319: Mast Cell Activation Syndrome: What is MCAS + Why It's So Devastating w/ Dr. Jill Carnahan

Jennifer Fugo (00:08.91)
Dr. Jill Carnahan, welcome to the Healthy Skin Show. It's an honor to have you here.

Dr. Jill (00:13.762)
Thank you, it's an honor to be here.

Jennifer Fugo (00:16.174)
So I thought you would be the perfect person to maybe ask a little bit about MCAS or Mast Cell Activation Syndrome. We have not really talked about it on the Healthy Skin Show. I have spoken about histamine intolerance before because I do see a lot of clients who struggle with this, especially those who are struggling with chronic hives and dermatographia and whatnot. But I feel like MCAS is, for a lack of better word, beast of a condition, unfortunately. Do you want to share a little bit about what exactly is MCAS and what makes it different from histamine intolerance?

Dr. Jill (01:00.086)
I love that you're going here because I do think this is number one, it's absolutely increasing in prevalence right now. Like a lot of people, COVID really stirred up our immune systems and that was one more infection that can cause MCAS, which I'll describe in a moment, but obviously many, many people affected. And so many, many, many more people are affected that got their mast cells irritated by this virus and that are now still dealing with a mast cell activation. So let's just talk about first, what is it?

So in medical school, we're taught about mastocytosis. This is a proliferation of this one type of primordial immune cell called a mast cell that throws out all kinds of things like prostaglandins and histamine, and all these things create inflammation. And they're supposed to protect us from bad bacteria and infections and chemicals and toxins and things. So they're doing their job. But the sad thing is now in our toxic world, we have so many chemicals and so many triggers like mold or chemical exposure or metals or parasites or COVID or other infections that are triggering those mast cells. 

So we went from mastocytosis being quite a rare thing where someone has a proliferation in their bone marrow of the type of cells almost like a pre-cancerous type of thing. That's not what we're talking about. It's not a cancerous thing. It's not a proliferation. It is literally your own mast cells that we all have being overly stimulated to become activated. So what happens in these patients, they could still have a larger number, but for the most part, they're not having excessive numbers, they're just having excess activation. And again, our mast cells are trying to protect us. So they're doing what they're supposed to do, but unfortunately in our common world right now, and post-COVID, there's a lot more toxins, triggers, infections, even EMFs, stress, lack of sleep, those kinds of things can also trigger mast cells through the epinephrine and through the HPA axis. So what we're seeing now is this epidemic of mast cell activation disorder.

And particularly, because the mast cells have their most common, I should just say the most thick, the place where they're most likely to reside is in the skin. I said that kind of took me a while to say it, but I don't lie to say in the skin, they manifest in the skin a lot. And I personally know this well because I grew up with severe eczema, which is a mast cell-derived disorder. And then when I got sick with cancer, chemo, all that kind of stuff, it affected my skin.

Dr. Jill (03:21.838)
I had horrible acne and then when I had mold-related illness. So even though now my skin's okay, I've been through a lot with like literally red puffy circles around my eyes, horrible eczema where I would scratch till I bled and terrible cystic acne during mold. So I have had my share of skin disorders and many times it was related to mast cell activation.

Jennifer Fugo (03:42.986)
And is this something, because I always think of mast cell as sort of a higher up on the severity totem pole compared to histamine intolerance, and I think people sometimes get them confused. Do you have an easy way to maybe help people differentiate between the two? Because I think sometimes when we're trying to do the search ourselves, because we don't have a physician or a partner to help us, we go down rabbit holes and sometimes can start to think we have something that we might not have. And I feel like you gotta be, you don't want mast cell activation. So we don't wanna go there unless it's really what's going on.

Dr. Jill (04:26.902)
Got it, yeah, so a couple things. So histamine is one of literally hundreds, maybe even thousands of chemicals that mast cells produce. So the histamine bucket is a much smaller derivative. It could be kind of under, it definitely comes from mast cells as one source. And when you think about histamine intolerance, you think about a couple things. First of all, where's the source from food? So if you have a lot of food in your diet that is high histamine, which comes from amines, which is from proteins that are broken down. So fermented foods.

Foods that are leftover or sitting out, like a protein that would be cooked, fish that's leftover or maybe not cooked immediately after catching it. Those are the kind of things that can produce more histamines. That's one source. If your body from genetics or otherwise, you maybe have methylation issues or low DAO and you can't break it down, that's another reason. So you might have not a high level in your body, but you can't break it down well. And then other things is when your mast cells do for some reason, some exposure, some trigger produce more histamine. 

So production, too much production, too much exogenous ingestion and not breaking it down, those things will lead, some compartment of those will lead to excessive histamine. And again, that can present with skin, it can present with rashes very, very commonly on skin. When you think about mast cell activation, it's a bigger bucket, it's a bigger deal, like you said, and it would involve by definition more than one system.

So if you only have a skin manifestation or you only have a gut manifestation of histamine intolerance, that may be the histamine intolerance or the poor breakdown, the excessive ingestion or the genetics. But if you have multiple systems like brain fog, leaky gut, excessive heartburn is a histamine thing, skin issues, rashes, eczema, acne, or maybe heart palpitations.

Or maybe you have, I could name all kinds of systems because the mast cells can really affect almost, lungs are a big one, so lung inflammation, asthma, shortness of breath, sinus congestion/inflammation. So the mast cell bucket is gonna affect more than two systems.

Jennifer Fugo (06:29.818)
And is there a criteria by which physicians are supposed to diagnose this?

Dr. Jill (06:37.93)
Yeah, so there's a wonderful consensus paper with the authors, Tanya Dempsey, Lawrence Afrin and more. There's a bunch of authors. Those are two big ones that are on there. I'm sure you know who they are. And it's Consensus-2 for mast cell activation disorder. And if you want it, it's free online. You can look it up. I don't have the site memorized, but it's the Consensus-2 statement for diagnosis of mast cell activation. And again, the authors Dempsey is one of them. Afrin is one of them. And that's a great place to look for the actual criteria.

It does not involve, the first consensus involved, you must have elevated tryptase in the blood. That's a marker that you can measure, but that's more related to mastocytosis, the first thing that I described, which is this excessive production of mast cells, not the activation of them. And so many people with mast cell activation do not have an elevated tryptase, and yet they still have the disease. So they created this Consensus-2 which really just involves the clinical presentation of more than one system.

And then response to treatment, which is histamine blockers, mast cell stabilizers, natural anti-inflammatories. Again, we can talk about all those if you want. And as you respond, then we know that's a clinical diagnosis. So it technically is a clinical diagnosis that does not require blood or urine test, although we still often do some of these blood and urine tests to determine.

Jennifer Fugo (08:00.634)
And you mentioned COVID earlier, and obviously, toxic black mold can be another factor. What are some environmental triggers that, environmental, but also, like you said, there can be maybe pathogens involved with this. What are some triggers that could trip you into this place of MCAS versus, you know, as you were saying, with histamine intolerance, it could be coming just from high histamine foods that you're struggling to break down. There can be obviously certain gut bugs, I've talked about this on the show, can produce histamine in the GI tract.

Dr. Jill (08:34.573)
Mm-hmm. Yes.

Jennifer Fugo (08:40.076)
So we can overload our bucket with unfortunately not that many things, but there's some, I think more distinct triggers for MCAS that are environmental that you could share.

Dr. Jill (08:50.922)
Yes, so toxins are one of them, and mold is probably the number one. In fact, I've talked to Dr. Theoharides in Boston and Lawrence Afrin and some of the experts, all they do is mast cell activation syndrome, and they're not necessarily functional or mold experts like myself, but they will all say that black mold is probably the number one trigger. Black mold just has this deep predisposition to trigger our immune system to be overactive through the mycotoxins it produces. 

So when I have someone who presents with new onset mast cell activation, the very first thing I wanna do is rule out a black mold exposure because I can do all the supplements, diet, lifestyle, or drugs in the world, and if they're living in a massively moldy home, they won't get well. So that is a big trigger. Number one is toxic black mold. That would be toxin. Heavy metals, parabens, phthalates, chemicals, that chemical aisle in your local grocery store can also be a trigger. So a lot of these people have both mast cell activation and multiple chemical sensitivity, which is slightly different as well.

The multiple chemical sensitivity relates to the bucket you mentioned, which I always use as an analogy too, and it's like how full is that bucket of toxins and exposures? And when it starts to fill up and go over the top, spill over the top, typically patients will present with autoimmunity, with cancer, with neurodegenerative disease, or cognitive issues, and they often will present with multiple chemical sensitivities where they react more to chemicals. But you could get a migraine from laundry detergent and not have mast cell activation.

So they're kind of different things, but they run together a lot. So toxic black mold number one, other toxins number two, infections, COVID's a big one, Epstein-Barr, CMV, herpetic viruses, tick-borne infections like Borrelia, Bartonella, Babesia, all of these kinds of things can be triggers. And then heat or cold or even pressure. Some people react to water, which is crazy, but it can be very simple things. So there's a whole long list and almost anything you can think of. Even sauna for some people can be a trigger for those mast cells to start to release their contents and create skin issues.

Jennifer Fugo (10:52.31)
And in terms of diet, do you believe that it could be an actual trigger for mast cells or do you think that it's more of an exacerbating factor and perhaps, because I think sometimes people think they can solve everything with diet and I probably am of the opinion that I think if you fall into the bucket of mast cell activation, you're beyond just a diet solution at this point.

Dr. Jill (11:18.702)
I love how you said that so clearly because I would agree and it's funny because 20 years ago when I started functional medicine I would do food sensitivity testing and take people off certain things. That helps unload that bucket because say if you're really reactive to gluten and dairy and corn you take those immune triggers out temporarily you unload that system and the system can work better and can heal. 

But as you mentioned really what happens is if you're having reactions, besides the true celiac, if you're really having an antigenic reaction to wheat or corn or soy or dairy, this is more a symptom of a leaky gut, which you know so well is related to skin. Like this might be the core issue of skin is when there's permeability. And how this relates to MCAS mast cell activation and histamine intolerance both, is histamine will by nature create more permeability in the gut. So what happens is again, if you temporarily unload those antigens, like whatever that person is sensitive to, you usually do get some relief. But as you mentioned, just to be clear, that is usually not the solution to mast cell activation syndrome.

Jennifer Fugo (12:17.81)
No. And there is, you mentioned a genetic component to MCAS. Obviously, there are issues with DAO or the diamine oxidase enzyme, but this is also part of methylation, the methylation pathway to break histamine down. So do you tend to see there being a genetic component with a lot of your patients? And is that a differentiating factor between maybe why one, like, does it matter? Is that why one person may be more prone to develop mast cell activation syndrome versus another person?

Dr. Jill (12:47.646)
Yes, and I'm actually glad you mentioned this because there's all the methylation, the SNPs, and there's about three or four, maybe 10 of them, truly that can relate. So that lays down a foundation for you to have less threshold to get to mast cell activation. So like for me, born on a farm, chemical exposures, mom probably had some issues in utero, whatever, but I had eczema basically from birth. So from birth, I had this genetic predisposition towards histamine intolerance, and mast cell activation. 

And part of that was the genetics because obviously I wasn't born totally intolerant to every food. So all those things played into that. But there's a KIT gene, K-I-T, that can be tested through any lab. And this is a high, high prevalence with mastocytosis. So there's actually a couple of genes that are really like almost diagnostic of the more severe forms of mast cell activation and mastocytosis. And KIT, K-I-T, happens to be one of them. I've had a few patients where we're looking at all this and we're doing all the right stuff.

Jennifer Fugo (13:38.766)
And… Yes?

Dr. Jill (13:43.426)
And they're not getting better, and those are the ones that typically have that mutation.

Jennifer Fugo (13:46.958)
Interesting. And with the exposure to COVID in any way, we'll just say whether you come in contact with the virus yourself or in some other fashion, I feel like we have to be careful now of how we discuss this, unfortunately. But why do you think that some people start to develop hives afterwards that are uncontrollable? So they end up with chronic urticaria or could develop mast cell activation disorder from that exposure?

Dr. Jill (14:17.874)
Yeah, so gosh, there's a lot going on there. I will say the spike protein is a problem. There's just no doubt with the research is out now, I can freely talk about it because the evidence shows this is true. And whether you and again, it can be a very mild case, the latest research from the CDC says one in five adults have long COVID symptoms, which could include mast cell activation, could include brain fog, could include, and I really believe as I see a lot more long COVID patients, meaning more than 3 months of symptoms after a case of COVID.

Dr. Jill (14:47.562)
And again, many times this is a very mild, like I could barely tell I had a cold or a flu kind of thing. Lately, the variants that we're having are pretty mild cases, but people will still have a very significant, long-extended thing. And in most of those mast cells are involved. And like I said, one in five is a statistic from the CDC. And part of this is because the spike protein happens to be encapsulated in our macrophages as they're trying to get rid of it.

And a lot of times the spike protein isn't cleared well, and it is like this ongoing trigger for the immune activation. So they're getting this innate immune activation, including mast cells and this inflammation. We can literally measure the cytokines in long COVID and see the pattern. So interferon-gamma is one of them, TNF-alpha (TNF-a) is one of them, and I'm measuring those in patients. So the ones with long COVID have a pattern of innate immune activation. And at the root, among other things, is the spike protein kind of contributing to this.

So until their cells actually get rid of the spike protein and die off, they often will have residual symptoms for a very long time.

Jennifer Fugo (15:50.346)
Hmm. This is just so interesting, because it's so different. And it's one of the reasons oftentimes I get requests from folks who want to work with me. They're like, “do you work with mast cell?” I'm like, no. No. You need to find…

Dr. Jill (16:03.874)
It's complex.

Jennifer Fugo (16:12.038)
It's very complex. And also, I do feel like, I don't know your opinion, but, you know, having a dad that was a doctor and seeing so many people in various states of suffering, and I think we obviously want to talk a little bit about when you get to a place where you don't have a lot of hope because your health is not great. But I do think there can be a time and a place for medication and supplements. And I think sometimes in the functional integrative space, I think sometimes people like to say medications are bad.

But I think in the case of MCAS, I think sometimes those medications can be helpful because there's no amount of quercetin and stinging nettles that's going to help you in a significant way. So are there some options or some tools that if somebody is struggling with this, that they should look into that could be helpful, like medications, maybe certain nutrients or certain types of supplements or even lifestyle changes that may be helpful?

Dr. Jill (17:14.474)
Yeah, I'm so glad you said that because I agree. I always try to do the most natural intervention first, but when I'm dealing with mast cell activation, the standard is layering interventions because patients with just, I love quercetin, it’s my first line thing, I love that, but very frequently that alone is not enough for the really sick patients. And so we're layering H1 blockers, H2 blockers, mast cell stabilizers, so that would be something like Zyrtec, ranitidine, montelukast, and then there's something called ketotifen that can be compounded, really effective. 

I wrote an article about low-dose naltrexone because it can actually alter the innate immune function. So that's a newer one that can help. And literally many of these people, in order to get them stabilized, they're on two, three, four, five medications. Now the tricky thing is the commercial, a lot of times they will tolerate the commercial formula for the antihistamine, but very frequently they're reacting to the polyethylene glycol in that conventional medicine. 

So the other thing that happens is a lot of times we have to compound them free of any sort of excipients, which are the things that just go in that capsule to make it a capsule. But the patients with mast cell activation disorder symptoms will react to those excipients, which are just added ingredients that aren't active, but for that mast cell patient, they're a big deal. So very frequently we have to go through and literally compound them free of anything and layer them. And I would say most of my patients with significant MCAS aren't controlled until they have three, four, five different agents.

So it's a really big deal and you're right. But it can be life-threatening. I mean it really can be serious. So steroids, again, I do not like steroids, but in this case that can be temporarily also really profound, and then there's some big guns of immune-modulating drugs like Xolair that can also be really helpful in the severe cases. And again, sometimes I've seen those be life-saving because this can so affect the gut, in fact my preface in my book is about a patient of mine that had mast cell and she literally died in her 20s.

And I kind of started with that because the truth is the bigger picture in this, she went on to literally create a foundation and like her life lived on after her. And I loved that story because it showed my humility as a physician. I can't cure everybody, right? And, and I know that, but if I can bring hope and this deeper meaning and purpose through our suffering to me, sometimes that's as important as the healing.

Jennifer Fugo (19:30.15)
And I'm glad that you brought that up because I have found that we'll just say after 2020 and everything that we have been through, there tends to be, it feels like people are losing more hope with their health, especially, and I can understand, you can get to a place that feels extremely dark. There are some people, depending on how severe their conditions are, who are, they may not want to wake up tomorrow. And they are very clear about that they will post things online in groups asking for help because they are so miserable and feel so desperate and they've just given up. And that was something in your book, Unexpected, which I have a copy of everyone and it's a wonderful book, especially, and this is not specific to skin, I think this is applicable to any person, especially in this community where you’re dealing with chronic health issues.

Jennifer Fugo (20:28.456)
And maybe you have a mother who's dealing with some other chronic health issue, it's really applicable to anyone who's struggling in their life with their health where you feel like your health has failed you and your body is failing you and you're not seeing hope at the end of the day. There was one really beautiful passage that was especially poignant that I did want to share from it because I think for those who are in that dark place where hope is so hard to come by.

I was particularly moved by a quote in your introduction. You said, “My own journey is about finding resilience when I least expected it and overcoming my difficulties through functional medicine, science, and faith. Although my journey is unique, so is yours. Even if you don't share my spiritual beliefs, there is a powerful message in the transcendence we can find when in the middle of the darkness, if we stay open to the unexpected.”

And I thought that was so beautiful. Can you share a little bit more about what you meant in sharing that thought?

Dr. Jill (21:35.658)
First of all, thank you so much for sharing that and thank you for allowing it to touch you and share with the audience because I almost get teary when I think of that because I know what it's like to suffer. I have had cancer and Crohn's and mold illness and I know what it's like to feel like you don't have hope. And yet what I have found in my journey and I know it's the same for anyone listening, when we take suffering and reframe it as a teacher, we don't make it, we don't minimize it, we don't not feel our pain, we don't dissociate, because those are not healthy either. We can feel all that stuff, the painful parts, but then in the midst of that, if we look at it as what is this here to teach me, how can this transform me and make me a better version of myself? So often there's these beautiful gifts that are hidden in the darkest, most difficult times, and we have to look for them because it doesn't always come easy, it's not fun.

I would never wish some of my suffering on anyone. But I also know looking back, those times were the most profound, transformative times in my life. And they led me to a powerful ability to help people and empathize with people and even to find answers. Like, unless I would have gone through the horrible mold illness where literally my skin was almost falling off my face, I looked horrendous. My eyes were just bloody and red around, rings around them. I had no lashes left. I can't even tell you how bad it was.

But going through that, when I see someone with skin issues and their face has, I remember sitting in a car one day, I was going into a meeting and I looked at my face in the rearview, the visor, and I was so scarred and red, and it was horrible, I cried, I can't go in there, I'm supposed to be a healer, right, I'm supposed to have, and my billboard, my face, which again, anyone who's dealt with skin issues knows how this is, to walk around with acne or scars or red things or whatever things that go on.

And I literally sat there and cried, because I thought, how in the world, for me as a healer, can I walk in and look like this, and people will take me seriously? And I think that core issue about who are we, what do we represent, and especially when it comes to skin, and especially nowadays when there is filters and there's social media, and there's everything that tells us we can't walk around with acne, we can't walk around with scars. And the truth is, those scars, those things actually, are what bring the deepest compassion, because we know what it's like to suffer.

Dr. Jill (23:56.426)
And so in that, I guess the bottom line is, if you're out there, you're suffering from a chronic illness, you feel like there's no hope. Number one, there's always hope, always. No man, no physician, no one can take that away from you. And I learned that from the people who've suffered far more than me, Viktor Frankl, Man's Search for Meaning, Edith Eger, The Gift, these are Holocaust survivors. I can't even compare to the suffering that they've endured. But as I read their writings, I am like, oh, this is so precious because you can show me the way to deal with suffering in a way that transforms me. 

And every one of us has that ability. So it's that frame in which we look at the things that come. And the sooner we get comfortable with the fact that life is gonna bring suffering, it's inevitable. We've either just gone through it, we're in it right now, or it's coming up. And when we can make friends with that and embrace it as a teacher, not minimize it, it actually has the power to transform us. And that is beautiful.

Jennifer Fugo (24:55.45)
It really is. It's beautiful, especially when I see it in clients and even sometimes children, watching how they keep putting one foot in front of the other. And they're like, I can do it. I can figure it out. It's really a… You use the word again and again in the book, resilience. And I do believe resilience is almost like a muscle that we have to build. It's not something you just naturally have…

Dr. Jill (25:21.034)
Yes! Mm-hmm.

Jennifer Fugo (25:25.324)
Maybe some people do, but I find it is something you have to practice and work on every single day. So for those who are feeling like their body has betrayed them, that was a phrase that got coined, I feel like 10 years ago, and I almost feel like it.

Dr. Jill (25:26.53)
Yes.

Jennifer Fugo (25:46.666)
It was a seed that tainted people's way of how they related to their relationship. Do you feel like your body betrayed you as you were going through cancer and dealing with black mold and whatnot and all of the Crohn's disease and everything? Do you think that that's the right way to look at it or is there a way to possibly reframe that? It's just for someone who's feeling like they lost their partner in their body.

Dr. Jill (26:16.262)
I love these parts you're picking out because they're so powerful and so transformative. So when I got cancer I was fighting cancer and then a year later I got Crohn's and I was fighting Crohn's and I did go through times where I'm like oh, my brain's still working but my body has betrayed me and I was so angry at my own flesh, my body for betraying me when I was supposed to be strong and healthy and overcoming and all this and I literally I think the most powerful part of my healing journey was years later when I realized, whether it's through the neuro-linguistic programming or just understanding our self-talk, that idea that my body betrayed me was really self-hatred. And at the core, Gabor Maté talks about autoimmunity metaphorically being loathing or hatred of parts of ourselves. And I started to realize, again, it took me several years, how much power that gave my body to attack self and to create more autoimmune, more inflammation. 

So I had to change that. And when you wanna change that programming, the first thing you have to do is trust yourself because when you have that like, oh, my body betrayed me, I'm so angry, you're not trusting your innate, given feelings, symptoms, emotions to guide you. You're just suppressing them and shutting them down because they're bad and they're hurting me and they're this. But what I had to do is kind of go out from dissociating. Before that, I lived with my head up and it was all about the analytical mind. 

And I said, shut up body, you're not behaving, you don't have any right to talk to me. But I had to make peace with that intuition. And that intuition, had I listened years before, might have told me that I was taking on too much and that I was in an incredibly stressful residency and all the things that led up to my cancer, I could have maybe heard the messages that my body was telling me through somatic symptoms, but I didn't. I suppressed it, I was like, shut up, you're betraying me. So in order to heal, number one, I had to trust my intuition, trust my body.

My physical body saying, oh, I'm having a little heartburn. I wonder if that's like, you know, what is that telling me? Or, oh, my stomach hurts, I'm nauseous. Maybe this isn't a good situation or a good relationship or a good, you know, whatever environment. So I started to first trust my body to tell me the clues that I needed in order to heal, in order to live well. And then, only then can you love yourselves, love your body completely, because if you don't trust yourself, you can't love yourself. And we talk about self-love, self-compassion.

Dr. Jill (28:39.422)
I think that's one of the most powerful things of healing, but it starts with trusting your body and listening to the signals that the body gives you about what relationships, what work environments, what physical environments, what foods are good for you and what are not good for you. And when you can trust yourself, then and only then can you start to love all of those parts of yourselves and integrate all of those parts, the ones even you've relegated to be bad or not good or not good enough or not worthy. And that's when we can experience true, profound healing.

Jennifer Fugo (29:09.702)
Well, I just want to thank you so much for not only coming on the show, because I know you're extremely busy and we went back and forth for a long while trying to even just like get this date booked, but also being so willing to share parts of your story that most people want to hide. They want to, they're like, I went through it. I don't want to talk about it. We're going to keep it locked over there. Nobody's going to know that even happened.

Dr. Jill (29:30.635)
Yeah.

Jennifer Fugo (29:39.676)
And you are sharing not only the physical manifestations of what you've gone through, but also the emotional and mental piece of that. And you have this really interesting perspective because you experienced it as a patient and you see it on the other side as a physician. And I know that that's one of the reasons that so many of your patients love working with you because of your level of compassion and empathy that you have for them so that they don't feel like they're alone. So I just, first of all, wanted to thank you so much again for being here and to remind all of our listeners to grab your book. It's called Unexpected. I believe it's available everywhere, correct? And you also do take patients. I know that. How can everybody find you? And you have a great podcast too for anybody who is a practitioner or really interested in functional medicine. So you're an amazing teacher.

Dr. Jill (30:33.542)
Thank you. Yeah, so everything is at jillcarnahan.com, my website, the blog, the podcast. I have a new nurse practitioner taking patients, which I help her with all of those cases. So yeah, we're finally taking new patients too.

Jennifer Fugo (30:47.354)
Awesome. Well, we'll put all the links to everything in the show notes, and I deeply appreciate you being here, and hopefully we can have you come back sometime!

Dr. Jill (30:55.822)
Sounds great Jen and thanks for the great work you do in the world as well.