Initiated by DARPA, the program had a single, ambitious goal.
To enable superior physical and physiological warfighter performance by controlling energy metabolism on demand.
The result was the creation of the world's first ketone ester.
Dr. Joseph Bielitzki, the Chief Program Manager that oversaw the decade-long ketone ester development, joins us this week to reveal the history that hasn't yet been covered in the books.
Geoff: Welcome to this week's episode of the HVMN Enhancement podcast. This is your host, Geoffrey Woo. I'm really, really, really excited to have Dr. Joseph Bielitzki come in to our program today. This is an especially special guest because he is very much integral with the ketone ester story and the HUMN ketone stories. By background, Joe was a program manager at DARPA, Defense Advanced Research Projects Agency that actually kicked off the whole metabolic dominance ketone ester research. So, welcome to the program, Joe. It's great to have some of the original characters back into the story.
Joe: Thanks. It's good to be here.
Geoff: So, the history is not well understood. I’m excited to tease into the history here and make sure it’s captured in the history books, so can you describe your experience ... I know you are the chief Veterinarian Officer for NASA ... how did you end up at DARPA and how did metabolic performance come into the picture. This is early 2000's, so almost 20 years ago.
Joe: That's a good question how I ended up at DARPA. Most of the Program Managers are brought in by invitation for a two to four-year period. Some of them may stay six, but pretty much you're brought in for new ideas and then you're let go because you've run out of them. I don't know if that sounds right, but it's pretty much the way it works. I was at NASA. I participated in several studies looking into infectious diseases and apparently, I got somebody's attention because I got a call one day that said, "How'd you like to come to D.C. and talk to us about maybe coming to DARPA on a temporary basis, so I did and it seemed to have worked out pretty well.
Geoff: What is your academic background? It is interesting because I know a lot of the veterinarians I talked to end up being more broad than human doctors just because it’s ... you have to get so deep across so many different physiologies and animals. Curious, even before NASA and DARPA, how did you get into veterinarian medicine.
Joe: I started out working in a zoo.
Joe: And after a couple of years, I took a position at the University of Washington Primate Center up in Seattle and I spent some time up there, some time at the Primate Center at Emory University, then I went to NASA, so I've spent about 20 years in biomedical research, working across all areas of science and you can't help but work with smart people and not pick up a little something in their fields.
Joe: So, over time I just ... I know a little about a lot of different things, but not a lot about one particular thing.
Geoff: So, you actually became the Chief Veterinarian Officer for NASA, so how many veterinarians ... I guess it's not surprising when you think about the first astronauts were dogs and monkeys, the cosmology program in the Soviet Union, so imagine there's a bunch of animal work there.
Joe: It kinda goes up and down as far as frequency. NASA typically employs, there's four or five veterinarians that NASA has. There's one astronaut who is in the veterinarian astronaut corps, Rick Linnehan. He was instrumental in convincing me I wanted to work with NASA. It's been a great time. I've gotten to do a lot of strange and different things. Working with our Russian colleagues, working with our Chinese colleagues, our European colleagues. Again, across all areas of science. When you're the veterinarian, you get the studies that they're doing, you don't get to pick which ones you work on. Your job is to make sure they go as well and and smoothly as possible.
Geoff: Right. So, you pulled together this broad background experience through NASA and you got the call from DARPA. So, folks that aren't aware of DARPA, it's sort of the sci-fi R & D center for the U.S. Military. And you got the call, you headed over to D.C. and what happens?
Joe: Well, DARPA's a little bit different because they don't tell you what you have to work on. Your job is to also determine what you want to work on. It has to have military relevance, it has to be forward-thinking, you can't be incremental, it has to be more revolutionary than evolutionary. So, I've always had an interest in endurance sports and what you need to do to complete iron man or half iron man in some kind of decent physical shape.
Joe: And so when I got to DARPA, it was ... we were involved in Iraq and Afghanistan.
Geoff: So, this was about 2001 2005.
Joe: Yeah, this is right after 9/11. One of the issues was how do you provide support to the war fighter, the young men and women who were going out into the field of combat in these places that really are pretty hostile environments when you think about working in 120 degrees, carrying 90 pounds, you don't wear body armor, and all the protective clothing and equipment you've gotta carry, so one of the questions was, "If we're gonna put them in that condition, how do we make sure that they have adequate calories that they can do their task, not become fatigued and not set them up to fail at a time when it;'s critical through their life. And so really, it came out of that kind of mindset. A combination of a traveling and endurance sports background and saying, "What does the war fighter need when they're going into a field of combat and how do you give them the best energy support you can?"
Or transition the kid who gets drafted from being an 18 19-year-old who's been playing video games and a couch potato over a 12-week period into someone who's physically fit. And part of the goal is to see if we could get a 20% improvement in strength and endurance in 12 weeks. So, those were pretty unreasonable requirements at the time we proposed it, but most of everything we did seems to have worked out. It does take some time from a concept to a product though.
Geoff: Right. We can talk about the full transition. This was conceptualized, as you were saying, in 2001 2005 tenure at DARPA and now in 2018, the DARPA program that you initiated became a commercial product for the first time and that's literally almost 20 years of progress.
Joe: The length of time it takes for new ideas to actually one, get the basic research established and there's been a lot of steps along the way, the synthetic process, safety, advocacy, testing. And then you'll get it through kind of an imaginary barrier of what the public and the consumers are willing to accept in things they want or need. And they're getting a product out there that keeps everybody happy. It has a marketplace. You can't sell something if it's going to lose money on a continuous basis, so there's a lot of barriers in getting a product from the scientific concept into a commercial market.
Geoff: Absolutely. Let's dive into that. But before talking about it, I wanna actually talk about your endurance, your hobby there. Sounds like you were ... were you competitive? Were you ... what times were you throwing up?
Joe: Just enjoying it. Good friends. It was good to be embarrassed every week with my friends and colleagues that raced with me. I usually finished in the top third, but it never got past that.
Joe: But you do learn a little bit about how to manage energy during a long race. You pretty much knew the half iron man, mile 30 -35, you're gonna be going, "Why am I out here doing this?", which is usually the first sign that you're hypoglycemic.
Joe: And then you're trying to fake it for the next 25 miles on the bike, the next 13 miles in the run, how do I get calories into my body so I can continue at a pace that's reasonable and not be totally embarrassed?
Geoff: Yeah. And then, a lot of our discussion with professional triathletes, they often say that ... for the triathlon, it's swim/cycle/run and the fourth sport of triathlons is nutrition. How do you fuel yourself over that five hours you're doing that half iron man or that 10 hours you're doing that full iron man? Nutrition is an art and a science in and of itself.
Joe: You talk to people who have just started and you tell them that ... everybody tries to figure out how to eat through this process, and you have to eat because you just can't get carbs otherwise ... but also learning to run on empty. Always being a little hypoglycemic or a little bit below optimal because your metabolism will adjust to that and I always tell people that I knew I had enough energy stored in my body for a couple weeks. I just couldn't get to it. So, the question was, "How do you go ahead and make that transition from carbohydrate metabolism to stored energy and fats?"
Geoff: And that brought you to the conception of the ketone ester, so again, to review the physiology here, when you're talking about reducing glycogen reserves or going hypoglycemic, our bodies only store a limited amount of glucose or sugar or carbohydrate, around 2,000 or so calories, and that will fuel you for a little bit but in a 3-4 hour run or cycle, you training for all of that. So, I'd say the old-school approach to solve that problem is the carb load. We've all heard the discussion, "Eat a ton of pasta before your marathon." Or "Slam all these sugar bombs or glucose strings." as you're racing. So, that must have been in your head as you're conceptualizing DARPA program.
Joe: You can only eat so much pasta the night before because you can only saturate your glycogen stores so much and then after that, when they're depleted, it's gotta come from someplace else. We metabolize glucose and fructose pretty quickly when it's taken orally and you could've ride the roller coaster up and down.
Geoff: Which enters into the world of ketones and ketosis and fat metabolism. I think when perhaps the layman thinks about X-men and super soldier serums, they're thinking crazy pharmaceutical compounds. I thought it was really interesting that you guys are not pursuing an investigative new drug. You guys are not going down the supplement pathway. This is nutritional food. This is a food substance with caloric value. It really looks like a fourth micronutrient. That must have confused people. Even with our label today, the three macronutrients, as people commonly look at them, fats/carbs/proteins, there's none of it in the ketone ester, but there's still caloric value and most people are like, "How's that even ... I don't understand." I can imagine 20 years ago, people were like, "Is this real?" What was the perception? What was the thought? People thought you were crazy? How was the skepticism?
Joe: Everybody that works with DARPA thinks the Program Managers are crazy, to some extent. You're expected to be off-the-wall, you're expected to push the envelope beyond where it could be and people say it's out-of-the-box thinking and I used to tell them, "We don't even believe there is a box." So, how far can you push it? We knew butyric was an end product of fat metabolism; that's where it enters the kreb cycle, so it was a rational, logical place to look. Anything before that was going to take some other enzyme systems and some breakdown mechanisms to get it to enter the energy cycle. We didn't know butyrate would work, we didn't know we could do it when we started. That's the nice thing about DARPA. They ask you to do things that nobody has done before, so it gives you a shot to be a little bit crazy.
Geoff: It was good engineering just rolling out possibilities. Right? As you mentioned. There's just an unlimited number of pathways that activate the kreb cycle, the citric acid cycle. If pyruvate or glycolysis has one pathway and that's well understood. People are already carb uploading, can we load the other side without just eating fat and that's not good enough. You can't eat fat directly. Can we hack or come up with new compounds that can enter the butyrate pathway? It sounds almost obvious or elegant, in retrospect, right? So, okay, we know this one pathway. We've tapped that out. Where else can we look? Well, it's gotta be the other possible pathway and then what can we do there?
Joe: You know, it looks elegant when it works.I t was the thought process that went behind it. It was looking at the metabolic pathways chart and saying, "Okay. Where can we play?" And really, there aren't that many places. From protein breakdown, you go through gluconeogenesis. This is the only other energy point that you can enter. The kreb cycle. With an exogenous product. And so, it was kinda focused on what's the inflection point? And we really wanted to get away from insulin ... you know what insulin is like ... this is not an insulin-dependent factor and it's a cycle that goes up and down and you've got peaks and valleys. You don't have to worry about that quite as much and so to keep the circulating levels up, you've got adequate energy and your muscles don't really object to living on butyrate.
Geoff: I think that's a subtle physiology that people don't understand and I think will become understood in the near future, hopefully. When people are slamming these glucose drinks and glucose shots, they are very aggressively spiking insulin and crashing insulin and spiking insulin and crashing insulin. A lot of these endurance athletes end up having pre-diabetic-looking biomarkers, with higher resting levels of insulin, higher H1VAC's, and I think that's why you see ketogenic diets. That’s why ketones getting more and more interest. Can you have a non-insulin or insulin-dependent, if you will, exogenous product that's a very efficient fuel for the body and brain.
Joe: And this doesn't play with any of those pathways associated with either Type 1 or Type 2 diabetes, so it's separate from that so we know is it more efficient? Time will tell. But right now, it looks like it's effective, which is ... first step is demonstrating efficacy and I think that's happening. We were confident from the theoretical point of view that it would happen and it really has taken 15 years to get here. Repeated testing, it's proving that this is a good way to give energy in a non-carbohydrate-based manner.
Geoff: Right. So, you're over at DARPA and some of the other key collaborators that you pull together include Professor Kieran Clark over at University of Oxford and Dr. Richard Veech at the National Institutes of Health, so how did all these characters come together under your watch? From my understanding, every RFP has multiple bidders, multiple potential pathways of execution in the Veech/Clark path ... can you describe that story and how that all came together?
Joe: DARPA doesn't write an RFP. They actually write something call the broad agency announcement.
Joe: So, when our people ask people what area they wanna work in and a broad agency announcement gives them a target that says, "We wanna create a ketogenic diet." Both Kieran and Bud, Richard, whichever name he's going by, I know him by Bud, both of them had interest in applications of butyrate to certain clinical problems that were basically revolved around carbohydrate metabolism. Both of them have pedigrees in metabolic physiology that you're not gonna replicate very many places. DARPA has a tendency to attract world-class researchers who can take a chance with their career. Taking three or four years off to try and create a butyrate-based diet and demonstrate its efficacy, could be career-ending if it doesn't work for young investigators, so you have a tendency to get young and crazy investigators who don't know the risk or really old established people who are willing to take the risk because they wanna leave a legacy behind as far as what they do with something, so I think both fall in that category, but they self-assembled. They came forward with this concept and said, "We think we know how to do this and we think we know how to control the chemistry." and they demonstrated they could.,
Geoff: For you, as a Program Manager and seeing this ... just a team to assemble to create this vision ... what was that back in 2003 is when I believe the announcement came out and some of the initial responses came in, what was your thought process? Did you think that no one will respond? Were you thinking, "Oh, this is a cool project. A lot of people will respond." I think the name itself, I believe you called it metabolic dominance. It's such a cool project name.
Joe: It was the same program, just a different acronym. So, it worked out fine, but it was all focused on mitochondrial function and typically, we'll spend a year, year and a half trying to conceptualize the program. What are the elements that need to go into it? Who may be the key players. In this country or globally? And you're looking for somebody who has confidence that they can pull something off because typically you're asking them to do something that nobody has ever done before so when you do that, you don't get everybody coming out of the woods saying, "I'm stupid enough to tell you I can do this when nobody's ever been able to before." It's confidence, good scientific pedigree, and having the vision of how to pull it off.
Geoff: Yeah. I think some of the most interesting scientific results from the research were that the results of keto metabolism was more efficient than glucose metabolism or even fat metabolism. I thought that was just so fundamental to ... it's literally the fundamental equation of life ... How much work can you get done with a given amount of substrate? That was one of the most interesting results that came from some of the work. I'm sure as you were monitoring and reviewing some of the work, there were ups and downs, surprises of results. What stuck out to you as some interesting results from the scientific side, from the product side, from the compound side, what were some of the surprises? What were some of the disappointments as you were working through the technology?
Joe: It's gonna sound real funny, but a lot of the real frustrating parts had nothing to do with the science. They had more to do with intellectual property and trying to sort out what needed to be protected, how it needed to be protected, so that this could actually become a product. And then, I think overcoming the flavor and aroma issue with this and finding the right compound of all the potential possibilities you have when you talk about butyrate. How do you minimize the negatives and optimize the positives? They were able to work through a lot of that and then backing it up with mice and rats that showed that they were able to function at a low level of physical activity over periods that were significantly longer than mice without it.
Geoff: Was this surprising to you? Just reading the published peer-review results, it was like, "Wow. Mice were literally solving mazes 30% faster than control." That's just like, "Holy shit."
Joe: Well, I expect the impossible to happen, so after a while, you find that you work with so many great scientists that everybody says is impossible, you're not surprised when it works. You're so pre-focused that this is gonna be successful because you've had to walk forward and get funding to distribute to the investigators, so you go in with a degree of optimism that the science that you've looked for and reassembling the pieces of the puzzle to form a different picture, is possible. But, as the data started coming in, it became more and more obvious that this was not only possible that we could overcome the issues, but that this was going to be a product that would be worthwhile.
Geoff: Any scientific result surprise you? Or were you just like, "Oh, of course. That's what I expect." I mean, none of the results surprised you?
Joe: Not really. Once they got the synthetic pathway down, because the had to come with a totally new synthetic process, once that happened, I think the physiology that I anticipated was there and the results they were getting was what I had prayed for and hoped for all along. So, I wasn't really surprised they got the results, but it did make me smile a lot.
Geoff: Yeah. I think, for somebody that doesn't have the theoretical background, some of the results are just ultra compelling, right? 40% reduction in lactic acid production and if you're doing an iron man, you're building up so much lactate, you're sore, you feel that burn… so that's an incredible number, right. You're increasing aerobic endurance performance. That's pretty phenomenal. Not a lot of things improve human performance. Making rats smarter. There's some data in the publication pipeline around and also reflected in humans as well. These are pretty sci-fi results. It's kinda funny to hear that. You knew that was gonna happen.
Joe: I think the other thing is that this was just 25% of the program, that this wasn't the only thing that we looked at because we looked at thermal control. By keeping you cooler, could you go longer? And the answer is you certainly can. We also looked at a number of polyphenols as far as the impact it had on mitochondria function and we knew that polyphenols are an important part of protecting you from free radicals and oxidative damage, but we didn't know really how it would work with the mitochondria. So, it was just looking ... I hate to say this ... looking at a lot of microbial physiology and looking at the mitochondria as a bacteria, you start to ask some questions about how would you put this together differently if you had to figure out how to make it work? So, some of it was just looking at the science differently, but also getting people to come forward and telling you, "I think this will contribute. I think it's gonna work." And then giving you good scientific evidence and why they're thinking contrary to what everybody else was thinking was possible. Butyrate fell into that category. I think a lot of people thought about it. The Atkins diet was emerging, South Beach diet was coming. I see a lot of things happening around this timeframe, but there were more skeptics that there were supporters.
Geoff: I think the ketone, the role that beta hydroxy butyrate played in Atkins or South Beach was relatively unknown. I think it was focused more on the protein, most recently carbs, but I think the implication of BHP itself was relatively less known, right?
Joe: They knew it was a ketogenic diet, but they hadn't really looked at the pathways, they hadn't really looked at what was going on with respect to fat metabolism because it was about suppressing carbohydrates. Ketones, you had to drink a lot of water to deal with the ketones that you were producing, but it ended up being a a little bit different than what everybody thought. That's the nice thing about it is over time, we've rewritten some of the chapters in the physiology book. For me, that's one of the more fun things is that there is new science that comes out and you have to be able to see it to take advantage of it.
Geoff: Yep. I think that's something that I think we'll be more and more well understood. That when you have a ketone nest or on top of a complete carb deplete human, you're in a novel state of physiology where you have dual fuel sources. That just doesn't occur in nature when you have full glycogen reserves and fully topped up with ketones. It's not an exaggeration to say, "This is novel physiology. This is a new chapter in the physiology text book."
Joe: There's a lot of things that switch over to fat metabolism. Hibernating animals have enough carbs to live through that hibernation period, so there's a lot of changes that happen. We have looked at hibernators as a basis for some of the metabolic things that happen, the transitions to support butyrate can be metabolized over long periods without harm.
Geoff: My understanding is that humans are the best animals that are ketogenic. In a sense that a large part of the evolutionary function was that you needed fuel for the brain and brain metabolism for the human is a lot greater than the requirements for a bear, for example. A bear doesn't need to have as much ketones to fuel the brain ... gluconeogenesis will provide enough glucose to fuel the brain over a long hibernation period, but it's not enough for humans and therefore, humans are one of the most ketonic animals.
Joe: Bears have different cognitive capabilities, but their brain still needs the same metabolic support, so actually the black bear will probably be the model for people as far as some forms of energy metabolism. The other thing is that this transition away from believing that the brain lived on just glucose. It's gonna upset a lot of people over time, because that was the dogma theory for a long long time. We're finding more and more that butyrate is an adequate energy source for the brain, that neurons don't object, that mitochondria are perfectly happy with it, so things are changing as a result of this too.
Geoff: Absolutely. There's more and more that's suggesting that ketones not just a source of metabolic substrate for the brain, but also preferred substrate for brain metabolism. It gets uptake first before glucose.
Joe: If you think about other non-human primates, they're kind of squat and dobble leaders. Baboon will stuff his mouth with as much as he can and then go off and digest what he's got stuffed in the cheek pouches, but they probably experience ketosis on a regular basis because food may not be readily available. They may be in a dry period of the year. So, all those things kinda come into play in how you think about what humans are capable of too. From an evolutionary point of view, we probably weren't always intended to be fat and sassy. That we were probably lean, we probably had a much higher daily energy requirement than we have now, and that we probably experienced long periods of ketosis.
Geoff: I think that's a good point. In our natural, more primal state, we were clearly in and out of ketosis. In our modern obese society, most Americans are on the path of being overweight, obese, if not pre-diabetic and diabetic. We're very much on the extreme side of energy consumption. I'm actually curious to dive into some of the other keto compounds. You were mentioning that, as you're identifying different butyrate compounds, obviously the one that we're commercializing is a D3 Beta Hydroxy Butyrate, but in the early planning and early research period, there are a bunch of candidate compounds. What were some of the challenges, surprises there? In my conversations with Kieran, for example, she mentions that, while the current ketone esters is still kinda crazy tasting, other ones are just even crazier, just completely horrible. Did you have a chance to start playing with them yourself? What was your experience there?
Joe: We always let somebody else taste the bad stuff. I think laying with the structure of the ester to some extent, and minimize the flavor component of it because there was no option. It may be really good for you, but if nobody will eat it, it doesn't make any difference. I think you could exclude a number of butyrate-based compounds just because there was nothing you could do with them chemically and there was nothing you could add that would mask it. It kinda became process of elimination. Certainly, the ester seemed to be superior to other compounds as far as flavor. There's still some more tweaking that probably could be done and we'll see where it's gonna go, but I think right now, it's not bad. It's not something I'd sit down with a big glass of and watch a late night movie, but on the other hand, for what it's intended to do, as an immediate energy source, it will work really well, I think.
Geoff: Yeah. We've gotten some feedback now and it's quite palatable. I think most people read the horror stories on the internet about how this tastes like rocket fuel or jet fuel and it's not that bad anymore. Because of the work that our team has done, it's actually not too crazy.
Joe: I think that was the direction it needed to go. That was always one of the limiting factors from this product was how do you take control of that really pungent odor and kind of bitter taste that goes along with it. I really don't even know how to describe it. It's something nobody should really want to experience is the taste of this native ester alone.
Geoff: My way to describe it is just nail polish remover bitter, it's just very weird.
Joe: And the other thing is it's ... the early products had a different viscosity. It kinda had greater mouth appeal and seemed to cling to your tongue and teeth for extended periods, which didn't help. I think it's moving in the right direction.
Geoff: So where do you think we are moving towards in the future? I know you hinted a little about the clinical applications, so the most robust published research relate to performance, especially endurance performance. I'm curious your thoughts on how this space unfolds. Can we see this as a fourth macronutrient in the sense that every single humans gotta have ketones every single day, is that in the cards? How do you think this ketone story unfolds?
Joe: Dr. Veech had an interesting observation. There's some people who don't tolerate carbs at all. So, they really need to be on a ketone-based diet. Managing your diet exclusively thorough intake is difficult, so this gives them a little bit easier way to manage some of that. I do think there probably will be long term applications, now that we know that the brain is happy metabolizing it. We know, for example, that Alzheimer's patients don't metabolize glucose, as far as the brain, as well as non-Alzheimer's patients, so whether it can improve cognitive function, you've got diabetic populations that don't absorb glucose into the cells, butyrate does get absorbed, so I think it's just right now at the edge of what its capabilities might be because it was never conceptualized originally to have clinical applications to other diseases. We knew that there was potential early on, but again that was kind of a pipe dream. If we could pull this off, could you actually impact that population? I think people will be asking those questions. We've never been able to manipulate energy metabolism because the only thing we've ever really had to put in the system was carbohydrates, so this gives us a little bit different entry point and now we’ll wait and see how neurons and muscle are actually gonna handle butyrate as far as an exogenous energy source.
Geoff: Obviously, we're standing on the shoulders of giants, like yourself, to get it to this point, but there's so much more work to be done. I think you put it absolutely right that initially, as a performance technology, it makes sense. These are the most robust populations, we can get more and more safety data and as that becomes more proven out, can we start attacking some of the most predacious health problems. I think you were just referencing some of them. Alzheimer's, diabetes. If we can, at some point, make some impact there, that would be exciting for the world. Not even just for ourselves as a small part of the story here.
Joe: It's gonna force people to look at metabolism differently and consider the options a little bit more. I think when you're looking at just a transition right now. People are looking at health too. Greater consideration as to what goes in my body, a bigger percentage of the population and so, being able to impact that. You see all kinds of changes going on with the world, with different diets, different energy sources, discussions that happen across the health professions and I'm not sure where it ends, but I think we're gonna do better in the future than we have in the past. I'd like to think, if this opens any doors or makes anybody's life better, extends life or quality of life for people, make me smile for a long long time. It's accidental consequences, it's collateral benefit rather than collateral damage.
Geoff: Yeah. I almost wanna leave it at that. I think the story around the ketone ester deserves to be told and I think a large part of how this product ... how this technology came into existence was under your guidance, so I hope the story doesn't end her just with our conversation, but more and more people realize that there's just so much work behind what we are doing here at HVMN. This product we put out there really came from years of research and the work at DARPA really dates back 10-15-20-20 plus years of just physiology metabolism mitochondrial thinking to even get to the point of kick this thing off over at Veech and Clark and from here, to hand it off to us to take to the world, so ...
Joe: You look at Dr. Veech's publications and you see co-author named Krebs. He was a student. He has an incredible pedigree. It just amazed me what their knowledge base and their ability to conceptualize the science differently. To set a target and to achieve it is really remarkable. Very few people have that privilege. Most people will get a publication out of it and they've done something that can actually change healthcare and performance, so all I can say is, "Thank you." to them.
Geoff: Thank you for taking the time, Joe. Appreciate it and we'll talk soon.
Joe: Thanks, Geoff.
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