Is the calorie-free sweetener erythritol safe? The FDA did not evaluate long-term use, and new research suggests it may cause blood clots in people with high blood pressure and other risk factors.
Table of Contents
- The American Heart Association Started Calling Cholesterol Bad When Companies Using Vegetable Oils Started Making Donations
- Cholesterol is Not the Cause of Heart Attacks
- Keys’ First Tactic was to Blind Doctors With Science
- Keys also convinced doctors in the AHA to accept funding from companies selling vegetable oil-based shortening.
- Keys Helped Design a Study to Test the Effects of a High-PUFA Diet
- The Minnesota Coronary Experiment Stacked the Dietary Deck in Favor of PUFA
- The BIG Question: Does a High-PUFA, Cholesterol-Lowering Diet Reduce Mortality?
- PUFAs Increase Mortality
- To Hide the Facts About Fat the AHA and Keys Hid Smoking Data for 25 Years
- Why Single Out Ancel Keys?
- Related Content on DrCate.com:
The American Heart Association Started Calling Cholesterol Bad When Companies Using Vegetable Oils Started Making Donations
Today I want to make it clear that, if you’ve adapted a low-PUFA lifestyle (PUFA=PolyUnsaturated Fatty Acid) and your cholesterol has gone up, it’s actually a good thing in spite of what the AHA says. I wrote this post originally in 2016, but updated it in 2020 to better drive home these key takeaways and help dispel the fears many of us have from seeing our own cholesterol numbers, especially LDL cholesterol, climb:
- The American Heart Association recommends consuming “more vegetable oil” because it’s low in saturated fat and high in polyunsaturated fat (PUFA) and shows no concern that we’re already consuming historically high amounts of both vegetable oil and PUFA.
- The AHA’s has failed to publish the available evidence that consuming these oxidation-prone oils at current levels is radically harmful to our health in any of their dozen or so professional journals.
- It’s clear that PUFA consumption reduces blood cholesterol, but what’s less clear is why this happens.
- There are many reasons to conclude that eating enough PUFA to lower cholesterol is terrifically harmful to your health.
- The best study ever designed to test the idea that PUFAs are healthy ultimately showed that they were unhealthy, so the study authors didn’t publish it.
- This is scientific fraud.
- The AHA has been engaging in scientific deception around saturated fat, cholesterol and PUFAs for decades.
- Doctors who dispense the American Heart Association’s dietary advice are doing more harm than they know.
Cholesterol is Not the Cause of Heart Attacks
When your primary care doctor recommends cutting out foods like butter and eggs in favor of Smart Balance and egg beaters, or your naturopathic doctor tells you cow’s milk is unhealthy because of saturated fat and you’d be better off with rice milk, when your trainer tells you to eat skinless boneless chicken breast and protein powders, when your McDonald’s fries are soaked in seed oils instead of beef tallow, and your take out pizza is made with soy oil instead of olive oil, it’s important to realize that all these changes are taking the freshness and realness of your diet down a notch or two—and some of these newer alternatives are outright toxic.
Nobody would want these lower-quality processed foods were it not for the idea that saturated fat and cholesterol clog your arteries. This idea has made us afraid of the very foods our bodies need the most, and it’s enabled the processed food industry to thrive as never before. The saturated fat lie helped to create a demand for alternative fats that come from soy, corn, and other subsidized monoculture crops soaked in pesticides and herbicides, destroying the soil and with it our ability to live sustainably off the land.
The myth that saturated fat and cholesterol clog arteries has acted like a virus, a contagious idea that infected humanity’s relationship with food and separated us from thousands of years of culinary tradition and farming wisdom. It has allowed for the painting of all animal products with one brush, as if how they’re fed and raised makes no difference, putting thousands of traditional family farms out of business. Instead of being raised by farmers who treat their animals like family, most cattle, pork, and poultry are now subjected to horrific treatment in industrial-scale agricultural operations. This is affecting farmers and people who love animals, certainly, but it also affects all of us because it means poultry, pork, and beef all taste worse and are far less nutritious.
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This one idea, that saturated fat, and cholesterol cause heart disease, has gradually turned us against nature, the source of human health. To really get comfortable with the fact that cholesterol is not your enemy and vegetable oils are, it’s helpful to understand the history of this idea.
Its origins can be traced back to an influential figure in the American Heart Association, named Ancel Keys.
Ancel Keys’ Sold the American Heart Association’s Soul for $1.7 Million
As I wrote in Chapter 7 of Deep Nutrition, called Good Fats and Bad, it all began back in the 1950s and 1960s, when an oceanographer and eel physiologist named Ancel Keys designed a series of highly influential experiments that forever altered the course of American dietary history. Keys had a powerful personality, which he used to influence the American Heart Association leadership. As a result, a deal was brokered where Proctor & Gamble, makers of hydrogenated vegetable oil, paid the AHA 1.7 million dollars.
Before Keys, Americans enjoyed traditional foods like butter, eggs, and bacon without worrying about their health. After Keys made the cover of Time Magazine on Jan 13, 1961, the American public was introduced to the idea that saturated fats were clogging their arteries. That idea ultimately led to a sea change in the foods we eat. Real fats would increasingly be replaced by factory-made seed oils, and the era of chronic disease would begin.
This article extends the arguments I made in Deep Nutrition to show how Keys and his allies misled doctors and hid the results of their own studies that would have proved them wrong.
Keys’ First Tactic was to Blind Doctors With Science
In the 1961 Time magazine article celebrating Keys, he is quoted as warning us that “Americans eat too much fat. With meat, milk, butter, and ice cream, the calorie-heavy U.S. diet is 40% fat, and most of that is saturated fat—the insidious kind…that increases blood cholesterol, damages arteries, and leads to coronary disease.”
During interviews like these where Keys discussed his research and experiments, he led the audience to believe that saturated fat from butter and eggs caused atherosclerosis. But during those interviews, he was not being completely honest. Had he been, he would have said that his studies showed margarine caused atherosclerosis. The margarine in his experiments contained saturated fats that had been artificially created from vegetable oils using a process called hydrogenation. Hydrogenated vegetable oils contain not just saturated fat but also trans fat and a whole host of other unnatural molecules. Trans fat is now known to have a multitude of toxic effects on the body, causing fatty liver, weight gain, as well as lead to heart attacks and stroke. It’s so unhealthy that cities like Manhattan and San Francisco have outlawed its use in restaurants.
Keys didn’t have to work very hard to hide this deception. One publication he authored entitled “Hydrogenated fats in the diet and lipids in the serum of man” should have been a red flag that he was not using real food in his experiments. But few recognized it as a red flag because few were conversant with the terms he was using. Although doctors do learn some biochemistry, food-processing terms like hydrogenation would not become part of the standard curriculum until 50 years after Keys, nearly a century after they were introduced into the food supply.
Keys also played games with statistics. Most notoriously, he cherry-picked data points that made it look like countries that ate the most fat also had the most heart attacks. In other words, he excluded countries that ate a lot of fat but had few heart attack deaths and vice versa. The details of this historic deception have been covered by many researchers including Dr. Uffe Ravnskoff, Dr. Malcolm Kendrick, journalist Nina Teicholz, and myself.
What’s less well known is that Keys also compiled smoking data starting in 1958 at the beginning of the Seven Country’s Study, but he failed to publish the smoking until 1980, well after he had successfully deluded Americans into believing saturated fat clogged arteries.
Keys was the first person to collect large amounts of data on the relationship between smoking and heart attacks. But Keys never talked about the smoking data he collected, and what was a very clear and very strong correlation between cigarette smoking and heart attacks wasn’t published until many years after the initial data was collected.
But by then, it was too late. The saturated-fat cat was out of the bag and nobody in any position of authority was willing or able to put it back in. The belief that saturated fat is unhealthy because it elevates cholesterol, which supposedly clogs our arteries and causes heart attacks and stores, now forms the basic foundation of most nutrition science in spite of the fact that it was based on a series of deceptions and scientific half-truths.
Fortunately, blockbuster books like Good Calories, Bad Calories, The Big Fat Surprise, and The Primal Blueprint, as well as my own books, have gone a long way towards informing the reading public on the health harms of hydrogenated vegetable oils, and the lack of harm from natural saturated fat. This information has trickled down to influence the thinking of some doctors as well, and a few have lifted their restrictions on butter and eggs.
But Keys did more than fool physicians into believing eating butter and eggs would kill us.
Keys also convinced doctors in the AHA to accept funding from companies selling vegetable oil-based shortening.
Keys was a major fundraiser for the American Heart Association and a close associate of their medical leadership, most notably Paul Dudley White, who famously treated President Eisenhauer after his first of several heart attacks. Dr. White was not initially in step with Keys about the idea that saturated fat causes heart attacks, but soon after they met he changed his opinion. That flip-flop was perhaps an outgrowth of the need for corporate sponsorships for the American Heart Association, which Dr. White directed for several years.
As Nina Teiholz writes in The Wall Street Journal, “In 1948, P&G made the AHA the beneficiary of the popular ‘Walking Man’ radio contest, which the company sponsored. The show raised $1.7 million for the group and transformed it (according to the AHA’s official history) from a small, underfunded professional society into the powerhouse that it remains today.”
It’s possible that Keys brokered the deal, but that is a question that for now remains unanswered. The fact is, the AHA was clearly in bed with the biggest vegetable-oil company in the world at the time and Keys’ linguistic tricks and statistical deceptions made Procter & Gamble’s product look healthier than their only competition at the time, the traditional fats like butter, tallow, and lard. It’s entirely possible that Keys at one point in his career truly believed that traditional fats like butter, tallow, and lard caused heart attacks. But once his reputation became dependent on the idea, he crossed a line. The next section discusses what I think is the worst example of how Keys’ and the AHA’s medical leadership worked together in an attempt to make vegetable oil look healthy.
Keys Helped Design a Study to Test the Effects of a High-PUFA Diet
In the 1960s, Ancel Keys and the president of the Minnesota chapter of the AHA, Dr. Ivan Frantz, designed one of the largest, most rigorous experiments ever conducted to test an important question: how do vegetable oils affect our health. Called The Minnesota Coronary Experiment (MCE), it was the highest-quality kind of study, a double-blind randomized controlled trial. And it was huge, a massive undertaking involving thousands of adult residents of six state mental hospitals and one nursing home, where inmates had no choice but to eat what was put in front of them and so compliance with the experimental diets was practically guaranteed. Everything was done to assure the that results were going to be about as reliable and meaningful as possible.
The study was composed of two parts, designed to test the validity of two different hypotheses:
1) That a diet high in polyunsaturated fat from vegetable oils would lower cholesterol.
2) That this reduction in cholesterol levels would prevent atherosclerosis and deaths from heart attack and stroke.
Both hypotheses are important, but number two is even more important because if PUFAs do in fact lower cholesterol but this fails to translate to a reduction in heart attacks and strokes, this challenges the idea that cholesterol is the cause of heart attacks.
To test the two hypotheses, the study subjects were divided into two groups and fed two different diets for at least a year. One diet, called the control, was intended to mimic the typical American’s diet and was relatively high in saturated fat. The other, called the experimental diet, was low in saturated fat and high in polyunsaturated fat from corn oil.
The Minnesota Coronary Experiment Stacked the Dietary Deck in Favor of PUFA
The experimental, high polyunsaturated-fat diet contained lean meats “filled” with vegetable oil (called “filled meats”), skim milk, and cheeses to which corn or other vegetable oils were added, along with some margarine—no butter or natural animal fats. But the so-called control diet was not exactly what most Americans at the time would eat. Rather than containing butter and animal fats, it was full of margarine and shortening as these are also rich sources of saturated fats.
What’s key here is that this so-called control diet contained substantial quantities of trans fat. In other words, the experimental diet was being compared to a very unhealthy diet, not a true control. What was in fact being examined was not the effect of saturated fat versus PUFA but, rather, the effect of trans fat plus saturated fat from hydrogenated oils versus PUFA. By comparing PUFA to unnatural factory foods, Keys stacked the deck in favor of PUFA. Given that Keys had been studying trans fat’s effects for years before this study started, I doubt this little cheat was accidental.
Even with this deck stacking, real science would make an appearance in the form of meaningful results that were not what the researchers were hoping to see.
Part 1, Question 1) Do PUFAs Lower Cholesterol?
Both the control and study groups had their cholesterol levels tested at the onset of their participation in the study and again one year later. In the beginning, the numbers were very well matched and nearly identical. One year later, the high-PUFA diet group had cholesterol levels 30 points lower, on average, than those in the so-called control group. This was not an entirely new finding since many other less well designed studies and animal experiments had already demonstrated that PUFAs reduce cholesterol.
It’s important to know that this predictable reduction in cholesterol is the American Heart Association’s justification for recommending vegetable oils. That’s why products like Smart Balance and thousands of other high-PUFA products claim to be “heart-healthy.”
But here’s the problem: we’ve never shown that lowering cholesterol by eating more PUFAs prevents heart attacks. That’s the question that part 2 of the study was designed to test.
Part 2, Question 2) Do PUFAs Prevent Heart Attacks?
Both groups were followed for an average of 3 1/2 years, or until their deaths. Participants needed to have been on the diet for at least one year before death for the result to be counted. Upon dying, an autopsy was performed to determine the cause of death. While they gathered all the data that would have answered the second question, and almost certainly were aware of what it showed, they simply never published it. Fortunately, the lead scientist, Dr. Frantz, left most of the data, some 2355 medical charts and 149 completed autopsy files crammed into dusty boxes, undisturbed in his basement.
Some 30 years later, Christopher E. Ramsden, described as the Indiana Jones of medical research, gained access to what remained of the raw data. Most of it was there, but many of the autopsy reports necessary to determine the cause of death were missing. That meant the remaining data couldn’t definitively answer the question about heart attacks. But there was enough data to determine how many people in each group died, which is a very important question.
The BIG Question: Does a High-PUFA, Cholesterol-Lowering Diet Reduce Mortality?
That’s kind of the point, right? Not dying? Even if the diet reduces deaths from heart attacks, if it increases deaths from other conditions, we’d need to know that before making any recommendations to include PUFAs in our diet. So the mortality question is the BIG question that needed to be addressed.
As Dr. Ramsden writes in his landmark article Re-evaluation of the traditional diet-heart hypothesis: analysis of recovered data from Minnesota Coronary Experiment (1968-73). “The number, proportion, and probability of death increased as serum cholesterol decreased.” In other words, the more a person’s cholesterol dropped, the more likely they were to die. For each 30 mg/dL reduction in serum cholesterol, the risk of death increased by 22%. Ramsden said in an interview that “[w]e were able to find that actually those that lowered their cholesterol more actually had increased rather than reduced risk of death,” adding, “It was surprising.”
If this data is valid, it’s more than a surprise. It’s kind of a big deal. Actually, it’s an outrageously big deal. Why wasn’t this information published as soon as it was available? According to the lead author’s son (interviewed by Malcolm Gladwell for a podcast called The Basement Files), these results were so shocking to Dr. Frantz, he didn’t know what to make of it all and simply “couldn’t bring himself to publish them.”
Some suggest we should let these guys off the hook, rationalizing that it wasn’t self-interest holding them back; it was self-doubt. It’s human nature for researchers to doubt their results when the results are unexpected.
But I’m not making excuses for these two icons of nutrition science whose careers would have been dramatically altered by results that proved them wrong. They may have had some interest in nutrition science, but I reckon they were also interested in money. By failing to show their results, that PUFAs kill people more often than deadly trans fat, they protected the American Heart Association’s chief source of funding, which was at that time the seed oil industry.
PUFAs Increase Mortality
Keep in mind, the differences shown in the mortality rates of women and men and women over sixty-five are significant enough that any drug that could effectively address the effects of PUFA would be a blockbuster.
The AHA Is Giving Us Unhealthy Advice, and Harvard Doesn’t Care
Perhaps the most influential person in the nutrition world today, Dr. Walter Willet—who has a school at Harvard named after him—has called Ramsden’s study “an interesting historical footnote that has no relevance to current dietary recommendations.”
Here’s why Dr. Willet is wrong about the study’s relevance.
- The AHA ignores contradictory evidence like this at our peril. As Ramsden suggests, the AHA has been ignoring similar evidence for a long time, and “Recovery of unpublished data can alter the balance of evidence and, in some instances, can lead to a reversal of established policy or clinical practice positions.”
- The AHA still recommends “<10% of calories from saturated fats. Replace with unsaturated fat, particularly PUFA.”
- The Average American is following the AHA’s advice on fatty acids (whether they know it or not), and is now eating a diet very similar to the Minnesota Coronary Experiment’s experimental diet in terms of its fatty acid profile. Here’s my evidence:
- The MCE study diet limited saturated fat to between 8.0% to 12.3% of calories and today’s guidelines recommend limiting saturated fat to 10% of calories.
- The MCE study diet’s linoleic acid levels ranged from about 11.3% to 16.5% of calories, and today’s linoleic acid intake is probably very similar. (In 1999, this study cites linoleic acid consumption at 7% of daily calories, and that PUFA consumption has nearly doubled between then and now).
- Not only did Ramsden’s study show that the diet the AHA has most of us eating fails to reduce mortality, it actually increases mortality compared to the study’s control.
- The so-called control was radically unhealthy due its inclusion of trans fat—now accepted by the AHA to be deadly—and yet the high-PUFA diet proved either to be equally deadly or, in the case of women and seniors, notably more deadly, suggesting the AHA’s current dietary guidelines are radically unhealthy.
- Ramsden writes, “[i]t is clear from the MCE grant proposal that common margarines and shortenings (major sources of trans fat) were important components of the baseline hospital diets and the control diet (but not the intervention [high-PUFA] diet).”
- The diet the AHA has us eating may actually cause heart attacks in spite of its cholesterol-lowering effect.
- Ramsden et al point out (in the discussion section of the BMJ publication) PUFAs probably lower cholesterol because they cause “lipoprotein particle oxidation that could plausibly increase risk of coronary heart disease.”
- I’ve been warning my readers that LDL particle oxidation causes heart attacks for years, so I’m glad to see that an MD at the Lipid Peroxidation Unit of the NIH also thinks the same way. (See Chapter 7 of the 2017 Deep Nutrition entitled Good Fats and Bad.)
- The willingness of the AHA to ignore evidence that contradicts their theories on the cause of heart disease calls to question the very idea that LDL cholesterol is inherently “bad.”
Thousands of doctors across the country look at their patients’ cholesterol numbers every day and advise dietary changes and metabolism altering statin drugs based on a theory that would appear to have been proven wrong by this study. Harvard calls that an irrelevant footnote. I call it a strong indication that the American Heart Association is not looking out for your health.
Does High Cholesterol Even Matter?
It’s not often discussed, but there are decades of high-quality studies showing that death by cancer, pneumonia and other infections, and dementia are more common among folks with lower cholesterol, while high cholesterol is protective against death from these conditions.
All told, there’s enough evidence to suggest that there’s probably no such thing as ‘bad’ cholesterol. Just as having higher HDL is associated with better health, higher LDL appears also to be associated with better health as well—although that may only hold true when you’re diet is free (or nearly free) of vegetable oils. I will be offering classes on interpreting your cholesterol numbers starting in 2021, and if you are interested please subscribe to my newsletter to be notified.
To Hide the Facts About Fat the AHA and Keys Hid Smoking Data for 25 Years
In 1956, the AHA downplayed the role of smoking, claiming, “Much greater knowledge is needed before conclusions can be drawn concerning possible relationships between tobacco smoking and increased death rates from coronary heart disease.” The AHA defends this 1956 position on smoking by stating “This is an early illustration that all research and AHA statements are based on conclusive evidence.” [sources: https://professional.heart.org/en/research-programs/aha-research-accomplishments/historic-moments-and-research-funded-by-the-american-heart-association]
To collect that evidence, they’d been planning a massive study, the organization of which began back 1953, called the Seven Countries Study.
In 1956, the same year the AHA claims that there was insufficient data linking smoking to heart attacks, they asserted, “Fat and cholesterol linked” and “assume a leading role in urging Americans to change their eating habits.” The troubling thing is that one would think taking this extraordinary measure of advising a nation to abandon the natural whole foods that had kept us healthy for centuries would require them to also definitively link either fat or cholesterol with heart disease. Seems little to ask from an institution that boasts of its insistence on “conclusive evidence.” The reality, however, was that although dietary fat and cholesterol were linked to each other, there was little to no credible evidence they were linked to heart attacks. [sources: https://professional.heart.org/en/research-programs/aha-research-accomplishments/historic-moments-and-research-funded-by-the-american-heart-association]
In 1958, the Seven Countries Study was launched. It collected data on smoking as well as eating habits, according to this statement: “When the Seven Countries Study started in 1958 the prevalence of smokers was very high and ranged from 44% in Belgrade professors in Serbia to 78% in fishermen from Ushibuka in Japan.” Available on this website: https://www.sevencountriesstudy.com/smoking-and-coronary-heart-disease/ Although the same people were simultaneously collecting data on smoking and dietary habits, making correlations and comparisons between the two quite straight-forward, the study would run for 25 years before the AHA would publish their findings on smoking, which had a much stronger correlation with heart attacks than fat intake. The only explanation is that the Seven Countries Study should be seen as the poster child of confirmation bias.
By 1961, the American Heart Association issued its first dietary guidelines that warn saturated fat raises cholesterol and causes heart disease, citing data from the same Seven Countries Study that was supposedly designed to evaluate smoking and heart disease risk. Data showing any correlation between smoking and heart disease was not ready for prime time. Had the AHA simply provided the American people the image of the left half of the graph (see above, entitled The AHA Will Never Show You This Graph), no doubt many physicians and their patients would have chosen to keep the real food and ditch the smokes.
In the same year, in his famous Time Magazine Interview, Keys actively undermines the risks of smoking, suggesting that smoking is not an important factor in causing heart disease but fat intake is. “Though Keys’s theory gained sanction from the American Heart Association last month (TIME, Dec. 26), it is still questioned by some other researchers with conflicting ideas of what causes coronary disease. The main difference is that they variously blame hypertension, stress, smoking and physical inactivity, while Keys gives these causes only minor roles.”
By 1968, a decade after it’s launch in 1958, the ten-year smoking data from the Seven Countries Study was available, according to this website which states, “The 10-year follow-up data showed that smoking was associated with a higher risk of CHD [coronary heart disease] mortality in countries where there were enough events for analysis and the strongest associations were observed in northern Europe where CHD was highest.” In other words, the evidence linking smoking and heart attacks was rock solid. But I find no evidence the AHA published this potentially life-saving information before 1980.
In 1981, deaths caused by cardiovascular diseases fell below 50 percent of deaths from all causes for the first time since 1949. The smoking rates also declined while saturated fat intake changed little.
Why Single Out Ancel Keys?
Keys apologists have told me it’s unfair to criticize the scientific integrity of anyone who isn’t alive to defend themselves. Poppycock. First of all, if any of the Ancel-Keys defenders would like to take me on, name the time and place. Secondly, there are plenty of dead people in our history who have earned our criticism and ire. What’s more, Keys’ assertions are alive and well. It is the life’s blood beating through the machinery of the American Heart Association who still benefit by citing his work. Thanks to the multiple tricks Keys used to fool the cardiologists of his day, American physicians still recommend polyunsaturated fats and are unknowingly putting their patients at risk of death and disability. This is why every doctor should learn the truth about Ancel Keys’ experiments.
Notice I’m haven’t played around with numbers. I haven’t said your HDL should be X or your LDL should by Y, although I have had such discussions becuase it can help give you insights into the current state of your metabolism. Today’s message is simple. If you’re following a low-PUFA lifestyle and the other advice in Deep Nutrition and FATBURN Fix, you don’t need to worry about cholesterol going up or increasing your chance of getting a heart attack. Get Ancel Keys and the AHA out of your head, out of your heart, and out of your diet. If you can do that, then we will have finally put Dr. Keys to rest.
- Cholesterol: What the American Heart Association is hiding from you – Part 1
- Cholesterol: What the American Heart Association is hiding from you – Part 2
- Cholesterol: What the American Heart Association is hiding from you – Part 3
- More Cholesterol articles
A 2014 article defending Keys reputation was, at the time, being publicly called to question because of how he covered up data in his famous 7-countries study. This was before the 2016 article came out implicating Keys in an entirely different cover up.
The 7-countries study controversy, covered by Authority Nutrition with a cute video.
A brief movie about Keys. At minute 22 we gain some insights into how Keys public humiliation at a scientific meeting in 1955 may have lead to his obsession with proving fat intake was the problem. Rather than being driven to find the truth, he was driven by a desire to redeem his idea, “I’ll show those guys.”
Harvard’s rebuttal of Dr. Ramsden’s study by Dr. Willet, who defends the status-quo and blames the increased deaths in the polyunsaturated arm of the study on the lack of supplemental omega-3. This suggestion seems absurd, since the polyunsaturated corn oil would have contained more omega-3 than the hydrogenated oil diet that outperformed it. He also states the study was not long enough. It was, in reality, one of the longest if not the longest study to date.