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Vitamin A

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File:Retinol 3Dstructure.png
The structure of retinol, the most common dietary form of vitamin A

Vitamin A is a vitamin which is needed by the retina of the eye in the form of a specific metabolite, the light-absorbing molecule retinal. This molecule is absolutely necessary for both scotopic and color vision. Vitamin A also functions in a very different role, as an irreversibly oxidized form retinoic acid, which is an important hormone-like growth factor for epithelial and other cells.

In foods of animal originhguretinyl palmitate]], which is converted to an alcohol (retinol) in the small intestine. The retinol form functions as a storage form of the vitamin, and can be converted to and from its visually active aldehyde form, retinal. The associated acid (retinoic acid), a metabolite which can be irreversibly synthesized from vitamin A, has only partial vitamin A activity, and does not function in the retina or some essential parts of the reproductive system.

All forms of vitamin A have a beta-ionone ring to which an isoprenoid chain is attached, called a retinyl group. This structure is essential for vitamin activity.[1] The orange pigment of carrots - beta-carotene - can be represented as two connected retinyl groups, which are used in the body to contribute to vitamin A levels. Alpha-carotene and gamma-carotene also have a single retinyl group which give them some vitamin activity. None of the other carotenes have vitamin activity. The carotenoid beta-cryptoxanthin possesses an ionone group and has vitamin activity in humans.

Vitamin A can be found in two principal forms in foods:

  • retinol, the form of vitamin A absorbed when eating animal food sources, is a yellow, fat-soluble substance. Since the pure alcohol form is unstable, the vitamin is found in tissues in a form of retinyl ester. It is also commercially produced and administered as esters such as retinyl acetate or palmitate.
  • The carotenes alpha-carotene, beta-carotene, gamma-carotene; and the xanthophyll beta-cryptoxanthin (all of which contain beta-ionone rings), but no other carotenoids, function as vitamin A in herbivores and omnivore animals, which possess the enzyme required to convert these compounds to retinal. Carnivores in general are poor converters of ionine-containg carotenoids, and pure carnivores such as cats and ferets lack beta-carotene 15,15'-monooxygenase and cannot convert any carotenoids to retinal (resulting in none of the carotenoids being forms of vitamin A for these species).

History

The discovery of vitamin A may have stemmed from research dating back to 1906, indicating that factors other than carbohydrates, proteins, and fats were necessary to keep cattle healthy.[2] By 1917 one of these substances was independently discovered by Elmer McCollum at the University of Wisconsin–Madison, and Lafayette Mendel and Thomas Burr Osborne at Yale University. Since "water-soluble factor B" (Vitamin B) had recently been discovered, the researchers chose the name "fat-soluble factor A" (vitamin A).[2] Vitamin A was first synthesized in 1947 by two Dutch chemists, David Adriaan van Dorp and Jozef Ferdinand Arens.

Equivalencies of retinoids and carotenoids (IU)

As some carotenoids can be converted into vitamin A, attempts have been made to determine how much of them in the diet is equivalent to a particular amount of retinol, so that comparisons can be made of the benefit of different foods. Unfortunately the situation is confusing because the accepted equivalences have changed. For many years, a system of equivalencies was used in which an international unit (IU) was equal to 0.3 μg of retinol, 0.6 μg of β-carotene, or 1.2 μg of other provitamin-A carotenoids.[3] Later, a unit called retinol equivalent (RE) was introduced. 1 RE corresponded to 1 μg retinol, 2 μg β-carotene dissolved in oil (it is only partly dissolved in most supplement pills, due to very poor solubility in any medium), 6 μg β-carotene in normal food (because it is not absorbed as well as when in oils), and 12 μg of either α-carotene, γ-carotene, or β-cryptoxanthin in food (these molecules only provide 50% of the retinol as β-carotene, due to only half the molecule being convertible to usable vitamin).

Newer research has shown that the absorption of provitamin-A carotenoids is only half as much as previously thought, so in 2001 the US Institute of Medicine recommended a new unit, the retinol activity equivalent (RAE). 1 μg RAE corresponds to 1 μg retinol, 2 μg of β-carotene in oil, 12 μg of "dietary" beta-carotene, or 24 μg of the three other dietary provitamin-A carotenoids.[4]

Substance and its chemical environment Micrograms of retinol equivalent per microgram of the substance
retinol 1
beta-carotene, dissolved in oil 1/2
beta-carotene, common dietary 1/12
alpha-carotene, common dietary 1/24
gamma-carotene, common dietary 1/24
beta-cryptoxanthin, common dietary 1/24

Because the production of retinol from provitamins by the human body is regulated by the amount of retinol available to the body, the conversions apply strictly only for vitamin A deficient humans. The absorption of provitamins also depends greatly on the amount of lipids ingested with the provitamin; lipids increase the uptake of the provitamin.[5]

The conclusion that can be drawn from the newer research is that fruits and vegetables are not as useful for obtaining vitamin A as was thought; in other words, the IU's that these foods were reported to contain were worth much less than the same number of IU's of fat-dissolved oils and (to some extent) supplements. This is important for vegetarians. (Night blindness is prevalent in countries where little meat or vitamin A-fortified foods are available.)

A sample vegan diet for one day that provides sufficient vitamin A has been published by the Food and Nutrition Board (page 120[4]). On the other hand, reference values for retinol or its equivalents, provided by the National Academy of Sciences, have decreased. The RDA (for men) of 1968 was 5000 IU (1500 μg retinol). In 1974, the RDA was set to 1000 RE (1000 μg retinol), whereas now the Dietary Reference Intake is 900 RAE (900 μg or 3000 IU retinol). This is equivalent to 1800 μg of β-carotene supplement (3000 IU) or 10800 μg of β-carotene in food (18000 IU).

Vitamin A
Dietary Reference Intake[6]:

Life Stage Group Recommended Dietary Allowances (RDA)

Adequate Intakes (AI*)
μg/day

Upper Limit

μg/day

Infants

0–6 months
7–12 months


400*
500*
600
600
Children

1–3 years
4–8 years


300
400
600
900
Males

9–13 years
14–18 years
19 - >70 years


600
900
900
1700
2800
3000
Females

9–13 years
14–18 years
19 - >70 years


600
700
700
1700
2800
3000
Pregnancy

<19 years
19 - >50 years


750
770
2800
3000
Lactation

<19 years
19 - >50 years


1200
1300
2800
3000

(Note that the limit refers to synthetic and natural retinoid forms of vitamin A. Carotene forms from dietary sources are not toxic.[7][8])

According to the Institute of Medicine of the National Academies, "RDAs are set to meet the needs of almost all (97 to 98 percent) individuals in a group. For healthy breastfed infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover the needs of all individuals in the group, but lack of data prevent being able to specify with confidence the percentage of individuals covered by this intake."[9]

Sources

Egg.

Vitamin A is found naturally in many foods:

Note: data taken from USDA database bracketed values are retinol activity equivalences (RAEs) and percentage of the adult male RDA per 100g.

Conversion of carotene to retinol varies from person to person and bioavailability of carotene in food varies.[11][12]

Metabolic functions

Vitamin A plays a role in a variety of functions throughout the body, such as:

  • Vision
  • Gene transcription
  • Immune function
  • Embryonic development and reproduction
  • Bone metabolism
  • Haematopoiesis
  • Skin health
  • Antioxidant Activity

Vision

The role of vitamin A in the vision cycle is specifically related to the retinal form. Within the eye, 11-cis-retinal is bound to rhodopsin (rods) and iodopsin (cones) at conserved lysine residues. As light enters the eye the 11-cis-retinal is isomerized to the all-"trans" form. The all-"trans" retinal dissociates from the opsin in a series of steps called bleaching. This isomerization induces a nervous signal along the optic nerve to the visual center of the brain. Upon completion of this cycle, the all-"trans"-retinal can be recycled and converted back to the 11-"cis"-retinal form via a series of enzymatic reactions. Additionally, some of the all-"trans" retinal may be converted to all-"trans" retinol form and then transported with an interphotoreceptor retinol-binding protein (IRBP) to the pigment epithelial cells. Further esterification into all-"trans" retinyl esters allow this final form to be stored within the pigment epithelial cells to be reused when needed.[13] The final conversion of 11-cis-retinal will rebind to opsin to reform rhodopsin in the retina. Rhodopsin is needed to see black and white as well as see at night. It is for this reason that a deficiency in vitamin A will inhibit the reformation of rhodopsin and lead to night blindness.[14]

Gene transcription

Vitamin A, in the retinoic acid form, plays an important role in gene transcription. Once retinol has been taken up by a cell, it can be oxidized to retinal (by retinol dehydrogenases) and then retinal can be oxidized to retinoic acid (by retinal oxidase). The conversion of retinal to retinoic acid is an irreversible step, meaning that the production of retinoic acid is tightly regulated, due to its activity as a ligand for nuclear receptors.[13] Retinoic acid can bind to two different nuclear receptors to initiate (or inhibit) gene transcription: the retinoic acid receptors (RARs) or the retinoid "X" receptors (RXRs). RAR and RXR must dimerize before they can bind to the DNA. RAR will form a heterodimer with RXR (RAR-RXR), but it does not readily form a homodimer (RAR-RAR). RXR, on the other hand, readily forms a homodimer (RXR-RXR) and will form heterodimers with many other nuclear receptors as well, including the thyroid hormone receptor (RXR-TR), the Vitamin D3 receptor (RXR-VDR), the peroxisome proliferator-activated receptor (RXR-PPAR) and the liver "X" receptor (RXR-LXR).[15] The RAR-RXR heterodimer recognizes retinoid acid response elements (RAREs) on the DNA whereas the RXR-RXR homodimer recognizes retinoid "X" response elements (RXREs) on the DNA. The other RXR heterodimers will bind to various other response elements on the DNA.[13] Once the retinoic acid binds to the receptors and dimerization has occurred, the receptors undergo a conformational change that causes co-repressors to dissociate from the receptors. Coactivators can then bind to the receptor complex, which may help to loosen the chromatin structure from the histones or may interact with the transcriptional machinery.[15] The receptors can then bind to the response elements on the DNA and upregulate (or downregulate) the expression of target genes, such as cellular retinol-binding protein (CRBP) as well as the genes that encode for the receptors themselves.[13]

Dermatology

Vitamin A appears to function in maintaining normal skin health. The mechanisms behind retinoid's therapeutic agents in the treatment of dermatological diseases are being researched. For the treatment of acne, the most effective drug is 13-cis retinoic acid (isotretinoin). Although its mechanism of action remains unknown, it dramatically reduces the size and secretion of the sebaceous glands. Isotretinoin reduces bacterial numbers in both the ducts and skin surface. This is thought to be a result of the reduction in sebum, a nutrient source for the bacteria. Isotretinoin reduces inflammation via inhibition of chemotatic responses of monocytes and neutrophils.[13] Isotretinoin also has been shown to initiate remodeling of the sebaceous glands; triggering changes in gene expression that selectively induces apoptosis.[16] Isotretinoin is a teratogen and its use is confined to medical supervision.

Retinal/retinol versus retinoic acid

Vitamin A deprived rats can be kept in good general health with supplementation of retinoic acid. This reverses the growth-stunting effects of vitamin A deficiency, as well as xerophthalmia. However, such rats show infertility (in both male and females) and continued degeneration of the retina, showing that these functions require retinal or retinol, which are intraconvertable but which cannot be recovered from the oxidized retinoic acid.[17]

Deficiency

Main article: Vitamin A deficiency

Vitamin A deficiency is estimated to affect millions of children around the world. Approximately 250,000-500,000 children in developing countries become blind each year owing to vitamin A deficiency, with the highest prevalence in Southeast Asia and Africa.[18] According to the World Health Organization (WHO), vitamin A deficiency is under control in the United States, but in developing countries vitamin A deficiency is a significant concern. With the high prevalence of vitamin A deficiency, the WHO has implemented several initiatives for supplementation of vitamin A in developing countries. Some of these strategies include intake of vitamin A through a combination of breast feeding, dietary intake, food fortification, and supplementation. Through the efforts of WHO and its partners, an estimated 1.25 million deaths since 1998 in 40 countries due to vitamin A deficiency have been averted.[19]

Vitamin A deficiency can occur as either a primary or secondary deficiency. A primary vitamin A deficiency occurs among children and adults who do not consume an adequate intake of yellow and green vegetables, fruits and liver. Early weaning can also increase the risk of vitamin A deficiency. Secondary vitamin A deficiency is associated with chronic malabsorption of lipids, impaired bile production and release, low fat diets, and chronic exposure to oxidants, such as cigarette smoke. Vitamin A is a fat soluble vitamin and depends on micellar solubilization for dispersion into the small intestine, which results in poor utilization of vitamin A from low-fat diets. Zinc deficiency can also impair absorption, transport, and metabolism of vitamin A because it is essential for the synthesis of the vitamin A transport proteins and the oxidation of retinol to retinal. In malnourished populations, common low intakes of vitamin A and zinc increase the risk of vitamin A deficiency and lead to several physiological events.[13] A study in Burkina Faso showed major reduction of malaria morbidity with combined vitamin A and zinc supplementation in young children.[20]

Since the unique function of retinyl group is the light absorption in retinylidene protein, one of the earliest and specific manifestations of vitamin A deficiency is impaired vision, particularly in reduced light - night blindness. Persistent deficiency gives rise to a series of changes, the most devastating of which occur in the eyes. Some other ocular changes are referred to as xerophthalmia. First there is dryness of the conjunctiva (xerosis) as the normal lacrimal and mucus secreting epithelium is replaced by a keratinized epithelium. This is followed by the build-up of keratin debris in small opaque plaques (Bitot's spots) and, eventually, erosion of the roughened corneal surface with softening and destruction of the cornea (keratomalacia) and total blindness.[21] Other changes include impaired immunity, hypokeratosis (white lumps at hair follicles), keratosis pilaris and squamous metaplasia of the epithelium lining the upper respiratory passages and urinary bladder to a keratinized epithelium. With relations to dentistry, a deficiency in Vitamin A leads to enamel hypoplasia.

Adequate supply of Vitamin A is especially important for pregnant and breastfeeding women, since deficiencies cannot be compensated by postnatal supplementation.[22][23]. However, excess Vitamin A, especially through vitamin supplementation, can cause birth defects and should not exceed recommended daily values.

Toxicity

Main article: Hypervitaminosis A

Since vitamin A is fat-soluble, disposing of any excesses taken in through diet is much harder than with water-soluble vitamins B and C, thus vitamin A toxicity may result. This can lead to nausea, jaundice, irritability, anorexia (not to be confused with anorexia nervosa, the eating disorder), vomiting, blurry vision, headaches, hairloss, muscle and abdominal pain and weakness, drowsiness and altered mental status.

Acute toxicity generally occurs at doses of 25,000 IU/kg of body weight, with chronic toxicity occurring at 4,000 IU/kg of body weight daily for 6–15 months.[24] However, liver toxicities can occur at levels as low as 15,000 IU per day to 1.4 million IU per day, with an average daily toxic dose of 120,000 IU per day. In people with renal failure 4000 IU can cause substantial damage. Additionally, excessive alcohol intake can increase toxicity. Children can reach toxic levels at 1,500 IU/kg of body weight.[25]

In chronic cases, hair loss, dry skin, drying of the mucous membranes, fever, insomnia, fatigue, weight loss, bone fractures, anemia, and diarrhea can all be evident on top of the symptoms associated with less serious toxicity.[26]

It has been estimated that 75% of people may be ingesting more than the RDA for vitamin A on a regular basis in developed nations. Intake of twice the RDA of preformed vitamin A chronically may be associated with osteoporosis and hip fractures. This may be due to the fact that an excess of vitamin A can block the expression of certain proteins that are dependent on vitamin K. This could hypothetically reduce the efficacy of vitamin D, which has a proven role in the prevention of osteoporosis and also depends on vitamin K for proper utilization[27].

High vitamin A intake has been associated with spontaneous bone fractures in animals. Cell culture studies have linked increased bone resorption and decreased bone formation with high vitamin A intakes. This interaction may occur because vitamins A and D may compete for the same receptor and then interact with parathyroid hormone which regulates calcium.[25] Indeed, a study by Forsmo et al. shows a correlation between low bone mineral density and too high intake of vitamin A.[28]

Toxic effects of vitamin A have been shown to significantly affect developing fetuses. Therapeutic doses used for acne treatment have been shown to disrupt cephalic neural cell activity. The fetus is particularly sensitive to vitamin A toxicity during the period of organogenesis.[13]

These toxicities only occur with preformed (retinoid) vitamin A (such as from liver). The carotenoid forms (such as beta-carotene as found in carrots), give no such symptoms, but excessive dietary intake of beta-carotene can lead to carotenodermia, which causes orange-yellow discoloration of the skin.[29][30][31]

Researchers have succeeded in creating water-soluble forms of vitamin A, which they believed could reduce the potential for toxicity.[32] However, a 2003 study found that water-soluble vitamin A was approximately 10 times as toxic as fat-soluble vitamin.[33] A 2006 study found that children given water-soluble vitamin A and D, which are typically fat-soluble, suffer from asthma twice as much as a control group supplemented with the fat-soluble vitamins.[34]

Chronically high doses of Vitamin A can produce the syndrome of "pseudotumor cerebri".[35] This syndrome includes headache, blurring of vision and confusion. It is associated with increased intracerebral pressure.[36]

Vitamin A and derivatives in medical use

Retinyl palmitate has been used in skin cremes, where it is broken down to retinoic acid, which has potent biological activity, as described above.

The retinoids, a class of chemical compounds that are related chemically to retinoic acid, are used in medicine to modulate gene functions in place of this counpound. In general, like retinoic acid itself, these compounds do not have full vitamin A activity.[37]

References

  1. ^ Carolyn Berdanier. 1997. Advanced Nutrition Micronutrients. pp 22-39
  2. ^ a b Wolf, George (2001-04-19). "Discovery of Vitamin A". Encyclopedia of Life Sciences. doi:10.1038/npg.els.0003419. Retrieved 2007-07-21.
  3. ^ Composition of Foods Raw, Processed, Prepared USDA National Nutrient Database for Standard Reference, Release 20 USDA, Feb. 2008
  4. ^ a b Chapter 4, Vitamin A of Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, hickel, Silicon, Vanadium, and Zinc, Food and Nutrition Board of the Institute of Medicine, 2001
  5. ^ NW Solomons, M Orozco. Alleviation of Vitamin A deficiency with palm fruit and its products. Asia Pac J Clin Nutr, 2003
  6. ^ Dietary Reference Intakes: Vitamins
  7. ^ "Sources of vitamin A". Retrieved 2007-08-27.
  8. ^ "Linus Pauling Institute at Oregon State University: Vitamin A Safety". Retrieved 2007-09-02.
  9. ^ Food and Nutrition Board. Institute of Medicine. National Academies. (2001) "Dietary Reference Intakes"
  10. ^ The RAE value in the USDA data for broccoli leaves is similar to the IU value for broccoli florets, which implies that the leaves have about 20 times as much beta-carotene.
  11. ^ Borel P, Drai J, Faure H; et al. (2005). "[Recent knowledge about intestinal absorption and cleavage of carotenoids]". Ann. Biol. Clin. (Paris) (in French). 63 (2): 165–77. PMID 15771974. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  12. ^ Tang G, Qin J, Dolnikowski GG, Russell RM, Grusak MA (2005). "Spinach or carrots can supply significant amounts of vitamin A as assessed by feeding with intrinsically deuterated vegetables". Am. J. Clin. Nutr. 82 (4): 821–8. PMID 16210712.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ a b c d e f g Combs, Gerald F. (2008). The Vitamins: Fundamental Aspects in Nutrition and Health (3rd ed.). Burlington: Elsevier Academic Press. ISBN 9780121834937.
  14. ^ McGuire, Michelle (2007). Nutritional sciences: from fundamentals to food. Belmont, CA: Thomson/Wadsworth. ISBN 0534537170. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  15. ^ a b Stipanuk, Martha H. (2006). Biochemical, Physiological and Molecular Aspects of Human Nutrition (2nd ed.). Philadelphia: Saunders. ISBN 978116002093. {{cite book}}: Check |isbn= value: length (help)
  16. ^ Nelson, A. M. (2008). "Neutrophil gelatinase-associated lipocalin mediates 13-cis retinoic acid-induced apoptosis of human sebaceous gland cells". Journal of Clinical Investigation. 118 (4): 1468–1478. doi:10.1172/JCI33869. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  17. ^ http://la.rsmjournals.com/cgi/content/abstract/5/2/239 Lab Anim 1971;5:239-250. The production of experimental vitamin A deficiency in rats and mice. T. Moore and P. D. Holmes. doi:10.1258/002367771781006492.
  18. ^ "Office of Dietary Supplements. Vitamin A". National Institute of Health. Retrieved 2008-04-08.
  19. ^ "Micronutrient Deficiencies-Vitamin A". World Health Organization. Retrieved 2008-04-09.
  20. ^ Zeba AN, Sorgho H, Rouamba N; et al. (2008). "Major reduction of malaria morbidity with combined vitamin A and zinc supplementation in young children in Burkina Faso: a randomized double blind trial". Nutr J. 7: 7. doi:10.1186/1475-2891-7-7. PMC 2254644. PMID 18237394. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  21. ^ Roncone DP (2006). "Xerophthalmia secondary to alcohol-induced malnutrition". Optometry (St. Louis, Mo.). 77 (3): 124–33. doi:10.1016/j.optm.2006.01.005. PMID 16513513. {{cite journal}}: |access-date= requires |url= (help)
  22. ^ Strobel M, Tinz J, Biesalski HK (2007). "The importance of beta-carotene as a source of vitamin A with special regard to pregnant and breastfeeding women". Eur J Nutr. 46 Suppl 1: I1–20. doi:10.1007/s00394-007-1001-z. PMID 17665093.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ Schulz C, Engel U, Kreienberg R, Biesalski HK (2007). "Vitamin A and beta-carotene supply of women with gemini or short birth intervals: a pilot study". Eur J Nutr. 46 (1): 12–20. doi:10.1007/s00394-006-0624-9. PMID 17103079.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Rosenbloom, Mark. "Toxicity, Vitamin". eMedicine.
  25. ^ a b Penniston, Kristina L. (February 1, 2006). "The acute and chronic toxic effects of vitamin A". Am. J. Clin. Nutr. 83 (2): 191–201. PMID 16469975. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  26. ^ Eledrisi, Mohsen S. "Vitamin A Toxicity". eMedicine.
  27. ^ Masterjohn, C (December 4, 2006). "Vitamin D toxicity redefined: vitamin K and the molecular mechanism". Medical Hypotheses.
  28. ^ Forsmo, Siri (2008). "Childhood Cod Liver Oil Consumption and Bone Mineral Density in a Population-based Cohort of Peri- and Postmenopausal Women: The Nord-Trøndelag Health Study". Am. J. Epidemiol. 167 (4): 406–411. doi:10.1093/aje/kwm320. PMID 18033763. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  29. ^ Sale TA, Stratman E (2004). "Carotenemia associated with green bean ingestion". Pediatr Dermatol. 21 (6): 657–9. doi:10.1111/j.0736-8046.2004.21609.x. PMID 15575851.
  30. ^ Nishimura Y, Ishii N, Sugita Y, Nakajima H (1998). "A case of carotenodermia caused by a diet of the dried seaweed called Nori". J. Dermatol. 25 (10): 685–7. PMID 9830271.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  31. ^ Takita Y, Ichimiya M, Hamamoto Y, Muto M (2006). "A case of carotenemia associated with ingestion of nutrient supplements". J. Dermatol. 33 (2): 132–4. doi:10.1111/j.1346-8138.2006.00028.x. PMID 16556283.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ Science News. Water-soluble vitamin A shows promise.
  33. ^ Myhre AM, Carlsen MH, Bøhn SK, Wold HL, Laake P, Blomhoff R (2003). "Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations". Am. J. Clin. Nutr. 78 (6): 1152–9. PMID 14668278. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  34. ^ Kull I, Bergström A, Melén E; et al. (2006). "Early-life supplementation of vitamins A and D, in water-soluble form or in peanut oil, and allergic diseases during childhood". J. Allergy Clin. Immunol. 118 (6): 1299–304. doi:10.1016/j.jaci.2006.08.022. PMID 17157660. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  35. ^ Brazis PW (2004). "Pseudotumor cerebri". Current neurology and neuroscience reports. 4 (2): 111–6. doi:10.1007/s11910-004-0024-6. PMID 14984682. {{cite journal}}: Unknown parameter |month= ignored (help)
  36. ^ AJ Giannini, RL Gilliland. The Neurologic, Neurogenic and Neuropsychiatric Disorders Handbook. New Hyde Park, NY. Medical Examination Publishing Co., 1982,pp. 182-183.
  37. ^ American Cancer Society: Retinoid Therapy

Further reading

  • Litwack, Gerald (2007). Vitamin A. Vitamins and Hormones. Vol. 75. San Diego, CA: Elsevier Academic Press. ISBN 9780127098753.

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