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Yuan D, Li Q, Zhan N, Zhang L, Wang J, Liu M, Geng F. Longitudinal associations of menstrual characteristics with mental health problems among Chinese girls. Eur Child Adolesc Psychiatry 2024; 33:2547-2556. [PMID: 38150148 DOI: 10.1007/s00787-023-02345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/28/2023] [Indexed: 12/28/2023]
Abstract
Cross-sectional studies indicate that menstrual problems are related to poorer mental health; however, longitudinal studies are limited. This longitudinal study aimed to determine whether baseline menstrual characteristics were risk factors for incident and persistent mental health problems. The study was conducted among Chinese adolescent girls. Menstrual characteristics including menarche, menstrual cycle and menstrual pain were assessed at baseline, whereas mental health problems including PTSD, depression, anxiety, ADHD, insomnia, psychotic-like experiences, non-suicidal self-injury, suicide ideation, suicide plan, and suicide attempt were assessed at baseline (n = 1039) and at the 1-year follow-up (n = 946) by self-administered, structured questionnaires. Multiple logistic regressions were performed to examine whether menstrual characteristics were associated with incident (e.g., PTSD at follow-up but not baseline) and persistent (e.g., PTSD at both time points) mental health problems. The results demonstrated that early menarche was related to persistence of psychotic-like experiences; irregular menstruation was associated with higher rates of incident anxiety and insomnia, and persistent depression, anxiety, ADHD, insomnia, non-suicidal self-injury, suicide ideation, and suicide plan; menstrual pain was associated with elevated rates of incident PTSD and depression, and persistent depression, insomnia, psychotic-like experiences, non-suicidal self-injury, suicidal ideation, suicide plan, and suicide attempt. In conclusion, irregular menstruation and menstrual pain specifically contributed to the development of emotional problems and insomnia, and were associated with maintenance of the most mental health problems in early adolescence. The long-term effects of menstrual problems on mental health need further study.
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Affiliation(s)
- Danyan Yuan
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China
| | - Qiaoqiao Li
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China
| | - Nalan Zhan
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China
| | - Lan Zhang
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China
| | - Jian Wang
- Shenzhen Mental Health Center, Shenzhen Kangning Hospital, Shenzhen, China
| | - Mingfan Liu
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China
| | - Fulei Geng
- School of Psychology, Jiangxi Normal University, 99 Ziyang Ave, Nanchang, 330022, Jiangxi, China.
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Shiraseb F, Mirzababaei A, Daneshzad E, Khosravinia D, Clark CCT, Mirzaei K. The association of dietary approaches to stop hypertension (DASH) and Mediterranean diet with mental health, sleep quality and chronotype in women with overweight and obesity: a cross-sectional study. Eat Weight Disord 2023; 28:57. [PMID: 37395824 DOI: 10.1007/s40519-023-01581-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/13/2023] [Indexed: 07/04/2023] Open
Abstract
PURPOSE Mental and sleep disorders are global public health problems, especially in Middle Eastern countries, and are significantly associated with circadian rhythm. This study sought to investigate the association between the dietary approaches to stop hypertension (DASH) and Mediterranean diet scores and mental health, sleep quality, and circadian rhythm. METHODS We enrolled 266 overweight and obese women, and depression, anxiety, and stress scale (DASS) score, Pittsburgh Sleep Quality Index (PSQI), and Morning-Evening Questionnaire (MEQ), were assessed. The Mediterranean and DASH diet score was measured using a validated semi-quantitative Food Frequency Questionnaire (FFQ). The physical activity was evaluated using the International Physical Activity Questionnaire (IPAQ). Analysis of variance and analysis of covariance, chi-square, and multinomial logistic regression tests were used as appropriate. RESULTS Our results showed that there was a significant inverse association between adherence to the Mediterranean diet and mild and moderate anxiety scores (p < 0.05). In addition, there was an inverse association between adherence to the DASH diet and the risk of severe depression and extremely severe stress scores (p < 0.05). Moreover, higher adherence to both dietary scores was associated with good sleep quality (p < 0.05). There was a significant relationship between circadian rhythm and the DASH diet (p < 0.05). CONCLUSION A significant association exists between a DASH and Mediterranean diet with sleep status, mental health, and chronotype in women of childbearing age with obesity and overweight. LEVEL OF EVIDENCE Level V, Cross-sectional observational study.
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Affiliation(s)
- Farideh Shiraseb
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), P.O. Box: 14155-6117, Tehran, Iran
| | - Atieh Mirzababaei
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), P.O. Box: 14155-6117, Tehran, Iran
| | - Elnaz Daneshzad
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Darya Khosravinia
- Department of Nutrition, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Cain C T Clark
- Centre for Intelligent Healthcare, Coventry University, Coventry, CV1 5FB, UK
| | - Khadijeh Mirzaei
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), P.O. Box: 14155-6117, Tehran, Iran.
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Sheikhi A, Siassi F, Djazayery A, Guilani B, Azadbakht L. Plant and animal protein intake and its association with depression, anxiety, and stress among Iranian women. BMC Public Health 2023; 23:161. [PMID: 36694166 PMCID: PMC9872399 DOI: 10.1186/s12889-023-15100-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/25/2022] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Mental disorders are conditions that affect the usual function of the brain, causing a huge burden on societies. The causes are often unclear, but previous research has pointed out, as is the case with many other diseases, that nutrition could have a major role in it. Amino acids, the building blocks of proteins, are the main precursor of neurotransmitters (the chemical messengers in the brain) malfunction of which is heavily associated with a wide range of brain disorders. METHODS We assumed different sources of dietary protein could have different impacts on mental well-being. Hence, we decided to collect the nutritional data (with a validated and reliable semi-quantitative food-frequency questionnaire) from a sample of 489 Iranian women and investigate the association between animal and plant protein sources and the risk of depression, anxiety, and stress. Symptoms of these mental disorders were assessed using a validated Depression, Anxiety, and Stress Scales (DASS) questionnaire with 21 items. RESULTS After multivariable adjustment, it was shown that women in the highest tertile of animal protein intake were more likely to show symptoms of depression (OR: 2.63; 95% CI: 1.45, 4.71; P = 0.001), anxiety (OR: 1.83; 95% CI: 1.04, 3.22; P = 0.03), and stress (OR: 3.66; 95% CI: 2.06, 6.50; p < 0.001). While no significant association was seen between plant protein and any of the studied mental disorders. CONCLUSION Overall, our findings suggest that a diet high in animal protein could predispose individuals to mental illnesses.
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Affiliation(s)
- Ali Sheikhi
- grid.411705.60000 0001 0166 0922Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box: 1416643931, Tehran, Iran
| | - Fereydoun Siassi
- grid.411705.60000 0001 0166 0922Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box: 1416643931, Tehran, Iran
| | - Abolghassem Djazayery
- grid.411705.60000 0001 0166 0922Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box: 1416643931, Tehran, Iran
| | - Bijan Guilani
- grid.46072.370000 0004 0612 7950Department of Clinical Psychology, University of Tehran, Tehran, Iran
| | - Leila Azadbakht
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P. O. Box: 1416643931, Tehran, Iran. .,Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, IR, Iran.
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Pestana JE, Islam N, Van der Eyk NL, Graham BM. What Pre-clinical Rat Models Can Tell Us About Anxiety Across the Menstrual Cycle in Healthy and Clinically Anxious Humans. Curr Psychiatry Rep 2022; 24:697-707. [PMID: 36255558 PMCID: PMC9633475 DOI: 10.1007/s11920-022-01376-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Anxiety symptoms increase during the peri-menstrual phase of the menstrual cycle in people with anxiety disorders. Whether this reflects a heightened variant of normal menstrual-related changes in psychological states experienced by healthy (i.e. non-anxious) people is unknown. Moreover, menstrual-related change in anxiety symptoms is a poorly understood phenomenon, highlighting a need for pre-clinical models to aid mechanistic discovery. Here, we review recent evidence for menstrual effects on anxiety-like features in healthy humans as a counterpart to recent reviews that have focused on clinically anxious populations. We appraise the utility of rodent models to identify mechanisms of menstrual effects on anxiety and offer suggestions to harmonise methodological practices across species to advance knowledge in this field. RECENT FINDINGS Consistent with reports in clinical populations, some evidence indicates anxiety symptoms increase during the peri-menstrual period in healthy people, although null results have been reported, and these effects are heterogeneous across studies and individuals. Studies in rats show robust increases in anxiety during analogous phases of the oestrous cycle. Studies in female rats are useful to identify the evolutionarily conserved biological mechanisms of menstrual-related changes in anxiety. Future experimental approaches in rats should model the heterogeneity observed in human studies to increase alignment across species and advance understanding of the individual factors that increase the propensity to experience menstrual-related changes in anxiety.
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Affiliation(s)
- Jodie E Pestana
- School of Psychology, The University of New South Wales Australia, Sydney, NSW, Australia
| | - Nusaibah Islam
- School of Psychology, The University of New South Wales Australia, Sydney, NSW, Australia
| | - Natasha L Van der Eyk
- School of Psychology, The University of New South Wales Australia, Sydney, NSW, Australia
| | - Bronwyn M Graham
- School of Psychology, The University of New South Wales Australia, Sydney, NSW, Australia.
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Mullarkey M, Dobias M, Sung J, Ahuvia I, Shumake J, Beevers C, Schleider J. Web-Based Single Session Intervention for Perceived Control Over Anxiety During COVID-19: Randomized Controlled Trial. JMIR Ment Health 2022; 9:e33473. [PMID: 35230962 PMCID: PMC9007232 DOI: 10.2196/33473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Anxiety is rising across the United States during the COVID-19 pandemic, and social distancing mandates preclude in-person mental health care. Greater perceived control over anxiety has predicted decreased anxiety pathology, including adaptive responses to uncontrollable stressors. Evidence suggests that no-therapist, single-session interventions can strengthen perceived control over emotions like anxiety; similar programs, if designed for the COVID-19 context, could hold substantial public health value. OBJECTIVE Our registered report evaluated a no-therapist, single-session, online intervention targeting perceived control over anxiety in the COVID-19 context against a placebo intervention encouraging handwashing. We tested whether the intervention could (1) decrease generalized anxiety and increase perceived control over anxiety and (2) achieve this without decreasing social-distancing intentions. METHODS We tested these questions using a between-subjects design in a weighted-probability sample of US adults recruited via a closed online platform (ie, Prolific). All outcomes were indexed via online self-report questionnaires. RESULTS Of 522 randomized individuals, 500 (95.8%) completed the baseline survey and intervention. Intent-to-treat analyses using all randomized participants (N=522) found no support for therapeutic or iatrogenic effects; effects on generalized anxiety were d=-0.06 (95% CI -0.27 to 0.15; P=.48), effects on perceived control were d=0.04 (95% CI -0.08 to 0.16; P=.48), and effects on social-distancing intentions were d=-0.02 (95% CI -0.23 to 0.19; P=.83). CONCLUSIONS Strengths of this study included a large, nationally representative sample and adherence to open science practices. Implications for scalable interventions, including the challenge of targeting perceived control over anxiety, are discussed. TRIAL REGISTRATION ClinicalTrials.gov NCT04459455; https://clinicaltrials.gov/show/NCT04459455.
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Affiliation(s)
- Michael Mullarkey
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Mallory Dobias
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Jenna Sung
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Isaac Ahuvia
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Jason Shumake
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Christopher Beevers
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Jessica Schleider
- Department of Psychology, Stony Brook University, Stony Brook, NY, United States
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Abstract
LEARNING OBJECTIVE After participating in this activity, learners should be better able to:• Discuss and outline the general and overlapping effects of the menstrual cycle on women's mental health. ABSTRACT A growing body of research demonstrates menstrual cycle-dependent fluctuations in psychiatric symptoms; these fluctuations can therefore be considered as prevalent phenomena. Possible mechanisms underlying these fluctuations posit behavioral, psychological, and neuroendocrine influences. Recent reviews document cyclic exacerbation of symptoms and explore these mechanisms in the context of specific and often single disorders. The question remains, however, as to whether there are general and overlapping effects of the menstrual cycle on women's mental health. To address this gap, we synthesized the literature examining the exacerbation of a variety of psychiatric symptoms across the menstrual cycle in adult women. Results show that the premenstrual and menstrual phases are most consistently implicated in transdiagnostic symptom exacerbation. Specifically, strong evidence indicates increases in psychosis, mania, depression, suicide/suicide attempts, and alcohol use during these phases. Anxiety, stress, and binge eating appear to be elevated more generally throughout the luteal phase. The subjective effects of smoking and cocaine use are reduced during the luteal phase, but fewer data are available for other substances. Less consistent patterns are demonstrated for panic disorder, symptoms of posttraumatic stress disorder, and borderline personality disorder, and it is difficult to draw conclusions for symptoms of generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and trichotillomania because of the limited data. Future research should focus on developing standardized approaches to identifying menstrual cycle phases and adapting pharmacological and behavioral interventions for managing fluctuations in psychiatric symptoms across the menstrual cycle.
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Zamani B, Daneshzad E, Siassi F, Guilani B, Bellissimo N, Azadbakht L. Association of plant-based dietary patterns with psychological profile and obesity in Iranian women. Clin Nutr 2019; 39:1799-1808. [PMID: 31399262 DOI: 10.1016/j.clnu.2019.07.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 05/02/2019] [Accepted: 07/19/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND A bidirectional association exists between psychological disorders and obesity. Also, diet could impact on both of these disorders. The aim of this study was to evaluate the association between plant-based dietary patterns and psychological profile and obesity. METHODS This cross-sectional study was performed in a sample of 435 Iranian women. A validated and reliable semi-quantitative food-frequency questionnaire was used to collect dietary data. Three dietary indices including an overall plant-based diet (PDI), healthful plant-based diet (hPDI), and unhealthful plant-based diet (uPDI) were determined. Body mass index (BMI) and waist circumference (WC) were used to define general and abdominal obesity, respectively. Psychological profile status was determined from the DASS-21 questionnaire. RESULTS We found that higher uPDI scores increased the odds of overall (PDI: 2.62; 95% CI 1.28-5.35, Ptrend = 0.01) and abdominal (PDI: 2.36; 95% CI 1.11-5.02, Ptrend = 0.03) obesity in comparison with lower scores. Moreover, an inverse association was observed between higher PDI and hPDI scores and depression (PDI: 0.41; 95% CI 0.23-0.71, Ptrend = 0.001, hPDI: 0.44; 95% CI 0.25-0.76, Ptrend = 0.003), anxiety (PDI: 0.56; 95% CI 0.33-0.94, Ptrend = 0.03, hPDI: 0.55; 95% CI 0.33-0.94, Ptrend = 0.03), and psychological distress (PDI: 0.44; 95% CI 0.26-0.75, Ptrend = 0.003, hPDI: 0.49; 95% CI 0.29-0.82, Ptrend = 0.009). For uPDI, higher scores were associated with depression (uPDI: 1.91; 95% CI 1.03-3.55, Ptrend = 0.03). CONCLUSIONS A plant-based diet, particularly healthful-rich plant foods were inversely associated with psychological disorders. Furthermore, unhealthy plant foods were associated with increased risk of obesity as well as depression.
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Affiliation(s)
- Behzad Zamani
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran; Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Elnaz Daneshzad
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Fereydoun Siassi
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Bijan Guilani
- Department of Clinical Psychology, University of Tehran, Tehran, Iran
| | | | - Leila Azadbakht
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran; Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Science, Isfahan, Iran.
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Psychometric Validation of the Mandarin Version Control Attitudes Scale-Revised Questionnaire in Taiwanese Patients With Heart Failure. J Cardiovasc Nurs 2018. [DOI: 10.1097/jcn.0000000000000431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hantsoo L, Epperson CN. Anxiety Disorders Among Women: A Female Lifespan Approach. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2017; 15:162-172. [PMID: 28966563 DOI: 10.1176/appi.focus.20160042] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Anxiety symptoms may present differently between women and men, and at different points in the female lifespan. The female lifespan includes distinct epochs of hormonal function, including puberty, the premenstruum, in some women pregnancy or postpartum, and the menopausal transition. These stages give rise to important treatment considerations when treating anxiety in women. When making assessments, the clinician should consider reproductive events and hormonal status, as well as sex differences in anxiety presentation. This review is structured to: 1) Define major epochs of the female lifespan, 2) Provide a brief summary of the major anxiety disorders, with a focus on prevalence and presentation in the context of sex differences and at points in the female lifespan, 3) Describe potential biopsychosocial underpinnings of anxiety disorders among women, 4) Provide guidelines for assessment and differential diagnosis, and 5) Describe treatment options with attention to reproductive events such as pregnancy.
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Affiliation(s)
- Liisa Hantsoo
- Clinical Psychologist & Instructor, Penn Center for Women's Behavioral Wellness, Perelman School of Medicine, University of Pennsylvania
| | - C Neill Epperson
- Professor of Psychiatry and Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania and Director of the Penn Center for Women's Behavioral Wellness and Penn PROMOTES Research on Sex and Gender in Health, Perelman School of Medicine, University of Pennsylvania
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Manikandan S, Nillni YI, Zvolensky MJ, Rohan KJ, Carkeek KR, Leyro TM. The role of emotion regulation in the experience of menstrual symptoms and perceived control over anxiety-related events across the menstrual cycle. Arch Womens Ment Health 2016; 19:1109-1117. [PMID: 27562823 PMCID: PMC6730650 DOI: 10.1007/s00737-016-0661-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/12/2016] [Indexed: 02/06/2023]
Abstract
Hormonal variation throughout the menstrual cycle is posited to impact various physical and mental health symptoms; however, this is not observed in all women and mechanisms are not well understood. Difficulty in emotion regulation may elucidate differences that women experience in physical and mental health functioning between menstrual phases. We examined the moderating role of difficulty in emotion regulation in the relation between menstrual phase and menstrual symptom severity and perceived control over anxiety-related events, in healthy, regularly menstruating women. The participants were 37 women (Mage = 26.5, SD = 9.6). A series of regression analyses were used to examine whether individual differences in emotion regulation difficulties moderate the relation between menstrual phase and our outcomes, severity of menstrual symptoms and perceived control over anxiety-related events, using a within-subjects design. The analyses revealed that difficulty in emotion regulation significantly moderated the relation between menstrual phase and perceived control over anxiety-related events (β = -0.42, p < .05), but not menstrual symptom severity. Women who reported higher emotion regulation difficulty experienced greater differences in perceived control over anxiety-related events between menstrual phases. Specifically, women with lower difficulty in emotion regulation report greater increase in control over anxiety during the late luteal phase compared to women with higher emotion regulation difficulty. Difficulty in emotion regulation may play an important role in understanding differences in menstrual phase-associated impairments, thereby informing the development of targeted interventions for vulnerable women.
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Affiliation(s)
| | - Yael I. Nillni
- National Center for PTSD Women’s Health Sciences Division at VA Boston Healthcare system, Boston, USA,Boston University School of Medicine, Boston, USA
| | | | | | | | - Teresa M. Leyro
- Rutgers, The State University of New Jersey, New Brunsick, USA
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