Healthy body with vitamin B4. Vitamin B4 (choline) - a description of the properties of its benefits, as well as a list of foods in which it is contained

Many experts still cannot form a consensus on whether it is possible to consider vitamin B4 complete vitamin. Some prefer to call it a vitamin-like substance, a kind of precursor to acetylcholine. Despite the fact that choline has been known to scientists since the 19th century, its importance for the human body was only proven in 1930. As for its role, the debate on this matter has not yet been completed, as well as numerous studies regarding the significance of vitamin B4 .

Useful properties of vitamin B4

A significant benefit of vitamin B4 lies in the fact that it is one of the main elements that regulate metabolism in the human body, positively affects the functioning of the intestines and becomes the main substance necessary for the transmission of nerve impulses. Many scientists note its importance for the normal functioning of memory and intelligence, and also mention the ability to slow down the inevitable aging process that takes place in the cells of the brain and other organs of the human body.

The role of choline in the normal functioning of the liver is very large, because. its important functions are the normalization of the excretion of fats from the human body, as well as the responsibility for the regeneration process taking place in the cells. A sufficient amount of vitamin B4 in the body can naturally protect against atherosclerosis, heart attack and stroke. Also, a choline-containing diet can be an excellent prevention against Alzheimer's disease or memory loss.

Scientists have proven that the use of foods containing vitamin B4 or synthetic multivitamins, which include choline in certain amounts, can significantly improve brain function in old age, and there is also an improvement in memory in school-age children who took choline.

What foods contain vitamin B4

It is known that the greatest amount of choline is found in food of animal origin. But plant foods can also saturate the human body with vitamin B4. These are, for example, unrefined vegetable oil, peanuts and bran. One of the champions among such sources is yeast, and a lot of choline can be found in spinach, cabbage, carrots and tomatoes.

Particular attention should be paid to the full consumption of vitamin B4 for vegetarians who prefer to get it from synthetic medicines. Doctors note that the indiscriminate use of lecithin (a synthesized choline substitute recommended by pharmacists) can lead to an imbalance of B vitamins and various negative consequences. There are two ways out: either to refuse synthetics altogether, which will be optimal, or to use measuredly and deliberately.

A great influence on the question of the significance of choline was the fact that B4 is able to be synthesized by the human body and does not really need to be obtained from food. In addition, the ability to assimilate it from a wide variety of food products makes it possible (in the absence of diseases and disorders of the body) to obtain B4 in sufficient quantities for the body. For the same reason, there are no well-defined recommendations regarding the daily intake of choline for the body.

Lack of vitamin B4

Deficiency of this useful substance can manifest itself both in violation of memory functions and lead to complete disintegration of the psyche, characteristic of the senile body. In this case, in the human body there is a constant slowdown of all metabolic processes, fatigue, apathy, and sometimes depression appear.

Also, a lack of vitamin B4 can provoke a significant increase in blood pressure, problems with the digestibility of fats, as well as arrhythmia, indigestion and tinnitus.

Vitamin B4 overdose

Cases of an overdose of choline in medicine have not yet been described, however, it is known that exceeding the norm of B vitamins in the body can provoke bad breath, diarrhea, and constipation. It is also known that it is almost impossible to get an overdose from products of natural origin. All cases of overdose with B vitamins were recorded as a result of taking synthetic drugs or medications containing a certain vitamin. Therefore, we advise you to abandon synthetics and give preference to natural products, fresh vegetables and fruits.

Choline is conventionally considered vitamin B4. It is more correct to call it a vitamin-like substance.

Choline was excluded from the list of vitamins for the reason that a healthy body produces it on its own.

Therefore, it is rare to find a person with a lack of choline.

Like other B vitamins, choline is water soluble. Another distinctive feature of this group is their active participation in cellular metabolism.

The role of vitamin B4 in the body

Choline is involved in the emulsification (grinding) of fats, it is part of lecithin and other phospholipids that transport fats and nourish the nervous system. Vitamin B4 regulates insulin levels, helps repair liver cells and prevents the development of gallstones.

Let's summarize the main functions of vitamin B4 in the body, and below we will tell you more about them:

  1. Protecting the health of the liver, accelerating its metabolic processes.
  2. Improving the functioning of the brain and the state of the nervous system.
  3. Reducing the level of bad cholesterol, the fight against atherosclerosis.

Without choline, the liver cannot convert fats. The liver is the biochemical laboratory of the body; various lipids enter it from the blood for processing.

And if lipid metabolism is disturbed, then the fats that enter the liver are retained there. There is fatty liver, and then cirrhosis.

At the same time, other organs suffer from hunger, those that were intended for the construction and restoration of lipids “stuck” in the liver. The CNS is especially affected. This is expressed through asthenia, depression.

Choline is needed by the nervous system to form acetylcholine, a neurotransmitter (conductor) for:

  • neuromuscular transmission of impulses (transmits excitation from nerves to muscles and is responsible for the strength of contractile activity),
  • parasympathetic (nourishing, restoring) part of the autonomic nervous system, which regulates the involuntary work of organs (breathing, heartbeat, secretion of glands).

Choline lowers cholesterol levels. Cholesterol-fighting substances usually block it in the gastrointestinal tract. Choline acts differently - as an emulsifier.

Cholesterol emulsion consists of tiny particles that can no longer attach to platelets and arterial walls. These cholesterol particles lack the stickiness to create clots that promote atherosclerosis.


For adults, the daily dose of choline is 400-600 mg, maximum for adults - 3500 mg.

Pure choline and phosphatidylcholine containing it are taken 3 times a day, 500 mg each. Vitamin B4 is best taken in the form of lecithin capsules: 2 pieces of 1200 mg twice a day. Or in granular form: 1200 mg is contained in 19 granules.

For better absorption, choline is consumed with meals.

Signs of a Vitamin B4 Deficiency

Choline deficiency symptoms:

  • A sharp increase in body weight and its retention.
  • Poor memory, especially short-term.
  • High cholesterol.
  • In lactating women, a violation of the formation of breast milk is found.

Consequences of lack

With choline deficiency, obesity will primarily affect the liver. Changes will be devastating if you do not change the diet and add choline to it. Lack of vitamin B4 can cause diseases of the nervous system.

The reasons

A lack of choline can also be observed with too little protein in the diet. Also, vitamin B4 is easily destroyed by alcohol and antibiotics.

Indications for use

Vitamin B4 is prescribed to restore liver cells in diseases of the liver and gallbladder.

Choline helps to cure endometriosis, which is the cause of infertility in women. It is used after chemotherapy and with severe heartburn.

Choline is indicated for those who want to improve their memory or for upcoming mental stress. It relieves the symptoms of Parkinson's disease.

Video: "How to protect the liver?"

Sources

Many foods contain choline, it is difficult to find food that does not contain it. It is both animal and vegetable food. Basically, these are protein products that contain methionine, necessary for the body to produce choline.

Vitamin B4 is found in egg yolk, liver, kidney, meat, fish, cottage cheese, cheese. Plant foods contain in legumes, oatmeal, cabbage, tomatoes, carrots, spinach, bran.

Medicinal herbs also contain choline. These are elderberry, nettle, hawthorn, coltsfoot, plantain, dandelion, chicory, yarrow.

Video: "Choline and its effect on the body"

Vitamin-mineral complexes containing vitamin B4

If your diet does not allow you to consume a daily dose of choline, then you can buy it in the form of supplements. The easiest and most common way is to take lecithin. It is considered an excellent source of B4.

When ingested, lecithin breaks down into several components, one of them is choline.

To improve memory and stimulate cerebral circulation there is an encapsulated complex "Memory Forte". It also fights against age-related changes, maintaining the working capacity of the brain.

For weight loss and body shaping created "Citrimax Plus" in tablets. It not only helps to reduce weight, as stated in the instructions, but also helps to part with fat in problem areas.

Reduce appetite called pills "Diet 45 Plus". This drug is designed to maintain normal weight in women during menopause.

Interaction of vitamin B4 with other substances

B vitamins are often combined in one vitamin complex. The reason for this is in similar conditions for good assimilation and the relationship in metabolic processes.

For example, with a low intake of vitamins B9 (folic acid) and B12, a lack of choline can occur. And choline deficiency creates a lack of carnitine (B11), which is involved in the utilization of fats and is necessary for muscle work.

Signs of a choline overdose and how to deal with them

Excessive doses of choline can cause increased sweating, increased secretion of the salivary glands, decreased blood pressure, nausea and vomiting, and intestinal disorders.

If you consume about 10 g per day, there will be violations of cardiac activity, and a fishy smell may begin to come from the body.

With these symptoms, you should immediately stop taking drugs that include choline and temporarily reduce the amount of foods containing it in the diet.

Need to remember

Choline must be consumed so that there are no diseases of the liver, nervous and cardiovascular systems.

In order not to experience a lack of vitamin B4, it is enough to properly build your diet. The food from which the body can obtain choline can be of animal and vegetable origin. The most common foods contain choline.

To improve brain function, you can use lecithin, from which the body receives choline, or pick up a vitamin-mineral complex for yourself, there are a great many of them. The composition of tablets or capsules depends on the problems in the body with which they are designed to cope.

Exceeding the dose of choline will cause unpleasant changes in the body, they pose the greatest danger to the heart.

Daily intake of a daily dose of choline improves memory even in very advanced cases.

Nutritionist, Endocrinologist, Diabetologist

Advises patients on issues of excess weight, provides individual support to the patient on nutrition issues, makes individual diets for weight loss, taking into account the taste preferences of the patient.


The minimum daily intake of this B vitamin is 500-1000 mg. The amount strongly depends on the consumption and state of health, as well as the presence of stress and mental stress. The maximum allowable daily amount for children is 2000 mg, and for adults - 3500 mg.

Avitaminosis can occur for various reasons. For example, if a person is exposed to stress, then the body consumes trimethylethanolamine in double the amount. In this case, the body may try to replenish the content of B4 by using other substances, but this can cause serious harm to health.

Deficiency symptoms include:

  • sleep problems
  • irritability, nervous breakdowns,
  • noise in ears,
  • memory problems,
  • headache,
  • arrhythmia
  • sudden weight gain
  • deterioration in concentration and coordination,
  • increased cholesterol.

If the body does not receive choline for a long time, then hypertension, atherosclerosis, gastritis, problems with growth, liver and genital organs may develop.

Although the lack of vitamin B4 is dangerous, you should not bring the body to a state of hypervitaminosis. This will threaten you with fishy breath, loss of appetite, increased pressure and problems with the gastrointestinal tract. To address these issues, it is enough to reduce the consumption of foods rich in choline.

Features of interaction

In some cases, other substances can enhance the effect of vitamin B4 or, on the contrary, it improves their work.

  • If pantothenic acid is present along with choline, then B4 is synthesized into acetylcholine. We have already written about it in more detail before.
  • Combined use with B8 improves liver metabolism and reduces plaque buildup in blood vessels.
  • You can enhance the work of nutrients by adding cobalamin and folic acid to trimethylethanolamine.
  • Choline helps to neutralize the harm from nicotinic acid.

The combination of vitamin with oral contraceptives is undesirable. They destroy up to 50% of the useful substance. Antibiotics, alcohol solutions and steroids also have a harmful effect. They reduce the benefits of choline by almost half.

pharmaceuticals

If it is not possible to restore the health of the body by establishing a nutrition system, then people often resort to the use of drugs.

For example, Vitrum Beauty tablets contains almost all representatives of group B, including B4. The instructions for use indicate dosages for adults - two tablets per day, after meals. For children, the complex is prohibited.

The maximum effect can be achieved by increasing the dose to three tablets, but prior consultation with your doctor is necessary.

One of the options for vitamin b4 in ampoules is called Choline chloride. This is a 20% solution, which must be applied in a teaspoon (the volume should not exceed 5 ml) up to five times a day. The course lasts two or three weeks.

A one percent solution can be administered intravenously with droppers. The price starts from 60 rubles.

As part of the Duovit Memo vitamin complex, there is choline, as well as lecithin, which is important for the functioning of B4. Duovit is useful for high mental stress, nutritional problems, constant stress, and is also a means of combating a lack of B vitamins. Take three plates a day with food.

Gleacer - ampoules containing choline alfoscerate. It is prescribed as a nootropic agent, it is also an anticholinergic. Gleacir has a beneficial effect on the passage of blood and the metabolism of the central nervous system. It can lead to a regression of neurological pathologies, improve the reactions of people with brain diseases like encephalopathy.

It has a number of side effects on the gastrointestinal tract, general condition and skin, so you can not prescribe Gleatser yourself. The same applies to any other medication - you should always consult with a knowledgeable doctor first.

The price of choline alfoscerate is from 250 rubles.

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Stay strong!

Artem and Elena Vasyukovich

Choline is a vitamin-like nutrient that is important for normal liver, brain, nervous system, muscle function, energy levels, and healthy metabolism.

Vitamin B4, unlike other B vitamins, can be produced in small amounts by the human body. That is why some classifications tend to attribute it to vitamin-like substances. However, the vital need for choline experienced by a person has become the reason why it is still positioned as a vitamin. Vitamin B4 starts many processes and performs the functions necessary for the full functioning of the human body.

Choline is present as phosphatidicholine, a compound that is a structural component of fat, and therefore can be found in various types of foods that naturally contain certain fats. It plays a role in several important processes in the body that occur hundreds of times every day.

Vitamin B4 (choline) for what the human body needs

Thermostable alcohol, also known as choline, vitamin B4 and trimethylethanolamine, is an extremely important element in the human body. The most commonly used term choline is derived from the English name for bile and owes this to the fact that it was first synthesized from there. Some biochemical schools tend to refer to choline as a vitamin-like water-soluble substance, even recognizing its undeniable influence on protein and lipid metabolism. It has been reliably established that a lack of choline in the body leads to overweight.

Vitamin B4, being an integral part of lecithin, a vital element in the functioning and functioning of cells, is involved in the construction of the main structural element of cells, and hence the tissues of the whole organism.

Crystalline substance, colorless, easily soluble in water. It plays a huge role in many processes occurring in the human body:

  • In the nervous system, it is one of the builders of the protective sheath, its presence allows you to save the myelin layer and protect nerve cells from destruction;
  • As a precursor of acetylcholine (a transmitter of nerve impulses), it helps prevent the possible destruction of nerve cells;
  • Choline is indispensable for alcohol intoxication, food poisoning, pathogenic viruses and drug addiction, because it has hepatoprotective properties and is able to accelerate and optimize the recovery of liver cells;
  • By improving liver function, it reduces the likelihood of stones in the gallbladder and prevents their formation;
  • By lowering the level of fatty acids in the blood, trimethylethanolamine also reduces the level of cholesterol, thereby preventing the formation of cholesterol plaques;
  • Vitamin B4 is directly involved in the synthesis of methionine, a substance that can remove excess homocysteine, which causes pathologies of the cardiovascular system;
  • By promoting the synthesis of methionine, choline strengthens the heart muscle and optimizes its activity;
  • Participating in carbohydrate metabolism, vitamin B4 normalizes the membranes of cells that produce insulin (in type 1 diabetes, it can reduce the need for insulin, in type 2, it reduces its excess);
  • Reproductive function is not complete without choline: the biosynthesis of prostaglandins and sperm motility are impossible without its participation, and in old age it prevents prostate diseases.

One of the main functions of a useful crystalline substance is the enzymatic breakdown of fats. It helps to normalize lipid metabolism and indirectly affects many processes in the body. The normal state of fat metabolism helps prevent a variety of diseases. Clinical studies have shown that the use of choline by pregnant women leads to potentiation of the mental activity of the born child. This made it possible to prove that choline is an indispensable building material for the human brain.

The average daily intake of choline for an adult is 500 mg, and the body is able to produce part of the required amount itself.

For pregnant women, the consumption rate is 450-550 mg;

For breastfeeding women - 550 mg.

For childhood, it depends on the number of years and the need for a substance looks like in the following way:

  • from 0 to 7 months - 50-70 mg;
  • from 1 year to 3 years - 70-90 mg;
  • from 3 to 7 years - 100-200 mg;
  • from 7 to 18 years - 200-500 mg.

Its need depends on age and gender:

For girls over 14 years old - 425-550 mg;

For boys over 14 years old - 550 mg;

For teenagers from 8 to 13 years old - 250-375 mg.

The conducted studies have proved that the opinion about thermostable alcohol, the name of which comes from the English name of bile, as a secondary substance, is erroneous. This is one of the main vitamins that the human body needs.

Vitamin B4 deficiency and its consequences

Choline deficiency is caused either by not getting enough of it from food, or by insufficient amounts of two components that help its absorption. These are folic acid and cyanocobalamin. However, there are other factors that can affect the decline in the level of a vital vitamin. These factors include:


Vitamin B4 deficiency leads to a variety of negative consequences. A person has:

Insomnia;

Headache;

Dizziness;

Noise in ears;

Muscle pain;

Loss of concentration;

Memory problems.

Personal changes are noted in the form of unjustified fears, frequent and unexpected nervous breakdowns.

A lack of choline provokes a sharp increase in weight, impaired coordination of movement, and even cardiac arrhythmia. There is a weakening of the immune system, which leads to the emergence of various diseases.

Vitamin B4 overdose

Choline is considered a safe nutrient and rarely causes negative side effects. However, like any substance, choline in excess can harm the human body. An excess of vitamin B4 can lead to the development of negative symptoms and cause undesirable consequences. In large quantities, it can become toxic.

Constant nausea, the specific smell of fish that accompanies the patient, high blood pressure, excessive salivation and hyper sweating, make it possible to diagnose an excess of the optimal level of vitamin B4 in the body.

Sometimes the general symptoms are accompanied by disturbances in the digestive system (diarrhea and flatulence, loss of bowel functionality), allergic reactions in various forms of manifestation may be even rarer.

What products contain

To replenish the level of vitamin B4, if its lack is not very serious, it is enough to eat foods that can compensate for the missing amount. Choline-rich foods include:

  • Meat;
  • Seafood;
  • fish;
  • Liver;
  • Eggs (yolks).

In vegetables and fruits, this vitamin is much less. If you use them in parallel with food containing folic acid and vitamin B12, you can significantly increase the percentage of digestibility of choline, and if you cook choline-containing foods for a short time, you can avoid the loss of the substance that occurs during prolonged heat treatment.

With vitamin B4 deficiency, nutritionists recommend eating dried herbs and seasonings, because they contain more of it than fresh herbs. The same goes for unrefined grains, which are much healthier in this regard than refined grains.

Peas, soybeans, beef, egg yolk, chicken eggs, pork and beef liver, quail eggs - these are the products that you can rely on when compiling a diet menu. Vegetarians, due to the low content of choline in plant foods, will find it difficult to make up for its deficiency in a short time.

Choline for children

An infant receives Vitamin B4 along with mother's milk. At a later age, given the small daily dose required for the child's body, its deficiency can be easily replenished by including in the menu those foods that contain the necessary dose of the vitamin.

If the baby's food contains eggs, liver, sour cream or cream, sunflower oil, nuts, you can not be afraid for the development of a deficiency. Children's diet can be replenished with vitamin supplements, which are used with the knowledge and approval of the doctor. Receiving vitamin complexes, the child simultaneously consumes ascorbic acid, Omega-3 fats and other B vitamins that are part of them. A positive point is the ability to accurately determine the amount of vitamin B4.

Choline preparations

Choline preparations for adults are available in the form of capsules and tablets, vitamins in the composition of complexes, powder for oral administration and solution for intravenous injection. To calculate the dosage, the optimal form of administration and concomitant medications, it is better to contact your doctor, who will consider the appropriateness of the appointment.

Higher levels of choline are prescribed to boost brain function and preserve memory. In some cases, choline from food may simply not be absorbed by the body, which can be one of the main reasons for the deficiency of this vitamin. This is often the case in people with liver disease, as choline is partly produced in the liver. In this situation, choline preparations or supplements are also required.

When shopping for choline supplements, it's best to opt for those made from foods that are high in choline. Such additives are more "friendly" to the human body and will be better absorbed. While synthetic drugs are only partially.

This is due to the fact that in the body choline is converted into a molecule of acetylcholine. The different types of choline also differ in their ability to cross the blood-brain barrier once ingested.

Choline and soy lecithin

It is also worth noting that choline can be found in soy products, especially in soy lecithin. Choline is a key component of lecithin (phosphatidylcholine), which is a fat-like substance found in our cells.

Soy lecithin contains choline and other molecules including fatty acids, glycerol and phospholipids. It was originally extracted from egg yolks, but today it is obtained from cottonseeds, marine sources, milk, sunflowers or, most commonly, soybeans. Lecithin itself plays an important role in the body, including helping to maintain cell membranes and transmit nerve impulses.

Soy lecithin is added to many foods during processing because it helps bind foods and acts as an emulsifier, preserving their texture and making them more shelf-stable. While soy lecithin is considered safe, at times it can lead to adverse reactions, including nausea, bloating, constipation, skin rashes, stomach pain, and other digestive problems.

Some research suggests that soy lecithin can be even more dangerous and can have long-term negative effects, including impaired reflexes, pain, slowed metabolism, and nerve dysfunction. The soy lecithin debate is still ongoing. Therefore, you should not take risks with its use in order to make up for the lack of choline.

When it comes to getting choline from soy products, it's best to consume fermented soy products such as miso, natto, and others in moderation and avoid unfermented soy. Of particular note is that most of the soybeans on the market are genetically modified. In addition to it, there are quite a few other products from which you can get vitamin B4 with health benefits and without any risk.

Vitamin B4 (choline) is a vitamin for a healthy liver and good memory. It plays an extremely important role in the normal functioning of the human body.

Description of Vitamin B4 (Choline):
Choline is a vitamin-like compound, in the form of a base, which is a colorless crystals that are readily soluble in water. Choline is commonly referred to as vitamin B4. For the first time this substance was obtained from bile at the beginning of the 20th century, at the same time experiments began and the study of the effect of choline on the body. It is thanks to research that humanity has learned about the vital need for vitamin B4 for humans.
Choline plays a very important role for the body, participating in many biochemical processes. It can be synthesized in sufficient quantities in the body, and also comes with food. In addition, there are drugs of choline, which are prescribed by doctors for certain diseases and a lack of this vitamin.

Why does the body need vitamin B4 (choline):

  • Choline is extremely important for normal mental activity, intelligence development, memory improvement and concentration. This vitamin is essential for the formation and normal functioning of brain cells.
  • It is an important substance for the proper functioning of the nervous system, helps to cope with stress and depression. Part of the choline in the body goes to the production of acetylcholine, which is responsible for the transmission of nerve impulses.
  • Vitamin B4 protects cell membranes from damage.
  • Strengthens the heart muscle, helps to normalize the heart rhythm.
  • Participates in the transportation, processing and metabolism of fats. Normalizes cholesterol levels, thereby reducing the risk of cholesterol plaques.
  • Choline is extremely important for the liver. Accelerates the recovery of its cells after the toxic effects of drugs, alcohol and other harmful substances. Protects the liver from obesity.
  • Improves the function of the pancreas and gallbladder. Prevents the development of gallstone disease, reduces the risk of diabetes.
  • Choline helps to be absorbed in the body by others, such as, and.
  • Vitamin B4 is essential for the development of the child's body. While still in the womb, the baby needs this substance. That is why, along with folic acid, doctors often prescribe choline to pregnant women. The formation of intellectual abilities, the full development of the nervous system and brain - this is not a complete list of the functions of choline in the body of a child.
    Sufficient intake of vitamin B4 helps protect the unborn child from many diseases both in the womb and after birth throughout life.
  • Choline is important for the male reproductive system. This vitamin enhances sperm motility, helps protect the prostate gland from inflammation.
  • Many scientists suggest that vitamin B4 can slow down the aging process in the body.

Daily requirement for vitamin B4 (choline):
The required amount of vitamin B4 (choline) depends on age, gender, health status and lifestyle. For an adult, the daily requirement for choline is about 500 mg. With increased mental and physical stress, as well as with frequent stressful situations, during pregnancy and lactation, the need for vitamin B4 increases significantly.

What foods contain vitamin B4 (choline):
As mentioned above, the human body is able to synthesize vitamin B4 on its own, but often this amount is not enough to cover the need for this vitamin and it must be obtained from outside.
The source of choline (vitamin B4) is ordinary foods such as, (yolks), cheese, cottage cheese, sea fish (and), meat (including), nuts (, etc.). Choline is also found in soy, and other foods.
During heat treatment of products, the amount of vitamin B4 is reduced.

Lack of vitamin B4 (choline) in the body:
The lack of choline in the body can be manifested by increased irritability, fatigue, mental decline, forgetfulness and other symptoms. Chronic deficiency of vitamin B4 can lead to serious diseases of the digestive, nervous and cardiovascular systems, as well as to the development of mental disorders, sexual dysfunction and other unpleasant consequences.

An excess of vitamin B4 (choline) in the body:
An excess of choline occurs with uncontrolled long-term use of preparations containing this vitamin and can be manifested by nausea, low blood pressure, intestinal upset and other symptoms.

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