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Ostadmohammadi V, Namazi MJ, Rezasoltani M, Kheirkhah D, Rajabi M, Sharif A, Taghavi Ardakani A, Raygan F, Assareh AA, Sharif MR. Effects of Zinc Supplementation on Inflammatory Status and Nonalcoholic Steatohepatitis in Overweight or Obese Children: a Randomized Clinical Trial. Biol Trace Elem Res 2024; 202:3496-3503. [PMID: 37989929 DOI: 10.1007/s12011-023-03954-z] [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: 07/28/2023] [Accepted: 11/03/2023] [Indexed: 11/23/2023]
Abstract
The purpose of the present clinical trial was to determine the impact of zinc supplementation on serum liver enzymes, steatosis severity, lipid profile, and inflammatory status in overweight or obese children with nonalcoholic steatohepatitis (NASH). This randomized controlled trial was conducted by enrolling 60 children with NASH, aged 10-18 years old. The participants were randomly assigned to two groups that received either 30 mg/day of elemental zinc or placebo for 16 weeks. The severity of liver steatosis was evaluated using liver ultrasonography. Fasting blood samples were collected from each patient at the beginning and after 16 weeks of intervention to measure biochemical parameters. Following a 16-week intervention, zinc supplementation compared with placebo significantly decreased serum alanine aminotransferase (ALT) concentrations and high-sensitivity C-reactive protein and considerably enhanced HDL-cholesterol values. However, zinc intake had no considerable impact on aspartate aminotransferase, the severity of liver steatosis, anthropometric parameters, and other lipid indices versus the placebo group. Overall, zinc supplementation showed a promising impact on serum ALT, HDL-cholesterol, and inflammatory status in overweight or obese children suffering from NASH. Zinc supplementation may be a new strategy for the amelioration of NASH in overweight or obese children. This trial has been registered on the Iranian website for registration of clinical trials with the special ID of IRCT20200531047614N1 ( https://www.irct.ir/trial/48543 ).
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Affiliation(s)
- Vahidreza Ostadmohammadi
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.
- Clinical Research Development Unit, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran.
| | - Mohammad Javad Namazi
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
- Department of Health Sciences and Social Work, Western Illinois University, Macomb, USA
- School of Medicine, Islamic Azad Medical University, Tehran, Iran
| | - Mahsa Rezasoltani
- Clinical Research Development Unit, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
- School of Medicine, Islamic Azad Medical University, Tehran, Iran
| | - Davood Kheirkhah
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohammad Rajabi
- Department of Pediatrics, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Alireza Sharif
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Abbas Taghavi Ardakani
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Fariba Raygan
- Clinical Research Development Unit, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Amelia A Assareh
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Mohammad Reza Sharif
- Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran.
- Clinical Research Development Unit, Shahid Beheshti Hospital, Kashan University of Medical Sciences, Kashan, Iran.
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Vitamin D and Zinc are Interlinked but Affected by Different Growth Factors in Iranian Children and Adolescents: Vitamin D and Zinc in Iranian Children and Adolescents. IRANIAN JOURNAL OF PEDIATRICS 2022. [DOI: 10.5812/ijp-127158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: Zinc and vitamin D are essential factors required for growth. Recently, studies have shown a possible link between serum zinc and vitamin D levels. Objectives: This study was designed to evaluate this link and its possible affecting growth factors in children and adolescents in Iran. Methods: This cross-sectional study was performed on the data obtained from children aged 2 to 18 years old referring to a growth assessment clinic for routine growth follow-ups in the city of Shiraz from April to August 2019. A total of 454 children who were checked for 25-hydroxyvitamin D and zinc simultaneously were included. Results: Vitamin D was negatively correlated with body mass index (BMI) z-scores, while zinc was positively correlated with vitamin D and height z-scores. Subjects with vitamin D levels ≤ 8.6 ng/mL were 2.081 times more likely to have a zinc deficiency. Vitamin D insufficiency was significantly higher in overweight and obese children. Mean vitamin D and zinc levels were significantly lower, and vitamin D insufficiency was significantly higher in boys than girls. While mean zinc levels were significantly lower in short children, the prevalence of zinc deficiency was not statistically different between short and normal height statures. Conclusions: Very low vitamin D levels are likely to be accompanied by zinc deficiency, possibly caused by malnutrition and the modulatory effect of serum vitamin D on zinc absorption. Unlike zinc deficiency, vitamin D insufficiency is much more prevalent in Iranian children than in children from other countries. Vitamin D and zinc are associated with BMI and height z-scores, respectively.
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Hussain A, Jiang W, Wang X, Shahid S, Saba N, Ahmad M, Dar A, Masood SU, Imran M, Mustafa A. Mechanistic Impact of Zinc Deficiency in Human Development. Front Nutr 2022; 9:717064. [PMID: 35356730 PMCID: PMC8959901 DOI: 10.3389/fnut.2022.717064] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 01/31/2022] [Indexed: 12/15/2022] Open
Abstract
Zinc (Zn) deficiency in humans is an emerging global health issue affecting approximately two billion people across the globe. The situation prevails due to the intake of Zn deficient grains and vegetables worldwide. Clinical identification of Zn deficiency in humans remains problematic because the symptoms do not appear until impair the vital organs, such as the gastrointestinal track, central nervous system, immune system, skeletal, and nervous system. Lower Zn body levels are also responsible for multiple physiological disorders, such as apoptosis, organs destruction, DNA injuries, and oxidative damage to the cellular components through reactive oxygen species (ROS). The oxidative damage causes chronic inflammation lead toward several chronic diseases, such as heart diseases, cancers, alcohol-related malady, muscular contraction, and neuro-pathogenesis. The present review focused on the physiological and growth-related changes in humans under Zn deficient conditions, mechanisms adopted by the human body under Zn deficiency for the proper functioning of the body systems, and the importance of nutritional and nutraceutical approaches to overcome Zn deficiency in humans and concluded that the biofortified food is the best source of Zn as compared to the chemical supplementation to avoid their negative impacts on human.
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Affiliation(s)
- Azhar Hussain
- Department of Soil Science, The Islamia Diversity of Bahawalpur, Bahawalpur, Pakistan
| | - Wenting Jiang
- College of Life Sciences, Yan'an University, Yan'an, China
| | - Xiukang Wang
- College of Life Sciences, Yan'an University, Yan'an, China
| | - Shumaila Shahid
- Department of Soil Science, The Islamia Diversity of Bahawalpur, Bahawalpur, Pakistan
| | - Noreena Saba
- Qaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur, Pakistan
| | - Maqshoof Ahmad
- Department of Soil Science, The Islamia Diversity of Bahawalpur, Bahawalpur, Pakistan
| | - Abubakar Dar
- Department of Soil Science, The Islamia Diversity of Bahawalpur, Bahawalpur, Pakistan
| | - Syed Usama Masood
- Clinical Fellow Pediatric Nephrology, Children Hospital and Institute of Child Health Multan, Multan, Pakistan
| | | | - Adnan Mustafa
- Faculty of Chemistry, Institute of Chemistry and Technology of Environmental Protection, Brno University of Technology, Brno, Czechia
- Department of Agrochemistry, Soil Science, Microbiology and Plant Nutrition (FA), Mendel University, Brno, Czechia
- Institute of Environmental Studies, Charles University Prague, Prague, Czechia
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Correlation between Serum Zinc Levels and Levodopa in Parkinson's Disease. Nutrients 2021; 13:nu13114114. [PMID: 34836369 PMCID: PMC8621473 DOI: 10.3390/nu13114114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Long-term intake of potential zinc-chelating drugs may cause zinc deficiency. We postulated that zinc deficiency in Parkinson's disease (PD) patients was related to the intake of drugs such as levodopa. We investigated the relationship between zinc levels and levodopa administration period, dosage, and symptoms of zinc deficiency in PD patients. We measured serum zinc levels and analyzed correlations between serum zinc levels, the levodopa oral administration period, dosage, dosing frequency, and zinc deficiency symptoms including taste disorders. Data analyses were performed using Spearman's rank correlation coefficient. The mean serum zinc level was 60.5 ± 11.6 μg/dL. The mean administration period for levodopa was 8.0 ± 5.5 years, mean administration frequency 3.4 ± 0.9 times/d, and mean administration dose 420.6 ± 237.1 mg/d. Negative correlations between zinc levels and levodopa dosage and dosing frequency were found. Multiple regression analysis showed a significant correlation with the frequency of levodopa (β = -0.360, p = 0.007). No significant change in clinical symptoms was observed after zinc administration, but anxiety tended to improve. Our results indicated that frequent levodopa administration strongly influenced serum zinc levels which may have alleviating effects on psychiatric symptoms; therefore, preventing zinc deficiency can be important during PD treatment.
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Abstract
Since the discovery of manifest Zn deficiency in 1961, the increasing number of studies demonstrated the association between altered Zn status and multiple diseases. In this chapter, we provide a review of the most recent advances on the role of Zn in health and disease (2010-20), with a special focus on the role of Zn in neurodegenerative and neurodevelopmental disorders, diabetes and obesity, male and female reproduction, as well as COVID-19. In parallel with the revealed tight association between ASD risk and severity and Zn status, the particular mechanisms linking Zn2+ and ASD pathogenesis like modulation of synaptic plasticity through ProSAP/Shank scaffold, neurotransmitter metabolism, and gut microbiota, have been elucidated. The increasing body of data indicate the potential involvement of Zn2+ metabolism in neurodegeneration. Systemic Zn levels in Alzheimer's and Parkinson's disease were found to be reduced, whereas its sequestration in brain may result in modulation of amyloid β and α-synuclein processing with subsequent toxic effects. Zn2+ was shown to possess adipotropic effects through the role of zinc transporters, zinc finger proteins, and Zn-α2-glycoprotein in adipose tissue physiology, underlying its particular role in pathogenesis of obesity and diabetes mellitus type 2. Recent findings also contribute to further understanding of the role of Zn2+ in spermatogenesis and sperm functioning, as well as oocyte development and fertilization. Finally, Zn2+ was shown to be the potential adjuvant therapy in management of novel coronavirus infection (COVID-19), underlining the perspectives of zinc in management of old and new threats.
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Affiliation(s)
- Anatoly V Skalny
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Yaroslavl State University, Yaroslavl, Russia
| | - Michael Aschner
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Alexey A Tinkov
- IM Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia; Yaroslavl State University, Yaroslavl, Russia.
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Azemati B, Khoramdad M, Qorbani M, Rastad H, Shafiee G, Heshmat R, Kelishadi R. Percentile values of serum zinc concentration and prevalence of its deficiency in Iranian children and adolescents: the CASPIAN-V study. J Pediatr Endocrinol Metab 2020; 33:525-531. [PMID: 32134735 DOI: 10.1515/jpem-2019-0520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/31/2020] [Indexed: 11/15/2022]
Abstract
Background To determine the prevalence of serum zinc deficiency and provide the age- and sex-specific percentile values of serum zinc in children and adolescents. Methods We used the gathered data through the CASPIAN-V study, a national survey conducted on 3500 students aged 7-18 years from 30 provinces of Iran. In this study, 1370 blood samples were selected randomly, and serum zinc concentration was measured using a Hitachi automated analyzer. Zinc deficiency was defined as a serum zinc level of less than 75 μg/dL. Age-sex specific reference percentile values were developed for serum zinc concentration. Results The mean age of participants was 12.4 ± 3.0 years; 49.3% were girls and 73% were urban inhabitants. Mean (standard deviation [SD]) of serum zinc concentration was 107.23 (25.81) μg/dL with a significant sex difference; 109.03 ± 26.12 μg/dL for males compared to 105.41 ± 25.3 μg/dL for females (p = 0.009). The prevalence of subclinical zinc deficiency was 4.9% (95% confidence intervals [CI]: 3.0, 6.9) in children and adolescents. Both zinc deficient and sufficient groups were similar in terms of age, sex and residential areas (all p-value > 0.05). Overall, the 5th and 95th percentile values for serum zinc were 68.28 and 151.87 μg/dL, respectively. The value of all percentiles consistently decreased with age. The 10-99th percentile values for serum zinc were greater in boys than girls at all ages. Conclusions Nearly 5% of subjects had zinc deficiency. Age-sex specific percentile values were established for Iranian children and adolescents.
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Affiliation(s)
- Bahar Azemati
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Khoramdad
- Department of Epidemiology,School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
- Endocrinology and Metabolism Research Center, EMRI (Endocrinology and Metabolism Clinical Sciences Institute), Tehran University of Medical Sciences, 5th Floor, Shariati Hospital, North Kargar Ave., Tehran 1411413137, Iran, Phone: 88220094-95, Fax: 84902755
| | - Hadith Rastad
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Gita Shafiee
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Endocrinology and Metabolism Research Center, EMRI (Endocrinology and Metabolism Clinical Sciences Institute), Tehran University of Medical Sciences, 5th Floor, Shariati Hospital, North Kargar Ave., Tehran 1411413137, Iran, Phone: 88220094-95, Fax: 84902755
| | - Roya Kelishadi
- Department of Pediatrics, Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
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Anbari-Nogyni Z, Bidaki R, Madadizadeh F, Sangsefidi ZS, Fallahzadeh H, Karimi-Nazari E, Nadjarzadeh A. Relationship of zinc status with depression and anxiety among elderly population. Clin Nutr ESPEN 2020; 37:233-239. [PMID: 32359749 DOI: 10.1016/j.clnesp.2020.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/24/2019] [Accepted: 02/15/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIMS Population aging is a global challenge. Old populations are prone to zinc deficiency. This study aimed to determine the association of zinc status with depression and anxiety among men and women aged 60+ years old. METHODS In this cross-sectional study, 297 elderly participants (144 males and 153 females) were studied. The dietary and serum zinc were assessed using a three-day dietary record and an auto-analyzer, respectively. Depression and anxiety were measured using Geriatric Depression Scale and Hamilton Anxiety Rating Scale, respectively. Chi-squared test was used to compare qualitative variables. Multiple logistic regression analysis was conducted to assess relationship between zinc status and depression/anxiety. RESULTS The total zinc deficiency based on serum values was 23.2%. Dietary intake of zinc in 72.4%of participants was less than of the Estimated Average Requirement (EAR). The total depression prevalence was 42.2%. Moreover, 52.5% of the participants suffered from anxiety. The odds of depression among participants in the third tertile of serum zinc concentration was 51% lower than those in the first tertile (OR = 0.49, CI = 0.25-0.96, p = 0.03). No significant relationship was found between zinc intake and depression. Furthermore, serum or dietary zinc levels were not related to anxiety. CONCLUSIONS This study showed a considerable zinc deficiency and depression/anxiety in the old population. A significant relation was found between serum zinc concentration and depression. Further surveys, especially cohort studies and clinical trials are needed to confirm these results.
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Affiliation(s)
- Zainab Anbari-Nogyni
- Department of Aging Health, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Elderly Health Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Reza Bidaki
- Psychiatrist Associate Professor, Research Center of Addiction and Behavioral Sciences, Yazd, Iran; Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Farzan Madadizadeh
- Research Center of Prevention and Epidemiology of Non-Communicable Disease, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Departments of Biostatistics and Epidemiology, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Zohreh Sadat Sangsefidi
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Fallahzadeh
- Research Center of Prevention and Epidemiology of Non-Communicable Disease, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Departments of Biostatistics and Epidemiology, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Elham Karimi-Nazari
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Azadeh Nadjarzadeh
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
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Moshtagh M, Amiri R. Role of Zinc Supplementation in the Improvement of Acute Respiratory Infections among Iranian Children: A Systematic Review. TANAFFOS 2020; 19:1-9. [PMID: 33101426 PMCID: PMC7569495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Respiratory infectious disease is considered as one of the most serious problems among children in developing countries. The importance of zinc in the improvement of respiratory disease has been indicated. However, there are some unanswered questions and uncertainty. This systematic review aimed at assessing the therapeutic benefits of zinc supplementation on respiratory infections of Iranian children. MATERIALS AND METHODS Databases, such as PubMed, Scopus, Embase, Magiran, and IranDoc, were searched for randomized controlled trials published from January 1998 to December 2017 on Zinc supplementation for the treatment or improvement of acute respiratory disease among Iranian children, during March 2018. Studies were screened according to the PICO framework, and irrelevant studies were excluded. RESULTS A total of 5 studies conducted on 522 children were included in this review. Except for one study, others had indicated the beneficial effect of zinc supplement on improving signs and symptoms of respiratory infectious disease and earlier discharge from the hospital. CONCLUSION Although studies on the efficacy of zinc on respiratory infectious disease of children in Iran have not widely considered and more studies should be conducted, all published articles (except for one of them) had indicated the effectiveness of zinc supplementation on respiratory infections among children. Other criteria, such as age, gender, birth weight, diet, and type of respiratory infections, should be considered during zinc therapy. Controlling these confounding variables and measuring the level of blood zinc are necessary to understand how much zinc should be prescribed for respiratory treatment of children.
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Affiliation(s)
- Mozhgan Moshtagh
- Social Determinants of Health Research Center, Faculty of Health, Birjand University of Medical Sciences, Birjand,Iran
| | - Rana Amiri
- Visiting Scholar, Department of Geography and Environmental Sciences, Northumbria University, UK
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Prasad AS, Bao B. Molecular Mechanisms of Zinc as a Pro-Antioxidant Mediator: Clinical Therapeutic Implications. Antioxidants (Basel) 2019; 8:antiox8060164. [PMID: 31174269 PMCID: PMC6617024 DOI: 10.3390/antiox8060164] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/21/2019] [Accepted: 05/27/2019] [Indexed: 02/07/2023] Open
Abstract
The essentiality of zinc as a trace mineral in human health has been recognized for over five decades. Zinc deficiency, caused by diet, genetic defects, or diseases, can cause growth retardation, delayed sexual maturation, depressed immune response, and abnormal cognitive functions in humans. Zinc supplementation in zinc-deficient individuals can overcome or attenuate these abnormalities, suggesting zinc is an essential micro-nutrient in the body. A large number of in vitro and in vivo experimental studies indicate that zinc deficiency also causes apoptosis, cellular dysfunction, deoxyribonucleic acid (DNA) damage, and depressed immune response. Oxidative stress, due to the imbalance of reactive oxygen species (ROS) production and detoxification in the anti-oxidant defense system of the body, along with subsequent chronic inflammation, is believed to be associated with many chronic degenerative diseases such as diabetes, heart diseases, cancers, alcohol-related disease, macular degenerative disease, and neuro-pathogenesis. A large number of experimental studies including cell culture, animal, and human clinical studies have provided supportive evidence showing that zinc acts as an anti-oxidative stress agent by inhibition of oxidation of macro-molecules such as (DNA)/ribonucleic acid (RNA) and proteins as well as inhibition of inflammatory response, eventually resulting in the down-regulation of (ROS) production and the improvement of human health. In this article, we will discuss the molecular mechanisms of zinc as an anti-oxidative stress agent or mediator in the body. We will also discuss the applications of zinc supplementation as an anti-oxidative stress agent or mediator in human health and disease.
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Affiliation(s)
- Ananda S Prasad
- Department of Oncology, School of Medicine, Wayne State University and Karmanos Cancer Center, Detroit, MI 48201, USA.
| | - Bin Bao
- Department of Oncology, School of Medicine, Wayne State University and Karmanos Cancer Center, Detroit, MI 48201, USA.
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