Episode 99 Summary

  • Dr Deepa Mahananda is an expert in Women's Health -  Dr Deepa established the Sydney Low Carb Specialists Clinic along with her husband and provides valuable assistance to many women on their low carb journeys. 
  • At the age of 23, following investigations into severe pelvic pain,  Dr Mahananda was diagnosed with severe endometriosis - Dr Deepa had a history of extremely painful periods, but unfortunately, like many women, had been told that this is normal. Painful periods are not normal and should be investigated properly. 
  • Following investigative surgery her diagnosis was confirmed - Dr Deepa's active endometriosis was surgically treated and she commenced hormonal treatment, but was told that this was likely to be a chronic and lifelong disease. Dr Deepa Mahananda began to search for a way to manage her symptoms and control this disease, which eventually led her to a lecture by Dr Gary Fettke, then Low Carb Down Under, and she developed an interest in using nutrition to assist in managing chronic diseases.
  • Endometriosis - Endometriosis is a condition where the lining of the uterus and those particular cells that are unique to that organ, actually are found growing outside of that area. 
  • In endometriosis - Uncontrolled growth of endometrial tissue may occur in and on the ovaries, outside the uterus, outside the bowel and may grow through the bowel as well outside the bladder. It can occur in any area within the pelvic region, and in some severe cases it may proliferate in the abdominal cavity as well. 
  • The cause of endometriosis isn’t well understood -There are several hypotheses with regards to this. One factor that potentially drives it is “retrograde menstruation” where during a period the blood moves up the fallopian tubes and into the ovaries and the pelvic area instead of being evacuated through the cervix and out of the vaginal canal. Some of the endometrial cells contained in this blood may begin to grow in the new environment. 
  • Other factors are involved - 90% of women experience retrograde menstruation yet 90% of women do not have endometriosis. So there are other factors involved such as excessive androgenisation, and inflammation. Part of this inflammation can be driven from a metabolic syndrome standpoint.
  • Dr Deepa Mahananda adopted a well formulated ketogenic diet - She eliminated processed food and gluten and has been able to manage her endometriosis without medication. She now has two children. 
  • Including a lot of seed oils and processed foods in the diet can lead to a pro-inflammatory state - this may worsen autoimmune and inflammatory disease processes.
  • The gut is an important entrance point to the human body - The bulk of your immune system lives in your gut. Be mindful of what you are eating as what you eat interacts with a very thin lining, one cell thick and will make a difference to the entire environment within your body. The number one step for improving gut health is to reduce your intake of processed food. Avoid gluten. Gluten is not essential nor a nutrient you need and it doesn’t benefit you in any way, even for those who do not have coeliac disease. Epigenetic changes may be triggered by gluten, increasing your vulnerability to disease processes. This is a good reason to avoid many low carb, high protein breads and wraps sold in supermarkets which are often based on gluten.
  • Epigenetics is - The study of how your behaviours and environment can cause changes that affect the way your genes work. Unlike genetic changes, epigenetic changes may be reversible and do not change your DNA sequence, but they can change how your body reads a DNA sequence. (Source CDC) 
  • We cannot alter our DNA, but understanding epigenetics means - Our genes may be affected by environmental triggers and unlike our DNA this is something we do have some control over. Use this information to empower you in your choices and as Dr Lucy says, “Look at our life, our health, as a deck of cards. And you can't change your deck, but you can change the way you play them.”

Connect with Deepa

https://sydneylowcarb.com.au/ 

https://www.instagram.com/sydneylowcarb/ 

https://www.facebook.com/sydneylowcarbspecialist

Dr Deepa Mahananda graduated from Western Sydney University in 2012 and completed her junior medical officer training at Concord, Canterbury and Broken Hill hospitals. Her postgraduate qualifications include the Fellowship of the College of General Practitioners, Sexual Health & Family Planning Certificate and Diploma in Child Health (University of Sydney). She is passionate about teaching and is a Conjoint Lecturer with Western Sydney University.

She currently works full time at Sydney Low Carb Specialists. She is passionate about using low carbohydrate nutrition for both optimal health and chronic disease management, especially in womens’ health.

She is currently leading an educational network for low carb practising GPs in Sydney.

Dr. Deepa Mahananda is a Certified Ketogenic Nutrition SpecialistSM, credentialed by the American Nutrition Association® through its Board for Certification of Nutrition Specialists™. She is also a member of Low Carb Down Under.

Show notes:

Healing Endometriosis with Real Food

Dr Mary Barson: (0:11) Hello, my lovely listeners. I'm Dr. Mary Barson.

 

Dr Lucy Burns: (0:15) And I'm Dr. Lucy Burns. Welcome to this episode of Real Health and Weight Loss. Good morning, lovely listeners, it's Dr. Lucy here. Today I have a wonderful, wonderful guest, who I will introduce soon. But I did just want to read out one of our fabulous reviews on the podcast. And this one, I'm so grateful to somebody whose name is RubyRed29, because she's written the most beautiful thing. And she said to us that “This is a great show if you want some practical and easy to understand information about healthy eating and lifestyle. Doctors Lucy and Mary have so much real experience and knowledge about improving health and well-being. From foods to improve health and weight loss to meditation, stress reduction, psychology, hypnosis, and guests who have followed their programs with great stories of their journey. Wonderful show, highly recommended.” Ruby Red, thank you so much for saying that. It is so kind and I really, really appreciate that you took the time to write that for us. Darling listeners. If you feel like writing a review, we would be so grateful. It really helps us just spread the word for the podcast and allow other people to get on their journey to real health and weight loss. 

 

Today I have a fantastic guest for you. You'll be super excited to meet her. Her name is Dr Deepa Mahananda and she is one half of Low Carb Sydney Specialists clinic. Her passion is helping women in particular, enjoy a low carb lifestyle that can help with some of their underlying issues. So Deepa, I'd love to welcome you to the podcast.

 

Dr Deepa Mahananda: (2:01) Thank you, Lucy, and thanks for inviting me to be on. 

 

Dr Lucy Burns: (2:05) Ah, you're welcome. Well, darling, you know, we have a lot of lady listeners and I think that you are going to have a wealth of knowledge to share with them. So I thought it's really like a no brainer for me, why wouldn't we have you on? So the first thing I would love for you to share with us is how you came across low carb and whether it's helped you in your health.

 

Dr Deepa Mahananda: (2:29) Yeah, so I think in terms of how low carb first came on the scene was probably by accident, and maybe also out of curiosity as well. So it was the week before my final year medical school exams and I was studying rather intensively as we all do prior to an exam period. And I developed a really sharp, left sided pelvic pain out of the blue, took my breath away and just persisted for most of an afternoon before I thought, “Okay, it's really time I need to actually go take myself to an emergency department”. Fast forward a couple of days later, I was sitting in a gynaecologist's rooms, and I was being told I had stage four endometriosis, which is the most severe form of endometriosis that you can have. That was his suspicion. Of course, it had to be officially diagnosed. 

 

(3:25) From what they could already see on some of the investigations, there were signs of what they call endometriomas, which are basically chocolate looking cysts that can be seen on an ultrasound. So, accordingly, as is medical practice, they recommended I undergo a laparoscopic procedure, which is a keyhole procedure to have a look if this is truly what we're dealing with. And to take some samples and also, at the same time do what they call a therapeutic removal of all the endometrioma which is probably the reason I'd had such excruciating pain to begin with. Likely one of those endometriomas had actually pressed on something quite significant, causing that severe pain. But it all suddenly seemed to make sense because I'd suffered for years since the first time I had a period, with severe pain prior to each period and very heavy periods as well. So it made a lot of sense. I was about 23 or 24 years old at the time when I was diagnosed, and to me, I'd always just been told having a painful period was normal. My mum had it, and my aunts had it. Everybody seemed to normalise that. And unfortunately, as I know now, actually having such painful periods is not a normal thing at all. Even though they were regular,  it just it isn't normal to be so incapacitated by pain that you can't carry out your normal daily activities. You can't attend school, you can't study, you can't work. So that isn't normal. So that sort of sprung me into a bit of a vortex because I had significant surgery, I actually had endometrioma on my bowel, outside of my bowel. So I needed partial bowel resection as well. 

 

(5:17) So really from there, that's when I started to consider, what could I do that was more in my control that might limit this disease? Because when I was told I had the diagnosis, I was told it's likely to be chronic and likely to be there lifelong. Probably, there'll be things that we can do to reduce the severity - in terms of medications and surgeries - and possible recurrent surgeries if needed, but nobody really said that there could be a way to put it into remission. And that's sort of what sprang me into action, to go, “Okay, well, what can I do with my medical knowledge and my ability to read the literature and have a look into things that might work?” And probably around the same time, as the years went on, I started to discover that there were lots of people getting great benefits from a low carb carbohydrate diet. And it was Dr. Gary Fettke, who probably planted that seed. Probably the first lectures I listened to were by him, and I started to think more about it. I caught up with the group Low Carb Down Under and went to their conferences. And I just felt that once I saw the benefits that it had on a wide ranging - not just for metabolic health or metabolic diseases, but even beyond that - I thought, “Well, what can be achieved when that’s applied to different conditions where the pathogenesis of those conditions are not well known, and still are yet to be fully understood. But is there a role of improving our nutrition in the mix?” 

(7:01) So putting that into practice, in my day to day life, I have found that I haven't needed to ever rely on any systemic medications. So I've only ever used a Mirena initially, to control the symptoms of endometriosis. After that initial surgery, I brought forward my family planning. I thought, “Well, look, children are always going to be on the cards for me”. And the same time I was diagnosed, we had only just gotten married six months earlier. So for us, it was a no brainer to try to have children earlier. Because fertility is something that all of a sudden was thrown into the limelight, after you get a diagnosis like that and you realise that, yes, our eggs are not finite. It is very useful if I wanted to have a family, to try earlier and probably, likely be more effective. And luckily, now I've got two children. But certainly I think in and amongst all of that my diet has just undergone a rapid overhaul. I've taken a lot of processed food out of the mix since 2012, when I was diagnosed, and to the point where now I would be on what you would call more a well formulated ketogenic diet. And I haven't had any symptoms of endometriosis, even after the times through pregnancies where you would expect that these symptoms should go away. So I've always waited with bated breath after a pregnancy once I've delivered going, “Oh, is this about to rear its head?” And there's been nothing! And I don't know, I can't fully attribute that to the diet. You know, there's certainly been the surgery, that initial surgery, which I think would have taken a whole lot of load away, but that was 10 years ago now and I haven't used a Mirena in recent times. So I can't even say that it was the local progesterone that's helped it. So it's been a real eye opening personal experience.

 

(9:02) And in that way, that's sort of what brought me into the low carb space, because it was that interest in nutrition as a useful tool within medicine and treating conditions. But also, the fact that you've lived a life or a childhood, at least, and into my early 20s of a diet that was very much a standard diet, probably far more processed foods than you would even need. But just to think about what is the long term impact as you move through life? And that, yes, there's this concept, you can get away with a bad diet when you're young, but actually you can't because there is a lot that's laid down at an early age and you always sort of wonder “Well, how much of my environment and the nutrition that I had interacted with at a younger age have changed the way I am today?” Biologically, physically, and even socially, you know? Your impact on cognitive and mental health as well, which is really something that underpins your relationships with people. So it's profound. And I think recognising that and bringing it into my general practice work with patients has made a huge difference. So now when I think about women's health issues, I'm always thinking, “Well, okay, let's go back to, let's go all the way back to what are the root causes? When did this start? And is it something that you didn't even realise was a symptom?” Like, for me, I didn't even realise painful periods were a symptom of anything.

 

Dr Lucy Burns: (10:35) Ah, Deepa, you have brought up so many points in my head. I've been going “Right. I'm gonna talk about this I’m gonna, talk about this, gonna talk about this. So the first thing I want to talk about is painful periods. And this normalising of women's suffering. And that if you talk about it or complain about it, that somehow you're just a wuss, and you just need to toughen up princess and crack on. And I think there's probably 1000s of women like you who have sort of suffered in silence, thinking that a) this is normal, and b) everyone else seems to be fine with it. So obviously, I'm just, I'm just weak and carrying on. So I guess, lovely listeners, if you or your daughters or your nieces or your grandchildren, if anybody has painful periods. Periods are not supposed to be excruciating. Some people might have a little bit of discomfort, some dullness, some, you know, a dragging feeling but not incapacitating pain. So if you have any of that, please go and get checked. The second thing that I would love for you to just maybe explain is what endometriosis actually is. And I know, it's commonly referred to now as Endo, so people are talking about their Endo, this is what they're talking about. So what exactly is it?

 

Dr Deepa Mahananda: (11:52) So endometriosis is a condition where the lining of the uterus and those particular cells that are unique to that organ, actually are found growing outside of that area. So you can actually find uncontrolled growth of this in and on the ovaries outside the uterus, outside the bowel and can grow through your bowel as well as outside the bladder. So it can involve any area  in the pelvic region, and in some severe cases can also encroach on the abdominal cavity as well. So the phenomenon that causes it isn't well understood. There's a lot of hypotheses put forward as to what sort of drives it, but what we know now is that it's probably a mixture of a couple of things but physical, so they often talk about retrograde menstruation, which is sort of where you have a period, but part of that period, blood is actually going up into the fallopian tubes and spilling out into the ovaries and the outer pelvic area. So, that area can then obviously pick up some of these cells and these cells can find a nice habitat in which to take up home. So that's one sort of theory, and it has held up a little bit over time, but in conjunction with that, it's probably more than just this that's occurring, because it's actually found that 90% of women can experience this retrograde menstruation, yet 90% of women do not have endometriosis. 

 

(13:25) So the other things that might control some of the phenotype of endometriosis, and actually ending up with this problem, is inflammation. So we talk about pro-inflammatory mediators in the body and forms of chronic inflammation as well. Some of this can be driven by things that are related to hormones alone, so in the form of excessive androgenizations, so those sorts of elements, but there's also the side that can be driven from a metabolic syndrome standpoint. And so there are some overlaps here, between what are the drivers of the inflammation and because it's quite systemic, it can affect many different organs and the uterus being one of those organs. So when the uterus is under such an environment, it can essentially have functional issues. And this is another reason why it's thought that endometriosis can rear its head. And then there are also genetic underlying features. So, that again, it's not a well understood field. There's a lot of different genes that have been proposed or put forward. But we haven't really been able to identify a particular one that we can target with a meaningful treatment. So, that's all sort of esoteric, I suppose. It's not really a practical thing that we can put our hat on just yet anyway. But I would say, reading the literature around endometriosis, and its overlap as a autoimmune disease to an extent because these cells that are growing outside the uterus where they normally shouldn't grow, that brings to mind the idea of oh, they're acting like a cancer-like cell, they're growing in a way that is uncontrolled outside of a setting where they normally are. So, that means that these cells have escaped immune surveillance. So it is a dysfunction of our immune system, because we actually rely upon the immune system to put a stop to that fairly quickly if it's functioning appropriately. So I think at the end of all, that, it's probably a very multifactorial cause behind what drives endometriosis. And sometimes it can be difficult to find exactly what that root cause is. But potentially, there are ways we can mitigate some of those pathways. And that's one area where nutrition comes into it.

 

Dr Lucy Burns: (15:55) I love that idea that it's an inflammatory process, or that it's a result of an inflammatory process, because you're absolutely right and for many people, now our bodies are exposed to low grade, but long-term inflammation. So, day in day out levels, and inflammation has a role in the acute setting, also in the short term setting, for managing infections and all sorts of things like that. But our bodies are not designed to endure long term, low grade inflammation and so there are disease processes that occur when the body is in that process. So yes, maybe endometriosis is one of those such diseases. So that would give then a nice hypothesis, I guess, on why something like low carb, and it probably, certainly low carb, but a real food diet at the front, because we love the idea of low carb, but real food, because you can do low carb processed food. And I think that for a lot of people, they do not see the health benefits from doing a low carb processed food diet, compared to a low carb real food diet. So, that would make complete sense for me. So therefore, what you're describing is that you changed your diet reduced a lot of the processed food, which will therefore reduce the seed oils, and the other things being that a lot of the fillers and the chemicals and the numbers and all those things which we assume are harmless, but just maybe, they're not.

 

Dr Deepa Mahananda: (17:41) I think with those particular foods, you know, sometimes it's the dose that makes the poison. So for someone, you know, just to throw a hypothetical out there: someone same age as me who didn't have endometriosis, felt well, but was eating a very similar diet, it's not to say that they would go on to continue enjoying that good health for some time, probably at some stage and phase of life that would catch up with them and have some interplay with their environment. But it just so happens that because, particularly in these types of conditions, and very much so in autoimmune conditions that overlap with endometriosis - so things like hashimoto's, coeliac disease is another one that comes to mind - so these are things that are triggered with a genetic vulnerability. But the environment certainly has a huge part to play. When it comes to seed oils, obviously, having quite a lot of seed oils in the diet can lead to a proinflammatory state, which can make this worse and bring to light some of the underlying vulnerabilities that are already there. And it makes a lot of sense to not have a lot of nutrient-devoid processed foods, as you’re describing, because you're also not actually creating a nourishing environment for good health, and particularly in women for hormone health. So the imbalance of hormones as well, particularly between oestrogen and progesterone can also theoretically drive some of these problems that arise around abnormal uterine bleeding, of which endometriosis does come under that umbrella. So I think it is that by changing your nutrition, you're modifying the controllables, which is your environment. And you may not be able to change your genetics, but you can certainly change whether or not they get switched on. And that's sort of where the critical part is. And to the extent I believe that you can switch some of these things off eventually, with time. That has been, you know, elucidated in the literature that that's quite possible.

 

Dr Lucy Burns: (20:01) And epigenetics is an emerging field. And those lovely listeners are the switches that turn genes off and on. Because, even though you can't change your DNA, your blueprint, the blueprint isn't all on or all off. The genes are in there, it's so complex, and some come on, and some come off, and there are environmental triggers that will turn some on. And it's the reason why some people smoke, and they might get emphysema and some terrible lung diseases, but they don't get cancer. And other people might even smoke less and they'll get cancer. And that's because they may have a gene that is more susceptible to that cigarette smoke and therefore is turned on. So it is always complicated, but I think if we can look at our life, our health, as a deck of cards. And you can't change your deck, but you can change the way you play them.

 

Dr Deepa Mahananda: (20:57) It's a beautiful analogy. I love that one.

 

Dr Lucy Burns: (21:01) Yeah, I love… Analogies are my favourite thing. But definitely having your nutrition as a cornerstone along with all those other lifestyle factors that we talk about, as I'm sure you talk about in your clinic, Deepa of, getting good sleep, managing your stress, looking after your gut. And I mean, the best way to look after your gut, like seriously, is to reduce your processed food. That should be the number one step. Reducing your processed food is the first step, and then we see what happens.

 

Dr Deepa Mahananda: (21:32) Absolutely. I mean, the gut is, the entrance point to your human body. And it's also where the bulk of your immune system lives. So it's very obvious to think that what interacts with that very thin lining, one cell thick there, that will make a difference to the rest of the environment, within your body. So things like gluten in particular, come to mind. Gluten is not even necessary for anyone. There isn't one reason to include gluten in the diet. I can't even think of one positive. It doesn't happen. It's not a nutrient you need, nothing essential about it. So the presence of gluten in such an overwhelming number of foods in our supermarkets is really distressing, I think, because so much disease can and may be also turned on by the presence of gluten in the environment. So I think it was a huge game changer when that was discovered. But also, now that we know about it, I think it's really important to raise that with the people that we see in our clinics and address gut health definitely, as a priority when dealing with a lot of chronic conditions. Because a lot of the time some of this can actually be alleviated and a lot of pain and suffering is there for nothing, just from people eating things in their diet that they had no idea could be harmful.

 

Dr Lucy Burns: (23:04)  Absolutely. And I think, you know, it's really interesting, because certainly in the medical world, we're well aware of coeliac disease, and we're well aware that it's an autoimmune condition. And people who have coeliac disease cannot even have a sniff of, like nothing, no gluten ever. But there's also this huge subset of people that I think probably the bulk of our medical colleagues would not classify as having any problems with gluten, but we know and you know, if you're one of them, that you're gluten intolerant. That when you have gluten, your gut plays up, you get diarrhoea, you get cramping pain, you get bloating, your skin plays up, you start getting sinus symptoms, like all sorts of things that, you know, are happening. But you know, maybe, as I said, aspects of the medical fraternity, which can sometimes be very black and white, you either have coeliac or you don't, would not be listening to you.

 

Dr Deepa Mahananda: (24:03) Yeah, it's a concept of if there's a test that we can show you and show you that it's negative, and that's the case closed. That's unfortunately, sometimes the paradigm that the medical profession come to, treating symptoms that can't be nicely put into a mould or nicely come under a diagnosis. And that's probably not the most ideal way to move forward when we know that there's actually quite a big mix and there's a mix of different things at play. It's not just black and white. Yes, there are guidelines and they're there for a reason because they give us a map or a or a direction to go in. But those maps are also used in a way to be able to exercise our judgement and our clinical judgement and acknowledge as well, the real lived experience of our patients because having these symptoms and then being told that there's actually nothing at play, but not being willing to take that next step and explore different options with our patients. I think that's sort of where I'm hopeful that there are more medical practitioners who will want to take that journey with their patients, and, rather than just being very black and white about it. I think that's probably the future of medicine. Really being able to look at a whole different cluster of symptoms, and move away from that systems based approach where it's either a gut disease, or it's not a gut disease, because yeah, it's not really that. 

 

Dr Lucy Burns: (25:48) Yeah, yeah, I totally agree. And I think there's a whole history of this happening. And you know, and certainly in recent times, things like fibromyalgia and chronic fatigue syndrome have been poo pooed by the medical world, because we don't have a test to prove it. And look, really, honestly, that’s just bunkum. We don't need a test, you just need to listen to your patients, and they give you everything you need. You don't need tests to make a diagnosis. What I love, Mary and I love this, we’ll call pleiotropy, which is where doing one thing helps a whole lot of other things. And so changing your nutrition to a whole food diet, lowering your carbs, if you can, you know, if you need to, in particular,  then it helps so many things in your life. It almost feels sometimes too good to be true. I kind of go and every now and then have to remind myself not everything gets better by reducing your carbs. But so many things do that. It's totally worth it.

 

Dr Deepa Mahananda: (26:43) Yeah, absolutely. I think nutrition as an adjunct to the mainstay of treatment, especially for different diseases like diabetes and heart disease as well. I mean, I think the thing to say about any sort of real food diet, whether it's very low carb, moderate low carb, liberal low carb, whatever that may look like for the individual, is that you're taking a movement to give yourself a lot more nutrients than you had previously. And that probably makes the biggest difference because it's those nutrients that have become devoid in the modern food environment.

 

Dr Lucy Burns: (27:25) Yeah, absolutely. And I think processed foods, in particular processed breakfast cereals, managed to meet their five star health rating targets by putting in fortified, so adding vitamins out of a factory. It's not the same as eating the vitamins from your food. 

 

Dr Deepa Mahananda: (27:44) Absolutely. 

 

Dr Lucy Burns: (27:45) Good. Deepa, it has been a delight to talk to you and I actually think we will get you back on the podcast because I know that you've got a big interest in perimenopause and I think that lots of our listeners would benefit greatly from hearing you speak on that, so lovelies look out for Deepa she'll be back. And Deepa we would love to have you back.

 

Dr Deepa Mahananda: (28:07) Thank you very much Lucy, I'd love to be back on again in the future.

 

Dr Lucy Burns: (28:11) Wonderful, so lovely. If people want to follow you, which I'm sure they would, why wouldn't they want to follow you? You’re wonderful! How can they connect with you?

 

Dr Deepa Mahananda: (28:18) Yeah, so we're on social media, different channels are Instagram and Facebook. And we've also got a website at https://www.sydneylowcarb.com.au. So you can feel free to check those out.

 

Dr Lucy Burns: (28:32) Excellent. And your socials are Sydney Low Carb? 

 

Dr Deepa Mahananda: (28:36) Yeah, SydneyLowCarb. Yep. 

 

Dr Lucy Burns: (28:38) Great. Awesome. And we'll link it all in the show notes below, lovely folks, but definitely go follow Deepa. She's beautiful. 

 

Dr Deepa Mahananda: (28:45) Thanks, Lacey. 

 

Dr Lucy Burns: (28:46) Alright, lovelies, Have a wonderful week. I'll catch up with you next week. Bye for now. So my lovely listeners that ends this episode of Real Health and Weight Loss. I'm Dr. Lucy Burns,

 

Dr Mary Barson: (29:04) and I'm Dr. Mary Barson. We’re from Real Life Medicine. To contact us, please visit https://www.rlmedicine.com


Dr Lucy Burns: (29:15) And until next time, thanks for listening. The information shared on the Real Health and Weight Loss Podcast, including show notes and links provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns.