Jump to content
  • Welcome to Celiac.com!

    You have found your celiac tribe! Join us and ask questions in our forum, share your story, and connect with others.


  • Celiac.com Sponsor (A1):
    Celiac.com Sponsor (A1-M):
  • Get Celiac.com Updates:
    Support Our Content
    eNewsletter
    Donate

Biopsy Results Inconclusive; Early Celiac, Sibo, Something Else?


NotMollyRingwald

Recommended Posts

NotMollyRingwald Apprentice

Just got the word from my GI – the biopsy results are inconclusive. <_< I don’t have a copy of the report yet, but my doc explained there was a small amount of damage to my villi.  However, it was not full villus atrophy as would be expected from a full blown Celiac.   He believes the damage could be from “early Celiac disease” or it could be the result of a severe gastrointestinal virus (I had a nasty stomach bug last Christmas).   Given my significant positive improvement on a gluten-free diet, he leans towards the early Celiac theory, but doesn’t want to official diagnose that at this point as my blood work (tTg IgA) was negative (8 with 1-10 being normal).   He doesn’t want to exclude Celiac at this point either, as I was 6 weeks gluten-free at the time of the blood work and it’s possible my tTg would have been higher before going gluten-free.   ARRRRRRGH.   Anyone have a time machine that I could use to go back to February and see a doctor BEFORE going gluten-free?? :P *Sigh*

 

So, we also discussed options.  1) take the gene test and hope it is negative (so we could positively rule out Celiac),  2) treat as Celiac/NCGI and go along my merry way on the gluten-free diet (complete with a referral to the hospital dietician), 3) go back to eating gluten for EIGHT MORE WEEKS and run a full panel of bloodwork again in August.

 

So here’s the thing.  If I have Celiac, I want my son to be tested.  When it comes down to it, the diagnosis/ruling out of Celiac is only important to me for that reason.  I already know gluten is poison to my system…the gluten challenge proved that beyond a doubt.  I can’t go through another 2 weeks (much less *8* weeks) of gluten hell.  I just can’t do it.  :wacko:   So, I opted for #1 & #2.  Hopefully, the gene test is negative & Celiac is ruled out.  If it’s positive, well, I guess I cross that bridge when/if I come to it.  (Sidenote: if this is what “early” Celiac is like, I cannot imagine the misery so many of you endured when eating gluten!!!)

So, long story even longer, I’m wondering about the possibility of the villi damage being done by a stomach virus/SIBO/lingering stomach virus.  The GI originally planned to take a sample to test for SIBO during the EGD, but wasn't able to (the only tube they had for the procedure is made of latex, I'm allergic).  He mentioned a breath test as an alternative, but doesn't feel like that is a strong option at this point.  Thoughts?  Any insight?

 

Once again, I am so appreciative of you all - the opinion of those who have been- there-done-that- and-should-have-a-medical-degree-from-the-experience is HIGHLY valued by this girl!!

 

 


Celiac.com Sponsor (A8):
Celiac.com Sponsor (A8):



Celiac.com Sponsor (A8-M):



Celiac Mindwarp Community Regular

Hi Amy

How frustrating for you. It sounds to me like you have the right approach, gluten-free plus gene test.

I did this, but managed to sneak a celiac blood test for my son before I got my negative gene test. His results were negative.

I am now gluten-free, and keeping a close eye on my son. Maybe you could persuade the doctors to test him, then try him gluten-free if you have any specific concerns right now.

In good news, now you have decided to go gluten-free, you can start your recovery.

Looks like welcome to the NCGI club (though I suspect that in a few years the tests will catch up with the spectrum nature of the condition that specialists are starting to describe, and that 'early celiac' will make a whole lot more sense).

GottaSki Mentor

So frustrating....

 

First -- not having the two genes generally tested for can NOT rule out Celiac Disease -- although my guess is you are carrying them.

 

Second -- request a written or electronic copy of both the procedural report AND the pathology report and let us chime in if you feel comfortable to do so.

 

Third -- the most important factor is your improvement gluten-free :)

 

Hang in there!

1desperateladysaved Proficient

Hi Amy,

 

Other reasons for villi problems are possible.  One of my sons had Giarrdia which damage the villi.  This is a parasite.

 

Still with your improvement gluten free;  you probably conclude that gluten free is the way for you to go.

 

Diana

IrishHeart Veteran

I think you have celiac--they can call it "early" if they want, but does that equate to "early stages of pregnancy"? It's still  a done deal. I can link you to what celaic experts say about "early celiac" if you want.

 

You do not want to know what "late stage celiac" is. It is dead woman walking ugly.

 

I want to know what the MARSH scale says?? (ask him to tell you this)

Like SKI says...get the PATH report.

 

While other conditions may cause villous atrophy, your improvement on the gluten-free diet is the key!!.

If it were something else,  you would not  feel better off gluten because the underlying condition would still be present. See what I mean?

 

I know,  I am not a doctor ....but when it quacks like a duck and walks like a duck, it's a flippin duck.

 

I suggest have the doc order the gene test. And why can't he run the SIBO test???

 

You know you are not eating gluten ever again (that is a given) and whatever you do from here regarding your son, is entirely up to you

and who gives a flying fig if you call yourself NCGI or celiac. Gluten is poison to you. 

 

IMHO as always. I admire you for sticking it out on the gluten challenge. You're a trooper, honey!!

Deaminated Marcus Apprentice

Hi Amy

 

Here is a link to other causes of villi damage:

 

Open Original Shared Link

 

 

If you are still eating gluten or want to continue eating gluten for a few more weeks, you could do the DGP-IgG.

 

I think you should test your son as well if he's eating gluten with the same  DGP-IgG test.

IrishHeart Veteran

Hi Amy

 

Here is a link to other causes of villi damage:

 

Open Original Shared Link

 

 

If you are still eating gluten or want to continue eating gluten for a few more weeks, you could do the DGP-IgG.

 

I think you should test your son as well if he's eating gluten with the same  DGP-IgG test.

 

 

She said she is done eating gluten and feels better and does not want to continue. She had a horrible time with the gluten challenge.

 

  I can’t go through another 2 weeks (much less *8* weeks) of gluten hell.  I just can’t do it.  


Celiac.com Sponsor (A8):
Celiac.com Sponsor (A8):



Celiac.com Sponsor (A8-M):



NotMollyRingwald Apprentice

I am now gluten-free, and keeping a close eye on my son. Maybe you could persuade the doctors to test him, then try him gluten-free if you have any specific concerns right now.

In good news, now you have decided to go gluten-free, you can start your recovery.

 

I have considered asking his Ped to test him, regardless.  He doesn't have classic Celiac symptoms, (nor do I) but does have there are a few things (e.g. frequent bouts of constipation, bloated stomach, sleep disturbances).  I think the biggest hurdle here is my husband "it's just normal kids stuff." UGH. 

 

And you are absolutely right, getting back to gluten free has already improvement in my symptoms (headache gone, tad more energy, fog lifting).  I am so excited to see what life will be like fully recovered!  :)

 

So frustrating....

 

First -- not having the two genes generally tested for can NOT rule out Celiac Disease -- although my guess is you are carrying them.

 

Second -- request a written or electronic copy of both the procedural report AND the pathology report and let us chime in if you feel comfortable to do so.

 

Third -- the most important factor is your improvement gluten-free :)

Hang in there!

1st - :blink:  Well that's disappointing. Should I check with him on certain genes before I go get my blood drawn?

2nd - Will do. Absolutely.

3rd - You are 100% correct.   B)  

 

Hi Amy,

 

Other reasons for villi problems are possible.  One of my sons had Giarrdia which damage the villi.  This is a parasite.

 

Still with your improvement gluten free;  you probably conclude that gluten free is the way for you to go.

 

Diana

Diana - Parasite?! Yikes.  If you don't mind my asking, what symptoms did your son have?  

 

Regardless, gluten free *is* the way to go, no dobut...but the thought just occurred to me that there could be more than one thing going on.   :o

 

I think you have celiac--they can call it "early" if they want, but does that equate to "early stages of pregnancy"? It's still  a done deal. I can link you to what celaic experts say about "early celiac" if you want.

 

You do not want to know what "late stage celiac" is. It is dead woman walking ugly.

 

I want to know what the MARSH scale says?? (ask him to tell you this)

Like SKI says...get the PATH report.

 

While other conditions may cause villous atrophy, your improvement on the gluten-free diet is the key!!.

If it were something else,  you would not  feel better off gluten because the underlying condition would still be present. See what I mean?

 

I know,  I am not a doctor ....but when it quacks like a duck and walks like a duck, it's a flippin duck.

 

I suggest have the doc order the gene test. And why can't he run the SIBO test???

 

You know you are not eating gluten ever again (that is a given) and whatever you do from here regarding your son, is entirely up to you

and who gives a flying fig if you call yourself NCGI or celiac. Gluten is poison to you. 

 

IMHO as always. I admire you for sticking it out on the gluten challenge. You're a trooper, honey!!

 

All very good points and input, Irish, thanks.  I will ask him about the MARSH scale next time we talk!  LOL at the duck comment!  I don't think I asked him specifically (errrrrrr...memory fail) to explain his reasoning for forgoing the breath test, but I got the impression he doesn't think SIBO is my issue. I think if I called and told him I want to do it anyway, he'd order...think I should do that?

1desperateladysaved Proficient

 

Diana - Parasite?! Yikes.  If you don't mind my asking, what symptoms did your son have?  

 

Failure to grow (off the chart in weight and height)  at 9 years.

Chronic infection in ear.  (This may have lowered resistance rather than been due to the parasite)

Ferocious appetite!

Diarrhea would be a symptom, but he didn't have it..

 

He ended up needing two rounds of antibiotics then a course of herbal anti-parasite, Then an anti-fungal along with probiotics to combat a yeast infection realized in the treatment. 

 

He didn't start growing until he also had a round of glutamine and began to use digestive enzymes.  Now, he is growing rapidly!  Two and 1/2 inches in 3 months at last count.

 

Giarrdia are found in some US water supplies.  Thankfully, the rest of the family didn't get it.

 

Diana

 

 

GottaSki Mentor

 

 

1st - :blink:  Well that's disappointing. Should I check with him on certain genes before I go get my blood drawn?

2nd - Will do. Absolutely.

3rd - You are 100% correct.   B)  

 

 

Was set to come back and answer...then saw a similar thread that you might want to read....

 

https://www.celiac.com/forums/topic/102004-opt-for-genetic-test/?p=870894

 

ps...thanks ravenwoodglass :)

gatita Enthusiast

Was set to come back and answer...then saw a similar thread that you might want to read....

 

https://www.celiac.com/forums/topic/102004-opt-for-genetic-test/?p=870894

 

ps...thanks ravenwoodglass :)

 

 

Yup, this is true.

 

After all, "they" say the DQ2 and DQ8 are found in around 97 percent of celiacs. So what genes do the other three percent have? And there are two reputable studies linking DQ9 (which I have) to celiac.

 

So while doctors like to say a negative gene test is definitive, it ain't.

NotMollyRingwald Apprentice

Yup, this is true.

After all, "they" say the DQ2 and DQ8 are found in around 97 percent of celiacs. So what genes do the other three percent have? And there are two reputable studies linking DQ9 (which I have) to celiac.

So while doctors like to say a negative gene test is definitive, it ain't.

Ugh. This kinda makes me want to bang my head against a hard object. LOL

If they cant rule out Celiac and the SIBO tests are only 60% accurate and no reliable testing exists for other intolerances (e.g. Lactose), the only real viable option to determine what the heck is wrong with me is __________? Elimination diet? Give gluten-free/DF a shot and reassess after 3 mo? Rubber room with a special white jacket??

foam Apprentice

If your Doctor will run you through a diagnostic course of Rifiamixin or even metronidazole you'll soon find out if it's sibo or even a small parasite. I'd take the gene test if I was you anyway. Chances are it'll be positive, if gluten makes you very sick it basically has to be positive. Those two things will help you understand what is going on if nothing else. I have a son due within weeks and I'm just not going to give him any gluten until I see proof he hasn't inherited DQ2 from me.

 

I had a burning gut for years, most my other gut problems went away off gluten but the ever present burn never did. I did 6 days of metronidazole a couple of months ago and have had no burning since

Celiac Mindwarp Community Regular

Not sure I agree that it has to be positive if gluten makes you sick. I got a negative and gluten ain't my friend :(

I found an elimination diet incredibly useful, along with a food diary.

I had terrible problems with sugar, including fruit, and thought I might have SIBO, but I can now handle a bit of fruit every day. It is 5 months since I started my elimination. I feel better than I have for 20 years, and have a long list of intolerances. I reckon some will come back in time.

Mw x

IrishHeart Veteran

Not sure I agree that it has to be positive if gluten makes you sick. I got a negative and gluten ain't my friend :(

I found an elimination diet incredibly useful, along with a food diary.

I had terrible problems with sugar, including fruit, and thought I might have SIBO, but I can now handle a bit of fruit every day. It is 5 months since I started my elimination. I feel better than I have for 20 years, and have a long list of intolerances. I reckon some will come back in time.

Mw x

 

 

EXACTLY!!!!  well said, MW.

 

Gene tests are not the" be all, end all" They are not "diagnostic" of celiac either. Many people have the genes, but never trigger with celiac.

 

In the end, you are the only one who can determine what's best. If gluten makes you sick,well......... DO NOT EAT IT.

 

Eggs make me sick (not baked  IN things, just eggs baked, fried, or boiled) so I do not eat them. 

Soy makes me sick, so I do not eat any soy.

 

No one needs "permission" to go gluten-free.  :)

NotMollyRingwald Apprentice

No one needs "permission" to go gluten-free. :)

Thank the good Lord for that! :D

NotMollyRingwald Apprentice

If your Doctor will run you through a diagnostic course of Rifiamixin or even metronidazole you'll soon find out if it's sibo or even a small parasite. I'd take the gene test if I was you anyway. Chances are it'll be positive, if gluten makes you very sick it basically has to be positive. Those two things will help you understand what is going on if nothing else. I have a son due within weeks and I'm just not going to give him any gluten until I see proof he hasn't inherited DQ2 from me.

I had a burning gut for years, most my other gut problems went away off gluten but the ever present burn never did. I did 6 days of metronidazole a couple of months ago and have had no burning since

Will def keep this in mind! Admittedly, I wouldn't opt to try antibiotics w/o reasonable suspicion of SIBO (am allergic to several and they make me nervous), but if it needs doing, it needs doing! :)

taynichaf Contributor

How long were you gluten free prior to the challenge? How long was your challenge? Maybe it was too short, so that's why your results were inconclusive.

NotMollyRingwald Apprentice

How long were you gluten free prior to the challenge? How long was your challenge? Maybe it was too short, so that's why your results were inconclusive.

I was gluten-free 6 weeks before the blood work, and 8 weeks total before the challenge started. I suppose it's possible that my 4 weeks back on gluten weren't long enough to redo the damage undone by 8 weeks of healing, especially since I was "gluten light" prior to going gluten free for about a year...so many "ifs" and "buts" and "maybes" in my situation. One thing is for sure, that challenge was 4 weeks of hell, and, at this moment, I have no doubt that Celiac or NCGI is to blame. Luckily, I don't *need* a diagnosis for school/work/etc at this point. And I did decide to talk to my son's pediatrician at his next well check. Hopefully she is willing to run the Celiac panel if only for my piece of mind. :)

taynichaf Contributor

I was gluten-free 6 weeks before the blood work, and 8 weeks total before the challenge started. I suppose it's possible that my 4 weeks back on gluten weren't long enough to redo the damage undone by 8 weeks of healing, especially since I was "gluten light" prior to going gluten free for about a year...so many "ifs" and "buts" and "maybes" in my situation. One thing is for sure, that challenge was 4 weeks of hell, and, at this moment, I have no doubt that Celiac or NCGI is to blame. Luckily, I don't *need* a diagnosis for school/work/etc at this point. And I did decide to talk to my son's pediatrician at his next well check. Hopefully she is willing to run the Celiac panel if only for my piece of mind. :)

As long as your happier gluten free! :)

 

Ohh.. She better run the tests! I would be so angry if she didn't!

Archived

This topic is now archived and is closed to further replies.

  • Get Celiac.com Updates:
    Support Celiac.com:
    Join eNewsletter
    Donate

  • Celiac.com Sponsor (A17):
    Celiac.com Sponsor (A17):





    Celiac.com Sponsors (A17-M):




  • Recent Activity

    1. - Wheatwacked replied to Scott Adams's topic in Post Diagnosis, Recovery & Treatment of Celiac Disease
      50

      Supplements for those Diagnosed with Celiac Disease

    2. - knitty kitty replied to catnapt's topic in Celiac Disease Pre-Diagnosis, Testing & Symptoms
      3

      results from 13 day gluten challenge - does this mean I can't have celiac?

    3. - knitty kitty replied to Scott Adams's topic in Post Diagnosis, Recovery & Treatment of Celiac Disease
      50

      Supplements for those Diagnosed with Celiac Disease

    4. - Florence Lillian replied to Jane02's topic in Gluten-Free Foods, Products, Shopping & Medications
      11

      Desperately need a vitamin D supplement. I've reacted to most brands I've tried.

    5. - catnapt replied to catnapt's topic in Celiac Disease Pre-Diagnosis, Testing & Symptoms
      3

      results from 13 day gluten challenge - does this mean I can't have celiac?

  • Celiac.com Sponsor (A19):
  • Member Statistics

    • Total Members
      133,355
    • Most Online (within 30 mins)
      7,748

    Amy Immerman
    Newest Member
    Amy Immerman
    Joined
  • Celiac.com Sponsor (A20):
  • Celiac.com Sponsor (A22):
  • Forum Statistics

    • Total Topics
      121.6k
    • Total Posts
      1m
  • Celiac.com Sponsor (A21):
  • Who's Online (See full list)

    • There are no registered users currently online
  • Upcoming Events

  • Posts

    • Wheatwacked
      Raising you vitamin D will increase absorption of calcium automatically without supplementation of calcium.  A high PTH can be caused by low D causing poor calcium absorption; not insuffient calcium intake.  With low D your body is not absorbing calcium from your food so it steals it from your bones.  Heart has priority over bone. I've been taking 10,000 IU D3 a day since 2015.  My doctor says to continue. To fix my lactose intolerance, lots of lactobacillus from yogurts, and brine fermented pickles and saurkraut and olives.  We lose much of our ability to make lactase endogenosly with maturity but a healthy colony of lactobacillus in our gut excretes lactase in exchange for room and board. The milk protein in grass fed milk does not bother me. It tastes like the milk I grew up on.  If I drink commercial milk I get heartburn at night. Some experts estimate that 90% of us do not eat Adequite Intake of choline.  Beef and eggs are the principle source. Iodine deficiency is a growing concern.  I take 600 mcg a day of Liquid Iodine.  It and NAC have accelerated my healing all over.  Virtually blind in my right eye after starting antihypertensive medication and vision is slowly coming back.  I had to cut out starches because they drove my glucose up into the 200+ range.  I replaced them with Red Bull for the glucose intake with the vitamins, minerals and Taurine needed to process through the mitochodria Krebs Cycle to create ATP.  Went from A1c 13 down to 7.9.  Work in progress. Also take B1,B2,B3,B5,B6. Liquid Iodine, Phosphatidyl Choline, Q10, Selenium, D and DHEA.     Choline supplemented as phosphatidylcholine decreases fasting and postmethionine-loading plasma homocysteine concentrations in healthy men +    
    • knitty kitty
      @catnapt, Wheat germ has very little gluten in it.  Gluten is  the carbohydrate storage protein, what the flour is made from, the fluffy part.  Just like with beans, there's the baby plant that will germinate  ("germ"-inate) if sprouted, and the bean part is the carbohydrate storage protein.   Wheat germ is the baby plant inside a kernel of wheat, and bran is the protective covering of the kernel.   Little to no gluten there.   Large amounts of lectins are in wheat germ and can cause digestive upsets, but not enough Gluten to provoke antibody production in the small intestines. Luckily you still have time to do a proper gluten challenge (10 grams of gluten per day for a minimum of two weeks) before your next appointment when you can be retested.    
    • knitty kitty
      Hello, @asaT, I'm curious to know whether you are taking other B vitamins like Thiamine B1 and Niacin B3.  Malabsorption in Celiac disease affects all the water soluble B vitamins and Vitamin C.  Thiamine and Niacin are required to produce energy for all the homocysteine lowering reactions provided by Folate, Cobalamine and Pyridoxine.   Weight gain with a voracious appetite is something I experienced while malnourished.  It's symptomatic of Thiamine B1 deficiency.   Conversely, some people with thiamine deficiency lose their appetite altogether, and suffer from anorexia.  At different periods on my lifelong journey, I suffered this, too.   When the body doesn't have sufficient thiamine to turn food, especially carbohydrates, into energy (for growth and repair), the body rations what little thiamine it has available, and turns the carbs into fat, and stores it mostly in the abdomen.  Consuming a high carbohydrate diet requires additional thiamine to process the carbs into energy.  Simple carbohydrates (sugar, white rice, etc.) don't contain thiamine, so the body easily depletes its stores of Thiamine processing the carbs into fat.  The digestive system communicates with the brain to keep eating in order to consume more thiamine and other nutrients it's not absorbing.   One can have a subclinical thiamine insufficiency for years.  A twenty percent increase in dietary thiamine causes an eighty percent increase in brain function, so the symptoms can wax and wane mysteriously.  Symptoms of Thiamine insufficiency include stunted growth, chronic fatigue, and Gastrointestinal Beriberi (diarrhea, abdominal pain), heart attack, Alzheimer's, stroke, and cancer.   Thiamine improves bone turnover.  Thiamine insufficiency can also affect the thyroid.  The thyroid is important in bone metabolism.  The thyroid also influences hormones, like estrogen and progesterone, and menopause.  Vitamin D, at optimal levels, can act as a hormone and can influence the thyroid, as well as being important to bone health, and regulating the immune system.  Vitamin A is important to bone health, too, and is necessary for intestinal health, as well.   I don't do dairy because I react to Casein, the protein in dairy that resembles gluten and causes a reaction the same as if I'd been exposed to gluten, including high tTg IgA.  I found adding mineral water containing calcium and other minerals helpful in increasing my calcium intake.   Malabsorption of Celiac affects all the vitamins and minerals.  I do hope you'll talk to your doctor and dietician about supplementing all eight B vitamins and the four fat soluble vitamins because they all work together interconnectedly.  
    • Florence Lillian
      Hi Jane: You may want to try the D3 I now take. I have reactions to fillers and many additives. Sports Research, it is based in the USA and I have had no bad reactions with this brand. The D3 does have coconut oil but it is non GMO, it is Gluten free, Soy free, Soybean free and Safflower oil free.  I have a cupboard full of supplements that did not agree with me -  I just keep trying and have finally settled on Sports Research. I take NAKA Women's Multi full spectrum, and have not felt sick after taking 2 capsules per day -  it is a Canadian company. I buy both from Amazon. I wish you well in your searching, I know how discouraging it all is. Florence.  
    • catnapt
      highly unlikely  NOTHING and I mean NOTHING else has ever caused me these kinds of symptoms I have no problem with dates, they are a large part of my diet In fact, I eat a very high fiber, very high vegetable and bean diet and have for many years now. It's considered a whole foods plant based or plant forward diet (I do now eat some lean ground turkey but not much) I was off dairy for years but recently had to add back plain yogurt to meet calcium needs that I am not allowed to get from supplements (I have not had any problem with the yogurt)   I eat almost no processed foods. I don't eat out. almost everything I eat, I cook myself I am going to keep a food diary but to be honest, I already know that it's wheat products and also barley that are the problem, which is why I gradually stopped eating and buying them. When I was eating them, like back in early 2024, when I was in the middle of moving and ate out (always had bread or toast or rolls or a sub or pizza) I felt terrible but at that time was so busy and exhausted that I never stopped to think it was the food. Once I was in my new place, I continued to have bread from time to time and had such horrible joint pain that I was preparing for 2 total knee replacements as well as one hip! The surgery could not go forward as I was (and still am) actively losing calcium from my bones. That problem has yet to be properly diagnosed and treated   anyway over time I realized that I felt better when I stopped eating bread. Back at least 3 yrs ago I noticed that regular pasta made me sick so I switched to brown rice pasta and even though it costs a lot more, I really like it.   so gradually I just stopped buying and eating foods with gluten. I stopped getting raisin bran when I was constipated because it made me bloated and it didn't help the constipation any more (used to be a sure bet that it would in the past)   I made cookies and brownies using beans and rolled oats and dates and tahini and I LOVE them and have zero issues eating those I eat 1 or more cans of beans per day easily can eat a pound of broccoli - no problem! Brussels sprouts the same thing.   so yeh it's bread and related foods that are clearly the problem  there is zero doubt in my mind    
×
×
  • Create New...

Important Information

NOTICE: This site places This site places cookies on your device (Cookie settings). on your device. Continued use is acceptance of our Terms of Use, and Privacy Policy.