text:
Vitamin A

Vitamin A is a fat-soluble vitamin, hence an essential nutrient. The term "vitamin A" encompasses a group of chemically related organic compounds that includes retinol, retinal (also known as retinaldehyde), retinoic acid, and several provitamin (precursor) carotenoids, most notably beta-carotene. Vitamin A has multiple functions: essential in embryo development for growth, maintaining the immune system, and healthy vision, where it combines with the protein opsin to form rhodopsin – the light-absorbing molecule necessary for both low-light (scotopic vision) and color vision.

Vitamin A occurs as two principal forms in foods: A) retinol, found in animal-sourced foods, either as retinol or bound to a fatty acid to become a retinyl ester, and B) the carotenoids alpha-carotene, β-carotene, gamma-carotene, and the xanthophyll beta-cryptoxanthin (all of which contain β-ionone rings) that function as provitamin A in herbivore and omnivore animals which possess the enzymes that cleave and convert provitamin carotenoids to retinal and then to retinol. Some carnivore species lack this enzyme. The other carotenoids have no vitamin activity.

Dietary retinol is absorbed from the digestive tract via passive diffusion. Unlike retinol, β-carotene is taken up by enterocytes by the membrane transporter protein scavenger receptor B1 (SCARB1), which is upregulated in times of vitamin A deficiency. Storage of retinol is in lipid droplets in the liver. A high capacity for long-term storage of retinol means that well-nourished humans can go months on a vitamin A- and β-carotene-deficient diet, while maintaining blood levels in the normal range. Only when the liver stores are nearly depleted will signs and symptoms of deficiency show. Retinol is reversibly converted to retinal, then irreversibly to retinoic acid, which activates hundreds of genes.

Vitamin A deficiency is common in developing countries, especially in Sub-Saharan Africa and Southeast Asia. Deficiency can occur at any age but is most common in pre-school age children and pregnant women, the latter due to a need to transfer retinol to the fetus. Vitamin A deficiency is estimated to affect approximately one-third of children under the age of five around the world, resulting in hundreds of thousands of cases of blindness and deaths from childhood diseases because of immune system failure. Reversible night blindness is an early indicator of low vitamin A status. Plasma retinol is used as a biomarker to confirm vitamin A deficiency. Breast milk retinol can indicate a deficiency in nursing mothers. Neither of these measures indicates the status of liver reserves.

The European Union and various countries have set recommendations for dietary intake, and upper limits for safe intake. Vitamin A toxicity also referred to as hypervitaminosis A, occurs when there is too much vitamin A accumulating in the body. Symptoms may include nervous system effects, liver abnormalities, fatigue, muscle weakness, bone and skin changes, and others. The adverse effects of both acute and chronic toxicity are reversed after consumption of high dose supplements is stopped.

Definition
Vitamin A is a fat-soluble vitamin, a category that also includes vitamins D, E and K. The vitamin encompasses several chemically related naturally occurring compounds or metabolites, i.e., vitamers, that all contain a β-ionone ring. The primary dietary form is retinol, which may have a fatty acid molecule attached, creating a retinyl ester, when stored in the liver. Retinol – the transport and storage form of vitamin A – is interconvertible with retinal, catalyzed to retinal by retinol dehydrogenases and back to retinol by retinaldehyde reductases.
 * retinal + NADPH + H+ retinol + NADP+
 * retinol + NAD+ retinal + NADH + H+

Retinal, (also known as retinaldehyde) can be irreversibly converted to all-trans-retinoic acid by the action of retinal dehydrogenase
 * retinal + NAD+ + H2O → retinoic acid + NADH + H+

Retinoic acid diffuses into the cell nucleus where it regulates more than 500 genes by binding directly to gene targets via retinoic acid receptors.

In addition to retinol, retinal and retinoic acid, there are plant-, fungi- or bacteria-sourced carotenoids which can be metabolized to retinol, and are thus vitamin A vitamers.

There are also what are referred to as 2nd, 3rd and 4th generation retinoids which are not considered vitamin A vitamers because they cannot be converted to retinol, retinal or all-trans-retinoic acid. Some are prescription drugs, oral or topical, for various indications. Examples are etretinate, acitretin, adapalene, bexarotene, tazarotene and trifarotene.

Absorption, metabolism and excretion
Retinyl esters from animal-sourced foods (or synthesized for dietary supplements for humans and domesticated animals) are acted upon by retinyl ester hydrolases in the lumen of the small intestine to release free retinol. Retinol enters intestinal absorptive cells by passive diffusion. Absorption efficiency is in the range of 70 to 90%. Humans are at risk for acute or chronic vitamin A toxicity because there are no mechanisms to suppress absorption or excrete the excess in urine. Within the cell, retinol is there bound to retinol binding protein 2 (RBP2). It is then enzymatically re-esterified by the action of lecithin retinol acyltransferase and incorporated into chylomicrons that are secreted into the lymphatic system.

Unlike retinol, β-carotene is taken up by enterocytes by the membrane transporter protein scavenger receptor B1 (SCARB1). The protein is upregulated in times of vitamin A deficiency. If vitamin A status is in the normal range, SCARB1 is downregulated, reducing absorption. Also downregulated is the enzyme beta-carotene 15,15'-dioxygenase (formerly known as beta-carotene 15,15'-monooxygenase) coded for by the BCMO1 gene, responsible for symmetrically cleaving β-carotene into retinal. Absorbed β-carotene is either incorporated as such into chylomicrons or first converted to retinal and then retinol, bound to RBP2. After a meal, roughly two-thirds of the chylomicrons are taken up by the liver with the remainder delivered to peripheral tissues. Peripheral tissues also can convert chylomicron β-carotene to retinol.

The capacity to store retinol in the liver means that well-nourished humans can go months on a vitamin A deficient diet without manifesting signs and symptoms of deficiency. Two liver cell types are responsible for storage and release: hepatocytes and hepatic stellate cells (HSCs). Hepatocytes take up the lipid-rich chylomicrons, bind retinol to retinol-binding protein 4 (RBP4), and transfer the retinol-RBP4 to HSCs for storage in lipid droplets as retinyl esters. Mobilization reverses the process: retinyl ester hydrolase releases free retinol which is transferred to hepatocytes, bound to RBP4, and put into blood circulation. Other than either after a meal or when consumption of large amounts exceeds liver storage capacity, more than 95% of retinol in circulation is bound to RBP4.

Carnivores
Strict carnivores manage vitamin A differently than omnivores and herbivores. Carnivores are more tolerant of high intakes of retinol because those species have the ability to excrete retinol and retinyl esters in urine. Carnivores also have the ability to store more in the liver, due to a higher ratio of liver HSCs to hepatocytes compared to omnivores and herbivores. For humans, liver content can range from 20 to 30 μg/gram wet weight. Notoriously, polar bear liver is acutely toxic to humans because content has been reported in range of 2,215 to 10,400 μg/g wet weight. As noted, in humans, retinol circulates bound to RBP4. Carnivores maintain R-RBP4 within a tight range while also having retinyl esters in circulation. Bound retinol is delivered to cells while the esters are excreted in the urine. In general, carnivore species are poor converters of ionone-containing carotenoids, and pure carnivores such as felidae (cats) lack the cleaving enzyme entirely. They must have retinol or retinyl esters in their diet.

Herbivores
Herbivores consume ionone-containing carotenoids and convert those to retinal. Some species, including cattle and horses, have measurable amounts of beta-carotene circulating in the blood, and stored in body fat, creating yellow fat cells. Most species have white fat and no beta-carotene in circulation.

Activation and excretion
In the liver and peripheral tissues of humans, retinol is reversibly converted to retinal by the action of alcohol dehydrogenases, which are also responsible for the conversion of ethanol to acetaldehyde. Retinal is irreversibly oxidized to retinoic acid (RA) by the action of aldehyde dehydrogenases. RA regulates the activation or deactivation of genes. The oxidative degradation of RA is induced by RA - its presence triggers its removal, making for a short-acting gene transcription signal. This deactivation is mediated by a cytochrome P450 (CYP) enzyme system, specifically enzymes CYP26A1, CYP26B1 and CYP26C1. CYP26A1 is the predominant form in the human liver; all other human adult tissues contained higher levels of CYP26B1. CYP26C1 is expressed mainly during embryonic development. All three convert retinoic acid into 4-oxo-RA, 4-OH-RA and 18-OH-RA. Glucuronic acid forms water-soluble glucuronide conjugates with the oxidized metabolites, which are then excreted in urine and feces.

Metabolic functions
Other than for vision, the metabolic functions of vitamin A are mediated by all-trans-retinoic acid (RA). The formation of RA from retinal is irreversible. To prevent accumulation of RA it is oxidized and eliminated fairly quickly, i.e., has a short half-life. Three cytochromes catalyze the oxidation of retinoic acid. The genes for Cyp26A1, Cyp26B1 and Cyp26C1 are induced by high levels of RA, providing a self-regulating feedback loop.

Vision and eye health
Vitamin A status involves eye health via two separate functions. Retinal is an essential factor in rod cells and cone cells in the retina responding to light exposure by sending nerve signals to the brain. An early sign of vitamin A deficiency is night blindness. Vitamin A in the form of retinoic acid is essential to normal epithelial cell functions. Severe vitamin A deficiency, common in infants and young children in southeast Asia causes xerophthalmia characterized by dryness of the conjunctival epithelium and cornea. Untreated, xerophthalmia progresses to corneal ulceration and blindness.

Vision
The role of vitamin A in the visual cycle is specifically related to the retinal compound. Retinol is converted by the enzyme RPE65 within the retinal pigment epithelium into 11-cis-retinal. Within the eye, 11-cis-retinal is bound to the protein opsin to form rhodopsin in rod cells and iodopsin in cone cells. 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 photo-bleaching. This isomerization induces a nervous signal along the optic nerve to the visual center of the brain. After separating from opsin, the all-trans-retinal is recycled and converted back to the 11-cis-retinal form by a series of enzymatic reactions, which then completes the cycle by binding to opsin to reform rhodopsin in the retina. In addition, some of the all-trans-retinal may be converted to all-trans-retinol form and then transported with an interphotoreceptor retinol-binding protein to the retinal pigmented epithelial cells. Further esterification into all-trans-retinyl esters allow for storage of all-trans-retinol within the pigment epithelial cells to be reused when needed. It is for this reason that a deficiency in vitamin A will inhibit the reformation of rhodopsin, and will lead to one of the first symptoms, night blindness.

Night blindness
Vitamin A deficiency-caused night blindness is a reversible difficulty for the eyes to adjust to dim light. It is common in young children who have a diet inadequate in retinol and beta-carotene. A process called dark adaptation typically causes an increase in photopigment amounts in response to low levels of illumination. This increases light sensitivity by up to 100,000 times compared to normal daylight conditions. Significant improvement in night vision takes place within ten minutes, but the process can take up to two hours to reach maximal effect. People expecting to work in a dark environment wore red-tinted goggles or were in a red light environment to not reverse the adaptation because red light does not deplete rhodopsin versus what occurs with yellow or green light.

Xerophthalmia and childhood blindness
Xerophthalmia, caused by a severe vitamin A deficiency, is described by pathologic dryness of the conjunctival epithelium and cornea. The conjunctiva becomes dry, thick, and wrinkled. Indicative is the appearance of Bitot's spots, which are clumps of keratin debris that build up inside the conjunctiva. If untreated, xerophthalmia can lead to dry eye syndrome, corneal ulceration and ultimately to blindness as a result of cornea and retina damage. Although xerophthalmia is an eye-related issue, prevention (and reversal) are functions of retinoic acid having been synthesized from retinal rather than the 11-cis-retinal to rhodopsin cycle.

Throughout southeast Asia, estimates are that more than half of children under the age of six years have subclinical vitamin A deficiency and night blindness, with progression to xerophthalmia being the leading cause of preventable childhood blindness. Estimates are that each year there are 350,000 cases of childhood blindness due to vitamin A deficiency. The causes are vitamin A deficiency during pregnancy, followed by low transfer of vitamin A during lactation and infant/child diets low in vitamin A or beta-carotene. The prevalence of pre-school age children who are blind due to vitamin A deficiency is lower than expected from incidence of new cases only because childhood vitamin A deficiency significantly increases all-cause mortality.

According to a 2017 Cochrane review, vitamin A deficiency, using serum retinol less than 0.70 μmol/L as a criterion, is a major public health problem affecting an estimated 190 million children under five years of age in low- and middle-income countries, primarily in Sub-Saharan Africa and Southeast Asia. In lieu of or in combination with food fortification programs, many countries have implemented public health programs in which children are periodically given very large oral doses of synthetic vitamin A, usually retinyl palmitate, as a means of preventing and treating VAD. Doses were 50,000 to 100,000 IU (International units) for children aged 6 to 11 months and 100,000 to 200,000 IU for children aged 12 months to five years, the latter typically every four to six months. In addition to a 24% reduction in all-cause mortality, eye-related results were reported. Prevalence of Bitot's spots at follow-up were reduced by 58%, night blindness by 68%, xerophthalmia by 69%.

Gene regulation
RA regulates gene transcription by binding to nuclear receptors known as retinoic acid receptors (RARs; RARα, RARβ, RARγ) which are bound to DNA as heterodimers with retinoid "X" receptors (RXRs; RXRα, RXRβ, RXRγ). RARs and RXRs must dimerize before they can bind to the DNA. Expression of more than 500 genes is responsive to retinoic acid. The process is that RAR-RXR heterodimers recognize retinoic acid response elements on DNA. 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. This response upregulates or downregulates the expression of target genes, including the genes that encode for the receptors themselves. To prevent excess accumulation of RA it must be metabolized and eliminated. Three cytochromes (Cyp26A1, Cyp26B1 Cyp26C1) catalyze the oxidation of RA. The genes for these proteins are induced by high concentrations of RA, thus providing a regulatory feedback mechanism.

Embryology
In vertebrates and invertebrate chordates, RA has a pivotal role during development. Altering levels of endogenous RA signaling during early embryology, both too low and too high, leads to birth defects, including congenital vascular and cardiovascular defects. Of note, fetal alcohol spectrum disorder encompasses congenital anomalies, including craniofacial, auditory, and ocular defects, neurobehavioral anomalies and mental disabilities caused by maternal consumption of alcohol during pregnancy. It is proposed that in the embryo there is competition between acetaldehyde, an ethanol metabolite, and retinaldehyde (retinal) for aldehyde dehydrogenase activity, resulting in a retenoic acid deficiency, and attributing the congenital birth defects to the loss of RA activated gene activation. In support of this theory, ethanol-induced developmental defects can be ameliorated by increasing the levels of retinol or retinal. As for the risks of too much RA, the prescription drugs tretinoin (all-trans-retinoic acid) and isotretinoin (13-cis-retinoic acid), used orally or topically for acne treatment, come with warnings to not be used by pregnant women or women who are anticipating becoming pregnant, as they are known human teratogens.

Immune functions
Vitamin A deficiency (VAD) has been linked to compromised resistance to infectious diseases. In countries where early childhood VAD is common, vitamin A supplementation public health programs initiated in the 1980s were shown to reduce the incidence of diarrhea and measles, and all-cause mortality. VAD also increases the risk of immune system over-reaction, leading to chronic inflammation in the intestinal system, stronger allergic reactions and autoimmune diseases.

Lymphocytes and monocytes are types of white blood cells of the immune system. Lymphocytes include natural killer cells, which function in innate immunity, T cells for adaptive cellular immunity and B cells for antibody-driven adaptive humoral immunity. Monocytes differentiate into macrophages and dendritic cells. Some lymphocytes migrate to the thymus where they differentiate into several types of T cells, in some instances referred to as "killer" or "helper" T cells and further differentiate after leaving the thymus. Each subtype has functions driven by the types of cytokines secreted and organs to which the cells preferentially migrate, also described as trafficking or homing.

Reviews based on in vitro and animal research describe the role that retinoic acid (RA) has in the immune system. RA triggers receptors in bone marrow, resulting in generation of new white blood cells. RA regulates proliferation and differentiation of white blood cells, the directed movement of T cells to the intestinal system, and to the up- and down-regulation of lymphocyte function. If RA is adequate, T helper cell subtype Th1 is suppressed and subtypes Th2, Th17 and iTreg (for regulatory) are induced. Dendritic cells located in intestinal tissue have enzymes that convert retinal to all-trans-retinoic acid, to be taken up by retinoic acid receptors on lymphocytes. The process triggers gene expression that leads to T cell types Th2, Th17 and iTreg moving to and taking up residence in mesenteric lymph nodes and Peyer's patches, respectively outside and on the inner wall of the small intestine. The net effect is a down-regulation of immune activity, seen as tolerance of food allergens, and tolerance of resident bacteria and other organisms in the microbiome of the large intestine. In a vitamin A deficient state, innate immunity is compromised and pro-inflammatory Th1 cells predominate.

Skin
Deficiencies in vitamin A have been linked to an increased susceptibility to skin infection and inflammation. Vitamin A appears to modulate the innate immune response and maintains homeostasis of epithelial tissues and mucosa through its metabolite, retinoic acid (RA). As part of the innate immune system, toll-like receptors in skin cells respond to pathogens and cell damage by inducing a pro-inflammatory immune response which includes increased RA production. The epithelium of the skin encounters bacteria, fungi and viruses. Keratinocytes of the epidermal layer of the skin produce and secrete antimicrobial peptides (AMPs). Production of AMPs resistin and cathelicidin, are promoted by RA.

Units of measurement
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. The situation can be confusing because the accepted equivalences have changed over time.

For many years, a system of equivalencies in which an international unit (IU) was equal to 0.3 μg of retinol (~1 nmol), 0.6 μg of β-carotene, or 1.2 μg of other provitamin-A carotenoids was used. This relationship was alternatively expressed by the retinol equivalent (RE): one RE corresponded to 1 μg retinol, to 2 μg β-carotene dissolved in oil, to 6 μg β-carotene in foods, and to 12 μg of either α-carotene, γ-carotene, or β-cryptoxanthin in food.

Newer research has shown that the absorption of provitamin-A carotenoids is only half as much as previously thought. As a result, in 2001 the US Institute of Medicine recommended a new unit, the retinol activity equivalent (RAE). Each 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.

Animal models have shown that at the enterocyte cell wall, β-carotene is taken up by the membrane transporter protein scavenger receptor class B, type 1 (SCARB1). Absorbed β-carotene is converted to retinal and then retinol. The first step of the conversion process consists of one molecule of β-carotene cleaved by the enzyme β-carotene-15, 15'-monooxygenase, which in humans and other mammalian species is encoded by the BCM01 gene, into two molecules of retinal. When plasma retinol is in the normal range, gene expression for SCARB1 and BC01 are suppressed, creating a feedback loop that suppresses β-carotene absorption and conversion. Absorption suppression is not complete, as receptor 36 is not downregulated.

Dietary recommendations
The US National Academy of Medicine updated Dietary Reference Intakes (DRIs) in 2001 for vitamin A, which included Recommended Dietary Allowances (RDAs). For infants up to 12 months there was not sufficient information to establish a RDA, so Adequate Intake (AI) is shown instead. As for safety, tolerable upper intake levels (ULs) were also established. For ULs, carotenoids are not added when calculating total vitamin A intake for safety assessments.

The European Food Safety Authority (EFSA) refers to the collective set of information as Dietary Reference Values, with Population Reference Intake (PRI) instead of RDA, and Average Requirement instead of EAR. AI and UL defined the same as in United States. For women and men of ages 15 and older, the PRIs are set respectively at 650 and 750 μg RE/day. PRI for pregnancy is 700 μg RE/day, for lactation 1300/day. For children of ages 1–14 years, the PRIs increase with age from 250 to 600 μg RE/day. These PRIs are similar to the US RDAs. The EFSA reviewed the same safety question as the United States, and set ULs at 800 for ages 1–3, 1100 for ages 4–6, 1500 for ages 7–10, 2000 for ages 11–14, 2600 for ages 15–17 and 3000 μg/day for ages 18 and older for preformed vitamin A, i.e., not including dietary contributions from carotenoids.

Safety
Vitamin A toxicity (hypervitaminosis A) occurs when too much vitamin A accumulates in the body. It comes from consumption of preformed vitamin A but not of carotenoids, as conversion of the latter to retinol is suppressed by the presence of adequate retinol.

Retinol safety
There are historical reports of acute hypervitaminosis from Arctic explorers consuming bearded seal or polar bear liver, both very rich sources of stored retinol, and there are also case reports of acute hypervitaminosis from consuming fish liver, but otherwise there is no risk from consuming too much via commonly consumed foods. Only consumption of retinol-containing dietary supplements can result in acute or chronic toxicity. Acute toxicity occurs after a single or short-term doses of greater than 150,000 μg. Symptoms include blurred vision, nausea, vomiting, dizziness and headache within 8 to 24 hours. For infants ages 0–6 months given an oral dose to prevent development of vitamin A deficiency, bulging skull fontanel was evident after 24 hours, usually resolved by 72 hours. Chronic toxicity may occur with long-term consumption of vitamin A at doses of 25,000–33,000 IU/day for several months. Excessive consumption of alcohol can lead to chronic toxicity at lower intakes. Symptoms may include nervous system effects, liver abnormalities, fatigue, muscle weakness, bone and skin changes and others. The adverse effects of both acute and chronic toxicity are reversed after consumption is stopped.

In 2001, for the purpose of determining ULs for adults, the US Institute of Medicine considered three primary adverse effects and settled on two: teratogenicity, i.e., causing birth defects, and liver abnormalities. Reduced bone mineral density was considered, but dismissed because the human evidence was contradictory. During pregnancy, especially during the first trimester, consumption of retinol in amounts exceeding 4,500 μg/day increased the risk of birth defects, but not below that amount, thus setting a "No-Observed Adverse-Effect Level" (NOAEL). Given the quality of the clinical trial evidence, the NOAEL was divided by an uncertainty factor of 1.5 to set the UL for women of reproductive age at 3,000 μg/day of preformed vitamin A. For all other adults, liver abnormalities were detected at intakes above 14,000 μg/day. Given the weak quality of the clinical evidence, an uncertainty factor of 5 was used, and with rounding, the UL was set at 3,000 μg/day. Despite a US UL set at 3,000 μg, it is possible to buy over-the-counter dietary supplement products which are 7,500 μg (25,000 IU), with a label caution statement "Not intended for long term use unless under medical supervision."

For children, ULs were extrapolated from the adult value, adjusted for relative body weight. For infants, several case studies reported adverse effects that include bulging fontanels, increased intracranial pressure, loss of appetite, hyperirritability and skin peeling after chronic ingestion of the order of 6,000 or more μg/day. Given the small database, an uncertainty factor of 10 divided into the "Lowest-Observed-Adverse-Effect Level" (LOAEL) led to a UL of 600 μg/day.

β-carotene safety
No adverse effects other than carotenemia have been reported for consumption of β-carotene rich foods. Supplementation with β-carotene does not cause hypervitaminosis A. Two large clinical trials (ATBC and CARET) were conducted in tobacco smokers to see if years of β-carotene supplementation at 20 or 30 mg/day in oil-filled capsules would reduce the risk of lung cancer. These trials were implemented because observational studies had reported a lower incidence of lung cancer in tobacco smokers who had diets higher in β-carotene. Unexpectedly, this high-dose β-carotene supplementation resulted in a higher incidence of lung cancer and of total mortality. Taking this and other evidence into consideration, the U.S. Institute of Medicine decided not to set a Tolerable Upper Intake Level (UL) for β-carotene. The European Food Safety Authority, acting for the European Union, also decided not to set a UL for β-carotene.

Carotenosis
Carotenoderma, also referred to as carotenemia, is a benign and reversible medical condition where an excess of dietary carotenoids results in orange discoloration of the outermost skin layer. It is associated with a high blood β-carotene value. This can occur after a month or two of consumption of beta-carotene rich foods, such as carrots, carrot juice, tangerine juice, mangos, or in Africa, red palm oil. β-carotene dietary supplements can have the same effect. The discoloration extends to palms and soles of feet, but not to the white of the eye, which helps distinguish the condition from jaundice. Consumption of greater than 30 mg/day for a prolonged period has been confirmed as leading to carotenemia.

U.S. labeling
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 A labeling purposes 100% of the Daily Value was set at 5,000 IU, but it was revised to 900 μg RAE on 27 May 2016. A table of the old and new adult daily values is provided at Reference Daily Intake.

Fortification
Some countries require or recommend fortification of foods. As of January 2022, 37 countries, mostly in Sub-Saharan Africa, require food fortification of cooking oil, rice, wheat flour or maize (corn) flour with vitamin A, usually as retinyl palmitate or retinyl acetate. Examples include Pakistan, oil, 11.7 mg/kg and Nigeria, oil, 6 mg/kg; wheat and maize flour, 2 mg/kg. An additional 12 countries, mostly in southeast Asia, have a voluntary fortification program. For example, the government of India recommends 7.95 mg/kg in oil and 0.626 mg/kg for wheat flour and rice. However, compliance in countries with voluntary fortification is lower than countries with mandatory fortification. No countries in Europe or North America fortify foods with vitamin A.

Separated from fortification via addition of synthetic vitamin A to foods, means of fortifying foods via genetic engineering have been explored. Research on rice began in 1982. The first field trials of golden rice cultivars were conducted in 2004. The result was "Golden Rice", a variety of Oryza sativa rice produced through genetic engineering to biosynthesize beta-carotene, a precursor of retinol, in the edible parts of rice. In May 2018, regulatory agencies in the United States, Canada, Australia and New Zealand had concluded that Golden Rice met food safety standards. On 21 July 2021, the Philippines became the first country to officially issue the biosafety permit for commercially propagating Golden Rice. However, in April 2023, the Supreme Court of the Philippines issued a Writ of Kalikasan ordering the Department of Agriculture to stop the commercial distribution of genetically modified rice in the country.

Vitamin A supplementation (VAS)

Delivery of oral high-dose supplements remains the principal strategy for minimizing deficiency. As of 2017, more than 80 countries worldwide are implementing universal VAS programs targeted to children 6–59 months of age through semi-annual national campaigns. Doses in these programs are one dose of 50,000 or 100,000 IU for children aged 6 to 11 months and 100,000 to 200,000 IU for children aged 12 months to five years, every four to six months.

Primary causes
Vitamin A deficiency is common in developing countries, especially in Sub-Saharan Africa and Southeast Asia. Deficiency can occur at any age, but is most common in pre-school-age children and pregnant women, the latter due to a need to transfer retinol to the fetus. The causes are low intake of retinol-containing, animal-sourced foods and low intake of carotene-containing, plant-sourced foods. Vitamin A deficiency is estimated to affect approximately one third of children under the age of five around the world, possibly leading to the deaths of 670,000 children under five annually.

Between 250,000 and 500,000 children in developing countries become blind each year owing to vitamin A deficiency. Vitamin A deficiency is "the leading cause of preventable childhood blindness", according to UNICEF. It also increases the risk of death from common childhood conditions, such as diarrhea. UNICEF regards addressing vitamin A deficiency as critical to reducing child mortality, the fourth of the United Nations' Millennium Development Goals.

During diagnosis, night blindness and dry eyes are signs of vitamin A deficiency that can be recognized without requiring biochemical tests. Plasma retinol is used to confirm vitamin A status. A plasma concentration of about 2.0 μmol/L is normal; less than 0.70 μmol/L (equivalent to 20 μg/dL) indicates moderate vitamin A deficiency, and less than 0.35 μmol/L (10 μg/dL) indicates severe vitamin A deficiency. Breast milk retinol of less than 8 μg/gram milk fat is considered insufficient. One weakness of these measures is that they are not good indicators of liver vitamin A stores as retinyl esters in hepatic stellate cells. The amount of vitamin A leaving the liver, bound to retinol binding protein (RBP), is under tight control as long as there are sufficient liver reserves. Only when liver content of vitamin A drops below approximately 20 μg/gram will concentration in the blood decline.

Secondary causes
There are causes for deficiency other than low dietary intake of vitamin A as retinol or carotenes. Adequate dietary protein and caloric energy are needed for a normal rate of synthesis of RBP, without which, retinol cannot be mobilized to leave the liver. Systemic infections can cause transient decreases in RBP synthesis even if protein-calorie malnutrition is absent. Chronic alcohol consumption reduces liver vitamin A storage. Non-alcoholic fatty liver disease (NAFLD), characterized by the accumulation of fat in the liver, is the hepatic manifestation of metabolic syndrome. Liver damage from NAFLD reduces liver storage capacity for retinol and reduces the ability to mobilize liver stores to maintain normal circulating concentration. Vitamin A appears is involved in the pathogenesis of anemia by diverse biological mechanisms, such as the enhancement of growth and differentiation of erythrocyte progenitor cells, potentiation of immunity to infection, and mobilization of iron stores from tissues.

Animal requirements
All vertebrate and chordate species require vitamin A, either as dietary carotenoids or preformed retinol from consuming other animals. Deficiencies have been reported in laboratory-raised and pet dogs, cats, birds, reptiles and amphibians, also commercially raised chickens and turkeys. Herbivore species such as horses, cattle and sheep can get sufficient β-carotene from green pasture to be healthy, but the content in pasture grass dry due to drought and long-stored hay can be too low, leading to vitamin A deficiency. Omnivore and carnivore species, especially those toward the top of the food chain, can accrue large amounts of retinyl esters in their livers, or else excrete retinyl esters in urine as a means of dealing with surplus. Before the era of synthetic retinol, cod liver oil, high in vitamins A and D, was a commonly consumed dietary supplement. Invertebrates cannot synthesize carotenoids or retinol, and thus must accrue these essential nutrients from consumption of algae, plants or animals.

Medical uses
In 2021, vitamin A was the 298th most commonly prescribed medication in the United States, with more than 500,000 prescriptions.

Preventing and treating deficiency
Recognition of its prevalence and consequences has led to governments and non-government organizations promoting vitamin A fortification of foods and creating programs that administer large bolus-size oral doses of vitamin A to young children every four to six months. In 2008, the World Health Organization estimated that vitamin A supplementation over a decade in 40 countries averted 1.25 million deaths due to vitamin A deficiency. A Cochrane review reported that vitamin A supplementation is associated with a clinically meaningful reduction in morbidity and mortality in children ages six month to five years of age. All-cause mortality was reduced by 14%, and incidences of diarrhea by 12%. However, a Cochrane review by the same group concluded there was insufficient evidence to recommend blanket vitamin A supplementation for infants one to six months of age, as it did not reduce infant mortality or morbidity.

Oral retinoic acid
Orally consumed retinoic acid (RA), as all-trans-tretinoin or 13-cis-isotretinoin has been shown to improve facial skin health by switching on genes and differentiating keratinocytes (immature skin cells) into mature epidermal cells. RA reduces the size and secretion of the sebaceous glands, and by doing so reduces bacterial numbers in both the ducts and skin surface. It reduces inflammation via inhibition of chemotactic responses of monocytes and neutrophils. In the US, isotretinoin was released to the market in 1982 as a revolutionary treatment for severe and refractory acne vulgaris. It was shown that a dose of 0.5‑1.0 mg/kg body weight/day is enough to produce a reduction in sebum excretion by 90% within a month or two, but the recommended treatment duration is 4 to 6 months. Isotretinoin is a known teratogen, with an estimated 20‑35% risk of physical birth defects to infants that are exposed to isotretinoin in utero, including numerous congenital defects such as craniofacial defects, cardiovascular and neurological malformations or thymic disorders. Neurocognitive impairments in the absence of any physical defects has been established to be 30‑60%. For these reasons, physician- and patient-education programs were initiated, recommending that for women of child-bearing age, contraception be initiated a month before starting oral (or topical) isotretinoin, and continue for a month after treatment ended.

In addition to the approved use for treating acne vulgaris, researchers have investigated off-label applications for dermatological conditions, such as rosacea, psoriasis, and other conditions. Rosacea was reported as responding favorably to doses lower than used for acne. Isotretinoin in combination with ultraviolet light was shown affective for treating psoriasis. Isotretinoin in combination with injected interferon-alpha showed some potential for treating genital warts. Isotretinoin in combination with topical fluorouracil or injected interferon-alpha showed some potential for treating precancerous skin lesions and skin cancer.

Topical retinoic acid and retinol

Retinoic acids tretinoin (all-trans-retinoic acid) and isotretinoin (13-cis-retinoic acid) are prescription topical medications used to treat moderate to severe cystic acne and acne not responsive to other treatments. These are usually applied as a skin cream to the face after cleansing to remove make-up and skin oils. Tretinoin and isotretinoin act by binding to two nuclear receptor families within keratinocytes: the retinoic acid receptors (RAR) and the retinoid X receptors (RXR). These events contribute to the normalization of follicular keratinization and decreased cohesiveness of keratinocytes, resulting in reduced follicular occlusion and microcomedone formation. The retinoid-receptor complex competes for coactivator proteins of AP-1, a key transcription factor involved in inflammation. Retinoic acid products also reduce sebum secretion, a nutrient source for bacteria, from facial pores.

These drugs are US-designated Pregnancy Category C (animal reproduction studies have shown an adverse effect on the fetus), and should not be used by pregnant women or women who are anticipating becoming pregnant. Many countries established a physician- and patient- education pregnancy prevention policy.

Trifarotene is a prescription retinoid for the topical treatment acne vulgaris. It functions as a retinoic acid receptor (RAR)-γ agonist.

Non-prescription topical products that have health claims for reducing facial acne, combating skin dark spots and reducing wrinkles and lines associated with aging often contain retinyl palmitate. The hypothesis is that this is absorbed and de-esterified to free retinol, then converted to retinaldehyde and further metabolized to all-trans-retinoic acid, whence it will have the same effects as prescription products with fewer side effects. There is some ex vivo evidence with human skin that esterified retinol is absorbed and then converted to retinol. In addition to esterified retinol, some of these products contain hydroxypinacolone retinoate, identified as esterified 9-cis-retinoic acid.

Biosynthesis
Carotenoid synthesis takes place in plants, certain fungi, and bacteria. Structurally carotenes are tetraterpenes, meaning that they are synthesized biochemically from four 10-carbon terpene units, which in turn were formed from eight 5-carbon isoprene units. Intermediate steps are the creation of a 40-carbon phytoene molecule, conversion to lycopene via desaturation, and then creation of ionone rings at both ends of the molecule. β-carotene has a β-ionone ring at both ends, meaning that the molecule can be divided symmetrically to yield two retinol molecules. α-Carotene has a β-ionone ring at one end and an Ɛ-ionone ring at the other, so it has half the retinol conversion capacity.

In most animal species, retinol is synthesized from the breakdown of the plant-formed provitamin, β-carotene. First, the enzyme beta-carotene 15,15'-dioxygenase (BCO-1) cleaves β-carotene at the central double bond, creating an epoxide. This epoxide is then attacked by water creating two hydroxyl groups in the center of the structure. The cleavage occurs when these alcohols are oxidized to the aldehydes using NAD+. The resultant retinal is then quickly reduced to retinol by the enzyme retinol dehydrogenase. Omnivore species such as dogs, wolves, coyotes and foxes in general are low producers of BCO-1. The enzyme is lacking in felids (cats), meaning that vitamin A requirements are met from the retinyl ester content of prey animals.

Industrial synthesis
β-carotene can be extracted from fungus Blakeslea trispora, marine algae Dunaliella salina or genetically modified yeast Saccharomyces cerevisiae, starting with xylose as a substrate. Chemical synthesis uses either a method developed by BASF or a Grignard reaction utilized by Hoffman-La Roche.

The world market for synthetic retinol is primarily for animal feed, leaving approximately 13% for a combination of food, prescription medication and dietary supplement use. Industrial methods for the production of retinol rely on chemical synthesis. The first industrialized synthesis of retinol was achieved by the company Hoffmann-La Roche in 1947. In the following decades, eight other companies developed their own processes. β-ionone, synthesized from acetone, is the essential starting point for all industrial syntheses. Each process involves elongating the unsaturated carbon chain. Pure retinol is extremely sensitive to oxidization and is prepared and transported at low temperatures and oxygen-free atmospheres. When prepared as a dietary supplement or food additive, retinol is stabilized as the ester derivatives retinyl acetate or retinyl palmitate. Prior to 1999, three companies, Roche, BASF and Rhone-Poulenc controlled 96% of global vitamin A sales. In 2001, the European Commission imposed total fines of 855.22 million euros on these and five other companies for their participation in eight distinct market-sharing and price-fixing cartels that dated back to 1989. Roche sold its vitamin division to DSM in 2003. DSM and BASF have the major share of industrial production. A biosynthesis alternative utilizes genetically engineered yeast species Saccharomyces cerevisiae to synthesize retinal and retinol, using xylose as a starting substrate. This was accomplished by having the yeast first synthesize β-carotene and then the cleaving enzyme β-carotene 15,15'-dioxygenase to yield retinal.

Brain
Animal research (on mice), which is pre-clinical, also found Retinoid acid, the bioactive metabolite of vitamin A, to have an effect on brain areas responsible for memory and learning.

Cancer
Meta-analyses of intervention and observational trials for various types of cancer report mixed results. Supplementation with β-carotene did not appear to decrease the risk of cancer overall, nor specific cancers including: pancreatic, colorectal, prostate, breast, melanoma, or skin cancer generally. High-dose β-carotene supplementation unexpectedly resulted in a higher incidence of lung cancer and of total mortality in people who were cigarette smokers.

For dietary retinol, no effects were observed for high dietary intake and breast cancer survival, risk of liver cancer, risk of bladder cancer or risk of colorectal cancer, although the last review did report lower risk for higher beta-carotene consumption. In contrast, an inverse association was reported between retinol intake and relative risk of esophageal cancer, gastric cancer, ovarian cancer, pancreatic cancer, lung cancer, melanoma, and cervical cancer. For lung cancer, an inverse association was also seen for beta-carotene intake, separate from the retinol results. When high dietary intake was compared to low dietary intake, the decreases in relative risk were in the range of 15 to 20%. For gastric cancer, a meta-analysis of prevention trials reported a 29% decrease in relative risk from retinol supplementation at 1500 μg/day.

Fetal alcohol spectrum disorder
Fetal alcohol spectrum disorder (FASD), formerly referred to as fetal alcohol syndrome, presents as craniofacial malformations, neurobehavioral disorders and mental disabilities, all attributed to exposing human embryos to alcohol during fetal development. The risk of FASD depends on the amount consumed, the frequency of consumption, and the points in pregnancy at which the alcohol is consumed. Ethanol is a known teratogen, i.e., causes birth defects. Ethanol is metabolized by alcohol dehydrogenase enzymes into acetaldehyde. The subsequent oxidation of acetaldehyde into acetate is performed by aldehyde dehydrogenase enzymes. Given that retinoic acid (RA) regulates numerous embryonic and differentiation processes, one of the proposed mechanisms for the teratogenic effects of ethanol is a competition for the enzymes required for the biosynthesis of RA from vitamin A. Animal research demonstrates that in the embryo, the competition takes place between acetaldehyde and retinaldehyde for aldehyde dehydrogenase activity. In this model, acetaldehyde inhibits the production of retinoic acid by retinaldehyde dehydrogenase. Ethanol-induced developmental defects can be ameliorated by increasing the levels of retinol, retinaldehyde, or retinaldehyde dehydrogenase. Thus, animal research supports the reduction of retinoic acid activity as an etiological trigger in the induction of FASD.

Malaria
Malaria and vitamin A deficiency are both common among young children in sub-Saharan Africa. Vitamin A supplementation to children in regions where vitamin A deficiency is common has repeatedly been shown to reduce overall mortality rates, especially from measles and diarrhea. For malaria, clinical trial results are mixed, either showing that vitamin A treatment did not reduce the incidence of probable malarial fever, or else did not affect incidence, but did reduce slide-confirmed parasite density and reduced the number of fever episodes. The question was raised as to whether malaria causes vitamin A deficiency, or vitamin A deficiency contributes to the severity of malaria, or both. Researchers proposed several mechanisms by which malaria (and other infections) could contribute to vitamin A deficiency, including a fever-induced reduction in synthesis of retinal-binding protein (RBP) responsible for transporting retinol from liver to plasma and tissues, but reported finding no evidence for a transient depression or restoration of plasma RBP or retinol after a malarial infection was eliminated.

In history
In 1912, Frederick Gowland Hopkins demonstrated that unknown accessory factors found in milk, other than carbohydrates, proteins, and fats were necessary for growth in rats. Hopkins received a Nobel Prize for this discovery in 1929. By 1913, one of these substances was independently discovered by Elmer McCollum and Marguerite Davis at the University of Wisconsin–Madison, and Lafayette Mendel and Thomas Burr Osborne at Yale University. McCollum and Davis ultimately received credit because they submitted their paper three weeks before Mendel and Osborne. Both papers appeared in the same issue of the Journal of Biological Chemistry in 1913. The "accessory factors" were termed "fat soluble" in 1918, and later "vitamin A" in 1920. In 1919, Harry Steenbock (University of Wisconsin–Madison) proposed a relationship between yellow plant pigments (beta-carotene) and vitamin A. In 1931, Swiss chemist Paul Karrer described the chemical structure of vitamin A. Retinoic acid and retinol were first synthesized in 1946 and 1947 by two Dutch chemists, David Adriaan van Dorp and Jozef Ferdinand Arens.

During World War II, German bombers would attack at night to evade British defenses. In order to keep the 1939 invention of a new on-board Airborne Intercept Radar system secret from Germany, the British Ministry of Information told newspapers an unproven claim that the nighttime defensive success of Royal Air Force pilots was due to a high dietary intake of carrots rich in beta-carotene, successfully convincing many people.

In 1967, George Wald shared the Nobel Prize in Physiology and Medicine for his work on chemical visual processes in the eye. Wald had demonstrated in 1935 that photoreceptor cells in the eye contain rhodopsin, a chromophore composed of the protein opsin and 11-cis-retinal. When struck by light, 11-cis-retinal undergoes photoisomerization to all-trans-retinal and via signal transduction cascade send a nerve signal to the brain. The all-trans-retinal is reduced to all-trans-retinol and travels back to the retinal pigment epithelium to be recycled to 11-cis-retinal and reconjugated to opsin. Wald's work was the culmination of nearly 60 years of research. In 1877, Franz Christian Boll identified a light-sensitive pigment in the outer segments of rod cells of the retina that faded/bleached when exposed to light, but was restored after light exposure ceased. He suggested that this substance, by a photochemical process, conveyed the impression of light to the brain. The research was taken up by Wilhelm Kühne, who named the pigment rhodopsin, also known as "visual purple." Kühne confirmed that rhodopsin is extremely sensitive to light, and thus enables vision in low-light conditions, and that it was this chemical decomposition that stimulated nerve impulses to the brain. Research stalled until after identification of "fat-soluble vitamin A" as a dietary substance found in milkfat but not lard, would reverse night blindness and xerophthalmia. In 1925, Fridericia and Holm demonstrated that vitamin A deficient rats were unable to regenerate rhodopsin after being moved from a light to a dark room.

title: Vitamin A


text:
Retinol

Retinol, also called vitamin A1, is a fat-soluble vitamin in the vitamin A family that is found in food and used as a dietary supplement. Retinol or other forms of vitamin A are needed for vision, cellular development, maintenance of skin and mucous membranes, immune function and reproductive development. Dietary sources include fish, dairy products, and meat. As a supplement it is used to treat and prevent vitamin A deficiency, especially that which results in xerophthalmia. It is taken by mouth or by injection into a muscle. As an ingredient in skin-care products, it is used to reduce wrinkles and other effects of skin aging.

Retinol at normal doses is well tolerated. High doses may cause enlargement of the liver, dry skin, and hypervitaminosis A. High doses during pregnancy may harm the fetus. The body converts retinol to retinal and retinoic acid, through which it acts.

Retinol was discovered in 1909, isolated in 1931, and first made in 1947. It is on the World Health Organization's List of Essential Medicines. Retinol is available as a generic medication and over the counter. In 2021, vitamin A was the 298th most commonly prescribed medication in the United States, with more than 500,000 prescriptions.

Medical uses
Retinol is used to treat vitamin A deficiency.

Three approaches may be used when populations have low vitamin A levels:

 * 1) Through dietary modification involving the adjustment of menu choices of affected persons from available food sources to optimize vitamin A content.
 * 2) Enriching commonly eaten and affordable foods with vitamin A, a process called fortification. It involves addition of synthetic vitamin A to staple foods like margarine, bread, flours, cereals, and infant formula during processing.
 * 3) By giving high-doses of vitamin A to the targeted deficient population, a method known as supplementation. In regions where deficiency is common, a single large dose is recommended to those at high risk twice a year.

Retinol is also used to reduce the risk of complications in measles patients.

Side effects
The Recommended Daily Intake (RDA) for preformed supplemental Vitamin A for adult men and women is 900 and 700 Retinol Activity Units(RAE)/day, respectively, or about 3,000 IU and 2,300 IU. For pregnant people, the Vitamin A RDA is 750-770 RAE/day (about 2,500-2,550 IU). During lactation, the RDA increases to 1,200-1,300 RAE/day (about 4,000-4,300 IU).

Retinol Activity Units can only be converted to IU (International Units) when the source of the Vitamin A is known. The IU values listed above do not apply to food sources of Vitamin A.

Too much vitamin A in retinoid form can be harmful. The body converts the dimerized form, carotene, into vitamin A as it is needed, so high levels of carotene are not toxic, whereas the ester (animal) forms are. The livers of certain animals, especially those adapted to polar environments, such as polar bears and seals, often contain amounts of vitamin A that would be toxic to humans. Thus, vitamin A toxicity is typically reported in Arctic explorers and people taking large doses of synthetic vitamin A. The first documented death possibly caused by vitamin A poisoning was that of Xavier Mertz, a Swiss scientist, who died in January 1913 on an Antarctic expedition that had lost its food supplies and fell to eating its sled dogs. Mertz may have consumed lethal amounts of vitamin A by eating the dogs' livers.

Vitamin A acute toxicity occurs when a person ingests vitamin A in large amounts more than the daily recommended value in the threshold of 25,000 IU/kg or more. Often, the patient consumes about 3–4 times the RDA's specification. Toxicity of vitamin A is believed to be associated with the methods of increasing vitamin A in the body, such as food modification, fortification, and supplementation, all of which are used to combat vitamin A deficiency. Toxicity is classified into two categories: acute and chronic. The former occurs a few hours or days after ingestion of a large amount of vitamin A. Chronic toxicity takes place when about 4,000 IU/kg or more of vitamin A is consumed for a long time. Symptoms of both include nausea, blurred vision, fatigue, weight-loss, and menstrual abnormalities.

Excess vitamin A is suspected to be a contributor to osteoporosis. This seems to happen at much lower doses than those required to induce acute intoxication. Only preformed vitamin A can cause these problems, because the conversion of carotenoids into vitamin A is downregulated when physiological requirements are met; but excessive uptake of carotenoids can cause carotenosis.

Excess preformed vitamin A during early pregnancy is associated with a significant increase in birth defects. These defects may be severe, even life-threatening. Even twice the daily recommended amount can cause severe birth defects. The FDA recommends that pregnant women get their vitamin A from foods containing beta carotene and that they ensure that they consume no more than 5,000 IU of preformed vitamin A (if any) per day. Although vitamin A is necessary for fetal development, most women carry stores of vitamin A in their fat cells, so over-supplementation should be strictly avoided.

A review of all randomized controlled trials in the scientific literature by the Cochrane Collaboration published in JAMA in 2007 found that supplementation with beta carotene or vitamin A increased mortality by 5% and 16%, respectively.

Studies emerging from developing countries India, Bangladesh, and Indonesia strongly suggest that, in populations in which vitamin A deficiency is common and maternal mortality is high, dosing expectant mothers can greatly reduce maternal mortality. Similarly, dosing newborn infants with 50,000 IU (15 mg) of vitamin A within two days of birth can significantly reduce neonatal mortality.

Biological roles
Retinol or other forms of vitamin A are needed for eyesight, maintenance of the skin, and human development. Other than for vision, the active compound is all-trans-retinoic acid, synthesized from retinal, in turn synthesized from retinol.

Embryology
Retinoic acid via the retinoic acid receptor influences the process of cell differentiation, hence, the growth and development of embryos. During development, there is a concentration gradient of retinoic acid along the anterior-posterior (head-tail) axis. Cells in the embryo respond to retinoic acid differently depending on the amount present. For example, in vertebrates, the hindbrain transiently forms eight rhombomeres and each rhombomere has a specific pattern of genes being expressed. If retinoic acid is not present the last four rhombomeres do not develop. Instead, rhombomeres 1–4 grow to cover the same amount of space as all eight would normally occupy. Retinoic acid has its effects by turning on a differential pattern of Homeobox (Hox) genes that encode different homeodomain transcription factors which in turn can turn on cell type specific genes. Deletion of the Homeobox (Hox-1) gene from rhombomere 4 makes the neurons growing in that region behave like neurons from rhombomere 2. Retinoic acid is not required for patterning of the retina as originally proposed, but retinoic acid synthesized in the retina is secreted into surrounding mesenchyme where it is required to prevent overgrowth of perioptic mesenchyme which can cause microphthalmia, defects in the cornea and eyelid, and rotation of the optic cup.

Stem cell biology
Retinoic acid is an influential factor used in differentiation of stem cells to more committed fates, echoing retinoic acid's importance in natural embryonic developmental pathways. It is thought to initiate differentiation into a number of different cell lineages by unsequestering certain sequences in the genome.

It has numerous applications in the experimental induction of stem cell differentiation; amongst these are the differentiation of human embryonic stem cells to posterior foregut lineages and also to functional motor neurons.

Vision
Retinol is an essential compound in the cycle of light-activated chemical reactions called the "visual cycle" that underlies vertebrate vision. Retinol is converted by the protein RPE65 within the pigment epithelium of the retina into 11-cis-retinal. This molecule is then transported into the retina's photoreceptor cells (the rod or cone cells in mammals) where it binds to an opsin protein and acts as a light-activated molecular switch. When 11-cis-retinal absorbs light it isomerizes into all-trans-retinal. The change in the shape of the molecule in turn changes the configuration of the opsin in a cascade that leads to the neuronal firing, which signals the detection of light. The opsin then splits into the protein component (such metarhodopsin) and the cofactor all-trans-retinal. The regeneration of active opsin requires conversion of all-trans-retinal back to 11-cis-retinal via retinol. The regeneration of 11-cis-retinal occurs in vertebrates via conversion of all-trans-retinol to 11-cis-retinol in a sequence of chemical transformations that occurs primarily in the pigment epithelial cells.

Without adequate amounts of retinol, regeneration of rhodopsin is incomplete and night blindness occurs. Night blindness, the inability to see well in dim light, is associated with a deficiency of vitamin A, a class of compounds that includes retinol and retinal. In the early stages of vitamin A deficiency, the more light-sensitive and abundant rods, which have rhodopsin, have impaired sensitivity, and the cone cells are less affected. The cones are less abundant than rods and come in three types, each contains its own type of iodopsin, the opsins of the cones. The cones mediate color vision, and vision in bright light (day vision).

Glycoprotein synthesis
Glycoprotein synthesis requires adequate vitamin A status. In severe vitamin A deficiency, lack of glycoproteins may lead to corneal ulcers or liquefaction.

Immune system
Vitamin A is essential to maintain intact epithelial tissues as a physical barrier to infection; it is also involved in maintaining a number of immune cell types from both the innate and acquired immune systems. These include the lymphocytes (B-cells, T-cells, and natural killer cells), as well as many myelocytes (neutrophils, macrophages, and myeloid dendritic cells).

Skin
Deficiencies in vitamin A have been linked to an increased susceptibility to skin infection and inflammation. Vitamin A appears to modulate the innate immune response and maintains homeostasis of epithelial tissues and mucosa through its metabolite, retinoic acid (RA). As part of the innate immune system, toll-like receptors in skin cells respond to pathogens and cell damage by inducing a pro-inflammatory immune response which includes increased RA production. The epithelium of the skin encounters bacteria, fungi and viruses. Keratinocytes of the epidermal layer of the skin produce and secrete antimicrobial peptides (AMPs). Production of AMPs resistin and cathelicidin, are promoted by RA. Another way that vitamin A helps maintain a healthy skin and hair follicle microbiome, especially on the face, is by reduction of sebum secretion, which is a nutrient source for bacteria. Retinol has been the subject of clinical studies related to its ability to reduce the appearance of fine lines on the face and neck.

Red blood cells
Vitamin A may be needed for normal red blood cell formation; deficiency causes abnormalities in iron metabolism. Vitamin A is needed to produce the red blood cells from stem cells through retinoid differentiation.

Units of measurement
When referring to dietary allowances or nutritional science, retinol is usually measured in international units (IU). IU refers to biological activity and therefore is unique to each individual compound, however 1 IU of retinol is equivalent to approximately 0.3 micrograms (300 nanograms).

Nutrition
This vitamin plays an essential role in vision, particularly night vision, normal bone and tooth development, reproduction, and the health of skin and mucous membranes (the mucus-secreting layer that lines body regions such as the respiratory tract). Vitamin A also acts in the body as an antioxidant, a protective chemical that may reduce the risk of certain cancers.

There are two sources of dietary vitamin A. Active forms, which are immediately available to the body are obtained from animal products. These are known as retinoids and include retinaldehyde and retinol. Precursors, also known as provitamins, which must be converted to active forms by the body, are obtained from fruits and vegetables containing yellow, orange and dark green pigments, known as carotenoids, the most well-known being β-carotene. For this reason, amounts of vitamin A are measured in Retinol Equivalents (RE). One RE is equivalent to 0.001 mg of retinol, or 0.006 mg of β-carotene, or 3.3 International Units of vitamin A.

In the intestine, vitamin A is protected from being chemically changed by vitamin E. Vitamin A is fat-soluble and can be stored in the body. Most of the vitamin A consumed is stored in the liver. When required by a particular part of the body, the liver releases some vitamin A, which is carried by the blood and delivered to the target cells and tissues.

Dietary intake
The Dietary Reference Intake (DRI) Recommended Daily Amount (RDA) for vitamin A for a 25-year-old male is 900 micrograms/day, or 3000 IU. National Health Service daily recommended values are slightly lower at 700 micrograms for men and 600 micrograms for women.

During the absorption process in the intestines, retinol is incorporated into chylomicrons as the ester form, and it is these particles that mediate transport to the liver. Liver cells store vitamin A as the ester, and when retinol is needed in other tissues, it is de-esterifed and released into the blood as the alcohol. Retinol then attaches to a serum carrier, retinol binding protein, for transport to target tissues. A binding protein inside cells, cellular retinoic acid binding protein, serves to store and move retinoic acid intracellularly.

Deficiency
Vitamin A deficiency is common in developing countries but rarely seen in developed countries. Approximately 250,000 to 500,000 malnourished children in the developing world go blind each year from a deficiency of vitamin A. Vitamin A deficiency in expecting mothers increases the mortality rate of children shortly after childbirth. Night blindness is one of the first signs of vitamin A deficiency. Vitamin A deficiency contributes to blindness by making the cornea very dry and damaging the retina and cornea.

Chemistry
Many different geometric isomers of retinol, retinal and retinoic acid are possible as a result of either a trans or cis configuration of four of the five double bonds found in the polyene chain. The cis isomers are less stable and can readily convert to the all-trans configuration (as seen in the structure of all-trans-retinol shown at the top of this page). Nevertheless, some cis isomers are found naturally and carry out essential functions. For example, the 11-cis-retinal isomer is the chromophore of rhodopsin, the vertebrate photoreceptor molecule. Rhodopsin is composed of the 11-cis-retinal covalently linked via a Schiff base to the opsin protein (either rod opsin or blue, red or green cone opsins). The process of vision relies on the light-induced isomerisation of the chromophore from 11-cis to all-trans resulting in a change of the conformation and activation of the photoreceptor molecule. One of the earliest signs of vitamin A deficiency is night-blindness followed by decreased visual acuity.

Many of the non-visual functions of vitamin A are mediated by retinoic acid, which regulates gene expression by activating nuclear retinoic acid receptors. The non-visual functions of vitamin A are essential in the immunological function, reproduction and embryonic development of vertebrates as evidenced by the impaired growth, susceptibility to infection and birth defects observed in populations receiving suboptimal vitamin A in their diet.

Biosynthesis
Retinol is synthesized from the breakdown of β-carotene. First, the β-carotene 15,15'-monooxygenase cleaves β-carotene at the central double bond, creating an epoxide. This epoxide is then attacked by water creating two hydroxyl groups in the center of the structure. The cleavage occurs when these alcohols are oxidized to the aldehydes using NADH. This compound is called retinal. Retinal is then reduced to retinol by the enzyme retinol dehydrogenase. Retinol dehydrogenase is an enzyme that is dependent on NADH.

Industrial synthesis
Retinol is made industrially via total synthesis using either a method developed by BASF or a Grignard reaction utilized by Hoffman-La Roche. The two major suppliers, DSM and BASF, are believed to use total synthesis.

The world market for synthetic retinol is primarily for animal feed, leaving approximately 13% for a combination of food, prescription medication and dietary supplement use. The first industrialized synthesis of retinol was achieved by the company Hoffmann-La Roche in 1947. In the following decades, eight other companies developed their own processes. β-ionone, synthesized from acetone, is the essential starting point for all industrial syntheses. Each process involves elongating the unsaturated carbon chain. Pure retinol is extremely sensitive to oxidization and is prepared and transported at low temperatures and oxygen-free atmospheres. When prepared as a dietary supplement or food additive, retinol is stabilized as the ester derivatives retinyl acetate or retinyl palmitate. Prior to 1999, three companies, Roche, BASF and Rhone-Poulenc controlled 96% of global vitamin A sales. In 2001, the European Commission imposed total fines of 855.22 Euros on these and five other companies for their participation in eight distinct market-sharing and price-fixing cartels that dated back to 1989. Roche sold its vitamin division to DSM in 2003. DSM and BASF have the major share of industrial production.

History
In 1912, Frederick Gowland Hopkins demonstrated that unknown accessory factors found in milk, other than carbohydrates, proteins, and fats were necessary for growth in rats. Hopkins received a Nobel Prize for this discovery in 1929. One year later, Elmer McCollum, a biochemist at the University of Wisconsin–Madison, and colleague Marguerite Davis identified a fat-soluble nutrient in butterfat and cod liver oil. Their work confirmed that of Thomas Burr Osborne and Lafayette Mendel, at Yale, also in 1913, which suggested a fat-soluble nutrient in butterfat. The "accessory factors" were termed "fat soluble" in 1918 and later "vitamin A" in 1920. In 1931, Swiss chemist Paul Karrer described the chemical structure of vitamin A. Retinoic acid and retinol were first synthesized in 1946 and 1947 by two Dutch chemists, David Adriaan van Dorp and Jozef Ferdinand Arens.

In 1967, George Wald was a co-recipient of the Nobel Prize in Physiology and Medicine "..."for their discoveries concerning the primary physiological and chemical visual processes in the eye." Photoreceptor cells in the eye contain a chromophore composed of the protein opsin and 11-cis retinal. When struck by light, 11-cis retinal undergoes photoisomerization to all-trans retinal and via signal transduction cascade send a nerve signal to the brain. The all-trans retinal is reduced to all-trans retinol and travels back to the retinal pigment epithelium to be recycled to 11-cis retinal and conjugated to opsin.

Although vitamin A was not confirmed as an essential nutrient and a chemical structure described until the 20th century, written observations of conditions created by deficiency of this nutrient appeared much earlier in history. Sommer classified historical accounts related to vitamin A and/or manifestations of deficiency as follows: "ancient" accounts; 18th- to 19th-century clinical descriptions (and their purported etiologic associations); early 20th-century laboratory animal experiments, and clinical and epidemiologic observations that identified the existence of this unique nutrient and manifestations of its deficiency.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Retinol


text:
Fortune-telling

Fortune telling is the unproven spiritual practice of predicting information about a person's life. The scope of fortune telling is in principle identical with the practice of divination. The difference is that divination is the term used for predictions considered part of a religious ritual, invoking deities or spirits, while the term fortune telling implies a less serious or formal setting, even one of popular culture, where belief in occult workings behind the prediction is less prominent than the concept of suggestion, spiritual or practical advisory or affirmation.

Historically, Pliny the Elder describes use of the crystal ball in the 1st century CE by soothsayers ("crystallum orbis", later written in Medieval Latin by scribes as orbuculum). Contemporary Western images of fortune telling grow out of folkloristic reception of Renaissance magic, specifically associated with Romani people. During the 19th and 20th century, methods of divination from non-Western cultures, such as the I Ching, were also adopted as methods of fortune telling in western popular culture.

An example of divination or fortune telling as purely an item of pop culture, with little or no vestiges of belief in the occult, would be the Magic 8-Ball sold as a toy by Mattel, or Paul the Octopus, an octopus at the Sea Life Aquarium at Oberhausen used to predict the outcome of matches played by the Germany national football team. There is opposition to fortune telling in Christianity, Islam, Baháʼísm and Judaism based on scriptural prohibitions against divination. Terms for one who claims to see into the future include fortune teller, crystal-gazer, spaewife, seer, soothsayer, sibyl, clairvoyant, and prophet; related terms which might include this among other abilities are oracle, augur, and visionary. Fortune telling is dismissed by skeptics as being based on pseudoscience, magical thinking and superstition.

Methods
Common methods used for fortune telling in Europe and the Americas include astromancy, horary astrology, pendulum reading, spirit board reading, tasseography (reading tea leaves in a cup), cartomancy (fortune telling with cards), tarot card reading, crystallomancy (reading of a crystal sphere), and chiromancy (palmistry, reading of the palms). The last three have traditional associations in the popular mind with the Roma and Sinti people.

Another form of fortune telling, sometimes called "reading" or "spiritual consultation", does not rely on specific devices or methods, but rather the practitioner gives the client advice and predictions which are said to have come from spirits or in visions:

 * Aeromancy: by interpreting atmospheric conditions.
 * Alectromancy: by observation of a rooster pecking at grain.
 * Aleuromancy: by flour.
 * Astrology: by the movements of celestial bodies.
 * Astromancy: by the stars.
 * Augury: by the flight of birds.
 * Auramancy by someone's aura or feelings
 * Bazi or four pillars: by hour, day, month, and year of birth.
 * Bibliomancy: by books; frequently, but not always, religious texts.
 * Cartomancy: by playing cards, tarot cards, or oracle cards.
 * Ceromancy: by patterns in melting or dripping wax.
 * Chiromancy: by the shape of the hands and lines in the palms.
 * Chronomancy: by determination of lucky and unlucky days.
 * Clairvoyance: by spiritual vision or inner sight.
 * Cleromancy: by casting of lots, or casting bones or stones.
 * Cold reading: by using visual and aural clues.
 * Crystallomancy: by crystal ball also called scrying.
 * Extispicy: by the entrails of animals.
 * Face reading: by means of variations in face and head shape.
 * Feng shui: by earthen harmony.
 * Gastromancy: by stomach-based ventriloquism (historically).
 * Geomancy: by markings in the ground, sand, earth, or soil.
 * Haruspicy: by the livers of sacrificed animals.
 * Horary astrology: the astrology of the time the question was asked.
 * Hydromancy: by water.
 * I Ching divination: by yarrow stalks or coins and the I Ching.
 * Kau cim by means of numbered bamboo sticks shaken from a tube.
 * Lithomancy: by stones or gems.
 * Molybdomancy: by molten metal after dumped in cold water.
 * Naeviology: by moles, scars, or other bodily marks.
 * Necromancy: by the dead, or by spirits or souls of the dead.
 * Nephomancy: by shapes of clouds.
 * Numerology: by numbers.
 * Oneiromancy: by dreams.
 * Onomancy: by names.
 * Onychomancy: by a form of palmistry looking at the fingernails.
 * Palmistry: by lines and mounds on the hand.
 * Parrot astrology: by parakeets picking up fortune cards
 * Paper fortune teller: origami used in fortune-telling games.
 * Pendulum reading: by the movements of a suspended object.
 * Pyromancy: by gazing into fire.
 * Rhabdomancy: divination by rods.
 * Runecasting or Runic divination: by runes.
 * Scrying: by looking at or into reflective objects.
 * Spirit board: by planchette or talking board.
 * Taromancy: by a form of cartomancy using tarot cards.
 * Tasseography or tasseomancy: by tea leaves or coffee grounds.

Sociology
Western fortune tellers typically attempt predictions on matters such as future romantic, financial, and childbearing prospects. Many fortune tellers will also give "character readings". These may use numerology, graphology, palmistry (if the subject is present), and astrology.

In contemporary Western culture, it appears that women consult fortune tellers more than men. Some women have maintained long relationships with their personal readers. Telephone consultations with psychics grew in popularity through the 1990s, and by the 2010s additional contact methods such as email and videoconferencing also became available, but none of these have completely replaced traditional in-person methods of consultation.

As a business in North America
Discussing the role of fortune telling in society, Ronald H. Isaacs, an American rabbi and author, opined, "Since time immemorial humans have longed to learn that which the future holds for them. Thus, in ancient civilization, and even today with fortune telling as a true profession, humankind continues to be curious about its future, both out of sheer curiosity as well as out of desire to better prepare for it." Although 5000 years ago, soothsayers were prized advisers to the Assyrians, they lost respect and reverence during the rise of Reason in the 17th and 18th centuries.

With the rise of commercialism, "the sale of occult practices [adapted to survive] in the larger society," according to sociologists Danny L. and Lin Jorgensen. Ken Feingold, writer of "Interactive Art as Divination as a Vending Machine," stated that with the invention of money, fortune telling became "a private service, a commodity within the marketplace".

As J. Peder Zane wrote in The New York Times in 1994, referring to the Psychic Friends Network, "Whether it's 3 P.M. or 3 A.M., there's Dionne Warwick and her psychic friends selling advice on love, money and success. In a nation where the power of crystals and the likelihood that angels hover nearby prompt more contemplation than ridicule, it may not be surprising that one million people a year call Ms. Warwick's friends."

Clientele
In 1994, the psychic counsellor Rosanna Rogers of Cleveland, Ohio, explained to J. Peder Zane that a wide variety of people consulted her: "Couch potatoes aren't the only people seeking the counsel of psychics and astrologers. Clairvoyants have a booming business advising Philadelphia bankers, Hollywood lawyers and CEO's of Fortune 500 companies... If people knew how many people, especially the very rich and powerful ones, went to psychics, their jaws would drop through the floor." Rogers "claims to have 4,000 names in her rolodex."

Janet Lee, also known as the Greenwich psychic, claims that her clientele often included Wall Street brokers who were looking for any advantage they could get. Her usual fee was around $150 for a session but some clients would pay between $2,000 and $9,000 per month to have her available 24 hours a day to consult.

Typical clients
In 1982, Danny Jorgensen, a professor of Religious Studies at the University of South Florida offered a spiritual explanation for the popularity of fortune telling. He said that people visit psychics or fortune tellers to gain self-understanding, and knowledge which will lead to personal power or success in some aspect of life.

In 1995, Ken Feingold offered a different explanation for why people seek out fortune tellers: "We desire to know other people's actions and to resolve our own conflicts regarding decisions to be made and our participation in social groups and economies. ... Divination seems to have emerged from our knowing the inevitability of death. The idea is clear—we know that our time is limited and that we want things in our lives to happen in accord with our wishes. Realizing that our wishes have little power, we have sought technologies for gaining knowledge of the future... gain power over our own [lives]."Ultimately, the reasons a person consults a diviner or fortune teller depend on cultural and personal expectations.

Services
Traditional fortune tellers vary in methodology, generally using techniques long established in their cultures and thus meeting the cultural expectations of their clientele.

In the United States and Canada, among clients of European ancestry, palmistry is popular and, as with astrology and tarot card reading, advice is generally given about specific problems besetting the client.

Non-religious spiritual guidance may also be offered. An American clairvoyant by the name of Catherine Adams has written, "My philosophy is to teach and practice spiritual freedom, which means you have your own spiritual guidance, which I can help you get in touch with."

In the African American community, where many people practice a form of folk magic called hoodoo or rootworking, a fortune-telling session or "reading" for a client may be followed by practical guidance in spell-casting and Christian prayer, through a process called "magical coaching".

In addition to sharing and explaining their visions, fortune tellers can also act like counselors by discussing and offering advice about their clients' problems. They want their clients to exercise their own willpower.

Full-time careers
Some fortune tellers support themselves entirely on their divination business; others hold down one or more jobs, and their second jobs may or may not relate to the occupation of divining. In 1982, Danny L., and Lin Jorgensen found that "while there is considerable variation among [these secondary] occupations, [part-time fortune tellers] are over-represented in human service fields: counseling, social work, teaching, health care." The same authors, making a limited survey of North American diviners, found that the majority of fortune tellers are married with children, and a few claim graduate degrees. "They attend movies, watch television, work at regular jobs, shop at K-Mart, sometimes eat at McDonald's, and go to the hospital when they are seriously ill."

Legality
In 1982, the sociologists Danny L., and Lin Jorgensen found that, "when it is reasonable, [fortune tellers] comply with local laws and purchase a business license." However, in the United States, a variety of local and state laws restrict fortune telling, require the licensing or bonding of fortune tellers, or make necessary the use of terminology that avoids the term "fortune teller" in favor of terms such as "spiritual advisor" or "psychic consultant." There are also laws that outright forbid the practice in certain districts.

For instance, fortune telling is a class B misdemeanor in the state of New York. Under New York State law, S 165.35: "A person is guilty of fortune telling when, for a fee or compensation which he directly or indirectly solicits or receives, he claims or pretends to tell fortunes, or holds himself out as being able, by claimed or pretended use of occult powers, to answer questions or give advice on personal matters or to exercise, influence or affect evil spirits or curses; except that this section does not apply to a person who engages in the aforedescribed conduct as part of a show or exhibition solely for the purpose of entertainment or amusement."

Lawmakers who wrote this statute acknowledged that fortune tellers do not restrict themselves to "a show or exhibition solely for the purpose of entertainment or amusement" and that people will continue to seek out fortune tellers even though fortune tellers operate in violation of the law. In the states of Minnesota, North Carolina, Oklahoma, Pennsylvania, and Wisconsin, all forms of fortune-telling are illegal.

Similarly, in New Zealand, Section 16 of the Summary Offences Act 1981 provides a one thousand dollar penalty for anyone who sets out to "deceive or pretend" for financial recompense that they possess telepathy or clairvoyance or acts as a medium for money through use of "fraudulent devices." As with the New York legislation cited above, however, it is not a criminal offence if it is solely intended for purposes of entertainment.

In Australia, fortune-telling is illegal in South Australia and the Northern Territory.

In Canada, being paid to fraudulently tell fortune is a criminal offence under the Criminal Code of Canada.

In Nigeria, "pretending to exercise witchcraft or tell fortunes" for gain or reward is punishable by a year's imprisonment.

Saudi Arabia also bans the practice outright, considering fortune telling to be sorcery and thus contrary to Islamic teaching and jurisprudence. It has been punishable by death.

Critical analysis
Fortune telling is easily dismissed by critics as magical thinking and superstition.

Skeptic Bergen Evans suggested that fortune telling is the result of a "naïve selection of something that have happened from a mass of things that haven't, the clever interpretation of ambiguities, or a brazen announcement of the inevitable." Other skeptics claim that fortune telling is nothing more than cold reading.

A large amount of fraud has been proven in the practice of fortune telling.

Fortune telling and how it works raises many critical questions. For example, fortune-telling occurs through various methods such as psychic readings and tarot cards. Similarly, these methods are largely based on random phenomena. For example, astrologers believe that the movement of stars in the sky can have implications on one's life. In the case of tarot cards, people believe that images displayed on the cards have significant meanings on their lives. However, there is a lack of evidence to support why such things, such as the stars, would have any implications on our lives.

Additionally, fortune-telling readings and predictions made by horoscopes, for example, are often general enough to apply to anyone. In cold reading, for example, readers often begin by stating general descriptions and continuing to make specifics based on the reactions they receive from the person whose life they are predicting. The tendency for people to deem general descriptions as being representative to themselves has been termed the Barnum effect and has been studied by psychologists for many years.

Nonetheless, even with a lack of evidence supporting the various methods of fortune-telling and the many frauds that have occurred by psychic readers, amongst others, fortune-telling continues to become popular around the world. There are many reasons for the appealing nature of fortune-telling such as that people often experience stress when there is uncertainty and thus seek to gain deeper insight into their lives.

title: Fortune-telling