Does the U.S. Food Stamp Program contribute to adult weight gain?

Obesity poses substantial costs both to the individual and society, mainly through its impact on health and labor productivity. Because obesity is more prevalent among the poor some have raised concerns that food assistance programs may encourage excess weight. This paper investigates whether the U.S. Food Stamp Program contributes to adult participants’ weight as measured by body mass index (BMI). Results suggest that the typical female food stamp participant's BMI is indeed more than 1 unit higher than someone with the same socioeconomic characteristics who is not in the program. For the average American woman, who is 5 ft 4 in. (1.63 m) tall, this means an increase in weight of 5.8 pounds (2.6 kg). While this association does not prove that the Food Stamp Program causes weight gain, it does suggest that program changes to encourage the consumption of high-nutrient, low-calorie foods should be considered.     

Over, under, or about right: misperceptions of body weight among food stamp participants

The purpose of this research was to investigate the associations between misperception of body weight and sociodemographic factors such as food stamp participation status, income, education, and race/ethnicity. National Health and Nutrition Examination Survey (NHANES) data from 1999-2004 and multivariate logistic regression are used to estimate how sociodemographic factors are associated with (i) the probability that overweight adults misperceive themselves as healthy weight; (ii) the probability that healthy-weight adults misperceive themselves as underweight; and (iii) the probability that healthy-weight adults misperceive themselves as overweight. NHANES data are representative of the US civilian noninstitutionalized population. The analysis included 4,362 men and 4,057 women. BMI derived from measured weight and height was used to classify individuals as healthy weight or overweight. These classifications were compared with self-reported categorical weight status. We find that differences across sociodemographic characteristics in the propensity to underestimate or overestimate weight status were more pronounced for women than for men. Overweight female food stamp participants were more likely to underestimate weight status than income-eligible nonparticipants. Among healthy-weight and overweight women, non-Hispanic black and Mexican-American women, and women with less education were more likely to underestimate actual weight status. We found few differences across sociodemographic characteristics for men. Misperceptions of weight are common among both overweight and healthy-weight individuals and vary across socioeconomic and demographic groups. The nutrition education component of the Food Stamp Program could increase awareness of healthy body weight among participants.     

Varying Body Mass Index Cutoff Points to Describe Overweight Prevalence Among U. S. Adults: NHANES III (1988 to 1994)

KUCZMARSKI, ROBERT J, MARGARET D CARROLL, KATHERINE M FLEGAL, RICHARD P TROIANO. Varying body mass index cutoff points to determine overweight prevalence among U. S. adults: NHANES III (1988 to 1994). Body mass index (BMI; kg/m²) distributions are commonly reported in the scientific literature to describe weight for stature. These data are collected for various groups of subjects in local health and body composition studies, and comparisons with national distributions are often desirable. Tabular data for population prevalence estimates from thethird National Health and Nutrition Examination Survey (NHANES III, 1988 to 1994) at selected gender- and age-specific BMI levels ranging from <18. 0 to >45. 0 are presented and compared with various examples of BMI criteria reported in the scientific literature. NHANE HI was a statistically representative national probability sample of the civilian, noninstitutionalized population of the United States in which height and weight were measured as part of a more comprehensive health examination. The implications of varying population prevalence estimates based on varying BMI cutoff points are briefly discussed for selected examples including World Health Organization overweight/obesity criteria and the U. S. Dietary Guidelines for Americans. The median BMI for U. S. adults aged 20 years and older is 25. 5 kg/m². Median stature and weight for men are 175. 5 cm and 80. 0 kg and for women are 161. 6 cm and 65. 6 kg, respectively. The percentage of the population with BMI <19. 0 is 1. 6% for men, 5. 7% for women; BMI 19. 0 to <25. 0 is 39. 0% for men, 43. 6% for women; BMI 25. 0 is 59. 4% for men, 50. 7% for women. An estimated 97. 1 million adults have a BMI 25. 0. Additional prevalence estimates based on other BMI cutoff points and ages are presented.     

Are Normal‐Weight Americans Over‐Fat?

Data from National Health and Nutrition Examination Surveys (NHANES) 1999-2004 have recently shown the percent body fat of American adults. Average American men and women have ~28 and 40% body fat. When categorized by BMI and age, the data also show high percent body fat values, particularly in lower BMI categories. These data should make one reflect on the health status of Americans in all BMI categories and the use of these data for public health recommendations.     

Comparisons for Body Mass Index and Body Fat Percent Among Puerto Ricans,Blacks, Whites and Asians Living in the New York City Area

The latest data (NHANES III) from the National Center for Health Statistics (NCHS) show that the black population has the highest proportion of overweight among all adult populations in the United States. The present study compared the body mass index (BMI) and body fat percent from dual-photon absorptiometry in 1,324 healthy adults aged 18 to 107 years recruited from four ethnic groups in the New York City area; 523 whites, 280 blacks, 267 Asians and 254 Puerto Ricans. Puerto Ricans had the largest BMI and the largest percent of subjects with body weight more than 120% of their ideal weight, and the largest fat percent of the four ethnic groups: 76% of Puerto Rican males had fat percent above the median value for white males (fat percent = 19.6%) and 95% of Puerto Rican females had fat percent above the median for white females (fat percent = 30.8%). Asians had the smallest BMI, but 63% of them had fat percent above the median values for whites in each gender. Puerto Ricans also had the largest waist-to-hip ratios among the four ethnic groups. In blacks, the percent of subjects with fat percent larger than the median for whites was slightly smaller than that for Puerto Ricans, 64% and 82% of males and females respectively. These results differ from the latest NCHS data and show that Puerto Ricans in this sample are heavier and fatter than blacks.     

Comparing Trends in BMI and Waist Circumference

The nature of excess body weight may be changing over time to one of greater central adiposity. The aim of this study is to determine whether BMI and waist circumference (WC) are increasing proportionately among population subgroups and the range of bodyweight, and to examine the public health implications of the findings. Our data are from two cross‐sectional surveys (the US National Health and Nutrition Examination Studies (NHANES) in 1988–1994 (NHANES III) and 2005–2006), from which we have used samples of 15,349 and 4,176 participants aged ≥20 years. Between 1988–1994 and 2005–2006 BMI increased by an average of 1.8 kg/m² and WC by 4.7 cm (adjusted for sex, age, race‐ethnicity, and education). The increase in WC was more than could be attributed simply to increases in BMI. This independent increase in WC (of on average, 0.9 cm) was consistent across the different BMI categories, sexes, education levels, and race‐ethnicity groups. It occurred in younger but not older age groups. Overall in each BMI category, the prevalence of low‐risk WC decreased and the prevalence of increased‐risk or substantially increased‐risk WC increased. These results suggest that the adverse health consequences associated with obesity may be increasingly underestimated by trends in BMI alone. Since WC is closely linked to adverse cardiovascular outcomes, it is important to know the prevailing trends in both of these parameters.     

Gender‐ethnic Disparity in BMI and Waist Circumference Distribution Shifts in US Adults

While obesity has been increasing in the United States, little is known about the variation in recent BMI and waist circumference (WC) distribution shifts across socio‐demographic groups. We assessed shifts in BMI and WC distributions and compared between‐group differences over the past decade, and projected future BMI and WC distributions and prevalence of obesity and central obesity using National Health and Nutrition Examination Survey (NHANES) 1988–1994 and 1999–2004 data. BMI/WC distributional shifts overall and in percentiles were compared across groups. Average yearly shift was calculated and used for projecting future distributions and prevalence. Both BMI and WC increased more in their uppermost percentile distribution, though BMI shift declined toward the uppermost percentiles among women. Heavier Americans gained more adiposity over the past decade. Ethnic (non‐Hispanic (NH) white vs. black) disparities in mean BMI and WC became wider. Over the survey period, mean BMI increased by 1.3 units vs. 1.8 units among men and women, whereas WC, by 4.2 cm vs. 4.8 cm. Young adults had the largest increase. Shift in women's WC was stable between the 25th and 75th percentiles, but gained pace at higher WC, while women's BMI and men's BMI and WC shifts increased linearly. NH black women had the largest shifts and would have central obesity and obesity prevalence of 90.8 and 70.7% by 2020. Shifts in BMI and WC distribution varied across age‐, gender‐, and ethnic groups. Future rise in the obesity and central obesity prevalence rates are expected, but would vary by demographic groups.     

Childhood Overweight Prevalence in the United States: The Impact of Parent‐reported Height and Weight

Parent‐reported height and weight are often used to estimate BMI and overweight status among children. The quality of parent‐reported data has not been compared to measured data on a national scale for all race/ethnic groups in the United States. Parent‐reported height and weight for 2–17‐year‐old children in two national health interview surveys—the 1999–2004 National Health Interview Survey (NHIS) and the 2003–2004 National Survey of Children's Health (NSCH)—were compared to measured values from a national examination survey—the 1999–2004 National Health and Nutrition Examination Survey (NHANES). Compared to measured data, parent‐reported data overestimated childhood overweight in both interview surveys. For example, overweight prevalence among 2–17‐year‐olds was 25% (s.e. 0.2) using parent‐reported NHIS data vs. 16% (s.e. 0.6) using measured NHANES data. Parent‐reported data overestimated overweight among younger children, but underestimated overweight among older children. The discrepancy between reported and measured estimates arose mainly from reported height among very young children. For children aged 2–11 years, the mean reported height from NHIS was 3–6 cm less than mean measured height from NHANES (P < 0.001) vs. no difference among children aged 16–17 years. Measured data remains the gold standard for surveillance of childhood overweight. Although this analysis compared mean values from survey populations rather than parent‐reported and measured data for individuals, the results from nationally representative data reinforce previous recommendations based on small samples that parent‐reported data should not be used to estimate overweight prevalence among preschool and elementary school–aged children.     

Food insecurity and increased BMI in young adult women

Food insecurity has been associated with weight status in children and adults although results have been mixed. We aimed to identify whether food insecurity was associated with BMI in young adults and whether this association differed by gender and was modified by food stamp use and the presence of children in the home. Cross-sectional data from wave 4 (2007-2008) of the National Longitudinal Study of Adolescent Health were analyzed. Multiple linear regression was used to investigate the association between food insecurity and BMI in gender stratified models of young adult women (n = 7,116) and men (n = 6,604) controlling for age, race/ethnicity, income, education, physical activity, smoking, alcohol use, the presence of children in the home, and food stamp use in young adulthood and/or adolescence. Food insecurity was more common in young adult women (14%) than young adult men (9%). After controlling for a variety of individual variables, food insecure women had a BMI that was on average 0.9 kg/m(2) units higher than women who were food secure. This difference in BMI persisted after controlling for recent or past food stamp use and was not different among women with or without children in the household. No relationship was found between food insecurity and BMI in young adult men. Providers should inquire about food insecurity, especially when treating obesity, and policy initiatives should address the role of access to healthy food in those facing food insecurity.     

Associations between Food Outlets around Schools and BMI among Primary Students in England: A Cross-Classified Multi-Level Analysis

IntroductionResearchers and policy-makers are interested in the influence that food retailing around schools may have on child obesity risk. Most previous research comes from North America, uses data aggregated at the school-level and focuses on associations between fast food outlets and school obesity rates. This study examines associations between food retailing and BMI among a large sample of primary school students in Berkshire, England. By controlling for individual, school and home characteristics and stratifying results across the primary school years, we aimed to identify if the food environment around schools had an effect on BMI, independent of socio-economic variables.MethodsWe measured the densities of fast food outlets and food stores found within schoolchildren’s home and school environments using Geographic Information Systems (GIS) and data from local councils. We linked these data to measures from the 2010/11 National Child Measurement Programme and used a cross-classified multi-level approach to examine associations between food retailing and BMI z-scores. Analyses were stratified among Reception (aged 4-5) and Year 6 (aged 10-11) students to measure associations across the primary school years.ResultsOur multilevel model had three levels to account for individual (n = 16,956), home neighbourhood (n = 664) and school (n = 268) factors. After controlling for confounders, there were no significant associations between retailing near schools and student BMI, but significant positive associations between fast food outlets in home neighbourhood and BMI z-scores. Year 6 students living in areas with the highest density of fast food outlets had an average BMI z-score that was 0.12 (95% CI: 0.04, 0.20) higher than those living in areas with none.DiscussionWe found little evidence to suggest that food retailing around schools influences student BMI. There is some evidence to suggest that fast food outlet densities in a child’s home neighbourhood may have an effect on BMI, particularly among girls, but more research is needed to inform effective policies targeting the effects of the retail environment on child obesity.     

Obesity, overweight, and their life course trajectories in veterans and non-veterans

Veterans comprise a large and growing segment of the US population. Results from national telephone surveys suggest higher prevalence of overweight among Veterans compared with demographically similar non-Veterans, based on self-reported height and weight. Using 1999-2008 data from the National Health and Nutrition Examination Survey (NHANES), we compared 3,768 Veterans and 21,974 non-Veterans on: (i) several measures of adiposity based on direct anthropometry; (ii) life-course of self-reported BMI; and (iii) behaviors related to weight loss or maintenance. Whether Veterans were more likely than demographically similar non-Veterans to be obese or overweight depended on the adiposity measure employed. On BMI, Veterans were about equally likely to be obese (30+ kg/m(2)), but more likely to be overweight (25-29.9 kg/m(2)) by both self-report and by direct measurement (significantly so only by self-report). On waist-stature ratio, a roughly similar pattern was observed. On waist circumference, Veterans tended to have larger values than demographically similar non-Veterans, with more Veterans in the largest two categories. But on dual-photon X-ray absorptiometry, Veterans were less likely to have 35+% body fat than non-Veterans of similar age, gender, and race/ethnicity. Life-course trends in self-reported BMI suggested a possible burst of weight gain after military discharge. These results suggest that Veterans may, on average, have less excess body fat than non-Veterans--a pattern not revealed by standard anthropometric measures.     

Adiposity is not equal in a multi-race/ethnic adolescent population: NHANES 1999-2004

BMI is the preferred measure of adiposity in adolescents. Recent evidence suggests that in adults the relationship between BMI and adiposity can vary by age and race/ethnicity. We investigated the relationship between BMI and percent body fat (%BF) in a large multi-ethnic, nationally representative sample of US adolescents (National Health and Nutrition Examination Survey, NHANES, 1999-2004). BMI was calculated; %BF was derived from dual-energy X-ray absorptiometry data and compared to BMI among adolescents from three groups: non-Hispanic white (NHW), non-Hispanic black (NHB), and Mexican-American (MA). Fractional polynomials were used to model a new equation to estimate %BF from a given BMI. MA boys weighed significantly less than either NHW or NHB boys, while only NHB girls weighed significantly more than the other girls. Among the boys there were no differences in mean BMI, whereas %BF differed significantly between all three groups. For the girls, both BMI and %BF differed significantly the groups with MA girls having the highest %BF. The significant correlates for modeling %BF from BMI included gender, age, race/ethnicity, weight, [formula in text]: the final model explained 79% of the variance in %BF. NHB adolescents had significantly lower %BF for BMI and MA had higher than NHW. Our results indicate that BMI may not be an equivalent measure of %BF in a multi-ethnic population of US adolescents.     

HLA associations with obesity

A subgroup of 351 subjects with human leukocyte antigen (HLA) typing were available from the Framingham Heart Study for analyses to identify associations with obesity. The subjects consisted of 143 males and 208 females aged 58-88 years at the 15th biennial examination in 1978. The obese classification was based on maximum body mass index (BMI) over the 16 available biennial examinations of the Framingham Heart Study. The subjects were classified as obese if they exceeded the 95th percentile of BMI for 20- to 29-year-old subjects as described in the NHANES II study; males were obese if BMI greater than 31.1 and females were obese if BMI greater than 32.3. There were 27 obese males (18.9%) and 44 obese females (21.2%) in the sample. Gene frequencies were compared between the nonobese and obese groups for the pooled sample as well as by sex. Among alleles previously shown to be related to obesity, HLA Bw35 appeared to be more frequent in obese females but these data did not confirm a difference for the B18 or Cw4 alleles. More importantly, HLA Aw30 was found to be significantly higher among the obese subjects in both males and females. Further analyses adjusting for potential confounding variables reduced the estimated relative risk for obesity for subjects with the Bw35 allele to approximately 1.30 and no longer significant for this sample size. In contrast, the relative risk for Aw30, while reduced, remained significant after adjustment for confounding variables. Based on these data, individuals with the Aw30 allele have a relative risk of 2.61 for obesity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Socio-economic status and z-score standardized height-for-age of U.S.-born children (ages 2–6)

This study explores socio-economic gradients in height (stature-for-age) among a nationally representative sample of 2–6 year old children in the United States. We use NHANES III (1988–1994) Youth data linked with a special Natality Data supplement which contains information from birth certificates among sampled NHANES III Youth who are <7 years of age. Our results indicate significant socio-economic gradients for both maternal education and family income, net of controls for confounders, including: birth weight, gestational age, family size, and parental heights. These results are in stark contrast to those from other developed countries that seem to indicate diminished or eliminated socio-economic disparities, net of known confounders. In the United States, it appears that socio-economic gradients have an effect on birth outcomes, and continue to have an additional direct and independent effect on height, even in early childhood.     

Food prices, access to food outlets and child weight

This study examines the importance of food prices and restaurant and food store outlet availability for child body mass index (BMI). We use the 1998, 2000 and 2002 waves of the child-mother merged files from the 1979 cohort of the National Longitudinal Survey of Youth combined with fruit and vegetable and fast food price data obtained from the American Chamber of Commerce Researchers Association and outlet density data on fast food and full-service restaurants and supermarkets, grocery stores and convenience stores obtained from Dun & Bradstreet. Using a random effects estimation model, we found that a 10% increase in the price of fruits and vegetables was associated with a 0.7% increase in child BMI. Fast food prices were not found to be statistically significant in the full sample but were weakly negatively associated with BMI among adolescents with an estimated price elasticity of −0.12. The price estimates were robust to whether we controlled for outlet availability based on a per capita or per land area basis; however, the association between food outlets and child BMI differed depending on the definition. The associations of fruit and vegetable and fast food prices with BMI were significantly stronger both economically and statistically among low- versus high-socioeconomic status children. The estimated fruit and vegetable and fast food price elasticities were 0.14 and −0.26, respectively, among low-income children and 0.09 and −0.13, respectively, among children with less educated mothers.     

Toward generation XL: Anthropometrics of longevity in late 20th-century United States

All-cause and cause-specific mortality among white U.S. men and women are analyzed using the NHANES I data (1971-1975) and epidemiologic follow-up to 1992, to examine the effect of physical stature on mortality, controlling for other confounding variables within a discrete-time framework. We find an association between mortality and both body mass index (BMI) and height, but the height effect is sensitive with respect to the age range under consideration. Although the resulting minimum-mortality BMI is higher than the widely accepted healthy range, the recent increase in weight implies that further gains in life expectancy are unlikely to derive from the anthropometry-mortality relationship.     

Development of Health‐Related Waist Circumference Thresholds Within BMI Categories

Objective: To develop and cross‐validate waist circumference (WC) thresholds within BMI categories. The utility of the derived values was compared with the single WC thresholds (women, 88 cm; men, 102 cm) recommended by NIH and Health Canada. Research Methods and Procedures: The sample included adults classified as normal weight (BMI = 18.5 to 24.9), overweight (BMI = 25 to 29.9), obese I (BMI = 30 to 34.9), and obese II+ (BMI ≥ 35) from the Third U.S. National Health and Nutrition Examination Survey (NHANES III; n = 11, 968) and the Canadian Heart Health Surveys (CHHS; n = 6286). Receiver operating characteristic curves were used to determine the optimal WC thresholds that predicted high risk of coronary events (top quintile of Framingham scores) within BMI categories using the NHANES III. The BMI‐specific WC thresholds were cross‐validated using the CHHS. Results: The optimal WC thresholds increased across BMI categories from 87 to 124 cm in men and from 79 to 115 cm in women. The validation study indicated improved sensitivity and specificity with the BMI‐specific WC thresholds compared with the single thresholds. Discussion: Compared with the recommended WC thresholds, the BMI‐specific values improved the identification of health risk. In normal weight, overweight, obese I, and obese II+ patients, WC cut‐offs of 90, 100, 110, and 125 cm in men and 80, 90, 105, and 115 cm in women, respectively, can be used to identify those at increased risk.     

Multi-Institutional Sharing of Electronic Health Record Data to Assess Childhood Obesity

Objective

To evaluate the validity of multi-institutional electronic health record (EHR) data sharing for surveillance and study of childhood obesity.

Methods

We conducted a non-concurrent cohort study of 528,340 children with outpatient visits to six pediatric academic medical centers during 2007–08, with sufficient data in the EHR for body mass index (BMI) assessment. EHR data were compared with data from the 2007–08 National Health and Nutrition Examination Survey (NHANES).

Results

Among children 2–17 years, BMI was evaluable for 1,398,655 visits (56%). The EHR dataset contained over 6,000 BMI measurements per month of age up to 16 years, yielding precise estimates of BMI. In the EHR dataset, 18% of children were obese versus 18% in NHANES, while 35% were obese or overweight versus 34% in NHANES. BMI for an individual was highly reliable over time (intraclass correlation coefficient 0.90 for obese children and 0.97 for all children). Only 14% of visits with measured obesity (BMI ≥95%) had a diagnosis of obesity recorded, and only 20% of children with measured obesity had the diagnosis documented during the study period. Obese children had higher primary care (4.8 versus 4.0 visits, p<0.001) and specialty care (3.7 versus 2.7 visits, p<0.001) utilization than non-obese counterparts, and higher prevalence of diverse co-morbidities. The cohort size in the EHR dataset permitted detection of associations with rare diagnoses. Data sharing did not require investment of extensive institutional resources, yet yielded high data quality.

Conclusions

Multi-institutional EHR data sharing is a promising, feasible, and valid approach for population health surveillance. It provides a valuable complement to more resource-intensive national surveys, particularly for iterative surveillance and quality improvement. Low rates of obesity diagnosis present a significant obstacle to surveillance and quality improvement for care of children with obesity.     

Group harmony in gibbons: Comparison between white-handed gibbon (Hylobates lar) and siamang (H. syndactylus)

The siamang (Hylobates syndactylus) is exceptional among gibbons in that its area of distribution almost completely overlaps those of other gibbons, namely the white-handed gibbon (H. lar) and the agile gibbon (H. agilis) of the lar group. The siamang has almost twice the body weight of the gibbons of the lar group (ca. 11 kg vs. 5–6 kg), and it has been suggested that distinct ecological and behavioural differences exist between the siamang and its two sympatric species. The siamang has been claimed to differ from the white-handed gibbon “in the closer integration and greater harmony of group life” (Chivers, 1976, p. 132). However, few quantitative data exist to support this hypothesis. In the present study, intra-group interactions in captive family groups of white-handed gibbons and siamangs (two groups of each species) were recorded by focal-animal sampling. These data failed to show a consistent association between species and most of the behavioural patterns recorded, such as frequency of aggression, percentage of successful food transfer, frequency of social grooming bouts, and duration of social grooming/animal/hr. A significant difference was found for only two of the variables: Individual siamangs in this study showed longer grooming bout durations, and made fewer food transfer attempts than lar individuals. Only the first of these two differences is consistent with the hypothesis mentioned above, whereas the lower frequency of food transfer attempts in siamangs is the opposite of what should be expected under the hypothesis. On the other hand, two of these behavioural patterns showed a significant correlation with the parameters group size and individual age: Both individuals in larger groups and younger individuals tended to show shorter grooming bouts and a smaller proportion of successful food transfers. Our findings indicate that social cohesion within these gibbon groups may be much more flexible according to and depending on social or ecological influences and less rigidly linked to specific gibbon taxa than previously assumed. A considerably larger number of gibbon groups would have to be compared to provide reliable evidence for or against species-specific differences in group cohesion. Another finding of this study—a positive correlation between the frequency of aggression and grooming—is discussed in the light of the functional interpretations commonly attributed to allogrooming behaviour in primates.     

Foraging strategies as a function of season and rank among wild female chimpanzees (Pan troglodytes)

Among mammals, female reproduction is generally thought to befood limited, and dominance should theoretically afford high-rankingfemales with access to better food resources. Although the importanceof dominance rank among female chimpanzees (Pan troglodytes)has been debated in the past, mounting evidence suggests thatrank is very important among females (P. t. schweinfurthii)at Gombe National Park, Tanzania. In this study, we investigatedthe influence of season and dominance rank on female foragingstrategies. We found that high-ranking females spent less timeforaging and tended to have a narrower diet breadth and higherdiet quality than subordinate females. In this way, subordinatefemale foraging strategies were consistent with how femalesin general adapted to periods of food scarcity. The resultsof this study therefore suggest that low-ranking females mayface persistent "food scarcity" as a result of interferencefood competition. We also provide evidence that subordinatesmay forage less efficiently because they occupy lower qualityhabitats or avoid associating with dominant females in sharedareas.