LEAFLET 06 DISPLAY SCREEN EQUIPMENT

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1 CONTENTS Foreword 1. Scope 2. Introduction 3. Objectives 4. Definitions 5. Rest Breaks 6. Training and Information 7. Assessment 8. Eye and Eyesight Tests 9. Work with Portable DSE Annexes LEAFLET 06 DISPLAY SCREEN EQUIPMENT A. Seating and Posture for Typical Office Tasks B. Office Environment C. Keyboards and Mouse Techniques D. Workstation Assessment Checklist (HSMF 07) E. DSE Effects on Health F. DSE Exercises FOREWORD This leaflet is published under the authority of Lincolnshire Partnership NHS Foundation Trust (LPFT) Health and Safety Committee (HSC). This leaflet is for application across all areas of LPFT and reflects recent changes in legislation and or LPFT practices. 1. SCOPE 1.1. This leaflet advises all managers of the statutory duties on Lincolnshire Partnership NHS Foundation Trust (LPFT) required by the Health and Safety (Display Screen Equipment Regulations 1992 known as DSE), and the way these regulations are to be implemented in LPFT. The Regulations are backed by an Approved Code of Practice (ACOP L26). However, in compliance with the Secretary of State s Policy Statement on Safety, Health, Environmental Protection and Sustainable Development, standards and management arrangements are to be put in place which are, so far as is reasonably practicable. 2. INTRODUCTION 2.1. Display Screen Equipment (DSE) is a device or equipment that has an alphanumeric or graphic display screen, regardless of the display process involved; it includes both conventional display screens and those used in emerging technologies such as laptops, touch-screens and other similar devices. The Health and Safety (Display Screen Equipment) Regulations 1992 as amended by the Health and Safety (Miscellaneous Amendments) Regulations This regulation originally came into force on 1st January Page 1 of 21

2 1993. The regulations implement the European Directive, which specifies minimum safety and health requirements for work with Display Screen Equipment (DSE) The Trust also recognises that its duties to employees using Display Screen Equipment are also covered in the Health and Safety at Work etc. Act 1974 and further regulations, which include:- Management of Health and Safety at Work Regulations 1999 Workplace (Health, Safety and Welfare) Regulations 1992 The Provision and Use of Work Equipment Regulations This Trust procedure aims to assist all staff in preventing health problems such as Musculoskeletal disorders (MSD), fatigue and stress, psychosocial issues by encouraging good ergonomic design of equipment, furniture, the working environment and the job. 3. OBJECTIVES 3.1. The Trust will take all reasonable steps so ensure the health and safety of employees who work with DSE To ensure that managers recognise their responsibility to safeguard the health and safety of users of DSE as delegated to them by the Trust To ensure that adequate training and briefing on the Health and safety DSE Regulations 1992 is given to all applicable staff To ensure senior staff, e.g. Senior Managers, Heads of Department, designated competent persons or equivalent persons, assess and control risks arising from the use of display screen equipment in the Trust. 4. DEFINITIONS 4.1. The workstation is defined as: The screen itself (any computer or terminal screen) but not window typewriters, cash registers or calculators. Any optical accessories to the display screen equipment. Any disk drive, telephone, modem, printer, scanner, work chair, work desk, work surface, document holder, footrest or other peripheral to the Display Screen Equipment. The immediate work environment around the Display Screen Equipment Display Screen User It will generally be appropriate to classify the person concerned as a user if most or all of the following criteria apply: - The individual depends on the use of Display Screen Equipment to do the job, as alternative means are not readily available for achieving the same results. The individual has no discretion as to use or non-use of the Display Screen Equipment to do the job. Page 2 of 21

3 5. REST BREAKS The individual needs significant training and/or particular skills in the use of DSE to do the job. The individual normally uses DSE for continuous spells of an hour or more at a time. The individual uses DSE in this way more or less daily. Fast transfer of information between the user and screen is an important requirement of the job. The performance requirements of the system demand high levels of attention and concentration but the user, for example; where the consequences of error may be critical Breaks or changes of activity should be included in working time. They should reduce the workload at the screen, ie should not result in a higher pace or intensity of work on account of their introduction Breaks should be taken when performance and productivity are still at a maximum, before the user starts getting tired. This is better than taking a break to recover from fatigue. Appropriate timing of the break is more important than its length Short, frequent breaks are more satisfactory than occasional, longer breaks: for example a 5-10 minute break after minutes continuous screen and/or keyboard work is likely to be better than a minute break every 2 hours Wherever practicable, users should be allowed some discretion as to when to take breaks and how they carry out tasks; individual control over the nature and pace of work allows optimal distribution of effort over the working day Changes of activity (time spent doing other tasks not using the DSE) appear from study evidence to be more effective than formal rest breaks in relieving visual fatigue If possible, breaks should be taken away from the DSE workstation, and allow the user to stand up, move about and/or change posture. 6. TRAINING AND INFORMATION 6.1. Users should be provided with Health and Safety training and information related to working with DSE. This should include the recognition of hazards and risks and what actions can be taken to reduce these Any training given to users must be recorded and maintained by Managers Information on seating and posture can be found in Annex A, Office Environment in Annex B, and Keyboard technique within Annex C Display Screen Equipment (DSE) Training course is mandatory for all staff and should be completed at appointment and then when personal circumstances or the environment in which you work changes. You should complete the 'Health and Safety for DSE users' and 'Risk Assessment for Page 3 of 21

4 DSE users' courses. If you would like to access a step by step user guide click on the link: Web link: It is the responsibility of the local manager and the individual DSE user to resolve any concerns highlighted by the on line risk assessment. The risk assessment certificate must only be signed off when all the identified concerns have been resolved If necessary, specialist advice on DSE and office ergonomics can be obtained from the Back Care Team. This team also provides more detailed on site assessments for staff with existing health problems related to DSE The on-line risk assessment must be repeated if the member of staff moves to a new office location or if there are other significant changes to the office environment or work situation. 7. ASSESSMENT 7.1. All users must have a workplace assessment completed by a competent assessor (Annex D) or through the e-learning package for Display Screen Equipment Training and Assessment recognised by the Trust. Where a DSE issue is identified this should be resolved with the line manager at first instance using the DSE form in Annex D, If a problem still exists get in contact with the Back Care Team. Web link: Assessments must be recorded and records maintained by the users Manager Assessments should be reviewed if there is a major change to software or hardware. A major change to the workstation, a change to the user s task requirements, or the workstation is recited. 8. EYE AND EYESIGHT TESTS 8.1. A user of Display Screen Equipment is entitled to a free eyesight test before they commence work as a user and at further intervals recommended by either Occupational Health or an Optometrist. The user can also have a further test carried out if they experience difficulties Lincolnshire Partnership Foundation Trust operates a Visual Display Unit (VDU) eye care voucher scheme with Specsavers. The voucher allows employees to have a free eye test from Specsavers as well as a contribution made towards corrective glasses should it be found that glasses are required solely and specifically for VDU use People who qualify as a VDU user and would like an eye care voucher should obtain one from HR in advance of their appointment. No other receipts from opticians or organisations will be refunded. Page 4 of 21

5 8.4. Eye care vouchers can be obtained from the Human Resources Department by calling and a voucher will be posted out to the employee as soon as possible On completion of the eye examination, should it be identified that glasses are required solely and specifically for VDU use, the employee will be able to select a pair of glasses from the 45 Specsavers range, which are fitted with PENTAX CR39 single vision plus scratch-resistant treatment as standard. Alternatively the 45 contribution can be used as an upgrade to other frame ranges The optometrist will hand a completed VDU Certificate of Recommendation to the employee. This should be returned to Human Resources for our records Should an employee have an eyesight test/purchase glasses from another optician or from Specsavers without a Specsavers eye care voucher then the Trust will not reimburse the employee for the cost. 9. WORK WITH PORTABLE DSE 9.1 Users, who use portable computers for lengthy or repeated use in the same location, require the same risk assessment, training and information in safe use of DSE. They also need to report any issues or health problems to their manager as soon as possible. 9.2 As well as the risks common to both portables and desk top DSE work, the following additional risks may be associated specifically with portable DSE work and need to be taken into account by users and their managers: Manual handling risk when moving between locations, bearing in mind other equipment and bags may add to the load for the staff member. Risk of theft and possibly involving an assault. 9.3 Users should ensure that when they use a lap top computer for lengthy or repeated use that they use either a docking station or a suitable stand that is height adjustable to prevent health risks, a separate mouse, tracker ball or other pointing device should also be used. 9.4 The weight of the portable computer should ideally be below 3kg and keep accessories as few and as light as possible. 9.5 It is advisable to consider a backpack bag for the laptop to cut down strain on arms and distribute loads evenly across the body (or wheeled luggage might be worth considering). 9.6 All users should take sensible precautions such as not leaving or using a portable computer in a parked car; and taking extra care in public places. It should be stored safely and out of view when in the car. Page 5 of 21

6 Annex A SEATING AND POSTURE FOR TYPICAL OFFICE TASKS Seat back adjustable Good lumbar support Seat height adjustable No excess pressure on underside of thighs and backs of knees Foot support if needed Space for postural change, no obstacles under desk Forearms approximately horizontal Wrists not excessively bent (up, down or sideways) Screen height and angle to allow comfortable head position Space in front of keyboard to support hands/wrists during pauses in keying Page 6 of 21

7 Annex B OFFICE ENVIRONMENT Office environment to be considered Adequate lighting Adequate contrast, no glare or distracting reflections Distracting noise minimised Leg room and clearances to allow postural changes Window covering if needed to minimise glare Software: appropriate to task, adapted to user, providing feedback on system status, no undisclosed monitoring Screen: stable image, adjustable, detachable, legible Work surface: with space for flexible arrangement of equipment and documents; glare free Chair: stable and adjustable Footrest if user needs one Page 7 of 21

8 Annex C KEYBOARDS AND MOUSE TECHNIQUES Keyboard Adjust your keyboard to get a good keying position. There should be a space between the edge of the desk and beginning of the keyboard approximately 30cm.This will allow room for resting the hands and wrists when not keying. Using a Mouse The mouse should be appropriate for the hand size, preference, and frequency of use. Check that it fits comfortably into the hand. Keep the mouse as close to the keyboard as you can (side depends whether left or right handed) and use a mouse mat. Position the mouse to avoid cable drag. Try and limit mouse use by using any function commands or programmable buttons wherever possible to avoid quick repetitive movements. Break up mousing activity with other tasks. Keep mouse mat clean so the contact ball and wheels move freely and replace immediately if the mouse is faulty. Page 8 of 21

9 Annex D (HSMF07) WORKSTATION ASSESSMENT CHECKLIST Username: Workstation Location: Line Manager: Checklist Completed by: Matt Hulley, Health & Safety Advisor Date Completed: It is important that you are comfortable when using your DSE workstation. Your workstation includes the screen, keyboard, mouse, desk, chair, work area and environment etc. Risk Factor Yes No Comments 1. The job a) Does your job involve a variety of tasks other than DSE work? b) Do you take regular breaks from DSE work? c) Have you received adequate information & training to allow you to use your workstation comfortably? d) Have you been advised of your entitlement to eye & eyesight testing? What was the date of the last test provided/paid for by your employer? 2. Display Screen a) Are the characters on the screen clear and readable? The screen should be kept clean and suitable cleaning materials should be made available for users. Action Required (what, when & who by) Page 9 of 21

10 Risk Factor Yes No Comments The software settings may need adjusting if the text size is too small or too big. Action Required (what, when & who by) b) Is the screen image stable i.e. free from flicker/jitter? Try different screen colours and set ups if problems persist get the set-up checked e.g. by the equipment supplier. c) Is the screen suitable for its intended use? Intensive graphic work of fine detail may require a larger screen. d) Does it swivel and tilt? Swivel & tilt need not be built in and mechanisms can be added. e) Are brightness and/or contrast adjustable? f) Is the screen free of glare and reflection? Identify the source of any glare or reflection. You may need to move the screen and even the desk or you may need to shield the screen. 3. Keyboard a) Is the keyboard separate from the screen? If necessary portable computers can be used with a separate keyboard when at a fixed workstation. Page 10 of 21

11 Risk Factor Yes No Comments Action Required (what, when & who by) b) Does the keyboard tilt? Tilt need not be built in c) Can you find a comfortable keying position & technique? Hands shouldn t be bent up or down at the wrist, you shouldn t need to overstretch your fingers or apply more than a soft touch on the keys. There should be enough space to rest your hands in front of the keyboard. d) Are characters on the keys easy to read? Keyboards should be kept clean. There should not be glare or reflection from the keyboard. 4. Mouse, trackball etc. a) Is the device suitable for the tasks it is used for? If not try a different type. They are available in a wide variety of types, shapes and sizes. b) Is the mouse or trackball etc. positioned close to you? Most devices are best placed as close as possible e.g. next to the keyboard. You should be able to find a comfortable working position. c) Is there enough support for your wrist and forearm? E.g. from the desk Page 11 of 21

12 Risk Factor Yes No Comments surface or chair arm. If not a separate supporting device may help. Action Required (what, when & who by) d) Does the device work smoothly and at the right pace? Cleaning may be required. e) Can you easily adjust the speed and accuracy of the pointer with the software? 5. Desk/Working Surface a) Is the surface large enough for the monitor keyboard, documents, files etc? There should be scope for flexible arrangement of the equipment Consider the need for extra data &/or electrical sockets so equipment can be moved. Cables trailing across the floor should be avoided. b) Can you comfortably reach all the equipment, files and papers that you need to use? If necessary rearrange the equipment and files etc. c) Is the desk surface at a suitable height? If not the height may need adjusting. d) Is there sufficient legroom? Obstacles under the desk may prevent comfortable positioning Page 12 of 21

13 Risk Factor Yes No Comments of the feet. Action Required (what, when & who by) e) Is the desk surface free from reflection or glare? 6. Document Holder a) Do you have a document holder? See Section 5b if one is required. b) Is it at a suitable height and position relative to the screen? c) Is it adjustable & easy to use? 7. Chair a) Is it suitable, stable and in good repair? b) Is it adjustable (swivel, seat height, backrest height & tilt, armrest height)? Do the mechanisms work? c) Are your forearms horizontal and your eyes toughly at the same height as the top of the VDU? Adjust your chair to get your arms in the right position and then adjust the VDU height if necessary (it may need to be placed on something suitable) d) Are your feet flat on the floor without too much pressure on the backs of your legs? If not, you may need a footrest. See Section 8. Page 13 of 21

14 Risk Factor Yes No Comments Action Required (what, when & who by) e) Is the small of your back supported when working? There should be adequate space for your bottom between the seat and backrest to allow you to sit comfortably with your lower back supported by the backrest. f) Is your back straight and are your shoulders relaxed when working? Your back should be supported by the backrest and you should not need to lean forward. g) If your chair has arms do they allow you to get close enough to the keyboard etc? 8. Footrest a) Has a footrest been provided if necessary? b) If yes, is it adjusted so that your feet are flat without too much pressure from the seat on the backs of your legs? 9. Space a) Is there adequate space around your workstation to allow you to change position and vary movements? You need space to move around and to fidget it is not good to stay in one position for a long time. 10. Lighting Page 14 of 21

15 Risk Factor Yes No Comments Action Required (what, when & who by) a) Is there adequate natural or artificial lighting? Users should be able to control light levels to your satisfaction e.g. by blinds & light switches. Problem light sources could be shaded or repositioned. Local lighting may be necessary. b) Are windows fitted with blinds or other protective coverings that work? c) Is the workstation free from reflection and /or glare? This can arise from natural or artificial lighting. Use a mirror to find the source of reflections. 11. Environmental factors a) Are temperature, ventilation and humidity levels comfortable? Can heating be satisfactorily controlled? Does humidity need to be increased? b) Are noise levels comfortable? 12. Software a) Is the software suitable for the task? b) Is software easy to use? c) Does the software give adequate feedback where necessary (e.g. Page 15 of 21

16 Risk Factor Yes No Comments suitable help and error messages). Action Required (what, when & who by) d) Do you require training / further training on the use of the software? 13. Other comfort problems. a) Has the checklist covered all the problems you might have working with your DSE? b) Have you experienced any discomfort or other symptoms, which you think is related to your VDU? Assessment carried out by: Signature: Date: Follow up action to be completed by: Reviews This assessment will need to be reviewed if: a) Significant changes are made to equipment, software or furniture. b) Workstations are re-sited. c) The nature of the work changes significantly. d) New users start or existing users change workstations. Review date: Reviewed by: Follow up action to be completed by: Page 16 of 21

17 Annex E DSE EFFECTS ON HEALTH DSE Equipment Many of the health problems associated with using DSE such as pains in the arms, shoulders or neck are attributed to poor workstation design. Display screens and equipment that is used with them should be adaptable to individual needs, e.g. detachable keyboards, tilt / swivel facilities, chairs with variable height and back support. Members of staff are therefore encouraged to make appropriate adjustments before commencing work. It is also important that a clear and stable image is maintained on the screen, as drifting or flickering can lead to eyestrain or headaches. Any problems with the image on the screen should therefore be reported promptly. Lighting Inappropriate or inadequate lighting can lead to headaches and eye problems. Direct glare from windows or lights or reflections on the display screen can be a particular problem and should be eliminated or minimised by using curtains or blinds. Reflected glare can also be minimised by choosing equipment with features such as matt keyboard surrounds. When positioning equipment, the light sources within a room (both natural and artificial) should be taken into account and adjustments should be made accordingly. Ventilation and Humidity Where a number of DSE are in operation within a work area, a certain amount of heat may be generated and attention should be given to humidity and ventilation in order to avoid drowsiness and soreness or dryness of eyes. Noise Generally noise from equipment such as printers at DSE workstations should be kept to levels which do not impair concentration or prevent normal conversation. If this is not the case methods of reducing the level of noise should be considered including possible solutions such as using partitions, sound proofing or repositioning of equipment. Rest Breaks A rest break means a break from the use of DSE, to carry out alternative work. In order to make efficient use of staff the Trust will endeavour to ensure that alternative work is available at regular intervals. In some cases, it may be necessary to rearrange job content to ensure sufficient opportunities for breaks arise. Where practicable, breaks should be taken away from the screen. Fixed breaks should be avoided unless there is no alternative, as they reduce flexibility for both employers and employee. Short frequent breaks or changes in activity are recommended e.g. 2-3 minutes every half an hour. Eye and Eyesight Medical evidence shows that using DSE equipment is not associated with damage to eyes or eyesight; nor does it make existing defects worse. But some workers may experience temporary visual fatigue, leading to a range of symptoms such as impaired visual performance, red or sore eyes and headaches, or the adoption of awkward posture which can cause further discomfort in the limbs. These may be caused by: staying in the same position and concentrating for a long time; poor positioning of the display screen equipment; Page 17 of 21

18 poor legibility of the screen or source documents; poor lighting, including glare and reflections; a drifting or flickering images on screen. Like other visually demanding tasks, DSE work does not cause eye damage but it may make workers with pre-existing vision defects more aware of them. Such uncorrected defects can make work with a display screen more tiring or stressful than would otherwise be the case. Photosensitive Epilepsy DSE work does not cause epilepsy and a person suffering from this complaint should not be prevented from undertaking DSE work. However, one type of epilepsy photosensitive epilepsy can make the sufferer susceptible to flickering lights or striped patterns. It is relatively rare, however, and its onset usually occurs in the 10 to 14 age range, it is very unlikely that someone of employable age would be unaware of the problem. Advice should be sought from local offices of the Employment Medical Advisory Service if someone suffering from this condition wishes to operate a display screen. Skin Complaints There have been some reports of DSE users suffering from skin irritation or redness. Such problems may be due to the electrostatic field generated by the DSE and / or dry atmosphere. Filters, anti-static carpeting and humidity adjustments may alleviate any difficulties. In some cases, such symptoms may of course be quite unconnected with DSE work and a visit to your General Practitioner is advisable if problems persist. Musculoskeletal Problems Where DSE operators complain of discomfort in the neck, shoulders or arms, adjustments to their workstation, environment, work pattern, posture or technique will usually provide the answer. It is likely that combinations of factors are concerned. Prolonged static posture of the back, neck and head are known to cause musculoskeletal problems. Awkward positioning of the hands and wrist (e.g. as a result of poor working technique or inappropriate work height) are further likely factors. Outbreaks of soft tissue disorders among keyboard workers have often been associated with high workloads combined with tight deadlines. The research does suggest that for a number of people, these problems can develop into a chronic and persistent condition. Such conditions have until recently fallen under the general heading of Repetitive Strain Injury (RSI) and involve recurrent or persistent pain, disability or loss of function in any part of the body, but mainly in the upper limbs and neck. They are now more commonly known as work related upper limb disorders (WRULDS). This variety of factors contributing to display screen work risk requires a risk reduction strategy, which embraces proper equipment, furniture, training, job design and work planning. There has been much debate regarding how such conditions develop and what should be done in terms of prevention and cure. Any member of staff experiencing persistent problems in this area should consult with their General Practitioner for a proper diagnosis and advice. Page 18 of 21

19 Good equipment and workstation design, linked with training in the health and safety aspects of working with DSE should help to prevent these problems. Radiation and Pregnancy Scientific research has concluded that there is no risk from radiation emitted by DSE. There is no evidence to suggest that it causes miscarriages, and pregnant women should therefore be advised accordingly and encouraged to continue working with DSE. However, it is clear that a pregnant woman should avoid anxiety and stress and so members of staff who are concerned about adverse reports should be given the opportunity to discuss the matter with a suitably qualified person. Page 19 of 21

20 Annex F DSE EXERCISES Workplace Exercises For the Neck Sit up straight with your shoulders square to your desk then perform the following three exercises: Turn your head as far to the right as possible, without moving your shoulders. Then turn your head to the left. Look straight ahead. Gently drop the ear to one shoulder, then lift your head and let it gently fall to the other side. Finish this series with head half-circles. Drop your chin to your chest, and roll your ear to your shoulder. Roll your head forward and then to the other side. Workplace Exercises for the Arms, Hands and Fingers Extend your arms directly out in front of you. Fan your fingers, palm down, then make a tight fist with each hand. Repeat this move two or three times. Shake your hands and fingers vigorously. Turn your palms toward the ceiling, curl your fingers in one at a time to make a fist. With one wrist flexed, grasp one hand with the other, and gently pull back on the hand, holding for three to five seconds. Point fingers toward the floor and gently pull, holding three to five seconds and repeat. Repeat both exercises on the other hand. Workstation Ergonomics...Good Sitting Sense Set up your workstation to minimise stress on your muscles and joints and encourage good sitting posture: Ears, shoulders and hips should line up. Maintain the natural curves of the spine. The top of the monitor screen should be at or slightly below eye level. When your fingers are on the keyboard, maintain at least a 90-degree angle at the elbow joint. Curve your fingers (like a piano player) when striking the keys. Adjust your backrest to allow firm support in the lumbar region of the spine. Your thighs should be parallel to the floor with your knees slightly lower than your hips. Allow enough space between your knees and the table top to shift your position easily. Workplace Exercises: Deep Breathing Sit in a relaxed position, with your back straight and your eyes closed. Take three deep breaths. Inhale through your nose and exhale through your mouth. Exhale twice as slow as you inhale. Page 20 of 21

21 Workplace Exercises: Deep Breathing Sit in a relaxed position, with your back straight and your eyes closed. Take three deep breaths. Inhale through your nose and exhale through your mouth. Exhale twice as slow as you inhale. Workplace Exercises for the Shoulders and Upper Back Shrug your shoulders by elevating both of your shoulders towards your ears and then drop them. Repeat three or four times. Place your hands on your shoulders, and touch your elbows in front of your chest. Now try to touch your elbows behind your back. Repeat three times. Place your hands on top of your shoulders. Draw a big circle with your elbows, three or four times. Repeat in the opposite direction. Overhead reach: Start with your arms dangling outside the armrest of your chair. Slowly raise your arms by your sides until they are directly over your head. Reach toward the ceiling for a few seconds then lower your arms to the starting position. Repeat two or three times. Workplace Exercises for the Lower Back Push your chair away from your desk. Lean forward as far as you can toward your knees, then dangle your fingertips toward the floor and hold that position for eight to ten seconds. Curl up slowly, returning to a seated position. Pull one knee to your chest and hold three to five seconds. Repeat using your other leg. Repeat the full sequence three times. Workplace Exercises for the Lower Legs Extend one leg. Point your toe, flex your foot and rotate your ankle in one direction and then in the other direction. Repeat the sequence using your other leg. Workplace Exercises for the Eyes In order to relieve the symptoms of strained, tired eyes, try these simple techniques: Rub your hands together and cup them over each eye. The warmth from your hands helps to relieve tension while shielding your eyes from the light. Gently massage around your eyes using your index and middle finger in a circular pattern. Look away from your screen and focus on something at least 20 feet away. Return your focus to your screen and repeat three times. To work the muscles surrounding your eyes, look to all four directions, left, right, up and down. Close your eyes tightly, then open them as wide as you can. Repeat three times. Page 21 of 21