We’re back after a long hiatus and our first show of 2014 is really exciting. I interviewed Dr. Terry Wahls, who many of you, I’m sure, have already heard of. She is a physician who has made remarkable progress with her multiple sclerosis using Paleo principles and functional medicine.
We haven’t talked a lot about MS on this show, so I thought it would be fantastic to have her on and discuss her own experience as well as her research with other patients with MS and her upcoming book, The Wahls Protocol.
In this episode, we cover:
3:22 What did Chris eat for breakfast on the book tour?
8:10 How Dr. Wahls beat progressive MS
12:30 Conventional MS treatment approaches
17:13 The importance of getting nutrients from food (not supplements)
19:55 What exactly is MS?
26:52 The Wahls Protocol for treating MS and Autoimmune Conditions
Links We Discuss
Dr. Terry Wahls New Book: The Wahls Protocol
- Dr. Wahls controversial TEDx Talk on “Minding Your Mitochondria”
Full Text Transcript:
Steve Wright: Hey, everyone. Welcome to another episode of the Revolution Health Radio Show. This show is brought to you by ChrisKresser.com. I’m your host, Steve Wright from SCDlifestyle.com, and with me is integrative medical practitioner, healthy skeptic, and newly a New York Times bestselling author, Chris Kresser. How are you doing today, man?
Chris Kresser: I’m good. It’s good to be home. I have to say I really enjoyed the book tour. It was actually a lot of fun and was not as hard on me as I feared that it would be, and at the same time, I’m really glad to be home and happy to be back recording a new episode here.
Steve Wright: Yeah, this is our first one for 2014, and I think we need a big round of applause here for the success that you have and have had with the book and everything you’ve been doing on the road.
Chris Kresser: Well, thanks. As I said, it’s been fun. It was really great to get out and meet people face to face that have been following my work and reading the blog, listening to the show. I met several patients face to face that I hadn’t had a chance to meet yet, people I’ve been working with long distance, and definitely happy with the success of the book. Yeah, it’s been a big learning experience, it’s been lots of fun, it’s been rich all around, so I’m grateful that I had the opportunity to do this, and as I said, I’m happy to be home. How about you, Steve?
Steve Wright: Well, there’s nothing like home base, I definitely know. I’ve been on the road a lot in January but not quite like you’ve been on the road. When you can get back into your environment where you get to control things and it’s your bed, that’s a big deal. Plus, with your family.
Chris Kresser: Yeah, I’d say the biggest thing was missing my family, missing Sylvie, in particular. But they came up to Portland and finished the rest of the West Coast tour with me, which was nice, Portland, LA, San Diego. The second biggest thing was missing home-cooked meals. I mean, I don’t eat out a lot. We cook most of our own food, and it was a drag to have to eat out nearly every single meal for almost three weeks. In some places, I was able to stay in suites, like an Embassy Suites type of place that had a kitchen, and so I was able to prepare at least maybe one meal a day, but because of how hectic my travel schedule was, even when I had a place with a kitchen, in some cases I was in a town for less than 24 hours, so I didn’t really even have time to go to the store and get stuff. So, I’m really, really excited to be able to cook my own food again.
What Did Chris Eat for Breakfast on the Book Tour?
Steve Wright: Nice. And rather than asking what you ate for breakfast today, why don’t you share what your go-to breakfast option was on the road, like, in those cities where you literally don’t have time to hit up Whole Foods or something like that?
Chris Kresser: Well, fortunately breakfast was pretty easy because I would typically have eggs or an omelet of some kind if they had it and bacon and then potatoes. And instead of toast I would ask for a side of spinach, like steamed or sautéed spinach, which they usually have because they often will include it in omelets. In the summertime, I might have also asked for tomatoes or something. They’re not that great in the winter in most places, so I was just sticking to the green veggies. But that was a pretty standard breakfast that I could have just about anywhere, and of course, it varied in terms of quality depending on where I was, but it was pretty easy to find that. Lunch and dinner were sometimes harder.
I wrote a blog post a couple weeks back about how to stay healthy on the road with some of my reflections from the book tour, and generally nowadays in major cities it’s pretty easy to find a place, a restaurant that has some meat or fish, a non-starchy vegetable, and a salad or perhaps a starchy vegetables like potato or maybe even sweet potato or winter squash or something. So, that was my pretty standard fare for lunch and dinner, and you can get that at all kinds of different restaurants, not even just American food restaurants or steakhouses, but many ethnic restaurants you can also get some version of that if you know what to ask for or if you just ask for it. So, I didn’t find it to be really that problematic in terms of the types of foods I was eating, but as we know, vegetables oils are typically used to cook with in restaurants except for some of the higher-end restaurants that have started to go back to using traditional fats, and you just never really completely know exactly what’s in the food, and you don’t have full control over it, as you mentioned. So, even though I was doing a pretty good job in terms of finding the right things to eat, the oils were not what I would use at home, and then generally restaurant food is not as simple as what I eat at home. I really like to eat simply, and restaurants tend to go out of their way to kind of make it fancy, and I’m always trying to tell them to make it simpler for me because that’s what works for me. And so, despite all of my efforts, the novelty wore off very quickly. Let’s put it that way!
Steve Wright: Yeah, I can tell you that even a couple days in a row of eating out every meal, I’m already starting to feel it. Even making the same selections that you’re talking about, doing my best to eat at the best restaurants, it doesn’t feel the same.
Chris Kresser: No, it’s not. So, yeah, it’s good, good, good to be back. I’m happy. Sorry I missed you in Boulder. I know you were away, but I’m coming back there in April, so hopefully we’ll be able to hook up then.
Steve Wright: All right. Hopefully it’s not during PaleoFX. Will you be there?
Chris Kresser: No, it’s the weekend before that.
Steve Wright: OK, good.
Chris Kresser: I will be at PaleoFX, too. I just confirmed that.
Steve Wright: Congratulations. We were asked to speak there as well, so we’ll see you.
Chris Kresser: That’s awesome. So, we have a really exciting show today for our first show of 2014 and back after a long hiatus. We’re going to be interviewing Dr. Terry Wahls, who many of you, I’m sure, have already heard of. She is a physician who has made remarkable progress with multiple sclerosis, which she was diagnosed with in the year 2000, using paleo principles and functional medicine. We haven’t talked a lot about MS on this show, so I thought it would be fantastic to have her on and discuss her own experience as well as her research with other patients with MS and her upcoming book, The Wahls Protocol, where she shares the details of all of that. So, let’s bring her on the line here, and we’ll get the show started.
Dr. Wahls, welcome. Glad you could join us.
Dr. Terry Wahls: Thank you.
How Dr. Wahls Beat Progressive MS
Chris Kresser: Can you tell us a little bit about your story? I’m sure many of my listeners know of you and have heard your story, but for those who haven’t, can you tell us a little bit about the background for this book and how you got into this?
Dr. Terry Wahls: Sure. I have multiple sclerosis. It was diagnosed in 2000 on the basis of an abnormal weakness in my left leg and some stumbling that I was doing. I had MRIs of my brain and spinal cord, a spinal tap. I had lesions in my spinal cord, I had a history of dim vision 13 years earlier, weakness in my left leg, so I had two lesions disseminated in time and space. I was told to proceed to get disease-modifying drugs, and so I decided that I would get a second opinion at the Cleveland Clinic, one of the internationally recognized MS centers, and they said, “Yes, you have MS,” and strongly urged me to begin one of the ABC drugs, and I started Copaxone. Over the next three years, I had only one episode of weakness that was involving my right arm, so that would be a success, but the problem was I had continually declined and my disease had converted to secondary progressive MS. I needed a tilt-recline wheelchair.
I should tell you that I had found Loren Cordain’s work in 2002, and after decades of being a vegetarian I had gone back to eating meat and had eliminated grain, legumes, and dairy, but had continued to decline. When I hit the wheelchair, I started reading the research literature on animal models of MS, Parkinson’s, dementia, Huntington’s disease, and decided that mitochondria were key. I managed to find some vitamins and supplements that were helpful to mitochondria, and that seemed to slow down the rate of my decline, but I was still declining.
By 2007, I had difficulty sitting up in a standard chair; my back was so weak. I could walk very short distances using two canes. And that’s when I discovered the Institute for Functional Medicine. I took their course, Neuroprotection: A functional medicine approach for common and uncommon neurologic syndromes, and had a much longer list of nutrients that were really important to my brain. I started taking those. Not much happened, but then I had this really brilliant insight that I should take this long list of nutrients and get them from the food I was eating. So, with more research, I figured out the food stuff that would supply those nutrients, reorganized my diet using paleo principles but to target these particular nutrients, and that’s when the magic began to happen. Within three months, I was walking with a cane between exam rooms. In six months, I was walking without a cane, and within the year, I was able to get on my bike and start biking again after not having been able to do so for five years.
Chris Kresser: Wow.
Dr. Terry Wahls: And then I was even able to do an 18-mile bike ride with my family.
Chris Kresser: That’s amazing. Tell us a little bit about what those nutrients are. We might be jumping ahead here, but since you mentioned them, and I’m sure you go into much more detail in your book, but maybe just an overview.
Dr. Terry Wahls: In the very big sense, we need the whole family of B vitamins and vitamins A, C, K, and E, of course. Minerals are cofactors so the vitamins can do their job, and so there are the major minerals and some trace minerals that are very important, including things like iodine and selenium. Then a wide range of antioxidants that are very, very helpful. All in all, I end up with 31 nutrients that I’ve identified that the science has said are critical for brain cell growth, and those are the nutrients that we now track and be sure that we have a diet designed to maximize intake of those nutrients.
Conventional MS Treatment Approaches
Chris Kresser: Right. So, you’ve made this remarkable progress maximizing the nutrient density of your diet, eliminating food toxins, and using some functional medicine principles, but tell us, what’s the typical approach to MS? If someone were to find out they had MS and went to a conventional doctor who wasn’t thinking in these terms, what would be done and what is the efficacy of those treatments and the prognosis?
Dr. Terry Wahls: For a long time, there was absolutely no treatment that was available. And then the first set of treatments were the ABC drugs based first on interferons and then on Copaxone. And these drugs would reduce the number of attacks or relapses by about a third. At the time, they were pretty expensive, $700 to $1000 a month, and they were injections. The interferons were more likely to cause problems with depression, fatigue, and a lot of muscle pain, particularly if you took the Avonex or the Rebif. Copaxone had slightly different sets of problems, a little more heart palpitations and some problems with shrinkage of tissue where you would inject, so people could run out of injection sites. Now they have these much more expensive drugs that are very specific at turning off the immune system, things like Tysabri and Gilenya, that cost between $36,000 and $51,000 a year.
Chris Kresser: Wow. And are these covered by insurance companies typically?
Dr. Terry Wahls: Well, it would depend on the type of insurance that people have. They are sometimes covered, sometimes not. And they’re very effective at turning off the acute relapses, the inflammation sequence. But the problem is if you turn off part of our inflammation response so effectively, because inflammation is a key function in our body’s ability to repair and defend itself, people have a very extensive list of side effects, including death.
Chris Kresser: Yeah. I know you’re actively researching. I imagine you’re in communication with a lot of colleagues who also treat MS. What has been the response to your experience and now your research and your work with the book? Are you finding that it’s being well received in the medical community? Are you finding skepticism initially that then transforms into more open-mindedness? What has that been like for you?
Dr. Terry Wahls: Certainly here at the University of Iowa, when I first recovered, we did grand rounds and I presented my case and the theories about why I thought I recovered, and the response there was sort of twofold. About the half the audience thought this was the most brilliant grand rounds they had ever seen, and the other half thought this was strange and were very critical of it. And people correctly criticized me and said, “Yeah, you need to do the research,” and so we did that. We wrote the grant, got funding, and we have the research going on now testing this protocol in others with MS. And every year, twice a year, we have our research day. We put up our posters, people see my preliminary data, and the data is very exciting. So, people are coming by, talking to me, asking to be part of my study team because they know I’m freezing a lot of blood and people are very curious. They’re proposing to do analyses on the frozen blood to try and figure out why I’m seeing the very exciting results that we’re getting. As a result, now I’m doing research seminars around the university, and I’ve been invited to do seminars around the country, and now last fall I was in China talking about my work. So, the word is beginning to get out. People are interested. And I’m certainly quite confident that many, many neurologists are having to talk about food because their patients are coming in and saying, “What about that TED talk? What about food?”
The Importance of Getting Nutrients from Food (Not Supplements)
Chris Kresser: Mm-hmm. So, let’s talk a little bit about food. I have always emphasized the importance of obtaining nutrients from food whenever possible, and I have my reasons for that. I’d be curious to hear your take on that and why once you’d discovered all of these nutrients that were beneficial for brain health, why you didn’t just take a bunch of supplements instead of emphasizing the importance of getting them from the diet.
Dr. Terry Wahls: Well, this was sort of a long process for me. The first step was I started adding animal protein and eating meat again in 2002. Then in 2003 when I hit the wheelchair, I started reading and adding some vitamins and supplements to my diet. And then when I got the functional medicine piece, I added more vitamins and supplements. And then, thank goodness, I sat down and reflected on that if I did this through food, I would get these specific nutrients in their natural milieu along with all the cofactors. I wouldn’t be taking synthetic compounds that were probably a mixture of racemic forms of the compounds.
Chris Kresser: Right.
Dr. Terry Wahls: And in addition, I would probably be getting all of the related compounds that were biologically active. I think food is so filled with more information for our cells than we realize. I feel very strongly that food is critical. When we take the vitamins and supplements, we’re more likely to get synthetic forms, more likely to get them out of proportion, and for, I think, many things in our body, it’s the ratios of various amino acids, ratios of fats that provide a tremendous amount of information for our cells.
Chris Kresser: Yeah, those are essentially the same reasons I recommend it, and this concept of food synergy, which is so fascinating, I’ve found a few papers on it even in the literature that really make it clear that there’s so much about the interaction between various nutrients in foods that we still don’t even understand yet, and when we isolate nutrients and take them, as you pointed out, perhaps out of proportion or in different proportions than they are delivered in a food, we don’t really know what the long-term effects of that are.
Dr. Terry Wahls: And the synthetic compounds, you know, lipoic acid made synthetically. Is that biologically the same as what we’re going to get eating organ meat? I think not.
What Exactly Is MS?
Chris Kresser: Yeah, I agree. So, tell us a little bit about, stepping back, a bigger picture of MS. Is it like many other autoimmune diseases? Is the incidence increasing significantly now over the last several years? And maybe we should even talk a little bit about just what is MS and how it affects people for those that aren’t familiar with it.
Dr. Terry Wahls: Well, let me step back to, what is MS? It was first described in the 1800s as there was a lot of white scarring in the brain, so that’s why it was called multiple sclerosis or multiple scars. And over time, they decided that the immune cells were attacking the myelin, or the fatty insulation on the brain, leading to these scars. When you have an acute attack, that’s called a relapse. Things get worse. Your brain or spinal cord is able to create a few more sodium channels, and it can bypass that scar for a while. The longer you have the disease, the more likely you are to have parts of the brain and spinal cord deteriorate and the axons, or the connecting wires, begin to break. In that phase of the disease, that’s called the progressive phase. And you can either be primary progressive so you never have acute relapses, you’re just slowly deteriorating, and we think there are a lot of breakages going on in those connecting wires. Or you can have the relapsing-remitting, where you have acute worsening, you get better, acute worsening, you get better. But after 10 years or so, about half of these people will convert to the secondary progressive phase, where now the axons are breaking and there’s steady deterioration despite the best treatments.
In the US, about 400,000 people are diagnosed with MS, and what we see is the rate of diagnosis is increasing and the age of first diagnosis is dropping. I believe the youngest person that has been diagnosed was diagnosed at age 6, so it’s certainly very troubling that people are being diagnosed earlier and earlier. And of course, now there’s a push to use these disease-modifying drugs and a lot of enthusiasm for these very, very potent drugs like Tysabri and Gilenya coming on board.
Chris Kresser: What do you attribute this increase in incidence to and the earlier age of diagnosis to?
Dr. Terry Wahls: Well, I think autoimmunity, in general, has increased, and part of the reasons are the increased toxic load, the more heavy metals, plastics, and solvents in our food supply, air and water, so that increases inflammation. In addition, the low vitamin D. Physicians have made us terrified of the sun, so people are putting on sunscreen, which is toxic in itself, and blocking the tan also blocks the ability to make vitamin D, so I see epidemics of vitamin D deficiency. And then I have grave reservations about the genetically modified organisms. Is one of the unintended consequences of GMOs in the genetically susceptible person increasing the probability of some type of autoimmune problem?
Chris Kresser: Mm-hmm. You mentioned earlier when we were talking about the importance of the mitochondria in MS. Tell us a little bit about that and why it’s so crucial to understand.
Dr. Terry Wahls: Let me remind the listeners about mitochondria. About one and a half billion years ago oxygen became in abundance in our atmosphere, and that killed off about 90% of all the living bacteria. There were a few bacteria that learned how to use this poisonous compound oxygen to create energy very efficiently, and these little tiny bacteria were engulfed by larger bacteria. And this new super-bacteria was very effective, very efficient, and over time, that efficiency allowed it to develop a multicellular organism and then an animal that could walk and move and eventually that would become us. So, all of our cells have these ancient bacteria that are living in all of our cells that are producing our energy more efficiently. The brain, the retina, and the heart are the most packed cells with mitochondria per cell because you have to produce so much energy to think, so much energy to see and, of course, to maintain our heart. For many, many people with MS – and frankly many conditions – they’re experiencing huge problems with fatigue, exhaustion, or brain fog, and that’s really a very good clinical sign that the mitochondria are not producing the energy as efficiently. And the reasons for that most commonly are nutrition and toxic load. Chronic co-infections could be doing that as well, but nutrition and toxins are really the most common.
Chris Kresser: Is there any conventional testing or functional testing that you use to determine the function of the mitochondria, or do you just look at it using clinical signs and symptoms?
Dr. Terry Wahls: In an integrative practice or a functional medicine practice, one can use something like Genova Diagnostics NutrEval that has a very nice assessment of how efficiently the electron transport chain and the citric acid cycle are working for that person, and that really is a terrific test. In fact, we’re using that test in our clinical research. In my clinical practice, I don’t have access to that type of integrative lab testing, so there I rely on history and some very basic lab tests that I talk about in the book. In my experience, a good history and paying attention to the signs of the fatigue and brain fog is very revealing.
The Wahls Protocol for Treating MS and Autoimmune Conditions
Chris Kresser: Right. Tell us now a little bit more about your protocol, and I’m not sure if you’re at liberty to discuss your research and its status either in general or more specific terms, but if so, I’d be curious to hear about that and what the actual protocol is in broad brushstrokes and maybe a little bit more about your book.
Dr. Terry Wahls: Sure. The protocol is we have the diet, which is paleo that’s been very structured. Then I teach people how to meditate. We do a mantra-based meditation. We also teach some very simple self-massage of the face and hands. We design an exercise program specific to that individual since people with MS in our study, some folks are walking with a cane and others are struggling to walk with a walker, so there’s a big difference capability there. And we also use neuromuscular electrical stimulation of the muscles. So, we would design an exercise program, we’d design an electrical stimulation program specific to them, and then we would advance that as they would tolerate that.
Now, in terms of our research, we’ve presented our preliminary data at the 2011 Neuroscience Conference and got a hot topics award for that. And we were able to talk about the significant drop in fatigue that we were seeing early on. It’s sort of interesting, Chris. Because this is such a radical new intervention, the institutional review board told us that we could do 10, and we’d have to file a safety report to make sure we didn’t hurt anyone, and then we could do our second 10. So, we have now published the results of our first 10, and that just has been accepted, sort of in the process of getting through, so that will be coming out certainly very soon. But again, it’s our first 10, very exciting results. I’d say that the most important thing is we were able to show that people could do it, no one was harmed, and that we see very exciting data, particularly in the effect on fatigue.
Chris Kresser: Right. And what’s the time length of the intervention and the study period?
Dr. Terry Wahls: The study period, it’s a year, although we will be following people for a total of three years. And then the second group of 10, because our results were so exciting, I went back to the agency that funded us and talked to them about adding an MRI at baseline and the end to the second 10, and they said yes.
Chris Kresser: Oh, great.
Dr. Terry Wahls: So, we’ll have MRIs that we’ll be able to talk about, and we’ll have a functional MRI so we know how the blood flow to the brain changes. And it’ll be very interesting to be able to compare that to outcomes.
Chris Kresser: Great. Yeah, I look forward to seeing that research. And the book, I imagine this is geared towards a lay audience, correct?
Dr. Terry Wahls: Yes. We worked very hard to make this very approachable and very, very readable. In addition, I have all the references for all my physicians and scientific and nutrition colleagues in the back of the book. We have these amazing appendices that show people the nutrient density for all those 31 nutrients I said were so important, how much there is in the average American diet, in the Wahls Diet, the Wahls Paleo, and the Wahls Paleo Plus. So, nutritionists who are frightened about, “Oh, my gosh, they’re taking away these very important food groups,” will be able to see that, yes, we did take away some big food groups, but the nutrient density exceeds the RDAs two- to tenfold depending on the nutrient and which dietary level you’re in, so no one’s going to be in trouble eating this diet.
Chris Kresser: That’s great. So, someone who has MS and is interested in this approach will be able to buy this book and do a lot of it on their own and maybe use it as a springboard for discussion with their physician.
Dr. Terry Wahls: Correct. And I do spend some time coaching people on how to talk to their doctor, how to talk to their neurologist or their primary care doc, and that for most people, even if their neurologist is not comfortable, the primary care doc will likely be very comfortable talking about nutrition and monitoring some of the labs that I suggest.
Chris Kresser: Yeah. It seems like primary care doctors tend to be a little more open-minded about these things than specialists, at least in my experience.
Dr. Terry Wahls: Yes.
Chris Kresser: So, tell us a little bit about what’s next for you. You have this next group of 10 people that you’re going to be studying, and what are some more intermediate or long-term plans in terms of this research or your work in general?
Dr. Terry Wahls: We have now some studies that are looking at what’s the impact of just doing e-stim and exercise, and then I have another study what’s the impact of just doing the diet without the electrical stimulation of muscles or exercise. I’m writing the grant to study this in fibromyalgia, again using the diet, and then having conversations with a Parkinson’s researcher here about the possibility of studying this in that group. Certainly in my clinical practice and in my many followers, it’s clear that this approach has dramatic impact for many, many disease states. This is much more than MS, of course.
Chris Kresser: Sure. Many autoimmune diseases share some common mechanisms, so we might expect it to work well for several other autoimmune conditions and perhaps several other neurological conditions, as you pointed out.
Dr. Terry Wahls: Yeah, we have some great stories of people with Parkinson’s who have experienced dramatic improvement and were able to get back to work, back to very functional lives.
Chris Kresser: That’s amazing. My last question for you is, aside from the diet, which obviously has been the cornerstone, it sounds like, what other things have led to the biggest change for you? You mentioned that you’re doing e-stim and also meditation and tailoring exercise programs for people, but on a personal level, outside of the diet, what have you found has had the biggest impact on you?
Dr. Terry Wahls: For four years, I really did a lot of e-stim with my workout. That was probably very helpful. What I see clinically for many of my patients and in our trial is people can be doing the diet really well, doing their exercise and e-stim, and they seem to be getting stuck, not really improving. And when I sit down, we often uncover this high level of stress over something, a family conflict or a financial issue, although I will say family conflict usually has been number one there. And I help people realize that the diet is certainly the bedrock, but if your cortisol is still through the roof, that is so inflammatory that if you don’t address that high cortisol state, you’re likely to get yourself stuck.
Chris Kresser: Right.
Dr. Terry Wahls: So, we initially work very hard on helping people get the diet down, I think that’s very important, but when people get stuck – and that happened to me, too, because I’m a bit of an overachiever and I get too much stress going on, and so I had to get back into a very deliberate program of meditating twice a day. And now that I’m much more careful and prioritize that much more highly, things are going very well again.
Chris Kresser: Yeah. I have a similar experience personally and also in my work with patients. I see a lot of people who focus almost obsessively on diet, and of course, we need to focus on what we eat probably more than anything else, but I’ve had a similar experience where people can get really stuck when they’re only paying attention to that and neglecting other things like sleep and especially stress management, so it’s interesting to hear that that’s been a factor for you as well.
Dr. Terry Wahls: Personally, yes, and in our clinical trial, yes. That certainly has caught my attention.
Chris Kresser: Yeah. Well, The Wahls Protocol, it looks like it’s going to be out on March 13 this year. Is that correct?
Dr. Terry Wahls: Yes, that is correct.
Chris Kresser: I’m sure it will be a fascinating read for anybody. I certainly plan to buy it. And of course, if you’re dealing with MS and any other neurological condition or, I would say, any other autoimmune condition, you’d be a great candidate for this book. Thanks so much for joining us, Dr. Wahls, and good luck with your ongoing research.
Dr. Terry Wahls: Thank you very much.
Chris Kresser: My pleasure.