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Weinhold KR, Light S, Bittoni AM, Zick S, Orchard TS. A remote Whole Food Dietary Intervention to Reduce Fatigue and Improve Diet Quality in Lymphoma Survivors: Results of a Feasibility Pilot Study. Nutr Cancer 2023; 75:937-947. [PMID: 36755357 DOI: 10.1080/01635581.2023.2173259] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Long-term, persistent cancer-related fatigue (CRF) is the most common side effect reported by lymphoma survivors. CRF reduces quality of life, and treatments are limited. This pilot study aimed to determine feasibility of recruiting and retaining diffuse large B-cell lymphoma (DLBCL) survivors in a 12-week remote Fatigue Reduction Diet (FRD) intervention and evaluate preliminary efficacy of the intervention. Participants met remotely with a registered dietitian nutritionist for eight individual sessions. FRD goals included consuming specific fruits, vegetables, whole grains, and omega-3 fatty acid rich foods. Acceptability was assessed by session attendance, FRD goal attainment, and exit surveys. Self-reported dietary intake and fatigue were measured using the Healthy Eating Index-2015 and PROMIS Fatigue Short Form, respectively, at baseline and post-intervention. Ten DLBCL survivors enrolled; nine attended all sessions and completed the intervention. Weekly adherence to targeted food intake goals improved significantly throughout the study (all p < 0.05), with participants meeting goals over 4 day per week by week 11. Mean[SD] diet quality improved significantly from baseline (65.9[6.3]) to post-intervention (82.2[5.0], p < 0.001). Mean[SD] fatigue reduced significantly from baseline (50.41[9.18]) to post-intervention (45.79[6.97], p < 0.05). The 12-week remote FRD intervention was feasible, acceptable, and holds promise to improve diet quality and fatigue in DLBCL survivors.
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Affiliation(s)
- Kellie R Weinhold
- Human Sciences Department, The Ohio State University, Columbus, Ohio, USA
| | - Sarah Light
- Human Sciences Department, The Ohio State University, Columbus, Ohio, USA
| | - Anna Maria Bittoni
- Department of Nutrition Services, The Ohio State University Wexner Medical Center and Arthur G. James Cancer hospital and Richard J. Solove Research Institute, Columbus, Ohio, USA
| | - Suzanna Zick
- Department of Family Medicine and Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Tonya S Orchard
- Human Sciences Department, The Ohio State University, Columbus, Ohio, USA
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Weinhold KR, Andridge RR, Bomser JA, Sasaki GY, Bruno RS, Orchard TS. Sugars measured enzymatically in a fasting overnight urine sample are not sensitive biomarkers of dietary added sugar intake in postmenopausal women. Nutr Health 2022:2601060221106819. [PMID: 35679080 DOI: 10.1177/02601060221106819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Restricting dietary sugar is a leading recommendation, but limited biomarkers assessing intake exist. Although 24-h urinary sucrose (U-Suc) and urinary fructose (U-Fruc) excretion has been used with mixed success, collection is burdensome. AIM This study aimed to test the sensitivity of an enzymatic assay of U-Suc and U-Fruc to detect changing added sugar intake using low-burden overnight urine samples in 30 postmenopausal women. METHODS Women consumed usual dietary intake during day 1 and usual intake plus a sugar sweetened beverage during day 2. Weighed, photographed food records assessed intake. Enzymatic assay measured U-Suc and U-Fruc from fasting overnight samples; liquid chromatography mass spectrometry (LC-MS) validated U-Suc findings. RESULTS Dietary added sugars increased significantly during day 2 (p < 0.001), but urinary sugars were not significantly increased. Enzymatic assay detected urinary sugars in 75% (U-Suc) and 35% (U-Fruc) of samples. Dietary sucrose was not associated with U-Suc, however dietary fructose was significantly associated with U-Fruc [β = 0.031; p < 0.05] among women with detectable urinary sugars. Participants with detectable U-Fruc consumed more energy from added sugars [12.6% kcal day 1; 21.5% kcal day 2] than participants with undetectable U-Fruc [9.3% kcal day 1; 17.4% kcal day 2], p < 0.05. Using LC-MS, U-Suc predicted sucrose and added sugar intake [β = 0.017, β = 0.013 respectively; both p < 0.05]. CONCLUSIONS Urinary sugars measured enzymatically from overnight urine samples were not sensitive biomarkers of changing added sugar intake in postmenopausal women. However, urinary fructose measured by enzymatic assay or LC-MS may differentiate low versus high added sugar consumers.
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Affiliation(s)
- Kellie R Weinhold
- Human Sciences Department, College of Education and Human Ecology, 2647The Ohio State University, Columbus, OH, USA
| | - Rebecca R Andridge
- Division of Biostatistics, College of Public Health, 2647The Ohio State University, Columbus, OH, USA
| | - Joshua A Bomser
- Human Sciences Department, College of Education and Human Ecology, 2647The Ohio State University, Columbus, OH, USA
| | - Geoffrey Y Sasaki
- Human Sciences Department, College of Education and Human Ecology, 2647The Ohio State University, Columbus, OH, USA
| | - Richard S Bruno
- Human Sciences Department, College of Education and Human Ecology, 2647The Ohio State University, Columbus, OH, USA
| | - Tonya S Orchard
- Human Sciences Department, College of Education and Human Ecology, 2647The Ohio State University, Columbus, OH, USA
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Johnson KM, Weinhold KR, Andridge R, Arnold K, Chu PP, Orchard TS. Associations of Erythrocyte Polyunsaturated Fatty Acids with Inflammation and Quality of Life in Post-Menopausal Women with Obesity Completing a Pilot Dietary Intervention. Nutrients 2019; 11:nu11071589. [PMID: 31337035 PMCID: PMC6683028 DOI: 10.3390/nu11071589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 12/03/2022] Open
Abstract
Study objectives were to determine if erythrocyte omega-3 polyunsaturated fatty acids (n-3 PUFAs) increased in women participating in a dietary intervention that reduced inflammation and body weight and examine PUFA associations with markers of inflammation and quality of life (QOL). An experimental pre-post test, single group design was used. Fifteen post-menopausal women with obesity were enrolled in a 12-week pilot intervention focusing on lowering added sugars and increasing fiber and fish rich in n-3 PUFAs. Measurements included fasting blood samples, anthropometric, lifestyle and dietary data collected at baseline, end of intervention (Week 12) and follow-up (Week 24). Primary outcomes were change in erythrocyte PUFAs and associations between erythrocyte PUFAs, QOL (Short Form 12), and inflammatory markers (interleukin-6, tumor necrosis factor-α-receptor 2, and high sensitivity C-reactive protein (CRP)). Fourteen women completed all intervention visits. Mean erythrocyte docosahexaenoic acid and arachidonic acid (AA) increased at Week 12 and Week 24 (p < 0.001 for both), while eicosapentaenoic acid increased at Week 24 (p < 0.01). After adjustment for percent weight change, week 12 QOL related to physical function was significantly associated with erythrocyte linoleic acid (p < 0.05) and trended toward significant association with EPA (p = 0.051); week 24 CRP was directly associated with erythrocyte AA (p < 0.05). Erythrocyte n-3 PUFAs were not associated with inflammation.
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Affiliation(s)
- Kylie M Johnson
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH 43210, USA
| | - Kellie R Weinhold
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH 43210, USA
| | - Rebecca Andridge
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH 43210, USA
| | - Kristen Arnold
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH 43210, USA
| | - Panchita P Chu
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH 43210, USA
| | - Tonya S Orchard
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, Columbus, OH 43210, USA.
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Arnold K, Weinhold KR, Andridge R, Johnson K, Orchard TS. Improving Diet Quality Is Associated with Decreased Inflammation: Findings from a Pilot Intervention in Postmenopausal Women with Obesity. J Acad Nutr Diet 2018; 118:2135-2143. [PMID: 30139630 DOI: 10.1016/j.jand.2018.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/15/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chronic inflammation is associated with obesity, morbidity, and mortality in postmenopausal women. OBJECTIVE The objective of this pilot study was to determine preliminary feasibility and efficacy of a dietary intervention to improve diet quality and lower inflammation. DESIGN The study had a single-arm, pre- and posttest design. PARTICIPANTS/SETTING Fourteen postmenopausal women (body mass index >30 [calculated as kg/m2]) from the greater Columbus, OH, area participated between August 2015 and April 2016. INTERVENTION This was a 12-week individualized dietary intervention targeting lower consumption of added sugars and increased fiber and fatty fish. MAIN OUTCOME MEASURES Primary outcomes of this analysis were serum tumor necrosis factor α receptor-2 (TNFαR-2), interleukin-6 (IL-6), and high sensitivity C-reactive protein (hsCRP); other outcomes included intake of targeted food components and Healthy Eating Index-2010 (HEI-2010) scores calculated from food frequency questionnaires at baseline, end of intervention (week 12 [WK12]), and 24-week (WK24) follow-up. STATISTICAL ANALYSES PERFORMED Repeated measures analysis of variance and partial Pearson correlations, respectively, were used to assess changes in outcomes and associations between dietary variables and inflammatory markers, controlling for percent weight change. RESULTS Mean levels of TNFαR-2 decreased pre- to postintervention (P<0.01) and remained reduced at WK24 (P<0.001). Mean intake of added sugars and n-3-rich fish improved from baseline to WK12 and remained better at WK24 (all P<0.001); mean fiber intake did not change significantly (P=0.66; baseline to WK24). Mean HEI-2010 score increased (P<0.001; baseline to WK12). Change in HEI-2010 score inversely correlated with change in TNFαR-2 (P<0.05; baseline to WK24). Change in added sugars directly correlated with change in TNFαR-2 (P<0.05; baseline to WK24), but inversely correlated with change in hsCRP (P<0.05; baseline to WK12, and WK12 to WK24). All participants lost weight by WK12 (P<0.001). CONCLUSIONS These pilot intervention findings suggest that improving diet quality is associated with decreases in TNFαR-2.
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Orchard TS, Gaudier-Diaz MM, Weinhold KR, Courtney DeVries A. Clearing the fog: a review of the effects of dietary omega-3 fatty acids and added sugars on chemotherapy-induced cognitive deficits. Breast Cancer Res Treat 2016; 161:391-398. [PMID: 27933449 DOI: 10.1007/s10549-016-4073-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/29/2016] [Indexed: 02/07/2023]
Abstract
Cancer treatments such as chemotherapy have been an important part of extending survival in women diagnosed with breast cancer. However, chemotherapy can cause potentially toxic side effects in the brain that impair memory, verbal fluency, and processing speed in up to 30% of women treated. Women report that post-chemotherapy cognitive deficits negatively impact quality of life and may last up to ten years after treatment. Mechanisms underlying these cognitive impairments are not fully understood, but emerging evidence suggests that chemotherapy induces structural changes in the brain, produces neuroinflammation, and reduces adult hippocampal neurogenesis. Dietary approaches that modify inflammation and neurogenesis are promising strategies for reducing chemotherapy-induced cognitive deficits in breast cancer survivors. In this review, we describe the cognitive and neuronal side effects associated with commonly used chemotherapy treatments for breast cancer, and we focus on the often opposing actions of omega-3 fatty acids and added sugars on cognitive function, neuroinflammation, and adult hippocampal neurogenesis. Omega-3 fatty acids administered concurrently with doxorubicin chemotherapy have been shown to prevent depressive-like behaviors and reduce neuroinflammation, oxidative stress, and neural apoptosis in rodent models. In contrast, diets high in added sugars may interact with n-3 FAs to diminish their anti-inflammatory activity or act independently to increase neuroinflammation, reduce adult hippocampal neurogenesis, and promote cognitive deficits. We propose that a diet rich in long-chain, marine-derived omega-3 fatty acids and low in added sugars may be an ideal pattern for preventing or alleviating neuroinflammation and oxidative stress, thereby protecting neurons from the toxic effects of chemotherapy. Research testing this hypothesis could lead to the identification of modifiable dietary choices to reduce the long-term impact of chemotherapy on the cognitive functions that are important to quality of life in breast cancer survivors.
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Affiliation(s)
- Tonya S Orchard
- Department of Human Sciences, The Ohio State University, 325 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA.
| | - Monica M Gaudier-Diaz
- Department of Neuroscience, The Ohio State University Wexner Medical Center, 614 Biomedical Research Tower, 460 West 12th Avenue, Columbus, OH, 43210, USA
| | - Kellie R Weinhold
- Department of Human Sciences, The Ohio State University, 325 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA
| | - A Courtney DeVries
- Department of Neuroscience, The Ohio State University Wexner Medical Center, 614 Biomedical Research Tower, 460 West 12th Avenue, Columbus, OH, 43210, USA
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Miller CK, Weinhold KR, Nagaraja HN. Impact of a Worksite Diabetes Prevention Intervention on Diet Quality and Social Cognitive Influences of Health Behavior: A Randomized Controlled Trial. J Nutr Educ Behav 2016; 48:160-9.e1. [PMID: 26787601 PMCID: PMC4788518 DOI: 10.1016/j.jneb.2015.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/02/2015] [Accepted: 12/04/2015] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To evaluate the impact of a worksite diabetes prevention intervention on secondary outcomes regarding the change in diet quality and components of the Health Action Process Approach (HAPA) theoretical framework. DESIGN Pretest-posttest control group design with 3-month follow-up. SETTING University worksite. PARTICIPANTS Employees aged 18-65 years with prediabetes (n = 68). INTERVENTION A 16-week group-based intervention adapted from the Diabetes Prevention Program. MAIN OUTCOME MEASURES Diet quality was assessed using the Alternative Healthy Eating Index 2010; HAPA components were assessed via written questionnaire. ANALYSIS Repeated-measures ANOVA compared the between- and within-group change in outcomes across time. RESULTS Significant difference occurred between groups for the change in consumption of nuts/legumes and red/processed meats postintervention and for fruits at 3-month follow-up (all P < .05); a significant increase in total Alternative Healthy Eating Index 2010 score occurred postintervention in the experimental group (P = .002). The changes in action planning, action self-efficacy, and coping self-efficacy from HAPA were significantly different between groups after the intervention; the change in outcome expectancies was significantly different between groups at 3-month follow-up (all P < .05). CONCLUSIONS AND IMPLICATIONS The worksite intervention facilitated improvement in diet quality and in planning and efficacious beliefs regarding diabetes prevention. Further research is needed to evaluate the long-term impact of the intervention.
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Affiliation(s)
- Carla K. Miller
- Professor, Department of Human Sciences, Human Nutrition, , 614-292-1391
| | - Kellie R. Weinhold
- Graduate Research Assistant, Department of Human Sciences, Human Nutrition,
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Weinhold KR, Miller CK, Marrero DG, Nagaraja HN, Focht BC, Gascon GM. A Randomized Controlled Trial Translating the Diabetes Prevention Program to a University Worksite, Ohio, 2012-2014. Prev Chronic Dis 2015; 12:E210. [PMID: 26605710 PMCID: PMC4674443 DOI: 10.5888/pcd12.150301] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Working adults spend much time at the workplace, an ideal setting for wellness programs targeting weight loss and disease prevention. Few randomized trials have evaluated the efficacy of worksite diabetes prevention programs. This study evaluated the efficacy of a worksite lifestyle intervention on metabolic and behavioral risk factors compared with usual care. Methods A pretest–posttest control group design with 3-month follow-up was used. Participants with prediabetes were recruited from a university worksite and randomized to receive a 16-week lifestyle intervention (n = 35) or usual care (n = 34). Participants were evaluated at baseline, postintervention, and 3-month follow-up. Dietary intake was measured by a food frequency questionnaire and level of physical activity by accelerometers. Repeated measures analysis of variance compared the change in outcomes between and within groups. Results Mean (standard error [SE]) weight loss was greater in the intervention (−5.5% [0.6%]) than in the control (−0.4% [0.5%]) group (P < .001) postintervention and was sustained at 3-month follow-up (P < .001). Mean (SE) reductions in fasting glucose were greater in the intervention (−8.6 [1.6] mg/dL) than in the control (−3.7 [1.6] mg/dL) group (P = .02) postintervention; both groups had significant glucose reductions at 3-month follow-up (P < .001). In the intervention group, the intake of total energy and the percentage of energy from all fats, saturated fats, and trans fats decreased, and the intake of dietary fiber increased (all P < .01) postintervention. Conclusion The worksite intervention improved metabolic and behavioral risk factors among employees with prediabetes. The long-term impact on diabetes prevention and program sustainability warrant further investigation.
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Affiliation(s)
| | - Carla K Miller
- The Ohio State University, 1787 Neil Ave, 325 Campbell Hall, Columbus, OH 43210.
| | - David G Marrero
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Gregg M Gascon
- The Ohio State University Health Plan, Inc, Columbus, Ohio
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Miller CK, Nagaraja HN, Weinhold KR. Early weight-loss success identifies nonresponders after a lifestyle intervention in a worksite diabetes prevention trial. J Acad Nutr Diet 2015; 115:1464-71. [PMID: 26095435 DOI: 10.1016/j.jand.2015.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 04/27/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND People with prediabetes are at increased risk for developing type 2 diabetes mellitus. Weight reduction through lifestyle modification can significantly reduce diabetes risk. Yet, weight loss varies among individuals and some people do not achieve clinically meaningful weight loss after treatment. OBJECTIVE Our aim was to evaluate the time point and threshold for achieving ≥5% weight loss after completion of a 16-week worksite, lifestyle intervention for diabetes prevention. DESIGN Weight change before and after the behavioral intervention among participants randomized to the experimental group was examined. PARTICIPANTS/SETTING Individuals with prediabetes aged 18 to 65 years with a body mass index (calculated as kg/m(2)) of 25 to 50 at Ohio State University were eligible. INTERVENTION The 16-week, group-based intervention, adapted from the Diabetes Prevention Program, was delivered to 32 participants in the experimental group. MAIN OUTCOME MEASURES Percent weight loss was assessed weekly during the intervention and at 4- and 7-month follow-up. STATISTICAL ANALYSES PERFORMED Linear regression modeled the relationship between percent weight loss during month 1 of the intervention and percent weight loss at 4 and 7 months. Logistic regression modeled failure to lose ≥5% weight loss at 4 and 7 months using weekly weight change during the first month of intervention. RESULTS Percent weight loss at intervention week 5 was significantly associated with percent weight loss at 4 and 7 months (all P<0.001). Only 11.1% and 12.5% of participants who failed to achieve a 2.5% weight-loss threshold during month 1 achieved ≥5% weight loss at months 4 and 7, respectively. CONCLUSIONS The first month of lifestyle treatment is a critical period for helping participants achieve weight loss. Otherwise, individuals who fail to achieve at least 2.5% weight loss may benefit from more intensive rescue efforts or stepped-care interventions.
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Miller CK, Weinhold KR, Marrero DG, Nagaraja HN, Focht BC. A Translational Worksite Diabetes Prevention Trial Improves Psychosocial Status, Dietary Intake, and Step Counts among Employees with Prediabetes: A Randomized Controlled Trial. Prev Med Rep 2015; 2:118-126. [PMID: 25798374 PMCID: PMC4363734 DOI: 10.1016/j.pmedr.2015.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Few worksite trials have examined the impact of diabetes prevention interventions on psychological and behavioral outcomes. Thus, the impact of a worksite lifestyle intervention on psychosocial outcomes, food group intake, and step counts for physical activity (PA) was evaluated. METHOD A randomized pretest/posttest control group design with 3-month follow-up was employed from October 2012 to May 2014 at a U.S. university worksite among employees with prediabetes. The experimental group (n=35) received a 16-week group-based intervention while the control group received usual care (n=33). Repeated measures analysis of variance compared the change in outcomes between groups across time. RESULTS A significant difference occurred between groups post-intervention for self-efficacy associated with eating and PA; goal commitment and difficulty; satisfaction with weight loss and physical fitness; peer social support for healthful eating; generation of alternatives for problem solving; and intake of fruits, meat, fish, poultry, nuts, and seeds (all ps < .05). The experimental group significantly increased step counts post-intervention (p = .0279) and were significantly more likely to report completing their work at study end (p = .0231). CONCLUSION The worksite trial facilitated improvement in modifiable psychosocial outcomes, dietary patterns, and step counts; the long-term impact on diabetes prevention warrants further investigation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01682954.
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Affiliation(s)
- Carla K. Miller
- Department of Human Sciences, Human Nutrition, Ohio State University, 1787 Neil Ave., 325 Campbell Hall, Columbus, OH 43210, USA
| | - Kellie R. Weinhold
- Department of Human Sciences, Human Nutrition, Ohio State University, Columbus, OH, USA
| | - David G. Marrero
- Indiana University School of Medicine, 410 W. 10th Street, Room 1140, Indianapolis, IN 46202, USA
| | - Haikady N. Nagaraja
- Division of Biostatistics, College of Public Health, Ohio State University, Columbus, OH, USA
| | - Brian C. Focht
- Department of Human Sciences, Kinesiology, Ohio State University, Columbus, OH, USA
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