Dr Nirala Jacobi:

Welcome to another episode of the SIBO Doctor Podcast, and today I'm welcoming back to the podcast Dr. Steven Sandberg-Lewis. Dr. Steven Sandberg-Lewis has been a professor at National University of Natural Medicine since 1985, focusing on gastroenterology and gut associated physical medicine. Within gastroenterology, he has a special interest and expertise in inflammatory bowel disease, irritable bowel syndrome, small intestine bacterial overgrowth, hiatal hernia, gastroesophageal and bile reflux, biliary dyskinesia, and chronic states of nausea and vomiting. He's the author of the medical text book, Functional Gastroenterology: Assessing and Addressing the Cause of Functional Digestive Disorders, now in its second edition, and he also authors a monthly column in the Townsend Letter For Doctors. He has recently opened Hive Mind Medicine, a highly specialized clinic focused on digestive and mental health in downtown Portland, Oregon. We've also had the great pleasure to have Dr. SSL, as he's known in our industry, out in Australia to present a two day seminar on learning how to conduct functional gastrointestinal physical exams, which is a wonderful course for practitioners specializing in functional GIT disorders, and that course is available on thesibodoctor.com. So welcome. Welcome back to the podcast Steven.

Dr Steven Sandberg-Lewis:

Thank you. Thank you.

Dr Nirala Jacobi:

I'm really looking forward to talk to you today because we are very close to launching a new course on The SIBO Doctor, that you and Dr. Kievan Jenna will be presenting on liver and gallbladder disorders, and your focus will be on the gallbladder and also on NASH. So let's start out with just giving a bit of a preview of what this course is about.

Dr Steven Sandberg-Lewis:

Yeah actually Kievan Jenna and I have been teaching this course for about, I think 17 or 18 years at National University of Natural Medicine. This is the first time we're doing it online like this, for other practitioners, so that's exciting. The course, we call it the Liver in Health and Disease when we teach it at the university, and Kievan is actually a naturopathic hepatologist, and has focused his Chinese medicine and his naturopathic medicine on liver conditions since 2001 or so, when he graduated. I was teaching a course on the liver and asked him to join me, once he was in practice for some years, and the guy is so knowledgeable and of course can talk about Chinese medicine and Western medicine, either one very eloquently, and the use of botanicals and nutrition too, to treat the liver and focusing on hepatitis in his lectures.

Dr Steven Sandberg-Lewis:

My lectures, two webinars, will be focused as you said on non-alcoholic steatohepatitis and fatty liver disease in general, as well as the sterolbiome, which I didn't know about until about four years' ago, when I came across several articles in PubMed, about how all of the cholesterol based steroid hormones are functioning within the small and large bowel, mostly in the small bowel, and this relates very much to SIBO and how steroid hormone endocrine function and balance is so closely controlled and balanced through the microbiome in the small bowel, and how they metabolize bile, and conjugation of bile and deconjugation of bile, and primary and secondary bile acids, and all these dramatic effects, basically the bugs in the small bowel and to a little bit of a degree the large bowel, basically turning on and turning off genes throughout the epithelium of the 18 to 20 feet of small bowel, and controlling in large part the human genome.

Dr Steven Sandberg-Lewis:

An interesting little tidbit is that if you put together all the genes of all the 400 to 500 species of bacteria, just bacteria alone in the large and small bowel and stomach, you have at least 100 times more genes than you would in the human genome which is about 23,000 genes or so, and you know 100 times that, some say up to 300 times that in the genome of the bacteria that live and line the gut.

Dr Nirala Jacobi:

So will you be talking about, I mean what you're talking about is sort of activation of these hormones, if you will, by gut bacteria, is that sort of the focus? I mean I think also in your course you'll be going through the path of physiology of different gall bladder issues, with a focus on this particular sterolbiome, is that correct?

Dr Steven Sandberg-Lewis:

Yeah, in large part talking about how they control the toxification pathways through the bile, and how they activate and deactivate steroid hormones, produce some of the steroid hormones, as well as producing neurotransmitters such as serotonin and GABA, and then also like I said, affecting human genome by the FXR pathway, the PXR pathway, that are major, major pathways that control all metabolism throughout the entire body systemically, as well as in the gut, and have tremendous effects on glucose metabolism, fat metabolism, and many of the basic pathways in the human body. So it's huge and you might think of it as the sterolbiome as basically a steroid hormone endocrine system based in the gut, that we didn't even know was there.

Dr Nirala Jacobi:

So that's when bile actually arrives in the small intestine right, and those bacteria then sort of act upon it as well, but before it arrives. I always learn so much from you. Before I really focused in on digestive health, I never heard about biliary dyskinesia until you discussed it and then really learned a lot more about it, and talk about it occasionally in the podcast or in my presentations et cetera, but you're really the master of it, so that's going to be one of the topics that we discuss. Because this is the SIBO Doctor, what is the relationship between SIBO and gall bladder diseases or disorders?

Dr Steven Sandberg-Lewis:

Yeah, so first of all there's lots of research that connects non-alcoholic steatohepatitis and other fatty liver diseases with SIBO, S.I.B.O I call it. There's a strong connection there and in this country we've changed the term for methane dominant S.I.B.O, and we're calling it intestinal methanogen overgrowth. So I really think intestinal methanogen overgrowth is perhaps even more potent in effecting motility in general through the gut, including motility of the gallbladder and bile secretion, and metabolism. So I really find that very often, and we'll talk about that, how there's a strong connection there. I'm not so sure if the hydrogen dominant S.I.B.O is as dramatic in its effects on the gall bladder itself, but certain it's highly related just to non-alcoholic steatohepatitis and fatty liver, very direct connection. And there is a relationship with gallstones and bacterial overgrowth as well, and certainly biliary dyskinesia and intestinal methanogen overgrowth, I see that all the time.

Dr Nirala Jacobi:

This reminds me of the podcast that I did a couple of years ago with Dr. Sam Rahbar in L.A., and he often finds with IMO or intestinal methanogen overgrowth as we call it now, this issue with bile reflux. Is that what you're talking about? And can you talk about bile reflux a little and its significance.

Dr Steven Sandberg-Lewis:

Yeah, so bile reflux, he does some really nice work with that. Bile reflux is of course the backward flow of bile from the duodenum up through the pylorus into the stomach, which may be further refluxed from the stomach into the esophagus, and I'm going to talk about why I think that Barrett's esophagus and dysplasia of the esophagus and tendencies towards cancer of the lower esophagus are highly fueled by this bile reflux. We know that secondary bile acids are carcinogens and so if you're refluxing a carcinogen from your small intestine up into your lower esophagus, you're going to have a much more evil fluid coming up, than just stomach acid and pepsin. It makes it even more carcinogenic, and I think that that's a big factor in Barrett's esophagus being a risk factor for esophageal cancer.

Dr Steven Sandberg-Lewis:

You know normally we don't have bile in the stomach and I have more and more patients now, I must have about 10 patients now, that have had upper endoscopes or other forms of diagnosis that show bile pooling in the stomach. You know they'll actually estimate the amount of CCs in there and that is just not supposed to be happening. Very often these people have intestinal methanogen overgrowth as well, that's fueling that reverse activity.

Dr Nirala Jacobi:

So what you're saying is people that have high levels of methane are more at risk for like a retrograde motility, kind of like the stuff sort of flows backwards?

Dr Steven Sandberg-Lewis:

Yep and the biliary dyskinesia as well, which is the flow of bile from the gallbladder through the cystic duct into the small intestine.

Dr Nirala Jacobi:

So can you explain what biliary dyskinesia is for those listeners who maybe the first time that they've heard that?

Dr Steven Sandberg-Lewis:

Sure. Kinesia of course is movement, dys as you know is trouble with or dysfunction. So trouble with motion. You can have dyskinesia in many places, and when you have it in the gallbladder, the patient may or may not have gallstones, they usually have at least sludge, meaning that their bile is thickened, it's tending to form cholesterol crystals, and it's sludgy and doesn't flow well, and everything is slowed down. That's part of biliary dyskinesia, often is this thick bile that doesn't move well, so it doesn't come out very well. The diagnostic test for biliary dyskinesia is to do the HIDS scan, which actually measures the amount of bile that is ejected out of the gallbladder when it contracts, and it's normally going to be at least 35% or more. I have patients that have it in the teens or below 10. I have one patient who had a 0 ejection fraction of his gallbladder, we've been working with him for several years now, he's doing a lot better, and he had mega meth as well, his methane levels were in the 60s and 70s. So he's a classic example of that relationship.

Dr Nirala Jacobi:

So do you then see improvement, I mean I know we always have a sort of a comprehensive approach towards conditions like that, and I'm assuming you would do more than just treat methane. But have you seen good results with improvement of slow bile flow, just with treatment of methanogen overgrowth?

Dr Steven Sandberg-Lewis:

Well, I have to say if a patient has sludge, meaning crystallized cholesterol that's thickening their bile, I'm not just going to treat their methanogen overgrowth, I'm also going to be using Choleretics and/or Cholagogues, and other things to thin the bile, make it flow better, and make it less lithogenic, less crystallized. So I can't say, just like you probably, you all get this, is that we rarely do just one thing. But I think that if you did nothing else, you'd probably get pretty darn good results if you just treated the methanogen issue.

Dr Nirala Jacobi:

That's always a really good reminder. I think that the gallbladder is sort of, A that the gallbladder is under appreciated and bile is sort of underappreciated, and it's sort of made a comeback with I think the SIBO education that we've received over the years with bile being really important, and bile being denatured, when people have SIBO because of bacterial or gas damage to the bile acid. So how often do you, you know there are so many different protocols out there, and we're pretty consistent with how we approach our patients, but how often do you find you need to use supplements like Ox Bile?

Dr Steven Sandberg-Lewis:

I don't use it as much as I used to, but it's a very useful tool. Certainly if I have a patient that has bile reflux, I'm not going to give them that, because their already refluxing bile, would just give them more bile to reflux. It's certainly used to help the crystallization, decrease the crystallization of bile, to make it flow better. It's often used to help reduce the size of gravel, and it certainly can help someone who has trouble with fat malabsorption. You know you might do a pancreatic elastase or chymotrypsin in the stool, and find out that the person has excellent pancreatic enzyme function, but you're also seeing that they've got fat malabsorption, based on how their stools look and their weight loss, and all these other problems. Very often that's more of a bile issue and it may be a bile issue secondary to the overgrowth of bacteria in the small intestine converting bile to secondary bile acids which are less effective of digesting fat.

Dr Nirala Jacobi:

So can you just briefly talk about, you may have just done it, but primary and secondary bile acids, what the difference is, for those listeners who are not really familiar with that concept?

Dr Steven Sandberg-Lewis:

Yeah, you know I go into all the details of that in the seminar. But basically there are two initial primary bile acids that are produced in the liver, and then when the bile is secreted through the sphincter body into the small intestine, then bacteria, because they don't like it, you know we know that bile is irritating to bacteria, it starts to breakdown their outer cell wall, they don't like it, so they will convert the bile to secondary bile acids, which are less toxic to them, which also don't digest the fat as well, don't emulsify the fat as well. They also may take bile that has been conjugated in the liver, as part of the detoxification pathway and they may deconjugate it and make your patient more toxic. So it's not only the metabolic byproducts of the bacteria such as the polysaccharides and other irritating metabolic byproducts, but also the fact that you have this less effective fat digestion and you may get deficiencies of several essential fatty acids and fat soluble vitamins, but also you've got this reconjugation or deconjugation kind of undoing the detoxification pathway of the liver.

Dr Nirala Jacobi:

I think that's a really, really important point and you know as I've been moving more also into the mold illness field, as it relates to SIBO and it's so relevant when we talk about bile because micro toxins are secreted or excreted into the bile, and then if bile is then deconjugated your patient possibly reabsorbs some of these micro toxins, and like you say all these other metabolites that come from that. And the other important point that I sort of picked up from what you just said, because you know I see a lot of patients where I do stool testing or CDSA or complete digestive stool analysis and panel, and so many patients have high fecal fat, it's really amazing to me. I mean I know I have a selection bias with the type of patients I get, but it's just all the time I see it in the stool. So meaning that they're likely not having the bile acids to be able to emulsify that fat.

Dr Nirala Jacobi:

You know it's also really hard to determine if it's just a high fat intake, I mean it's not that hard to determine that, but it is so prevalent that I see this high fecal fat, I wish there was an easy test to see if it's just bile acids, you know that are deconjugated or if that person is actually secreting bile. Is there such an easy test?

Dr Steven Sandberg-Lewis:

No, there isn't.

Dr Nirala Jacobi:

Yeah I know. I wish it was easy. But the important thing you had said before was that a lot of people just give Cholagogues like you say, or herbs that stimulate bile flow and thin the bile and give supplements. But it's also really important to remember to perhaps replace or replenish some of these fat soluble vitamins and the essential fatty acids, because they've gone maybe years without vitamin A or E and essential fatty acids. So I think that's a really good point. I can't wait to listen to this one, is about the sphincter of OD dysfunction, which I suspected exists, and you'll be talking about it. So I'm really looking forward to that. But just briefly can you talk about what that actually is?

Dr Steven Sandberg-Lewis:

Yeah, it's not considered to be very common. It's a term that's mostly used after cholecystectomy. So you know common scenario, many people who have their gallbladders removed, it really, really makes them feel so much better, you know because of toxic gallbladder that's full of stones can really make somebody sick, feel sick all the time. But there are, if you don't go ahead and clean it up, like we tend to do, if the gallbladder though is removed, I get all these patients who've had their gallbladders out and it didn't take care of their pain or didn't take care of the dysfunction that they were having, the reason they had the surgery to begin with, it's usually because of bouts of intense pain.

Dr Steven Sandberg-Lewis:

So they're coming to me post-cholecystectomy, and these are not common in general, but one of the more common post-cholecystectomy syndromes is sphincter body syndrome. You can think of that as basically sphincter body dyskinesia. You know there's no gallbladder anymore, there is a cystic duct that's usually left in, but the sphincter body, the entrance of bile into the small intestine from the common bile duct is functioning improperly. That's the theory. And so again, you know nobody's taken care of their methanogen overgrowth, likely, and that's going to be really important if you're trying to take care of dyskinesia anywhere, especially in the upper gut.

Dr Nirala Jacobi:

Really fascinating. I look forward to learning more about that. I know I have patients with this, and when I look through the itinerary of what you'll be talking about, I just was like, "Oh man, I can't wait for that one." Really good. So what are the typical symptoms for patients. Sometimes patients listen to this podcast, even though it is for practitioners, but you know people are always looking for answers. So what are some of the more common symptoms that are associated with just general, that something is going on with the gallbladder? Some practitioners also maybe not that honed in on the gallbladder, so it might be good to review some of those.

Dr Steven Sandberg-Lewis:

Well a big one is chronic nausea, certainly right upper quadrant pain. Sometimes it's related to, at least in Chinese medicine perspective, people who have a terrible time making decisions, it's really hard for them to make decisions, and they can have brain fog of different types. Certainly, they may have trouble digesting fats, just like someone with hypochlorhydria might have trouble digesting protein and minerals, and they do tend to be constipated. There is bile acid diarrhea which we're going to talk about, but that's not so much a gallbladder problem, it's more related to the liver, and the metabolism, and the reabsorption of bile, so we'll talk about that. But most of these patients have, I call it, LLC, lifelong constipation. That's my typical patient who has a gallbladder problem. And often they have insulin resistance too, pre-diabetes or insulin resistance syndrome in general. They may be diabetic as well, but you don't have to be diabetic to have this problem, you can be pre-diabetic or just in the insulin resistance stage. So those are some real common symptoms I see.

Dr Nirala Jacobi:

Okay. Great and that's a nice segue into the other module that you teach in this course, which is NASH or non-alcoholic steatohepatitis, and you have a really unique approach to this, where you sort of have a comprehensive approach, can you talk a little bit more about that?

Dr Steven Sandberg-Lewis:

Yeah, so as I've discussed with you before, I think that NASH is so key to what at least 25%, if not 35, 40% of our patient have, and that's insulin resistance. In this case it's hepatic insulin resistance, just as in polycystic ovary syndrome it is ovarian insulin resistance, and it's so, so basic and fundamental in terms of a person's entire health. But we know that for instance if someone has diabetes Type 1 or 2, they have a pretty high percentage of having gastroparesis, especially Type 1 diabetes, it's up to at least 40%, some say higher of patients that have delayed gastric emptying. And then of course it's not just the stomach, it can be the small intestine transit, migrating motor complex in general, and can even be colonic transit. So insulin resistance and diabetes in general, and blood sugar metabolism all is very much related to problems with motility, overgrowth of bacteria in the small bowel, and this surge of extra work that the liver has to do to deal with not only the blood sugar problem.

Dr Steven Sandberg-Lewis:

So the liver starts making more fat to try to get a different energy source, but also the liver has this highway, the portal vein, that just brings all this lipopolysaccharide and proteoglycans from the small intestine directly to the liver and just it's auto-intoxication. You know it's what the old time naturopathic doctors always talked about, they tended to think that it was more toxic liver due to the colon being slowed down in its function, and retention of stool and all that. But really it's a combination, and even more so it's the dysmotility in the small bowel, that leads to these kinds of fatty changes in the liver.

Dr Nirala Jacobi:

And your approach is sort of unique, in that you do not just focus on the liver but really systemic, like you really have a systemic approach, right?

Dr Steven Sandberg-Lewis:

Yeah, well if nothing else, if you don't change the microbiome in the small bowel, you're never really going to get the right balance of steroid hormones, short chain fatty acids, all these major substances that control metabolism, blood sugar, insulin sensitivity and resistance, all these things that are controlled by the bacteria, and all these synthesized substances from the gut. Three years ago I think it was, at one of these GI conferences we do at the university, I decided I was going to prove once and for all to myself, that it doesn't all start in the gut, but the gut is at the center of the universe. So I did a lot of research and I did a talk, presentation on the relationships among the GI tract, the cardiovascular system, and the renal system. And I was out to prove it to myself that it wasn't all about gut.

Dr Steven Sandberg-Lewis:

And I became even more convinced that it all starts in the gut. There were renal toxins, there were cardiovascular toxins produced in the gut, that are very commonly produced from things like tryptophan and choline, and other common nutrients and amino acids, when the bacteria act on them to either ferment them or to cause putrefaction of proteins, these toxins get produced, and go systemic, and feed all of these cardiovascular and renal degenerative processes. I wrote a song about it, because it all starts in the gut, because it's really true now. I know it's true.

Dr Nirala Jacobi:

It's so great when our old philosophies are validated by science. It always is extremely gratifying I find. Definitely the gut has been center stage in so much research over the past few years, and everybody is so interested in gut health, so this is very on point I think. So it sounds like it's going to be an absolutely amazing course, because also what Dr. Jenna will talk about is really deep dive into the whole detoxification aspects and healthy liver, diseased liver, different liver enzymes, how they actually read them correctly, and all of that. So I think it's going to be a really useful course, not just for people that focus on SIBO, but like you say, the gut has such an array of metabolites or the metabolome of the gut is so influential on all these different systemic illnesses, that I think it's going to be a really key piece or pieces of information, that will kind of come together with this course.

Dr Nirala Jacobi:

So I'm really excited to be offering it. And it's some amazing, 16 years, that's crazy how long you guys have been teaching that course. And obviously in that 16 years, a lot of updates and a lot of developments, especially in how SIBO relates to all of that. Not quite in closing, we've got a few more minutes, so gallbladder issues, NASH, in terms of NASH or this particular type of liver inflammation really, what are some of the symptoms that people and practitioners should look out for, that are associated with NASH, that your patient might actually be having this issue, besides getting an ultrasound of the liver?

Dr Steven Sandberg-Lewis:

What kind of symptomatic?

Dr Nirala Jacobi:

Yeah, what are the some of the symptoms that a patient may be presenting with, that might give a practitioner, you know pause or indication of further testing and things like that?

Dr Steven Sandberg-Lewis:

Well, the funny part is that a good, strong minority or most of the patients are "asymptomatic". That's what it says in all the books and the articles. I don't believe that, I think from a naturopathic point of view, there are very few asymptomatic patients. I think most doctors have such brief visits and such a narrow focus, that they don't even recognize the patient has symptoms or signs of NASH. But I think we would tend to appreciate them, and again they might be things like moderate indigestion, and low-grade nausea, and low energy, and you can find things that patients will have, that just don't come up in a five minute visit, in standard medicine, so they are considered asymptomatic. But the first and most common sign would be hepatomegaly, or right upper quadrant pain or discomfort.

Dr Steven Sandberg-Lewis:

So that's probably your best symptom, would be a patient who has tenderness to palpation or talks about how it just aches in the right upper quadrant. That's maybe 25 to 30% of patients with NASH, that have that. But again I think that all the symptoms of pre-diabetes and insulin resistance should alert you to the fact that you need to look into this. Even if they are "asymptomatic," which is rare.

Dr Nirala Jacobi:

Good, all right. Now I also want to give you an opportunity to talk about your clinic, because you have just opened this beautiful clinic in downtown Portland, and for those practitioners that, if you have a case that you're stumped with, I think you have a master diagnostician here with Dr. Steven Sandberg-Lewis. If your patient is in America, I would recommend that you look his clinic up, as a point of referral. Do you get a lot of referrals to your clinic? Obviously you have the whole gut as an area of specialty, and as you mentioned before gut and mental health. But maybe talk a bit more about your practice, because I think that people, especially practitioners should know about it, if they're, like I said really stumped with a case.

Dr Steven Sandberg-Lewis:

Yeah. Of course right now it doesn't matter probably where your patient is from because we're doing telemedicine. You know everybody's distancing. But yeah our clinic is focused on finding underlying causes of GI problems, and as they relate to mental health as well, you know the gut-brain axis. So at our clinic we have neurofeedback counseling specialist, we have about six different forms of neurofeedback that we use. I do my functional testing and more advanced GI motility testing. We have a Heidelberg machine for checking gastric pH, and of course lots of testing that all of our practitioners do when we think the patient has S.I.B.O, which everyone else is learning how to do as well. But we kind of focus on the cases where people have issues that either have defied diagnosis because doctors are thinking too much in the box and not out of the box, or you know they have some diagnoses but nobody's really put it together, what you could do to actually address them with treatment.

Dr Steven Sandberg-Lewis:

So yeah, I get a lot of referrals to help docs kind of figure out where to focus and where to put the energy, and what kinds of treatments might be most appropriate.

Dr Nirala Jacobi:

That's great. We've had many, well not many, but at least two of your colleagues on this podcast. We've had Lisa Shaver, De, Lisa Shaver talk about... I'm must blanking.

Dr Steven Sandberg-Lewis:

Coeliac disease.

Dr Nirala Jacobi:

Coeliac disease and non-Coeliac gluten sensitivity, thank you, and then we've also had your wife Kayle Sandberg-Lewis talk about the different types of biofeedback she uses for traumatic brain injury, but lots of other uses of the different types of biofeedback. So I think it's a really fabulous center for people to know about and to consider going there, if you're a patient listening or if you are somebody who's looking for a fantastic team of practitioners. Okay, anything in closing Steven?

Dr Steven Sandberg-Lewis:

I'll just give you a little fun fact, and that is that the definition of non-alcoholic steatohepatitis is the weight of the liver, that is the percentage that is fat is 5% or more. That's the definition of non-alcoholic fatty liver disease. Unfortunately, ultrasound often doesn't show that fatty infiltration until it's 15% or more. So I'm going to tell you that many of your patients have a fatty liver, that have a totally normal ultrasound. So you're going to have to have a high index of suspicion based on their waist circumference, their blood lipid levels, their hemoglobin A1C, their family history, all kinds of things like that, that will tip you off to the fact that, "Well shall we wait until it's 15% and it shows up," sometimes even 25% before it shows up on the ultrasound. Or can we start treating it now and reversing it, before we have to wait for more damage to occur?

Dr Steven Sandberg-Lewis:

I think that's the beauty of naturopathic medicine and Chinese medicine, and other forms of vitalistic medicine, that we don't have to wait until it's a full-blown disease and it's diagnosable by an ultrasound or some other imaging technique, before we can start addressing it. We'll get into the weeds about that.

Dr Nirala Jacobi:

Sounds really fabulous, and I forgot to mention that all the information about Dr. Steven Sandberg-Lewis's practice and clinic are in the show notes, as well as the link to the course. Thank you so much for your time. I didn't mention before, but because we are pre-recording this for the release of the course, but yes, we are in the midst of the COVID-19 pandemic and I hope by the time this will be released, that the worst is over and we are emerging from our shellshocked existence that is happening right now. So thank you so much for taking the time to talk to me Steven, and I wish you all the best in the next coming weeks, and hopefully I think it will be a changed world when everything is said and done. But hopefully we don't forget to take care of each other and to also be not totally consumed with fear, yeah and be there for each other and be in the moment. So did you want to add anything to that, before we part ways?

Dr Steven Sandberg-Lewis:

No, I say ditto and it's always great to talk with you Nirala.

Dr Nirala Jacobi:

Thanks so much. And everything like I said will be in the show notes and I hope you sign up for this incredible course practitioners, and we'll see you very soon, hopefully actually our conferences were canceled, that we were going to see each other, so it'll have to wait a year at least. So, all the best to you and Kayle, and take care.

Dr Steven Sandberg-Lewis:

Thanks.