Food Handling in the Home What are Consumers Really Doing and How Effective are the Risk Communication Messages They a

1. Food Handling in the Home What are Consumers Really Doing and How Effective are the Risk Communication Messages They are Receiving? Lydia C. Medeiros, Ph.D., R.D. Professor, Human Nutrition and Food Safety Department of Human Nutrition The Ohio State University

2. Objectives for Today�s Talk What are the important consumer food handling behaviors and do they practice this behavior in the home? Where do consumers get their food safety information and do they use it effectively?

3. . . .is most effective when targeted toward changing those behaviors that are most likely to result in foodborne illness. Food Safety Education . . . Our educational philosophyOur educational philosophy

4. Food Handling Behaviors to Control Foodborne IllnessesMethods Expert Panel Web-based Delphi study Review, Revision, Reflection Application Our first step was to identify and validate food handling behaviors experts said were most important to target Convened an expert panel of microbiologists, educators, regulatory officials Completed a 4 round web-based Delphi study ( a technique to bring order to unordered information) Followed with a period of review, revision and reflection before accepting the list Designed studies to test, verify, document and attempt to change behavior through educational intervention Our first step was to identify and validate food handling behaviors experts said were most important to target Convened an expert panel of microbiologists, educators, regulatory officials Completed a 4 round web-based Delphi study ( a technique to bring order to unordered information) Followed with a period of review, revision and reflection before accepting the list Designed studies to test, verify, document and attempt to change behavior through educational intervention

5. Human Fecal Pathogens Norovirus Shigella spp. Hepatitis A All cause illness with small number of cells Practice Personal Hygiene We organized our results into 5 pathogen control factors that have served as constructs in our subsequent studies The first pathogen control factor relies on personal hygiene as the critical control factor and targets foods prepared for service without an in-home pasteurization step. The pathogens have in common that they are highly infective due to low infective doses.We organized our results into 5 pathogen control factors that have served as constructs in our subsequent studies The first pathogen control factor relies on personal hygiene as the critical control factor and targets foods prepared for service without an in-home pasteurization step. The pathogens have in common that they are highly infective due to low infective doses.

6. Wash hands with warm soapy water before handling food If you are ill with diarrhea, only prepare food for yourself but not others Properly bandage and glove cuts and burns on hands before handling food Practice Personal Hygiene Today I am showing a selection of the 3 to 10 behaviors that we identified for each pathogen control factor. A complete list has been published in the Journal of the American Dietetic Association. For each pathogen control factor, I will highlight one or two of the behaviors and follow with data that we have gathered in our descriptive and intervention studies that indicate how well consumers are practicing these various food handling behaviors. All of our studies probe various factors related to hand washing. We have frankly never found anyone in the home situation who abstains from food preparation in the home if the are ill and if they are the primary food preparer, nor have we encounter anyone who gloves in the home. So � do consumers wash their hands before they prepare food? Today I am showing a selection of the 3 to 10 behaviors that we identified for each pathogen control factor. A complete list has been published in the Journal of the American Dietetic Association. For each pathogen control factor, I will highlight one or two of the behaviors and follow with data that we have gathered in our descriptive and intervention studies that indicate how well consumers are practicing these various food handling behaviors. All of our studies probe various factors related to hand washing. We have frankly never found anyone in the home situation who abstains from food preparation in the home if the are ill and if they are the primary food preparer, nor have we encounter anyone who gloves in the home. So � do consumers wash their hands before they prepare food?

7. Washed hands with warm soapy water before handling foodLow-Income Women, Simulated Food Prep Study (n=70) This was one of our first studies to validate items for evaluation instruments. This data came from a video-taped simulated food preparation activity with low-income women to observe various food handling behaviors, including hand washing. The incidence of hand washing was compared in the study to same person self-reported behavior. The purpose was to assess criterion validity, which was confirmed for hand washing. Those who reported washing hands before food preparation also practiced the behavior in the video-taped portion (agreement = 90% between self-report and observed behavior).This was one of our first studies to validate items for evaluation instruments. This data came from a video-taped simulated food preparation activity with low-income women to observe various food handling behaviors, including hand washing. The incidence of hand washing was compared in the study to same person self-reported behavior. The purpose was to assess criterion validity, which was confirmed for hand washing. Those who reported washing hands before food preparation also practiced the behavior in the video-taped portion (agreement = 90% between self-report and observed behavior).

8. How often do you typically wash your hands in a day?Rural Farm and Non-Farm Homeowners (n=52) Since the previous study was a simulated activity and may differ from behavior in the home, we have repeated assessment of self-reported hand washing behavior in all of our studies. This data is part of a study in process that will be completed this summer. The study is an educational intervention with rural farm and non-farm households that either have or do not have on-residence contact with ruminant animals. Most of the homeowners self-reported that they frequently wash their hands each day.Since the previous study was a simulated activity and may differ from behavior in the home, we have repeated assessment of self-reported hand washing behavior in all of our studies. This data is part of a study in process that will be completed this summer. The study is an educational intervention with rural farm and non-farm households that either have or do not have on-residence contact with ruminant animals. Most of the homeowners self-reported that they frequently wash their hands each day.

9. Do you wash your hands with soap and water prior to eating? Rural Farm and Non-Farm Homeowners (n=52) We further asked the homeowners how frequently they washed their hands prior to eating. Surprisingly, only about one half stated they always wash before eating, and 2% said they never did. There was no difference between the farm and non-farm households so there is a possibility that pathogens could be transferred to food prepared without heat treatment and eaten in the household. It will be interesting to see what differences we find when we collect the post-education data this summer.We further asked the homeowners how frequently they washed their hands prior to eating. Surprisingly, only about one half stated they always wash before eating, and 2% said they never did. There was no difference between the farm and non-farm households so there is a possibility that pathogens could be transferred to food prepared without heat treatment and eaten in the household. It will be interesting to see what differences we find when we collect the post-education data this summer.

10. Zoonotic Pathogens Campylobacter jejuni Salmonella spp. Vibrio spp. Toxoplasma gondii Yersinia enterocolitica E. coli O157:H7 Same pathogens are associated with both control factors Cook Food Adequately andAvoid Cross-Contamination The most serious and costly foodborne illnesses are caused by zoonotic pathogens, but control in the household is fairly straight forward if the consumer controls cross-contamination and follows with adequate cooking to pasteurize the foods. Thus, we view behaviors controlling cross-contamination from these pathogens as a control factor and adequate cooking as the critical control factor for consumers, as with food production, processing or retail.The most serious and costly foodborne illnesses are caused by zoonotic pathogens, but control in the household is fairly straight forward if the consumer controls cross-contamination and follows with adequate cooking to pasteurize the foods. Thus, we view behaviors controlling cross-contamination from these pathogens as a control factor and adequate cooking as the critical control factor for consumers, as with food production, processing or retail.

11. Use a thermometer to make sure that meat and poultry are cooked to safe temperatures Cook shellfish until the shell opens and flesh is fully cooked; cook fish until flesh is opaque and flakes easily with a fork If pregnant, immunocompromised, or elderly, heat hot dogs and lunch meats to steaming hot or 165o Cook Foods Adequately The United States Department of Agriculture has released consumer education materials that promotes use of a food thermometers to verify end-point temperature as the most effective means to control pathogens in cooked foods. We and others have found that consumers resist using food thermometers in foods other than large cuts of meats because of the convenience and difficulty to accurately measure temperature in fragile or small pieces of food. We have found that consumers in general rarely associate use of a food thermometer with foods cooked in the microwave oven or with foods other than meats.The United States Department of Agriculture has released consumer education materials that promotes use of a food thermometers to verify end-point temperature as the most effective means to control pathogens in cooked foods. We and others have found that consumers resist using food thermometers in foods other than large cuts of meats because of the convenience and difficulty to accurately measure temperature in fragile or small pieces of food. We have found that consumers in general rarely associate use of a food thermometer with foods cooked in the microwave oven or with foods other than meats.

12. How would you judge if the following meats are adequately cooked prior to consumption?  Rural Farm and Non-Farm Homeowners (n=52) In our farm and non-farm study, we found that thermometer use was more commonly used with larger cuts of meats compared to thin meats commonly cooked on open grills in the US, but by only half of our study sample. Visual cues to doneness was the most commonly identified method to judge doneness of thinner meats, even though the United State Department of Agricultural consumer education guidelines state that color does not necessarily change to brown as internal temperature increases in meat. Takeuchi et al., J Am Diet Assoc 2006 Feb; 106 (2): 262-6. (Val�s thermometer study)In our farm and non-farm study, we found that thermometer use was more commonly used with larger cuts of meats compared to thin meats commonly cooked on open grills in the US, but by only half of our study sample. Visual cues to doneness was the most commonly identified method to judge doneness of thinner meats, even though the United State Department of Agricultural consumer education guidelines state that color does not necessarily change to brown as internal temperature increases in meat. Takeuchi et al., J Am Diet Assoc 2006 Feb; 106 (2): 262-6. (Val�s thermometer study)

13. Wash knives, cutting boards and food preparation surfaces with hot water and soap after contact with raw poultry, meat and seafood Clean food preparation surfaces with paper towels or clean cloths and hot soapy water before and after food preparation. Avoid Cross-Contamination Our education messages about avoiding cross-contamination in the home focus on the cleaning and sanitization of food preparation surfaces. In our farm and non-farm household study we have used the report of numerous variables related to food handling in principle component analysis, then used the factors identified as independent variables in multiple linear regression analysis. We had an unusual finding.Our education messages about avoiding cross-contamination in the home focus on the cleaning and sanitization of food preparation surfaces. In our farm and non-farm household study we have used the report of numerous variables related to food handling in principle component analysis, then used the factors identified as independent variables in multiple linear regression analysis. We had an unusual finding.

14. Risk Factors for ContaminationHousehold Listeria monocytogenesRural Farm and Non-Farm Homeowners (n=52) Variables associated with animals of all types present in the household clustered into several factors, one of which was a series of items related to cats in the household. This factor was the only independent variable that was predictive of the presence of Listeria monocytogenes in the interior environment of the home. Sinks, counters where food was prepared, and the bottom shelf of refrigerators were sampled. The multiple linear regression model was highly significant but only about 18% of the variation was explained by this one independent factor. If this holds true as we continue to sample and analyze data, it may indicate that household cats that also go outdoors may be the source of environmental contamination in the kitchen. Handling of the cats or direct contact of the cat with the food preparation surface appears to be the source of cross-contamination. The advice to clean and sanitize food preparation surfaces both before and after food preparation is timely � most of our subjects stated they only clean and sanitize immediately after food preparation.Variables associated with animals of all types present in the household clustered into several factors, one of which was a series of items related to cats in the household. This factor was the only independent variable that was predictive of the presence of Listeria monocytogenes in the interior environment of the home. Sinks, counters where food was prepared, and the bottom shelf of refrigerators were sampled. The multiple linear regression model was highly significant but only about 18% of the variation was explained by this one independent factor. If this holds true as we continue to sample and analyze data, it may indicate that household cats that also go outdoors may be the source of environmental contamination in the kitchen. Handling of the cats or direct contact of the cat with the food preparation surface appears to be the source of cross-contamination. The advice to clean and sanitize food preparation surfaces both before and after food preparation is timely � most of our subjects stated they only clean and sanitize immediately after food preparation.

15. Pathogens associated with temperature abuse C. perfringens Staph aureus Bacillus cereus Cause relatively mild illnesses Keep Foods at Safe Temperatures Illnesses caused by temperature abuse of food are less common in the United States compared with reported incidences even a decade ago. This is not true of all countries and is more common where home refrigeration is less common. However, we have noticed in our work that education programs in the US. typically teach consumers about the need to cool foods in a timely manner, or to hold the food hot. We feel that this is because these are relatively simple behaviors to teach people and the people are receptive to changing a behavior that is easy to incorporate into their daily lives without disruption to their usual routine. In contrast to using a food thermometer, remembering to refrigerate food once a meal provides a sense of accomplishment that the consumer is �doing the right thing,� but a greater public health impact could be achieved if more attention were paid to cross-contamination and adequate cooking.Illnesses caused by temperature abuse of food are less common in the United States compared with reported incidences even a decade ago. This is not true of all countries and is more common where home refrigeration is less common. However, we have noticed in our work that education programs in the US. typically teach consumers about the need to cool foods in a timely manner, or to hold the food hot. We feel that this is because these are relatively simple behaviors to teach people and the people are receptive to changing a behavior that is easy to incorporate into their daily lives without disruption to their usual routine. In contrast to using a food thermometer, remembering to refrigerate food once a meal provides a sense of accomplishment that the consumer is �doing the right thing,� but a greater public health impact could be achieved if more attention were paid to cross-contamination and adequate cooking.

16. Store all perishable foods at or below 40�F (4.4�C) Do not prepare food more than 2 hours before serving without plans for proper cooling and reheating Keep hot food at or above 140�F (60�C) Keep Foods at Safe Temperatures However, even self-limiting foodborne illnesses are not desirable to the person who has the illness. Also, if we don�t continue to teach consumers about proper holding temperature, there could be a resurgence of illnesses. There were only 3 behaviors that we identified in our Delphi study related to food temperature: cold holding, hot holding and time at temperature.However, even self-limiting foodborne illnesses are not desirable to the person who has the illness. Also, if we don�t continue to teach consumers about proper holding temperature, there could be a resurgence of illnesses. There were only 3 behaviors that we identified in our Delphi study related to food temperature: cold holding, hot holding and time at temperature.

17. Refrigerator Temperature Rural Farm and Non-Farm Homeowners (n=52) Several research groups have reported consumer refrigerator temperatures in audits of households. We also monitored the temperature of the refrigerators in our farm and non-farm household study. We found that the mean temperature was about 40 degrees F or 4.4 degrees C, which of course is the high end of the recommended temperature range. Nineteen households had warmer temperatures placing them at greater risk for growth of Listeria, if the pathogen is present in that environment or a stored food.Several research groups have reported consumer refrigerator temperatures in audits of households. We also monitored the temperature of the refrigerators in our farm and non-farm household study. We found that the mean temperature was about 40 degrees F or 4.4 degrees C, which of course is the high end of the recommended temperature range. Nineteen households had warmer temperatures placing them at greater risk for growth of Listeria, if the pathogen is present in that environment or a stored food.

18. Defined as refrigerated, ready-to-eat foods produced or processed in some way that doesn�t kill pathogens Some foods are higher risk than others Level of risk dependent on life-stage and immune status pregnancy, childhood, elderly, immune-compromised Avoid Foods from Unsafe Sources Most of our later work has focused on groups at high risk for foodborne illnesses, and most of our funding has specified Listeria monocytogenes. As health professionals who educate susceptible populations, we feel that some foods have particular risk and should be avoided by members of the most vulnerable groups.Most of our later work has focused on groups at high risk for foodborne illnesses, and most of our funding has specified Listeria monocytogenes. As health professionals who educate susceptible populations, we feel that some foods have particular risk and should be avoided by members of the most vulnerable groups.

19. Drink only pasteurized milk and fruit juices Avoid eating raw sprouts If pregnant, immunocompromised, or elderly: avoid soft cheeses, cold smoked fish, cold deli salads avoid hot dogs and lunch meats that have not been reheated to steaming hot or 165� F Avoid Foods from Unsafe Sources These guidelines are not aimed at the general population; however, we have found that compliance with this advice, even with very immune compromised individuals, is dependent on multiple factors. A major factor effecting compliance is food preference. These guidelines are not aimed at the general population; however, we have found that compliance with this advice, even with very immune compromised individuals, is dependent on multiple factors. A major factor effecting compliance is food preference.

20. Food PreferencesPregnant Women We have interviewed many pregnant women, the elderly, and people who are immune compromised due to chronic diseases or medical therapies. With each group, we have reviewed each of the behaviors on our list and asked for their perception of the benefits and barriers to compliance. No one was motivated or inspired by the guidelines or their health circumstances to follow all of our advice. They were selective. One of the more commonly expressed barriers to compliance was whether or not the person liked the high risk food. This is data from our interviews with pregnant women. This show that the more popular and commonly consumed foods are the most preferred foods. It is not difficult to say you will not consume a high risk food if you either don�t care for the food or you don�t have access to the food, which is common for unpasteurized milk in the US. We have interviewed many pregnant women, the elderly, and people who are immune compromised due to chronic diseases or medical therapies. With each group, we have reviewed each of the behaviors on our list and asked for their perception of the benefits and barriers to compliance. No one was motivated or inspired by the guidelines or their health circumstances to follow all of our advice. They were selective. One of the more commonly expressed barriers to compliance was whether or not the person liked the high risk food. This is data from our interviews with pregnant women. This show that the more popular and commonly consumed foods are the most preferred foods. It is not difficult to say you will not consume a high risk food if you either don�t care for the food or you don�t have access to the food, which is common for unpasteurized milk in the US.

21. Factors influencing cancer patients� willingness to follow food safety recommendations. This slide shows a figure in a manuscript that we have recently had accepted for publication. This is taken from the same study as the data on the previous slide and shows how we have organized our findings into a model that could be used to predict how likely a high risk consumer might follow food safety advice. A consistent finding with all of our high risk groups is that the preferred source of food safety information is the physician or the surrogate health professionals they most often interact with during their medical care. When we interviewed the health professionals, including physicians, we learned they were either not knowledgeable of food safety in general, or their information was out-of-date, or they simply did not make food safety education a priority. In our study, high risk individuals did not use media or the internet for information about food safety because they could not verify the accuracy of the information. Credible sources were their priority.This slide shows a figure in a manuscript that we have recently had accepted for publication. This is taken from the same study as the data on the previous slide and shows how we have organized our findings into a model that could be used to predict how likely a high risk consumer might follow food safety advice. A consistent finding with all of our high risk groups is that the preferred source of food safety information is the physician or the surrogate health professionals they most often interact with during their medical care. When we interviewed the health professionals, including physicians, we learned they were either not knowledgeable of food safety in general, or their information was out-of-date, or they simply did not make food safety education a priority. In our study, high risk individuals did not use media or the internet for information about food safety because they could not verify the accuracy of the information. Credible sources were their priority.

22. Acknowledgements Funded by USDA, National Research Initiative USDA, National Integrative Food Safety Initiative Research Team Ohio State University Jeffery LeJeune Gang Chen Janet Buffer Colorado State University John Sofos Patricia Kendall Mary Schroeder Washington State University Virginia �Val� Hillers Verna Bergman We have several different studies underway at the moment, one of which is a randomized controlled educational intervention with low income pregnant women. We are using both education and microbiological outcome indicators and hope to gain insight into whether we can successfully motivate and intervene with behaviors that will protect the mothers and their fetuses. The study is in it earliest stages and like our Farm and Non-Farm study, we hope to find ways that consumer risk for foodborne illnesses can be better controlled. These are the main players in our studies and there are also many students and educators who are part of the team. We very much appreciate their contributions and acknowledge that the work cannot be completed without them.We have several different studies underway at the moment, one of which is a randomized controlled educational intervention with low income pregnant women. We are using both education and microbiological outcome indicators and hope to gain insight into whether we can successfully motivate and intervene with behaviors that will protect the mothers and their fetuses. The study is in it earliest stages and like our Farm and Non-Farm study, we hope to find ways that consumer risk for foodborne illnesses can be better controlled. These are the main players in our studies and there are also many students and educators who are part of the team. We very much appreciate their contributions and acknowledge that the work cannot be completed without them.

23. Questions?