottesville, Virginia, so I'm on the East Coast. As I mentioned earlier, I work alongside Ryan Hall, a nutritionist, so we work together as part of our clinic resilient roots. We're doing both the full scope care with folks in Virginia. I can do full scope care in Virginia or folks who come to Virginia, but also still doing telemedicine and sort of the functional medicine nutrition world with folks across the country, so yeah, Resilient Roots: Functional & Evolutionary Medicine is our full name of the clinic.
Christopher: That's great. I love the name, by the way.
Rob: Yeah. I can't take credit for it. Ryan made up the name and his wife made our logo, so no creative credit on my end, but yeah, we're really trying to change the dynamic of how to work together and deliver functional care. Make sure you get the links if folks are interested to work with us. If they're in the East Coast area in Virginia, that would be awesome. We're growing and wanting to work with folks and provide really value-based care. I've been super excited about it. The transition from residency to doing that has been night and day and doing what I love every day of the week.
Christopher: Tell me about the telemedicine part. Do I need to come and see you once in person first?
Rob: Yeah. In order for me to be able to do full scope care, yes, I have to see someone in the State of Virginia, but we can do basically full scope functional care across telemedicine. I can't prescribe someone a medication who I've never seen before in person or go through insurance avenues.
Christopher: I will of course link to your practice in the show notes. It's Resilient Roots: Functional & Evolutionary Medicine. That is awesome. I love it. It's too long, but then it's got to be long so you won't get the domain name, but it's obvious what it means. I really like that. Yeah, that's really great.
Rob: That's the title of the study and the title of our clinic. You know what it is.
Christopher: Yeah, so you've got people writing titles. That's fantastic. Well, Rob, I think you're doing fantastic work and I look forward to seeing you in San Diego. And then I also look forward to seeing the results of your next study. Maybe we can do another podcast and catch up then.
Rob: Yeah, I would love to. If you haven't already, I'll make sure to connect you with Lucy and get her on the show to talk about all things gut because she's just a wealth of information, so yeah, I'm really excited to be able to sit more in the backseat on this one. I did a lot of heavy lifting for this study to be able to sit back and --
Christopher: I can only imagine. You know what? I thought that Tommy was going to interview Lucy and somehow, it hasn't happened, but I will be taking my recording gear to the Ancestral Health Symposium and hijacking people and having them -- "kidnapping" is maybe a better word, kidnapping people and having them record a podcast with me. Maybe I could get Lucy then.
Rob: That would be awesome. She's great. She's just wonderful.
Christopher: Awesome. Well, thank you so much, Rob. I really appreciate you.
Rob: Yeah. Thank you for having me back and for helping to make this study possible in the first place. It's been really wonderful. I should put in context, we did all this in less than a year, the whole process.
Christopher: Yeah, it's amazing.
Rob: It's pretty awesome.
Christopher: Congratulations. Thank you.
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