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Martemucci G, Portincasa P, Di Ciaula A, Mariano M, Centonze V, D'Alessandro AG. Oxidative stress, aging, antioxidant supplementation and their impact on human health: An overview. Mech Ageing Dev 2022; 206:111707. [PMID: 35839856 DOI: 10.1016/j.mad.2022.111707] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 12/12/2022]
Abstract
Aging is characterized by a progressive loss of tissue and organ function due to genetic and environmental factors, nutrition, and lifestyle. Oxidative stress is one the most important mechanisms of cellular senescence and increased frailty, resulting in several age-linked, noncommunicable diseases. Contributing events include genomic instability, telomere shortening, epigenetic mechanisms, reduced proteome homeostasis, altered stem-cell function, defective intercellular communication, progressive deregulation of nutrient sensing, mitochondrial dysfunction, and metabolic unbalance. These complex events and their interplay can be modulated by dietary habits and the ageing process, acting as potential measures of primary and secondary prevention. Promising nutritional approaches include the Mediterranean diet, the intake of dietary antioxidants, and the restriction of caloric intake. A comprehensive understanding of the ageing processes should promote new biomarkers of risk or diagnosis, but also beneficial treatments oriented to increase lifespan.
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Affiliation(s)
- Giovanni Martemucci
- Department of Agricultural and Environmental Sciences, University of Bari Aldo Moro, Via G. Amendola, 165/A, 70126 Bari, Italy
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Agostino Di Ciaula
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy.
| | - Michele Mariano
- Unità Operativa Complessa di Radiodiagnostica Universitaria, Policlinico di Bari, Piazza Giulio Cesare, 11, 70124 Bari, Italy
| | - Vincenzo Centonze
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari, Italy
| | - Angela Gabriella D'Alessandro
- Department of Agricultural and Environmental Sciences, University of Bari Aldo Moro, Via G. Amendola, 165/A, 70126 Bari, Italy
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Abstract
PURPOSE OF REVIEW This article will briefly describe the role of specific dietary components, mainly micronutrients, in supporting the immune response and summarise the literature regarding foods and dietary patterns in the context of immunity and infectious illness. Literature on SARS-COV-2 infection and COVID-19 is referred to where appropriate. RECENT FINDINGS Micronutrients, other nutrients and plant bioactives have roles in supporting the immune response. Low status of a number of micronutrients is associated with increased risk and severity of COVID-19. Recent studies report associations of plant-based diets with lower risk of, and less severe, COVID-19. SUMMARY In order to support the immune response, sufficient amounts of a range of essential and non-essential nutrients and other bioactives, mainly from a plant-based diet should be consumed. Further research should define cause-and-effect relationships of intakes of individual dietary components and foods, and of dietary patterns with susceptibility to, and severity of, viral infections.
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Affiliation(s)
- Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, United Kingdom,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton SO16 6YD, United Kingdom
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Miles EA, Calder PC. Effects of Citrus Fruit Juices and Their Bioactive Components on Inflammation and Immunity: A Narrative Review. Front Immunol 2021; 12:712608. [PMID: 34249019 PMCID: PMC8264544 DOI: 10.3389/fimmu.2021.712608] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 12/19/2022] Open
Abstract
The immune system provides defence to the host against pathogenic organisms. A weak immune system increases susceptibility to infections and allows infections to become more severe. One component of the immune response is inflammation. Where inflammation is excessive or uncontrolled it can damage host tissues and cause pathology. Limitation of oxidative stress is one means of controlling inflammation. Citrus fruit juices are a particularly good source of vitamin C and folate, which both have roles in sustaining the integrity of immunological barriers and in supporting the function of many types of immune cell including phagocytes, natural killer cells, T-cells and B-cells. Vitamin C is an antioxidant and reduces aspects of the inflammatory response. Important bioactive polyphenols in citrus fruit juices include hesperidin, narirutin and naringin. Hesperidin is a glycoside of hesperetin while narirutin and naringin are glycosides of naringenin. Hesperidin, hesperetin, naringenin, naringin and narirutin have all been found to have anti-inflammatory effects in model systems, and human trials of hesperidin report reductions in inflammatory markers. In humans, orange juice was shown to limit the post-prandial inflammation induced by a high fat-high carbohydrate meal. Consuming orange juice daily for a period of weeks has been reported to reduce markers of inflammation, including C-reactive protein, as confirmed through a recent meta-analysis. A newly emerging topic is whether polyphenols from orange juice have direct anti-viral effects. In summary, micronutrients and other bioactives present in citrus fruit juices have established roles in controlling oxidative stress and inflammation and in supporting innate and acquired immune responses. Trials in humans demonstrate that orange juice reduces inflammation; its effects on innate and acquired immunity require further exploration in well-designed trials in appropriate population sub-groups such as older people.
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Affiliation(s)
- Elizabeth A. Miles
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Philip C. Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton National Health Service (NHS) Foundation Trust and University of Southampton, Southampton, United Kingdom
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Dams S, Holasek S, Tsiountsioura M, Malliga DE, Meier-Allard N, Poncza B, Lackner S, Jansenberger Y, Lamprecht M. An encapsulated fruit, vegetable and berry juice powder concentrate increases plasma values of specific carotenoids and vitamins. INT J VITAM NUTR RES 2019; 91:77-86. [PMID: 31726948 DOI: 10.1024/0300-9831/a000609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Vitamins and carotenoids are organic compounds that are important for vital functions of the human organism. Since the human body is not able to synthesize most of these micronutrients, they need to be supplied by the intake of food or supplements. The aim of this study was to analyze whether a whole food based, encapsulated fruit, berry, and vegetable juice powder concentrate provides bioavailable carotenoids and vitamins A (all-trans retinol), E and C. Eighteen healthy subjects received 6 capsules a day for 8 weeks, which provided 2.91 mg β-carotene, 490 μg vitamin A, 18.7 mg vitamin E, 159 mg vitamin C, 6.1 mg lutein and 1 mg lycopene. Plasma concentrations of several carotenoids and vitamins before and after supplementation were measured. After 8 weeks of supplementation, the plasma concentration of the following carotenoids increased significantly: α-carotene increased from 59.6 ± 22.4 nmol/L to 85.7 ± 24.2 nmol/L (p = 0.002), β-cryptoxanthin from 106.7 ± 39.8 nmol/L to 151.9 ± 57.9 nmol/L (p = 0.017), and lycopene from 1.2 ± 0.5 μmol/L to 1.7 ± 0.5 μmol/L (p = 0.005). Significant increases were also observed for plasma concentrations of vitamin C from 70 ± 20 μmol/L to 90 ± 10 μmol/L (p < 0.001), all-trans retinol from 1.99 ± 0.24 μmol/L to 2.30 ± 0.66 μmol/L (p = 0.015), and α-tocopherol from 27 ± 6 μmol/L to 32 ± 6 μmol/L (p = 0.008). For those micronutrients with accepted plasma reference ranges, all observed increases levelled off around the upper limit of the individual reference range. The data demonstrate that the investigated supplement is able to increase plasma concentrations of certain carotenoids and vitamins of healthy subjects within 8 weeks.
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Affiliation(s)
- Sebastian Dams
- Otto Loewi Research Center, Division of Immunology and Pathophysiology, Medical University of Graz, Graz, Austria.,Green Beat - Institute of Nutrient Research and Sport Nutrition, Graz, Austria
| | - Sandra Holasek
- Otto Loewi Research Center, Division of Immunology and Pathophysiology, Medical University of Graz, Graz, Austria
| | - Melina Tsiountsioura
- Green Beat - Institute of Nutrient Research and Sport Nutrition, Graz, Austria.,The Juice Plus+® Science Institute, Memphis, Tennessee, USA
| | - Daniela-Eugenia Malliga
- Green Beat - Institute of Nutrient Research and Sport Nutrition, Graz, Austria.,Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Nathalie Meier-Allard
- Otto Loewi Research Center, Division of Immunology and Pathophysiology, Medical University of Graz, Graz, Austria
| | - Brigitte Poncza
- Otto Loewi Research Center, Division of Immunology and Pathophysiology, Medical University of Graz, Graz, Austria
| | - Sonja Lackner
- Otto Loewi Research Center, Division of Immunology and Pathophysiology, Medical University of Graz, Graz, Austria
| | - Yvonne Jansenberger
- Green Beat - Institute of Nutrient Research and Sport Nutrition, Graz, Austria
| | - Manfred Lamprecht
- Green Beat - Institute of Nutrient Research and Sport Nutrition, Graz, Austria.,The Juice Plus+ Science Institute, Memphis, Tennessee, USA.,Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
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Hosseini B, Berthon BS, Saedisomeolia A, Starkey MR, Collison A, Wark PAB, Wood LG. Effects of fruit and vegetable consumption on inflammatory biomarkers and immune cell populations: a systematic literature review and meta-analysis. Am J Clin Nutr 2018; 108:136-155. [PMID: 29931038 DOI: 10.1093/ajcn/nqy082] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/28/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Inflammation is associated with an increased risk of a range of chronic diseases. A diet high in fruit and vegetables may help to reduce inflammation, as fruit and vegetables are rich sources of antioxidants and other biologically active substances, which may improve immune function. OBJECTIVE To summarize the evidence, we executed a systematic review and meta-analysis examining the effects of fruit and/or vegetable intake on inflammatory biomarkers and immune cells in humans with different diseases and conditions. Design Electronic databases including PubMed, Cochrane, CINAHL, and EMBASE were systematically searched up to March 2018. RESULTS Eighty-three studies were included. Of these, 71 (86%) were clinical trials, and 12 were observational studies (n = 10 cross-sectional and n = 2 cohort). Amongst the observational research, n = 10 studies found an inverse association between intakes of fruit or vegetables and inflammatory biomarkers. Similarly, the majority of the intervention studies (68%, n = 48) reported beneficial effects of fruit or vegetable intake on ≥1 biomarker of systemic or airway inflammation. A meta-analysis of included studies showed that fruit or vegetable intake decreased circulating levels of C-reactive protein and tumor necrosis factor-α (P < 0.05) and increased the γδ-T cell population (P < 0.05). Conclusions In conclusion, this review suggests that higher intakes of fruit and vegetables lead to both a reduction in proinflammatory mediators and an enhanced immune cell profile.
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Affiliation(s)
- Banafshe Hosseini
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Bronwyn S Berthon
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Ahmad Saedisomeolia
- School of Medicine, Western Sydney University, Sydney, Australia.,School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Malcolm R Starkey
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Adam Collison
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Peter A B Wark
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Lisa G Wood
- Grow Up Well Priority Research Centre and Priority Research Centre for Healthy Lungs and, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
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Zhou X, Perez-Cueto FJA, Santos QD, Monteleone E, Giboreau A, Appleton KM, Bjørner T, Bredie WLP, Hartwell H. A Systematic Review of Behavioural Interventions Promoting Healthy Eating among Older People. Nutrients 2018; 10:E128. [PMID: 29373529 PMCID: PMC5852704 DOI: 10.3390/nu10020128] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 12/21/2022] Open
Abstract
Because eating habits are inseparably linked with people's physical health, effective behaviour interventions are highly demanded to promote healthy eating among older people. The aim of this systematic review was to identify effective diet interventions for older people and provide useful evidence and direction for further research. Three electronic bibliographic databases-PubMed, Scopus and Web of Science Core Collection were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria. English language peer-reviewed journal articles published between 2011 and 2016 were selected for data extraction and quality assessment. Finally, a total of 16 studies were identified. The studies' duration ranged from three weeks to seven years. The majority of studies were carried out in European countries. Seven studies had a moderate quality while the remaining studies were at a less than moderate level. Three dietary educational interventions and all meal service related interventions reported improvements in older people's dietary variety, nutrition status, or other health-related eating behaviours. Multicomponent dietary interventions mainly contributed to the reduction of risk of chronic disease. The results supported that older people could achieve a better dietary quality if they make diet-related changes by receiving either dietary education or healthier meal service. Further high-quality studies are required to promote healthy eating among older people by taking regional diet patterns, advanced information technology, and nudging strategies into account.
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Affiliation(s)
- Xiao Zhou
- Department of Food Science, University of Copenhagen, 1958 Frederiksberg C, Denmark.
| | | | - Quenia Dos Santos
- Department of Food Science, University of Copenhagen, 1958 Frederiksberg C, Denmark.
| | - Erminio Monteleone
- Department of Management of Agricultural, Food and Forestry Systems, University of Florence, 50144 Florence, Italy.
| | - Agnès Giboreau
- Centre for Food and Hospitality Research, Institute Paul Bocuse, 69130 Ecully, France.
| | - Katherine M Appleton
- Research Centre for Behaviour Change, Department of Psychology, Faculty of Science and Technology, Bournemouth University, Poole BH12 5BB, UK.
| | - Thomas Bjørner
- Department of Architecture, Design and Media Technology, Aalborg University, 9000 Aalborg, Denmark.
| | - Wender L P Bredie
- Department of Food Science, University of Copenhagen, 1958 Frederiksberg C, Denmark.
| | - Heather Hartwell
- Faculty of Management, Bournemouth University, Poole BH12 5BB, UK.
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The Effects of Nutritional Juice Supplementation on the Extent of Climacteric Symptoms: An Observational Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:2636542. [PMID: 27668002 PMCID: PMC5030430 DOI: 10.1155/2016/2636542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 11/17/2022]
Abstract
Objective. This study aims to evaluate the effect of daily dietary nutritional supplement on somatic, psychological, and urogenital symptoms in postmenopausal women. Material and Methods. In this study 28 healthy, symptomatic, peri- and postmenopausal women of 47–67 years of age were allocated to use the nutritional supplement JuicePLUS+®. Primary research parameters: Menopause Rating Scale (MRS) was used to assess menopausal symptoms at baseline and after 8 and 16 weeks of treatment. Secondary parameters: proliferation behaviour of vaginal smear was scored at baseline and after treatment. Results. Treatment with the supplement resulted in a reduction of somatic, psychological, and urogenital symptoms. The overall MRS score showed an average improvement of 44.01%. Most benefits were observed for the psychological symptoms irritability (60.55%) and physical and mental exhaustion (49.08%); modest effects were observed for hot flashes (44.86%) and sleeping problems (35.56%). There was a minor improvement in sexual problems; 6 women reported an increased libido. No statistically significant effect was found in vaginal dryness and proliferation behaviour of vaginal mucosa. No adverse effects were observed. Conclusion. Dietary nutritional supplement may constitute an effective alternative therapy to conventional alternative medicine for somatic, psychological, and sexual symptoms.
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Scientific Opinion on the substantiation of health claims related to beta carotene and physiological immune responses of the skin in relation to UV radiation (sun exposure) (ID 198, 1463) pursuant to Article 13(1) of Regulation (EC) No 1924/2006. EFSA J 2009. [DOI: 10.2903/j.efsa.2009.1231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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ZHENG JIE, OU SHIYI, DUAN HANYING, HUANG XUESONG, FU LIANG, TANG SHUZE, WU JIANZHONG. PREPARATION OF LEAFY VEGETABLE PAPER. J FOOD PROCESS PRES 2009. [DOI: 10.1111/j.1745-4549.2009.00367.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Aralas S, Mohamed M, Fadzelly Abu Bakar M. Antioxidant properties of selected salak (Salacca zalacca) varieties in Sabah, Malaysia. ACTA ACUST UNITED AC 2009. [DOI: 10.1108/00346650910957492] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lin JY, Tang CY. Total phenolic contents in selected fruit and vegetable juices exhibit a positive correlation with interferon-γ, interleukin-5, and interleukin-2 secretions using primary mouse splenocytes. J Food Compost Anal 2008. [DOI: 10.1016/j.jfca.2007.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nantz MP, Rowe CA, Nieves C, Percival SS. Immunity and antioxidant capacity in humans is enhanced by consumption of a dried, encapsulated fruit and vegetable juice concentrate. J Nutr 2006; 136:2606-10. [PMID: 16988134 DOI: 10.1093/jn/136.10.2606] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The daily consumption of fruits and vegetables is a common dietary recommendation to support good health. We hypothesized that a commercially available encapsulated fruit and vegetable juice powder concentrate (FVJC) could support functional indices of health due to increased intake of various phytonutrients. This was a double-blind, randomized, placebo-controlled investigation of 59 healthy law students who consumed either FVJC or placebo capsules for 77 d. Blood was collected on d 1, 35, and 77 to examine the number of circulating alphabeta- and gammadelta-T cells, cytokine production, lymphocyte DNA damage, antioxidant status, and levels of carotenoids and vitamin C. A log of illnesses and symptoms was also kept. The FVJC group tended to have fewer total symptoms than the placebo group (P < 0.076). By d 77 there was a 30% increase in circulating gammadelta-T cells and a 40% reduction in DNA damage in lymphocytes in the FVJC group relative to the placebo group. Plasma levels of vitamin C and of beta-carotene, lycopene, and lutein increased significantly from baseline in the FVJC group as did plasma oxygen radical absorptive capacity (50%). Interferon-gamma produced by phorbol-stimulated lymphocytes was reduced 70% in the FVJC group, whereas other cytokines (IL-4, IL-6, transforming growth factor beta) were unchanged relative to treatment or time. FVJC consumption during this study period resulted in increased plasma nutrients and antioxidant capacity, reduction in DNA strand breaks, and an increase in circulating gammadelta-T cells.
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Affiliation(s)
- Meri P Nantz
- Food Science and Human Nutrition Department University of Florida Gainesville, Florida 32611, USA
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Kiefer I, Prock P, Lawrence C, Wise J, Bieger W, Bayer P, Rathmanner T, Kunze M, Rieder A. Supplementation with Mixed Fruit and Vegetable Juice Concentrates Increased Serum Antioxidants and Folate in Healthy Adults. J Am Coll Nutr 2004; 23:205-11. [PMID: 15190044 DOI: 10.1080/07315724.2004.10719362] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Epidemiological studies have shown that low plasma levels of antioxidant micronutrients, which are commonly found in fruit and vegetables, are associated with increased risk for diseases such as heart disease, cancer, metabolic disorders and the like. The aim of this study was to monitor the dietary habits of a group of healthy, middle-aged, men and women and to assess the effect of supplementation with a natural phytonutrient preparation from fruits and vegetables, on plasma levels of various antioxidant micronutrients and oxidative stress assessed by measuring 8-oxodGuo (8-oxo-7,8-dihydro-2'-deoxyguanosine) in urine. METHODS The study followed a double-blind randomized cross-over design involving 59 healthy men and women (40-60 years of age). The supplement or a placebo was given to two groups for a total period of 14 weeks (crossover week 7). Blood levels of beta-carotene, vitamin C, vitamin E, selenium and folate were measured at 0, 7 and 14 weeks. Fruit and vegetable consumption was monitored by means of a retrospective food frequency questionnaire at week 0, 7 and 14. Urinary 8-oxodGuo was also determined at these time points. RESULTS Significant increases in blood nutrient levels after active supplementation were observed for beta-carotene, vitamin C, vitamin E, selenium and folate. Ranges measured, after supplementation, often fell into those associated with a reduced risk for disease. Our data suggests that, although generally health conscious, participants still fell short of the recommended five portions of fruit and vegetables per day. No significant group changes were noted for 8-oxodGuo concentration in urine. CONCLUSION Supplementation with mixed fruit and vegetable juice concentrates effectively increased plasma levels of important antioxidant nutrients and folate.
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Affiliation(s)
- Ingrid Kiefer
- Institute of Social Medicine, Department of Public Health, Medical University Vienna, Vienna, Austria.
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