Motivators and Barriers to Cooking and Refrigerator Thermometer Use among Consumers and Food Workers: A Review.

Temperature control prevents the rapid growth of foodborne pathogens during food storage and assures adequate heating to destroy pathogens prior to consumption. The use of thermometers is a recognized best practice among consumer and food worker guidelines; however, compliance with this recommendation is quite low. Eighty-five studies from the past 21 years were reviewed and an analyzed for the knowledge, attitudes, and behaviors associated with thermometer use and the motivators and barriers to cooking and refrigerator thermometer use among consumers and food workers. Barriers to thermometer were categorized into two major groups: "the belief that a thermometer is not necessary" and "the difficulty of selecting and using a thermometer." Each group has its unique aspects. Four barriers were recognized in the "not necessary" group: (i) preference for alternative techniques, (ii) mainstream media and food professionals seldom serve as role models and often negate the need for food thermometers, (iii) limited awareness of potential health issues associated with current practices, and (iv) limited knowledge and awareness related to thermometer usage for specific food groups. Six barriers were recognized in the "difficult to select and use" group: (i) difficulties in selecting the type of food thermometers, (ii) availability of food thermometers, (iii) lack of skills related to the usage of food thermometers, (iv) limited knowledge related to endpoint temperatures, (v) inability to calibrate food thermometers, and (vi) lack of knowledge about food thermometer cleaning and sanitation. These findings will facilitate the development and adoption of effective strategies to increase thermometer use and increase food safety education efficacy with a positive impact on public health.

Parent and household influences on calcium intake among early adolescents.

BACKGROUND: Calcium intake during early adolescence falls short of requirements for maximum bone accretion. Parents and the home food environment potentially influence children's calcium intakes. This study aimed to quantify parental psychosocial factors (PSF) predicting calcium intakes of Asian, Hispanic, and non-Hispanic white (NHW) early adolescent children from a parental perspective. METHODS: This was a cross-sectional study involving the administration of a validated calcium-specific food frequency questionnaire to a convenience sample of children aged 10-13 years and the primary individual responsible for food acquisition in the child's household. Based on Social Cognitive Theory, parental factors potentially associated with children's calcium intake were also assessed via parent questionnaires. The total study sample consisted of 633 parent-child pairs (Asian = 110, Hispanic = 239, NHW = 284). Questionnaires were completed at community-based centers/sites. Outcome measures were the association between parent-child calcium (mg), milk (cups/day), and soda (cans/day) intakes and the predictive value of significant parental PSF towards calcium intakes of their children. Sex-adjusted linear regression and multivariate analyses were performed. RESULTS: Calcium intakes of parent-child pairs were positively associated among all ethnic groups (r = 0.296; P < 0.001). Soda intakes were positively associated among Hispanic parent-child pairs only (r = 0.343; P < 0.001). Home availability of calcium-rich foods (CRF), parental rules and expectations for their child's intake of beverages, and parents' calcium intake/role modeling were positively associated with children's calcium intake and overwhelmed all other PSF in multivariate analyses. Significant cultural differences were observed. Parental role modeling was a significant factor among Hispanic dyads only. Multivariate models explained 19-21% of the variance in children's calcium intakes. CONCLUSIONS: Nutrition interventions to improve children's calcium intakes should focus on parents and provide guidance on improving home availability of CRF and increasing rules and expectations for the consumption of CRF. Among Hispanic families, interventions promoting parental modeling of desired dietary behaviors may be most successful.

Evaluation of emotion-based messages designed to motivate Hispanic and Asian parents of early adolescents to engage in calcium-rich food and beverage parenting practices.

BACKGROUND/OBJECTIVES: Setting healthful beverage expectations, making calcium-rich foods and beverages (CRF/B) available, and role modeling are parenting practices promoting calcium intake among early adolescents. This study aimed to evaluate emotion-based messages designed to motivate parents of early adolescents to perform these practices. SUBJECTS/METHODS: Emotion-based messages were developed for each parenting practice and tested in 35 parents from 5 states. Findings were used to modify messages and develop a survey administered via Amazon MechanicalTurk to a convenience sample of Asian (n = 166) and Hispanic (n = 184) parents of children 10-13 years. Main outcome measures were message comprehension, motivation, relevance, acceptability, and novelty. Engagement in the parenting practices was also assessed. RESULTS: Message comprehension was acceptable for the majority of parents. Most also agreed that messages were motivational (setting healthful beverage expectations (69.0%), making CRF/B available (67.4%), and role modeling (80.0%)), relevant and acceptable. About 30-50% indicated they had not seen the information before. Many parents indicated they were already engaging in the practices (> 70%). No racial/ethnic differences were observed for responses to messages or engaging in parenting practices. CONCLUSIONS: Results indicate that emotion-based messages designed to motivate parents to engage in parenting practices that promote calcium intake among early adolescents were motivating, relevant, and acceptable.

Field testing a questionnaire assessing parental psychosocial factors related to consumption of calcium-rich foods by Hispanic, Asian, and Non-Hispanic white young adolescent children.

Intervention strategies to increase calcium intake of parents and young adolescent children could be improved by identifying psychosocial factors influencing intake. The objective was to develop a tool to assess factors related to calcium intake among parents and Hispanic, Asian, and non-Hispanic white young adolescent children (10-13 years) meeting acceptable standards for psychometric properties. A parent questionnaire was constructed from interviews conducted to identify factors. Parents (n = 166) in the United States completed the questionnaire, with seventy-one completing it twice. Two constructs (Attitudes/Preferences and Social/Environmental) were identified and described by eighteen subscales with Cronbach's alpha levels from .50 to .79. Test-retest coefficients ranged from .68 to .85 (p < .001). Several subscales were statistically significantly associated with parent characteristics consistent with theory and published literature. This tool shows promise as a valid and reliable measure of factors associated with calcium-rich food intake among parents and young adolescent children.

Dietary sources of calcium among parents and their early adolescent children in the United States by parent race/ethnicity and place of birth.

Dietary calcium sources may differ by race/ethnicity and dietary acculturation. A cross-sectional, convenience sample including 587 United States (US) Asian, Hispanic and non-Hispanic White parent-child (10-13 years) pairs completed a calcium food frequency questionnaire. Calcium sources were ranked by mean percent contribution to total adjusted calcium intake, and compared by ethnic group and parents' location of birth. Five foods (fluid milk, cheese, milk on cereal, yogurt, and lattes) represented 49% of total calcium intake for parents. The same foods (except lattes) represented 55% of total calcium for early adolescent children. Fluid milk provided the largest mean percentage of intake for all race/ethnic groups among parents and children. Several food sources of calcium were greater for foreign-born versus US-born Asian or Hispanic parents and children. Understanding calcium food sources and changes in dietary patterns that affect calcium intake among parents and children is important to better promote adequate intake.

Perceptions of how parents of early adolescents will personally benefit from calcium-rich food and beverage parenting practices.

OBJECTIVE: To identify and rank perceived personal benefits from parenting practices that promote intake of calcium-rich foods and beverages (CRF/B) by early adolescents. METHODS: A convenience sample of parents/caregivers (n = 133) of early adolescents (10-13 years) from 6 states (CA, HI, MN, OH, OR, UT) participated in a qualitative study using a Nominal Group Technique process. Benefits identified by parents/caregivers were ranked by importance, given a score weight, and summed to create a total weighted score across states. RESULTS: The top benefit from making CRF/B available was parent emotional rewards. The top benefit perceived by parents from role modeling intake of CRF/B and setting expectations for intake of CRB was child health promotion. CONCLUSIONS AND IMPLICATIONS: Child health promotion and parent emotional rewards were important perceived benefits derived from CRF/B parenting practices, and thus, should be included as the focus of education to increase the frequency of these practices.

Addressing mental health stigma among young adolescents: evaluation of a youth-led approach.

Stigma around mental illness puts adolescents at risk for not seeking help for themselves or helping peers dealing with mental distress. This program evaluation looks at a youth-led mental health awareness promotion campaign, in which high school students led educational workshops for at-risk middle school students in an after-school program. Pre- and posttests were used to measure knowledge about mental illness as well as social distance; a total of 57 pre- and posttests were analyzed. Analyses revealed statistically significant changes in both the Knowledge and Social Distance scales. The results suggest that salutary results can be realized as a result of very brief intervention with youths around the topic of mental health awareness.

Development and evaluation of a university campus-based food safety media campaign for young adults.

Food safety information campaigns are more likely to be most effective if the messages are tailored to the needs of a specific audience. Designing effective campaigns involves careful study of the target population and working with them using a community-based participatory research model. Thus, the development of the campaign materials for a university campus-based food safety media campaign for young adults followed intense efforts of working with the target audience to gather the baseline data needed to characterize this audience, to identify the most salient messages for college students, and to create materials and events that would resonate with them. This campaign was implemented and evaluated on eight university campuses in the United States. The results indicate that the campaign significantly increased self-ratings of food safety knowledge and skill, actual food safety knowledge, food safety self-efficacy, stage of change for safe food handling, and reported hand washing behaviors of a geographically and racially diverse group of college students. The positive study outcomes support the value of engaging in these research and development efforts and reflect the usefulness of the audience-specific materials and activities developed for the campaign. The findings also demonstrate the versatility and utility of the materials on different campuses. Developing health media campaigns specifically for unique populations is key to ensuring health messages reach the target audience and, even more importantly, appeal to them. The detailed overview of the development of a food safety media campaign aimed at young adults presented in this article illustrates how health professionals can work with their target population to develop a focused, effective health promotion campaign.

Parent calcium-rich-food practices/perceptions are associated with calcium intake among parents and their early adolescent children.

OBJECTIVE: The study aimed to (i) segment parents of early adolescents into subgroups according to their Ca-rich-food (CRF) practices and perceptions regarding early adolescent CRF intake and (ii) determine whether Ca intake of parents and early adolescents differed by subgroup. DESIGN: A cross-sectional convenience sample of 509 parents and their early adolescent children completed a questionnaire in 2006-2007 to assess parent CRF practices and perceptions and to estimate parent and child Ca intakes. SETTING: Self-administered questionnaires were completed in community settings or homes across nine US states. SUBJECTS: Parents self-reporting as Asian, Hispanic or non-Hispanic White with a child aged 10-13 years were recruited through youth or parent events. RESULTS: Three parent CRF practice/perception segments were identified, including 'Dedicated-Milk Providers/Drinkers' (49 %), 'Water Regulars' (30 %) and 'Sweet-Drink-Permissive Parents' (23 %). Dedicated-Milk Providers/Drinkers were somewhat older and more likely to be non-Hispanic White than other groups. Ca intakes from all food sources, milk/dairy foods and milk only, and milk intakes, were higher among early adolescent children of Dedicated-Milk Providers/Drinkers compared with early adolescents of parents in other segments. Soda pop intakes were highest for early adolescents with parents in the Water Regulars group than other groups. Dedicated-Milk Providers/Drinkers scored higher on culture/tradition, health benefits and ease of use/convenience subscales and lower on a dairy/milk intolerance subscale and were more likely to report eating family dinners daily than parents in the other groups. CONCLUSIONS: Parent education programmes should address CRF practices/perceptions tailored to parent group to improve Ca intake of early adolescent children.

Burger preparation: what consumers say and do in the home.

Ground beef has been linked to outbreaks of pathogenic bacteria like Escherichia coli O157:H7 and Salmonella. Consumers may be exposed to foodborne illness through unsafe preparation of ground beef. Video footage of 199 volunteers in Northern California preparing hamburgers and salad was analyzed for compliance with U.S. Department of Agriculture recommendations and for violations of the U.S. Food and Drug Administration's Food Code 2009. A questionnaire about consumer attitudes and knowledge about food safety was administered after each filming session. The majority of volunteers, 78%, cooked their ground beef patties to the Food Code 2009 recommended internal temperature of 155°F (ca. 68°C) or above, and 70% cooked to the U.S. Department of Agriculture consumer end-point guideline of 160°F (ca. 71°C), with 22% declaring the burger done when the temperature was below 155°F. Volunteers checked burger doneness with a meat thermometer in 4% of households. Only 13% knew the recommended internal temperature for ground beef. The average hand washing time observed was 8 s; only 7% of the hand washing events met the recommended guideline of 20 s. Potential cross-contamination was common, with an average of 43 events noted per household. Hands were the most commonly observed vehicle of potential cross-contamination. Analysis of food handling behaviors indicates that consumers with and without food safety training exposed themselves to potential foodborne illness even while under video observation. Behaviors that should be targeted by food safety educators are identified.

Individual and family correlates of calcium-rich food intake among parents of early adolescent children.

BACKGROUND: Most adults do not meet calcium intake recommendations. Little is known about how individual and family factors, including parenting practices that influence early adolescents' intake of calcium-rich foods, affect calcium intake of parents. This information could inform the development of effective nutrition education programs. OBJECTIVE: To identify individual and family factors associated with intake of calcium-rich foods among parents of early adolescents (aged 10 to 13 years). DESIGN: A cross-sectional survey was used with 14 scales to assess attitudes/preferences and parenting practices regarding calcium-rich foods and a calcium-specific food frequency questionnaire (2006-2007). PARTICIPANTS/SETTING: A convenience sample of self-reporting non-Hispanic white, Hispanic, and Asian (n=661) parents was recruited in nine states. Parents were the primary meal planner/preparer and completed questionnaires in homes or community settings. MAIN OUTCOME MEASURES: Predictors of calcium intake from three food groupings-all food sources, dairy foods, and milk. STATISTICAL ANALYSES PERFORMED: Multivariate regression analyses identified demographic, attitude/preference, and behavioral factors associated with calcium intake. RESULTS: Most respondents were women (∼90%) and 38% had a college degree. Education was positively associated with calcium intake from all three food groupings, whereas having an Asian spouse compared to a non-Hispanic white spouse was negatively associated with calcium intake only from all food sources and from dairy foods. Expectations for and encouragement of healthy beverage intake for early adolescents were positively associated with calcium intake from dairy foods and milk, respectively. Parental concern regarding adequacy of intake was negatively associated, whereas perception of health benefits from calcium-rich foods was positively associated with calcium intake from all food sources and from dairy foods. Between 20% and 32% of the variance in calcium intake from all food groupings was explained in these models. CONCLUSIONS: Individual factors and positive parenting practices may be important considerations for nutrition education programs targeted to parents.

Influence of race, acculturation, and socioeconomic status on tendency toward overweight in Asian-American and Mexican-American early adolescent females.

BACKGROUND: Health disparities in chronic disease prevalence exist in the United States among racial/ethnic groups. This study explores relationships between physical, socioeconomic, and cultural characteristics of a multi-ethnic sample of early adolescent females which may assist health educators in designing programs targeting these groups. METHODS: Mexican-American and Asian-American sixth grade females (n = 144) were enrolled in Adequate Calcium Today. Physical measurements included weight, height, and BMI. Dual energy X-ray absorptiometry determined percent body fat (%BF). Socioeconomic status was determined by enrollment in free or reduced meal program (FRMP). An adapted Acculturation Rating Scale for Mexican-Americans-II (ARSMA-II) measured acculturation. RESULTS: Mexican-Americans had greater height, BMI, %BF, and a greater tendency toward overweight (P < 0.01) than Asian-American. Asian-Americans were more acculturated than MA (P < 0.005), attributed to a lower ethnic orientation scale score. Within Asian-Americans, %BF was higher among FRMP participants than non-participants (P < 0.05). DISCUSSION: Income and acculturation may affect tendency toward chronic disease.

Development of a food allergy education resource for primary care physicians.

BACKGROUND: Food allergy is estimated to affect 3-4% of adults in the US, but there are limited educational resources for primary care physicians. The goal of this study was to develop and pilot a food allergy educational resource based upon a needs survey of non-allergist healthcare providers. METHODS: A survey was undertaken to identify educational needs and preferences for providers, with a focus on physicians caring for adults and teenagers, including emergency medicine providers. The results of the survey were used to develop a teaching program that was subsequently piloted on primary care and emergency medicine physicians. Knowledge base tests and satisfaction surveys were administered to determine the effectiveness of the educational program. RESULTS: Eighty-two physicians (response rate, 65%) completed the needs assessment survey. Areas of deficiency and educational needs identified included: identification of potentially life-threatening food allergies, food allergy diagnosis, and education of patients about treatment (food avoidance and epinephrine use). Small group, on-site training was the most requested mode of education. A slide set and narrative were developed to address the identified needs. Twenty-six separately enrolled participants were administered the teaching set. Pre-post knowledge base scores increased from a mean of 38% correct to 64% correct (p < 0.001). Ability to correctly demonstrate the use of epinephrine self injectors increased significantly. Nearly all participants (>95%) indicated that the teaching module increased their comfort with recognition and management of food allergy. CONCLUSION: Our pilot food allergy program, developed based upon needs assessments, showed strong participant satisfaction and educational value.

Strategies of Asian, Hispanic, and non-Hispanic white parents to influence young adolescents' intake of calcium-rich foods, 2004 and 2005.

INTRODUCTION: Optimal intake of dietary calcium is critical to prevent osteoporosis later in life, yet most young adolescents do not consume the recommended amount. We describe parental strategies that can influence young adolescents' calcium intake in Asian, Hispanic, and non-Hispanic white households METHODS: A qualitative research design employed semistructured individual interviews with a convenience sample of mostly female parents self-reported as Asian (n = 48), Hispanic (n = 44), or non-Hispanic white (n = 76) having a child aged 10 to 13 years at home. Interviews were conducted in homes or community centers in 12 states. Interview data were analyzed by using qualitative data analysis software and thematic content analysis procedures. RESULTS: Parents monitored calcium intake by making calcium-rich foods available, preparing calcium-rich foods, and setting expectations that children would consume calcium-rich foods. As mentors, parents encouraged intake of calcium-rich foods and advised children to moderate or increase intake of specific foods. Although parents perceived modeling of calcium intake as important, some were ambivalent about its effects. We noted minimal differences by racial/ethnic groups and sex of children in reported availability of selected calcium-rich foods at home, parental modeling of intake, and mentoring behaviors. CONCLUSION: Our findings suggest that interventions to help parents increase children's intake of calcium should focus on types of foods made available, giving age-appropriate encouragement and advice, and modeling proper intake.

Risky eating behaviors of young adults-implications for food safety education.

Young adults engage in risky eating behaviors like eating raw/undercooked foods of animal origin that put them at increased risk for foodborne disease. This cross-sectional survey assessed the self-reported risky eating behaviors of young adults enrolled in higher education as a part of a large-scale survey administered over 10 months. Participants (N=4,343) completed a risky eating questionnaire by indicating which of the foods listed they consumed (the list included a random sequence of foods that are considered safe or risky to eat). Each risky food consumed earned one point, with the risky eating score calculated by summing points earned (range 0 to 27). Higher scores indicated more risky eating behaviors. Food safety knowledge and self-efficacy and stage of change for safe food handling were also assessed. Mean risky eating score (5.1+/-3.6) indicated that young adults consumed risky foods. Male respondents and whites consumed more risky foods compared with female respondents and nonwhites, respectively. As stage of change (movement to higher stages) and self-efficacy increased, risky eating score decreased; those who believed food poisoning was a personal threat tended to eat fewer risky foods. Regression models indicated that the strongest predictor of risky eating was self-efficacy score followed by stage of change. These variables, together with sex and race, explained about 10% of the variance in risky eating score. Although food safety knowledge correlated weakly with risky eating score, it did not significantly predict it. Efforts to improve current food-handling behaviors and self-efficacy through education are important to reduce prevalence of risky eating behaviors within this population.

At-home and away-from-home eating patterns influencing preadolescents' intake of calcium-rich food as perceived by Asian, Hispanic and Non-Hispanic white parents.

OBJECTIVE: To explore at-home and away-from-home eating patterns influencing Asian, Hispanic, and non-Hispanic white preadolescents' intake of calcium-rich food from a parental perspective. DESIGN: Individual semistructured interviews. SETTING: Home or community site. PARTICIPANTS: Convenience sample (n = 201) of self-reported Asian (n = 54), Hispanic (n=57), and non-Hispanic white (n = 90) parents of 10- to 13-year-old children recruited from community youth programs. PHENOMENON OF INTEREST: Description of at-home and away-from-home family eating patterns. ANALYSIS: NVivo software to code and sort transcript segments, qualitative data analysis procedures. RESULTS: Participants from all groups shared common at-home and away-from-home meal patterns. A lack of time often resulted in negative factors that impacted intake of calcium-rich food and beverages including breakfast on the run, fewer home-prepared or shared family meals, and more frequent meals eaten away from home. Asian and Hispanic parents indicated eating out less frequently than non-Hispanic white parents. Parents from all groups lacked expectations for their child to drink calcium-rich beverages with meals. CONCLUSIONS AND IMPLICATIONS: Practical strategies are needed to facilitate intake of calcium-rich food and beverages through more frequent family meals at home and parental expectations for children's intake of calcium-rich beverages with meals.

Food safety self-reported behaviors and cognitions of young adults: results of a national study.

With limited opportunities to learn safe food handling via observation, many young adults lack the knowledge needed to keep them safe from foodborne disease. It is important to reach young adults with food safety education because of their current and future roles as caregivers. With a nationwide online survey, the demographic characteristics, self-reported food handling and consumption behaviors, food safety beliefs, locus of control, self-efficacy, stage of change, and knowledge of young adults with education beyond high school (n = 4,343) were assessed. Young adults (mean age, 19.92 +/- 1.67 SD) who participated were mainly female, white, never married, and freshmen or sophomores. Participants correctly answered 60% of the knowledge questions and were most knowledgeable about groups at greatest risk for foodborne disease and least knowledgeable about common food sources of foodborne disease pathogens. They reported less than optimal levels of safe food handling practices. Young adults generally had a limited intake of foods that increase the risk of foodborne disease, positive food safety beliefs, an internal food safety locus of control, and confidence in their ability to handle food safely, and they were contemplating an improvement in, or preparing to improve, their food handling practices. Females significantly outperformed males on nearly all study measures. Future food safety educational efforts should focus on increasing knowledge and propelling young adults into the action stage of safe food handling, especially males. Efforts to improve knowledge and, ultimately, food safety behaviors are essential to safeguard the health of these young adults and enable them to fulfill the role of protecting the health of their future families.

Development of a decision tree to determine appropriateness of NVivo in analyzing qualitative data sets.

A decision tree was developed to determine when NVivo is an appropriate tool for qualitative analysis. NVivo, a qualitative analysis software package, was used to analyze interviews of 204 Asian, Hispanic, and white parents in 12 states. The experience provided insight into issues that should be considered when deciding to use the software. NVivo can enhance the qualitative research process, quickly process queries, and expand analytical avenues. Before using, however, the following must be considered: training time, establishing inter-coder reliability, number and length of documents, coding time, coding structure, use of automated coding, and possible need for separate databases or additional supporting software.

Position of the American Dietetic Association: Agricultural and food biotechnology.

It is the position of the American Dietetic Association that agricultural and food biotechnology techniques can enhance the quality, safety, nutritional value, and variety of food available for human consumption and increase the efficiency of food production, food processing, food distribution, and environmental and waste management. The American Dietetic Association encourages the government, food manufacturers, food commodity groups, and qualified food and nutrition professionals to work together to inform consumers about this new technology and encourage the availability of these products in the marketplace.

Development of a food frequency questionnaire to estimate calcium intake of Asian, Hispanic, and white youth.

OBJECTIVE: To develop a food frequency questionnaire (FFQ) that estimates calcium intake of Asian, Hispanic, and white youth living in the western United States. DESIGN: A list of 80 foods was assembled to create an FFQ to measure calcium intake. Evaluation of the FFQ spanned four consecutive weeks. An FFQ was completed during Week 1 and Week 4, and a 24-hour dietary recall was completed during Week 2 and Week 3.Subjects/setting A convenience sample of 162 Asian, Hispanic, and white youth ages 10 to 18 years was selected. Statistical analyses performed Percent agreement, paired t tests, Pearson correlation coefficients of cube-root transformed values, and deattenuated Pearson correlation coefficients of cube-root transformed values were used to evaluate the FFQ. RESULTS: The correlation between calcium intake estimates, when measured by first and second administrations of the FFQ, was 0.68 (Pearson's r) for the total sample. Correlations differed by age, sex, and ethnic subgroups as follows: 10 to 13 years (r=0.62), 14 to 18 years (r=0.73), male (r=0.73), female (r=0.64), Asian (r=0.77), Hispanic (r=0.72), and white (r=0.48). The correlation between calcium intakes as estimated by the second FFQ vs the average of the two 24-hour dietary recalls was 0.54 (deattenuated Pearson's r) for the total sample. This correlation differed by age, sex, and ethnic subgroups as follows: 10 to 13 years (r=0.46), 14 to 18 years (r=0.59), male (r=0.65), female (r=0.45), Asian (r=0.64), Hispanic (r=0.18), and white (r=0.57). CONCLUSIONS: A unique dietary survey has been developed to estimate calcium intake among Asian, Hispanic, and white youth in the United States.