ArticlePDF Available

Contribution of selected vitamins and trace elements to immune function

Authors:
Silvia Maggini at Bayer
Silvia Maggini
E S Wintergerst
E S Wintergerst
E S Wintergerst
  • This person is not on ResearchGate, or hasn't claimed this research yet.
S Beveridge
S Beveridge
S Beveridge
  • This person is not on ResearchGate, or hasn't claimed this research yet.
DH Hornig
DH Hornig
DH Hornig
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Download full-text PDF
Read full-text
Download citation
Content uploaded by Silvia Maggini
Author content
All content in this area was uploaded by Silvia Maggini on Oct 19, 2015
Content may be subject to copyright.
1
st
International Immunonutrition Workshop, Valencia, 3–5 October 2007, Valencia, Spain
Contribution of selected vitamins and trace elements to immune function
S. Maggini
1
, E. S. Wintergerst
2
, S. Beveridge
1
and D. Hornig
3
1
Bayer Consumer Care, Basel, Switzerland,
2
Bayer Diabetes Care, Basel, Switzerland and
3
Bayer Diabetes Care,
Reinach, Switzerland
The immune system requires essential nutrients to function efficiently. Inadequate intake and status of vitamins and trace elements may
lead to suppressed immunity, which predisposes to infections and aggravates undernutrition. Available data indicate a role for vitamins A,
B
6
,B
12
, C, D and E and folate and for the trace elements Se, Zn, Cu and Fe in the immune response. Evidence has accumulated that in
human subjects these nutrients selectively influence the immune response, induce dysregulation of a coordinated host response to infec-
tions in the case of deficiency and oversupply, and that deficiency may impact on the virulence of otherwise harmless pathogens. Thus,
micronutrients are required at appropriate intakes for the immune system to function optimally and contribute to the body’s natural
defences on three levels by supporting the physical barriers (skin and mucosa), cellular and humoral immunity. Vitamins A, C and E and
the trace element Zn assist in enhancing the skin barrier function. The vitamins A, B
6
,B
12
, C, D and E and folic acid and the trace
elements Fe, Zn, Cu and Se work in synergy to support the protective activities of immune cells. Finally, all these micronutrients, except
vitamin C and Fe, are essential for antibody production.
The table summarises the most important roles of selected vitamins and trace elements in immune function
(1–3)
.
Micronutrient Main roles in the immune system
Vitamin A Normal differentiation of epithelial tissue and gene expression
Important role both in humoral antibody response and cell-mediated immunity
Deficiency impairs innate immunity, induces inflammation, potentiates existing inflammatory conditions and impairs ability
to defend against extracellular pathogens
Supplementation is of benefit in reducing the morbidity and mortality from infectious diseases (especially children)
Vitamin D Potent immune system modulator when metabolized to 1,25-dihydroxycholecalciferol, is involved in cell proliferation and enhances
innate immunity by increasing the differentiation of monocytes to macrophages
Deficiency correlates with higher susceptibility to infections as a result of impaired localized innate immunity and defects in antigen
specific cellular immune response
Supplementation together with a high-Ca diet inhibits progression of autoimmune disorders
Vitamin E Optimizes and enhances immune response (T-helper (Th) 1 response)
Supplementation in healthy adults increases T-cell proliferation, improves the CD4 + :CD8 + , and decreases indices of oxidative stress
Supplementation of elderly individuals improves overall immune function
Vitamins B
6
and B
12
and folic acid
Interfere with immune function through involvement in nucleic acid and protein biosynthesis
Maintain Th1 immune response (vitamin B
6
), innate immunity (natural killer (NK) cell activity; folate) and act as
immunomodulatory for cellular immunity, especially with effects on cytotoxic cells (NK; CD8 + T lymphocytes; vitamin B
12
)
Vitamin C Maintains redox integrity of cells and protection against reactive oxygen species (ROS) generated during respiratory burst and inflammatory response
Stimulates leucocyte functions (neutrophil, monocytes movement)
Role in antimicrobial and NK cell activities, lymphocyte proliferation, chemotaxis and delayed-type hypersensitivity response
Decreases duration and severity of common cold
Se Antioxidant essential for optimal immune response, influencing both the innate and the acquired immunity
Deficiency impairs antibody production and causes viruses to undergo mutations to more virulent forms
Supplementation normalizes age-related decline in immune response
Zn Influences both innate and acquired immunity, supports Th1 response, helps to maintain skin and mucosal integrity
Deficiency leads to thymic atrophy, decreased cell-mediated cytotoxicity, helper T-cell and NK cell activities
Cu Part of Cu/Zn-superoxide dismutase, a key enzyme in the defence against ROS
Maintains intracellular antioxidant balance, suggesting an important role in inflammatory response
Adequate intake supports a Th1 response and both deficiency and oversupply modulate the immune response
Fe Essential for cell differentiation and growth, component of enzymes critical for functioning of immune cells
Involved in the regulation of cytokine production and action
Insufficient intake of micronutrients occurs in individuals with eating disorders, in smokers (both active and passive), in individuals
with chronic alcohol abuse, in patients with certain diseases, during pregnancy and lactation, and in the elderly. With aging a variety of
changes are observed in the immune system, which translate to less-effective innate and adaptive immune responses and increase
susceptibility to infections. Overall, inadequate intake and status of vitamins A, B
6
,B
12
, C, D and E and folate and of the trace elements
Se, Zn, Cu and Fe may lead to suppressed immunity, which predisposes to infections and aggravates malnutrition. Thus, supplementation
with a combination of these selected micronutrients can support the body’s natural defence system by enhancing all three levels of
immunity: epithelial barriers; cellular immunity; antibody production.
1. Wintergerst ES, Maggini S & Hornig DH (2006) Ann Nutr Met 50, 85–94.
2. Wintergerst ES, Maggini S & Hornig DH (2007) Ann Nutr Met 51, 301–323.
3. Maggini S, Wintergerst ES, Beveridge S & Hornig DH (2007) Br J Nutr 98, Suppl. 1, S29–S35.
Proceedings of the Nutrition Society (2008), 67 (OCE), E84 doi:10.1017/S0029665108006939
... A study in South Ethiopia reported a 5.8% increase in CL occurrence among individuals under 18 with low BMI, highlighting the need to address malnutrition in the CL endemic area (31,32). Evidences showed higher poverty is linked to increased leishmaniasis incidence, as malnutrition weakens immune responses and favors antiinflammatory prostaglandin production over pro-inflammatory cytokines (33,34). Poverty and malnutrition have been identified as influencing the occurrence of leishmaniasis in affected populations (3). ...
... This indicates the effect of malnutrition on CL clinical forms. This is align with studies showing malnutrition exacerbates disease's severity (30,34). A correlation between low weight, hypoalbuminemia, and MCL has been shown is reported (17). ...
Self-Reporting Cutaneous Leishmaniasis Patients and Nutritional Status: A Study of the Host Factor in Remote Areas of Ethiopia
Article
  • Mar 2025
Background: Leishmania aethiopica is the leading cause of cutaneous leishmaniasis (CL) in Ethiopia. Different clinical manifestations might be related to host immunity, which itself can be influenced by the host's nutritional status. However, there is limited evidence that associates nutritional status with CL in Ethiopia. We investigated the relationship between clinical variables of CL and malnutrition. Methods: A retrospective study was conducted in June 2024. Patient data was analyzed from those treated for CL and screened for nutrition from January 2022 to May 2024 at Tefera Hailu and Addis Zemen Primary Hospitals. Nutritional status was assessed through Anthropometric measurements. Results: A total of 470 CL patients were treated, with a prevalence of 14.65/100, 000 population affected. Out of the total CL patients, 217 were assessed for nutrition, 22% were malnourished. Malnutrition was most prevalent in mucosal (30%) and recurrent cases (38.5%), compared to localized (20%) and new cases (21%) respectively. Conclusions: Malnutrition might have the potential to shape the clinical manifestation and treatment outcome in CL patients. In CL endemic areas nutritional supplement with the treatment of CL could require for better patient outcome.
View
... An optimal immune response necessitates a sufficient nutritional status of the host [96]. Micronutrient insufficiency hampers immunological functioning by impacting the adaptive antibody response and T-cellmediated immune response, resulting in the disruption of the balanced host response [97]. Studies conducted on humans, especially older individuals, have found a correlation between deficiencies in immunological markers and low levels of micronutrients such as vitamin C, vitamin B6, Fe, and zinc [98,99]. ...
... Vitamin A and D play important roles in cell-mediated and humoral antibody responses [97]. Supplementing with vitamin A in several infectious diseases, has demonstrated the capacity to enhance the immune response to certain vaccines, such as those for rabies [105] and measles [106]. ...
How does geographical diversity shape vaccine efficacy?
Article
Full-text available
  • Oct 2024
Vaccination is a cornerstone of public health, saving millions of lives each year by preventing a variety of infectious diseases. Yet, despite global vaccination efforts, emerging research highlights significant geographical disparities in vaccine efficacy and immunogenicity. These variations underscore the critical interplay between immunological factors and environmental, genetic, and nutritional elements across different populations. Our review article aimed to explore the multifactorial reasons behind geographical variations in vaccine efficacy. Also, this study has shown how important host factors like age, obesity, gender, and genetic diversity, especially within the major histocompatibility complex, are in determining how well a vaccine works. Nutritional status, namely deficiencies in micronutrients such as vitamins and zinc, and lifestyle factors including stress, sleep, alcohol consumption, and physical activity are also shown to have profound effects on vaccine-induced immunity. Importantly, our paper also brought to light the influence of microbial and ecological factors, such as the gut microbiome and environmental pollutants, on the immune system's response to vaccination. The findings emphasize the importance of tailoring vaccination strategies to accommodate the unique immunological landscapes shaped by geographical and societal factors. This tailored approach could enhance vaccine efficacy, reduce disparities in vaccine response, and ultimately contribute to the global fight against infectious diseases.
View
... IL-2 production by T cells and strengthens the Type 1 T helper (Th1) cell response (Wintergerst et al., 2007). ...
... Vitamin E, Se, and Cu are antioxidants essential for maintaining healthy skin (Wintergerst et al., 2007). In the present study, serum vitamin E levels were significantly lower in the infected group than in the control group. ...
View
... Moreover, dietary management is recommended as an approach to minimize potential risks of COVID-19 infection and its mortality (6). Numerous trace elements and vitamins are necessary for the normal function of the immune system (7), which could be important weapons against . Supplementation with these trace elements and vitamins, including vitamin A, vitamin D, zinc (Zn), selenium (Se), copper (Cu) and magnesium (Mg) can enhance innate and adaptive immune systems against viral infections (9)(10)(11). ...
Original Article Assessment of Vitamin D, Vitamin B12, Retinol-binding Protein (RBP), Zinc, Selenium, Copper and Magnesium in Iranian COVID-19 Patients and Their Relationships with the Disease Linked Death
Article
Full-text available
  • Mar 2025
Materials and Methods: This cross-sectional study was carried out in hospitals affiliated to Hamadan University of Medical Sciences, Hamadan, Iran, on 98 COVID-19 positive patients, March to May 2020. Demographic and clinical data of the patients were collected from their clinical records. Blood samples of 5 ml were collected from the patients, which were used for hospital routine laboratory assays as well as measuring trace elements and vitamins. Comparison of chemical biomarkers based on the patient's treatment outcomes was carried out using Mann-Whitney U test. For data analysis, Stata Software v.14 was used. Results: From 98 COVID-19 positive patients, 16 (13.33%) patients died during the treatment. These patients had higher proportions of heart diseases (37.5% against 10.98%, p = 0.007). Moreover, the median of white blood cell counts was significantly higher in patients, who died during treatment (p = 0.002). For vitamin D3, vitamin B12, RBP, zinc, selenium, cupper and magnesium, 59.2, 12.24, 53.08, 30.61, 88.71, 16.33 and 26.53% of the patients had values below the reference value ranges of these elements, respectively. Comparison of chemical biomarkers based on the patient's treatment outcomes did not show significant differences (p > 0.05). Conclusions: Although results of this study did not show significant differences between the levels of the trace elements and vitamins with the outcomes in COVID-19 patients due to the small sample size of the present study, assessment of these relationships needs stronger evidence by designing large studies.
View
... The iron content of one ounce of sunflower seeds accounts for approximately 10% of the daily value. Iron is essential for transporting oxygen to the lungs, blood, and cells, and a deficiency can lead to anemia, fatigue, and increased susceptibility to infections (Wintergerst et al., 2007). These findings align with those of Holliday and Phillips (2001), who highlighted sunflower seeds as one of the best complete foods, easy to incorporate into diets and a great nutritional source. ...
View
... This hypothesis is grounded in the premise that better overall health and lifestyle practices may enhance immune function and reduce susceptibility to infections [9,10]. Previous studies have demonstrated associations between individual components of cardiovascular health, such as physical activity and diet, and improved immune function [11,12]. Furthermore, research has shown that lifestyle factors can influence the risk and persistence of HPV infection [6,13]. ...
Exploring the association between lifestyle and cardiovascular health metrics and HPV infection risk: insights from the National Health and Nutrition Examination Survey 2005–2016 data
Article
Full-text available
  • Oct 2024
  • BMC PUBLIC HEALTH
Background Human Papillomavirus (HPV) infection has garnered significant attention due to its high prevalence and association with various cancers and other health conditions. Composite lifestyle factors may influence the risk of HPV infection, yet their cumulative impact remains insufficiently explored. This study aims to explore the association between the Life’s Essential 8 (LE8) Score and HPV infection status, highlighting the potential role of lifestyle and health behaviors in HPV infection prevention. Methods Utilizing data from the National Health and Nutrition Examination Survey (NHANES) spanning 2005–2016, we analyzed the health and nutritional statuses of 6,773 participants after excluding those with missing HPV infection status, inability to calculate the LE8 Score, and missing covariate data. The LE8 Score was computed based on eight cardiovascular health metrics, encompassing both health factors (BMI, non-HDL cholesterol, blood pressure, and blood glucose) and health behaviors (physical activity, diet, sleep duration, and nicotine exposure). HPV infection status was determined through vaginal swab specimens analyzed using various Roche assays. Multivariate logistic regression, the restricted cubic splines (RCS) analysis and weighted quantile sum (WQS) regression were employed to assess the association between LE8 Score and HPV infection risk. Results Our findings indicate a significant inverse association between the LE8 Score and HPV infection risk. Participants with medium and high LE8 Scores exhibited a 21% and 31% lower risk of HPV infection, respectively, compared to those with low LE8 Scores in multivariate logistic regression models. The analysis also revealed that lifestyle factors, particularly nicotine exposure and blood pressure, significantly contributed to the observed association. Conclusion The study underscores the importance of healthy lifestyle behaviors in reducing the risk of HPV infection. Public health strategies promoting such behaviors could complement existing HPV prevention measures, potentially lowering the burden of HPV-related diseases. Future research should further investigate the mechanisms underlying this association and the effectiveness of lifestyle interventions in diverse populations.
View
NUTRITION-RELATED BEHAVIORS AND THE QUALITY OF LIFE AMONG INDIVIDUALS DIAGNOSED WITH HIV/AIDS: A CROSS-SECTIONAL STUDY EXAMINING THE INFLUENCE OF SOCIO-ECONOMIC STATUS AND NUTRITIONAL HABITS IN ALBANIA
Article
  • Jan 2025
Objective. The present study aims to assess the influence of socioeconomic status on the dietary patterns and nutritional practices of individuals affected by AIDS in Albania. Methods and materials. Through a descriptive cross-sectional research design with non-random sampling, the study’s objective is to explore the specified group’s social, economic, and health-related encounters and relationships. A total of 264 individuals living with HIV were assessed regarding their dietary behaviors and quality of life during the preceding six months. Results. Results show that notwithstanding the comparatively low socioeconomic status of individuals living with HIV (PLHIV) in Albania, they exhibit well-developed coping mechanisms, resilience and adaptability in face of stressors. Dietary supplements and vitamins appear to be significantly influenced by the insufficient focus on nutritional programs and financial limitations. Findings from the Mann-Whitney U-test illustrate a definitive correlation between educational attainment and dietary practices. Those possessing higher levels of education demonstrate a pronounced propensity towards healthier nutritional habits, while individuals with only elementary education show a diminished inclination. The correlational analysis revealed a positive association between overall nutritional behavior and education, a positive correlation with income, and a negative relationship with adherence to antiretroviral therapy (ART). A noteworthy finding was the establishment of a negative correlation between nutritional behaviors and fixed sexual partnership status. Conclusion. Promoting healthy nutritional practices through a proactive approach and substantial financial and educational backing from all segments of society is imperative. Additional empirical research is essential to address the existing gaps in literature and scientific knowledge related to the Albanian context. Keywords: Nutritional behavior, PLHIV, Socioeconomic Status, Adherence to Antiretroviral Therapy, Quality of Life.
View
Influence of blood trace elements on immune responses and adverse symptoms subsequent to Sinopharm COVID-19 vaccination
Article
Full-text available
  • Nov 2024
Trace elements, specifically magnesium (Mg), zinc (Zn), and selenium (Se) have been linked with immunomodulatory properties. This research delves into identifying the potential impression of serum levels Mg, Zn, and Se on the protective immunity arisen through Sinopharm COVID-19 vaccine in the vaccinated subjects. Levels of Mg, Zn, and Se, cytokine and antibody production as well as virus neutralization potency were investigated in 75 males and 75 females before and 2 weeks after first and second dose of vaccination. Level of Mg, Zn, and Se did not change significantly before and 2 weeks after first and second dose of vaccine administration. Concentrations of Interleukin (IL)-2, IL-6, and Interferon (IFN)-γ were significantly higher in the supernatant of peripheral blood mononuclear cells (PBMCs) obtained from subjects 2 weeks after both first and second dose of vaccination compared to before vaccination. Serum level IgG was significantly higher 2 weeks after first and second dose of vaccination compared to before vaccination. Serum level IgM was only higher after first dose of vaccination compared with before vaccine. Also, 2 weeks after both first and second dose of vaccination compared to before vaccination, FRNT50 titer was significantly higher. Levels of Mg, Zn, and Se did not significantly correlate with levels of IL-2, IL-6, IFN-γ, IgM and IgG, and FRNT50 after first and second dose of vaccination. No severe unwanted clinical symptoms were detected after vaccination. Mg, Zn, and Se do not play a role in modulating protective immunity during Sinopharm COVID-19 vaccine. Supplementary Information The online version contains supplementary material available at 10.1038/s41598-024-80787-3.
View
HELIANTHUS ANNUS (SUNFLOWER): THE MAGNIFICENT PLANT-A REVIEW
Article
Full-text available
  • Nov 2024
A popular plant in India is Helianthus annuus, often known as the "Sunflower." It comes from North America natively. The history, biological origin, microscopy, and other elements of a sunf lower plant with aesthetic value are covered in the current review. Along with the geographic distribution, harvesting, and culture of Helianthus annuus, it also includes the adulteration and substitution of H. annuus. The medicinal qualities of Helianthus annuus are attributed to a variety of bioactive components, including phenol, terpene compounds, carbohydrates, flavonoids, tannins, alkaloids, saponins, and steroids. Many activities of H. annuus, such as anti-inflammatory, anti-oxidant, anticancer, anti-asthmatic, antigen, antipyretic, astringent, anti -hypoglycaemic effect, antifungal and antibacterial properties, are being investigated pharmacologically. In addition to this, the current research includes comprehensive details about over-the-counter helianthus products as well as home therapies.
View
View
Immune-Enhancing Role of Vitamin C and Zinc and Effect on Clinical Conditions
Article
Full-text available
  • Feb 2006
Vitamin C concentrations in the plasma and leukocytes rapidly decline during infections and stress. Supplementation of vitamin C was found to improve components of the human immune system such as antimicrobial and natural killer cell activities, lymphocyte proliferation, chemotaxis, and delayed-type hypersensitivity. Vitamin C contributes to maintaining the redox integrity of cells and thereby protects them against reactive oxygen species generated during the respiratory burst and in the inflammatory response. Likewise, zinc undernutrition or deficiency was shown to impair cellular mediators of innate immunity such as phagocytosis, natural killer cell activity, and the generation of oxidative burst. Therefore, both nutrients play important roles in immune function and the modulation of host resistance to infectious agents, reducing the risk, severity, and duration of infectious diseases. This is of special importance in populations in which insufficient intake of these nutrients is prevalent. In the developing world, this is the case in low- and middle-income countries, but also in subpopulations in industrialized countries, e.g. in the elderly. A large number of randomized controlled intervention trials with intakes of up to 1 g of vitamin C and up to 30 mg of zinc are available. These trials document that adequate intakes of vitamin C and zinc ameliorate symptoms and shorten the duration of respiratory tract infections including the common cold. Furthermore, vitamin C and zinc reduce the incidence and improve the outcome of pneumonia, malaria, and diarrhea infections, especially in children in developing countries.
View
Selected vitamins and trace elements support immune function by strengthening epithelial barriers and cellular and humoral immune responses
Article
Full-text available
  • Nov 2007
Adequate intakes of micronutrients are required for the immune system to function efficiently. Micronutrient deficiency suppresses immunity by affecting innate, T cell mediated and adaptive antibody responses, leading to dysregulation of the balanced host response. This situation increases susceptibility to infections, with increased morbidity and mortality. In turn, infections aggravate micronutrient deficiencies by reducing nutrient intake, increasing losses, and interfering with utilization by altering metabolic pathways. Insufficient intake of micronutrients occurs in people with eating disorders, in smokers (active and passive), in individuals with chronic alcohol abuse, in certain diseases, during pregnancy and lactation, and in the elderly. This paper summarises the roles of selected vitamins and trace elements in immune function. Micronutrients contribute to the body's natural defences on three levels by supporting physical barriers (skin/mucosa), cellular immunity and antibody production. Vitamins A, C, E and the trace element zinc assist in enhancing the skin barrier function. The vitamins A, B6, B12, C, D, E and folic acid and the trace elements iron, zinc, copper and selenium work in synergy to support the protective activities of the immune cells. Finally, all these micronutrients, with the exception of vitamin C and iron, are essential for antibody production. Overall, inadequate intake and status of these vitamins and trace elements may lead to suppressed immunity, which predisposes to infections and aggravates malnutrition. Therefore, supplementation with these selected micronutrients can support the body's natural defence system by enhancing all three levels of immunity.
View
Contribution of Selected Vitamins and Trace Elements to Immune Function
Article
  • Feb 2007
  • ANN NUTR METAB
Adequate intakes of vitamins and trace elements are required for the immune system to function efficiently. Micronutrient deficiency suppresses immune functions by affecting the innate T-cell-mediated immune response and adaptive antibody response, and leads to dysregulation of the balanced host response. This increases the susceptibility to infections, with increased morbidity and mortality. In turn, infections aggravate micronutrient deficiencies by reducing nutrient intake, increasing losses, and interfering with utilization by altering metabolic pathways. Insufficient intake of micronutrients occurs in people with eating disorders, in smokers (both active and passive), in individuals with chronic alcohol abuse, in patients with certain diseases, during pregnancy and lactation, and in the elderly. With aging a variety of changes are observed in the immune system, which translate into less effective innate and adaptive immune responses and increased susceptibility to infections. Antioxidant vitamins and trace elements (vitamins C, E, selenium, copper, and zinc) counteract potential damage caused by reactive oxygen species to cellular tissues and modulate immune cell function through regulation of redox-sensitive transcription factors and affect production of cytokines and prostaglandins. Adequate intake of vitamins B(6), folate, B(12), C, E, and of selenium, zinc, copper, and iron supports a Th1 cytokine-mediated immune response with sufficient production of proinflammatory cytokines, which maintains an effective immune response and avoids a shift to an anti-inflammatory Th2 cell-mediated immune response and an increased risk of extracellular infections. Supplementation with these micronutrients reverses the Th2 cell-mediated immune response to a proinflammatory Th1 cytokine-regulated response with enhanced innate immunity. Vitamins A and D play important roles in both cell-mediated and humoral antibody response and support a Th2-mediated anti-inflammatory cytokine profile. Vitamin A deficiency impairs both innate immunity (mucosal epithelial regeneration) and adaptive immune response to infection resulting in an impaired ability to counteract extracellular pathogens. Vitamin D deficiency is correlated with a higher susceptibility to infections due to impaired localized innate immunity and defects in antigen-specific cellular immune response. Overall, inadequate intake and status of these vitamins and minerals may lead to suppressed immunity, which predisposes to infections and aggravates malnutrition.
View
  • Jan 2007
  • 301-323
  • E S Wintergerst
  • S Maggini
  • D H Hornig
Wintergerst ES, Maggini S & Hornig DH (2007) Ann Nutr Met 51, 301-323.
  • Jan 2007
  • 29-35
  • S Maggini
  • Es Wintergerst
  • S Beveridge
  • Dh Hornig
Maggini S, Wintergerst ES, Beveridge S & Hornig DH (2007) Br J Nutr 98, Suppl. 1, S29–S35.