Speaker 1: So Perry. When I was in college and my brother
Speaker 1: was also in college, we came home one year for
Speaker 1: Thanksgiving and my brother had a cold, and you know
Speaker 1: people get sick whenever he's a college student. He has
Speaker 1: a cold. It kind of goes on for a little while,
Speaker 1: and then it's like the day before Thanksgiving. My parents
Speaker 1: are like, you still have this cold? Like what do
Speaker 1: you think it's just a cold. He's like, yay, yeah,
Speaker 1: I think it's just a cold. There is one other
Speaker 1: thing it could be, oh like like what and he's like, well,
Speaker 1: I was hiking in lime, Connecticut, and then later I
Speaker 1: found a tick and then I noticed this very specific
Speaker 1: kind of rash on my back. It looks like a bullseye,
Speaker 1: so it could be something like lime disease. And my
Speaker 1: parents were It was like a moment which now I
Speaker 1: reflect on as a parent, where they're just like, are
Speaker 1: you kidding? It's like the day before Thanksgiving and now
Speaker 1: we have to call our friends and be like, how
Speaker 1: can we get some doxy cyclic? So teenage boys the worse,
Speaker 1: if anything, totally, is.
Speaker 2: There anything worse than a teenage boy trying to take
Speaker 2: care of their own health or ticks in lime Connecticut,
Speaker 2: and there's nothing.
Speaker 1: It was so it was so specific, and today we're
Speaker 1: going to talk about ticks and there are many, many problems.
Speaker 2: Oh, it's our creepiest episode so far, creepy Crawley episode
Speaker 2: of wellness actually, but you know, coming to you here together,
Speaker 2: we're party still Broadcast Center in Connecticut, birthplace of lime disease.
Speaker 1: No better place to discuss ticks. So far, the room
Speaker 1: has no ticks. But we'll have to say how things evolved.
Speaker 1: I'm Emily Aster, I'm an economist and a data expert.
Speaker 2: And I'm Perry Wilson, I'm a medical doctor.
Speaker 1: It's Thursday, August twentieth, twenty twenty six, and this is wellness.
Speaker 2: Actually, because you're getting a staggering amount of health and
Speaker 2: wellness information nowadays from every source imaginable, and some of
Speaker 2: it is awesome.
Speaker 1: And some of it is well well actually both Fortunately,
Speaker 1: we're both people who know how to read studies, how
Speaker 1: to parse the data, and can tell you what's worth
Speaker 1: thinking about and what you can safely ignore.
Speaker 2: But before we dig in, a note that this podcast
Speaker 2: is for educational purposes and should not be construed as
Speaker 2: medical advice. We don't know your unique situation, so talk
Speaker 2: to your doctor for personal health decisions.
Speaker 1: This week, we're asking what's the deal with ticks Perry
Speaker 1: and I will give the official smash or pass if
Speaker 1: I think we're going to pass, but let's see, and
Speaker 1: then we'll get to your question of the week. But first,
Speaker 1: let's do the health news roundup after the break.
Speaker 2: And we're back with the health news of the week.
Speaker 2: First bit of health news. I needed to get your
Speaker 2: opinion on Emily because I saw this and I was like, oh,
Speaker 2: it turns out I'm the best parent ever. Okay. So
Speaker 2: a study shows that less unsupervised physical activity and more
Speaker 2: screen time in childhood is associated with better cognitive outcomes
Speaker 2: in adolescents. Okay, So less physical activity, more screen time,
Speaker 2: smarter kids. I'm doing great. My kids waking up and
Speaker 2: picking up an iPad while they eat their like process
Speaker 2: cereal is high quality parenting. We probably shouldn't even discuss it.
Speaker 2: Let's move on to our next helf item. So fine,
Speaker 2: what's your.
Speaker 1: Opinion of Okay, So we have seen so much data
Speaker 1: in the other direction, and I am always crapping on
Speaker 1: that data because you see a lot of DA that
Speaker 1: says screens are bad and physical activity is good, and
Speaker 1: most of that is just driven by biases, other differences
Speaker 1: between families, et cetera. This study is also bad, but
Speaker 1: it is it's in the other direction bad. And this
Speaker 1: this study has both the problem that all the other
Speaker 1: studies do, which is that it's got parents who are
Speaker 1: different in different ways. It's very small, it's like a
Speaker 1: few hundred people, so it's not that important. But it
Speaker 1: also has a very very important problem, which is that
Speaker 1: in all of their analyzes they control for a baseline
Speaker 1: cognitive metric, so it's like the outcome is a is
Speaker 1: like cognition now, and then they have some controls for
Speaker 1: like how much physical activity and screen time you have,
Speaker 1: but there's also a control for when they enrolled you
Speaker 1: in study initially what your cognition was, and so that's
Speaker 1: actually soaking up like almost all the variation because there's
Speaker 1: so much correlation over time, and when you soak up
Speaker 1: all that variation, you get a lot of random noise out.
Speaker 2: In that really just on the margins.
Speaker 1: So it's really just on the margins. And then small
Speaker 1: biases and differences will drive stuff, and some most of
Speaker 1: their stuff is not significant. There's like a little p
Speaker 1: Hackings paper has a lot of problems, but that is.
Speaker 2: Getting a lot of press though.
Speaker 1: You got a lot of press because people love people
Speaker 1: are like you. They will like people love to hear
Speaker 1: what they think already is. They love to hear they're
Speaker 1: doing a good jobs.
Speaker 2: Zee Commanuel has a whole book about why it's healthy
Speaker 2: to eat ice cream.
Speaker 1: Right, and people like that. That book sold really well. Yeah,
Speaker 1: because people want to hear that what they're doing is okay,
Speaker 1: and what you're doing probably is okay. But this study
Speaker 1: doesn't tell you anything about that.
Speaker 2: Stay tuned for our episode next week where we talk
Speaker 2: about the benefits of cocaine and methamphetamy.
Speaker 1: Totally okay. Next up, the AJ updated their cholesterol targets. Yeah,
Speaker 1: tell me more. Yeah, I mean this is this is
Speaker 1: not as interesting.
Speaker 2: It's not the sexiest bit of news, but it is important.
Speaker 2: The AJA has not updated its cholesterol targets since twenty eighteen,
Speaker 2: so it's been a fair amount of time, and there's
Speaker 2: been a lot of research in the interim about the
Speaker 2: relative benefits of reducing bad cholesterol, typically LDL cholesterol. It's
Speaker 2: a big document. Go through just some of the highlights.
Speaker 2: The broad strokes here is that they recommend screening earlier
Speaker 2: and getting LDL lower for longer. So they actually say
Speaker 2: that kids should be screened between ages nine and eleven
Speaker 2: for cholesterol checking, and they sort of reduce their targets
Speaker 2: across the board, so for people, for everyone, no matter
Speaker 2: what your cardiovascular risk is, the LDL target is less
Speaker 2: than one sixty now. And then they recommend a risk
Speaker 2: assessment system. There's a scoring system called Prevent which input
Speaker 2: a bunch of stuff like are you smoker, diabetes, other things.
Speaker 2: It calculates your risk of heart disease in the next
Speaker 2: ten years, and then there are targets based on the
Speaker 2: various risk thresholds. The other addition to this from the
Speaker 2: prior guidelines was that among adults who are on therapy,
Speaker 2: like on a statin or something to reduce their bad
Speaker 2: LDL cholesterol, that we should measure APO B, which is
Speaker 2: a different lipoprotein, a different type of cholesterol that's not
Speaker 2: typically measured in the screening tests, and that all adults
Speaker 2: should have LP little a measured once. LP LITTLEA is
Speaker 2: an interesting little type of cholesterol lipoprotein that clearly is
Speaker 2: associated with heart disease risk over time. So people with
Speaker 2: higher levels do have more heart disease over time. We
Speaker 2: know that. However, it's mediated almost entirely genetically, so as
Speaker 2: opposed to LDL, which has lifestyle dietary implications, LP little
Speaker 2: A is like you get what you get, which is
Speaker 2: why they're only recommending that you measure it once. And
Speaker 2: actually the therapies to lower LP little A are still
Speaker 2: are still in the sort of research phases, although I
Speaker 2: think we'll see some commercialization soon. So yeah, get your
Speaker 2: cholesterol lower.
Speaker 1: I guess this kind of cutoff in medicine is something
Speaker 1: economists like a lot because it suggests good opportunities for
Speaker 1: figuring out how much different treatments matter, like in the
Speaker 1: real world. So it's you say, you know the cutoff
Speaker 1: is one hundred, then doctors treat people with one hundred
Speaker 1: and one different from people with nine, even though it's
Speaker 1: super super dominant. We can talk about why, but like
Speaker 1: that is definitely how it happens. And so when you
Speaker 1: move these cutoffs, it provides more interesting opportunities for identification.
Speaker 1: So economists listening, you got like two years, and then
Speaker 1: you can use these new cutoffs to do stuff exciting.
Speaker 2: I love a good natural experiment, good natural experiment.
Speaker 1: Also, I think my LDL is higher than one hundred,
Speaker 1: so I'm I'm a bit concerned. But let's move on.
Speaker 2: But I suspect you're not at borderline risk, which is
Speaker 2: what the one hundred target is. It's one hundred and
Speaker 2: sixty for people with low risk. Okay, great, yeah, but
Speaker 2: you can ensue maybe who knows. I know there's family
Speaker 2: history stuff in the risk score, so you can check
Speaker 2: it out. All right, has there been a new album drop?
Speaker 2: If so, be careful because a new study finds a
Speaker 2: fifteen percent increase in traffic fatalities on the day of
Speaker 2: a top ten streaming album release compared to the day
Speaker 2: before or after. So the idea here being we're in
Speaker 2: our car Taylor drops her new album and we're like
Speaker 2: just we're rocking out, our eyes are closed, and traffic
Speaker 2: fatalities go up quite a bit. I think you have
Speaker 2: a connection to this paper.
Speaker 1: Yeah. So the senior author on this paper is a
Speaker 1: guy named Babu Jenna who is at Harvard, who is
Speaker 1: perfect for the Wellness Actually podcast because Bapu is an
Speaker 1: mdphd and his PhD is in economics. He was actually
Speaker 1: my student at Chicago and there aren't very many people
Speaker 1: with an mdphd in economics. It's an unusual combination of things.
Speaker 1: But he writes a lot of very interesting papers that
Speaker 1: have some similarities to this. So he has some papers
Speaker 1: on how more people die of heart attacks during marathons,
Speaker 1: not because they are running, but because you cannot get
Speaker 1: to the hospital if you have a heart attack.
Speaker 2: Oh, because there's the roads are all closed and stuff.
Speaker 1: Yeah, marathons are deadly. Look it up. But in this case,
Speaker 1: what they find is they use this nice identification strategy
Speaker 1: around album releases, and they show that people are more
Speaker 1: distracted and it's particularly men. Not that surprising, And I
Speaker 1: would guess if I had to guess, and I didn't,
Speaker 1: I don't think they have a lot of heterogeneity by
Speaker 1: like what type of music it is. But I would guess,
Speaker 1: like the Noah Kahan album, like people are not you know,
Speaker 1: like driving going you're just like you're not going ninety
Speaker 1: or just like cry maybe you're crying. So anyway, Oh
Speaker 1: that's true.
Speaker 2: Yeah, Okay, what I wonder you know, I did see
Speaker 2: in the study that they adjusted for the day of
Speaker 2: the week and and like the number of subscriptions to
Speaker 2: the service and stuff. Over time, Like there's obviously confounders here,
Speaker 2: But what I was kind of thinking is like how
Speaker 2: sophisticated are record producers or distribution companies in terms of
Speaker 2: picking that date? Like do they know? Like are they
Speaker 2: going for a date that's gonna be that's important in
Speaker 2: a way that we're not adjusting here for and I
Speaker 2: don't know what it is, Like are they looking for
Speaker 2: dates that are high literally high traffic? Like do they
Speaker 2: want to release on dates when there are a lot
Speaker 2: of people on the road just to get those get
Speaker 2: those clicks, get those streams? Do not?
Speaker 1: I think that that is stretching crewdu I mean, is
Speaker 1: the right question to ask about identification? But I think
Speaker 1: it is very unlikely that this that surely they are
Speaker 1: choosing for some reason. But as long as that reason
Speaker 1: is not about traffic fatalities, which seems less plausible than
Speaker 1: this identification strategy, is fine, all right, And based on
Speaker 1: the timing of choosing book releases, I would say it's
Speaker 1: mostly random. Somebody in the office is like, I've thought
Speaker 1: about it, and July fifteenth, it's like they're just like.
Speaker 2: Yeah, all right. Whenever do you worry about kids listening
Speaker 2: to music when they drive. My daughter is always listening
Speaker 2: to music and does, like I do, worry that it's
Speaker 2: one extra I would.
Speaker 1: Prefer my children never drive, So I'm going to go
Speaker 1: with I just don't. I don't like the idea of
Speaker 1: children children driving. I haven't thought about the music part
Speaker 1: of it, honestly, I'm still getting past the driving part.
Speaker 1: That is it for the health news of the week. Now,
Speaker 1: what's the deal with ticks?
Speaker 2: What's the deal?
Speaker 1: What's the deal?
Speaker 2: What's going on?
Speaker 1: Ticks? Ticks? Why are you here?
Speaker 3: Oh?
Speaker 1: Geez?
Speaker 2: Okay, all right, I have to start with a corrections
Speaker 2: buds per usually at the at the end of last
Speaker 2: week's episode, when we said this week is what's the
Speaker 2: deal with ticks? I think I made a comment like
Speaker 2: those those bugs, I call them bugs, and you know,
Speaker 2: the entomololi just get really upset when you call an
Speaker 2: animal a bug that's not a bug, even like insects,
Speaker 2: Like there's some insects which are bugs, but not all
Speaker 2: insects are bugs.
Speaker 1: Okay, it's like a square and a rectangle.
Speaker 2: Yeah, but like bug, I thought that bug was a
Speaker 2: colloquial term for a creepy crawley thing. But there's also
Speaker 2: like an entomological term for this is not ticks aren't bugs.
Speaker 2: They're not even insects. They're not even insects. They are
Speaker 2: a racknids. They're more closely related to spiders than they
Speaker 2: are to mosquitoes or other blood suckers. That's interesting.
Speaker 1: That is interesting. Are they so? And also like related
Speaker 1: to mites, yes, different kinds of mites.
Speaker 2: Yeah, other iracnid racknin type stuff.
Speaker 1: Yep, I'm already I don't like I don't like bugs.
Speaker 1: I guess in this case, that's fine because this isn't
Speaker 1: about bugs, as previously noted.
Speaker 2: That crawl on you.
Speaker 1: They crawl on you.
Speaker 2: No, agreed, No, this is this is a creepy episode.
Speaker 1: As we said, all right, so ticks eat blood. They
Speaker 1: need blood in order to move forward with their life cycle.
Speaker 1: And when they get on you, they get on and
Speaker 1: they feed in your blood and they get enormous. They
Speaker 1: can go like up six hundred times their weight while
Speaker 1: they suck your juices.
Speaker 2: It's super gross. I've never had a tick on me
Speaker 2: that got that big, but I have had like a
Speaker 2: tick on a dog that is just just gigantic.
Speaker 1: And yeah, okay, we.
Speaker 2: Have to stop. We have to take a break already
Speaker 2: have made it this far.
Speaker 1: Okay, But it turns out that the stage of the
Speaker 1: tick that matters the most is the nymph. They're very,
Speaker 1: very very small, which is which is why they are
Speaker 1: the most dangerous, because that is the thing that you
Speaker 1: would not see or it's very hard to see. It
Speaker 1: looks like a little tiny poppy seed.
Speaker 2: Yeah, dear tech nymph in particular, which are you know,
Speaker 2: the main vectors for lime disease, which is which is
Speaker 2: the big the big one when it comes to tick
Speaker 2: born diseases, but by no means the only one. And
Speaker 2: you mentioned that blood meals are necessary to advance in
Speaker 2: the stage of the life cycle, and like not just
Speaker 2: the way that well, everyone has to eat to grow bigger,
Speaker 2: but ticks go from you know, larva to nymph to
Speaker 2: I think one more stage and then adult, and each
Speaker 2: of those things needs a blood meal to like unlock
Speaker 2: the genetic machinery. So they literally level up every time
Speaker 2: they feed off of someone. And yeah, if you don't
Speaker 2: get them off, they feed until they get gigantic and
Speaker 2: then they just fall off on the ground and then
Speaker 2: go through their next little molting life SiGe and wait
Speaker 2: for the next blood meal to come by.
Speaker 1: So for lime disease, which we are going to get to,
Speaker 1: but we're actually gonna there's a lot to talk about.
Speaker 1: So we're going gonna start the episode by talking about
Speaker 1: things that are not lime disease, and then we're gonna
Speaker 1: get to lime. But for lime, the one thing I
Speaker 1: will say now is that the tick has to stay
Speaker 1: attached for something like thirty six to forty eight hours.
Speaker 1: You actually have quite a long time to remove the
Speaker 1: tick in lime disease before it would cause disease. Is
Speaker 1: not going to be true for for every everything else.
Speaker 1: So we're gonna get to line, but we're gonna start
Speaker 1: with generally what can happen. Ticks so responsible for many diseases,
Speaker 1: and they kind of work in three different ways. So
Speaker 1: I thought, rather than talking about the entire list, we'll
Speaker 1: say for listeners. Perry had a like spreadsheet and had
Speaker 1: like forty five rows, and I thought he was gonna
Speaker 1: we were gonna go through every tick disease, Tick disease
Speaker 1: number thirty sevens like this episode would be boring, and
Speaker 1: so instead we're gonna we're gonna focus a little bit
Speaker 1: on the sort of three ways that the tick can
Speaker 1: actually impact you your health, impact your health.
Speaker 2: Yeah, yes, yeah, so I think. I mean, honestly, the
Speaker 2: tick born diseases are super fascinating. But yes, three big ways.
Speaker 2: The first thing that a tick can do to make
Speaker 2: you sick is it can infect you with something, be
Speaker 2: it virus, bacteria, et cetera. And we'll obviously talk about
Speaker 2: a sampling of those, but just so you know, there
Speaker 2: are many more, and we'll miss, uh, we'll miss quite
Speaker 2: a few of them in the interest of time. The
Speaker 2: second thing a tick can do is poison you. So
Speaker 2: we'll talk about some ticks that have substances in their saliva,
Speaker 2: so non infectious, but nevertheless chemical substances that can have
Speaker 2: really devastating effects on humans. And the third thing is
Speaker 2: that they can rewire your immune system. And there is
Speaker 2: a few themes that have come up in the Wellness
Speaker 2: Actually podcast when it comes to allergy and immunology, and
Speaker 2: one of them is this understanding that when you deliver
Speaker 2: something into your body not through the normal way, like
Speaker 2: not by eating it, you can get allergic to the
Speaker 2: substance in a way that you wouldn't get if you
Speaker 2: ate it. And because ticks are injecting stuff, basically directly
Speaker 2: into your bloodstream. It opens up the door to all
Speaker 2: sorts of really interesting allergies. So I think if we
Speaker 2: hit some representative sampling there before we get to all
Speaker 2: the lime disease stuff, that would be great.
Speaker 1: Okay, So we're gonna start with the infection one because
Speaker 1: it has is actually both the way the lime works
Speaker 1: and also the way that what I think is by
Speaker 1: far the scariest tick disease works. So the scariest tick
Speaker 1: disease I think is poasen. Is that how you saying it?
Speaker 2: Poson polawson? Yeah, pos and virus, the.
Speaker 1: Posts and virus, and the post and virus is spread
Speaker 1: by the same tick as lime disease. It is the
Speaker 1: black leg deer tick. And this is the thing. There
Speaker 1: are two really really scary aspects of this. So one
Speaker 1: is that it can happen very fat. So lime disease
Speaker 1: needs a very long time this virus for the tick
Speaker 1: the chick to be attached. And this virus needs fifteen minutes. Yeah,
Speaker 1: and it is very possible for you to miss I mean,
Speaker 1: it's very possible to miss a tick for two days.
Speaker 1: It's really possible to miss it tick for fifteen minutes.
Speaker 2: One hundred percent. If you see a deer tick on
Speaker 2: you and it has bitten, like it's not crawling, but
Speaker 2: it's in and you have to pull it off, and
Speaker 2: in theory it could have transmitted poots and virus.
Speaker 1: And the pous and virus is very scary.
Speaker 2: It's very scary. So all right, if you if you
Speaker 2: look this up, what you'll find it's that POAs and
Speaker 2: virus is a virus with no treatment and a ten
Speaker 2: percent case fatality rate, which is like, oh, so I
Speaker 2: can walk through the woods of Connecticut where a deer
Speaker 2: tick abound, and I can have a tick on me
Speaker 2: for fifteen minutes and then I have a ten percent
Speaker 2: death rate. This is not entirely true, but the broad
Speaker 2: strokes and the way the data we have will lead
Speaker 2: to some people saying these things. So, so what the
Speaker 2: virus does in most people is nothing. Now, that's not
Speaker 2: what you'll see when you google. What you'll see when
Speaker 2: you Google is that polas and virus causes meningitis. So
Speaker 2: it's a brain inflammatory virus. And indeed, if you develop
Speaker 2: meningitis from polos and virus, you're going to go to
Speaker 2: the hospital. You're going to be very sick. It's a virus,
Speaker 2: so antibiotics don't work. You're going to get supportive care
Speaker 2: ivy fluids and pain control and fingers crossed. And the
Speaker 2: case fatality rate is about ten percent, So that's super scary.
Speaker 2: But most people don't ever get symptoms from it.
Speaker 1: Yeah, And I think we sort of have to know
Speaker 1: that that has to be true just based on the
Speaker 1: base rate. You know, there are many, many, many cases
Speaker 1: of lime every year spread by the same tick. There
Speaker 1: are very small number of cases of this, so so
Speaker 1: far in twenty twenty six there have been thirty. Last
Speaker 1: year there were seventy six. That's a very small number.
Speaker 1: Of the US is three hundred and thirty million people.
Speaker 1: The Northeast has many, many, many tens of millions of people.
Speaker 1: This is a very small number. And there is some
Speaker 1: sero prevalence work, which means like testing people to see
Speaker 1: if there's evidence that they've been exposed to this with
Speaker 1: suggest much higher rates of exposure, so.
Speaker 2: Have an antibody to the virus, but you never were sick.
Speaker 1: Yeah, So one way to think about this is conditional
Speaker 1: on arriving at the hospital very sick. With this, the
Speaker 1: fatality rate is quite high. The vast majority of people
Speaker 1: who get this do not actually develop this virus. So
Speaker 1: it's not that it's not scary, like it is. This
Speaker 1: is very scary. It's very scary, but there are many
Speaker 1: other things that are scarier in the world. Yeah.
Speaker 2: Yeah, If insofar as this motivates you to like do
Speaker 2: the anti tick measures, we'll talk about some of the
Speaker 2: things you can do to prevent getting tick bites, then great.
Speaker 2: But yeah, don't let keep you up at night.
Speaker 1: I mean I do if you think, like things like
Speaker 1: this are very salient to people. When you say, you know,
Speaker 1: there's a thing that could happen, you get bit by
Speaker 1: a tick and you could, you know, have a ten
Speaker 1: percent fatality, that is really scary, and then that lives
Speaker 1: in your head because people are very poor at understanding
Speaker 1: small probabilities. The fact that it's seventy six out of
Speaker 1: you know, seventy five million people, it just feels like, well,
Speaker 1: it could it could be a chance, it could have
Speaker 1: could happen. It's like the lottery. It's worth putting it
Speaker 1: in the space of you know, you are an awful
Speaker 1: lot more likely to die in a car in your
Speaker 1: car on the way to the woods than you are
Speaker 1: to die of a tick that you get in the woods.
Speaker 1: I'm not saying you should be afraid of going hiking,
Speaker 1: but like, in the space of risks you're taking, this
Speaker 1: is very small.
Speaker 2: The health benefits of going on that hike probably outweigh
Speaker 2: any risk.
Speaker 1: Yes, if you did this sort of minute calculation, you're
Speaker 1: you're on a good path.
Speaker 2: Absolutely, absolutely, Okay.
Speaker 1: Yeah, So the second way, so that's tick infections, and
Speaker 1: there are other diseases that that can be spread by
Speaker 1: ticks in this same way. Yeah, what's your favorite other infection?
Speaker 2: I know, No, I mean there's so many interesting tickborne diseases,
Speaker 2: and I feel like people have their favorites, and someone's
Speaker 2: gonna be like, you didn't mention rocking mountains about a fever.
Speaker 2: You didn't mention it antaplasmosis. I think bibeziosis to me
Speaker 2: because we see this in the hospital not infrequently, and
Speaker 2: it is the closest thing to malaria that we have
Speaker 2: in the United States. So bibeziosis is bacterial infection that
Speaker 2: gets a parasite that gets inside red blood cells. So
Speaker 2: just like the malaria parasite. I mean, it's not the same,
Speaker 2: it's a different parasite, but that's its mechanism. It gets
Speaker 2: in these red blood cells and people come in with
Speaker 2: severe anemia and actually like very similar symptoms that malaria
Speaker 2: presents with. So you sort of learn about malaria and
Speaker 2: medical school because malaria is the biggest killer of humans,
Speaker 2: infectious these color of humans in the world. And then
Speaker 2: you know, you come here to Connecticut and you see
Speaker 2: people coming in with the same symptoms and it'll be bibziosis.
Speaker 1: There are about one hundred to five hundred cases of
Speaker 1: this your favorite every year. Okay, great, all right, great
Speaker 1: for you, But I'm just telling people that's not very
Speaker 1: very common.
Speaker 2: Yeah, there is selection bias here too, because a lot
Speaker 2: of people at thebeziosis will have some kidney dysfunctions, so
Speaker 2: they call people like me.
Speaker 1: Okay. So the second thing that ticks can do is
Speaker 1: they can poison you. And the best poison tick disease
Speaker 1: is tick paralysis. Yeah, it's the best one because it's
Speaker 1: super interesting. It's a neurotoxin in the saliva of some
Speaker 1: kinds of ticks and it causes paralysis.
Speaker 2: And it causes a very particular type of paralysis. So
Speaker 2: what it is is it's a flaccid paralysis. So a
Speaker 2: weakness as opposed to spasticity. So there's kind of two
Speaker 2: types of paralysis, a weak paralysis that goes from your
Speaker 2: legs and goes up your body. And if you're a
Speaker 2: doctor listening to this and you saw a patient that
Speaker 2: had that pattern of paralysis, you would be like, that's
Speaker 2: Giambre syndrome because it looks exactly the same.
Speaker 1: But actually it's ticks. And if you remove the tick,
Speaker 1: the paralysis goes away.
Speaker 2: Which is awesome, Which is awesome.
Speaker 1: And there is an episode of House in which this happens. Yes,
Speaker 1: there's an episode of House in which there is a person,
Speaker 1: a teenage girl, and this is what House thinks is happening.
Speaker 1: And everyone says that he's an idiot because they can't
Speaker 1: find a tick and they look for a tick and
Speaker 1: blah blah blah. But then it turns out that her
Speaker 1: boyfriend had snuck in and he had picked up a
Speaker 1: tick and they had had sex, and actually the tick
Speaker 1: was in her vagina and that was what House identified.
Speaker 1: So for me, this is like suck in my I
Speaker 1: don't know, I really liked that show. Oh no, I
Speaker 1: like the show too, And so then the things and
Speaker 1: that was an episode that suck with me. And also
Speaker 1: the fact that they always thought it was Wilson's disease,
Speaker 1: Like every single time it was Wilson's disease.
Speaker 2: Oh that's funny.
Speaker 1: It's like not a lot of people. Well anyway, that's
Speaker 1: a different topic.
Speaker 2: Yeah, Wilson's is a disease of no relationsition copper metabolism
Speaker 2: the cause of liver failure. So it is worth it
Speaker 2: to know for clinicians that if someone presents with Giambret syndrome,
Speaker 2: that you should do a tick check. Generally we advise
Speaker 2: looking at the scalp.
Speaker 1: But I suppose that's why House is a genius.
Speaker 2: You should do a thing.
Speaker 1: He doesn't just do the first thing.
Speaker 2: You should do a thorough tck check if you have
Speaker 2: a patient with giambre syndrome. But it is cool. The
Speaker 2: prolyssis goes away within hours of removing the tick, So
Speaker 2: miracle stuff.
Speaker 1: All right. Third thing is that the tick can rewire
Speaker 1: your immune system in this crazy way. And this is
Speaker 1: the one actually everyone has been talking about. Yeah, or
Speaker 1: at least one of the diseases that's caused, and this
Speaker 1: caused by this mechanism, which is alpha gal. Alpha gal
Speaker 1: has been the talk of Nantucket this summer because one
Speaker 1: of the things that happens, the thing that happens with
Speaker 1: this is that you cannot tolerate meat. Yeah, and there's
Speaker 1: been some discussion, which I think is totally overblown that
Speaker 1: like the stores on Nantucket have stopped stocking Hamburgers because
Speaker 1: too many people have alpha, which I don't think is true.
Speaker 1: But but this is.
Speaker 2: Like, it's probably the ozempic.
Speaker 1: I will guess it's but let's, you know, move on,
Speaker 1: so what like it's but it's totally weird.
Speaker 2: Oh, it's it's it's it's super fascinating. And I alluded
Speaker 2: to this earlier that allergies tend to develop when you
Speaker 2: get exposed to a potential allergen, not through your GI tract,
Speaker 2: like through some other way. So what alpha gal is
Speaker 2: is I guess we need to know is that every species,
Speaker 2: every mammalian species, on the surface of their cells has
Speaker 2: a sugar called galactose alpha one three galactose except the
Speaker 2: Old World apes, the Old World primates like us and
Speaker 2: chimpanzees and gorillas, So we lost that in our evolutionary history.
Speaker 2: We like the gene to make that sugar just went wait,
Speaker 2: we do not make it anymore. I don't think it
Speaker 2: causes us a particular problem.
Speaker 1: I don't know.
Speaker 2: That's evolution for you all other mammals except us in
Speaker 2: the chimpanzees and the gorillas. Okay, so we don't see
Speaker 2: that protein that sugar in our body, but we eat
Speaker 2: meat and as long as it goes through our GI tract,
Speaker 2: that's fine. This tick, and in this case it's the
Speaker 2: lone star tick primarily in its saliva has galactose alpha
Speaker 2: one three galactose for other reasons, presumably obviously it's not mammalian,
Speaker 2: but it injects that into you, and in theory, because
Speaker 2: it's going in through your skin and not through your
Speaker 2: GI tract, you can develop analogy to it. What is
Speaker 2: a little unusual about this allergy is it's not usually
Speaker 2: full blown anaphylaxis, where like you, I don't know, you
Speaker 2: have a bite of hamburger and two minutes later you're
Speaker 2: on the floor. It's usually a hours after, so probably
Speaker 2: something you probably have to digest, Some stuff got to
Speaker 2: get into your system for things to happen. And usually
Speaker 2: the presenting symptoms are GI in nature, like pain, bloating, diarrhea,
Speaker 2: sometimes vomiting, and because of that time between when you
Speaker 2: ate and when you got sick is so long it's
Speaker 2: like not immediately obvious to people that it is analergy.
Speaker 2: There can be allergic symptoms as well, so it's a
Speaker 2: really interesting bit of physiology that like we're really only
Speaker 2: just starting to understand.
Speaker 1: It is also a place where testing has revealed that
Speaker 1: a lot of people seem to have been exposed in
Speaker 1: this way. So they're like, Sarah, there's a test for this.
Speaker 1: You can test for the serum alpha gal antibody antibody,
Speaker 1: and when you do that in some sort of places
Speaker 1: with a lot of chicks, you get actually quite high rates.
Speaker 1: So somebody did a residual blood donor sample and the
Speaker 1: seral prevalence was like twenty four percent. Wow. And of
Speaker 1: course twenty four percent of people in you know, Arkansas, Kentucky, Missouri,
Speaker 1: and Tennessee are not allergic to.
Speaker 2: To be devastating to the local economy.
Speaker 1: And so so you know, and we're seeing like five
Speaker 1: hundred cases a year diagnosed of this. So I think
Speaker 1: it's it's one of these places where obviously people have
Speaker 1: this without actually having having symptoms, and it does go
Speaker 1: away for most people over time.
Speaker 2: That's right, that's right. If you if you avoid further
Speaker 2: tick bites, the symptoms get better. But for some people
Speaker 2: they can really never eat meet again. And the immune
Speaker 2: system is an incredibly complex thing, and an antibody tighter
Speaker 2: is not the same as, you know, a full blown
Speaker 2: immune reaction, so it can be it can be hard
Speaker 2: to tease out.
Speaker 1: But yeah, you know, stay away from those loans to
Speaker 1: start to so interesting.
Speaker 2: It is it is.
Speaker 1: The body is very cool, absolutely, all right. So those
Speaker 1: are your three big tick approaches. And we're very sorry
Speaker 1: to the entomologists listeners that we have not covered Perry's
Speaker 1: spreadsheet of ticks tickborn diseases. But we're going to take
Speaker 1: a break and when we come back, we're going to
Speaker 1: talk about line disease. All right, We're back, and we're
Speaker 1: going to talk about lime, which is the most common
Speaker 1: tick born disease in the US. It's actually not clear
Speaker 1: how many cases there are in the year in a
Speaker 1: given year, but it's in the hundreds of thousands we
Speaker 1: we think. And lime disease really begins with some moms
Speaker 1: in Old Lime, Connecticut, who had identified they all had
Speaker 1: children who had been diagnosed with juvenile arthritism, trid arthritis,
Speaker 1: which is basically joint like joint pain. And they just
Speaker 1: felt that was not could not really it didn't seem right.
Speaker 1: It's not very common. That isn't typically a cluster disease.
Speaker 2: When why do all these kids have it?
Speaker 1: And they pushed and pushed and pushed, and eventually a
Speaker 1: researcher at Yale sort of took them seriously, worked this
Speaker 1: up and identified a bacteria which was is spread by
Speaker 1: ticks that was causing this set of symptoms and conditions.
Speaker 1: And I actually think this story and we can talk
Speaker 1: much more about the microbiology, but just from a kind
Speaker 1: of sociological standpoint, this story is the beginning of lime disease.
Speaker 1: And it's also like the middle and the end because
Speaker 1: so much of what happens in the discussion of lime disease,
Speaker 1: particularly around chronic lime, feels like patients feel like they're
Speaker 1: not being listened to doctors totally by doctors, And this
Speaker 1: is like it sort of started.
Speaker 2: It started that way.
Speaker 1: It started that way. It's DNA and so so that's
Speaker 1: that's where that's where the start. And this all happened
Speaker 1: in like the mid mid nineteen seventies early nineteen eighties.
Speaker 2: Yeah, it was Willy Burgdorfer who actually identified the bacteria.
Speaker 2: It's called the spier key. It's kind of a spirally
Speaker 2: shaped bacteria. It's named after him, Brellia burgdor For I
Speaker 2: we'll hear more about Willie Bergdorfer when we talked about
Speaker 2: some of the interesting lime disease conspiracy theories that that
Speaker 2: are out there. But before we get to that, we
Speaker 2: should just talk about, like what LI disease?
Speaker 1: What is it?
Speaker 2: What I think people people probably know? But okay, so
Speaker 2: we've got this bacteria that lives in a tick. The
Speaker 2: vector is typically the deer tick. It can be carried
Speaker 2: by some other ticks. And as you pointed out, the
Speaker 2: nymph stages where we see most of the transmission, not
Speaker 2: because it's uniquely infected, but because it's so tiny, poppy
Speaker 2: seed size, little black thing, super easy and miss, especially
Speaker 2: in the hair. As you said, it takes a while
Speaker 2: for it to transmit. That's actually because the tick has
Speaker 2: to start feeding and process and it actually inject it
Speaker 2: like metabolizes some of your blood and it puts it
Speaker 2: back in you. And that's how that takes some time,
Speaker 2: and it and and that's how we're getting creepy again,
Speaker 2: but that's actually how the spier keat gets into you.
Speaker 2: And the entomologists will go out and like take samples
Speaker 2: of deer ticks and look and just measure the ticks,
Speaker 2: and about twenty five to fifty percent of them are
Speaker 2: lime disease positive. So it's like, if you have a
Speaker 2: deer tick, the chances are it's got lime disease in it,
Speaker 2: or at least the chances are very good it's got
Speaker 2: lime disease in it. Clinically, the standard way to define
Speaker 2: lime disease is we say early or localized lime disease,
Speaker 2: and then late or disseminated lime disease. And if you
Speaker 2: see me using air quotes or trying to hedge my
Speaker 2: bets with the tone of my voice, that's because various
Speaker 2: other societies have created different staging systems, so this is
Speaker 2: the most common one. Early localized disease is the rash.
Speaker 2: It's known as air thema migrants classic target shaped rash
Speaker 2: looks like a bullseye, looks like a bullseye, correct, and
Speaker 2: it can be you know, you'll see pictures online that's like, oh,
Speaker 2: it's clearly a bulls eye. But my daughter had lime disease.
Speaker 2: I took a picture of like a vague ring shaped
Speaker 2: thing on her back. I was like, I think this
Speaker 2: is air thema migrants and I sent it to Repediatrey
Speaker 2: and they were like, nah, it looks it doesn't really
Speaker 2: look like that, like it's too faint or whatever. It
Speaker 2: like wasn't. Yeah, she had limezse so okay. Also in
Speaker 2: that early period, you can get those flu like cold
Speaker 2: like symptoms, fatigue, headache and stuff like that, and ideally
Speaker 2: you want to treat at that point in time. You
Speaker 2: don't want to let it get to disseminated lime disease.
Speaker 2: That's where you can get a lot of other symptoms.
Speaker 2: Now it's spread throughout your body and so you can
Speaker 2: see symptoms and other organ systems, classically joints. My daughter,
Speaker 2: because she wasn't treated at the early stage, had a
Speaker 2: big like joint effusion in her knee. That's how she
Speaker 2: ended up getting diagnosed. But you can have cardiac abnormalities.
Speaker 2: Facial palsy is actually fairly common. You know, it can
Speaker 2: look almost like you have a stroke or something like
Speaker 2: that with UH because there's some nerve stuff there. This
Speaker 2: all gets better with treatment. And I will say explicitly
Speaker 2: you can have lime disease without the rash. So seventy
Speaker 2: to eighty percent of lime disease cases will have arithema migrants,
Speaker 2: but not every single one, so you do have to
Speaker 2: be suspicious.
Speaker 1: So part of what is complicated here is of course,
Speaker 1: for some set of people, like let divide a little
Speaker 1: bit into kind of like the best almost like the
Speaker 1: best case scenario here, which is you have an identified
Speaker 1: tick bite, there is a bullseye shaped rash that you
Speaker 1: notice immediately, and then there is a very clear treatment.
Speaker 1: There's no testing. We assume that you have lime disease,
Speaker 1: that you take a dose of doxie cyclin and that
Speaker 1: fixes the problem. Doxie cyclines and antibatic. It treats deals
Speaker 1: with the bacteria, and we're and we're good.
Speaker 2: Yeah, several doses of doctor, several doses.
Speaker 1: It's like it's yeah, don't just like take one.
Speaker 2: Well, I mentioned that because there are there are pediatricians
Speaker 2: who will recommend a prophylactic doxie cycling dose with any
Speaker 2: tick bite, Like no ration, you got a tick bite,
Speaker 2: just like take a doxy cyclin. There's not good randomized
Speaker 2: trial ev it's to support that. So just you might
Speaker 2: hear it, But that's there is.
Speaker 1: There is a more complicated question about if your child
Speaker 1: has been exposed to a tick, should you take the
Speaker 1: full dose of doxi cyclin as if you have been
Speaker 1: And there's also some debate.
Speaker 2: Of antibiotics.
Speaker 1: So okay, So that's like the sort of I know
Speaker 1: what's happening. I've fixed the problem in the short term. Fine.
Speaker 1: It is much more complicated if you have gotten to
Speaker 1: this later potential phase, particularly if you're not sure it
Speaker 1: was a tick. So think about the case in which
Speaker 1: someone's bitten by a tick, the tick is on for
Speaker 1: a long time, the tick falls off, they don't notice,
Speaker 1: they never get a rash, and then all of a
Speaker 1: sudden they have a series of complicated symptoms polsy, nerve pain,
Speaker 1: disseminated rashes. There's a lot of difference. That's a hard
Speaker 1: that's a hard diagnostic problem. And the testing here is
Speaker 1: actually not it's not a single test that for shore
Speaker 1: tells you what is going on.
Speaker 2: Yeah, so testing for lime disease, and we're gonna get
Speaker 2: to this a little bit when we talk about chronic
Speaker 2: lime disease. So let's carve that out for a minute.
Speaker 2: Testing relies typically on looking for antibodies against the lime
Speaker 2: spier key against the bacteria. The FDA and the CDC
Speaker 2: recommend a two tiered testing system, so they have you
Speaker 2: do an initial test that is fairly sensitive, so it's
Speaker 2: going to look like really it'll pick up kind of anything,
Speaker 2: so a high false positive rate but also a high
Speaker 2: true positive rate an initial test. If that's positive, then
Speaker 2: you move on to a secondary test that's more specific,
Speaker 2: and there's a couple of different approved tests for that,
Speaker 2: and putting those two things together in an approved laboratory
Speaker 2: gets you a pretty high ability to detect, but not
Speaker 2: perfect to detect the disease. I think it's something like,
Speaker 2: you know, you would detect eighty percent of them, eighty
Speaker 2: percent of positive infections, and you'd have a false positive
Speaker 2: rate of like ten percent or so, so it's not terrible,
Speaker 2: not perfect. What the problem is that they're is an
Speaker 2: entire ecosystem of unlicensed testing for lime disease and labs
Speaker 2: that use different thresholds for these antibody levels, which can
Speaker 2: give rise to false positive rates north of fifty percent.
Speaker 2: We'll talk about why this ecosystem exists. You mentioned at
Speaker 2: the beginning that the story of lime is really a
Speaker 2: story about doctors and patients not seeing eye to eye
Speaker 2: and a lot of doctors not listening to their patients.
Speaker 2: And whenever that happens, people come in to fill that void,
Speaker 2: and some are very well intentioned and some are not
Speaker 2: so well intentioned. So we'll get there. Testing's not perfect,
Speaker 2: but not bad.
Speaker 1: It can miss early on. I mean, antibody tests can
Speaker 1: miss early on. They can also pick up in like
Speaker 1: past infection because antibodies maintain for a long time. So
Speaker 1: not perfect, but there is some testing you can do.
Speaker 1: This is generally not something you would do. If somebody
Speaker 1: shows up with a standard rash, they're just given the
Speaker 1: DICI cycline and.
Speaker 2: Those people just treat. I know some docs who will
Speaker 2: treat and test too, just to like have it in
Speaker 2: the record or something. But yeah, I think if you,
Speaker 2: you know, you come up with a rash like that.
Speaker 1: You're getting You're not waiting.
Speaker 2: You're waiting.
Speaker 1: You're not waiting in part because the test is most
Speaker 1: likely to be a false negative early on, before you've
Speaker 1: mentioned an antibody response, which is why we're giving you
Speaker 1: the yeah datty cycling. Okay, So before we get into
Speaker 1: the chronic lime space, I want to ask you a question,
Speaker 1: Actually I want to I'm not going to ask you.
Speaker 1: I'm going to ask the Health Secretary of America a question, okay,
Speaker 1: about whether lime is a bioweapon. Let's hear what he
Speaker 1: has to say.
Speaker 4: Clearly, COVID nineteen pandemic and many other global pandemics that
Speaker 4: we have have come from in a functional research. The
Speaker 4: RSV epidemics that we have that is the biggest killer
Speaker 4: of kids in this country today came from these kind
Speaker 4: of experiments. The lime disease almost certainly came from this
Speaker 4: kind of research.
Speaker 1: Okay, So it sounds like it sounds like maybe, yes,
Speaker 1: tell me where this came from.
Speaker 2: I have to admit that until I heard RFK Junior
Speaker 2: say that lime disease is a result of gain of
Speaker 2: function research and in other places he's described it as
Speaker 2: like a literal bioweapon, I kind of didn't know this story,
Speaker 2: and it's really fascinating. So let me let me walk
Speaker 2: you through why this is like remotely a thing at all,
Speaker 2: and also tell you why I think it's not a bioweapon.
Speaker 2: So this all starts in two thousand and four. There's
Speaker 2: a book by guy named Michael Carroll it's called Lab
Speaker 2: two fifty seven about the Plumb Island Animal Disease Center,
Speaker 2: which is on the eastern tip of Long Island. And yes,
Speaker 2: there is an animal disease research center on the eastern
Speaker 2: tip of Long Island. And yes they study animal diseases
Speaker 2: and some tickborne diseases. And lime Connecticut is just across
Speaker 2: the sound from there. But that's sort of mostly where
Speaker 2: that story stops, like, we don't have evidence that they
Speaker 2: were doing any particular experiments with limee there. However, remember Burgdorfer,
Speaker 2: the guy who discovered Barellia, burgdorf Ride, who discovered the
Speaker 2: spire keat, so he actually did work at a government
Speaker 2: facility that did study tickborne diseases. Let me see if
Speaker 2: I can find the name for you. So it was
Speaker 2: a program called Rocky Mountain Labs. It was indeed an
Speaker 2: entomological warfare program. So the US government was interested in, like, hey,
Speaker 2: can we have insects spread.
Speaker 1: Diseases by the way, a thing which definitely has happened
Speaker 1: in the past. I mean, this is how we got malaria.
Speaker 1: I mean the spread all the.
Speaker 2: Time insect spread diseases, but we didn't we have a blaria.
Speaker 2: But yes, biological warfare has happened. There are some, okay,
Speaker 2: but that's all we have. So we've got the guy
Speaker 2: who studied tick diseases was also working at the government
Speaker 2: studying tick diseases. Like of course he was like, if
Speaker 2: you're going to develop this program, like, maybe you have
Speaker 2: a guy who knows about tick diseases. But here's the
Speaker 2: issue with all of this theory is that lime disease
Speaker 2: was identified in the nineteen seventies. These programs that they're
Speaker 2: talking about were maybe open in the late in the sixties,
Speaker 2: but actually lime disease has been around way longer than that.
Speaker 2: So we have direct evidence of lime disease infection in
Speaker 2: whitefooted mice from museum specimens. So you go in back
Speaker 2: of these like little museums and you test the whitefooted mice,
Speaker 2: and at least as early as eighteen ninety eight we
Speaker 2: have lime disease in mice. So this is long before
Speaker 2: the government had any type of biological warfare weapon. The
Speaker 2: other source of evidence is that genetic sequencing can tell
Speaker 2: you how diverse Burrellia burgdor fry is. If Burrellia burdorfry
Speaker 2: were released at a discrete time, let's say in nineteen
Speaker 2: seventy to in Lime, Connecticut. I don't know why we're
Speaker 2: doing it, but let's do it. Let's let's affect the
Speaker 2: people of Lime the genetic similarity because it's only been
Speaker 2: what fifty years, it would be highly genetically similar to
Speaker 2: itself as its spread because it had a point source
Speaker 2: in time. And in fact, it's very diverse, and there
Speaker 2: are all sorts of methods to tell how long something
Speaker 2: has been around. And the thoughts are actually that Burrelli
Speaker 2: Burgdorfry has a long lineage going back millions of years
Speaker 2: in mammalian species.
Speaker 1: This is also the dumbest animal like inst to use
Speaker 1: for a bioweapon, Like mosquitoes are of just a much better,
Speaker 1: clearly much better bioweapon, right tics, And you've got to
Speaker 1: leave it on for like two days?
Speaker 2: Yeah, I mean you had you had one job, evil scientists.
Speaker 1: Well, let me think, I've got this animal that flies
Speaker 1: around and bites you immediately, or I have this other
Speaker 1: one then crawls around and you have to leave on
Speaker 1: for Oh we're going to go with the crawler. Uh, well,
Speaker 1: could go wrong?
Speaker 2: Yeah, yeah, totally, I think So it's not a bioweapon.
Speaker 2: I guess the question I have for you is like,
Speaker 2: so why you know so these coincidences, It's hard not
Speaker 2: to see similar things with COVID nineteen. I'm not getting
Speaker 2: into lab leak versus not lab leak, but like, you know,
Speaker 2: there's a virological institute near the place where the epidemic starts.
Speaker 2: I guess there's a resonance there with lime disease although
Speaker 2: it's across Long Island. Sound. I don't know why you
Speaker 2: don't just do it on Long Island, but whatever, But like,
Speaker 2: is it because lime disease is scary? You know, we
Speaker 2: know it can have these long term effects potentially, and
Speaker 2: believing that and that quote from RFK, like he mentioned
Speaker 2: lime diseas mentioned RSV, he mentioned COVID. All of these
Speaker 2: things is like potential bioweapons or gain function research, like
Speaker 2: the result of human human messin with nature. And in
Speaker 2: some way I'm getting put in my non psychologist talent.
Speaker 2: In some ways, it's satisfying to people to be like, well,
Speaker 2: if all these bad things out there that could happen
Speaker 2: at any time, my kid could get RSV and could
Speaker 2: be terrible, if they're the result of human mouthfeasance, then
Speaker 2: there is a future where we can stop that mouthfeasance right,
Speaker 2: like the good guys can win, whereas if not, if
Speaker 2: this stuff just happens randomly and like stuff evolves and
Speaker 2: all of a sudden, we have a pandemic, like we
Speaker 2: have no control over that. Is that what's attractive about I.
Speaker 1: Think it's simpler than that. I think it's that people
Speaker 1: like explanations, and so people want to understand why things
Speaker 1: are happening, and they want to understand why bad things happen,
Speaker 1: and the explanation of just like animals have diseases and
Speaker 1: sometimes you get them is not actually a super satisfying explanation.
Speaker 1: It's much better to have an explanation like it is,
Speaker 1: because I mean, I think it's the same reason why
Speaker 1: people like this idea that there's a conspiracy between you know,
Speaker 1: big Pharma and big food to give your kids diabetes,
Speaker 1: as opposed to just saying like food companies are trying
Speaker 1: to sell stuff and people like to buy delicious food, Like,
Speaker 1: you know, there's a lot in here where it would
Speaker 1: be nice to have someone to blame because it would
Speaker 1: help you organize and understand the world of why bad
Speaker 1: stuff happens. And I think that's related to the good
Speaker 1: and evil, but I think almost like just one rung
Speaker 1: down of complication. I also think in the case of lime,
Speaker 1: and maybe it's a good pivot to the chronic lime discussion,
Speaker 1: it lends itself well because of the origin story. Because
Speaker 1: the origin story is people were being ignored. A lot
Speaker 1: of the current discussion has focused on this question of
Speaker 1: like is chronic lime?
Speaker 2: Are people still being ignored?
Speaker 1: People still being ignored with this thing, and so to
Speaker 1: sort of have in the middle, it's not surprising that
Speaker 1: it's like we're being ignored. And also, by the way,
Speaker 1: this is the fault of you know, this DoD scientist.
Speaker 2: So all right, so let's turn to chronic lime disease.
Speaker 2: And I think we have to define our terms before
Speaker 2: we get too deep in this because they are going
Speaker 2: to be people listening who are like, what are you
Speaker 2: talking about? So first of all, I will say that
Speaker 2: earlier I talked about late disseminated lime disease. So the
Speaker 2: lime disease, untreated lime disease that can cause you know,
Speaker 2: joint swelling, heart problems, nerve problems, brain problems. In some sense,
Speaker 2: that's chronic lime disease. You've had it for a long time,
Speaker 2: not years, but you've had it for you know whatever,
Speaker 2: a few weeks or something. It hasn't been treated and
Speaker 2: you get these di few symptoms, but that's late disseminated
Speaker 2: lime disease. That is not what we mean we say
Speaker 2: chronic lime disease. Medically speaking, the most people will refer
Speaker 2: to a syndrome called post treatment lime disease syndrome, which
Speaker 2: is what it sounds like. You had lime disease that
Speaker 2: was documented, it was treated, your post treatment, and you
Speaker 2: still have something wrong with you, which is not how
Speaker 2: this is supposed to go. This is a bacterial infection.
Speaker 2: You should get antibiotics and be better. That's how these
Speaker 2: things are supposed to work. But post treatment lime disease
Speaker 2: syndrome exists. We'll talk about what those symptoms can be,
Speaker 2: and we need to begin to understand how this weird
Speaker 2: bacteria can affect your body downstream, even after it's dead.
Speaker 2: Chronic lime disease, though, is a catchier term than post
Speaker 2: treatment lime disease syndrome, and not only encompasses post treatment
Speaker 2: lime disease syndrome people who documented lime treated still sick,
Speaker 2: but also a much larger group of people potentially without
Speaker 2: documented lime without a known tick bite sometimes who also
Speaker 2: have long term symptoms, and they can get caught up
Speaker 2: in this lime disease ecosystem for a variety of reasons,
Speaker 2: including the testing issues that we talked about, and the
Speaker 2: chronic lime disease ecosystem is filled with some very good
Speaker 2: practitioner who know a lot about infectious disease and lime
Speaker 2: disease and other tickmore illnesses, and some charlatans unfortunately, And I.
Speaker 1: Think this space is so hard to talk about. It's
Speaker 1: so hard to talk about because there are many people
Speaker 1: who are genuinely suffering and who really deserve better answers
Speaker 1: and research, and there are also things that are being
Speaker 1: wildly over sold. And there's a balance between not wanting
Speaker 1: to say, you know, you are being oversold this thing
Speaker 1: which is not going to fix your problems, and saying
Speaker 1: you have no problems. And I think people here you
Speaker 1: have no problems. This is all in your head. This
Speaker 1: is like a classic like chronic anything in particularly for
Speaker 1: women here, so frequently this is on your head, This
Speaker 1: is all on your head. And then people it's not
Speaker 1: surprising that people would go out and search for someone
Speaker 1: who is going to take their very real concerns and
Speaker 1: This is why we actually need to see what the
Speaker 1: data says and why this deserves more research rather than
Speaker 1: being left to you know, Charlotte and who are taking
Speaker 1: advantage of people suffering.
Speaker 2: Yeah, yeah, absolutely, So let me just talk about the symptoms. Yeah,
Speaker 2: here's the problem.
Speaker 1: They're everything.
Speaker 2: It's there's a lot of different symptoms that are lumped
Speaker 2: into both post treatment lime disease syndrome and chronic lime disease. Fatigue,
Speaker 2: brain fog, joint pain, intermittent rashes, gastrointestinal distress, psychological discernments, depression, mania, psychosis,
Speaker 2: so hallucinations, and you know these can be debilitating the
Speaker 2: air people who are unable to walk because of these issues.
Speaker 2: And yet those are also symptoms that can occur from
Speaker 2: a lot of other diseases, including other infectious diseases. And
Speaker 2: there is not a clear diagnostic test or either post
Speaker 2: treatment lime disease syndrome or chronic lime disease. So we
Speaker 2: have a bad case definition. And one of the problems
Speaker 2: with like this comes up with the long COVID discussion
Speaker 2: a lot. I've criticized the case definition for long COVID
Speaker 2: because when a case definition isn't narrow, it actually becomes
Speaker 2: harder to study. And when people were making the case
Speaker 2: definition for long COVID, everyone was so concerned about having
Speaker 2: a big tent, right, like, it can be long COVID,
Speaker 2: if you're tired, it can be long COVID. If you
Speaker 2: have postural attack cardio syndrome, it can be long COVID,
Speaker 2: if you have brain fog. It was so diffuse that
Speaker 2: it actually was difficult to study because you look at
Speaker 2: biomarker differences and people with and without long COVID, and
Speaker 2: like they all look the same. But the people with
Speaker 2: long COVID, it's this very heterogeneous group. So sometimes you
Speaker 2: actually want a case definition that's super tight, even if
Speaker 2: it'll exclude people from diagnosis, so that you can actually
Speaker 2: figure out what the testing should be. And that wasn't
Speaker 2: done for long COVID. It wasn't done for chronic line.
Speaker 1: And I think in the case of chronic lime, you know,
Speaker 1: and in some ways you would think, okay, so part
Speaker 1: of that should be you know, tick bite and basic
Speaker 1: like some evidence that you have had acute lime disease.
Speaker 1: But since our tests for this are potentially false positive,
Speaker 1: potentially we have a lot of false positives and potentially
Speaker 1: some false negatives, and because sometimes you get bitten by
Speaker 1: a tick and then you don't it falls off and
Speaker 1: you don't know that actually can't be a or at
Speaker 1: least that's not necessarily a perfect diagnostic criteria. So by
Speaker 1: leaving the tent open, we don't have a we don't
Speaker 1: even have that, which would seem like the basic yeah,
Speaker 1: the sort of first basic yeah.
Speaker 2: And again you know the pathway for this is you
Speaker 2: start with the narrow case definition, then you get your
Speaker 2: diagnostic tests, then you expand those to other people with
Speaker 2: more like without as classic symptoms, and then you can
Speaker 2: enlarge the tent. I said several times there's an ecosystem here,
Speaker 2: and I think what people need to be aware of is, okay,
Speaker 2: I have if you're in an ambiguous state, you don't
Speaker 2: remember a tick bite, you didn't have a rash, but
Speaker 2: you're feeling all these vague symptoms. You can get sort
Speaker 2: of funneled into, often through social media or through the Internet,
Speaker 2: to a self described group of practitioners called lime literate doctors.
Speaker 2: And this is another term that's way too broad because
Speaker 2: there I know plenty of infectious disease doctors who would
Speaker 2: call themselves lime literate. I mean, especially here in Connecticut,
Speaker 2: we have great infectious disease doctors who know everything there
Speaker 2: is about my giant table of tick porn illnesses. Then
Speaker 2: there are sort of self described lime literate doctors who
Speaker 2: are part of this almost like a more shadowy medical
Speaker 2: adjacent ecosystem. And the reason I keep saying ecosystem is
Speaker 2: because these doctors refer to each other, so there's there's
Speaker 2: a sort of circular nature there. These doctors send blood
Speaker 2: tests to specific labs, so sort of lime literate labs,
Speaker 2: which often lack FDA clear and sometimes lack clear certification.
Speaker 2: These labs will run tests that are research tests on
Speaker 2: the blood to look for evidence of lime disease, look
Speaker 2: for evidence of the spiralkeat, and often will find evidence.
Speaker 2: But again we're very concerned about false positives because these
Speaker 2: are research tests and they set the thresholds for detection
Speaker 2: very low. There's a lot of cross reactivity, and I've
Speaker 2: seen patients kind of get drawn into this. They start
Speaker 2: with vague symptoms, then they get a confirmatory test that
Speaker 2: tells them they have lime disease, and they go down
Speaker 2: a treatment pathway which can actually be quite dangerous. Again,
Speaker 2: this is not to say that they don't have real symptoms.
Speaker 2: It's not even to say that they don't have lime disease.
Speaker 1: It's just not.
Speaker 2: The safe path to obtain the diagnosis and get the
Speaker 2: right treatments.
Speaker 1: And there is a treatment that is very common and
Speaker 1: has been tested repeatedly and doesn't work. So the most
Speaker 1: common treatment for this is like IVY antibiotics or very
Speaker 1: high dose, long term, long term IVY antibiotics. And you know,
Speaker 1: there's a trial in the New England Journal of Medicine
Speaker 1: which does not see any differences in health related quality
Speaker 1: of life with people who are given your long term
Speaker 1: antibiotics versus a shorter course. And this is a long
Speaker 1: term I mean people are on these antibiotics for like months.
Speaker 2: Yeah, and at a time. The risks of long term
Speaker 2: intravenous antibiotics are quite quite high, just to say them
Speaker 2: out loud. You've got an indwelling catheter, so some right,
Speaker 2: you got to infuse it somehow. Pickline a central line
Speaker 2: of some kind that's breaking the skin, so that increases
Speaker 2: the risk of skin borne bacteria getting into your bloodstream
Speaker 2: and causing sepsis. You're getting antibiotics, which increases your risk
Speaker 2: for seedficile, that bad diarrheal infection that happens when you
Speaker 2: kill off your good, healthy gut bacteria and the bad
Speaker 2: evil bacteria takeover. You dramatically increase your risk for candida infections.
Speaker 2: So yeast doesn't get killed by traditional bacteria. If you
Speaker 2: take an antibiotic, you're at high risk for yeast infections.
Speaker 2: But those yeast infections can happen in the blood in
Speaker 2: people with indwelling lines, and they're a disaster. I mean,
Speaker 2: they really are life threatening. So this approach to therapy
Speaker 2: is super dangerous. And as you said, there's not just
Speaker 2: one randomized trial of this in chronic lime disease. There's
Speaker 2: multiple randomized trials. So some people got placebo and some
Speaker 2: people got long term intravenous antibiotics, and there's no difference
Speaker 2: in outcomes. It just doesn't work. And it's one of
Speaker 2: the red flags I have for people that are going
Speaker 2: through this and who are you know, seeing a practitioner
Speaker 2: that's diagnosing them this way. If they get to the
Speaker 2: point where they want to put a line in you
Speaker 2: and give you several months of antibiotics, that's really time
Speaker 2: to get a second opinion. I really think that's a
Speaker 2: red flag.
Speaker 1: And I mean I think that the truth is of
Speaker 1: course there people will say, well I did this and
Speaker 1: it helped.
Speaker 2: Oh my gosh, look on Instagram.
Speaker 1: Yeah, and you know, the placebo effect is really really
Speaker 1: powerful effect. That is why we need randomized trial data,
Speaker 1: and especially in a case like this where the potential
Speaker 1: downsides are very, very very real. He is very important
Speaker 1: to make these decisions based on actual trial data. This
Speaker 1: is not you know, taking a sugar pill and just
Speaker 1: using the placebo effect for.
Speaker 2: Yeah. There's also some confirmation bias that I've seen happen.
Speaker 2: So you know, you get your antibiotics and you feel better, Okay, great,
Speaker 2: that's confirmation that it worked. You get your antibox and
Speaker 2: you feel worse because you get diarrhea or one of
Speaker 2: the other many side effects from antibiotic use. There are
Speaker 2: people say, oh, that's the Gerrish Herzheimer reaction or the
Speaker 2: community called it jerksing. This is a true thing. So
Speaker 2: any spira keat for whatever reason when you kill it
Speaker 2: with so the other common one is syphalis. When you
Speaker 2: either kill syphlis or lime disease acute lime disease with
Speaker 2: an antibiotic, the spier keats lies and they release a
Speaker 2: lot of inflammatory stuff and for about twenty four hours
Speaker 2: you can get like fevers and chills and stuff. It's
Speaker 2: more commonly described in syphilis with initial treatment. So that
Speaker 2: happens in acute limes or can in a subset of
Speaker 2: people with acute lime disease. But there's there's no real
Speaker 2: reason to think it would happen in chronic lime disease
Speaker 2: because we can't isolate the bacteria. Like it's not like
Speaker 2: we can see the bacteria in your blood that's floating around.
Speaker 2: It's not there, you know. The tests don't show that,
Speaker 2: so it's not lising. So but what people will, they'll
Speaker 2: just attribute any negative symptom to jerk saying, and any
Speaker 2: positive symptom to getting better, and it becomes this self
Speaker 2: reinforcing thing. And by the way, here's another red flag
Speaker 2: if you're seeing one of these practitioners, if they're not
Speaker 2: taking your insurance. Okay, if you're paying out of pocket
Speaker 2: for this. These intravenous infusions can cost thousands and thousands
Speaker 2: and thousands of dollars. And I've seen patients who do
Speaker 2: it for three months, maybe they feel better, they stop,
Speaker 2: they feel worse again. They do it for another three months,
Speaker 2: it can be really financially devastating.
Speaker 1: Yeah, I mean, I think the last thing I would
Speaker 1: just want to end on in this in this discussion
Speaker 1: I think we're going to answer these questions is you know,
Speaker 1: people are going this route because the medical system has
Speaker 1: failed them. And so it's I think fine to it's
Speaker 1: reasonable to say, you know, you shouldn't go this route,
Speaker 1: but to just say you shouldn't go this route and whatever,
Speaker 1: so just like live with it is also terrible correct.
Speaker 1: And so I think there are there was real research
Speaker 1: that needs to happen, and I think some of it
Speaker 1: is happening, but you know, real things they need to
Speaker 1: be done, and people do need to be listened to,
Speaker 1: and if they were listened to, it would potentially close
Speaker 1: some of this uh.
Speaker 2: Distrust exactly that exists. Absolutely. Actually, just today I saw
Speaker 2: HHS had announced a series of new initiatives towards lime disease,
Speaker 2: including some research funding directed towards understanding these long term
Speaker 2: post treatment syndromes. That's good.
Speaker 1: Yeah. Ross douth that, by the way, has a very
Speaker 1: good book called The Deep Places. Ross is a columnist
Speaker 1: for The Times. You had had chronic lime and it's
Speaker 1: it's an interesting book to read because you know, this
Speaker 1: is a very broadly scientifically minded person who goes in
Speaker 1: directions that I think he would even he would say,
Speaker 1: we're very unscientific and experimental just in a curve, and
Speaker 1: you can sort of feel the like, I just need
Speaker 1: to figure out something to fix this because it is
Speaker 1: ruining my life.
Speaker 2: Yeah, the desperation, the desperation, and doctors are you know,
Speaker 2: I'll tell you from a from a physician standpoint, it
Speaker 2: is it's really hard to not be able to offer
Speaker 2: a patient something. You know, they come in and it's like,
Speaker 2: you know, they're having all this stuff and I can
Speaker 2: do these tests and if I'm not coming up with anything,
Speaker 2: it feels terrible. But the truth is those are the
Speaker 2: places where research is most needed, and until that good,
Speaker 2: high quality research is done, we are going to see
Speaker 2: a parallel ecosystem emerge. It's it's sort of the natural thing.
Speaker 2: People are going to offer solutions, and I don't want
Speaker 2: to discourage people from exploring any potential solution, with the
Speaker 2: potential exception of long term entreveno standouts, because they really
Speaker 2: can be so harmful and potentially fatal. So that's the
Speaker 2: that's the only one that I really do worry about
Speaker 2: in this space. Otherwise, we just have to do better.
Speaker 2: Listen to your patients, work through if you have to
Speaker 2: go symptom by symptom, go symptom by symptom, get them
Speaker 2: to the right specialists. Figure out other mechanisms, other solutions
Speaker 2: to this.
Speaker 1: Okay, I want to end on a more positive note,
Speaker 1: which is about the vaccine. So you know a lot
Speaker 1: of people, specifically my husband asked me three times a
Speaker 1: week why there's no lime disease vaccine because he hates sticks.
Speaker 2: My dog gets a vaccine, jo your dog.
Speaker 1: Gets one, and amazingly we used to have one. So
Speaker 1: there was a there was a lime disease vaccine called Limericks,
Speaker 1: which was pulled off the market in two thousand and two.
Speaker 1: It did work, there was a litigation backdrop. People said
Speaker 1: they're autoimmune side effects. They just decided it was I
Speaker 1: don't think it made enough money. Honestly, people didn't. People
Speaker 1: didn't want it. But it's bad, not that, but something else.
Speaker 1: There's a new lime diseased vaccine that just complete completed
Speaker 1: its trial in March. Seventy three percent efficacy against infection
Speaker 1: the confidence interval is enormous, sixteen to ninety three percent,
Speaker 1: very big. Not enough people in your trial cases. But
Speaker 1: but you know, it seems like we are moving the
Speaker 1: direction of having this, so Jesse hopefully soon for you
Speaker 1: lime disease. And let me say one other thing before
Speaker 1: we smash our past our ticks, which is you should
Speaker 1: be avoiding ticks moving away from lime disease you want.
Speaker 2: To avoid, Yeah, to get started.
Speaker 1: Okay, So the two things about avoiding ticks. One is
Speaker 1: there's stuff comes in an orange spray bottle you can
Speaker 1: spray and it's called pirethron oh permethrin, and you can spray
Speaker 1: your clothes with it. That's a really good idea if
Speaker 1: you're going to be hiking in tickborn areas, because it
Speaker 1: like repels the ticks off your clothing. Okay, that's a
Speaker 1: really good idea. Bugs spread also works. DT is fine,
Speaker 1: it's not poison. You can use it also perfects you.
Speaker 1: It's mosquitoes. And you should check people for tics. In
Speaker 1: your family. You should check each other for tics. It's
Speaker 1: not gonna fix your powasen problem. But for lime taking
Speaker 1: ticks off if you see them as good and so
Speaker 1: you should check yourself. There's also a really good country
Speaker 1: song with.
Speaker 2: That lyric, check yourself for tics.
Speaker 1: No, it's like I want the lyric is I want
Speaker 1: to check you for tics? And you know it's romantic.
Speaker 1: I guess poor play.
Speaker 2: Sure, primates do groom each other?
Speaker 1: All right, Perry, are you a smash? Are you a smash?
Speaker 1: Your pass on tics?
Speaker 2: I'm gonna pass on tics. I think you should stay
Speaker 2: away from them. I think they should stay away from us.
Speaker 2: You know, I don't know ecologically, do they have some role?
Speaker 4: You know?
Speaker 2: I like, if I could snap my fingers and eliminate
Speaker 2: all ticks, would it cause some horrible like would then
Speaker 2: all of a sudden, like all the ducks would die?
Speaker 2: I don't know, but yeah, pass How about you.
Speaker 1: Emily, I'm a I'm a pass on tics. Yeah, I'm
Speaker 1: a pass on them. That's very cool. Controversial, controversial, controversial,
Speaker 1: take don't like ticks?
Speaker 4: All right?
Speaker 2: When we come back your question of the week and
Speaker 2: we're back with our question of the week. If you
Speaker 2: have a question for us, drop us a line at
Speaker 2: Wellness actually dot FM or mail bag. Question of the
Speaker 2: week is here.
Speaker 3: Hey, Emily and Perry, This is Nate from a Kansas uh,
Speaker 3: simple question, is VO two max a good indicator of
Speaker 3: overall health? Fix?
Speaker 2: Okay, Emily v O two max. This is right down
Speaker 2: the middle for an Emily Oster question, what is VO
Speaker 2: two max? What do you think my VO two max is?
Speaker 2: What is your VO two max? And how good is
Speaker 2: it as an indicat overall health?
Speaker 1: Amazing? Okay, so VO two I'm made for this question. So,
Speaker 1: votwo max is the highest amount of oxygen that your
Speaker 1: body can use during hard exercise. So it is a
Speaker 1: measure of how well your heart and lungs and muscles
Speaker 1: working together. Is the vias volume? O two is oxygen,
Speaker 1: so max is means the maximum?
Speaker 2: Okay.
Speaker 1: So it is a common metric of like aerobic fitness.
Speaker 1: Hire is better, hire is better, higher is better. It
Speaker 1: goes down with age. And the reason this gets a
Speaker 1: lot of attention is if you ran a regression, like
Speaker 1: an analysis of like lunge, so looked at correlations between
Speaker 1: longevity and many other many metrics, you would have this
Speaker 1: loads the strongest. So this is like the highest value
Speaker 1: predictor of things like longevity that we have. Okay, interesting, Yeah,
Speaker 1: And overall strength beats it beats like finger strength. Although
Speaker 1: finger strength. We can get another episode how stupid that is.
Speaker 1: But this is really it beats you know, resting heart rate.
Speaker 1: It beats like bmib like it's really really good, Okay,
Speaker 1: And so what people like to interpret that as like,
Speaker 1: you know, if I changed this, it would be really beneficial.
Speaker 1: I think that that's too far. I think the issue
Speaker 1: is that this is something that moves very readily with
Speaker 1: a lot of the kinds of behaviors we know are effective.
Speaker 1: So this is a this is something you can move
Speaker 1: pretty easily with exercise. And so even when people who
Speaker 1: don't exercise at all exercise for small amounts, you will
Speaker 1: already move their VO two max. And so it's just
Speaker 1: like a very sensitive measure. And so that's why the
Speaker 1: correlation is so good. But and so there are many
Speaker 1: things that you could do to move this which would
Speaker 1: probably be good for you. But like if just one
Speaker 1: day you woke up and nothing else had change and
Speaker 1: all of a sudden, your VIEO two max was highed, Like,
Speaker 1: that's probably not makingful. What's a good number?
Speaker 2: How do I measure it?
Speaker 1: Yeah, so if you have a wearable it will measure
Speaker 1: it will give you a kind of correlationally appropriate but
Speaker 1: noisy and kind of garbage like, but like you're wearable
Speaker 1: to measure this if you really want to measure this,
Speaker 1: like you're in the you know, cycling on or whatever. Yeah,
Speaker 1: you got to get on a like you get on
Speaker 1: a on a treadmill with a mask on, and then
Speaker 1: you like run to exhaustion and that will measure your
Speaker 1: vo your vo two max.
Speaker 2: Don't threaten me with a good time people.
Speaker 1: People don't really people don't really do that. There's no
Speaker 1: reason to do that. But if you have a wearable
Speaker 1: they'll like and you start exercising more. This is a
Speaker 1: number of people will see move. It's like a good motivator.
Speaker 1: I would guess yours is like forty five is okay?
Speaker 2: What's yours?
Speaker 1: Fifty five?
Speaker 2: Oh, all right, that's fine. I don't really know what
Speaker 2: that means, but I'm flattered that you're going to give
Speaker 2: me ninety percent.
Speaker 1: Yeah, it's like, you know, truly like exceptional elite athletes
Speaker 1: will be like the eighties, but that would be like
Speaker 1: very unusual. This sort of average for people is in
Speaker 1: the thirties.
Speaker 2: Have you done the full mask?
Speaker 1: No, No, I didn't. I did consider it, but I had
Speaker 1: trouble finding a lab because I'm crazy, and I ultimately
Speaker 1: decided there was no point in knowing that number except
Speaker 1: to tell you to say it on a podcast and
Speaker 1: just noigher than I am. I'm regretting it, but I
Speaker 1: was able to I was able to assert that I
Speaker 1: was ten point higher than you with no evidence.
Speaker 2: Emily and I are doing a VO two max competition.
Speaker 2: I will probably die. That's it for us today. We
Speaker 2: are actually off. Next week we'll be rerunning a classic episode.
Speaker 2: It's definitely worth a listen, enjoy the end of the summer.
Speaker 1: It was great to see in person today, and I
Speaker 1: want to thank the audio engineer here at Eale, Ryan McAvoy.
Speaker 2: Thanks Ryan.
Speaker 1: Wellness Actually is produced in association with iHeartMedia. Our senior
Speaker 1: producer is Tamar Avishei. Our executive producer at iHeart is
Speaker 1: Jennifer Bassett. Our theme music is by Eric Deutsch, and
Speaker 1: our content is for educational purposes only.
Speaker 2: If you like the show, help other people find us,
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Speaker 2: head over to Wellness Actually dot fm and leave us
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Speaker 1: We'll let the influencers have the last word.
Speaker 4: You see class my line, disease turned out to be psychosomatic.
Speaker 1: Does that mean you're crazy? Oh, that means he was
Speaker 1: faking it. No, actually it was a little of both.