METABOLISM OF FAT SOLUBLE VITAMINS

Supporting Lecturer :

Dr. Anita Joeliantina, S.Kep.Ns., M.Kes

NIP : 197107231995032002

Arranged By :
Rizka Arifin Yulianto : P27820723161
Lailatul Fitriani : P27820723152
Khusnul Hotimah : P27820723151
Anargya Danendra H. : P27820723138

LEVEL 1 INTERNATIONAL CLASS

NURSE PROFESSIONAL EDUCATION STUDY PROGRAM

UNDERGRADUATE LEVEL APPLIED NURSING

HEALTH POLYTECHNIC OF HEALTH MINISTRY SURABAYA

ACADEMIC YEAR 2023-2024

 KATA PENGANTAR

We give thanks to the presence of God Almighty because with His grace, taufik and
guidance we were able to complete this paper on Roy's theory in nursing even though there
are still many shortcomings in it. And we also thank Mr. Dr. Anita Joeliantina, S.Kep.Ns.,
M.Kes ss a lecturer who has given us this assignment.
The author really hopes that this paper can be used by readers as a reference in the
future or as a reference for practice. The author really hopes that this paper can increase the
knowledge and experience of its readers.
Apart from all that, we are fully aware that there are still shortcomings both in terms of
sentence structure and grammar. Therefore, we accept all suggestions and criticism from
readers with open arms so that this paper can be improved.

Surabaya, 19 October 2023

Writers
 TABLE OF CONTENT

KATA PENGANTAR.................................................................................................................2
TABLE OF CONTENT.............................................................................................................3
CHAPTER 1...............................................................................................................................3
1.2 Problem Formulation........................................................................................................3
1.3 Objective...........................................................................................................................3
CHAPTER II..............................................................................................................................4
2.1 Definition of Fat Soluble Vitamins...................................................................................4
2.2 Cellular Level...................................................................................................................4
2.3 Funtcion............................................................................................................................4
2.4 Pathophysiology...............................................................................................................5
1) Deficiency.......................................................................................................................5
2) Toxicity...........................................................................................................................7
2.5 Fundamentals....................................................................................................................7
CHAPTER III.............................................................................................................................9
3.1 Conclusion........................................................................................................................9
REFERENCE...........................................................................................................................10

CHAPTER 1

INTRODUCTION

1.1 Background
 Vitamins are vital micronutrients that cannot be synthesized endogenously or in
insufficient amounts, and the principal means by which we get vitamins is through our
diet. Vitamins can classify as water-soluble or fat-soluble. The fat-soluble vitamins
include vitamins A, D, E, and K. Fat-soluble vitamins play integral roles in a multitude
of physiological processes such as vision, bone health, immune function, and
coagulation. This review discusses the biochemistry, transport, and roles of these
vitamins highlighting deficiency syndromes and potential toxicities.
1.2 Problem Formulation
1. What is the definition of a fat soluble vitamin?
2. How many types of fat soluble vitamins are there?
3. Function of fat soluble vitamins?
4. Source of fat soluble vitamins?
5. What are the effects of excess and deficiency?
1.3 Objective
1. Know the definition of fat soluble vitamins
2. Know the various types of fat soluble vitamins
3. Understand the function of fat soluble vitamins
4. Find out where the sources of soluble vitamins in fat come from
5. Know the effects of deficiencies and excesses of fat-soluble vitamins

CHAPTER II

DISCUSSION
2.1 Definition of Fat Soluble Vitamins
Fat-soluble vitamins are hydrophobic molecules, all of which are isoprene
derivatives. These molecules are not synthesized by the body in adequate amounts so
they must be supplied from the diet. The supply of these fat-soluble vitamins requires
normal fat absorption for them to be efficiently absorbed. Impaired fat absorption caused
by biliary system disorders will result in impaired absorption of fat-soluble vitamins.
Once absorbed, these vitamins are carried to the liver in the form of chylomicrons and
stored in the liver or in fatty tissues. In the blood, fat-soluble vitamins are transported by
lipoproteins or specific binding proteins (Specific Binding Protein), and because they are
not water-soluble, they are excreted through bile, which is excreted with feces.
2.2 Cellular Level
Despite structural differences between fat-soluble vitamins, they are absorbed and
transported similarly due to their low solubility in hydrophilic media. The body absorbs
fat-soluble vitamins into newly forming micelles in the small intestine. Micelles are lipid
clusters that contain hydrophobic groups internally and hydrophilic groups externally.
This process relies on the secretion of bile and pancreatic enzymes. After absorption into
enterocytes, fat-soluble vitamins become packaged into chylomicrons, which then get
secreted into the lymphatic system before entering the bloodstream. Chylomicrons are
metabolized by lipoprotein lipase, which causes the release of fat-soluble vitamins into
tissues for use and storage.

Because they are stored in tissue, the fat-soluble vitamins are retained by the body
for a longer time than the water-soluble vitamins. Remnants of the chylomicron are then
taken back up by the liver and recycled. Alpha-tocopherol is targeted into lipoproteins in
the liver by a specific tocopherol transfer protein (TTP), mutations of which can result in
vitamin E deficiency.

2.3 Funtcion
1) Vitamin A
Vitamin A plays an integral role in the differentiation and proliferation of
epithelial cells in the eyes, salivary glands, and genitourinary tract. Vitamin A is a
precursor to the nuclear hormone all-trans retinoic acid, which heterodimerizes with
retinoic acid receptors (RAR) in the nucleus. RAR-retinoid X receptor heterodimers
serve as transcription factors that bind certain elements in promoters of genes. These
genes encode important structural proteins, extracellular matrix proteins, and enzymes
throughout the body. Retinal, a component of vitamin A, derives its name from its
ability to produce rhodopsin in the retina, thereby aiding in vision, especially in low
light settings. Additionally, vitamin A stimulates T-lymphocyte differentiation and B-
lymphocyte activation in response to immune stimuli.

2) Vitamin D
The primary function of vitamin D is to raise plasma calcium and phosphate
concentrations, which promotes the mineralization of osteoid in the bone. The ability
 to elevate calcium levels is necessary for the proper functioning of the neuromuscular
junction, nerve transmission, and secretion and actions of hormones. Vitamin D3 from
the skin and vitamin D2 from the diet are prohormones that undergo hydroxylation to
25-hydroxycholecalciferol in the liver via the enzyme 25-hydroxylase. 25-
hydroxycholecalciferol becomes further hydroxylated in the kidney to its biologically
most active form, 1,25-dihydroxycholecalciferol. Hydroxylation in the kidney into a
biologically active form occurs via 1-a-hydroxylase, an enzyme under tight regulation
by parathyroid hormone. The active form of vitamin D increases the duodenal
absorption of calcium and phosphate and calcium reabsorption from the distal
convoluted tubule by upregulating calcium transporters that move calcium across
epithelial cells. Importantly, vitamin D activates osteoclasts, our body’s bone-
resorbing cells. The human body maintains equilibrium with bone formation and
resorption. To effectively mineralize bone, some level of bone resorption is necessary.
3) Vitamin E
Vitamin E, exclusively acquired from the diet, is best known for its
antioxidant activity. Vitamin E inhibits the generation of reactive oxygen species
during fat oxidation. It protects polyunsaturated fatty acids in cell membranes from
oxidative destruction, thereby maintaining membrane fluidity and stability. While it
inhibits lipid peroxidation, including oxidation of LDL, supplementation has not
resulted in a reduction in cardiovascular events.
4) Vitamin K
Vitamin K is necessary to activate certain clotting factors in the liver, which
are responsible for coagulation. For activation to occur, the clotting proteins must
bind calcium. Vitamin K-dependent gamma-carboxylation of certain glutamic acid
residues allows the proteins to bind calcium and carry out the coagulation cascade.
Specifically, vitamin K serves as a cofactor for gamma-glutamyl carboxylase and
catalyzes the post-translational synthesis of gamma-carboxy-glutamyl residues. This
process activates prothrombin and factors VII, IX, X, protein C and S. Oxidation of
vitamin K hydroquinone supplies energy for these carboxylation reactions.
Regeneration of vitamin K hydroquinone relies on vitamin K epoxide reductase and
vitamin K quinone reductase.
2.4 Pathophysiology
1) Deficiency
a) Vitamin A
Although rare in developed nations, vitamin A deficiency is a significant
health concern in non-industrialized countries. It is responsible for over 500,000
cases of corneal lesions in children per year. In the United States, vitamin A
deficiency most commonly results from fat malabsorption syndromes, alcoholism,
and liver disease. Uptake of vitamin A can also become impaired by iron
deficiency, pancreatic insufficiency, and inflammatory bowel disease. Severe
deficiency can lead to various ocular signs, most notably night blindness
(nyctalopia) and xerophthalmia. Keratin accumulation in the conjunctiva causing
Bitot’s spots is a pathognomic physical finding. Other ocular manifestations
include conjunctival xerosis, corneal drying and ulceration, and follicular
hyperkeratosis. Due to the role of vitamin A in T-lymphocyte proliferation and
 differentiation, deficiency also increases the risk of infections. Notably, vitamin A
is an effective treatment for measles, decreasing mortality in children and
hospitalized patients. Additionally, by inducing differentiation of acute
promyelocytic anemia cells, all-trans retinoic acid (ATRA) is considered an
effective treatment for acute promyelocytic leukemia. In outpatient settings,
isotretinoin is a common prescription for the treatment of severe acne vulgaris.
b) Vitamin D
Vitamin-D deficiency has become a global concern with dire health
consequences. Common risk factors include old age, exclusively breastfed infants,
immobility, reduced kidney function, dark skin, malabsorption syndromes,
decreased sunlight exposure, and obesity. Manifestations of deficiency include
muscle aches and weakness with bone pain in the back, extremities, and pelvis. In
children, vitamin-D deficiency leads to impaired mineralization of cartilage at
growth plates leading to rickets. Patients with rickets may have a bow-leg
deformity, rachitic rosary, stunted growth with short stature, dental deformities,
abnormal spinal curvature, craniotabes, and frequent fractures. In adults, low
vitamin-D levels lead to impaired mineralization of osteoid, leading to
osteomalacia. Osteomalacia characteristically demonstrates diffuse bone and joint
pain, myopathy, hypocalcemic tetany, and a waddling gait.
c) Vitamin E
Vitamin-E deficiency is extremely rare and principally occurs in individuals
with fat malabsorption and abetalipoproteinemia (defect in microsomal transfer
protein) and hypobetalipoproteinemia (mutation in apolipoprotein B) disorders.
Symptoms of deficiency include limb and truncal ataxia, hyporeflexia, and upward
gaze limitations. Rarer manifestations are muscle weakness and constriction of
visual fields. If left untreated, deficiency can result in blindness, memory
impairment, and arrhythmias. Multiple clinical trials have shown that vitamin-E
supplementation decreases histological and biochemical evidence of liver
dysfunction in patients with nonalcoholic fatty liver disease (NAFLD) and
nonalcoholic steatohepatitis (NASH). The increased inflammation and oxidative
stress observed in obesity theoretically heighten vitamin-E requirements in this
subset of patients. Additionally, these findings raise the question of whether
vitamin-E deficiency could exacerbate liver dysfunction.
d) Vitamin K
Vitamin-K deficiency is clinically significant due to its prevalence in a
variety of patient populations. Risk factors include antibiotic use, which interferes
with vitamin-K production in the gut, nutritional deficiency, and high ingestion of
vitamins A and E. Newborns are also at risk for deficiency due to immature gut
flora, poor placental transfer, and low content in breast milk. The risk in newborns
becomes further increased with a maternal history of anticonvulsant and
anticoagulant use. A common clinical syndrome that results from vitamin-K
deficiency is a hemorrhagic disease of the newborn, a life-threatening bleeding
condition in neonates. Neonates with this condition present with failure to thrive,
 low birth weight, and excessive bleeding from the umbilical stump and mucous
membranes. They are at higher risk for intracranial hemorrhage. This condition is
treated prophylactically through vitamin-K injections at birth. In adults, deficiency
can also cause easy bleeding and bruising with an elevated PT.
2) Toxicity
a) Vitamin A
Vitamin-A toxicity most commonly is the result of over-supplementation,
wild game liver consumption, and isotretinoin therapy. Hypervitaminosis A leads to
intracranial swelling, which manifests as headaches, papilledema, and seizures.
Other findings include arthralgias, alopecia, dry mucous membranes, desquamation
of skin, hypercalcemia, and liver damage. Isoretinoic acid, an acne treatment, is
contraindicated in women who are pregnant or may become pregnant due to a risk
of spontaneous abortion and birth defects in the fetus.
b) Vitamin D
Vitamin-D toxicity, although rare, can occur in individuals taking large
doses of vitamin-D supplements with a heavy intake of fortified foods. The
majority of symptoms of hypervitaminosis D stem from hypercalcemia caused by
excessive calcium absorption in the duodenum and distal convoluted tubule.
Clinical manifestations include gastrointestinal issues such as decreased appetite,
diarrhea, nausea, vomiting, and constipation. Hypercalcemia can result in polyuria,
polydipsia, pruritus, and the development of kidney stones. Bone, muscle, and joint
pain are also common manifestations.
c) Vitamin E
Hypervitaminosis E is most commonly a result of over-supplementation and
is otherwise very rare. Since high doses of Vitamin E (800 mg per day) inhibit
platelet aggregation, it is contraindicated in patients on anticoagulants.
d) Vitamin K
Vitamin-K toxicity is uncommon overall but is more prevalent in formula-
fed infants and those who receive menadione injections, a synthetic vitamin-K
precursor that is water-soluble. Symptoms on hypervitaminosis K include
hemolytic anemia, jaundice in newborns with hyperbilirubinemia, and liver
damage.
2.5 Fundamentals
1) Vitamin A
In animals, the body stores vitamin A as a molecule called retinol. Egg yolk,
milk, liver, cheese, and butter are all rich in vitamin A. We derive vitamin A from
plant sources in the form of plant carotenoids, which convert to retinol during
digestion. Plants abundant in vitamin A include dark green leafy vegetables (spinach,
amaranth, among others), carrots, squash, yellow maize, mangoes, and papayas.
2) Vitamin D
 Vitamin D is found primarily in two forms, D2 and D3. Vitamin D2
(ergocalciferol) is present in certain foods such as salmon, tuna, and mackerel.
Smaller quantities are present in beef liver, cheese, and egg yolks. Many countries
fortify natural milk with vitamin D. This is a practice implemented to decrease the
prevalence of rickets and osteomalacia. Vitamin D3 (cholecalciferol) is synthesized in
the skin after exposure to sunlight, hence its nickname the "sunshine vitamin."
3) Vitamin E
The predominant form of vitamin E is a-tocopherol. However, other
tocopherols and tocotrienols are also present in circulation, such as the alpha, gamma,
beta, and delta forms. Naturally occurring sources of vitamin E include vegetable oils,
seeds, nuts, and whole grains.
4) Vitamin K
Vitamin K has two primary forms, K1 and K2. Vitamin K1 (phylloquinone) is
present in green leafy vegetables, cabbage, and cauliflower. Lesser quantities are in
fish, meat, and some fruits. The gut microflora synthesizes vitamin K2
(menaquinone).
 CHAPTER III

CLOSING

3.1 Conclusion
Fat soluble vitamins are a type of vitamins that dissolve in fat and are stored in
our body tissues. These particular vitamins, A, D, E and K play roles in various bodily
functions. For instance vitamin A is essential, for maintaining eye health while vitamin D
regulates the levels of calcium and phosphorus in our bodies. Vitamin E acts as an
antioxidant to protect our cells from damage and vitamin K plays a role in blood clotting
regulation. Deficiencies of these vitamins can lead to several health issues like vision
problems, bone disorders, abnormal blood clotting and skin conditions. However it's
important to strike a balance with the intake of these vitamins since amounts can also
have effects on our health. Foods such, as dairy products, fish oil, leafy greens vegetables
and fruits are sources of soluble vitamins. Hence it's crucial to ensure that we include
amounts of these vitamins in our diet to maintain overall bodily health and equilibrium.
Should you have any concerns regarding your intake of any vitamin mentioned above or
others alike; it is advisable to seek guidance from a professional or nutritionist.
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