{"id":176,"date":"2019-03-11T17:37:49","date_gmt":"2019-03-11T17:37:49","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/sunyltnutrition\/?post_type=chapter&#038;p=176"},"modified":"2019-04-12T18:16:17","modified_gmt":"2019-04-12T18:16:17","slug":"7-2-fat-soluble-vitamins","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/sunyltnutrition\/chapter\/7-2-fat-soluble-vitamins\/","title":{"raw":"7.2: Fat Soluble Vitamins","rendered":"7.2: Fat Soluble Vitamins"},"content":{"raw":"Now that you know the basics of what vitamins are, let's talk about the Fat Soluble Vitamins (FSV's) specifically. There are only four\u00a0FSV's: Vitamin A, Vitamin D, Vitamin E and Vitamin K. What makes them \"fat soluble\" is the fact that they dissolve in fats and oils but they won't dissolve in water. If you've ever seen a vitamin E capsule, you already know that inside the capsule is an oily substance containing vitamin E. The Fat soluble vitamins are present in many foods but they are especially high in foods like nuts and seeds that contain a high concentration of fats and oils. Though we will discuss each fat soluble vitamin separately, please keep in mind that in whole foods there are a variety of vitamins and minerals and other nutrients all working together. This is thought to be the reason that whole foods do such good things for the body whereas taking individual supplements doesn't usually benefit health and sometimes can be harmful. Many scientists and doctors (myself included) believe that it is the harmony of the nutrients coming in together that benefits our health and when we isolate an individual nutrient it cannot give the same benefits.\r\n\r\n<header>\r\n<h2 id=\"title\">7.2A: Vitamin A<\/h2>\r\n<\/header><section class=\"mt-content-container\">Vitamin A is a fat-soluble vitamin that is stored in the liver. There are two types of vitamin A that are found in the diet.\r\n<div id=\"ency_summary\">\r\n<ul>\r\n \t<li>Preformed vitamin A is found in animal products such as meat, fish, poultry and dairy foods.<\/li>\r\n \t<li>Pro-vitamin A is found in plant-based foods such as fruits and vegetables. The most common type of pro-vitamin A is beta-carotene. Pro-vitamin A must be converted into active vitamin A by the body.<\/li>\r\n<\/ul>\r\nVitamin A is also available in dietary supplements. It most often comes in the form of retinyl acetate or retinyl palmitate (preformed vitamin A), beta-carotene (pro-vitamin A) or a combination of preformed and pro-vitamin A.\r\n\r\n<\/div>\r\n<div id=\"section_1\" class=\"mt-section\">\r\n<h3 class=\"editable\">Function of Vitamin A<\/h3>\r\n<div id=\"section-1\" class=\"section-body\">\r\n\r\nVitamin A helps form and maintain healthy skin, teeth, skeletal and soft tissue, mucus membranes, and skin. It is also known as retinol because it produces the pigments in the retina of the eye. Vitamin A promotes good vision, especially in low light. It may also be needed for reproduction and breast-feeding. Retinol is an active form of vitamin A. It is found in animal liver, whole milk, and some fortified foods. Carotenoids are dark-colored dyes (pigments) found in plant foods that can turn into a form of vitamin A. There are more than 500 known carotenoids. One such carotenoid is beta-carotene.\r\n<ul>\r\n \t<li>Beta-carotene is an antioxidant. Antioxidants protect cells from damage caused by substances called free radicals. Free radicals are believed to contribute to certain chronic diseases and play a role in the aging processes.<\/li>\r\n \t<li>Diets containing food sources of carotenoids such as beta-carotene have been shown to\u00a0reduce the risk for cancer.<\/li>\r\n \t<li>Beta-carotene\u00a0<u>supplements<\/u>\u00a0(isolated Beta-carotene in concentrated form)\u00a0do not seem to reduce cancer risk.<\/li>\r\n<\/ul>\r\n<div class=\"mt-video-widget mt-video-width-50\">\r\n<div>\r\n\r\n[embed]https:\/\/www.youtube.com\/embed\/1pa9762jAgo[\/embed]\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<em>Video <\/em><strong>7.2A.1<\/strong><em>:\u00a0This video connects health-conscious individuals with important news and information in the fast-paced world of health. From recalls and outbreaks to diet, nutrition and fitness we cover everything you need to know about health, every day.<\/em>\r\n\r\n<\/div>\r\n<div id=\"section_2\" class=\"mt-section\">\r\n<h3 class=\"editable\">Food Sources of Vitamin A<\/h3>\r\n<div id=\"section-2\" class=\"section-body\">\r\n\r\nVitamin A comes from animal sources, such as eggs, meat, fortified milk, cheese, cream, liver, kidney, cod, and halibut fish oil. However, all of these sources, except for skim milk that has been fortified with Vitamin A, are high in saturated fat and cholesterol. Some good\u00a0sources of vitamin A are:\r\n<ul>\r\n \t<li>Eggs\u00a0(preformed vitamin A)<\/li>\r\n \t<li>Milk and other dairy products\u00a0(preformed vitamin A)<\/li>\r\n \t<li>Orange and yellow vegetables and fruits (pro-vitamin A)<\/li>\r\n \t<li>Other sources of beta-carotene such as broccoli, spinach, and most dark green, leafy vegetables\u00a0(pro-vitamin A)<\/li>\r\n<\/ul>\r\nThe more intense the color of a fruit or vegetable, the higher the beta-carotene content. Vegetable sources of beta-carotene are cholesterol-free.\r\n\r\n<\/div>\r\n<\/div>\r\n<div id=\"section_3\" class=\"mt-section\">\r\n<h3 class=\"editable\">Side Effects of too much or too little Vitamin A<\/h3>\r\n<div id=\"section-3\" class=\"section-body\">\r\n\r\nIf you do not get enough vitamin A, you are at increased risk for eye problems. These include reversible night blindness and then non-reversible corneal damage known as xeropthalmia. Lack of vitamin A can lead to hyperkeratosis or dry, scaly skin. If you get too much vitamin A, you can become sick. Large doses of vitamin A can also cause birth defects.\r\n<p class=\"mt-align-center\"><img class=\"internal default aligncenter\" src=\"https:\/\/med.libretexts.org\/@api\/deki\/files\/1302\/picture7-141D79B4665325131EE.jpg?revision=1&amp;size=bestfit&amp;width=413&amp;height=349\" alt=\"two hands, one with very yellow skin due to high levels of Carotenoids in the diet. \" width=\"413px\" height=\"349px\" \/><\/p>\r\nAcute vitamin A poisoning most often occurs when an adult takes several hundred thousand IUs of vitamin A. Symptoms of chronic vitamin A poisoning may occur in adults who regularly take more than 25,000 IU a day. Babies and children are more sensitive to vitamin A, and can become sick after taking smaller doses of vitamin A or vitamin A-containing products such as retinol (found in skin creams). Large amounts of beta-carotene do not cause harm. However, high levels\u00a0of beta-carotene can turn the skin yellow or orange. The skin color will return to normal once you reduce your intake of beta-carotene.\r\n\r\n<\/div>\r\n<\/div>\r\n<div id=\"section_4\" class=\"mt-section\">\r\n<h3 class=\"editable\">Recommendations for Vitamin A<\/h3>\r\n<div id=\"section-4\" class=\"section-body\">\r\n\r\nThe best way to get the daily requirement of essential vitamins is to eat a wide variety of fruits, vegetables, fortified dairy foods, legumes (dried beans), lentils, and whole grains.\r\n\r\nThe Food and Nutrition Board of the Institute of Medicine -- Dietary Reference Intakes (DRIs) Recommended Intakes for Individuals of Vitamin A:\r\n\r\nInfants (average intake)\r\n<ul>\r\n \t<li>0 to 6 months: 400 micrograms per day (mcg\/day)<\/li>\r\n \t<li>7 to 12 months: 500 mcg\/day<\/li>\r\n<\/ul>\r\nThe Recommended Dietary Allowance (RDA) for vitamins is how much of each vitamin most people should get each day. The RDA for vitamins may be used as goals for each person.\r\n\r\nChildren (RDA)\r\n<ul>\r\n \t<li>1 to 3 years: 300 mcg\/day<\/li>\r\n \t<li>4 to 8 years: 400 mcg\/day<\/li>\r\n \t<li>9 to 13 years: 600 mcg\/day<\/li>\r\n<\/ul>\r\nAdolescents and Adults (RDA)\r\n<ul>\r\n \t<li>Males age 14 and older: 900 mcg\/day<\/li>\r\n \t<li>Females age 14 and older: 700 mcg\/day (770 during pregnancy and 1,300 mcg during lactation)<\/li>\r\n<\/ul>\r\nHow much of each vitamin you need depends on your age and gender. Other factors, such as pregnancy and your health, are also important. Ask your health care provider what dose is best for you.\r\n\r\n<\/div>\r\n<\/div>\r\n<div id=\"section_5\" class=\"mt-section\"><header>\r\n<h2 id=\"title\">7.2B: Vitamin D<\/h2>\r\n<\/header><section class=\"mt-content-container\">Vitamin D\u00a0refers to a group of fat-soluble\u00a0secosteroids\u00a0responsible for increasing intestinal absorption of\u00a0calcium,\u00a0iron,\u00a0magnesium,\u00a0phosphate, and\u00a0zinc. In humans, the most important compounds in this group are vitamin D3\u00a0and vitamin D2.\u00a0Cholecalciferol\u00a0and\u00a0ergocalciferol\u00a0can be ingested from the diet and from supplements. Very few foods contain vitamin D; synthesis of vitamin D in the skin is the major natural source of the vitamin and is dependent on sun exposure (specifically\u00a0UVB radiation).\r\n<div class=\"note1\">\r\n<div class=\"textbox\">\r\n<h3 class=\"boxtitle\">DEFICIENCY:\u00a0RICKETS<\/h3>\r\n\r\n<hr \/>\r\n<p class=\"mt-align-justify\">A diet deficient in vitamin D in conjunction with inadequate sun exposure causes osteomalacia (or rickets when it occurs in children), which is a softening of the bones. In the developed world, this is a rare disease.\u00a0However, vitamin D deficiency has become a worldwide problem in the elderly and remains common in children and adults. Low blood calcifediol (25-hydroxy-vitamin D) can result from avoiding the sun.\u00a0Deficiency results in impaired bone mineralization and bone damage which leads to bone-softening diseases, including rickets and osteomalacia.<\/p>\r\n\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"256\"]<img class=\"internal\" src=\"https:\/\/med.libretexts.org\/@api\/deki\/files\/4099\/XrayRicketsLegssmall.jpg?revision=1\" alt=\"XrayRicketsLegssmall.jpg\" width=\"256\" height=\"406\" \/> Legs in a 2 year old child with rickets. Image used with permission (CC BY-SA 1.0;\u00a0Michael L. Richardson, M.D.).[\/caption]\r\n<p class=\"mt-align-justify\">Rickets, a childhood disease, is characterized by impeded growth and soft, weak, deformed long bones that bend and bow under their weight as children start to walk. This condition is characterized by bow legs,] which can be caused by calcium or phosphorus deficiency, as well as a lack of vitamin D; today, it is largely found in low-income countries in Africa, Asia, or the Middle East\u00a0and in those with genetic disorders such as pseudovitamin D deficiency rickets.\u00a0Maternal vitamin D deficiency may cause overt bone disease from before birth and impairment of bone quality after birth.\u00a0Nutritional rickets exists in countries with intense year-round sunlight such as Nigeria and can occur without vitamin D deficiency.<\/p>\r\n<p class=\"mt-align-justify\">Vitamin D deficiency remains the main cause of rickets among young infants in most countries, because breast milk is low in vitamin D and social customs and climatic conditions can prevent adequate sun exposure. In sunny countries such as Nigeria, South Africa, and Bangladesh, where the disease occurs among older toddlers and children, it has been attributed to low dietary calcium intakes, which are characteristic of cereal-based diets with limited access to dairy products.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<div id=\"section_1\" class=\"mt-section\">\r\n<h3 class=\"editable\">Synthesis in the Skin<\/h3>\r\n<p class=\"mt-align-justify\">Vitamin D<sub>3<\/sub>\u00a0is produced photochemically from 7-dehydrocholesterol in the skin of most vertebrate animals, including humans.\u00a0The precursor of vitamin D<sub>3<\/sub>, 7-dehydrocholesterol is produced in relatively large quantities. 7-Dehydrocholesterol reacts with\u00a0UVB light\u00a0at\u00a0wavelengths\u00a0between 270 and 300\u00a0nm, with peak synthesis occurring between 295 and 297\u00a0nm.\u00a0These wavelengths are present in sunlight, as well as in the light emitted by the UV lamps in\u00a0tanning beds\u00a0(which produce ultraviolet primarily in the\u00a0UVA\u00a0spectrum, but typically produce 4% to 10% of the total UV emissions as UVB). Exposure to light through windows is insufficient because glass almost completely blocks UVB light.<\/p>\r\n<p class=\"mt-align-justify\">Adequate amounts of vitamin D can be produced with moderate sun exposure to the face, arms and legs, averaging 5\u201330 minutes twice per week, or approximately 25% of the time for minimal sunburn. The darker the skin, and the weaker the sunlight, the more minutes of exposure are needed. Vitamin D overdose is impossible from UV exposure; the skin reaches an equilibrium where the vitamin degrades as fast as it is created.<\/p>\r\n\r\n<\/div>\r\n<div id=\"section_2\" class=\"mt-section\">\r\n<h3 class=\"mt-align-justify editable\">Dietary\u00a0Reference Intakes (USA)<\/h3>\r\n<p class=\"mt-align-justify\">Accordingly, the\u00a0Dietary Reference Intake\u00a0for vitamin D assumes no synthesis occurs and all of a person's vitamin D is from food intake. As vitamin D is synthesized in adequate amounts by most mammals exposed to sunlight,\u00a0it is not strictly a\u00a0vitamin, and may be considered a\u00a0hormone\u00a0as its synthesis and activity occur in different locations.\u00a0Vitamin D has a significant role in calcium homeostasis and metabolism. Its discovery was due to effort to find the dietary substance lacking in\u00a0rickets.<\/p>\r\n<p class=\"mt-align-justify\">Different institutions propose different recommendations concerning daily amounts of the vitamin.The recommended daily intake of vitamin D\u00a0<i>may<\/i>\u00a0not be sufficient if sunlight exposure is limited. According to the United States Institute of Medicine,<span class=\"mt-font-size-12\">\u00a0<\/span>the recommended dietary allowances (RDA) of vitamin D are (Conversion\u00a0: 1\u00a0\u00b5g = 40\u00a0IU\u00a0and 0.025\u00a0\u00b5g = 1 IU) :<\/p>\r\n\r\n<table class=\"mt-responsive-table\">\r\n<thead>\r\n<tr>\r\n<th class=\"mt-align-center\" scope=\"col\">Age group<\/th>\r\n<th class=\"mt-align-center\" scope=\"col\">RDA (IU\/day)<\/th>\r\n<\/tr>\r\n<\/thead>\r\n<tbody>\r\n<tr>\r\n<td class=\"mt-align-center\">Infants 0\u20136 months<\/td>\r\n<td class=\"mt-align-center\">400*<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\">Infants 6\u201312 months<\/td>\r\n<td class=\"mt-align-center\">400*<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\">1\u201370 years<\/td>\r\n<td class=\"mt-align-center\">600 (15 \u03bcg\/day)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\">71+ years<\/td>\r\n<td class=\"mt-align-center\">800 (20 \u03bcg\/day)<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\">Pregnant\/Lactating<\/td>\r\n<td class=\"mt-align-center\">600 (15 \u03bcg\/day)<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<ul>\r\n \t<li class=\"mt-align-justify\">Asterisk for infants indicates adequate intake (AI) for infants, as an RDA has yet to be established for infants.<\/li>\r\n<\/ul>\r\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For vitamin D labeling purposes 100% of the Daily Value was 400 IU (10 \u03bcg), but as of May 2016 it has been revised to 800 IU (20 \u03bcg). A table of the pre-change adult Daily Values is provided at\u00a0Reference Daily Intake. Food and supplement companies have until July 28, 2018 to comply with the change.<\/p>\r\n\r\n<header>\r\n<h2 id=\"title\">7.2C: Vitamin E<\/h2>\r\n<\/header><section class=\"mt-content-container\">\r\n<p class=\"mt-align-justify\"><b>Vitamin E<\/b>\u00a0refers to a group of\u00a0compounds\u00a0that include both\u00a0tocopherols\u00a0and\u00a0tocotrienols.\u00a0Of the many different forms of vitamin E,\u00a0\u03b3-tocopherol\u00a0is the most common form found in the North American diet.\u00a0\u03b3-Tocopherol can be found in corn oil, soybean oil, margarine, and dressings.<span class=\"mt-font-size-12\">\u00a0<\/span>\u03b1-tocopherol, the most biologically active form of vitamin E, is the second-most common form of vitamin E in the diet. This variant can be found most abundantly in wheat germ oil, sunflower, and safflower oils. As a fat-soluble\u00a0antioxidant, it interrupts the propagation of\u00a0reactive oxygen species\u00a0that spread through biological membranes or through a fat when its lipid content undergoes oxidation by reacting with more-reactive lipid radicals to form more stable products.<span class=\"mt-font-size-12\">\u00a0<\/span>Regular consumption of more than 1,000\u00a0mg (1,500\u00a0IU) of tocopherols per day\u00a0may be expected to cause\u00a0hypervitaminosis E, with an associated risk of\u00a0vitamin K\u00a0deficiency and consequently of bleeding problems.<\/p>\r\n\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"300\"]<img src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/8\/84\/Sample_of_alpha-tocopherol.jpg\/300px-Sample_of_alpha-tocopherol.jpg\" alt=\"\" width=\"300\" height=\"161\" \/> <em>Sample of \u03b1-tocopherol, one of the various forms of vitamin E<\/em>[\/caption]\r\n\r\n<div id=\"section_3\" class=\"mt-section\">\r\n<h3 class=\"mt-align-justify editable\">Functions<\/h3>\r\n<p class=\"mt-align-justify\">Vitamin E has many biological functions, including its role as a\u00a0fat-soluble\u00a0antioxidant.<\/p>\r\n\r\n<ul>\r\n \t<li class=\"mt-align-justify\">As an antioxidant, vitamin E acts as a\u00a0peroxyl radical\u00a0scavenger, disabling the production of damaging\u00a0free radicals\u00a0in tissues, by reacting with them to form a tocopheryl radical, which will then be\u00a0reduced\u00a0by a hydrogen donor (such as\u00a0vitamin C) and thus return to its reduced state. As it is fat-soluble, it is incorporated into cell membranes, which protects them from oxidative damage. Vitamin E has also found use as a commercial antioxidant in ultra high molecular weight polyethylene (UHMWPE) used in hip and knee\u00a0implants\u00a0by resisting oxidation.<\/li>\r\n \t<li class=\"mt-align-justify\">As an enzymatic activity regulator, for instance,\u00a0protein kinase C\u00a0(PKC), which plays a role in smooth muscle growth, can be inhibited by \u03b1-tocopherol. \u03b1-Tocopherol has a stimulatory effect on the dephosphorylation enzyme, protein phosphatase 2A, which in turn, cleaves phosphate groups from PKC, leading to its deactivation, bringing the smooth muscle growth to a halt.<\/li>\r\n \t<li class=\"mt-align-justify\">Vitamin E also has an effect on\u00a0gene expression.\u00a0Macrophages\u00a0rich in cholesterol are found in\u00a0atherosclerotic\u00a0tissue.\u00a0Scavenger receptor CD36 is a class B scavenger receptor found to be up-regulated by oxidized\u00a0<a title=\"4.71: Lipoproteins\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Nutrition\/Book%3A_Intermediate_Nutrition_(Lindshield)\/4%3A_Macronutrient_Uptake%2C_Absorption_and_Transport\/4.7%3A__Lipid_Uptake%2C_Absorption_and_Transport\/4.7A%3A_Lipoproteins\" rel=\"internal\">low density lipoprotein\u00a0(LDL)\u00a0<\/a>and binds it.\u00a0Treatment with \u03b1-tocopherol was found to downregulate the expression of the CD36 scavenger receptor gene and the scavenger receptor class A (SR-A)\u00a0and modulates expression of the\u00a0connective tissue growth factor\u00a0(CTGF).\u00a0The\u00a0CTGF\u00a0gene, when expressed, is responsible for the repair of wounds and regeneration of the extracellular tissue lost or damaged during atherosclerosis.<\/li>\r\n \t<li class=\"mt-align-justify\">Vitamin E also plays a role in eye and neurological functions,\u00a0and inhibition of\u00a0platelet\u00a0coagulation.<\/li>\r\n \t<li class=\"mt-align-justify\">Vitamin E also protects lipids and prevents the oxidation of\u00a0polyunsaturated fatty acids.<\/li>\r\n<\/ul>\r\n<p class=\"mt-align-justify\">Although most vitamin E supplementation studies used \u03b1-tocopherol individually, this design of studying only one isoform of vitamin E may introduce errors in interpreting overall vitamin E effects; for example, using only \u03b1-tocopherol in studies of\u00a0<a title=\"4.06: Tissue Injury and Aging\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Anatomy_and_Physiology\/Book%3A_Anatomy_and_Physiology_(OpenStax)\/Unit_1%3A_Levels_of_Organization\/4%3A_The_Tissue_Level_of_Organization\/4.06%3A_Tissue_Injury_and_Aging\" rel=\"internal\">inflammation\u00a0<\/a>can reduce serum \u03b3- and \u03b4-tocopherol concentrations.\u00a0Moreover, a 2013 review involving single long-term supplementation with \u03b1-tocopherol showed that many clinical studies revealed an inverse relationship between supplementation and cardiovascular disease risk or mortality, but other studies showed no effect.<\/p>\r\n\r\n<div id=\"section_4\" class=\"mt-section\">\r\n<h3 class=\"mt-align-justify editable\">Deficiency<\/h3>\r\n<p class=\"mt-align-justify\">Vitamin E deficiency can cause:<\/p>\r\n\r\n<ul>\r\n \t<li class=\"mt-align-justify\">spinocerebellar ataxia<\/li>\r\n \t<li class=\"mt-align-justify\">myopathies<\/li>\r\n \t<li class=\"mt-align-justify\">peripheral neuropathy<\/li>\r\n \t<li class=\"mt-align-justify\">ataxia<\/li>\r\n \t<li class=\"mt-align-justify\">skeletal myopathy<\/li>\r\n \t<li class=\"mt-align-justify\">retinopathy<\/li>\r\n \t<li class=\"mt-align-justify\">impairment of the immune response<\/li>\r\n \t<li class=\"mt-align-justify\">red blood cell\u00a0destruction<\/li>\r\n<\/ul>\r\n<div id=\"note\">\r\n<div class=\"textbox shaded\">\r\n<div id=\"section_3\" class=\"mt-section\">\r\n<div id=\"section_4\" class=\"mt-section\">\r\n<div id=\"note\">\r\n<h3 class=\"boxtitle\">SUPPLEMENTATION<\/h3>\r\n\r\n<hr \/>\r\n<p class=\"mt-align-justify\">Vitamin E supplementation has not been shown to have significant benefit for people who are healthy, and appears to be harmful.\u00a0It does not improve blood sugar control in an unselected group of people with\u00a0diabetes mellitus or decrease the risk of stroke. Daily supplementation of vitamin E does not decrease the risk of prostate cancer, and may increase it.\u00a0Studies on its role in\u00a0age-related macular degeneration\u00a0are ongoing, though if it is of a combination of dietary\u00a0antioxidants\u00a0used to treat the condition it may increase the risk. Routine supplementation with vitamin E during pregnancy has been shown to offer no benefit to the mother or the child. Vitamin E has been reported to cause more side effects, such as abdominal pain in pregnant women, and also the increased risk of having early rupture of membranes at term.<\/p>\r\n<p class=\"mt-align-justify\">Vitamin E, along with\u00a0\u03b2-carotene\u00a0and vitamin C, has no protective effect on reducing the risk of cataract, cataract extraction, progression of cataract, and slowing the loss of visual acuity.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<div id=\"section_5\" class=\"mt-section\">\r\n<h3 class=\"mt-align-justify editable\">Toxicity<\/h3>\r\n<p class=\"mt-align-justify\">The LD<sub>50<\/sub>, or the toxic dose required to kill 50% of group of rats and mice, respectively is 4000 mg of VitaminE E\/kg of rat and 4000 mg of Vitamin E\/kg of mouse. Comparatively speaking, and at lethal doses, Vitamin E is less toxic than table salt and acetaminophen and it is more toxic than ethanol and Vitamin C. Vitamin E can act as an anticoagulant, increasing the risk of bleeding problems. As a result, many agencies have set a tolerable upper intake levels (UL) at 1,000 mg (1,500 IU) per day. In combination with certain other drugs such as aspirin, hypervitaminosis E can be life-threatening. Hypervitaminosis E may also counteract vitamin K, leading to a vitamin K deficiency.<\/p>\r\n\r\n<\/div>\r\n<div id=\"section_6\" class=\"mt-section\">\r\n<h3 class=\"mt-align-justify editable\">Dietary Reference Intake<\/h3>\r\n<p class=\"mt-align-justify\">The Food and Nutrition Board (FNB) of the U.S. Institute of Medicine updated Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) for vitamin E in 2000. The current EAR for vitamin E for women and men ages 14 and up is 12\u00a0mg\/day. The RDA is 15\u00a0mg\/day. RDAs are higher than EARs so as to identify amounts that will cover people with higher than average requirements. RDA for pregnancy equals 15\u00a0mg\/day. RDA for lactation equals 19\u00a0mg\/day. For infants up to 12 months the Adequate Intake (AI) is 4\u20135\u00a0mg\/day and for children ages 1\u201313 years the RDA increases with age from 6 to 11\u00a0mg\/day. The FNB also sets Tolerable Upper Intake Levels (ULs) for vitamins and minerals when evidence is sufficient. In the case of vitamin E the UL is 1,000\u00a0mg\/day.<\/p>\r\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For vitamin E labeling purposes 100% of the Daily Value was 30\u00a0mg, but as of May 2016 it has been revised to 15\u00a0mg. A table of the pre-change adult Daily Values is provided at\u00a0Reference Daily Intake. Food and supplement companies have until July 28, 2018 to comply with the change.<\/p>\r\n\r\n<div id=\"note\">\r\n<div class=\"textbox shaded\">\r\n<h3 class=\"boxtitle\">VITAMIN E AND ATHEROSCLEROSIS<\/h3>\r\n\r\n<hr \/>\r\n<p class=\"mt-align-justify\">Atherosclerosis is a disease condition that refers to the buildup of plaque, which is a substance containing lipid and cholesterol (mainly the low-density lipoprotein or LDL cholesterol) on the inner layer of the arterial lumen.\u00a0With the existing plaque, instead of being smooth and elastic, the layers become thickened and irregular and the lumen of the artery become narrower. This vessel-narrowing effect lead to a reduction of blood circulation and can lead to or worsen the condition of hypertension.<\/p>\r\n<p class=\"mt-align-justify\">There are currently multiple theories explaining factors causing and affecting the cholesterol plaque build up within arteries with the most popular theory indicating that the rate of build up is affected by the oxidation of the LDL cholesterol. LDL cholesterol is one of the five major groups of lipoproteins with one of the physiological roles being lipid transportation. A typical LDL particle contain 2,700 fatty acid molecules and half of them are poly-unsaturated fatty acids, which are very oxidation sensitive. Once the oxidation of LDL occur, it will start a series of undesirable effects starting from the increase production of inflammatory cytokines by stimulating the endothelial cells and monocytes, followed by increased production of tissue factors, production of macrophages and monocytes, which eventually lead to the formation of foam cells and accelerated development of atherosclerosis. With the presence of adequate concentration of vitamin E, which is a very potent fat-soluble antioxidant, it can inhibit the oxidation of LDL, and this inhibition contributes protection against the development of atherosclerosis and can stabilize the existing plaque.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\nAccording to one\u00a0meta-analysis, nine cohort studies showed that high intake of tocopherol was associated with a lower risk of cardiovascular diseases compared with lower intake. In this study, higher dietary, supplementation and combined vitamin E intake was also associated with lower disease incidents. In 1993, a study of 39,919 male health professionals aged 40 to 75 showed that consumption of more than 60\u00a0IU of vitamin E (any form) per day was associated with a lower incidence of coronary heart disease compared with less than 7.5 IU\/day intake.\u00a0This study also showed an inverse association between vitamin E supplementation and the incidence of heart disease.\r\n\r\nA 2015\u00a0systematic review\u00a0of clinical trials concluded that vitamin E supplementation alone improved\u00a0endothelial\u00a0function as determined by measurements of forearm\u00a0blood flow, but when combined with vitamin C supplementation, it did not. A meta-analysis of clinical trials showed no significant association between vitamin E supplementation and cardiovascular\u00a0mortality.\r\n<div id=\"section_7\" class=\"mt-section\">\r\n<h2>7.2D: Vitamin K<\/h2>\r\n<header><\/header><section class=\"mt-content-container\">\r\n<p class=\"mt-align-justify\">Vitamin K (Figure 1) is a group of structurally similar, fat-soluble\u00a0vitamins\u00a0the human body requires for\u00a0complete synthesis\u00a0of certain proteins that are needed for blood\u00a0coagulation \u00a0(<a title=\"8.10: Blood Clotting\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Anatomy_and_Physiology\/Book%3A_Anatomy_and_Physiology_of_Animals_(Lawson)\/8%3A_Cardiovascular_System\/8.10%3A_Blood_Clotting\" rel=\"internal\">blood clotting<\/a>)\u00a0and which the body also needs for controlling the\u00a0binding of calcium in bones and other tissues.\u00a0The vitamin K-related modification of the proteins allows them to bind\u00a0calcium\u00a0ions, which they cannot do otherwise.<\/p>\r\n<p class=\"mt-align-justify\">In menaquinone, the side chain is composed of a varying number of\u00a0isoprenoid\u00a0residues. The most common number of these residues is four, since animal\u00a0enzymes\u00a0normally produce menaquinone-4 from plant phylloquinone. The three synthetic forms of vitamin K are vitamins K<sub>3<\/sub>\u00a0(menadione), K<sub>4<\/sub>, and K<sub>5<\/sub>, which are used in many areas, including the\u00a0pet food\u00a0industry (vitamin K<sub>3<\/sub>) and to inhibit\u00a0fungal\u00a0growth (vitamin K<sub>5<\/sub>).<\/p>\r\n\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"220\"]<img src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/9\/93\/Phylloquinone_structure.svg\/220px-Phylloquinone_structure.svg.png\" alt=\"\" width=\"220\" height=\"104\" \/> Figure 1: (left) Vitamin K1\u00a0(phylloquinone) \u2013 both forms of the vitamin contain a functional\u00a0naphthoquinone\u00a0ring and an\u00a0aliphatic\u00a0side chain. Phylloquinone has a\u00a0phytyl\u00a0side chain.[\/caption]\r\n\r\n[caption id=\"\" align=\"aligncenter\" width=\"220\"]<img src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/c\/c4\/Menaquinone.svg\/220px-Menaquinone.svg.png\" alt=\"\" width=\"220\" height=\"92\" \/> Vitamin K2\u00a0(menaquinone).[\/caption]\r\n<p class=\"mt-align-justify\">The MK-4 form of vitamin K<sub>2<\/sub>\u00a0is produced by conversion of vitamin K<sub>1<\/sub>\u00a0in the\u00a0testes,\u00a0pancreas, and\u00a0arterial\u00a0walls.\u00a0While major questions still surround the biochemical pathway for this transformation, the conversion is not dependent on\u00a0gut bacteria, as it occurs in germ-free rats and in parenterally-administered K<sub>1<\/sub>in rats.\u00a0In fact, tissues that accumulate high amounts of MK-4 have a remarkable capacity to convert up to 90% of the available K<sub>1<\/sub>\u00a0into MK-4.\u00a0There is evidence that the conversion proceeds by removal of the\u00a0phytyl\u00a0tail of K<sub>1<\/sub>\u00a0to produce\u00a0menadione\u00a0as an intermediate, which is then condensed with an activated\u00a0geranylgeranyl\u00a0moiety (see also\u00a0prenylation) to produce vitamin K<sub>2<\/sub>\u00a0in the MK-4 (menatetrione) form.<\/p>\r\n\r\n<div id=\"note\">\r\n<div class=\"textbox shaded\">\r\n<h3 class=\"boxtitle\">HEALTH EFFECTS OF VITAMIN\u00a0K<\/h3>\r\n\r\n<hr \/>\r\n\r\nWithout vitamin K, blood coagulation is seriously impaired, and uncontrolled bleeding occurs. Preliminary\u00a0clinical research\u00a0indicates that deficiency of vitamin K may weaken bones, potentially leading to\u00a0osteoporosis, and may promote\u00a0calcification\u00a0of arteries and other soft tissues. \u00a0Our main sources of vitamin K are\u00a0from leafy green vegetables and from the production by bacteria\u00a0in our large intestine.\r\n<ul>\r\n \t<li class=\"mt-align-justify\"><strong>Osteoporosis<\/strong>: A review of 2014 concluded that there is positive evidence that monotherapy using MK-4, one of the forms of Vitamin K<sub>2<\/sub>, reduces\u00a0fracture\u00a0incidence in post-menopausal\u00a0women with\u00a0osteoporosis, and suggested further research on the combined use of MK-4 with\u00a0bisphosphonates. In contrast, an earlier review article of 2013 concluded that there is no good evidence that vitamin K supplementation helps prevent osteoporosis or fractures in postmenopausal women. A Cochrane systematic review of 2006 suggested that supplementation with Vitamin K<sub>1<\/sub>\u00a0and with MK4 reduces bone loss; in particular, a strong effect of MK-4 on incident fractures among Japanese patients was emphasized. A\u00a0review article of 2016 suggested to consider, as one of several measures for bone health, increasing the intake of foods rich in vitamins K<sub>1<\/sub>\u00a0and K<sub>2<\/sub>.<\/li>\r\n \t<li class=\"mt-align-justify\"><strong>Cardiovascular health:\u00a0<\/strong>Adequate intake of vitamin K is associated with the inhibition of\u00a0arterial\u00a0calcification\u00a0and stiffening, but there have been few interventional studies and no good evidence that vitamin K supplementation is of any benefit in the primary prevention of\u00a0cardiovascular disease.<span class=\"mt-font-size-12\">\u00a0<\/span>One 10-year population study, the Rotterdam Study, did show a clear and significant inverse relationship between the highest intake levels of menaquinone (mainly MK-4 from eggs and meat, and MK-8 and MK-9 from cheese) and cardiovascular disease and all-cause mortality in older men and women.<\/li>\r\n \t<li class=\"mt-align-justify\"><strong>Cancer<\/strong>: Vitamin K has been promoted in supplement form with claims it can slow\u00a0tumor\u00a0growth; there is however no good\u00a0medical evidence\u00a0that supports such claims.<\/li>\r\n \t<li class=\"mt-align-justify\"><strong>Coumarin poisoning:<\/strong>\u00a0Vitamin K is part of the suggested treatment regime for poisoning by\u00a0rodenticide\u00a0(coumarin poisoning).<\/li>\r\n<\/ul>\r\n<p class=\"mt-align-justify\">Although\u00a0allergic reaction\u00a0from supplementation is possible, no known toxicity is associated with high doses of the phylloquinone (vitamin K<sub>1<\/sub>) or menaquinone (vitamin K<sub>2<\/sub>) forms of vitamin K, so no\u00a0tolerable upper intake level\u00a0(UL) has been set. Blood clotting (coagulation) studies in humans using 45\u00a0mg per day of vitamin K2\u00a0(as MK-4) and even up to 135\u00a0mg per day (45\u00a0mg three times daily) of K2\u00a0(as MK-4), showed no increase in blood clot risk. Even doses in rats as high as 250\u00a0mg\/kg, body weight did not alter the tendency for blood-clot formation to occur. Unlike the safe natural forms of vitamin K<sub>1<\/sub>\u00a0and vitamin K<sub>2<\/sub>\u00a0and their various\u00a0isomers, a synthetic form of vitamin K, vitamin K3\u00a0(menadione), is demonstrably toxic at high levels. The\u00a0U.S. FDA\u00a0has banned this form from\u00a0over-the-counter\u00a0sale in the\u00a0United States\u00a0because large doses have been shown to cause\u00a0allergic reactions,\u00a0hemolytic anemia, and\u00a0cytotoxicity\u00a0in\u00a0liver\u00a0cells.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<p class=\"mt-align-justify\">Phylloquinone (K<sub>1<\/sub>)\u00a0or menaquinone (K<sub>2<\/sub>) are capable of reversing the anticoagulant activity of the\u00a0anticoagulant\u00a0warfarin\u00a0(tradename Coumadin). Warfarin works by blocking recycling of vitamin K, so that the body and tissues have lower levels of active vitamin K, and thus a deficiency of vitamin K. Supplemental vitamin K (for which oral dosing is often more active than injectable dosing in human adults) reverses the vitamin K deficiency caused by warfarin, and therefore reduces the intended anticoagulant action of warfarin and related drugs. Sometimes small amounts of vitamin K are given orally to patients taking warfarin so that the action of the drug is more predictable.<span class=\"mt-font-size-12\">\u00a0<\/span>The proper anticoagulant action of the drug is a function of vitamin K intake and drug dose, and due to differing absorption must be individualized for each patient.\u00a0The action of warfarin and vitamin K both require two to five days after dosing to have maximum effect, and neither warfarin or vitamin K shows much effect in the first 24 hours after they are given.<\/p>\r\n\r\n<div id=\"section_1\" class=\"mt-section\">\r\n<h3 class=\"editable\">Absorption and Dietary Need<\/h3>\r\n<p class=\"mt-align-justify\">Previous theory held that dietary deficiency is extremely rare unless the\u00a0small intestine\u00a0was heavily damaged, resulting in\u00a0malabsorption\u00a0of the molecule. Another at-risk group for deficiency were those subject to decreased production of K<sub>2<\/sub>\u00a0by normal intestinal microbiota, as seen in\u00a0broad spectrum antibiotic\u00a0use.\u00a0<strong>Taking broad-spectrum antibiotics can reduce vitamin K production in the gut by nearly 74% in people compared with those not taking these antibiotics<\/strong>.\u00a0Diets low in vitamin K also decrease the body's vitamin K concentration.\u00a0Those with chronic\u00a0kidney disease\u00a0are at risk for vitamin K deficiency, as well as\u00a0vitamin D deficiency, and particularly those with the\u00a0apoE4\u00a0genotype.\u00a0Additionally, in the elderly there is a reduction in vitamin K<sub>2<\/sub>\u00a0production.<sup id=\"cite_ref-42\">\u00a0\u00a0<\/sup>Like other lipid-soluble vitamins (A,\u00a0D\u00a0and\u00a0E), vitamin K is stored in the fatty tissue of the human body.<\/p>\r\n<p class=\"mt-align-justify\">The\u00a0National Academy of Medicine\u00a0(NAM) updated an estimate of what constitutes an Adequate Intake (AI) for vitamin K in 2001. The NAM does not distinguish between K<sub>1<\/sub>\u00a0and K<sub>2<\/sub>\u00a0\u2013 both are counted as vitamin K. At that time there was not sufficient evidence to set the more rigorous Estimated Average Requirement (EAR) or\u00a0recommended dietary allowance\u00a0(RDA) given for most of the essential vitamins and minerals. The current daily AIs for vitamin K for adult women and men are 90\u00a0\u03bcg and 120\u00a0\u03bcg respectively. The AI for\u00a0pregnancy\u00a0and\u00a0lactation\u00a0is 90\u00a0\u03bcg. For infants up to 12 months the AI is 2\u20132.5\u00a0\u03bcg, and for children aged 1 to 18 years the AI increases with age from 30 to 75 \u03bcg. As for safety, the FNB also sets tolerable upper intake levels (known as ULs) for vitamins and minerals when evidence is sufficient. In the case of vitamin K no UL is set, as evidence for adverse effects is not sufficient. Collectively EARs, RDAs, AIs and ULs are referred to as\u00a0dietary reference intakes.<\/p>\r\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes, the amount in a serving is expressed as a percentage of daily value (%DV). For vitamin K labeling purposes the daily value was 80\u00a0\u03bcg, but as of May 2016 it has been revised upwards to 120\u00a0\u03bcg. A table of the pre-change adult daily values is provided at\u00a0Reference Daily Intake (Table\u00a0&lt;span id=\"MathJax-Element-1-Frame\" class=\"MathJax\" style=\"display: inline-table; font-style: normal; font-weight: normal; line-height: normal; font-size: 14.4px; text-indent: 0px; text-align: left; text-transform: none; letter-spacing: normal; word-spacing: normal; overflow-wrap: normal; white-space: nowrap; float: none; direction: ltr; max-width: none; max-height: none; min-width: 0px; min-height: 0px; border: 0px; padding: 0px; margin: 0px; position: relative;\" tabindex=\"0\" role=\"presentation\" data-mathml=\"7.2D.1\"&gt;<span id=\"MathJax-Span-1\" class=\"math\"><span id=\"MathJax-Span-2\" class=\"mrow\"><span id=\"MathJax-Span-3\" class=\"texatom\"><span id=\"MathJax-Span-4\" class=\"mrow\"><span id=\"MathJax-Span-5\" class=\"mn\">7.2<\/span><span id=\"MathJax-Span-6\" class=\"mi\">D<\/span><span id=\"MathJax-Span-7\" class=\"mo\">.<\/span><span id=\"MathJax-Span-8\" class=\"mn\">1<\/span><\/span><\/span><\/span><\/span><\/p>\r\n7.2D.1). Food and supplement companies have until 28 July 2018 to comply with the change.\r\n\r\n<\/div>\r\n<div id=\"section_2\" class=\"mt-section\">\r\n<h3 class=\"editable\">Deficiency<\/h3>\r\n<p class=\"mt-align-justify\">Average diets are usually not lacking in vitamin K, and primary deficiency is rare in healthy adults. Newborn infants are at an increased risk of deficiency. Other populations with an increased prevalence of vitamin K deficiency include those who suffer from liver damage or disease (e.g. alcoholics), cystic fibrosis, or inflammatory bowel diseases, or have recently had abdominal surgeries. Secondary vitamin K deficiency can occur in people with bulimia, those on stringent diets, and those taking anticoagulants. Other drugs associated with vitamin K deficiency include salicylates, barbiturates, and cefamandole, although the mechanisms are still unknown. Vitamin K<sub>1<\/sub>\u00a0deficiency can result in coagulopathy, a bleeding disorder. Symptoms of K<sub>1<\/sub>\u00a0deficiency include anemia, bruising, nosebleeds and bleeding of the gums in both sexes, and heavy menstrual bleeding in women.<\/p>\r\n\r\n<table class=\"mt-table-big mt-responsive-table\"><caption><em><em><strong>Table:\u00a0<\/strong><\/em><\/em><em>Vitamin K<\/em><\/caption>\r\n<thead>\r\n<tr>\r\n<th class=\"mt-align-center\" style=\"width: 121.5px\" scope=\"col\">Food<\/th>\r\n<th class=\"mt-align-center\" style=\"width: 66.5px\" scope=\"col\">Serving size<\/th>\r\n<th class=\"mt-align-center\" style=\"width: 54.5px\" scope=\"col\">Vitamin\r\nK<sub>1<\/sub>\u00a0(\u03bcg)<\/th>\r\n<th class=\"mt-align-center\" style=\"width: 8.5px\" scope=\"col\"><\/th>\r\n<th class=\"mt-align-center\" style=\"width: 93.5px\" rowspan=\"11\" scope=\"col\">Food<\/th>\r\n<th class=\"mt-align-center\" style=\"width: 68.5px\" scope=\"col\">Serving size<\/th>\r\n<th class=\"mt-align-center\" style=\"width: 54.5px\" scope=\"col\">Vitamin\r\nK<sub>1\u00a0<\/sub>(\u03bcg)<\/th>\r\n<\/tr>\r\n<\/thead>\r\n<tbody>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Kale, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">531<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Parsley, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">\u200a<sup>1<\/sup>\u2044<sub>4<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">246<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Spinach, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">444<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Spinach, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">145<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Collards, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">418<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Collards, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">184<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Swiss chard, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">287<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Swiss chard, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">299<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Mustard\u00a0greens, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">210<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Mustard greens, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">279<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Turnip\u00a0greens, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">265<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Turnip greens, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">138<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Broccoli, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">220<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Broccoli, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">89<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Brussels sprouts, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">219<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Endive, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">116<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Cabbage, cooked<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">82<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Green leaf lettuce<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">71<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Asparagus<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 66.5px\">4 spears<\/td>\r\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">48<\/td>\r\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\r\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Romaine lettuce, raw<\/td>\r\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\r\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">57<\/td>\r\n<\/tr>\r\n<tr>\r\n<td class=\"mt-align-justify\" style=\"width: 542.5px\" colspan=\"7\">Table from \"Important information to know when you are taking: Warfarin (Coumadin) and Vitamin K\", Clinical Center, National Institutes of Health Drug Nutrient Interaction Task Force.<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n<div id=\"section_3\" class=\"mt-section\">\r\n<h2 class=\"editable\">Vitiman A References<\/h2>\r\n<div id=\"section-Ref\" class=\"section-body\">\r\n<ol>\r\n \t<li>Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron Manganese, Molybdenium, Nickel, Silicon, Vanadium, and Zinc. National Academy Press. Washington, DC, 2001. PMID: 25057538\u00a0<a id=\"anch_27\" class=\"link-https\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25057538\" target=\"_blank\" rel=\"external nofollow noopener\">www.ncbi.nlm.nih.gov\/pubmed\/25057538<\/a>.<\/li>\r\n \t<li>Mason JB. Vitamins, trace minerals, and other micronutrients. In: Goldman L, Schafer AI, eds.\u00a0<em>Goldman's Cecil Medicine<\/em>. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 225.<\/li>\r\n \t<li>Salwen MJ. Vitamins and trace elements. In: McPherson RA, Pincus MR, eds.\u00a0<em>Henry's Clinical Diagnosis and Management by Laboratory Methods<\/em>. 22nd ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 26.<\/li>\r\n<\/ol>\r\n<\/div>\r\n<p class=\"mt-align-justify\">A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).<\/p>\r\n\r\n<h2>Contributers<\/h2>\r\n<\/div>\r\n<div id=\"section_3\" class=\"mt-section\">\r\n<ul>\r\n \t<li class=\"mt-align-justify\">Wikipedia<\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/section><footer class=\"elm-content-footer\"><\/footer><\/div>\r\n<\/div>\r\n<\/section><\/div>\r\n<div id=\"section_3\" class=\"mt-section\"><\/div>\r\n<\/section><\/div>\r\n<\/section>","rendered":"<p>Now that you know the basics of what vitamins are, let&#8217;s talk about the Fat Soluble Vitamins (FSV&#8217;s) specifically. There are only four\u00a0FSV&#8217;s: Vitamin A, Vitamin D, Vitamin E and Vitamin K. What makes them &#8220;fat soluble&#8221; is the fact that they dissolve in fats and oils but they won&#8217;t dissolve in water. If you&#8217;ve ever seen a vitamin E capsule, you already know that inside the capsule is an oily substance containing vitamin E. The Fat soluble vitamins are present in many foods but they are especially high in foods like nuts and seeds that contain a high concentration of fats and oils. Though we will discuss each fat soluble vitamin separately, please keep in mind that in whole foods there are a variety of vitamins and minerals and other nutrients all working together. This is thought to be the reason that whole foods do such good things for the body whereas taking individual supplements doesn&#8217;t usually benefit health and sometimes can be harmful. Many scientists and doctors (myself included) believe that it is the harmony of the nutrients coming in together that benefits our health and when we isolate an individual nutrient it cannot give the same benefits.<\/p>\n<header>\n<h2 id=\"title\">7.2A: Vitamin A<\/h2>\n<\/header>\n<section class=\"mt-content-container\">Vitamin A is a fat-soluble vitamin that is stored in the liver. There are two types of vitamin A that are found in the diet.<\/p>\n<div id=\"ency_summary\">\n<ul>\n<li>Preformed vitamin A is found in animal products such as meat, fish, poultry and dairy foods.<\/li>\n<li>Pro-vitamin A is found in plant-based foods such as fruits and vegetables. The most common type of pro-vitamin A is beta-carotene. Pro-vitamin A must be converted into active vitamin A by the body.<\/li>\n<\/ul>\n<p>Vitamin A is also available in dietary supplements. It most often comes in the form of retinyl acetate or retinyl palmitate (preformed vitamin A), beta-carotene (pro-vitamin A) or a combination of preformed and pro-vitamin A.<\/p>\n<\/div>\n<div id=\"section_1\" class=\"mt-section\">\n<h3 class=\"editable\">Function of Vitamin A<\/h3>\n<div id=\"section-1\" class=\"section-body\">\n<p>Vitamin A helps form and maintain healthy skin, teeth, skeletal and soft tissue, mucus membranes, and skin. It is also known as retinol because it produces the pigments in the retina of the eye. Vitamin A promotes good vision, especially in low light. It may also be needed for reproduction and breast-feeding. Retinol is an active form of vitamin A. It is found in animal liver, whole milk, and some fortified foods. Carotenoids are dark-colored dyes (pigments) found in plant foods that can turn into a form of vitamin A. There are more than 500 known carotenoids. One such carotenoid is beta-carotene.<\/p>\n<ul>\n<li>Beta-carotene is an antioxidant. Antioxidants protect cells from damage caused by substances called free radicals. Free radicals are believed to contribute to certain chronic diseases and play a role in the aging processes.<\/li>\n<li>Diets containing food sources of carotenoids such as beta-carotene have been shown to\u00a0reduce the risk for cancer.<\/li>\n<li>Beta-carotene\u00a0<u>supplements<\/u>\u00a0(isolated Beta-carotene in concentrated form)\u00a0do not seem to reduce cancer risk.<\/li>\n<\/ul>\n<div class=\"mt-video-widget mt-video-width-50\">\n<div>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"What are Antioxidants and Free Radicals Anyway?!\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/1pa9762jAgo?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<\/div>\n<\/div>\n<\/div>\n<p><em>Video <\/em><strong>7.2A.1<\/strong><em>:\u00a0This video connects health-conscious individuals with important news and information in the fast-paced world of health. From recalls and outbreaks to diet, nutrition and fitness we cover everything you need to know about health, every day.<\/em><\/p>\n<\/div>\n<div id=\"section_2\" class=\"mt-section\">\n<h3 class=\"editable\">Food Sources of Vitamin A<\/h3>\n<div id=\"section-2\" class=\"section-body\">\n<p>Vitamin A comes from animal sources, such as eggs, meat, fortified milk, cheese, cream, liver, kidney, cod, and halibut fish oil. However, all of these sources, except for skim milk that has been fortified with Vitamin A, are high in saturated fat and cholesterol. Some good\u00a0sources of vitamin A are:<\/p>\n<ul>\n<li>Eggs\u00a0(preformed vitamin A)<\/li>\n<li>Milk and other dairy products\u00a0(preformed vitamin A)<\/li>\n<li>Orange and yellow vegetables and fruits (pro-vitamin A)<\/li>\n<li>Other sources of beta-carotene such as broccoli, spinach, and most dark green, leafy vegetables\u00a0(pro-vitamin A)<\/li>\n<\/ul>\n<p>The more intense the color of a fruit or vegetable, the higher the beta-carotene content. Vegetable sources of beta-carotene are cholesterol-free.<\/p>\n<\/div>\n<\/div>\n<div id=\"section_3\" class=\"mt-section\">\n<h3 class=\"editable\">Side Effects of too much or too little Vitamin A<\/h3>\n<div id=\"section-3\" class=\"section-body\">\n<p>If you do not get enough vitamin A, you are at increased risk for eye problems. These include reversible night blindness and then non-reversible corneal damage known as xeropthalmia. Lack of vitamin A can lead to hyperkeratosis or dry, scaly skin. If you get too much vitamin A, you can become sick. Large doses of vitamin A can also cause birth defects.<\/p>\n<p class=\"mt-align-center\"><img decoding=\"async\" class=\"internal default aligncenter\" src=\"https:\/\/med.libretexts.org\/@api\/deki\/files\/1302\/picture7-141D79B4665325131EE.jpg?revision=1&amp;size=bestfit&amp;width=413&amp;height=349\" alt=\"two hands, one with very yellow skin due to high levels of Carotenoids in the diet.\" width=\"413px\" height=\"349px\" \/><\/p>\n<p>Acute vitamin A poisoning most often occurs when an adult takes several hundred thousand IUs of vitamin A. Symptoms of chronic vitamin A poisoning may occur in adults who regularly take more than 25,000 IU a day. Babies and children are more sensitive to vitamin A, and can become sick after taking smaller doses of vitamin A or vitamin A-containing products such as retinol (found in skin creams). Large amounts of beta-carotene do not cause harm. However, high levels\u00a0of beta-carotene can turn the skin yellow or orange. The skin color will return to normal once you reduce your intake of beta-carotene.<\/p>\n<\/div>\n<\/div>\n<div id=\"section_4\" class=\"mt-section\">\n<h3 class=\"editable\">Recommendations for Vitamin A<\/h3>\n<div id=\"section-4\" class=\"section-body\">\n<p>The best way to get the daily requirement of essential vitamins is to eat a wide variety of fruits, vegetables, fortified dairy foods, legumes (dried beans), lentils, and whole grains.<\/p>\n<p>The Food and Nutrition Board of the Institute of Medicine &#8212; Dietary Reference Intakes (DRIs) Recommended Intakes for Individuals of Vitamin A:<\/p>\n<p>Infants (average intake)<\/p>\n<ul>\n<li>0 to 6 months: 400 micrograms per day (mcg\/day)<\/li>\n<li>7 to 12 months: 500 mcg\/day<\/li>\n<\/ul>\n<p>The Recommended Dietary Allowance (RDA) for vitamins is how much of each vitamin most people should get each day. The RDA for vitamins may be used as goals for each person.<\/p>\n<p>Children (RDA)<\/p>\n<ul>\n<li>1 to 3 years: 300 mcg\/day<\/li>\n<li>4 to 8 years: 400 mcg\/day<\/li>\n<li>9 to 13 years: 600 mcg\/day<\/li>\n<\/ul>\n<p>Adolescents and Adults (RDA)<\/p>\n<ul>\n<li>Males age 14 and older: 900 mcg\/day<\/li>\n<li>Females age 14 and older: 700 mcg\/day (770 during pregnancy and 1,300 mcg during lactation)<\/li>\n<\/ul>\n<p>How much of each vitamin you need depends on your age and gender. Other factors, such as pregnancy and your health, are also important. Ask your health care provider what dose is best for you.<\/p>\n<\/div>\n<\/div>\n<div id=\"section_5\" class=\"mt-section\">\n<header>\n<h2 id=\"title\">7.2B: Vitamin D<\/h2>\n<\/header>\n<section class=\"mt-content-container\">Vitamin D\u00a0refers to a group of fat-soluble\u00a0secosteroids\u00a0responsible for increasing intestinal absorption of\u00a0calcium,\u00a0iron,\u00a0magnesium,\u00a0phosphate, and\u00a0zinc. In humans, the most important compounds in this group are vitamin D3\u00a0and vitamin D2.\u00a0Cholecalciferol\u00a0and\u00a0ergocalciferol\u00a0can be ingested from the diet and from supplements. Very few foods contain vitamin D; synthesis of vitamin D in the skin is the major natural source of the vitamin and is dependent on sun exposure (specifically\u00a0UVB radiation).<\/p>\n<div class=\"note1\">\n<div class=\"textbox\">\n<h3 class=\"boxtitle\">DEFICIENCY:\u00a0RICKETS<\/h3>\n<hr \/>\n<p class=\"mt-align-justify\">A diet deficient in vitamin D in conjunction with inadequate sun exposure causes osteomalacia (or rickets when it occurs in children), which is a softening of the bones. In the developed world, this is a rare disease.\u00a0However, vitamin D deficiency has become a worldwide problem in the elderly and remains common in children and adults. Low blood calcifediol (25-hydroxy-vitamin D) can result from avoiding the sun.\u00a0Deficiency results in impaired bone mineralization and bone damage which leads to bone-softening diseases, including rickets and osteomalacia.<\/p>\n<div style=\"width: 266px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"internal\" src=\"https:\/\/med.libretexts.org\/@api\/deki\/files\/4099\/XrayRicketsLegssmall.jpg?revision=1\" alt=\"XrayRicketsLegssmall.jpg\" width=\"256\" height=\"406\" \/><\/p>\n<p class=\"wp-caption-text\">Legs in a 2 year old child with rickets. Image used with permission (CC BY-SA 1.0;\u00a0Michael L. Richardson, M.D.).<\/p>\n<\/div>\n<p class=\"mt-align-justify\">Rickets, a childhood disease, is characterized by impeded growth and soft, weak, deformed long bones that bend and bow under their weight as children start to walk. This condition is characterized by bow legs,] which can be caused by calcium or phosphorus deficiency, as well as a lack of vitamin D; today, it is largely found in low-income countries in Africa, Asia, or the Middle East\u00a0and in those with genetic disorders such as pseudovitamin D deficiency rickets.\u00a0Maternal vitamin D deficiency may cause overt bone disease from before birth and impairment of bone quality after birth.\u00a0Nutritional rickets exists in countries with intense year-round sunlight such as Nigeria and can occur without vitamin D deficiency.<\/p>\n<p class=\"mt-align-justify\">Vitamin D deficiency remains the main cause of rickets among young infants in most countries, because breast milk is low in vitamin D and social customs and climatic conditions can prevent adequate sun exposure. In sunny countries such as Nigeria, South Africa, and Bangladesh, where the disease occurs among older toddlers and children, it has been attributed to low dietary calcium intakes, which are characteristic of cereal-based diets with limited access to dairy products.<\/p>\n<\/div>\n<\/div>\n<div id=\"section_1\" class=\"mt-section\">\n<h3 class=\"editable\">Synthesis in the Skin<\/h3>\n<p class=\"mt-align-justify\">Vitamin D<sub>3<\/sub>\u00a0is produced photochemically from 7-dehydrocholesterol in the skin of most vertebrate animals, including humans.\u00a0The precursor of vitamin D<sub>3<\/sub>, 7-dehydrocholesterol is produced in relatively large quantities. 7-Dehydrocholesterol reacts with\u00a0UVB light\u00a0at\u00a0wavelengths\u00a0between 270 and 300\u00a0nm, with peak synthesis occurring between 295 and 297\u00a0nm.\u00a0These wavelengths are present in sunlight, as well as in the light emitted by the UV lamps in\u00a0tanning beds\u00a0(which produce ultraviolet primarily in the\u00a0UVA\u00a0spectrum, but typically produce 4% to 10% of the total UV emissions as UVB). Exposure to light through windows is insufficient because glass almost completely blocks UVB light.<\/p>\n<p class=\"mt-align-justify\">Adequate amounts of vitamin D can be produced with moderate sun exposure to the face, arms and legs, averaging 5\u201330 minutes twice per week, or approximately 25% of the time for minimal sunburn. The darker the skin, and the weaker the sunlight, the more minutes of exposure are needed. Vitamin D overdose is impossible from UV exposure; the skin reaches an equilibrium where the vitamin degrades as fast as it is created.<\/p>\n<\/div>\n<div id=\"section_2\" class=\"mt-section\">\n<h3 class=\"mt-align-justify editable\">Dietary\u00a0Reference Intakes (USA)<\/h3>\n<p class=\"mt-align-justify\">Accordingly, the\u00a0Dietary Reference Intake\u00a0for vitamin D assumes no synthesis occurs and all of a person&#8217;s vitamin D is from food intake. As vitamin D is synthesized in adequate amounts by most mammals exposed to sunlight,\u00a0it is not strictly a\u00a0vitamin, and may be considered a\u00a0hormone\u00a0as its synthesis and activity occur in different locations.\u00a0Vitamin D has a significant role in calcium homeostasis and metabolism. Its discovery was due to effort to find the dietary substance lacking in\u00a0rickets.<\/p>\n<p class=\"mt-align-justify\">Different institutions propose different recommendations concerning daily amounts of the vitamin.The recommended daily intake of vitamin D\u00a0<i>may<\/i>\u00a0not be sufficient if sunlight exposure is limited. According to the United States Institute of Medicine,<span class=\"mt-font-size-12\">\u00a0<\/span>the recommended dietary allowances (RDA) of vitamin D are (Conversion\u00a0: 1\u00a0\u00b5g = 40\u00a0IU\u00a0and 0.025\u00a0\u00b5g = 1 IU) :<\/p>\n<table class=\"mt-responsive-table\">\n<thead>\n<tr>\n<th class=\"mt-align-center\" scope=\"col\">Age group<\/th>\n<th class=\"mt-align-center\" scope=\"col\">RDA (IU\/day)<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td class=\"mt-align-center\">Infants 0\u20136 months<\/td>\n<td class=\"mt-align-center\">400*<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\">Infants 6\u201312 months<\/td>\n<td class=\"mt-align-center\">400*<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\">1\u201370 years<\/td>\n<td class=\"mt-align-center\">600 (15 \u03bcg\/day)<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\">71+ years<\/td>\n<td class=\"mt-align-center\">800 (20 \u03bcg\/day)<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\">Pregnant\/Lactating<\/td>\n<td class=\"mt-align-center\">600 (15 \u03bcg\/day)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li class=\"mt-align-justify\">Asterisk for infants indicates adequate intake (AI) for infants, as an RDA has yet to be established for infants.<\/li>\n<\/ul>\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For vitamin D labeling purposes 100% of the Daily Value was 400 IU (10 \u03bcg), but as of May 2016 it has been revised to 800 IU (20 \u03bcg). A table of the pre-change adult Daily Values is provided at\u00a0Reference Daily Intake. Food and supplement companies have until July 28, 2018 to comply with the change.<\/p>\n<header>\n<h2 id=\"title\">7.2C: Vitamin E<\/h2>\n<\/header>\n<section class=\"mt-content-container\">\n<p class=\"mt-align-justify\"><b>Vitamin E<\/b>\u00a0refers to a group of\u00a0compounds\u00a0that include both\u00a0tocopherols\u00a0and\u00a0tocotrienols.\u00a0Of the many different forms of vitamin E,\u00a0\u03b3-tocopherol\u00a0is the most common form found in the North American diet.\u00a0\u03b3-Tocopherol can be found in corn oil, soybean oil, margarine, and dressings.<span class=\"mt-font-size-12\">\u00a0<\/span>\u03b1-tocopherol, the most biologically active form of vitamin E, is the second-most common form of vitamin E in the diet. This variant can be found most abundantly in wheat germ oil, sunflower, and safflower oils. As a fat-soluble\u00a0antioxidant, it interrupts the propagation of\u00a0reactive oxygen species\u00a0that spread through biological membranes or through a fat when its lipid content undergoes oxidation by reacting with more-reactive lipid radicals to form more stable products.<span class=\"mt-font-size-12\">\u00a0<\/span>Regular consumption of more than 1,000\u00a0mg (1,500\u00a0IU) of tocopherols per day\u00a0may be expected to cause\u00a0hypervitaminosis E, with an associated risk of\u00a0vitamin K\u00a0deficiency and consequently of bleeding problems.<\/p>\n<div style=\"width: 310px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/8\/84\/Sample_of_alpha-tocopherol.jpg\/300px-Sample_of_alpha-tocopherol.jpg\" alt=\"\" width=\"300\" height=\"161\" \/><\/p>\n<p class=\"wp-caption-text\"><em>Sample of \u03b1-tocopherol, one of the various forms of vitamin E<\/em><\/p>\n<\/div>\n<div id=\"section_3\" class=\"mt-section\">\n<h3 class=\"mt-align-justify editable\">Functions<\/h3>\n<p class=\"mt-align-justify\">Vitamin E has many biological functions, including its role as a\u00a0fat-soluble\u00a0antioxidant.<\/p>\n<ul>\n<li class=\"mt-align-justify\">As an antioxidant, vitamin E acts as a\u00a0peroxyl radical\u00a0scavenger, disabling the production of damaging\u00a0free radicals\u00a0in tissues, by reacting with them to form a tocopheryl radical, which will then be\u00a0reduced\u00a0by a hydrogen donor (such as\u00a0vitamin C) and thus return to its reduced state. As it is fat-soluble, it is incorporated into cell membranes, which protects them from oxidative damage. Vitamin E has also found use as a commercial antioxidant in ultra high molecular weight polyethylene (UHMWPE) used in hip and knee\u00a0implants\u00a0by resisting oxidation.<\/li>\n<li class=\"mt-align-justify\">As an enzymatic activity regulator, for instance,\u00a0protein kinase C\u00a0(PKC), which plays a role in smooth muscle growth, can be inhibited by \u03b1-tocopherol. \u03b1-Tocopherol has a stimulatory effect on the dephosphorylation enzyme, protein phosphatase 2A, which in turn, cleaves phosphate groups from PKC, leading to its deactivation, bringing the smooth muscle growth to a halt.<\/li>\n<li class=\"mt-align-justify\">Vitamin E also has an effect on\u00a0gene expression.\u00a0Macrophages\u00a0rich in cholesterol are found in\u00a0atherosclerotic\u00a0tissue.\u00a0Scavenger receptor CD36 is a class B scavenger receptor found to be up-regulated by oxidized\u00a0<a title=\"4.71: Lipoproteins\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Nutrition\/Book%3A_Intermediate_Nutrition_(Lindshield)\/4%3A_Macronutrient_Uptake%2C_Absorption_and_Transport\/4.7%3A__Lipid_Uptake%2C_Absorption_and_Transport\/4.7A%3A_Lipoproteins\" rel=\"internal\">low density lipoprotein\u00a0(LDL)\u00a0<\/a>and binds it.\u00a0Treatment with \u03b1-tocopherol was found to downregulate the expression of the CD36 scavenger receptor gene and the scavenger receptor class A (SR-A)\u00a0and modulates expression of the\u00a0connective tissue growth factor\u00a0(CTGF).\u00a0The\u00a0CTGF\u00a0gene, when expressed, is responsible for the repair of wounds and regeneration of the extracellular tissue lost or damaged during atherosclerosis.<\/li>\n<li class=\"mt-align-justify\">Vitamin E also plays a role in eye and neurological functions,\u00a0and inhibition of\u00a0platelet\u00a0coagulation.<\/li>\n<li class=\"mt-align-justify\">Vitamin E also protects lipids and prevents the oxidation of\u00a0polyunsaturated fatty acids.<\/li>\n<\/ul>\n<p class=\"mt-align-justify\">Although most vitamin E supplementation studies used \u03b1-tocopherol individually, this design of studying only one isoform of vitamin E may introduce errors in interpreting overall vitamin E effects; for example, using only \u03b1-tocopherol in studies of\u00a0<a title=\"4.06: Tissue Injury and Aging\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Anatomy_and_Physiology\/Book%3A_Anatomy_and_Physiology_(OpenStax)\/Unit_1%3A_Levels_of_Organization\/4%3A_The_Tissue_Level_of_Organization\/4.06%3A_Tissue_Injury_and_Aging\" rel=\"internal\">inflammation\u00a0<\/a>can reduce serum \u03b3- and \u03b4-tocopherol concentrations.\u00a0Moreover, a 2013 review involving single long-term supplementation with \u03b1-tocopherol showed that many clinical studies revealed an inverse relationship between supplementation and cardiovascular disease risk or mortality, but other studies showed no effect.<\/p>\n<div id=\"section_4\" class=\"mt-section\">\n<h3 class=\"mt-align-justify editable\">Deficiency<\/h3>\n<p class=\"mt-align-justify\">Vitamin E deficiency can cause:<\/p>\n<ul>\n<li class=\"mt-align-justify\">spinocerebellar ataxia<\/li>\n<li class=\"mt-align-justify\">myopathies<\/li>\n<li class=\"mt-align-justify\">peripheral neuropathy<\/li>\n<li class=\"mt-align-justify\">ataxia<\/li>\n<li class=\"mt-align-justify\">skeletal myopathy<\/li>\n<li class=\"mt-align-justify\">retinopathy<\/li>\n<li class=\"mt-align-justify\">impairment of the immune response<\/li>\n<li class=\"mt-align-justify\">red blood cell\u00a0destruction<\/li>\n<\/ul>\n<div id=\"note\">\n<div class=\"textbox shaded\">\n<div id=\"section_3\" class=\"mt-section\">\n<div id=\"section_4\" class=\"mt-section\">\n<div id=\"note\">\n<h3 class=\"boxtitle\">SUPPLEMENTATION<\/h3>\n<hr \/>\n<p class=\"mt-align-justify\">Vitamin E supplementation has not been shown to have significant benefit for people who are healthy, and appears to be harmful.\u00a0It does not improve blood sugar control in an unselected group of people with\u00a0diabetes mellitus or decrease the risk of stroke. Daily supplementation of vitamin E does not decrease the risk of prostate cancer, and may increase it.\u00a0Studies on its role in\u00a0age-related macular degeneration\u00a0are ongoing, though if it is of a combination of dietary\u00a0antioxidants\u00a0used to treat the condition it may increase the risk. Routine supplementation with vitamin E during pregnancy has been shown to offer no benefit to the mother or the child. Vitamin E has been reported to cause more side effects, such as abdominal pain in pregnant women, and also the increased risk of having early rupture of membranes at term.<\/p>\n<p class=\"mt-align-justify\">Vitamin E, along with\u00a0\u03b2-carotene\u00a0and vitamin C, has no protective effect on reducing the risk of cataract, cataract extraction, progression of cataract, and slowing the loss of visual acuity.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"section_5\" class=\"mt-section\">\n<h3 class=\"mt-align-justify editable\">Toxicity<\/h3>\n<p class=\"mt-align-justify\">The LD<sub>50<\/sub>, or the toxic dose required to kill 50% of group of rats and mice, respectively is 4000 mg of VitaminE E\/kg of rat and 4000 mg of Vitamin E\/kg of mouse. Comparatively speaking, and at lethal doses, Vitamin E is less toxic than table salt and acetaminophen and it is more toxic than ethanol and Vitamin C. Vitamin E can act as an anticoagulant, increasing the risk of bleeding problems. As a result, many agencies have set a tolerable upper intake levels (UL) at 1,000 mg (1,500 IU) per day. In combination with certain other drugs such as aspirin, hypervitaminosis E can be life-threatening. Hypervitaminosis E may also counteract vitamin K, leading to a vitamin K deficiency.<\/p>\n<\/div>\n<div id=\"section_6\" class=\"mt-section\">\n<h3 class=\"mt-align-justify editable\">Dietary Reference Intake<\/h3>\n<p class=\"mt-align-justify\">The Food and Nutrition Board (FNB) of the U.S. Institute of Medicine updated Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) for vitamin E in 2000. The current EAR for vitamin E for women and men ages 14 and up is 12\u00a0mg\/day. The RDA is 15\u00a0mg\/day. RDAs are higher than EARs so as to identify amounts that will cover people with higher than average requirements. RDA for pregnancy equals 15\u00a0mg\/day. RDA for lactation equals 19\u00a0mg\/day. For infants up to 12 months the Adequate Intake (AI) is 4\u20135\u00a0mg\/day and for children ages 1\u201313 years the RDA increases with age from 6 to 11\u00a0mg\/day. The FNB also sets Tolerable Upper Intake Levels (ULs) for vitamins and minerals when evidence is sufficient. In the case of vitamin E the UL is 1,000\u00a0mg\/day.<\/p>\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For vitamin E labeling purposes 100% of the Daily Value was 30\u00a0mg, but as of May 2016 it has been revised to 15\u00a0mg. A table of the pre-change adult Daily Values is provided at\u00a0Reference Daily Intake. Food and supplement companies have until July 28, 2018 to comply with the change.<\/p>\n<div id=\"note\">\n<div class=\"textbox shaded\">\n<h3 class=\"boxtitle\">VITAMIN E AND ATHEROSCLEROSIS<\/h3>\n<hr \/>\n<p class=\"mt-align-justify\">Atherosclerosis is a disease condition that refers to the buildup of plaque, which is a substance containing lipid and cholesterol (mainly the low-density lipoprotein or LDL cholesterol) on the inner layer of the arterial lumen.\u00a0With the existing plaque, instead of being smooth and elastic, the layers become thickened and irregular and the lumen of the artery become narrower. This vessel-narrowing effect lead to a reduction of blood circulation and can lead to or worsen the condition of hypertension.<\/p>\n<p class=\"mt-align-justify\">There are currently multiple theories explaining factors causing and affecting the cholesterol plaque build up within arteries with the most popular theory indicating that the rate of build up is affected by the oxidation of the LDL cholesterol. LDL cholesterol is one of the five major groups of lipoproteins with one of the physiological roles being lipid transportation. A typical LDL particle contain 2,700 fatty acid molecules and half of them are poly-unsaturated fatty acids, which are very oxidation sensitive. Once the oxidation of LDL occur, it will start a series of undesirable effects starting from the increase production of inflammatory cytokines by stimulating the endothelial cells and monocytes, followed by increased production of tissue factors, production of macrophages and monocytes, which eventually lead to the formation of foam cells and accelerated development of atherosclerosis. With the presence of adequate concentration of vitamin E, which is a very potent fat-soluble antioxidant, it can inhibit the oxidation of LDL, and this inhibition contributes protection against the development of atherosclerosis and can stabilize the existing plaque.<\/p>\n<\/div>\n<\/div>\n<p>According to one\u00a0meta-analysis, nine cohort studies showed that high intake of tocopherol was associated with a lower risk of cardiovascular diseases compared with lower intake. In this study, higher dietary, supplementation and combined vitamin E intake was also associated with lower disease incidents. In 1993, a study of 39,919 male health professionals aged 40 to 75 showed that consumption of more than 60\u00a0IU of vitamin E (any form) per day was associated with a lower incidence of coronary heart disease compared with less than 7.5 IU\/day intake.\u00a0This study also showed an inverse association between vitamin E supplementation and the incidence of heart disease.<\/p>\n<p>A 2015\u00a0systematic review\u00a0of clinical trials concluded that vitamin E supplementation alone improved\u00a0endothelial\u00a0function as determined by measurements of forearm\u00a0blood flow, but when combined with vitamin C supplementation, it did not. A meta-analysis of clinical trials showed no significant association between vitamin E supplementation and cardiovascular\u00a0mortality.<\/p>\n<div id=\"section_7\" class=\"mt-section\">\n<h2>7.2D: Vitamin K<\/h2>\n<header><\/header>\n<section class=\"mt-content-container\">\n<p class=\"mt-align-justify\">Vitamin K (Figure 1) is a group of structurally similar, fat-soluble\u00a0vitamins\u00a0the human body requires for\u00a0complete synthesis\u00a0of certain proteins that are needed for blood\u00a0coagulation \u00a0(<a title=\"8.10: Blood Clotting\" href=\"https:\/\/med.libretexts.org\/Bookshelves\/Anatomy_and_Physiology\/Book%3A_Anatomy_and_Physiology_of_Animals_(Lawson)\/8%3A_Cardiovascular_System\/8.10%3A_Blood_Clotting\" rel=\"internal\">blood clotting<\/a>)\u00a0and which the body also needs for controlling the\u00a0binding of calcium in bones and other tissues.\u00a0The vitamin K-related modification of the proteins allows them to bind\u00a0calcium\u00a0ions, which they cannot do otherwise.<\/p>\n<p class=\"mt-align-justify\">In menaquinone, the side chain is composed of a varying number of\u00a0isoprenoid\u00a0residues. The most common number of these residues is four, since animal\u00a0enzymes\u00a0normally produce menaquinone-4 from plant phylloquinone. The three synthetic forms of vitamin K are vitamins K<sub>3<\/sub>\u00a0(menadione), K<sub>4<\/sub>, and K<sub>5<\/sub>, which are used in many areas, including the\u00a0pet food\u00a0industry (vitamin K<sub>3<\/sub>) and to inhibit\u00a0fungal\u00a0growth (vitamin K<sub>5<\/sub>).<\/p>\n<div style=\"width: 230px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/9\/93\/Phylloquinone_structure.svg\/220px-Phylloquinone_structure.svg.png\" alt=\"\" width=\"220\" height=\"104\" \/><\/p>\n<p class=\"wp-caption-text\">Figure 1: (left) Vitamin K1\u00a0(phylloquinone) \u2013 both forms of the vitamin contain a functional\u00a0naphthoquinone\u00a0ring and an\u00a0aliphatic\u00a0side chain. Phylloquinone has a\u00a0phytyl\u00a0side chain.<\/p>\n<\/div>\n<div style=\"width: 230px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/upload.wikimedia.org\/wikipedia\/commons\/thumb\/c\/c4\/Menaquinone.svg\/220px-Menaquinone.svg.png\" alt=\"\" width=\"220\" height=\"92\" \/><\/p>\n<p class=\"wp-caption-text\">Vitamin K2\u00a0(menaquinone).<\/p>\n<\/div>\n<p class=\"mt-align-justify\">The MK-4 form of vitamin K<sub>2<\/sub>\u00a0is produced by conversion of vitamin K<sub>1<\/sub>\u00a0in the\u00a0testes,\u00a0pancreas, and\u00a0arterial\u00a0walls.\u00a0While major questions still surround the biochemical pathway for this transformation, the conversion is not dependent on\u00a0gut bacteria, as it occurs in germ-free rats and in parenterally-administered K<sub>1<\/sub>in rats.\u00a0In fact, tissues that accumulate high amounts of MK-4 have a remarkable capacity to convert up to 90% of the available K<sub>1<\/sub>\u00a0into MK-4.\u00a0There is evidence that the conversion proceeds by removal of the\u00a0phytyl\u00a0tail of K<sub>1<\/sub>\u00a0to produce\u00a0menadione\u00a0as an intermediate, which is then condensed with an activated\u00a0geranylgeranyl\u00a0moiety (see also\u00a0prenylation) to produce vitamin K<sub>2<\/sub>\u00a0in the MK-4 (menatetrione) form.<\/p>\n<div id=\"note\">\n<div class=\"textbox shaded\">\n<h3 class=\"boxtitle\">HEALTH EFFECTS OF VITAMIN\u00a0K<\/h3>\n<hr \/>\n<p>Without vitamin K, blood coagulation is seriously impaired, and uncontrolled bleeding occurs. Preliminary\u00a0clinical research\u00a0indicates that deficiency of vitamin K may weaken bones, potentially leading to\u00a0osteoporosis, and may promote\u00a0calcification\u00a0of arteries and other soft tissues. \u00a0Our main sources of vitamin K are\u00a0from leafy green vegetables and from the production by bacteria\u00a0in our large intestine.<\/p>\n<ul>\n<li class=\"mt-align-justify\"><strong>Osteoporosis<\/strong>: A review of 2014 concluded that there is positive evidence that monotherapy using MK-4, one of the forms of Vitamin K<sub>2<\/sub>, reduces\u00a0fracture\u00a0incidence in post-menopausal\u00a0women with\u00a0osteoporosis, and suggested further research on the combined use of MK-4 with\u00a0bisphosphonates. In contrast, an earlier review article of 2013 concluded that there is no good evidence that vitamin K supplementation helps prevent osteoporosis or fractures in postmenopausal women. A Cochrane systematic review of 2006 suggested that supplementation with Vitamin K<sub>1<\/sub>\u00a0and with MK4 reduces bone loss; in particular, a strong effect of MK-4 on incident fractures among Japanese patients was emphasized. A\u00a0review article of 2016 suggested to consider, as one of several measures for bone health, increasing the intake of foods rich in vitamins K<sub>1<\/sub>\u00a0and K<sub>2<\/sub>.<\/li>\n<li class=\"mt-align-justify\"><strong>Cardiovascular health:\u00a0<\/strong>Adequate intake of vitamin K is associated with the inhibition of\u00a0arterial\u00a0calcification\u00a0and stiffening, but there have been few interventional studies and no good evidence that vitamin K supplementation is of any benefit in the primary prevention of\u00a0cardiovascular disease.<span class=\"mt-font-size-12\">\u00a0<\/span>One 10-year population study, the Rotterdam Study, did show a clear and significant inverse relationship between the highest intake levels of menaquinone (mainly MK-4 from eggs and meat, and MK-8 and MK-9 from cheese) and cardiovascular disease and all-cause mortality in older men and women.<\/li>\n<li class=\"mt-align-justify\"><strong>Cancer<\/strong>: Vitamin K has been promoted in supplement form with claims it can slow\u00a0tumor\u00a0growth; there is however no good\u00a0medical evidence\u00a0that supports such claims.<\/li>\n<li class=\"mt-align-justify\"><strong>Coumarin poisoning:<\/strong>\u00a0Vitamin K is part of the suggested treatment regime for poisoning by\u00a0rodenticide\u00a0(coumarin poisoning).<\/li>\n<\/ul>\n<p class=\"mt-align-justify\">Although\u00a0allergic reaction\u00a0from supplementation is possible, no known toxicity is associated with high doses of the phylloquinone (vitamin K<sub>1<\/sub>) or menaquinone (vitamin K<sub>2<\/sub>) forms of vitamin K, so no\u00a0tolerable upper intake level\u00a0(UL) has been set. Blood clotting (coagulation) studies in humans using 45\u00a0mg per day of vitamin K2\u00a0(as MK-4) and even up to 135\u00a0mg per day (45\u00a0mg three times daily) of K2\u00a0(as MK-4), showed no increase in blood clot risk. Even doses in rats as high as 250\u00a0mg\/kg, body weight did not alter the tendency for blood-clot formation to occur. Unlike the safe natural forms of vitamin K<sub>1<\/sub>\u00a0and vitamin K<sub>2<\/sub>\u00a0and their various\u00a0isomers, a synthetic form of vitamin K, vitamin K3\u00a0(menadione), is demonstrably toxic at high levels. The\u00a0U.S. FDA\u00a0has banned this form from\u00a0over-the-counter\u00a0sale in the\u00a0United States\u00a0because large doses have been shown to cause\u00a0allergic reactions,\u00a0hemolytic anemia, and\u00a0cytotoxicity\u00a0in\u00a0liver\u00a0cells.<\/p>\n<\/div>\n<\/div>\n<p class=\"mt-align-justify\">Phylloquinone (K<sub>1<\/sub>)\u00a0or menaquinone (K<sub>2<\/sub>) are capable of reversing the anticoagulant activity of the\u00a0anticoagulant\u00a0warfarin\u00a0(tradename Coumadin). Warfarin works by blocking recycling of vitamin K, so that the body and tissues have lower levels of active vitamin K, and thus a deficiency of vitamin K. Supplemental vitamin K (for which oral dosing is often more active than injectable dosing in human adults) reverses the vitamin K deficiency caused by warfarin, and therefore reduces the intended anticoagulant action of warfarin and related drugs. Sometimes small amounts of vitamin K are given orally to patients taking warfarin so that the action of the drug is more predictable.<span class=\"mt-font-size-12\">\u00a0<\/span>The proper anticoagulant action of the drug is a function of vitamin K intake and drug dose, and due to differing absorption must be individualized for each patient.\u00a0The action of warfarin and vitamin K both require two to five days after dosing to have maximum effect, and neither warfarin or vitamin K shows much effect in the first 24 hours after they are given.<\/p>\n<div id=\"section_1\" class=\"mt-section\">\n<h3 class=\"editable\">Absorption and Dietary Need<\/h3>\n<p class=\"mt-align-justify\">Previous theory held that dietary deficiency is extremely rare unless the\u00a0small intestine\u00a0was heavily damaged, resulting in\u00a0malabsorption\u00a0of the molecule. Another at-risk group for deficiency were those subject to decreased production of K<sub>2<\/sub>\u00a0by normal intestinal microbiota, as seen in\u00a0broad spectrum antibiotic\u00a0use.\u00a0<strong>Taking broad-spectrum antibiotics can reduce vitamin K production in the gut by nearly 74% in people compared with those not taking these antibiotics<\/strong>.\u00a0Diets low in vitamin K also decrease the body&#8217;s vitamin K concentration.\u00a0Those with chronic\u00a0kidney disease\u00a0are at risk for vitamin K deficiency, as well as\u00a0vitamin D deficiency, and particularly those with the\u00a0apoE4\u00a0genotype.\u00a0Additionally, in the elderly there is a reduction in vitamin K<sub>2<\/sub>\u00a0production.<sup id=\"cite_ref-42\">\u00a0\u00a0<\/sup>Like other lipid-soluble vitamins (A,\u00a0D\u00a0and\u00a0E), vitamin K is stored in the fatty tissue of the human body.<\/p>\n<p class=\"mt-align-justify\">The\u00a0National Academy of Medicine\u00a0(NAM) updated an estimate of what constitutes an Adequate Intake (AI) for vitamin K in 2001. The NAM does not distinguish between K<sub>1<\/sub>\u00a0and K<sub>2<\/sub>\u00a0\u2013 both are counted as vitamin K. At that time there was not sufficient evidence to set the more rigorous Estimated Average Requirement (EAR) or\u00a0recommended dietary allowance\u00a0(RDA) given for most of the essential vitamins and minerals. The current daily AIs for vitamin K for adult women and men are 90\u00a0\u03bcg and 120\u00a0\u03bcg respectively. The AI for\u00a0pregnancy\u00a0and\u00a0lactation\u00a0is 90\u00a0\u03bcg. For infants up to 12 months the AI is 2\u20132.5\u00a0\u03bcg, and for children aged 1 to 18 years the AI increases with age from 30 to 75 \u03bcg. As for safety, the FNB also sets tolerable upper intake levels (known as ULs) for vitamins and minerals when evidence is sufficient. In the case of vitamin K no UL is set, as evidence for adverse effects is not sufficient. Collectively EARs, RDAs, AIs and ULs are referred to as\u00a0dietary reference intakes.<\/p>\n<p class=\"mt-align-justify\">For U.S. food and dietary supplement labeling purposes, the amount in a serving is expressed as a percentage of daily value (%DV). For vitamin K labeling purposes the daily value was 80\u00a0\u03bcg, but as of May 2016 it has been revised upwards to 120\u00a0\u03bcg. A table of the pre-change adult daily values is provided at\u00a0Reference Daily Intake (Table\u00a0&lt;span id=&#8221;MathJax-Element-1-Frame&#8221; class=&#8221;MathJax&#8221; style=&#8221;display: inline-table; font-style: normal; font-weight: normal; line-height: normal; font-size: 14.4px; text-indent: 0px; text-align: left; text-transform: none; letter-spacing: normal; word-spacing: normal; overflow-wrap: normal; white-space: nowrap; float: none; direction: ltr; max-width: none; max-height: none; min-width: 0px; min-height: 0px; border: 0px; padding: 0px; margin: 0px; position: relative;&#8221; tabindex=&#8221;0&#8243; role=&#8221;presentation&#8221; data-mathml=&#8221;7.2D.1&#8243;&gt;<span id=\"MathJax-Span-1\" class=\"math\"><span id=\"MathJax-Span-2\" class=\"mrow\"><span id=\"MathJax-Span-3\" class=\"texatom\"><span id=\"MathJax-Span-4\" class=\"mrow\"><span id=\"MathJax-Span-5\" class=\"mn\">7.2<\/span><span id=\"MathJax-Span-6\" class=\"mi\">D<\/span><span id=\"MathJax-Span-7\" class=\"mo\">.<\/span><span id=\"MathJax-Span-8\" class=\"mn\">1<\/span><\/span><\/span><\/span><\/span><\/p>\n<p>7.2D.1). Food and supplement companies have until 28 July 2018 to comply with the change.<\/p>\n<\/div>\n<div id=\"section_2\" class=\"mt-section\">\n<h3 class=\"editable\">Deficiency<\/h3>\n<p class=\"mt-align-justify\">Average diets are usually not lacking in vitamin K, and primary deficiency is rare in healthy adults. Newborn infants are at an increased risk of deficiency. Other populations with an increased prevalence of vitamin K deficiency include those who suffer from liver damage or disease (e.g. alcoholics), cystic fibrosis, or inflammatory bowel diseases, or have recently had abdominal surgeries. Secondary vitamin K deficiency can occur in people with bulimia, those on stringent diets, and those taking anticoagulants. Other drugs associated with vitamin K deficiency include salicylates, barbiturates, and cefamandole, although the mechanisms are still unknown. Vitamin K<sub>1<\/sub>\u00a0deficiency can result in coagulopathy, a bleeding disorder. Symptoms of K<sub>1<\/sub>\u00a0deficiency include anemia, bruising, nosebleeds and bleeding of the gums in both sexes, and heavy menstrual bleeding in women.<\/p>\n<table class=\"mt-table-big mt-responsive-table\">\n<caption><em><em><strong>Table:\u00a0<\/strong><\/em><\/em><em>Vitamin K<\/em><\/caption>\n<thead>\n<tr>\n<th class=\"mt-align-center\" style=\"width: 121.5px\" scope=\"col\">Food<\/th>\n<th class=\"mt-align-center\" style=\"width: 66.5px\" scope=\"col\">Serving size<\/th>\n<th class=\"mt-align-center\" style=\"width: 54.5px\" scope=\"col\">Vitamin<br \/>\nK<sub>1<\/sub>\u00a0(\u03bcg)<\/th>\n<th class=\"mt-align-center\" style=\"width: 8.5px\" scope=\"col\"><\/th>\n<th class=\"mt-align-center\" style=\"width: 93.5px\" rowspan=\"11\" scope=\"col\">Food<\/th>\n<th class=\"mt-align-center\" style=\"width: 68.5px\" scope=\"col\">Serving size<\/th>\n<th class=\"mt-align-center\" style=\"width: 54.5px\" scope=\"col\">Vitamin<br \/>\nK<sub>1\u00a0<\/sub>(\u03bcg)<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Kale, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">531<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Parsley, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">\u200a<sup>1<\/sup>\u2044<sub>4<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">246<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Spinach, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">444<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Spinach, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">145<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Collards, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">418<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Collards, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">184<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Swiss chard, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">287<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Swiss chard, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">299<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Mustard\u00a0greens, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">210<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Mustard greens, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">279<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Turnip\u00a0greens, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">265<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Turnip greens, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">138<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Broccoli, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">220<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Broccoli, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">89<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Brussels sprouts, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">219<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Endive, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">116<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Cabbage, cooked<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">\u200a<sup>1<\/sup>\u2044<sub>2<\/sub>\u00a0cup<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">82<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Green leaf lettuce<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">71<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-center\" style=\"width: 121.5px\">Asparagus<\/td>\n<td class=\"mt-align-center\" style=\"width: 66.5px\">4 spears<\/td>\n<td class=\"mt-align-center mt-column-width-15\" style=\"width: 54.5px\">48<\/td>\n<td class=\"mt-align-center mt-column-width-5\" style=\"width: 8.5px\"><\/td>\n<td class=\"mt-align-center\" style=\"width: 93.5px\">Romaine lettuce, raw<\/td>\n<td class=\"mt-align-center\" style=\"width: 68.5px\">1 cup<\/td>\n<td class=\"mt-align-center mt-noheading\" style=\"width: 54.5px\">57<\/td>\n<\/tr>\n<tr>\n<td class=\"mt-align-justify\" style=\"width: 542.5px\" colspan=\"7\">Table from &#8220;Important information to know when you are taking: Warfarin (Coumadin) and Vitamin K&#8221;, Clinical Center, National Institutes of Health Drug Nutrient Interaction Task Force.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<div id=\"section_3\" class=\"mt-section\">\n<h2 class=\"editable\">Vitiman A References<\/h2>\n<div id=\"section-Ref\" class=\"section-body\">\n<ol>\n<li>Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes: Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron Manganese, Molybdenium, Nickel, Silicon, Vanadium, and Zinc. National Academy Press. Washington, DC, 2001. PMID: 25057538\u00a0<a id=\"anch_27\" class=\"link-https\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/25057538\" target=\"_blank\" rel=\"external nofollow noopener\">www.ncbi.nlm.nih.gov\/pubmed\/25057538<\/a>.<\/li>\n<li>Mason JB. Vitamins, trace minerals, and other micronutrients. In: Goldman L, Schafer AI, eds.\u00a0<em>Goldman&#8217;s Cecil Medicine<\/em>. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 225.<\/li>\n<li>Salwen MJ. Vitamins and trace elements. In: McPherson RA, Pincus MR, eds.\u00a0<em>Henry&#8217;s Clinical Diagnosis and Management by Laboratory Methods<\/em>. 22nd ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 26.<\/li>\n<\/ol>\n<\/div>\n<p class=\"mt-align-justify\">A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC&#8217;s accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.&#8217;s editorial policy, editorial process and privacy policy. 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