Download Dietary Pattern and Lifestyle Factors Associated with Menopausal

Dietary Pattern and Lifestyle Factors 
Associated with Menopausal Symptoms
Maggie Chung, Alyssa Claxton, Gretchen Gibbons,
Stephanie LaPlant, Taylor Wang, Lauren Zuro
Advisor: Bonnie Beezhold, PhD, MHS, CHES
Introduction
Research Question
•
Do women on a plant-based diet have fewer menopausal
symptoms? Are there other lifestyle factors that also
impact menopause?
Hypothesis
•
Women who are vegetarians or vegans will report fewer
symptoms compared to those who are omnivores.
(Beezhold, Radnitz, Rinne, DiMatteo, 2015)1
Overview - Menopause
•
Menopause overview
•
Menopause symptoms
•
Hormone replacement
therapy
(Grant 20152, Opatrny 20083, Shumaker 20034)
Overview-Research Studies
•
Fewer menopausal symptoms associated with higher intake
of whole grains, F&V in Chinese postmenopausal women. 5
•
Decreased menopausal symptoms associated with high fiber
intake in women treated for breast cancer. 6
•
Plant-based diets are associated with favorable metabolic
profiles in pre- and post-menopausal women. 7
•
Vegan diet was associated with reduced HDL-C level in preand post-menopausal women. 8
5. Liu, 2015; 6. Gold, 2006; 7. Karelis, 2010; 8. Yee-Wen, 2014
Study Objectives
•
To investigate whether dietary patterns and behaviors
as well as specific foods were associated with symptoms
that occur during menopause in aging women.
•
To investigate whether demographic and lifestyle factors
were related to menopausal symptoms.
Methods – Study Design
•
Cross sectional survey study
•
Online delivery through convenience sampling using
SurveyMonkey
•
Eligibility requirements
• Females, ages 45-80 years old
• Willing to complete an online survey
Methods – Participant Recruitment
Methods – Survey
•
Survey completion
•
Survey components
•
•
Demographics
Lifestyle factors
Methods – Survey
• Severity of menopausal symptoms; Menopause-Specific
Quality of Life questionnaire (MENQOL)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hot flashes
Night sweats
Sweating
Being dissatisfied with personal life
Feeling anxious or nervous
Poor memory
Accomplishing less
Feeling depressed, down, or blue
Being impatient with others
Feelings of wanting to be alone
Increased facial hair
Changes in skin
Feeling bloated
Backaches
• Frequent urination
• Involuntary urination when
laughing or coughing
• Change in sexual desire
• Flatulence or gas pains
• Aching in muscles and joints
• Feeling tired or worn out
• Difficulty sleeping
• Aches in back of neck or head
• Decrease in physical strength
• Decrease in stamina
• Vaginal dryness during
intercourse
• Avoiding intimacy
Methods – Survey
•
Which of the following foods do you include in your
diet (at least monthly)?
• Meat (beef, pork, lamb); chicken or turkey; fish or
shellfish; eggs; dairy foods; none
•
Diet questions: foods, food groups, nutrients
• Fruits, vegetables, beverages, omega-3 fatty acids
Methods – Survey
FRUITS AND VEGETABLES
Apricots, plum, pear, apple
Berries (any type)
Citrus fruits (oranges, grapefruit,
tangerines)
Grapes
Pineapple, papaya, mango (fresh)
Broccoli, Brussels sprouts,
cauliflower, kale, mustard greens,
radish, turnips
Orange vegetables (carrots, sweet
potatoes, butternut squash,
pumpkin)
Spinach, Swiss chard, salad greens
Never or
less than
1X a mo
(1)
1-3X
Per
Mo
(2)
Once
A
Wk
(3)
2-4X
Per
Wk
(4)
5-6X
per
Wk
(5)
Once 2-3X 4-5X 6+X
a
per per per
Day
day day day
(6)
(7)
(8) (9)
Survey Validity & Reliability
Validity
•
Incorporated validated scales
•
•
Exercise and social support
Menopause-specific Quality of
Life questionnaire (MENQOL)
•
Use of clear and appropriate
language for survey questions
•
Pilot testing and feedback
•
Online delivery promoted large
geographic sample.
Reliability
•
Potentially unclear
questions were eliminated
•
Validated scales showed
strong internal consistency
and test-retest reliability
• MENQOL – Cronbach
alpha coefficient = 0.93
(0.81 to 0.89)
Methods - Statistical analysis
•
•
•
•
•
•
Correlational, differential analysis
Parametric statistics
Descriptive statistics
Pearson’s correlation coefficients and multiple linear
regression; Chi square tests
Independent t tests, ANOVA, ANCOVA
Significance - p < .05; SPSS version 23
Results
Menstrual Status
Perimenopausal
22.2%
n=109
Postmenopausal
77.8%
n=383
Diet Pattern
OMN
55.7%
n=248
VG
27.6%
n=123
VEG
16.6%
n=74
Vegetarian Types
•Semi-vegetarian
•Pescatarian
•Ovo-vegetarian
•Ovo-lactovegetarian
•Lactovegetarian
Location by Country
Canada 4.0%
n=18
Other 4.3%
n=19
United States
91.7%
n=408
Ethnicity
Asian 2.0%
n=9
Black 1.3%
n=6
Hispanic 3.1%
n=14
Other 4.0%
n=18
White
89.4%
n=398
Body Mass Index (BMI)
Overweight
23.0%
n=88
Obese
33.2%
n=127
Normal
43.9%
n=168
Education
Population Characteristics by Diet Type
Variables
Age
Country
(US/non-US)
Ethnicity
(white/other)
Education
(yrs beyond HS)
BMI
OMN
n=248
VEG
n=74
VG
n=123
Test
stat
p
value
Mean ± SD
Mean ± SD
Mean ± SD
445
59.17
± 7.85a
58.35
± 7.57b
55.15
± 6.29ab
F=12.28
<0.001
445
243 /
5ab
5a
27b
X2=57.9
4
<0.001
445
227 / 21
65 / 9
106 / 17
X2=2.73
0.255
445
7.46
± 3.63
8.03
± 3.77
6.96
± 3.39
F=2.09
0.125
395
29.02
± 7.12ab
25.89
± 5.77b
26.54
± 6.32a
F=8.23
<0.001
n
Same letters differ significantly
69 /
96 /
Menopausal Symptoms
Principle component analysis results:
Component 1:
Physical symptoms (17)
Component 2:
Mental symptoms (6)
Associations of Diet Type with Symptoms
Variables
N
Physical
symptoms
Mental
symptoms
r / p value
r / p value
Diet type (Omn/Vg)
371
-0.122 / 0.010
0.057 / 0.233
Total vegetables
432
-0.181 /<0.001
-0.142 / 0.003
Total fruits
431
-0.099 / 0.040
-0.100 / 0.039
Total flesh foods
431
0.173 /<0.001
-0.033 / 0.490
Beef
422
0.157 / 0.001
0.009 / 0.858
Total dairy foods
430
0.196 /<0.001
0.071 / 0.141
Total eggs
431
0.115 / 0.018
-0.043 / 0.378
Pearson’s correlation coefficients; p<.05 is significant
Multivariate Analysis – Predictors of
Menopausal Symptoms
PHYSICAL symptoms
Variable
β*
MENTAL symptoms
p
value
Variable
β*
p
value
Age
-0.234 <0.001 Social support
-0.246
<0.001
Vegan diet (N/Y)
-0.181
0.002 Age
-0.201
<0.001
BMI
0.157
0.004
-0.128
0.009
Sleep hrs/night
-0.106
0.040 Sweets intake freq
0.117
0.015
0.057 Sleep hrs/night
-0.096
0.046
0.107 Total exercise
-0.086
0.090
0.083
0.097
Sweets intake freq
Total exercise
0.103
-0.088
Berries intake
freq
BMI
R2
0.158
R2
0.187
Correlates with p values < .025 included in models. *Betas are standardized.
Comparison of Symptoms by Diet Groups
Symptoms
n
OMN
VEG
VG
n=248
n=74
n=123
F ratio
Adj
F ratio
Mean ±SD Mean ±SD Mean ±SD
Physical
symptoms
445
40.46
± 17.83a
41.12
± 17.78b
33.26
± 14.80ab
Mental
symptoms
445
13.64
± 6.32
15.35
± 7.97
13.87
± 7.27
** p<0.001, *p<0.05; ANOVA - same letters differ significantly.
1 ANCOVA adj means: 41.62a, 40.63b, 31.83ab, ƞ2= 0.062.
p
2 ANCOVA adj means: 14.12, 15.40b, 12.87b, ƞ2=0.016.
p
8.33**
1.78
12.83**1
3.52*2
Discussion
Vegan diet is associated with lower severity of physical
menopausal symptoms; vegans reported lower symptom
severity than those who ate animal foods.
•
Confirmed previously mentioned studies. 9,10
•
Vegan diet had highest dietary fiber intake vs
omnivorous diet. 11,12
9. Liu, 2015; 10. Gold, 2006; 11. Bani, 2013; 12. Park, 2011.
Sweets intake
•
Excess sugar consumption is linked to cell
aging, negative health ailments 13-15
•
Excess sugar consumption13 is linked to
deficiencies in memory, cognitive health, and
affects biological aging 16,17
13. World Health Organization, 2015; 14. Melton, 2000;
15. Mikulikova et al 2008; 16. Crane et al 2013; 17. Cassidy et al 2010
Methods
•
NIH Dietary Questionnaire II
We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or
less than 1-3 per
once a
month
month
(2)
(1)
Sweets (pastries, cakes, cookies,
brownies, candy, etc.)
Soft drinks (sugar-sweetened, non-diet)
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Results – Intake of Sweets / Soda
Variable
n
OMN
VEG
VG
p value*
Mean ± SD Mean ± SD Mean ± SD
Sweets
432
3.84
± 1.81a
3.44
± 1.87b
2.64
± 1.52ab
< .0011
Soda
424
1.61
± 1.28a
1.25
± 0.89b
1.13
± 0.55ab
< .0012
* ANOVA; groups with same letters differed significantly.
1 F = 18.8, ƞ2 = .08. 2 F = 8.8, ƞ2 = .04.
p
p
Results – Associations
Variables
n
Physical
symptoms
Mental
symptoms
(r/p)
(r/p)
Sweets intake
432 .167 / .001
.130 / .007
Soda intake
424
.118 / .015
.102 / .035
Total sweets intake
frequency
423
.179 / .001
.139 / .004
Pearson’s correlation coefficients; p<.05 is significant.
Results – Group Comparison
Total
sweets
variable
n
Never or
Less
rarely
frequently
eat sweets eat sweets
More
frequently
eat sweets
F ratio
Adj
F ratio
M ± SD
M ± SD
M ± SD
Physical
377
Symptoms
37.77 ±
17.55a
35.53 ±
13.98b
45.46 ±
20.47ab
11.33*
8.82*1
Mental
423
Symptoms
13.73 ±
7.11a
13.06 ±
5.99b
16.38 ±
7.63ab
8.07*
7.21*2
* p < .01; same letters differ significantly. 1 Adj means: 36.37, 35.64, 44.51, pƞ2 = 0.045.
2Adj means: 13.63, 13.26, 16.17, ƞ2 = 0.033
p
Discussion
Eating sweets was related to increased severity of
menopausal symptoms; females eating sweets more
frequently had higher symptom severity than those
who never or rarely ate sweets.
•
Intake of sweets was positively associated with the risk of
onset of menopausal symptoms18,19
•
Frequency of sweets intake was associated with chills20
18. Sabia et al 2008; 19. Herber-Gast & Mishra, 2013; 20. Ishizuka, 2008
Background – Berry Intake
•
Foods that contain phytoestrogens act as
antioxidants which may relieve menopausal
symptoms 21
•
Higher intake of flavonoids at midlife is
associated with greater wellbeing in the
elderly 22
21. Moreira et al, 2014; 22. Samieri et al, 2014
Methods
We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or 1-3 per
less than month
once a
(2)
month
(1)
Berries (any)
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Results – Intake of Berries
Variable
n
OMN
VEG
VG
Mean ± SD
Mean ± SD
Mean ± SD
Berry intake
419 3.72 + 1.65a
frequency
3.86 + 1.66b
p
value
4.54 + 1.87ab <.001*
* ANOVA, F ratio = 9.036, pƞ2= 0.042; groups with same letters differed significantly.
Results – Associations
Variables
Berry intake
frequency
n
Physical
Symptoms
(r/p)
Mental
Symptoms
(r/p)
119
- .208 / .000
- .188 / .000
Pearson’s correlation coefficients; p<.05 is significant.
Results – Comparison of Groups
Never or
Eat berries
rarely
weekly
eat berries
n
Eat
berries
daily
F
ratio
Adj
F ratio
M ± SD
M ± SD
M ± SD
Physical
373
Symptoms
44.84 ±
21.26a
38.38 ±
15.83
35.14 ±
15.56a
7.39*
3.78*1
Mental
420
Symptoms
16.15 ±
7.85a
13.80 ±
6.73
12.64 ±
5.97a
6.72*
4.93*2
* p < .05; groups with same letters differ significantly.
1 ANCOVA adj means: 43.41, 38.41, 36.61, ƞ2 = 0.02
p
2 ANCOVA adj means: 15.76, 13.88, 12.87, ƞ2 = 0.02
p
Discussion
Eating berries was related to decreased menopausal
symptoms; females eating berries daily had lower
symptoms than those never or rarely eating berries.
•
Decrease in estrogen during menopause increases oxidative
stress 23,24
•
Berry supplementation resulted in significant improvement
in symptoms 25
23. Manach et al, 2004; 24. Doshi et al, 2013; 25. Schrager et al, 2015
Background – Omega-3 Fats
•
Omega-3 fat26 supplementation decreased
depression symptoms and hot flash frequency 27
Animal Based
Plant Based
26. Mozaffarian et. al, 2011; 27. Freeman et. al, 2011
Methods
•
NIH Dietary Questionnaire II format; Omega-3
questionnaire (Sublette et al, 2011)
We are interested in whether you consume any of the following specific foods or beverages and how
frequently you do so.
ON AVERAGE OVER THE PAST YEAR
Never or
less than 1-3 per
once a
month
month
(2)
(1)
Walnuts or walnut oil, canola oil
Flaxseeds (ground) or flaxseed oil
Once
a
week
(3)
2-4
per
week
(4)
5-6
per
week
(5)
Once
a day
(6)
2-3
per
day
(7)
4-5
per
day
(8)
6+
per day
(9)
Results: Comparison of Groups
Variable
p
value
OMN
VEG
VG
M ± SD
M ± SD
M ± SD
Walnuts, canola
oil
2.53 ± 1.55
(n=238)
3.04 ± 1.78
(n=71)
3.11 ± 1.86
(n=116)
.0031
Flaxseed,
flaxseed oil
1.92 ± 1.58
(n=239)
2.51 ± 1.80
(n=73)
3.44 ± 2.01
(n=117)
<.0012
1ANOVA,
F ratio = 5.86, ƞ2= 0.027; 2ANOVA, F ratio = 29.56, ƞ2= 0.122
Results: Associations with
Symptoms
n
Physical
Symptoms
(r/p)
Mental
Symptoms
(r/p)
Walnuts
426
- .066 / .172
- .096 / .048
Flaxseeds
430
- .127 / .008
- .088 / .068
Total major ALA
sources
424
- .132 / .007
- .120 / .014
Frequency of
major ALA sources
Pearson’s correlation coefficients; p<.05 is significant.
Results: Comparisons of Groups
n
Never or Less freq More freq
rare freq of of major of major F ratio
major ALA
ALA
ALA
Adj
F ratio
M ± SD
M ± SD
M ± SD
Physical
424
Symptoms
40.37 ±
18.16a
39.57 ±
17.46
35.40 ±
15.87a
3.21*
1.56
Mental
424
Symptoms
14.95 ±
7.25a
14.13 ±
7.08
12.63 ±
6.18a
3.96*
3.47*1
* p < .05; groups with same letters differ significantly.
1 ANCOVA adj means: 14.94, 13.94, 12.86:, ƞ2= .016.
p
Discussion
Eating major ALA sources was associated with
decreased menopausal symptoms; those who ate
them more frequently vs never or rarely reported
less mental symptom severity.
•
•
Vegetarians reported better mood and higher PUFA than
omnivores 28
High ALA intake in vegetarians lowers the LA/ALA ratio 29
28. Beezhold et. al 2010; 29. Sanders 2009
Background
•
Diets rich in monounsaturated fatty acids
improved the quality of life for postmenopausal
women.30
•
Fast food consumption, starting in adolescents,
among those following a Western diet have a
stronger association with overweight/obesity,
and poor dietary outcomes.31
30. Anderson-Vasquez et. al, 2015; 31. Poti et. al, 2014
Methods
Which of the following best describes the type of meals you most frequently eat? .
ON AVERAGE OVER THE PAST YEAR
Never or
rarely
Convenience/Frozen Food
Home Cooked Meals
Eat out (fast food)
Eat at a full service restaurant
2-4
times
per
month
2-3
times
per
week
4-6
times
per
week
Once
per
day
2-3
times
per
day
Results – Comparison of Groups
Eating habits
Eat home-cook meals
Eat convenience
foods
Eat fast foods
Eat at full service
restaurants
OMN
VEG
VG
241
71
121
(n=243)
(n=71)
(n=122)
105
23
46
(n=240)
(n=72)
(n=115)
139
29
27
(n=240)
(n=72)
(n=117)
213
58
82
(n=245)
(n=72)
(n=121)
p
value*
.745
.199
.0001
.0022
*Chi-square; p<.05 is significant. 1X2(10, N= 429)= 44.06. 2X2(8, N= 438)= 24.41.
Results – Associations of Eating
Patterns
Physical
symptoms
(r/p)
Mental
symptoms
(r/p)
Eat home-cooked food 437
-.041 / .387
- .017 / .729
Eat convenience/
frozen food
428
.127 / .009
.102 / .035
Eat fast food
430
.179 / .000
.132 / .006
Eat at full-service
restaurants
439
-.004 / .932
- .120 / .012
Eating behavior
patterns
n
Pearson’s correlation coefficients; p<.05 is significant.
Fast Foods
Conv Foods
Results – Comparison of Groups
n
Never engaging
in eating pattern
M ± SD
Engaging in
eating pattern
M ± SD
t
statistic
F ratio
ANCOVA
Physical
Symptoms
379
37.03
± 16.44
41.77
± 18.57
-2.95*
2.92
Mental
Symptoms
428
13.44
± 6.92
14.87
± 6.78
-2.29*
2.14
Physical
Symptoms
383
35.85
± 16.49
43.31
± 18.11
-4.11*
8.15**1
Mental
Symptoms
430
13.24
± 6.53
15.08
± 7.32
-2.91*
7.35**2
Independent t test; p < .05; ** p < .01; groups with same letters differ
significantly. 1 ANCOVA adj means: 36.95, 41.97, pƞ2=0.045.
2ANCOVA adj means: 13.30, 15.01, ƞ2=0.017.
p
Discussion
Eating convenience or fast food is related to an increased
severity of menopausal symptoms, and those who
consumed fast foods reported more severe symptoms
than those who did not.
•
Those who ate fast food had less healthy dietary intake
overall32
•
Older women who did not eat fast foods reported fewer
and less severe symptoms33
•
Fast food frequency by women were lower in
vitamin A, carotenes and vitamin C density34
32. Wilcox et al, 2013; 33. Moore et al, 2009; 34. Bowman, 2004
Background- Physical Activity
•
Regular aerobic exercise is associated with improved
menopause symptoms, including anxiety and depression 35
•
Physically inactive menopausal women have more
depressed mood, memory/ concentration problems,
vasomotor symptoms than physically active women 36
35. Luoto et. al, 2012; 36. Mansikkamaki et. al, 2015
Methods
•
“Considering a 7-day period, how many times on average do
you do the following kinds of EXERCISE for more than 15
minutes during your free time?” (Responses 0-20x/week)
Strenuous
(heart beats rapidly)
• jogging, hockey,
soccer, basketball,
cross-country
skiing, judo, roller
blading, vigorous
swimming,
vigorous long
distance cycling
•
Moderate
(not exhausting)
Mild
(minimal effort)
• fast walking,
baseball, tennis,
easy bicycling,
volleyball, easy
swimming, alpine
skiing, dancing
• such as golf,
bowling, easy
walking
Total exercise: (Mild X 3) + (Mod X 5) + (Stren X 9)
Results – Comparison of Groups
OMN
n=248
VEG
n=151
VG
n=123
Means ± SD
Means ± SD
Means ± SD
Mild
4.88 ± 3.13
5.22 ± 3.30
5.41 ± 3.54
0.314
Moderate
3.10 ± 2.36
3.35 ± 2.42
3.67 ± 2.86
0.127
Strenuous
1.61 ± 1.31a
2.28 ± 1.84
1.92 ± 1.71a
0.0031
Total
45.11 ± 22.98a
55.04 ± 28.36 49.68 ± 25.51a
ANOVA test; groups with same letters differ significantly.
1 F ratio= 6.3, ƞ2= 0.18. 2 F ratio= 6.5, ƞ2= 0.28
p value
0.0022
Results - Associations with
Symptoms
Physical
Symptoms
r/p value
Mental
Symptoms
r/p value
Variable
N
Mild
Moderate
Strenuous
459
459
459
-.086 / .066
-.166 / .000
-.109 / .020
-.032 / .490
-.175 / .000
-.073 / .116
Total
459
-.177 / .000
-.140 / .003
Pearson’s correlation coefficients; p<.05 is significant.
Results- Comparison of Groups
Total Ex
Moderate Ex
n
Low
activity
Medium
activity
High
activity
F
ratio
Adj
F ratio
Mean ± SD Mean ± SD Mean ± SD
Physical
Symptoms
268
41.18
± 17.41
39.95
± 18.19
34.64
± 15.93
8.33
2.11
Mental
Symptoms
268
15.10
± 7.13a
14.64
± 6.87 b
11.81
± 6.01ab
8.97*
4.62*1
Physical
Symptoms
409
14.75
± 6.75a
14.66
± 7.13
12.79
± 6.59a
3.96*
5.07*2
Mental
Symptoms
409
42.40
± 18.33abc
39.78
± 17.04abc
34.95
± 16.52abc
7.43*
3.26*3
ANOVA, p<.05; groups with same letters differ significantly.
1ANCOVA adj means: 14.88 , 14.77, 11.92, ƞ2= 0.038; 2ANCOVA adj means: 14.82 , 14.67, 12.71,
p
2
3
2
pƞ = 0.022. ANCOVA adj means: 41.12, 40.03, 35.91, pƞ = 0.016.
Discussion
Moderate exercise (and total) was associated with lower
severity of menopausal symptoms, and those who
reported not engaging in moderate exercise had more
mental symptoms.
•
Those who reported less total exercise had more
menopausal symptom severity than those who reported
more total exercise.
•
Association of aerobic exercise and fewer physical and
mental symptoms in menopause studies 37,38
37. Kim, 2014; 38. Gutierrez, 2012
Key Findings
•
Vegans report lower severity of physical menopausal
symptoms than omnivores
•
Multiple factors were associated with lower severity of
menopausal symptoms
Decreased Symptom Severity
Increased Symptom Severity
Vegan Diet
Age
BMI
Sleep Hours
Social Support
Physical Activity
Education
Sweets, Fast & Convenience
Foods, Grapes, Coffee, Milk,
Orange/Grape Juices, Soda,
Green/Black Tea, Dark
Chocolate, Beef
Berries, Tree fruit, Spinach, Pomegranate
Juice, Plant Omega-3
Strengths and Limitations
•
Strengths
•
•
•
Large sample size
Exploration of a topic
with limited previous
research
Included many data
points
•
Limitations
•
•
•
•
•
•
Length and personal
nature of questions
Self-reported data
Retrospective
Food frequency only
Low generalizability
Correlational study
Conclusion
•
A plant-based diet may ease the menopausal
transition
•
Being physically active and healthier eating
habits (“slow” food) may also be beneficial
Images courtesy of sirrichards.com and tattly.com
Future Research
•
Experimental study with vegan vs omnivore diet
in menopausal women
•
Duration of adherence to a vegan diet in
menopausal women
•
Investigation of premenstrual symptoms and
plant-based diet
Questions?
Thank you for listening!
Image courtesy of publicdomainpictures.net