Listen To Your Gut, Navigating Gastrointestinal Issues

In this podcast, Lisa Jones interviews Stephanie Devine, MS, RD, about common gastrointestinal (GI) complications, misconceptions about GI health, and new interventions on the horizon.

Additional Resources:

• Devine nutrition and wellness. Accessed October 26, 2022. https://www.devinenutritionandwellness.com/ 
• The low FODMAP diet. Monash University. Accessed October 26, 2022. https://monashfodmap.com/
• Clinical guide to probiotics products available in USA. AEProbio. Accessed November 8, 2022. www.usprobioticguide.com
• Mindset health. Nerva. Accessed October 26, 2022. https://www.mindsethealth.com/hypnotherapy/nerva

Stephanie Devine, MS, RD, is a registered dietitian and owner of Devine Nutrition and Wellness, specializing in gastrointestinal issues (Princeton, New Jersey). 

Lisa Jones, MA, RDN, LDN, FAND, is a registered dietitian nutritionist, speaker, and author (Philadelphia, Pennsylvania).

TRANSCRIPTION:

Moderator: Hello and welcome to Nutrition411: The Podcast, a special podcast series led by registered dietician and nutritionist, Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Lisa Jones: Hello and welcome to Nutrition411: The Podcast where we communicate the information you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's episode, "Listen to Your Gut: Navigating Gastrointestinal Issues." Today my guest is Stephanie Devine. Welcome, Stephanie.

Stephanie Devine: Thank you, Lisa. I'm so excited to be here.

Lisa Jones: We are excited to have you. Before we start, I want to talk a little bit about Stephanie's bio. Stephanie is a registered dietitian and owner of Devine Nutrition and Wellness. She's located in Princeton, New Jersey. Stephanie specializes in gastrointestinal issues. She received her master's degree from California University of Pennsylvania and her undergraduate degree from West Virginia University. Stephanie completed her dietetic internship at Augusta Area Dietetic Internship. So there we have. Welcome Stephanie again.

Stephanie Devine: Thank you.

Lisa Jones: We are going to talk about GI issues today. So my first question for you, Stephanie, is what is the most common gastrointestinal issue that you come across in this practice setting?

Stephanie Devine: So the most common issue would be IBS and along with IBS would be SIBO. So I would say IBS first, SIBO maybe second. I'm not sure if you're aware, but with IBS they're saying at least 50% of people with IBS actually have SIBO.

Lisa Jones: And do you want to tell us a little bit more, for those that aren't familiar, if you're not a GI dietician or work in that area, I know pretty much all dieticians, we know what IBS is, but SIBO, do you want to talk a little bit about what that is?

Stephanie Devine: Sure, sure. So what SIBO is, it stands for small intestinal bacterial overgrowth. So it's basically when we end up having too much bacteria in our small intestine. And along with that we develop GI symptoms, such as it could be diarrhea, could be constipation, some people it's a mixture of both. They may experience bloating, abdominal pain, gas.

And with SIBO there's actually three types of SIBO. So the most common that are tested for are methane and hydrogen, but there's a third and it's more of a newer one, which is hydrogen sulfide SIBO. There's not really a lot of testing for that. So they're working on developing new tests for that. So SIBO is definitely something that's fairly common.

And if you don't mind, I'm going to talk about this. What I typically do, and most dieticians would try to do this, is we try to make sure other conditions have been rolled out. So if I'm suspecting that someone does have SIBO that's causing their IBS symptoms, then I'll ask them to ask their GI doctor to have a breath test to see if they do contain any of the gases for SIBO, they're positive.

Lisa Jones: Well, I find that really interesting. Because the other thing I wonder as you were talking about that is, so as you have these clients or that come to you and seek out your help with this and navigating, if there's three different types, I bet that can be really confusing for the patient too, right?

Stephanie Devine: Yes, it definitely can. And what happens is sometimes they take the test and they're told that they have SIBO, but they don't know what type. Well, the difference is that treatment wise, depending on what type of SIBO they have, the treatment could be a little bit different. So it is important to know. So sometimes I'll have them get the copy of the results or at least ask what type of SIBO they have. So at least we know a little bit more as far as factors and what treatment might be of benefit.

Lisa Jones: Oh, definitely. And it sounds like that's a good segue into talking about what are some of the common misconceptions about gut health? Again, I imagine them coming to see you and there's probably so many different misconceptions with this being just so many different things that can be possible here.

Stephanie Devine: Definitely, definitely. I would say one is, are you familiar with the low FODMAP diet?

Lisa Jones: Yes.

Stephanie Devine: Okay. So many people with IBS and they've found that about two thirds of people with IBS find relief on the low FODMAP diet. So one of the misconceptions is that this low FODMAP diet is something they should stay on indefinitely, and that's not how it works.

So with the low FODMAP diet, the elimination phase, typically they say it's about two to six weeks. But what I found is most clients find relief within the first two weeks. So what we would have is the first phase, the elimination phase, so approximately two weeks. And then the reintroduction phase is where they start to reintroduce different categories from the fermentable carbohydrates to determine dose wise if they do have an issue. Can they tolerate a two spheres of asparagus or can they tolerate seven spheres of asparagus? So the reintroduction phase is really, really a key component of the low FODMAP diet. So from that they, they're able to determine which FODMAP categories are an issue. So that's really important to do the reintroduction.

And then the third phase would be where they personalize. So it's kind of more of the practical phase. So we know of the six FODMAP categories that three of them are an issue. How can we learn to incorporate those foods that are high FODMAP? Maybe they can tolerate a small amount of that. So that the reintroduction and personalization phases are extremely important. And that's something that gets missed. Often they're given a sheet and said, "Okay, follow low FODMAP diet, this will help you." So it's really helpful to find a dietician that's trained in working with the low FODMAP diet.

And I did get certified through Monash University. They have a certificate program and it's really comprehensive, a lot of great information. Along with the diet, it also talks about other treatment strategies that are beneficial for people that have IBS.

Lisa Jones: Oh, that's fantastic. So it sounds like that's something that you would recommend other dieticians that are trying to get into the GI space do.

Stephanie Devine: Yes.

Lisa Jones: Make sure you're trained right. I'm going to date myself, but I remember in college, I don't remember, we had the GI part that we learned, but I don't remember it being this comprehensive. And I definitely don't remember FODMAP being talked about. So I'm not sure.

Stephanie Devine: Yeah, I think it was, if I'm correct, I think it's 2000, before 2010. I don't know the exact date, but I know it, I graduated much earlier than that. So yes, it hasn't been around as long.

Lisa Jones: Yeah, but I think it's fascinating all these different diets coming out, but especially ones that are geared towards this particular area of GI. Thank you for sharing that.

Stephanie Devine: Sure. And just to feed in from that, what happens to some people, they end up doing a low carb diet for low car keto diet for whatever reason. And sometimes they find much relief from their digestive symptoms. So they're like, "Oh, great." Well maybe it's because they're eating low FODMAP foods and that's helpful.

But the problem there, when you have someone that's following a keto or low carb diet long term, what we tend to happen is that the production of the short-chain fatty acids are reduced. And so long term, it's not something that we would want anyone to follow. So that's another misconception is that all carbs are bad, let's just take them out. I feel so much better. But you're not seeing the inside, You're not seeing what the gut looks like having been on a low carb or a keto diet for a long term.

And one important short-chain fatty acid that's being researched greatly right now is butyrate. And what they're finding with the butyrate that higher levels of butyrate can help decrease inflammation, increase immunity, potentially decrease appetite, and maintain the gut barrier so that we have a stronger gut. And you may have heard of leaky gut. So typically with butyrate, that's going to keep our gut intact. So there are fewer chances that we're going to have any type of digestive symptoms or gut issues.

Lisa Jones: Wow, that's an interesting fact you just shared. Thank you. I love hearing new research that's coming out. That's what I mean, a researcher will always have a job is there's something else to research. And then once they do the research, they say it needs more research. So we keep researching. But this particular area and then the whole microbiome, you can probably talk a whole nother podcast about that. There you go.

Stephanie Devine: Yes, there's so much to talk about.

Lisa Jones: I would love to hear some of your successes that will help other colleagues listening that are working in this particular population.

Stephanie Devine: Sure, definitely. So these may sound like really simple suggestions and maybe a little elementary, but they're really, really important. So with GI, many times we think about, okay, we have to watch what we're eating, change our diet, but there's really a few other factors that can have a nice impact as far as reducing symptoms. And those are just a few little strategies around eating.

So one thing, I'll just share a quick example. I had a client recently, probably about a month or so ago, and we were talking about her symptoms. And I always ask the question, "What type of pace do you eat at? Do you eat slow? Do you eat fast?" And most people, it might depend on if they're at work or what's going on, but in general they're able to answer the question and then we talk about, "Are you chewing?" Because as you know, or digestion starts in the mouth. So if we're not chewing thoroughly, then that digestion may not go as smoothly. So we really want to make sure people are taking their time when they're eating, they're chewing food thoroughly.

The other thing that I found, and this was big for this client herself, was that her eating environment was really, really stressful. So she was an adult, I think she was in her late twenties living with her fiance in her parents' house. And she knew certain foods were an issue for her. So she was trying to contribute to cooking. Her mom wanted total control, and it was unfortunately her eating environment was not relaxed. And I told her, I said, "That can really impact the symptoms." Not thinking that much would change there because that's where she was living and how could she change much of it?

Well, she followed up and she actually, she started eating in her bedroom, which probably isn't the best place to do it, but she said she felt so much better because she was relaxed and the setting was more comfortable for her.

Lisa Jones: So the message I'm hearing is even if it's your bedroom, you find somewhere that provides relaxation to you and that's where you should be eating.

Stephanie Devine: Yes.

Lisa Jones: It's a good tip. It's a really good tip. So note to a lot of us that may have stressful jobs and then we try to eat at our desk while we're trying to work at the same time. I mean, is that something that you see people reporting, your clients reporting?

Stephanie Devine: Yes.

Lisa Jones: That they're rushing through meals.

Stephanie Devine: Right.

Lisa Jones: Yeah, that makes a lot of sense.

Stephanie Devine: That makes sense. And then it's one, another interesting tidbit with that is you talk to people that come from a big family and they'll say, "I eat really fast because if I didn't, I wouldn't get to eat much growing up." So it's interesting how our childhood behavior sometimes can play a part in all of this as well.

Lisa Jones: Yes, that's such a great point. Thinking back to, I'm half Italian, so big Italian families, if you're not there first trying to get the food, they will stab your hand trying to get food. Make sure that you're, eat your food quickly. So I can relate to that. And I have to really remind myself to slow down. So that's a great tip. Just find the comfortable place and then eat slowly and just.

Stephanie Devine: But that takes, and I tell people, you have to remind yourself, you have to be mindful and think about it. Because if we're in a habit of eating fast and you've been doing it for 20, 30 years, 40 years, 50 years, whatever, it does take a little remembering and trying to remind yourself, eating relaxed environment, eating slowly. And with chewing, do you know how many with each bite, how many times you should be chewing?

Lisa Jones: What is it? I want to guess it, is it over 20 or something?

Stephanie Devine: They say 20 to 30.

Lisa Jones: I don't think... Probably guilty of that, especially if we're talking Halloween candy. I don't think I'm going to chew that 20 times.

Stephanie Devine: So that's something just to remember when you're eating. And I always say to when you're doing this, it depends on what you're eating. If you're eating something really soft, you're not going to chew at 20 or 30. But let's say for example, you're eating some almonds, you know, could probably count to 25.

Lisa Jones: Definitely, yeah, if you're eating a salad, you could probably count the 25. It's like those things that may not be as nutritious for you, that may take a little shorter. So it's a good tip.

Stephanie Devine: Yes, yes.

Lisa Jones: Anything else the colleagues should be aware of?

Stephanie Devine: I would say another thing that can be helpful is paying attention to when the symptoms occur, because sometimes they directly after eating, maybe they occur a few hours later. So just be in tune to asking about when in particular that the symptoms may start. Because that sometimes can give you an idea more of what's going on based on when the symptoms are occurring.

Lisa Jones: And that's probably why we always say in any setting, it's good to keep a food diary.

Stephanie Devine: Yes, most people don't like to do that, but I always say even if you miss a day, it's not a big deal. But if you're having symptoms, that's really, really, really helpful. I'll give another quick example.

I had a client earlier today and we had tried the low FODMAP diet for her and her main complaint was diarrhea, some fecal incontinence, and occasional bloating, but nothing crazy. And the low FODMAP diet did not work for her. Normally we'll give it a few weeks and we were going to give it another week. And I had actually reached out and said things weren't working that well, can we do something sooner? Or actually I suggested we make an appointment. So she came in today and based on her food diary and talking, I think she might have issues with histamine. So now we're going to be trying a low histamine diet for a couple weeks to see if that might help reduce her symptoms.

Lisa Jones: Oh wow. So it's kind of like you're trying to solve a puzzle.

Stephanie Devine: Yes.

Lisa Jones: In a sense. But that sounds fun.

Stephanie Devine: Yeah, it does. It definitely does. And I always tell them, there's a few other things I'm thinking, but this seems the most apparent right now. And the low FODMAP diet may not work, so let's try something new. Luckily it's not invasive and it's not hard. So she was agreeable.

Lisa Jones: Oh, nice. That's a great example. So what would you say is on the horizon for gut health?

Stephanie Devine: So I would say, you had mentioned the gut microbiome and that's really, there's so much to learn about that. And there are a few companies that do some stool testing to look at some of the bacteria. They may look at other things in the stools. So I think that's really big because what we can learn from analyzing this is that we know that some bacteria, higher levels or lower levels, maybe related to reduced or increased risk for particular diseases. One in particular that's getting a lot of attention right now is, and I may not pronounce it correct, I have a hard time pronouncing it, but it's akkermansia muciniphila. Have you heard of that?

Lisa Jones: No, but say that fast five times. No, I'm just kidding. Don't do that.

Stephanie Devine: I'm happy I said it correctly the first time. But what they found is that higher levels of this bacteria may help improve glucose, reduce obesity risk, improve immune response, improve lipids. So it's really getting a lot of attention.

So they've tried to come up the supplement, from the research I looked at, they're right now, we don't know if just supplementing with this particular bacteria is helpful. But what we do know is that certain foods help your body to produce the bacteria. So that's really encouraging. So for example, foods containing ellagic acid, tannins and catechins can help to increase your levels of akkermansia muciniphila. And this would be found in most berries, grapes, apples, walnuts, pecans. Just in general, we know that eating more of a whole foods plant-based side really helps our nutritional status. So these all kind of fall in the lines of that as well.

Lisa Jones: Yes. And what you just proved is it's hard to be a dietician that specializes in more than one particular area because just the immense research in GI alone. And it would be hard to be like, "Oh, I'm also a cardiovascular specialist." No, just stick to one area.

Stephanie Devine: It is. Even that I feel like I don't know as much and then I start talking. So, right, there's so much information out there. So really to try to specialize is great.

I did learn about this at the FNCE in Orlando that they have a wipe-based stool collection kit for microbiome profiling. So I don't know if you ever had to do a stool collection, it's not fun. So this you basically wipe and they use the wipe to collect. So I thought that was really, really interesting.

Lisa Jones: Yeah, advances in technology, right? Definitely, yeah. Thank you for sharing that.

Stephanie Devine: Sure, sure. A few other things. I was thinking of too that there's an app called Nerva. Are you familiar with that app?

Lisa Jones: No. How's it spelled?

Stephanie Devine: N-E-R-V-A.

Lisa Jones: Okay.

Stephanie Devine: And what this app is, it's for gut-directed hypnotherapy. So this I learned about as well with the Monash course, but what they found is that about two-thirds, so just as much relief from the low FODMAP diet people found by receiving gut hypnotherapy. Whether it be, there are actually psychiatrists and psychologists that are trained in gut hypnotherapy, but there's also the app, the Nerva app. And the app is, I think a couple years old. It is expensive if you look at prices of apps, because most apps are a few dollars. But if you think about the benefits you would be getting from the app, and I think it's a six week program where they do the hypnotherapy. They've had really some great success with the use of this app. So I do recommend that sometimes to my clients.

Lisa Jones: Wow, that's fascinating. So then the app, would you use the app in tandem with the diet or you don't even have to do the diet, you could just use the app?

Stephanie Devine: You could. I usually like to start with one piece first. So we'll start with the diet and then I'd like to know, because you want to find out, even supplement wise, I don't usually like to start with supplements because as you know, if you change more than one thing at one time, we don't know which is, right. If there's a benefit, which one was helping. Or if somebody that can't do the diet, let's say somebody with the history of eating disorders, that they're really fragile. So that may be somebody that focuses more on maybe the gut hypnotherapy, because we don't want to look at making too many restrictions, setting anything off in someone with a history of eating disorders.

Lisa Jones: Yeah, it's so true. Be cognizant of all that. Oh, that's so fascinating.

Stephanie Devine: Speaking of, I was going to add this little tidbit too, is I would say approximately 50% of my clients have anxiety or high stress in their life. So that really can impact any of their digestive symptoms.

Lisa Jones: Oh, definitely. Definitely a connection there.

Stephanie Devine: Yeah, big connection. I had a client years ago and he was saying that he had to be really careful of what he ate and he said he would go on vacation, he could eat everything. Nothing bothered him. So it's amazing how big stress can impact that.

Lisa Jones: Oh wow. And then he comes back and then everything bothered him.

Stephanie Devine: Yes. So the more of the story is stay on vacation all the time.

Lisa Jones: So you don't need to work, just stay on vacation. You don't need to hire a dietician, just go on vacation. No, I'm just kidding.

Stephanie Devine: Just go on vacation. But my dietician said I have to be on vacation all the time. My doctor said that.

Lisa Jones: Oh wow. Any other new interventions that you've heard of?

Stephanie Devine: Not really. I mean the only thing is they're coming out with, may have seen some of these at the expo in Orlando, but there are a lot of fermented foods. They're adding prebiotics and probiotics to some of the spritzer drinks. So you're finding a lot more of the prebiotics and probiotics and some of the food sources. So that's kind of on the newer end.

Lisa Jones: Yes. I'm sure you took some. I have still one sample I have to try. It's like a little packet you add to your water. I haven't tried it yet, but thought it was interesting.

Stephanie Devine: Yeah, definitely. A supplement that I really like to use is Atrantil. Have you heard of that one?

Lisa Jones: No. How that one spelled? I'm writing these down cause I'm learning so much from you.

Stephanie Devine: Sure. It's A-T-R-A-N-T-I-L. And it helps with the digestive symptoms, whether it be bloating, gas, abdominal pain, constipation, diarrhea. And a lot of times what I'll have people do is once they've gone through the low FODMAP diet and they've determined, let's say garlic and onions are in the fructan category, and they're usually one of the biggest offenders and they're really hard to maneuver, especially when you're in a social setting or you're going out, it's really hard to avoid those two. So I like to use the Atrantil like, okay, I'm going out and I can't control as much of what I'm eating. Then that supplement can be very helpful. And ingredients are peppermint, horse chestnut, and just some polyphenol. So it's pretty simple.

Lisa Jones: All right, I'll check that out. Sounds like anybody can use that even if you don't have a specific issue, right?

Stephanie Devine: Correct. Yes.

Lisa Jones: Right. Thanks for that tip.

Stephanie Devine: You're welcome.

Lisa Jones: All right. Would you share with us one story showcasing your work or an example of a client? I know you did one earlier, but if there's another one you want to share at this time.

Stephanie Devine: Sure, sure. So I had a client who was in her late fifties, and she had come to me for in inconsistent fecal incontinence and urgency while running. So she was a pacer with races. And so she was in these running groups and she was really struggling for about a year, not being able to run more than two miles without having to find the bathroom. So it was really impacting her life. Her quality of life was really minimal. She was nervous about eating anything because she really wanted to run and be able to still be a pacer. But it was a big struggle. So they did the test, colonoscopy, endoscopy, everything was pretty much normal.

And so when she first came to me, she was just basically eating an anti-inflammatory diet. Mainly whole foods a pretty clean diet. She was eating a large amount of fruits and vegetables. So what I decided to do, instead of going to the full low FODMAP diet, based on her, like you said, based on her diet history, I looked at what she was consuming. It looked like she was having a high intake of polyols, sorbitol, and mannitol. She was having high amounts of excess fructose with the higher amounts of fruits she was taking. And then her fructan intake was high as well.

And I talked to her potentially about looking into pelvic floor physical therapy to see if she had any issues with her pelvic floor. So she started with just reducing her intake of those three categories, the polyols, the excess fucose, and the fructans. And she followed up three weeks later and she wanted to buy me flowers. She was just so happy. I'm going to almost cry now cause I get so excited for my clients that she's like, "I can live again." And it's really why I do what I do.

And I decided to specialize in GI, and this was one of the reasons, not just her, but examples like her that I had worked somewhere and they were doing these full-day physicals and they would have a 15-page medical history and one full page was asking about gastrointestinal symptoms.

And people write no to everything. No diarrhea. They were all no. So as a dietician, you look at their medical history, you look at their labs, you do the assessment, you kind of plan, okay, this is what we'll talk about. So I sit down and I'm thinking, okay, well their cholesterol's high, I saw that on their labs, so I don't digest if they have no issues. And then I start talking and you're like, Well, I don't eat this food because it causes diarrhea. I don't eat this food because it causes... And they were so, they thought it was normal just to have all gas and diarrhea. And they thought it was normal to have to restrict so many foods and to live like that. And my phrase is, it's common, but it's not normal. You shouldn't have these symptoms on a regular basis. That's not normal.

Lisa Jones: That is the best story. And congratulations on that success because you're just proving the importance of registered dieticians in general because the fact that they're suffering from that for so long, that GI issue, and then all of a sudden you work with them and literally in three weeks, it's such a short time from the years that they've probably been suffering with this issue and that you turn and then they're ready to give you flowers. So well done round of applause.

Stephanie Devine: Actually, one of my colleagues who doesn't specialize, she does general nutrition. She referred her to me, she wanted to buy her flowers.

Lisa Jones: Wow.

Stephanie Devine: She was so happy. It's a great feeling to know that you're able to help someone.

Lisa Jones: Yeah, thank you for sharing. That was a really good one.

Stephanie Devine: You're welcome.

Lisa Jones: How about, what would you say, if you just had one bottom line takeaway to tell our audience about this particular area, what would you say for them to do? What should they do or what should they be aware of?

Stephanie Devine: Don't just focus on diet. Think about other factors. Stress, sleep is the major factor in our gut health. So chronic high stress, not sleeping well, those can have an impact. So whether it be if you're trying to help someone or just yourself, we have to really realize how much of an impact they have on not just your overall health, but our gut health as well.

Lisa Jones: Well, thank you. Thank you for sharing all your wisdom with us. And I want to just ask a couple of quick fun questions. And since Halloween is coming up, I want to know what is your favorite Halloween candy?

Stephanie Devine: My favorite Halloween candy is probably a Reese's Peanut Butter Cup. And it's low FODMAP, too.

Lisa Jones: So there you go. So you're being a good role model to your clients. And how would you describe a healthy Halloween?

Stephanie Devine: Well, you could have some pumpkin soup.

Lisa Jones: There you go. Yeah, well, I guess with the soup, we can probably have a salad with it or something. And then some candy as the dessert.

Stephanie Devine: Yeah, there you go.

Lisa Jones: Yeah, we planned our meal. All right. How about in all of the costumes or years that you had a costume, what was your favorite costume and why?

Stephanie Devine: Oh, this one's easy. I have a husband and two daughters. So my daughters now are 14 and 12, but I missed the days where I could pick out their Halloween costumes, I admit. So when they were younger, we would do a family theme. My costume, I was the map from Dora the Explorer, so I made it. That was when I had time because they didn't have 50 activities every evening. So I made the map. And then my oldest daughter was Boots, the monkey, so I got a onesie and made her little Boots costume. My youngest one looked a little bit like Dora, but we did buy a Dora costume. And then my husband was Diego, the Explorer. So that was my favorite.

Lisa Jones: Nice.

Stephanie Devine: What about yours?

Lisa Jones: I like that your husband participated. Mine just kind of dresses up as himself.

Stephanie Devine: Is that scary?

Lisa Jones: Yeah. So it can be scary. And then my daughter this year is going to be in unicorn, but I have to figure out how, she wants it to light up, so I have to figure out how to put the lights on it and make it light up.

Stephanie Devine: Oh, that's fun. How old is she?

Lisa Jones: She's four. So that'll be fun. Well, thank you so much for being on the show today and sharing your insights with us, Stephanie.

Stephanie Devine: Oh, well thank you so much for having me. This was fun.

Lisa Jones: And then to our audience, thanks for listening and please tune in again and share your comments and feedback on our site. Have a great day, and enjoy a healthier lifestyle with a 411 in mind.

Moderator: For more nutrition content, visit consultant360.com