Oxidation of fatty acids and

Ketogenesis
Dr.S.Chakravarty MBBS, MD,
dipHPE.
 Specific Learning Objectives
• At the end of this lecture students will be able to :-
– Describe the role of carnitine in fatty acid transport across mitochondria for
oxidation and list the fatty acids which do not require carnitine for transport.

– Describe the functions of Carnitine and its deficiency due to primary and
secondary causes.

– Differentiate the clinical features of CPT-1 and CPT-2 deficiency

– Differentiate the various types of oxidation of fatty acids and its importance

– Describe the clinical features of MCAD deficiency and its treatment

– Describe Zellweger syndrome and Jamaican vomiting sickness

Overview of fatty acid metabolism
 Triglycerides

Glucagon, Epinephrine
+ Hormone sensitive lipase

Glycerol Fatty acids

Glycerol kinase Beta

oxidation

Ketone body
Glycerol-3-PO4 Acetyl Co-A synthesis
Any cell with Liver
Liver mitochondria
Gluconeogenesis

Glucose Mobilization of triglycerides from adipose tissue

 Biomedical Importance
• Fatty acid oxidation is not the simple reverse of fatty acid
biosynthesis but an entirely different process taking place
in a separate compartment of the cell.

• Its an aerobic process requiring oxygen.

• Increased fatty acid oxidation is a characteristic of

starvation and of diabetes mellitus, leading to ketone body
production by the liver (ketosis). Ketone bodies are acidic
and when produced in excess over long periods, as in
diabetes, cause ketoacidosis, which is ultimately fatal.
• Gluconeogenesis is dependent upon fatty acid oxidation, any
impairment in fatty acid oxidation leads to hypoglycemia.

This occurs in various states of carnitine deficiency or

deficiency of essential enzymes in fatty acid oxidation, eg,
carnitine palmitoyltransferase, or inhibition of fatty acid
oxidation by poisons, eg, hypoglycin.
 Types of fatty acid oxidation:
Oxidation Organelle Fatty acids

Beta oxidation Mitochondria Long, medium and

short chain FA
Beta oxidation Peroxisomes Very long chain FA

Omega oxidation Endoplasmic reticulum Works only when

mitochondria does not
oxidize medium chain
FA

Alpha oxidation Peroxisomes Branched chain fatty

acids
Definition: - The process in which two carbons are cleaved at a time
from acyl-CoA molecules starting at the carboxyl end.

The chain is broken between the α(2)- and β(3)-carbon atoms—hence

the name β-oxidation.

• Tissue : Liver , adipose tissue , skeletal muscles

• Subcellular site :- Mitochondrion

• Transport of fatty acids in Blood :- In plasma, UFA (unesterified fatty

acids ) or (FFA) free fatty acids are combined with albumin.

• Inside the cell they are attached to fatty acid binding protein or Z-
binding protein. So infact they are never free.
 Three Stages of Beta-Oxidation

1 Activation of fatty acids.

2 Transport of activated fatty acids into mitochondria.

3 Oxidation of fatty acids.

 Step 1 : Activation of fatty acids
FFA + ATP +CoA acyl CoA
AMP + PPi + Acyl CoA
synthetase

PPi + H2O inorganic

2Pi
pyrophosphatase

THIS IS THE ONLY STEP THAT REQUIRES ATP

Step2. Long chain fatty acids penetrate inner mitochondrial
membrane as carnitine derivatives
Carnitine :--hydroxy  trimethyl ammonium
butyrate
 Acyl CoA
dehydrogenase
chain

2 Enoyl CoA
Hydratase

L(+)-3-hydroxy acyl
CoA
dehydrogenase

Thiolase

+
Step 3. Beta oxidation
of fatty acids
 Energetics of Beta oxidation
Eg. Palmitic acid (16 C)
Needs 7 cycles to produce 8 Acetyl CoA
Step Calculation ATP produce dor
consumed
Acyl CoA 7 cycles =7 FADH2 7 x 1.5 =10.5 10.5
dehydrogenase 1 FADH2 = 1.5 ATP

3-hydroxyacyl CoA 7 cycles = 7 NADH 7 X 2.5 = 17.5 17.5

dehydrogenase 1NADH=2.5 ATP
TCA CYCLE 8 acetyl CoA 10 x 8 =80 80
10ATP/acetyl CoA

ACTIVATION OF 2 -2
FATTY ACID
TOTAL 106
 Regulation of fatty acid oxidation:

Fatty acyl Co-A Malonyl Co-A

Cytoplasm
(-)
Carnintine acyl
Outer mitochondrial
Transferase -1 (CAT or membrane
CPT)

Mitochondrial matrix

Rate limiting step

Regulation of long chain fatty acid oxidation
in liver
 -oxidation
• Detected in Brain
• Removal of one carbon at a time from the carboxy end of the molecule.
• Alpha-oxidation of phytanic acid is believed to take place entirely within
peroxisomes.
• No requirement of CoA derivatives
• Does not generate high energy phosphates

 - oxidation
very minor pathway and is brought about by hydroxylases of cyt.P450 in E.R.

The –CH3 group is converted to –CH3OH and finally oxidized to –COOH , thus
forming a dicarboxylic acid.This is -oxidized usually to adipic(C6) or
suberic acids(C8) , which are excreted in the urine.
 Very long chain fatty acid >20 carbon
Step wise
process
Peroxisomes Very long chain acyl Co-A dehydrogenase

Long chain fatty acid 12- 20 carbon

Long chain acyl Co-A dehydrogenase

Medium chain fatty acid 6-12 carbon

Mitochondria
Medium chain acyl Co-A dehydrogenase

Short chain fatty acid <6 carbon

Short chain acyl Co-A dehydrogenase

Acetyl Co-A
 Peroxisomes
• A modified form of oxidation is found in peroxisomes and leads to the
formation of acetyl-CoA and H2O2 (from the flavoprotein-linked dehydrogenase
step), which is broken down by catalase.
• Thus, this dehydrogenation in peroxisomes is not linked directly to
phosphorylation and the generation of ATP. These enzymes are induced by
high-fat diets and in some species by hypolipidemic drugs such as clofibrate.

• The enzymes in peroxisomes do not attack shorter-chain fatty acids; the -

oxidation sequence ends at octanoyl-CoA.

• Octanoyl and acetyl groups are both further oxidized in mitochondria.

• Another role of peroxisomal oxidation is to shorten the side chain of

cholesterol in bile acid formation .

• Peroxisomes also take part in the synthesis of ether glycerolipids, cholesterol,

 Oxidation of odd chain fatty acids
• Oxidation of fatty acid with odd no. of carbon atom yields
acetyl CoA + Propionyl CoA( Enters TCA as Succinyl Co-A).Thus
this portion of odd chain fatty is glucogenic.
 Methylmalonic aciduria
• Deficiency of vitamin B12 – accumulation of methyl malonyl
Co-A.

• Mutation in methyl malonyl Co-A mutase

• Converted to Methyl malonic acid.

• Methylmalonic acidemia and later methylmalonic aciduria.

• Metabolic acidosis.
 Oxidation of unsaturated fatty acids:

• Lower energy yield compared to saturated

fatty acids of same number of carbon atoms.

• Also occurs in mitochondria with little

modification of few enzyme steps.
Fat is burnt on the wick of carbohydrates
• Oxidation of fats need the help of Oxaloacetate
which enters into the cycle and is regenerated in the
end .
• The major source of OAA is Pyruvate. (Carbohydrate)
 Clinical Aspects
• Impaired oxidation of fatty acids gives rise to
diseases associated with nonketotic hypoglycemia .

– Carnitine deficiency can occur in preterm babies owing to

inadequate biosynthesis or renal leakage.
• t/t is by giving oral carnitine supplements
– CPT 1 deficiency affects only the liver – hypoglycemia
– CPT2 deficiency affects primarily skeletal muscle and only
when severe the skeletal muscle .
 Medium chain acyl Co-A dehydrogenase
deficiency (MCAD)

• Most common inborn error of fatty acid

metabolism

• Defect in first step of beta oxidation

• Present in milk – seen in infants dependent on

mother’s milk.

• Accumulation of medium chain fatty acids.

 Cont…

• Alternate omega oxidation – leads to accumulation of

dicarboxylic acids adipic (C6), suberic (C8), sebacic (C10).

• Dicarboxylic aciduria and presence of medium chain acyl

carnitines in urine

• Profound Hypoglycemia – no ATPs for running gluconeogenesis.

• Absent ketone bodies in the blood why ? no acetyl Co-A

• Hyperammonemia - octanoic acid mitochondrial poison  coma.

• Common cause of sudden infant death syndrome (SIDS)

 Carnitine deficiency
• Newborn infants esp PRETERM –Inadequate
biosynthesis and renal leakage.
• Hypoglycemia .
• Oral Carnitine supplementation.
 Jamaican vomiting sickness:
• Unripe Ackee fruit – Hypoglycin

• Inactivates medium and short chain acyl Co-A

dehydrogenase.

• Dicarboxylic aciduria – due to omega oxidation.

• intractable vomiting, abdominal pain, and lethargy

and is profoundly hypoglycemic
 Zellweger syndrome
• Peroxisomal disorder
• Cerebrohepatorenal syndrome
• Defect in peroxisomal biogenesis in all tissues.

Clinical features: death by 1 year.

• Impaired neuronal migration and brain
development
• Craniofacial dysmorphism
• Renal cyst and Hepatomegaly.
 Refsum’s disease
• Refsum’s disease is a rare neurologic disorder
caused by accumulation of phytanic acid
formed from Phytol , a constituent of
chlorophyll .
• Susceptible people have a deficiency of
phytanoyl-CoA hydroxylase that prevents -
oxidation .
• Phytanic acid contains a methyl group on C3
that blocks -oxidation also.
 Acute fatty liver of pregnancy
• Defects are known in long chain 3-
hydroxyacyl-CoA dehydrogenase may be a
cause of acute fatty liver of pregnancy.
A 4-month-old infant presents with a seizure. His mother
reports that her infant has been irritable and lethargic over the
past several days. The infant is found to be profoundly
hypoglycemic and have low ketones . Short-chain dicarboxylic
acids are found to be elevated in the serum. The most likely
enzyme deficiency is which of the following?

(A) Medium-chain acyl CoA dehydrogenase (MCAD)

(B) Carnitine acyltransferase I
(C) Hormone-sensitive lipase
(D) Pyruvate carboxylase
(E) Fatty acyl CoA synthetase
What is the primary role of carnitine in fatty acid oxidation ?

(A) Activates long-chain fatty acids in the cytosol

(B) Transport of acyl groups across the inner mitochondrial membrane

(C) Is converted to enoyl CoA

(D) Is converted to β-hydroxyacyl CoA

(E) Is involved in breakdown of even-chain, but not odd-chain, fatty acids

An infant is born with a high forehead, abnormal eye folds, and deformed
ear lobes and shows little muscle tone and movement. After multiple
tests, he is diagnosed with Zellweger syndrome, a disorder caused by
peroxisome malformation. What type of fatty acid would you expect to
accumulate in patients with Zellweger syndrome?

(A) Short-chain fatty acids

(B) Acetyl CoA

(C) Dicarboxylic acids

(D) Long-chain fatty acids

(E) Very-long-chain fatty acids

Ketogenesis and Ketolysis
 Ketogenesis
• Ketogenesis Occurs When There Is a High Rate of Fatty Acid Oxidation in
the Liver

• Normal plasma ketone bodies concentration =0.2 mmol/L

• Loss via urine is less than 1mg/24hrs.
Formation utilization and excretion of
ketone bodies
The pathway of
ketogenesis
Utilization in extrahepatic tissues:
• Liver can only synthesize ketone bodies but it
cannot utilize them.

• Only extrahepatic tissues can utilize

acetoacetate – because of the enzyme
Succinyl-CoA-acetoacetate transferase –
(THIOPHORASE).
Transport of ketone bodies from the liver and pathways
of utilization and oxidation in extrahepatic tissues.
Levels of ketone bodies during various
phases of fasting:
Regulation of ketogenesis
1. Lipolysis in adipose tissue (as FFA are
precursors of KB)
2. After uptake by liver FFA are oxidized
to CO2 or esterified to triacylglycerol
and phospholipids .
3. acetyl CoA formed in -oxidation is
oxidized in TCA cycle or it enters the
pathway of ketogenesis to form
ketone bodies .
Complete oxidation of 1 mol of palmitate
actually produces 106mol ATP by TCA
but only 26 when acetoacetate is the
end product and 21 when 3-hydroxy
butyrate is the end product.
Thus , ketogenesis may be regarded as a
mechanism that allows the liver to
oxidize increasing quantity of fatty
acids within a tightly coupled system
of oxidative phosphorylation.
Ketosis : ketonemia and ketonuria

Ketosis

Pathological
physiological
form

High fat-Low Type -1

starvation
carb diet diabetes
 Diabetic ketoacidosis:
• Mainly seen in type-1 diabetes mellitus

• Hyperglycemia >300mg/dl

• Dehydration – Glucosuria, ketonuria

• High anion gap Metabolic acidosis (pH <7.2) – due to ketone bodies

• Low Bicarbonate levels (<15mEq/L) – used for neutralization

• Hyperkalemia - >5-5.5mg/dl
 Diabetic ketoacidosis:
• Decreased insulin glucagon ratio- increased fatty
acid oxidation  increased ketone bodies.

• At physiological pH  exists as ketoacids 

neutralized by bicarbonate  metabolic
acidosis.

• Also increased excretion of ketones in urine –

HCO3 also excreted to maintain urine pH.
• Glucose not entering cells of SEKLETAL MUSCLES
AND ADIPOSE TISSUE due to Insulin deficiency
(GLUT 4 receptors )

• CELLS is actually STARVING !!

• INCREASED MOBILIZATION OF LIPIDSIncreased

FATTY ACID OXIDATION Increased Acetyl CoA.

• Less OAA (less Pyruvate Less OAA)Less

utilization of acetyl CoA in TCA cycle
KETOGENESIS
 Diabetic ketoacidosis:
• Exacerbated by tissue hypoxia and infections.

• Nausea and vomiting

• Abdominal pain – due to a/c pancreatitis due to hypertriglyceridemia

• Kussumal’s breathing: metabolic acidosis.

• Fruity odour – acetone

• Hyperglycemia – Glucosuria with water loss.

• Hypotension and coma.

A 12-year-old boy presents with fatigue, polydipsia,
polyuria, and polyphagia. A fingerstick glucose
measurement shows a glucose level of 350mg/dL in his
serum. He is diagnosed with type 1 diabetes mellitus, a
disease characterized by a deficiency of insulin. Which
one of the following is most likely occurring in this
patient?

A) Increased fatty acid synthesis from glucose in liver

B) Decreased conversion of fatty acids to ketone bodies
C) Increased stores of Triacylglycerol in adipose tissue
D) Increased production of acetone
E) Chronic pancreatitis
Thank you