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Digestion and absorption of lipids-April 1998; Aug 2008; April 2001; Oct 2003
Digestion and absorption of Triacylglycerol - Aug 2010
Role of bile in the digestion and absorption of lipids. Oct 1999
Explain the metabolism and functions of HDL. Feb 2010
Role of HDL as scavenger of Cholesterol. Aug 2010
Digestion and absorption of Triacylglycerol. Aug 2010
Why Arachidonic acid is not considered purely an essential fatty acid?
What is Steatorrhoea ?
Draw a lebelled diagram of a basic structure of lipoproteins. Pon May 2010
What are the functions of cholesterol? Pon May 2010

Dietary lipids are triacyl glycerol, cholesterol and phospholipids. Indian diet contains 20-30
Digestion and absorption occurs in 6 steps:
a) Mouth and stomach by lipase;
b) Duodenum and intestine by pancreatic lipase;
c) Micelle formation;
d) Passive absorption in to intestinal cells;
e) Re esterification into TAG
f) Assembly into chylomicrons
1. Lingual and stomach phase:
a. The digestion of lipids is initiated in the stomach, catalysed by acid-stable
lipase. This enzyme (also called lingual lipase) is believed to originate from
the glands at the back of tongue.
b. Stomach contains a separate gastric lipase which can degrade fat containing
short chain fatty acids at neutral pH.
c. Lingual lipase acts on short chain triglycerides; Gastric lipase also acts on
triglycerides to convert into monoacylglycerols; it is secreted by chief cells
and stimulated by gastrin.
2. Intestine:
a. Lipids are first emulsified by converting into small droplets with reduced
surface tension and increase in surface area.
b. Role of bile:
i. Bile salts are the biological detergents synthesized from cholesterol in
the liver. They are secreted with bile into the duodenum.
ii. Bile salts possess steroid nucleus, the side chain of which is attached
to either glycine (glycocholic acid) or taurine (taurocholic acid).
iii. Bile salts are the most effective biological emulsifying agents. They
interact with lipid particles and the aqueous duodenal contents and
convert them into smaller particles (emulsified droplets).
iv. Further, bile salts stabilize the smaller particles by preventing them
from coalescing.
c. Surfactants:
i. The initial digestive products of lipids (catalysed by lipase) namely free
fatty acids and monoacylglycerols promote emulsification. These
compounds along with phospholipids are known as surfactants.
ii. Surfactants get absorbed to the water-lipid interfaces and increase the
interfacial area of lipid droplets.

d. Besides the action of bile salts and surfactants, the mechanical mixing due to
peristalsis also helps in the emulsification of lipids.
3. Intestinal Digestion of lipids by pancreatic enzymes:
a. Pancreatic lipase is the major enzyme that digests dietary fats. This enzyme
cleaves fatty acids into 2-monoacylglycerol and free fatty acids.
b. The activity of pancreatic lipase is inhibited by bile acids. This problem is
overcome by a small protein, colipase. lt is also secreted by pancreas as
procolipase and converted to active form by trypsin. Colipase binds at the
lipid-aqueous interface and helps to anchor and stabilize lipase.
c. Lipid esterase is a less specific enzyme present in pancreatic juice. lt acts on
monoacylglycerols, cholesteryl esters, vitamin esters etc. to liberate free fatty
acids. The presence of bile acids is essential for the activity of lipid esterase.
d. Cholesterol esterase (cholesteryl ester hydrolase) cleaves cholesteryl esters to
produce cholesterol and free fatty acids.
e. Phospholipids: Pancreatic juice is rich in phospholipaseA 2 which cleaves the
fatty acid at the 2nd position of phospholipids. The products are a free fatty
acid and a lysophospholipid. Phospholipase A 2 is secreted as a zymogen
which is activated in the intestine by the action of trypsin.
lingual lipase
in stomach:
Triglycerides (SCT,MCT) are digested into
Stomach Gastric lipase
free fatty acids and DAG
Stimulated by

Pancreatic lipase
with co-lipase


Bile emulsify fat for enzymes to act

Pancreatic lipase converts TAG with long
chain fatty acids into free fatty acids and
Co-lipase facilitates triacyl glycerol to be
acted upon by lipase


Cholesterol esterase converts cholesterol

ester into cholesterol and fatty acid
Phospholipase A2 phospholipids into
lyophospholipid and fatty acid

1. Lipolytic theory put forth by Verzar : According to this, fats are completely
hydrolysed to glycerol and free fatty acids. The latter are absorbed either as soaps or
in association with bile salts.
2. Partition theory proposed by Frazer: This theory states that the digestion of
triacylglycerols is partial and not complete. The partially digested triacylglycerols in
association with bile salts, form emulsions. The lipids are taken up by the intestinal
mucosal cells. As per this theory, resynthesis of lipids is not necessary for their entry
into the circulation.
3. Bergstrom theory :
a. This is a more recent and comprehensive theory to explain lipid absorption
The primary products obtained from the lipid digestion are 2monoacylglycerol, free fatty acids and free cholesterol

b. Bile salts are essential for absorption of lipids. Bile salts form mixed micelles
with lipids. These micelles are smaller in size than the lipid emulsion droplets.
The micelles have a disk like shape with lipids (monoacylglycerol, fatty acids,
cholesterol and phospholipids) in the interior and bile salts at the periphery.
The hydrophilic groups of the lipids are oriented to the outside (close to the
aqueous environment) and the hydrophobic groups to the inside. In this
fashion, the bile salt micelles exert a solubilizing effect on the lipids.
c. The mixed micelles serve as the major vehicles for the transport of lipids from
the intestinal lumen to the membrane of the intestinal mucosal cells, the site
of lipid absorption. The lipid components pass through the unstirred fluid layer
and are absorbed through the plasma membrane by diffusion.
d. Absorption is almost complete for monoacylglycerols and free fatty acids
which are slightly water soluble. However, for water insoluble lipids, the
absorption is incomplete. For instance, less than 40% of the dietary
cholesterol is absorbed. The micelle formation is also essential for the
absorption of fat soluble vitamins, particularly vitamins A and K.
e. Slightly water soluble nature of monoacylglycerols and free fatty acids & short
and medium chain fatty acids are not dependent on micelle formation for the

4. Enterohepatic circulation of bile salts: After forming mixed micelle the bile is left
behind. It is reabsorbed from the ileum and returned to liver for resecretion.
5. Inside the mucosal cell:
a. The fatty acids of short and medium chain length ( < 10 carbons), after their
absorption into the intestinal cells, do not undergo any modification. They
enter the portal circulation and are transported to the liver in a bound form to
b. The long chain fatty acids are activated by thiokinase (fatty acyl CoA
synthetase) in the intestinal cells. The acyl CoA derivatives so formed combine
2-monoacylglycerols to produce triacylglycerols.
These reactions are catalysed by a group of enzymes, namely acyltransferase.
c. Cholesterol is converted to cholesterylester, and phospholipids are
regenerated from the absorbed lysophospholipids.
a. The TAG, Cholesterol ester, phospholipid molecules accumulated in the jejunal
mucosal cell are combined with apoproteins B48 and apo-A 1 to form

b. Chylomicrons migrate to the plasma membrane of intestinal mucosal cells.
They are released into the lymphatic vessels by exocytosis.
c. They form the chyle and transported through lacteals and finally enter
thoracic duct to reach lymph circulation. Chylomicrons enter the large body
veins via the thoracic duct.
d. Chylomicrons are large lipoprotein particles that transport dietary lipids from
the intestines to other locations in the body.
e. The presence of chylomicrons gives the lymph a milky appearance, which is
observed after a lipid-rich meal.
f. Chylomicrons are one of the 5 major groups of lipoproteins (chylomicrons,
VLDL, IDL, LDL, HDL) which enable fats and cholesterol to move within the
water based solution of the blood stream.
g. Fate of chylomicrons:
a. From blood they get into adipose tissue and liver
b. Liver uses triglycerides form it to synthesis VLDL
c. During starvation the triglycerides are converted into free fatty acids
for oxidation by cells
7. Six Steps of Lipid Absorption
a. Minor digestion of triacylglycerols in mouth and stomach by lingual (acidstable) lipase.
b. Major digestion of all lipids in the lumen of the duodenum/jejunum by
pancreatic lipolytic enzymes.
c. Bile acid facilitated formation of mixed micelles.
d. Passive absorption of the products of lipolysis from the mixed micelle into the
intestinal epithelial cell.
e. Re-esterification of 2-monoacylglycerol with free fatty acids inside the
intestinal enterocyte.
f. Assembly of chylomicrons containing Apo B48, triacylglycerol, cholesterol
esters and phospholipids and export from intestinal cells to the lymphatics.
8. Abnormalities in absorption of lipids:
a. Steatorrhea : (S.N)
a. In pancreatic disease fat is not digested leading to stetorrhea
b. Absorption is defective in Coeliac disease, surgical removal of
intestines, biliary obstruction.(fat malabsorption syndromes)
c. lt is a condition characterized by the loss of lipids in the feces. It may
be due to a defect in the secretion of bile or pancreatic juice into the
intestine or impairment in the lipid absorption by the intestinal cells.
d. Steatorrhea is commonly seen in disorders associated with pancreas,
biliary obstruction, severe liver dysfunction etc.
b. Cystic fibrosis: Defective gene results in decreased secretion of chloride and
increased reabsorption of sodium and water. In the pancreas, the decreased
hydration results in thickened secretions such that pancreatic enzymes are
not able to reach the intestine, leading to pancreatic insufficiency and fat
c. Cholesterol stone formation in gall-bladder (gall stones) is a frequent health
complication. lt is found more frequently in females than in males often in
association with obesity. Cholesterol gall stones are formed when liver
secretes bile (containing phospholipids, bile acids etc.), supersaturated with
respect to cholesterol
d. Abnormal passage of chyle in urine (Chyluria) & in thorax called chylothorax.



1. Fatty acid synthesis. Aug 2005
1. Fatty acids are synthesized whenever an excess of calories is ingested. The major
source of carbon for the synthesis of fatty acids is dietary carbohydrate. An excess of
dietary protein also can result in an increase in fatty acid synthesis and stored as
2. The pathway is called Lynens spiral
3. Synthesis of fatty acids occurs predominantly in liver, kidney, adipose tissue and
lactating mammary glands
4. Fatty acids are synthesized mainly by a de novo synthetic pathway operating in
the cytosomal fraction of the cell. So it is referred to as extra mitochondrial or
cytoplasmic fatty acid synthase system.
5. Acetyl CoA is the source of carbon atoms while NADPH provides the reducing
equivalents and ATP supplies energy for fatty acid formation.
6. Fatty acid synthesis is the process of combining eight two-carbon fragments (acetyl
groups from acetyl CoA) to form a 16-carbon saturated fatty acid, palmitate.
7. The major fatty acid synthesised de novo is palmitic acid, the 16C saturated fatty
8. Palmitate can then be modified to give rise to the other fatty acids.
9. The fatty acid synthesis occurs in 3 stages
1. Production of acetyl CoA and NADPH
2. Conversion of acetyl CoA to malonyl CoA
3. Reactions of fatty acid synthase complex
10. Production of acetyl CoA and NADPH
4. The starting material for de novo synthesis is Acetyl CoA
5. Acetyl CoA for fatty acid synthesis comes mostly from Glycolytic breakdown
of glucose.
6. Acetyl CoA is transported from mitochondria to cytoplasm as citrate by a
7. Citrate, in turn, can be transported out of the mitochondria to the
cytoplasm (where fatty acid synthesis occurs), and there split to generate
cytoplasmic acetyl CoA for fatty acid synthesis.
11. Fatty acid synthase (FAS) :
This is a multienzyme complex. It is a dimer with two identical sub units. Each sub
unit consists of 3 domains and 7 enzymes:
8. Domain1 = condensing unit( acyl synthase; acetyl transferase; malonyl
trans acylase)
9. Domain 2 = reduction unit(dehydrogenase; enol reductase; acyl carrier
10. Domain 3 = releasing unit (thio esterase)
1. Acetyl CoA is carboxylated to malonyl CoA by the enzyrne acetyl CoA
carboxylase. This is an ATP-dependent reaction and requires biotin for CO 2
Acetyl CoA + HCO3- + ATP Malonyl CoA + ADP + Pi
2.A. The remaining reactions of fatty acid synthesis are catalysed by a multifunctional
enzyme known as fatty acid synthase (FAS) complex. The acetyl transacylase

transfers 2 carbon acetyl group to the cysteinyl SH group of the synthase
Acetyl CoA + (CE)-SH Acetyl S-(CE) + CoA

One molecule of Acetyl CoA (2C) and one molecule of melonyl CoA(3C) bind to
the FAS multienzyme complex. Malonyl group is transferred to SH group by acyl
carrier protein.
Malonyl CoA + ACP-SH Malonyl-S-ACP +CoA

3. The 2 C acetyl and 3 C melonyl units are condensed to form aceto acetyl ACP;
one C is lost as Co2; the enzyme is keto acyl synthase.
2 Acetyl-S-(CE) + 3 Malonyl ACP Aceto acetyl ACP
4. The aceto acetyl ACP is reduced by NADPH dependant beta-keto-acyl reductase
to form beta hydroxy fatty acyl ACP
Aceto acetyl ACP+ NADPH+H+ Beta hydroxy butyryl ACP+NADP
5. Beta hydroxy fatty acyl ACP is dehydrated to enoyl ACP by dehydratase
Beta hydroxy fatty acyl ACP Enoyl ACP + H2O

Enoyl ACP is reduced by enoyl reductase using 2 NADPH to form butyryl ACP
Enoyl ACP + 2 NADPH Butyryl ACP + NADP


Steps 3,4,5,6 are repeated to a total of 7 times till a 16 carbon palmitic acid is
Thioestrase release palmitic acid from multienzyme complex.

Synthesis Of Long Chain Fatty Acids From Palmitate:

a. Palmitate is the end product of the reactions of fatty acid synthase system
that occurs in cytosol. Chain elongation involves successive additions of
malonyl CoA with the participation of NADPH. These reactions are similar to
that catalysed by fatty acid synthase. A specific group of enzymes, namely
elongases bring about fatty acid chain elongation.
b. The mitochondrial chain elongation is almost a reversal of b-oxidation of fatty
acids. Acetyl CoA molecules are successively added to fatty acid to lengthen
the chain. The reducing equivalents are derived from NADPH.
Summary: the reaction summary is as follows:
1 Acetyl CoA + 7 Malonyl CoA + 14 NADPH + 14 H 1 Palmitate + 7 CO2 + 14
NADP + 8 CoA + 6 H2O


1. The reducing equivalents for fatty acid synthesis are provided by NADPH which come
either from citrate (acetyl CoA) transport or hexose monophosphate shunt.
2. Citrate availability is an important factor for fatty acid synthesis.
3. Acetyl CoA carboxylase is a rate limiting key enzyme;
4. Fatty acid synthesis decreases when Glucose level is low.
5. Insulin favours lipogenesis; Glucagon inhibits lipogenesis

6. Consumption of high carbohydrate or fat-free diet increases the synthesis of acetyl
CoA carboxylase and fatty acid synthase, which promote fatty acid formation. On the
other hand, fasting or high fat diet decreases fatty acid production by reducing the
synthesis of these two enzymes.
1. This system exists as a multi-enzyme complex. The enzymes form a dimer with
identical subunits.
Each subunit of the complex is organized into 3 domains with 7 enzymes.
2. Advantages of Multi-enzyme Complex:
a. Intermediates of the reaction can easily interact with the active sites of the
b. One gene codes all the enzymes; so all the enzymes are in equimolecular
c. So the efficiency of the process is enhanced.
3. 1st Domain or Condensing Unit:
It is the initial substrate binding site. The enzymes involved are beta-keto acyl
synthase or condensing enzyme (CE); acetyl transferase (AT) and malonyl trans
acylase (MT).
4. 2nd Domain or Reduction Unit:
It contains the dehydratase (DH); enoyl reductase (ER); beta-keto acyl reductase
(KR) and acyl carrier protein (ACP). The acyl carrier protein is a polypeptide chain
having a phospho-pantotheine group, to which the acyl groups are attached in
thioester linkage. So ACP acts like the CoA carrying fatty acyl groups
5. 3rd Domain or Releasing Unit:
It is involved in the release of the palmitate synthesised. It contains thio-esterase
(TE) or deacylase
6. Fatty acid synthase functions as a single unit catalysing all the seven reactions.
Dissociation of the synthase complex results in loss of the enzyme activities.
Synthesis of Triacylglycerol:
1. Triacylglycerol (TG) synthesis mostly occurs in Iiver and adipose tissue, and to a lesser
extent in other tissues. Fatty acids and glycerol must be activated prior to the
synthesis of triacylglycerols.
2. The TAG is synthesised by esterification of fatty acyl CoA with either glycerol-3phosphate or dihydroxy acetone phosphate (DHAP)
3. Step I: Synthesis of glycerol 3 phosphate:
a. Two mechanisms are involved for the synthesis of glycerol 3-phosphate
i. In liver, glycerol 3-phosphate is produced from the phosphorylation of
glycerol by glycerol kinase or from the reduction of dihydroxyacetone
phosphate (DHAP) derived from glycolysis.
ii. White adipose tissue lacks glycerol kinase and can produce glycerol 3phosphate only from glucose via DHAP by glycerol 3-phosphate
dehydrogenase. Thus, adipose tissue can store fatty acids only when
glycolysis is activated, that is, in the fed state.
4. Step II: Addition of acyl groups to form TG:
a. Glycerol 3 phosphate acyltransferase catalyses the transfer of an acyl group
to produce lysophosphatidica cid. DHAP can also accept acyl group, ultimately
resulting in the formation of lysophosphatidica cid.

b. Another acyl group is added to lysophosphatidic acid to form phosphatidic acid
(1 ,2-dia cylglycerolphosphate).
c. The enzyme phosphatase cleaves off phosphate of phosphatidic acid to
produce diacylglycerol.
d. lncorporationo f another acyl group finally results in synthesis of
5. The intermediates of TC synthesis phosphatidic acid and diacylglycerol are also
utilized for phospholipid synthesis


1. Write in detail about B-oxidation of fatty acids under the following heading:
Aug 2006
2. Write in detail about B-oxidation of fatty acids under the following heading:
Aug 2006
a. Definition
b. Site
c. Steps and
d. Energetic
3. Describe the site, process of B-oxidation of fatty acid and add a note on
role of CARNITIN. Write the energetic when palmitic acid is oxidised. Feb
4. Outline the steps involved in the beta oxidation of fatty acids. June 1990
5. S.N
1. Beta oxidation of fatty acids. Nov 1991; April 2000
2. Oxidation of odd carbon fatty acids. Nov. 1993
3. Oxidative phosphorylation. April 1996

1. Definition: Oxidation and splitting of two carbon units at the Beta-carbon atom.
Oxidation occurs sequentially by cleaving two carbon units, acetyl CoA.
2. Triacylglycerol (TC) is the stored fat in the adipose tissue. The enzyme triacylglycerol
lipase, removes the fatty acid either from carbon 1 or 3 of the triacylglycerol to form
diacylglycerol. The other two fatty acids of TC are cleaved by additional lipases
specific for diacylglycerol and monoacylglycerol. The complete degradation of
triacylglycerol to glycerol and free acids is known as lipolysis. Fatty acids are oxidized
by most of the tissues in the body. However, brain, erythrocytes and adrenal medulla
cannot utilize fatty acids for energy requirement.
3. The b-oxidation of fatty acids involves three stages
1. Activation of fatty acids occurring in the cytosol;
2. Transport of fatty acids into mitochondria;
3. B-Oxidation proper in the mitochondrial matrix.
4. Site:
1. Beta oxidation of fatty acids takes place in the mitochondrial matrix for the most
part. However, fatty acids have to be activated for degradation by coenzyme A
by forming a fatty acyl-CoA thioester.
2. For short and medium length fatty acids, they undergo this reaction in the
3. The long chain fatty acids can't go through the membrane though, so this
reaction occurs at the outer mitochondrial membrane and the product has to be
carried by carnitine across the inner mitochondrial membrane.
4. They are made into acylcarnitine derivatives by Carnitine acyltransferase I on the
outer side of the inner membrane. These are then transported across the
membrane by a translocase and then they are passed to carnitine acyltransferase
II on the matrix side which puts the fatty acyl group back on CoA leaving the
original fatty acyl-CoA.
Preparative steps: 4 steps
Step 1:
Fatty acids are activated to Fatty acyl CoA utilizing two high energy bonds
Fatty acid ------------------------------- Fatty acyl CoA
Step 2:
Role of Carnitine:
1. Carnitine is a quaternary ammonium compound biosynthesized from the
aminoacids lysine and methionine in liver and kidney. In living cells, it is
required for the transport of fatty acids from the cytosol into the mitochondria
during the breakdown of lipids (or fats) for the generation of metabolic energy.
Carnitine exists in two stereoisomers; its biologically active form is L-carnitine,
whiles its enantiomer, D-carnitine, is biologically inactive.
2. Fatty acyl CoA has to be transported through mitochondrial membrane for
further step. Hence Carnitine is used as a transporter. It is synthesised from
lysine and methionine in liver and kidney. Carnitine deficiency in preterm is
found to produce hypoglycaemic episodes. Medium and short chain fatty acids
do not require Carnitine and can pass through the membrane.
Step 3:
In cytosol, Carnitine combines with acyl CoA to form acyl Carnitine by caritine
acyl transferase-I (CAT I) and carried across membrane by translocase.
Carnitine + Fatty acyl CoA ------------- caritine acyl transferase-I (CAT I)
Caritine acyl transferase I (Cytosol)

Step 4:
In the mitochondria Acyl CoA is reformed by caritine acyl transferaseII(Cat II)
Acyl Carnitine + CoA ---------------- Acyl CoA + Carnitine
Caritine acyl transferase II (mitochondria)
Beta Oxidation:
The next 4 reactions are sequentially repeated for complete oxidation of fatty acids.
After one round of four metabolic steps, one acetyl CoA unit is split off and acyl CoA
with 2 carbon atoms less is generated. This would undergo the same series of
reactions again until the fatty acid is completely oxidised.
1. The fatty acyl CoA is dehydrogenated to a trans enol CoA transferring 2H to FAD.
FADH2 in electron transport chain will produce 2 ATP
Acyl CoA dehydrogenase
Fatty acyl CoA ----------------------------------------- Trans enol CoA
2. Trans enol CoA is converted to L isomer of beta hydroxy fatty acyl CoA
Enol CoA hydratase
Trans enol CoA ----------------------- beta hydroxy fatty acyl CoA
3. Beta hydroxy fatty acyl CoA is oxidised to beta keto fatty acyl CoA. NADH is
produced which yields 3 ATP in electron transport chain
Beta hydroxy fatty acyl CoA ---------------------------- beta keto fatty acyl

NADH+ + H+ 3 ATP

4. Beta keto fatty acyl CoA is cleaved forming fatty acyl CoA with 2 carbon less and
Acetyl CoA as follows:
Beta keto fatty acyl CoA + CoA-SH ------------------- fatty acyl CoA + Acetyl
Further cycles:
Fatty acyl CoA will sequentially undergo repetition of the Beta Oxidation Cycle until it
is completely converted to Acetyl CoA. This acetyl-CoA is then available to be further
metabolized in the TCA cycle, or it can be used as a substrate in amino acid
1. Eg of fatty acid: Palmitic acid:
2. contains 16 Carbon atoms and require 7 cycles of beta oxidation to produce 8
molecules of acetyl CoA; Each molecule of acetyl CoA will give 10 molecules of ATP in
TCA cycle:
3. Each FADH2 produces 1.5 molecules of ATP:
7FADH2x1.5 = 10.5
4. Each NADH produces 2.5 molecules of ATP:
= 17.5
5. In initial activation 2 high energy bonds are utilized:
- 2
6. Total:
108 - 2
= 106

Regulation of beta oxidation:
1. The availability of free fatty acids regulates the beta oxidation
2. Glucagon increase FFA and hence beta oxidation also increases
3. Insulin has the opposite effect
4. Malonyl-CoA can act to prevent fatty acyl-CoA derivatives from entering the
mitochondria by inhibiting the carnitine acyltranferase-I that is responsible for this
transport. Thus, inhibiting the beta oxidation pathway.
Beta oxidation of odd chain fatty acids:
1. Odd chain fatty acids are oxidised in the same way as even chain fatty acids
2. But at the end a carbon unit called propionyl CoA is produced
3. Steps:
1. Propionyl CoA is first carboxylated to D-methyl CoA by a biotin dependant
carboxylase utilizing one molecule of ATP
2. D-methyl CoA is converted to L-methyl melonyl CoA by racemase
3. L-methyl melonyl coa is rearranged to form succinyl coa by L-methyl melonyl
CoA mutase. B12 acts as coenzyme.
4. Succinyl coa the enters TCA cycle to form oxaloacetate used for
4. Propionyl CoA is also derived from valine and isoleucine
5. Propionate is an exception that it can enter neoglucogenic pathway unlike other fatty
6. Thus odd chain fatty acids can lead to neoglucogenic pathway
7. Cows milk contain more odd chain fatty acids
8. Inborn error of propionate metabolism:
1. Propionic academia occurs in carboxylase deficiency
2. Methyl malonic aciduria in mutase deficiency
Clinical Applications
1. Medium chain and short chain fatty acids do not require carnitine for transport across
the inner mitochondrial membrane. So medium chain and short chain fatty acids are
easily oxidised.
2. Carnitine deficiency is reported in preterm infants, in whom impaired fatty acid
oxidation is noticed. So more glucose is utilised, resulting in episodes of
3. Deficiency of translocase: It leads to defective metabolism of long chain fatty acids.
In this condition, muscle cramps are precipitated by fasting, exercise and high fat
4. Inherited CPT-I deficiency affects only the liver, resulting in reduced fatty acid
oxidation and ketogenesis, with hypoglycemia.
5. CPT-II deficiency affects primarily skeletal muscle and, when severe, the liver.
6. The sulfonylurea drugs (glibenclamide and tolbutamide), used in the treatment of
type 2 diabetes mellitus, reduce fatty acid oxidation and, therefore, hyperglycemia by
inhibiting CPT-I.
7. Organic Acidurias:
1. They are disorders of metabolism of fatty acids, branched chain and aromatic
amino acids and citric acid cycle. The incidence of "medium chain acyl CoA
dehydrogenase deficiency" is about 1 in 2,500 live births, and is the second
most common inborn error of metabolism.
2. The patients present with acidosis, vomiting, convulsions and coma. The
children often die in infancy; in case they survive, there is severe mental and
physical retardation. Examples:
i. Methyl malonic aciduria:
1. Deficiency of Methyl malonyl CoA mutase or B12 co-enzyme

2. Manifestations: Ketoacidosis, hypotonia, hypoglycemia,
hyperammonemia, hyperuricemia
ii. Propionic academia:
1. Deficiency of Propionyl CoA carboxylase
2. Manifestations: Ketoacidosis, hypotonia, vomiting, lethargy
iii. Glutaric aciduria
1. Deficiency of Glutaryl CoA dehydrogenase
2. Manifestations: ketoacidosis, convulsions, progressive
neurological defects, cerebral palsy.
Alpha oxidation:
1. It is a process by which fatty acids are oxidised by removing carbon atoms, one at a
time, from the carboxyl end. The process is important in brain.
2. The fatty acid does not need activation. Hydroxylation occurs at the alpha-carbon
atom. It is then oxidized to alpha-keto acid. The keto acid then undergoes
decarboxylation yielding a molecule of CO2 and a fatty acid with one carbon atom
3. This process occurs in the endoplasmic reticulum, does not require CoA, but does not
generate energy. Some fatty acids undergo alpha hydroxylation in peroxisomes also.
4. Alphaoxidation is mainly used for fatty acids that have a methyl group at the betacarbon, which blocks beta oxidation. A major dietary methylated fatty acid is
phytanic acid. It is derived from phytol present in chlorophyll, milk and animal fats.
5. Important fatty acid undergoing alpha oxidation is phytanic acid present in milk and
animal fats.
6. Refsums disease:
1. It is a metabolic error due to lack of alphahydroxylase (phytanic acid oxidase)
so that alpha oxidation does not occur and phytanic acid accumulates in the
2. The patient presents with severe neurological symptoms, polyneuropathy,
retinitis pigmentosa, nerve deafness and cerebellar ataxia. Regressions of
symptoms are observed with restricted dietary intake of phytanic acid.
3. Milk is a good source of phytanic acid, which may be avoided.
Omega oxidation:
1. It is a minor pathway taking place in microsomes, with the help of hydroxylase
enzymes involving NADPH and cytochrome P-450. The CH3 group is converted to
CH2OH and subsequently oxidised with the help of NAD+ to a COOH group to
produce dicarboxylic acids.
2. Minor pathway becomes more active in defective B oxidation
1. Write the structure, sources, synthesis and clinical importance of
cholesterol. October 1999
2. Discuss cholesterol synthesis and its regulation. Mention the various
substances obtained from cholesterol. Aug 2004
3. Describe the biosynthesis of cholesterol. Mention the important compounds
produced from cholesterol. March 1992
4. Describe in detail the cholesterol synthesis transport and excretion. Nov
5. What is normal serum cholesterol level? Describe the process of synthesis
of cholesterol. Feb 2006
Short notes:

6. Catabolism of cholesterol. Feb 2008
7. HDL cholesterol. Nov 1998
1. Cholesterol is the principal sterol synthesized by animals, but small quantities are
synthesized in other eukaryotes, such as plants and fungi. It is almost completely
absent among prokaryotes, which include bacteria.
2. Cholesterol is classified as a sterol (a contraction of steroid and alcohol).
3. Cholesterol has no significant role in energy metabolism.
4. In 70 kg man there is 140 gm of cholesterol
5. Cholesterol is present in tissues and in plasma either as free cholesterol or combined
with a long-chain fatty acid as cholesteryl ester, the storage form. In plasma, both
forms are transported in lipoproteins.
6. Plasma low-density lipoprotein (LDL) is the vehicle of uptake of cholesterol and
cholesteryl ester into many tissues.
7. Free cholesterol is removed from tissues by plasma high-density lipoprotein (HDL)
and transported to the liver, where it is eliminated from the body either unchanged or
after conversion to bile acids in the process known as reverse cholesterol transport
1. It occurs as a major constituent of the plasma membrane which modulates its fluid
2. It helps to insulate nerve fibers.
3. Cholesterol is the precursor of bile acids, which are essential for fat digestion.
4. It is the precursor of Vit. D
5. Cholesterol is the precursor of all steroid hormones: Androgens, estrogens,
gestagens, glucocorticosteroids, and mineralocorticoids.
1. Cholesterol can be ingested in the diet, recycled within the body through
reabsorption of bile in the digestive tract,
2. Produced de novo.
3. Dietary sources: Major dietary sources of cholesterol include cheese, egg yolks, beef, pork,
poultry, and shrimp. Human breast milk also contains significant quantities of cholesterol.
Cholesterol is not present in plant based food sources unless it has been added during the
food's preparation.
It is a sterol; made of 3 cyclohexane rings and a cyclopentane ring with a phenanthrene
arrangement; it is called cyclopentano perhydro phenanthrene ring stricture. There is
double bond between C 5 and 6. Hydroxyl group at the 3rd position. Totally 27 carbons.
The 17th carbon has 8 carbon side chain



1. Absorption of Cholesterol:
1. Cholesterol ester present in the diet is hydrolysed by cholesterol-esterase. The
free cholesterol is incorporated into bile salt micelle and absorbed into the
mucosal cell. Absorption needs micellar formation.
2. A protein designated NPC1L1 (Niemann Pick C1 Like1) is involved in the
absorption of cholesterol. The drug Ezetimibe is interfere with the function of
the protein and prevents absorption of cholesterol.
3. Inside the mucosal cell, cholesterol is re-esterified and incorporated into
chylomicrons. ABCG5 (Sterolin 1) and ABCG8 (Sterolin 2) act by limiting
cholesterol absorption. They promote the secretion of absorbed sterols from
intestinal epithelium back into the lumen and thus regulate the amount of
cholesterol incorporated into chylomicrons.
4. The chylomicrons reach the bloodstream through lymphatics. Thus dietary
cholesterol reaches the liver through chylomicron.
2. Transport of cholesterol:
1. Cholesterol is present in the plasma lipoproteins in two forms
1. About 70-75% of it is in an esterified form with long chain fatty acids.
2. About 25-30% as free cholesterol. This form of cholesterol readily
exchanges between different lipoproteins and also with the cell
2. Role of ICAT : High density lipoproteins (HDL) and the enzyme lecithincholesterol acyltransferase (LCAT) are responsible for the transport and
elimination of cholesterol from the body.
3. The cholesterol (cholesteryl) ester is trapped in HDL, by a reaction catalysed
by LCAT and then transported to liver for degradation and excretion. This
mechanism is commonly known reverse cholesterol transport.
3. Excretion:
1. Average diet contains 300 mg of cholesterol per day
2. Body synthesise 700 mg
3. Out 1000 mg 500 mg is excreted through bile
4. This is partly reabsorbed from intestines
5. The unabsorbed portion is acted upon by intestinal bacteria to form
cholesanol and coprasatnol and excreted in faeces.


1. Sites: liver, adrenal cortex, testis, ovaries and intestines

2. Partly in endoplasmic reticulum and partly in cytoplasm
3. The synthesiso f cholesterol may be learnt in 5 stages
a. Synthesiso f HMG CoA
b. Formation of mevalonate (6C)
c. Production of isoprenoid units (5C)
d. Synthesiso f squalene( 30C)
e. Conversion of squalene to cholesterol (27C).
4. Steps:
1. Condensation: Two molecules of acetyl CoA condense to form Acetoacetyl CoA
catalysed by synthase.

2. Production of HMG CoA: Third molecule of Acetoacetyl CoA combines with
Acetoacetyl CoA to form HMG CoA catalysed by HMG CoA synthase (cytosolic
3. The Committed Step: HMG CoA is reduced to mevlonate by HMG CoA
reductase using 2 molecules of NADPH; this is a rate limiting step.
4. Production of 5 Carbon Unit: Mevlonate is successively phosporylated to 5phospho-mevlonate 5-pyrophospho mevlonate 3-phospho 5pyrophospho-mevlonate; this then decarboxylated to a 5 carbon isopentenyl
pyrophosphate; totally 3 ATP s are utilised.
5. Condensation of 5-Carbon Units: 6 units 5 carbon isopentenyl pyrophosphate
condense stepwise to form 30 carbon Squalene
6. Cyclization:
i. Squalene undergoes oxidation by epoxidase to form 30 carbon
squalene epoxide using molecular oxygen and NADPH;
ii. Squalene epoxide is converted to lanosterol by cyclase.
7. Cutting to size:
A. 3 additional methyl groups on carbon atoms 4 and 14 are removed to
produce Zymosterol.
B. The double bond from 8-9 position shifts to 5-6 position forming
C. The double bond in side chain between 24 and 25 C is reduced by
NADPH to form cholesterol.
Regulation of Cholesterol synthesis:
1. HMG CoA reductase is the regulatory enzyme
2. Regulation at transcription: When sufficient cholesterol is present in the cell
transcription of gene for HMG CoA reductase is suppressed. When cholesterol is
low is increased.
3. Covalent modification: HMG CoA reductase is regulated by covalent modification
of the enzyme by cyclic AMP mediated cascade.
4. Insulin and thyroxin increase the activity of HMG CoA reductase
5. Glucagon and cortisol deceases its activity
6. Lovastatin decreases the activity of HMG CoA reductase
Substances derived from cholesterol:
1. Bile salts (or bile acids) are polar derivatives of cholesterol
2. Vitamin D is derived from 7-dehydrocholesterol by the action of the UV component of
sunlight on the skin. UV light brings about photolysis of 7-dehydrocholesterol
between C-9 and -10, leading to a rearrangement of the double bonds of the
molecule to form previtamin D3. This molecule spontaneously isomerizes to form
vitamin D3 (cholecalciferol).
3. Cholesterol is the precursor of the five major classes of steroid hormones. The
synthesis of steroid hormones is initiated by the removal of a six-carbon unit from
carbon 20 of the cholesterol side chain to form pregnenolone, the common precursor
of all steroid hormones. A series of reactions catalyzed by cytochrome P450 modify
pregnenolone to give rise to the individual hormones.
1. Progestagens
2. Androgens
3. Estrogens
4. Glucocorticoids
5. Mineralocorticoids
Catabolism of Cholesterol (Fate of cholesterol):
1. The total body cholesterol content varies from 130-150 grams. LDL (low density
lipoprotein) transports cholesterol from the liver to the peripheral tissues and HDL
(high density lipoprotein) transports cholesterol from tissues to liver. Cells of

extrahepatic tissues take up cholesterol from LDL. The free cholesterol released
within the cell has the following fates:
a. Incorporated into cell membranes.
b. Metabolised to steroid hormones, especially in adrenal cortex and gonads.
c. Esterified with saturated fatty acids and stored in the cell. The enzyme ACAT
(acyl cholesterol acyl transferase) helps in this reaction.
d. Esterified with poly-unsaturated fatty acids (PUFA) by the action of LCAT
(lecithin cholesterol acyl transferase) and incorporated into HDL, transported
and finally excreted through liver.
2. Average diet contains about 300 mg of cholesterol per day. Body synthesizes about
700 mg of cholesterol per day. Out of this total 1000 mg, about 500 mg of cholesterol
is excreted through bile. This cholesterol is partly reabsorbed from intestines.
Vegetables contain plant sterols which inhibit the re-absorption of cholesterol. The
unabsorbed portion is acted upon by intestinal bacteria to form cholestanol and
coprostanol. These are excreted (fecal sterols).
3. Another 500 mg of cholesterol is converted to bile acids, which are excreted in the
bile as bile salts.
4. Liver and Cholesterol: The liver has a major role in controlling the plasma levels of
LDL cholesterol.
a. Liver synthesises cholesterol
b. Liver removes cholesterol from Lipo Protein remnants.
c. Liver is the only organ that can excrete cholesterol through bile.
d. Liver converts cholesterol to bile acids.
Clinical significance of cholesterol:
1. Total plasma lipid is 400-600 mg/dl.
2. In healthy individuals, the total plasma cholesterol is in the range of 150-200 mg/dl.
In the new born, it is less than 100 mg/dl and rises to about 150 mg/dl within a year.
The women have relatively lower plasma cholesterol which is attributed to
oestrogens. Cholesterol level increases with increasing age (in women particularly
after menopause) and also in pregnancy.
3. In adults, the normal LDL-cholesterol is about 80-150 mg/dl while HDL-cholesterol is
around 30-60 mg/dl.
4. Elevation in plasma HDL cholesterol is beneficial to the body, since it protects the
body from atherosclerosis and coronary heart diseases (CHD). On the other hand,
increase in LDL-cholesterol is harmful to the body as it may lead to various
complications, including CHD.
5. Increase in plasma cholesterol (> 200 mg/dl) concentration is known as
hypercholesterolemia and is observed in many disorders:
1. If the hypercholesterolemia is hereditary (familial hypercholesterolemia), there
is more often a family history of premature, earlier onset atherosclerosis, as
well as familial occurrence of the signs mentioned above. Atherosclerosis is
characterized by deposition of cholesteryl esters and other lipids in the intima
of the arterial walls often leading to hardening of coronary arteries and
cerebral blood vessels.
2. Diabetes mellitus : Due to increased cholesterol synthesis since the
availability of acetyl CoA is increased
3. Hypothyroidism (myxoedema) : due to decrease in the HDL receptors on
4. Obstructive jaundice : Due to an obstruction in the excretion of cholesterol
through bile
5. Nephrotic syndrome: due to increase in plasma lipoprotein fractions.
6. Control of hypercholesterolemia:

1. Dietary intake of polyunsaturated fatty acids (PUFA) reduces the plasma
cholesterol level. PUFA will help in transport of cholesterol by LCAT mechanism
and its excretion from the body. The oils with rich PUFA content include
cottonseed oil, soya bean oil, sunflower oil, corn oil, fish oils etc. Ghee and
coconut oil are poor sources of PUFA.
1. Cholesterol is found only in animal foods & avoidance of cholesterol-rich foods
is advocated to be on the safe side.
2. Certain plant sterols and their esters (e.g. sitostanol esters) reduce plasma
cholesterol levels. They inhibit the intestinal absorption of dietary cholesterol.
3. Fiber present in vegetables decreases the cholesterol absorption from the
4. Diets rich in carbohydrates (particularly sucrose) should be avoided as the
increase triglycerides.
5. Elevation in plasma cholesterol is observed in people with smoking, abdominal
obesity, lack of exercise, stress, high blood pressure, consumption of soft
water etc. Therefore, adequate changes in the lifestyles will bring down
plasma cholesterol.
6. Red wine is particularly beneficial due to its antioxidants, besides low alcohol
7. Drugs such as lovastatin which inhibit HMG CoA reductase decrease
cholesterol synthesis. Clofibrate increases the activity of lipoprotein lipase and
reduces the plasma cholesterol and triacylglycerols.
2. A decrease in the plasma cholesterol, although less common, is also observed.
Hyperthyroidism, pernicious anemia, malabsorption syndrome, hemolytic jaundice
etc., are some of the disorders associated with hypocholesterolemia.
Lipid Profile
Total lipid
Total cholesterol
Free fatty acids

400-600 (mg/dl)
80-15 0
1 50-200
5-1 5

1. How are lipoproteins classified? What are their functions? Describe the
metabolism of low density lipoproteins. April 2001
2. Role of LDL receptors in metabolism of low density lipoproteins and the
disease caused by its defect. Oct 2003
3. Explain the metabolism and functions of HDL. Feb 2010
4. Role of HDL as scavenger of Cholesterol. Aug 2010
5. How are low-density lipoproteins (LDL) produced in the body? Describe,
with the help of a diagram, their metabolic fate. What determines this

process of their metabolic fate? Explain the clinical significance of this
lipoprotein. FEBRUARY 2014
Short notes:
1. Lipoproteins. March 2002
2. Metabolism of very low density lipoproteins. April 2000
3. Lipoproteins and their functions. Feb 2005
4. LDL metabolism Aug 2005
5. Apo lipoproteins and their significance. Aug 2007
6. High Density Lipoprotein cycle.
7. What is the function of Lipoprotein lipase?
8. Plasma lipoproteins. April 1997
9. Phospholipases. April 1999
10.Lipid Profile- Feb 2013
1. Fat absorbed from the diet and lipids synthesized by the liver and adipose tissue
must be transported between the various tissues and organs for utilization and
storage. Since lipids are insoluble in water, the problem of how to transport them in
the aqueous blood plasma is solved by associating nonpolar lipids (triacylglycerol and
cholesteryl esters) with amphipathic lipids (phospholipids and cholesterol) and
proteins to make water-miscible lipoproteins.
2. Lipoproteins are molecular complexes of lipids with proteins. They are the transport
vehicles for lipids in the circulation. Protein part is called apoprotein
3. Lipoproteins deliver the lipid components (cholesterol, triacylglycerol etc.) to various
tissues for utilization
Lipoprotein structure:
1. A lipoprotein basically consists of a neutral lipid core (with triacylglycerol and/or
cholesteryl ester) surrounded by a coat shell of phospholipids, apoproteins and
2. The polar portions (amphiphilic) of phospholipids and cholesterol are exposed on the
surface of lipoproteins so that lipoprotein is soluble in aqueous solution.
3. The protein components of lipoproteins are known as apoproteins. They perform the
following functions
1. Act as structural components of lipoproteins.
2. Recognize the cell membrane surface receptors.
3. Activate enzymes involved in lipoprotein metabolism.
4. Apo lipoproteins are divided by structure and function into five major classes, A
through E, with most classes having subclasses. Each has specific function. For
1. Apo-A-1: activates lecithin-cholesterol acyl transferase(LCAT); it is the ligand
for HDL receptor; it is anti atherogenic
2. Apo-B-100: only apoprotein in LDL; binds to LDL receptor on tissues.
3. Apo B-48: apoprotein of chylomicrons; derived from apo B-100 mRNA
following specific mRNA editing
4. Apo-C-II: activates lipoprotein lipase
5. Apo-E: arginine rich protein; present in chylomicrons; has 4 isoforms (i to iv);
implicated in diseases like Alzheimer and glomerulopathy.
Lipoprotein classification:
Depending on the density (by ultra-centrifugation) or on the electrophoretic mobility, the
lipoproteins in plasma are classified into five major types.
1. Chylomicrons
2. Very low density lipoproteins (VLDL)

3. Intermediate density lipoproteins (IDL)
4. Low density lipoproteins (LDL)
5. High density lipoproteins (HDL)
1. Chylomicrons are formed in the intestinal mucosal cells, and secreted into the
lacteals of lymphatic system.
2. Chylomicrons are large lipoprotein particles that transport dietary lipids from the
intestines to other locations in the body.
3. They are rich in triglycerides, Cholesterol ester, phospholipid molecules combined
with apoproteins B48 and apo-A (nascent chylomicron i.e without Apo-C II). Later
Apo CII and Apo-E are added during transport.
4. Metabolism of Chylomicrons
1. Main sites of metabolism of chylomicrons are adipose tissue and skeletal
muscle. The half-life of chylomicrons in blood is about 1 hour.
2. The enzyme lipoprotein lipase (LpL) is located at the endothelial layer of
capillaries of adipose tissue, muscles and heart; but not in liver. Apo C-II
present in the chylomicrons activates the LpL. The LpL hydrolyses
triglycerides present in chylomicrons into fatty acids and glycerol. Muscle or
adipose tissue cells take up the liberated fatty acids.
3. Lack of C-II leads to decreased activity of LpL and consequent accumulation of
chylomicrons and VLDL in blood.
4. Following injection of heparin, the LpL is released from the tissues and lipemia
is thus cleared. This is called post-heparin lipolytic activity. Insulin increases
LpL activity.
5. Chylomicron Remnants
1. As the chylomicron circulates and more than 90% of the triacylglycerol
in its core is degraded by lipoprotein lipase, the particle decreases in
size and increases in density. In addition, the C II apoproteins (but not
apo E) are returned to HDL.
2. The remaining particle, called a remnant, which contains cholesterol
and dissociates from the capillary endothelium and re-enters the
circulation where it is taken up by the liver.
6. Apolipoproteins, cholesteryl esters, and other components of the remnants are
hydrolytically degraded, releasing amino acids, free cholesterol, and fatty
7. Functions of Chylomicrons: Chylomicrons are the transport form of dietary
triglycerides from intestines to the adipose tissue for storage; and to muscle
or heart for their energy needs.
5. Lipoprotein lipase (LPL)
1. Lipoprotein lipase is located on the walls of blood capillaries, anchored to the
endothelium by heparan sulfate. It has been found in heart, adipose tissue,
spleen, lung, renal medulla, aorta, diaphragm, and lactating mammary gland,
although it is not active in adult liver. It is not normally found in blood;
however, following injection of heparin, lipoprotein lipase is released from its
heparan sulfate binding sites into the circulation.
2. Both phospholipids and apo C-II are required as cofactors for lipoprotein lipase
activity, while apo A-II and apo C-III act as inhibitors.
3. Lipoprotein lipase, activated by apo C-II on circulating lipoprotein particles,
hydrolyzes the triacylglycerol contained in these particles to yield fatty acids
and glycerol. The fatty acids are stored (by the adipose) or used for energy
(by the muscle). Glycerol is used by the liver, for example, in lipid synthesis,
glycolysis, or gluconeogenesis.

4. The degraded chylomicron by LPL is called chylomicron remnant and that of
LDL is called intermediate density lipoprotein (IDL)
5. Regulation of LPL:
1. Lipoprotein lipase synthesis and transfer to the luminal surface of the
capillary is stimulated by insulin
2. Lipoprotein lipase activity declines in adipocytes on starvation and
rises after feeding. Hence starvation reduces and feeding enhances the
uptake and storage of Fat by adipose tissue.
3. Starvation enhances lipoprotein lipase activity in cardiac and striated
muscles enabling them to take up and oxidise more of FA.
6. Structure of chylomicrons:


T (triacylglycerol); C (cholesterol
1. HDL has density >1.006; diameter 30 - 80nm
2. Synthesis:
a. VLDL are produced in the liver;
b. VLDL are secreted directly into the blood by the liver as nascent VLDL
particles containing apo B-100. They obtain apo C-II and apo E from
circulating HDL
c. apo C-II is required for activation of lipoprotein lipase.
3. Functions: Carries endogenous triglycerides from liver to peripheral tissues for
energy needs.
4. Metabolism:
a. Half life is 1-3 hours
b. In peripheral tissue apo C ii activates lipoprotein lipase and triacylglycerol is
degraded from VLDL releasing fatty acids and glycerol that are taken up by
adipose tissue and muscle. These fatty acids are oxidized as fuel by muscle
cells, used in the resynthesis of triacylglycerols in fat cells, and used for milk
production in the lactating breast.
c. Surface components, including the C and E apoproteins, are returned to HDL,
but the particles retain apo B-100.
d. Some triacylglycerols are transferred from VLDL to HDL in an exchange
reaction that concomitantly transfers some cholesteryl esters from HDL to
VLDL. This exchange is accomplished by cholesteryl ester transfer protein.
e. The residual particles remaining in the bloodstream are called VLDL remnants
(also called intermediate-density lipoprotein [IDL]).
f. IDL have two metabolic fates:
i. 50% to be up taken by hepatocytes in an Apo-E mediated process
ii. Rest continue losing TAG and become Low Density Lipoprotein (LDL
g. When IDL further loses triglycerides it becomes LDL.
h. VLDLIDLLDL is called lipoprotein cascade.
5. Clinical significance:

a. Fatty liver (hepatic steatosis) occurs in conditions in which there is an
imbalance between hepatic triacylglycerol synthesis and the secretion of
VLDL. Such conditions include obesity, uncontrolled diabetes mellitus, and
chronic ethanol ingestion.
b. Abetalipopro teinemia is a rare hypo lipoproteinemia caused by a defect in
microsomal triacylglycerol transfer protein (MTP), leading to an inability to
load apo B with lipid. As a consequence, no VLDL or chylomicrons are formed,
and triacyl glycerols accumulate in the liver and intestine.
c. patients who are homozygotic for apo E-2 are deficient in the clearance of
chylomicron remnants and IDL. These individuals have familial Type III
d. Apo E-4 isoform confers increased sus ceptibility to and decreased age of
onset of late-onset Alzheimer disease?
1. LDL is a cholesterol and cholesteryl esters rich lipoprotein containing only apo B-100
2. It is derived mainly from VLDL and small fraction from liver. Half-life is 2 days
3. Functions of LDL:
a. Transports cholesterol from liver to peripheral tissues
b. 75% of plasma cholesterol is in LDL.
c. LDL transports cholesterol from liver to the peripheral tissues. The cholesterol
thus liberated in the cell has three major fates:
i. It is used for the synthesis of other steroids like steroid hormones.
ii. Cholesterol may be incorporated into the membranes.
iii. Cholesterol may be esterified to a MUFA by acyl cholesterol acyl
transferase (ACAT) for storage.
4. Metabolism of LDL and LDL Receptors:
a. The primary function of LDL particles is to provide cholesterol to the
peripheral tissues (or return it to the liver). They do so by binding to cell
surface membrane LDL receptors that recognize apo B-100.
b. The LDL particles bind to the specific receptor pits (identified as glycoprotein)
on the cell membrane. The shape of the pit is stabilized by a protein called
clathrin. Apo B100 is responsible for the recognition of LDL receptor sites.
c. LDL receptors are abundant on hepatic cells. Apo B-100 binds to this receptor
and the complex is taken into hepatic cell by endocytosis. The receptor is then
returned for further cycles.
d. Within the cells, the LDL particles are hydrolysed by lysosomal hydrolases,
forming amino acids and free cholesterol.
5. Fate of LDL:
1. Half of the LDL is transported back to the liver
2. The remaining 40% of LDL particles is carried to extrahepatic tissues such as
adrenocortical and gonadal cells, for the synthesis of steroid hormones.
3. Some of the cholesterol of LDL is used for membrane synthesis and vitamin D
synthesis as well
4. Some Cholesterol from LDL is esterified by acyl CoA:cholesterol
acyltransferase (ACAT) producing a cholesteryl ester that can be stored in the
5. Some excess LDL particles are taken up by macrophages (scavenger cells)
present near the endothelial cells of arteries and is believed to induce an
inflammatory response by these cells initiating the cascade of atherosclerosis.


6. Clinical applications:
a. LDL is called bad cholesterol. Deposition in arterial wall form atheroma leading
to myocardial infarction
b. A defect in LDL receptors results in the elevation of plasma LDL, hence plasma
cholesterol. Deficiency of LDL receptors is observed in type II a hyperbeta
lipoproteinemia. This disorder is associated with a very high risk of athe
c. LDL has one fraction called Lipoprotein A (Lp a). Lp(a) has significant
homology with plasminogen. So it interferes with plasminogen activation and
impairs fibrinolysis. This leads to unopposed intravascular thrombosis and
possible myocardial infarction.
1. HDL contains cholesterol, phospholipid, apoA-I, apoA-II, apoE . They take up
cholesterol from peripheral tissues and return it to the liver as cholesteryl esters.
2. Synthesis:
a. HDL is synthesized and secreted from both liver and intestine. The intestinal
cells synthesise components of HDL and release into blood. Apo C and apo E
are synthesized in the liver and transferred from liver HDL to intestinal HDL
when the latter enters the plasma.
b. In the process of maturation, the nascent HDL particles accumulate
phospholipids and cholesterol from cells lining the blood vessels. The
cholesterol from the cell is transferred to HDL by a cholesterol efflux
regulator protein (ABCA1).
c. Then cholesterol in HDL is converted into cholesterol esters by the action of
lecithin- cholesterol acyl transferase (LCAT) which in turn is activated by apo

A-I. Cholesterol in HDL is esterified by lecithin component of HDL by
transferring PUFA molecue and this way there is progressive increase in
cholesterol esters
d. Esterification maintains the cholesterol concentration gradient, allowing
continued efflux of cholesterol to HDL. It also helps to trap cholesterol within
the HDL core. The cholesterol ester migrates to the core of the HDL particle
and is no longer free to return to the cell.
e. As the central hollow core of nascent HDL progressively fills with cholesterol
esters, HDL takes on a more globular shape to eventually form the mature
HDL particle (HDL-3).
f. Cholesterol ester transfer protein (CETP) moves some of the cholesteryl esters
from HDL to VLDL in exchange for triacylglycerol.
3. Metabolism:
a. The HDL particles, with cholesteryl ester trapped inside, enter the hepatocytes
by a receptor-mediated endocytosis. Class B scavenger receptor B1 (SR-B1)
binds HDL via apo-A1 and HDL is delivered to the cells. Hepatic lipase
hydrolyse HDL phospholipid and TAG, and cholesterol esters are released into
liver cells. The cholesterol that reaches the liver is used for synthesis of bile
acids or excreted as such in bile.
b. The scavenger receptor B1 (SR-B1) is identified as an HDL receptor with dual
role in HDL metabolism. In liver and steroidogenic tissues, it delivers
cholesteryl ester to tissues whereas in the tissues it is involved in reverse
cholesterol transfer.
c. When the HDL-3 remains in circulation, the cholesterol ester from HDL is
transferred to VLDL, IDL and LDL by a Cholesterol Ester Transfer Protein
(CETP). This will help to relieve product inhibition of LCAT so that more
cholesterol can be taken up. Triacyl glycerol from VLDL, IDL and LDL is
transferred to HDL in exchange for the cholesterol ester. The HDL particles
that are rich in triacyl glycerol and spherical are called HDL-2.
d. HDL subfractions: There are several sub fractions like HDL-1, 2a,2b,3a,3b,3c;
HDL2 ia a good cholesterol
4. Fate of HDL:
1. Mature HDL spheres are taken up by liver cells by apo-A-l mediated receptor
2. HDL is taken up by hepatic scavenger receptor B1. Hepatic lipase hydrolyses
HDL phospholipid and TAG, and cholesterol esters are released into liver cells.
3. The cholesterol that reaches the liver is used for synthesis of bile acids or
excreted as such in bile.
Reverse cholesterol transport:
1. The selective transfer of cholesterol from peripheral cells to HDL, and from
HDL to the liver for bile acid synthesis or disposal via the bile, and to
steroidogenic cells for hormone synthesis, is called reverse transport of
2. Reverse cholesterol transport steps:
i. efflux of cholesterol from peripheral cells to HDL,
ii. esterification of cholesterol by LCAT,
iii. binding of the cholesteryl esterrich HDL (HDL2) to liver and
steroidogenic cells,
iv. the selective transfer of the cholesteryl esters into these cells, and the
v. Release of lipid-depleted HDL (HDL3).

3. The efflux of cholesterol from peripheral cells is mediated by the transport
protein, ABCA1. Tangier disease is a very rare deficiency of ABCA1, and is
characterized by the absence of HDL particles.
4. The uptake of cholesteryl esters by the liver is mediated by a cell-surface
receptor, SR-B1 (scavenger receptor class B type 1) that binds HDL.
5. HDL3 , generated from discoidal HDL by the action of LCAT, accepts
cholesterol from the tissues via the SR-B1 and the cholesterol is then
esterified by LCAT, increasing the size of the particles to form the less dense
HDL2 .
6. HDL3 is then reformed, either after selective delivery of cholesteryl ester to
the liver via the SR-B1 or by hydrolysis of HDL2 phospholipid and
triacylglycerol by hepatic lipase and endothelial lipase. This interchange of
HDL2 and HDL3 is called the HDL cycle.
Functions of HDL:
1. Transport of cholesterol from peripheral tissue to liver and excreted in bile
(reverse transport). Transport of cholesterol (as ester) from peripheral tissue to
liver for its degradation and excretion (scavenger action).
2. The only excretory route of cholesterol from the body is the bile. Excretion of
cholesterol needs prior esterification with PUFA. Thus PUFA will help in lowering of
cholesterol in the body, and so PUFA is anti-atherogenic.
3. HDL particles serve as a circulating reservoir of apo C-II (the apolipoprotein that is
transferred to VLDL and chylomicrons, and is an activator of lipoprotein lipase),
and apo E (the apolipoprotein required for the receptor mediated endocytosis of
IDLs and chylomicron remnants).
4. HDL stimulates prostacyclin synthesis by the endothelial cells. Prostacyclins
inhibits platelets aggregation and thus HDL prevents thrombus formation.
5. HDL also helps in removal of macrophages from the arterial wall.
Regulation of HDL Concentration:
1. HDL concentration varies reciprocally with plasma TG concentrations, and indirectly
with the activity of lipopoprotein lipase.
Clinical significance:
1. HDL is anti atherogenic and good cholesterol.
2. HGDL level above 60 mg/dl protects and below 35 mg/dl increases the risk of
myocardial infarction.
1. They are also known as non-esterified fatty acids (NEFA)
2. It is complexed with albumin in plasma & contain long chain saturated or unsaturated
fatty acids
3. They are derived from triglycerides from adipose tissue by hormone sensitive lipase
4. Transported to heart, skeletal muscle etc.The free fatty acids are either oxidised to
supply energy or incorporated into tissue lipids by esterification.
5. Half-life is 1-2 minutes.
6. During starvation, about 40-50% energy requirement of the body is met by oxidation
of FFA.
7. Blood level of FFA is very low in the fully fed condition, high in the starved state, and
very high in uncontrolled diabetes mellitus.
1. Hypolipoproteinemia is abnormally low levels of lipids in the blood.
2. Low lipid levels may result from rare genetic abnormalities or other disorders.
3. People with these genetic abnormalities may have fatty stools, grow poorly, and be
mentally retarded.






No chylomicrons, vldls
or ldls due to defect in
apob expression

Malabsorption of fat, retinitis

pigmentosa, ataxic neuropathic
disease, erythrocytes have thorny
appearance (acnthocytes)

Autosomal dominant
Reduced HDL level
ATP-binding cassette
transporter I is

Yellow tonsils
Muscle atrophy
Peripheral neuropathy

Autosomal dominant
Serum HDL is
decreased Cholesterol
esters accumulate in

Increased risk coronary artery


Tangier disease



1. Hyperlipidemia, hyperlipoproteinemia or dyslipidemia is the presence of raised
or abnormal levels of lipids and/or lipoproteins in the blood.
2. Lipid and lipoprotein abnormalities are extremely common in the general population,
and are regarded as a highly modifiable risk factor for cardiovascular disease.
3. Deposition of lipid leads to xanthomas and cornel arcus
4. Inherited disorders of lipoproteins are due to genetic defects in lipoprotein
metabolism and transport. The secondary acquired lipoprotein disorders are due to
some other diseases ( e.g. diabetes mellitus, nephrotic syndrome, atherosclerosis
hypothyroidism etc.), resulting in abnormal lipoprotein pattern which often resembles
the primary inherited condition.
5. Hyperlipidemias are classified according to the Fredrickson classification which is
based on the pattern of lipoproteins on electrophoresis or ultracentrifugation:
1. Type I: This is due to familial lipoprotein Iipase deficiency. The enzyme defect
causes increase in plasma chylomicron and triacylglycerol levels.
2. Type lla: This is also known as hyperbetalipoproteinemia and is caused by a
defect in LDL receptors. Secondary type lla hyperlipoproteinemia is observed
in association with diabetes mellitus, hypothyroidism, nephrotic syndrome etc.
This disorder is characterized by hypercholesteroleima.
3. Type llb: Both LDL and VLDL increase along with elevation in plasma
cholesterol and
triacylglycerol. This is believed to be due to
overproduction of apo B.

4. Type lll: This is commonly known as broad beta disease and characterized by
the appearance of a broad p-band corresponding to intermediate density
lipoprotein (lDL) on electrophoresis.
5. Type lV: This is due to over production of endogenous triacylglycerols with a
concomitant rise in VLDL. Type lV disorder is usually associated with obesity,
alcoholism, diabetes mellitus etc.
6. Type V: Both chylomicrons and VLDL are elevated. This is mostly a secondary
condition, due to disorders such as obesity, diabetes and excessive alcohol
consumption etc.
1. Describe in detail the formation, fate and functions of bile acids. November
2. Role of bile in the digestion and absorption of dietary lipids. October 1999
3. Bile salts August 2004
4. Bile pigments April 2000
5. Formation and secretion of bile pigments. April 1997
1. Bile acids are steroid acids found predominantly in the bile of mammals. Cholesterol
is excreted from the body via the bile either in the unesterified form or after
conversion into bile acids in the liver. Coprostanol is the principal sterol in the feces;
it is formed from cholesterol by the bacteria in the lower intestine.
2. The most abundant bile acids in human bile are chenodeoxycholic acid (45%) and
cholic acid (31%). These are referred to as the primary bile acids.
3. Within the intestines the primary bile acids are acted upon by bacteria and converted
to the secondary bile acids, identified as deoxycholate (from cholate) and
lithocholate (from chenodeoxycholate).
4. Both primary and secondary bile acids are reabsorbed by the intestines and delivered
back to the liver via the portal circulation.
5. An increase in bile flow is exhibited with an increased secretion of bile acids.
6. The main function of bile acid is to facilitate the formation of micelles, which
promotes processing of dietary fat.
1. Bile acids is synthesised in liver from cholesterol; They contain 24 carbon atoms. All
have alpha oriented hydroxyl group at position 7.
2. Steps:
1. Hydroxylation:
i. The first and rate-limiting step is the introduction of this hydroxyl group
by the enzyme 7-alpha-hydroxylase. It is a microsomal enzyme.
ii. Then the beta-oriented OH group of C3 is converted to alpha type by
an isomerase.
iii. Two hydroxyl groups are added at positions 3 and 7 to form
Chenodeoxycholic acid.
iv. A third OH group is added at 12th carbon to form cholic acid.
v. Ring B is reduced in all cases.
2. Removal of 3 Carbon Unit
i. The side chain is first hydroxylated at 26 C and then oxidised to COOH
ii. This is followed by cleavage at 24 C, with removal of propionic acid (3
carbon) unit.

iii. The resulting compounds, cholic acid (a triol) and cheno deoxycholic
acid (a diol, are called primary bile acids.
3. Formation of Bile Salts
i. The primary bile acids are now conjugated with either glycine or
taurine to form conjugate bile acids. They are glyco-cholic acid, tauro
cholic acid, glyco chenodeoxycholic acid and tauro chenodeoxycholic
ii. The major conjugated bile acid is glycocholic acid.
iii. Conjugation adds more polar groups and increases the efficiency of bile
acids as surfactants.
iv. In the bile both are fully ionized (negatively charged) at physiologic pH;
thus, the conjugated forms are called primary bile salts. (Sodium or
potassium salts of conjugated bile acids). Bile salts are more effective
detergents than bile acids and only the bile salts are found in the bile.
v. The bile salts in the bile are stored in the gallbladder and released into
the intestine during a meal, where they in the digestion of dietary
4. Formation of Secondary Bile Acids/Bile Salts in the intestine:
i. Primary bile acids are acted upon by intestinal bacteria which result in
deconjugation. The deconjugated bile acids are then partly converted
to secondary bile acids by removal of the alpha hydroxyl group at
position 7.
ii. Cholic acid is thus converted to deoxycholic acid and chenodeoxycholic
acid to lithocholic acid. They are called secondary bile acids and on
ionization they form secondary bile salts.

5. Enterohepatic circulation:
1. Of the total bile salts reaching the intestine (15-30 g/day) only a very
small fraction, about 300-500 mg/day is excreted through feces. The
rest is reabsorbed from ileum, reaches liver and re-excreted through
bile. This is referred to as the enterohepatic circulation.
2. The primary and secondary bile acids are absorbed almost exclusively
in the ileum, and 9899% is returned to the liver in enterohepatic

circulation. However, lithocholic acid, because of its insolubility, is not
reabsorbed to any significant extent.
3. Only a small fraction of the bile salts escapes absorption and is
therefore eliminated in the feces. But this represents a major pathway
for the elimination of cholesterol.
6. Significance of enterohepatic circulation:
1. Enterohepatic circulation also means that some molecules which would
not otherwise be very toxic can become extremely hepatotoxic as they
reach unexpectedly high hepatic concentrations.
2. Drugs may remain in the enterohepatic circulation for a prolonged
period of time as a result of this recycling process.
3. The relative concentration of cholesterol in the bile favors the
precipitation and resultant stone formation; it is referred to as
lithogenic bile.
4. Bile acid sequestrants, such as cholestyramine, bind bile acids in the
gut, prevent their reabsorption, and so promote their excretion. They
are used in the treatment of hypercholesterolemia. Dietary fiber also
binds bile acids and increases their excretion
7. Functions of Bile acids:
1. The alkaline pH of the bile serves to neutralise the acidity of the gastric
2. The bile salts are efficient surfactants and detergents.
3. They facilitate the digestion of dietary triacylglycerols by acting as
emulsifying agents that render fats accessible to pancreatic lipases.
4. They facilitate the intestinal absorption of fat-soluble vitamins.
5. Bile is the only route of excretion for bilirubin, the end product of heme
6. It serves to excrete cholesterol, thus regulating the body cholesterol
7. Bile serves as the medium of excretion for several drugs, which are
detoxified by the liver.
8. Bile acids and phospholipids solubilise cholesterol in the bile, thereby
preventing the precipitation of cholesterol in the gallbladder.


1. Prostaglandins - Nov 1998; Feb 2005
2. Sources and functions of PUFA- April 1994


Small chain fatty acids:

1. Short chain fatty acids are a sub-group of fatty acids with aliphatic tails of less than
six carbons. They include:
1. Acetic acid
2. Propionic acid
3. Isobutyric acid
4. Butyric acid
5. Isovaleric acid
6. Valeric acid
7. Caproic acid
8. Lactic acid
9. Succinic acid
2. Short chain fatty acids, just as medium chain fatty acids, are taken up directly to the
portal vein during lipid digestion, in contrast to long chain fatty acids, which are
packed into chylomicrons and enter lymphatic capillaries and enter the blood first at
the subclavian vein.
3. Short chain fatty acids are produced when dietary fiber is fermented in the colon.
Medium chain fatty acids:
1. Contain 8-14 C atoms

Contain triglycerides that do not require prolonged digestion

3. MCTs passively diffuse from the GI tract to the portal system

4. In addition MCTs do not require bile salts for digestion.
5. Preferentially oxidised by peripheral cells
6. They are not deposited in adipose tissues
7. Patients who have malnutrition or malabsorption syndromes are treated with MCTs
because they do not require energy for absorption, utilization, or storage.
8. Rich sources of MCTs include coconut oil and palm kernel oils and are also found in
camphor tree drupes. The fatty acids found in MCTs are called medium chain fatty
9. The names of the medium chain fatty acids (and the corresponding number of
carbons) found in MCTs are:
1. caprylic acid (C8),
2. capric acid (C10) and
3. lauric acid (C12).
4. The milk fats of humans, dogs, and guinea pigs are largely made up of long
chain fatty acids. The milk fats of cows, sheep, and goats are rich in short-

chain acids. The milk fats of horses contain large amounts of medium chain
fatty acids[2]
Very long chain Fatty acids (VLCFA):

Fatty acids with 20 and more carbon atoms

Examples: Eicosa penta-enoic acid (EPA); docosa hexa-enoic acid (DHA)
DHA is synthesised in liver from linoleic acid
It is also available in fish oils
DHA is essential for development of brain and retina
In retinitis pigmentosa low levels of DHA is present
VLCFA is oxidised in peroxisomes to smaller fatty acids.
In neutrophils peroxisomal oxidation of VELCFA produce hydrogen peroxide that kills
9. In adrenoleukodystrophy peroxisomal oxidation enzymes are defective and death
occurs in infancy
10. Other related disorders are Zellweger syndrome and Refsums disease.
Mono unsaturated fatty acids:
1. Monounsaturated fats are fatty acids that have a single double bond in the fatty
acid chain. By contrast, polyunsaturated fatty acids have more than one double bond.
2. Monounsaturated fatty acids are liquids at room temperature and semisolid or solid
when refrigerated.
3. They are oxidised as in the case of saturated fatty acids; isomerase shifts the double
bond between 2 and 3 C and again beta- oxidation will proceed.
4. The energy yield will be less by 2 ATPs per double bond
5. Common monounsaturated fatty acids are palmitoleic acid and oleic acid
6. Foods containing monounsaturated fats lower LDL cholesterol, while possibly raising
HDL cholesterol.
7. Monounsaturated fats are found in natural foods such as nuts and avocados, and are
the main component of tea seed oil and olive oil (oleic acid).
8. Other sources include grape seed oil, ground nut oil, peanut oil, sesame oil, corn oil,
popcorn, whole grain wheat, cereal, oatmeal, safflower oil, sunflower oil etc.
1. PUFA are those which contain more than one double bond.
2. Important PUFA:
1. Linoleic acid
2. Linilenic acid
3. Arachidonic acid
3. Present more in veg.oils like sunflower oil
4. They esterify cholesterol and help in its excretion. Hence they are anti-atherogenic
5. Fish oil contains PUFA like timnodonic acid and cervonic acid
6. They are important for development of brain
7. Significance of PUFA:
1. They are nutritionally essential; and are called Essential Fatty Acids.
2. Prostaglandins, thromboxanes and leukotrienes are produced from arachidonic
3. PUFAs form integral part of mitochondrial membranes. In deficiency of PUFA,
the efficiency of biological oxidation is reduced.
4. They are components of membranes. Arachidonic acid is 10-15% of the fatty
acids of membranes.
5. As double bonds are in cis configuration; the PUFA molecule cannot be closely
packed. So PUFAs will increase the fluidity of the membrane.

6. As PUFAs are easily liable to undergo peroxidation, the membranes containing
PUFAs are more prone for damage by free radicals.
7. The production of DHA (docosa hexa enoic acid) from alpha linolenic acid is
limited. DHA is present in high concentrations in fish oils. DHA is present in
high concentations in retina, cerebral cortex and sperms.
8. Clinical Significance of PUFA
1. Persons with normal diet will not have any deficiency; but those who are on
parenteral nutrition for long periods will have deficiency.
2. PUFAs are used for esterification and excretion of cholesterol. PUFA will reduce
serum cholesterol level
3. Deficiency of EFA causes acanthocytosis, hyperkeratosis, acrodermatitis and
4. EFA deficiency is connected with acrodermatitis enteropathica, hepatorenal
syndrome and CNS manifestations
5. Elevated PUFA levels are seen in Zellweger's syndrome.
6. DHA levels in blood are low in patients with retinitis pigmentosa.
7. Trans fatty acids will compete with EFAs, and may increase the EFA deficiency
and decrease fluidity of membranes.
8. Trans fatty acids decrease HDL-cholesterol and may cause atherosclerosis.
Essential fatty acids:
1. Linoleic acid and linolenic acid are the only fatty acids that cannot be synthesised in
human body.
2. They have to be provided by food. Hence they are essential fatty acids.
3. There are two families of EFAs: -3 ( omega-3 ) and -6 (omega-6).
4. In the body, essential fatty acids serve multiple functions. In each of these, the
balance between dietary -3 and -6 strongly affects function.
5. Examples:
1. -3 fatty acids:
i. Linolenic acid
2. -6 fatty acids:
3. Linoleic acid
6. These two fatty acids cannot be synthesised by humans, as humans lack the
desaturase enzymes required for their production.
7. They are modified to make
1. the classic eicosanoids (affecting inflammation and many other cellular
2. the endocannabinoids (affecting mood, behaviour and inflammation)
3. The lipoxins from -6 EFAs and resolvins from -3 (in the presence of aspirin,
downregulating inflammation.)
4. the isofurans, neurofurans

They form the starting point for the creation of longer and more desaturated
fatty acids, which are also referred to as long-chain polyunsaturated fatty
acids (LC-PUFA):

8. Gamma-linolenic acid (GLA):

It is an essential fatty acid of omega-6 family.

It is produced form linoleic acid.
It forms arachidonic acid on desaturation.
It helps prevent cardiovascular disease; lowering B.P and preventing
5. It inhibits growth of tumours and prevents spread of cancers.
6. Source: human milk, plant-seed oils of primrose, black current and borage.

1. What are Eicosanoids? Discuss the biomedical importance of Arachidonic acid
and its derivatives. April 1999
2. Eicosanoids- Aug 2005
1. Prostaglandins and their related compounds- prostacyclins (PGl), thromboxanes
(TXA), leukotrienes (LT) and lipoxins are collectively known as eicosaniods, since
they all contain 20 carbons (Creek : eikosi-twenty).
2. Eicosanoids are considered as locally acting hormones with a wide range of
biochemical functions. Eicosanoids differ from the true hormones in that they are
produced in very small amounts in almost all tissues rather than in specialized
glands. They also act locally rather than after transport in the blood to distant
sites, as occurs with true hormones such as insulin.
3. Eicosanoids are not stored, and they have an extremely short half-life, being
rapidly metabolized to inactive products. Their biologic actions are mediated by
plasma membrane G proteincoupled receptors.
4. Classification:
i. Prostinoids:
1. 1-a



2. 1-b



3. 1-c



ii. Leukotrienes


iii. Lipoxins


Prostaglandins (PGs):
1. Prostaglandins are derivatives of a hypothetical 2O-carbon fatty acid namely
prostanoic acid hence known as prostanoids. This has a cyclopentane ring
(formed by carbon atoms 8 to 12) and two side chains, with carboxylg roup on
one side. They are derived from arachidonic acid.
2. Originally isolated from prostate and hence the name. Present in all tissues
3. Most potent biologically active substance; e.g. 1 ngm/ml can cause smooth
muscle contraction.
4. Also called local hormones
5. Structure:

derived from 20 c prostenoic acid;

saturated 5 carbon ring;

alpha oriented OH group at C 15






2. Nomenclature:&classification:
1. PG = prostaglandin
2. A.B,E, F etc= refers to group attached to the ring
3. 1,2,3 etc= no of double bonds in the structure
3. 5 PGs are widely distributed in the body: PGD2, PGE2, PGF2, PGI2 and Thromboxane A2
4. Biosynthesis:
1. They are synthesized in the cell from the essential fatty acids PUFA
2. An intermediate is created from phospholipase-A2,
3. Then brought out of one of either the cyclooxygenase pathway or the
lipoxygenase pathway to form either prostaglandin and thromboxane or
4. The cyclooxygenase pathway produces thromboxane, prostacyclin and
prostaglandin D, E and F.

The lipoxygenase enzyme pathway is inactive in leukocytes and in macrophages

and synthesizes leukotrienes.

Gamma-linolenic acid (GLA) via DGLA
Arachidonic acid (AA)
Eicosapentaenoic acid (EPA)

EFA Type


6. Steps:
1. The precursor is phospholipid which is stored in membranes
2. Phospholipase A2 release arachidonic acid from phospholipids
3. Arachidonic acid is converted to prostaglandin G2 by cyclo-oxygenase
(COX) (also called prostaglandin H synthase ), an enzyme that has two
activities, a cyclooxygenase and peroxidase. COX is present as two
isoenzymes, COX-1 and COX-2.
4. Prostaglandin G2 is transformed into PGH2 by peroxidase.
5. PGH2 is converted to PGI 2 by prostacyclin synthase and to TxA2 by
thromboxane synthase.

6. Other steps:



PGH2 -----------------PGD2------------------PGE2-------------PGF2

7. Regulation:
1. Phospholipase is activated by epinephrine, bradykinin, and
vasopressin. It is inhibited by steroids.
2. Cyclo-oxygenase is activated by catecholamines and inhibited by
3. Aspirin acetylates serine in the active site and irreversibly inhibits the
4. Cyclo-oxygenase is suicidal enzyme as it inactivates itself by selfcatalysis.
5. The half-life of prostaglandins is about 30 seconds. They are
inactivated by the 15-hydroxy-prostaglandin-dehydrogenase which
converts 15-OH group to keto group
8. Mechanism of action:
1. They are local hormones
2. They function through G proteins coupled receptors
3. In most tissues PGE increases cyclic AMP
4. PGI activates adenyl cyclase. But TXA inhibits adenyl cyclase
9. Biological actions and clinical applications:
i. CVS:
1. Prostacyclin or PGI2, synthesised in vascular endothelium,
produce vasodilatation and inhibits platelet aggregation and
protects against thrombus formation
2. Thromboxane TXA2 produced by platelets effects
vasoconstriction and platelet aggregation in vascular injury and
3. Prostaglandins lower BP
ii. Ovary and uterus:

1. PGF2 stimulates uterine muscles. Used in MTP and labour
induction and to arrest uterine bleeding after delivery.
2. PGs are used for ovulation and to increase fertility
iii. Respiratory tract:
1. PHF constricts bronchial smooth muscle
2. PGE produce bronchodilation and used to treat Br.asthma
iv. Immunity:
1. PGE2 reduces both T and B cell functions
v. Inflammation:
1. PGE2 and D2 produce induce inflammation by increasing
capillary permeability that induces oedema and erythema.
PGE2 is inhibited by aspirin and cortisol.
2. GIT:
3. PGs inhibit gastric secretion and increase motility. Used for acid
peptic disease.
vi. Metabolism:
1. PG E2 decreases lipolysis, increases calcium mobilization from
bone and also glycogen synthesis.
10. Leukotrienes: (LTs)
i. Leukotrienes are naturally produced eicosanoid lipid mediators,
which may be responsible for the effects of an inflammatory response
ii. Leukotrienes are produced in the body from arachidonic acid by the
enzyme 5-lipoxygenase.
iii. Examples of leukotrienes are LTA4, LTB4, LTC4, LTD4, LTE4, and LTF4.
iv. LTC4, LTD4 and LTE4 are often called cysteinyl leukotrienes due to
the presence of the amino acid in their structure. Together, the
cysteinyl leukotrienes make up the slow-reacting substance of
anaphylaxis (SRS-A).
v. Leukotrienes are involved in asthmatic and allergic reactions and act to
sustain inflammatory reactions.

vi. Leukotrienes assist in the pathophysiology of asthma, causing or
potentiating the following symptoms:

Airflow obstruction
Increased secretion of mucus
Mucosal accumulation
Infiltration of inflammatory cells in the airway wall

vii. Potent chemotactic agents i.e. attract inflammatory cells at the site of
1. Spingolipidoses (S.N)
2. Niemann-Pick disease
1. Sphingolipids are a class of lipids derived from the aliphatic amino alcohol sphingosine.

Two types:
1. Phosphosphingolipids :
1. sphingomyelin
2. Glycosphingolipids:
1. cerebrosides
2. Ceramid oligosaccharides
3. Gangliosides.

3. Ceramide is the basic structural unit of all sphingolipids

4. Synthesis of ceramide:
Pyridoxal phsphate
1. Palmitoyl CoA + Serine ------------------------3-ketohydroxy sphingosine + Co2

3-ketohydroxy sphingosine + NADPH+ + H+ -------------

dihydrosphinganine +NADP
Acyl transferase

3. Dihydrosphinganine + Fatty acyl CoA ------------------------ Dihydroxy ceramide +
4. Dihydroxy ceramide + FAD ----------------------------- Ceramide

Synthesis of Sphingomyelin:
Ceramide + CDP choline ------------------------------- sphingomyelin
5. Lipid Storage diseases
1. Otherwise called sphingolipidoses. They are a group of lysosomal storage
2. The disease results from failure of breakdown of particular sphingolipid due
deficiency of single enzyme
3. Children develop severe mental retardation and die early
4. Some examples:
1. Gaucher disease is the most common of the lipid storage diseases. It is
caused by a deficiency of the enzyme glucocerebrosidase.
may include enlarged spleen and liver, liver malfunction, skeletal disorders
and bone lesions that may cause pain, severe neurologic complications.
2. Niemann-Pick disease is actually a group of autosomal recessive
disorders caused by an accumulation of fat and cholesterol in cells of the
liver, spleen, bone marrow, lungs, and, in some patients, brain.
Neurological complications may include ataxia, eye paralysis, brain
degeneration etc.
3. Fabry disease, also known as alpha-galactosidase-A deficiency, causes a
build up of fatty material in the autonomic nervous system, eyes, kidneys,
and cardiovascular system
4. Farbers disease, also known as Farbers lipogranulomatosis or
ceramidase deficiency, describes a group of rare autosomal recessive
disorders that cause an accumulation of fatty material in the joints,
tissues, and central nervous system. The disorder affects both males and

5. The gangliosidoses are two distinct genetic groups of diseases. Both are
autosomal recessive and affect males and females equally.
1. The GM1 gangliosidoses are caused by a deficiency of betagalactosidase, with resulting abnormal storage of acidic lipid
materials in cells of the central and peripheral nervous systems,
but particularly in the nerve cells. GM1 has three forms: early
infantile, late infantile, and adult.
2. The GM2 gangliosidoses also cause the body to store excess
acidic fatty materials in tissues and cells, most notably in nerve
cells. These disorders result from a deficiency of the enzyme betahexosaminidase. The GM2 disorders include:
3. Tay-Sachs disease (also known as GM2 variant B). Tay-Sachs and
its variant forms are caused by a deficiency in the enzyme betahexosaminidase A.
4. Sandhoff disease (variant AB). This is a severe form of Tay-Sachs
disease. Onset usually occurs at the age of 6 months and is not
limited to any ethnic group.

1. Name ketone bodies. Enumerate the steps in the synthesis of ketone bodies.
How are they metabolised? Explain the biochemical basis and
consequences of excess production of ketone bodies in diabetes mellitus
and starvation. April 2000
2. Define ketosis. Name two conditions where it occurs. April 2001
3. Describe in detail the synthesis and utilization of ketone bodies. Name any
three conditions of increased production of Ketone bodies and mention
laboratory evaluation of ketone bodies. Feb 2005
4. Write an essay on ketone bodies synthesis and utilization. How are these
processes regulated? Add a note on clinical significance of ketone bodies. Nov
5. S.N
1. Ketogenesis and its clinical significance. Oct 2000
2. Formation of ketone bodies and their clinical significance. Feb 2007
3. Synthesis and utilization of ketone bodies. Aug 2007
4. Ketone bodies-with its clinical significance and tests for detection. Nov
5. Ketone bodies. Feb 2005
6. Ketone bodies and mention Laboratory evaluation of ketoacidosis. Feb
7. Ketosis. Nov 95; April 98; March 2002
1. Ketone bodies are three water-soluble compounds that are produced as by-products
when fatty acids are broken down for energy in the liver and kidney. They are used as
a source of energy in the heart and brain. In the brain, they are a vital source of
energy during fasting. Acetone, however, is an exception, since it cannot be

2. The three ketone bodies are acetone, acetoacetic acid, and beta-hydroxybutyric acid,
although beta-hydroxybutyric acid is not technically a ketone but a carboxylic acid.
Acetoacatate is primary ketone body while acetone and beta-hydroxybutyric acid are
secondary ketone bodies.
3. Synthesis is in liver mitochondria. During starvation and in diabetes mellitus, acetyl
CoA takes alternate pathway to form ketone bodies.
Ketogenesis: Acetyl CoA formed by oxidation of fatty acids, pyruvate or some amino acids,
is the precursor for ketone bodies.
1. Condensation: 2 molecules of Acetyl CoA condense to form aceto acetyl CoA
(aceto acetyl CoA synthetase)
2. Production of HMG CoA: 1 molecule of acetyl CoA again combines with aceto
acetyl CoA to form HMG CoA
HMG CoA synthase
Acetyl CoA + Aceto acetyl CoA ----------------HMG CoA
3. Lysis: HMG CoA is lysed to form acetoacetate by HMG CoA lyase.
HMG CoA lyase
HMG CoA ------------------------- Acetoacetate+Acetyl CoA
4. Reduction: Acetoacetate is reduced to Beta-hydroxy butyrate by dehydrogenase.
Acetoacetate + NADH+ + H+Beta-hydroxy butyrate+ NAD+
5. Spontaneous decarboxylation: Acetone is also produced from acetoacetate
spontaneously by decarboxylation.
Acetoacetate acetone + co2
Ketolysis : Use of ketone bodies by the peripheral tissues
1. Ketone bodies are formed in liver. But they are utilised by heart and kidney in
preference to glucose. Skeletal muscles and brain also use ketone for fuel in the
absence of glucose.
2. Steps:
1. Acetoacetate is is activated to acetoacetyl CoA by thiophorase.
Acetoacetate + succinyl CoA---------------- acetoacetyl CoA + Succinate
2. Acetoacetyl CoA enters beta oxidation pathway to produce energy.
1. Role of hormones: high glucagon insulin ratio is ketogenic
1. Glucagon:
1. Inhibits glycolysis
2. Activates gluconeogenesis






3. Activates lipolysis
4. Decreases [ydroxy CoA level
2. Insulin:
1. Favours Glycolysis
2. Depresses lipolysis
3. Increases [ydroxy CoA
2. Regulation of ketogenesis:
1. Level 1. Lipolysis: insulin inhibits lipolysis and glucagon favours lipolysis
2. Level 2: Increased CAT1 an decreased [ydroxy CoA stimulate beta
oxidation and increases acetyl CoA; decreased utilization leads to ketone
3. Level 3: acetyl CoA has to be oxidised in the citric acid cycle; due to
increased glcagon-insulin ratio more Gluconeogenesis takes place and
oxaloacetate is diverted to Gluconeogenesis; reduced utilization of acetyl
CoA diverts it to ketogenic pathway.
Definition:When ketone synthesis exceeds utilization ketonemia and ketonuria and smell
of ketone in breath occur. All these three constitute ketosis.
Blood level of ketone bodies is less than 1 mg/dl. Only traces are excreted in urine
1. Untreated diabetes mellitus: insulin deficiency causes increased lipolysis and
fatty acids in circulation. More acetyl CoA is available but could not be oxidised
due to lack of oxaloacetate and hence ketone formation.
2. Prolonged fasting: blood glucose is less; oxaloacetates are channelled to
Gluconeogenesis; glucagon favours ketogenesis from surplus acetyl CoA;
3. Hyper emesis gravidorum also leads to starvation like condition with ketosis.
Diagnosis: Laboratory evaluation of ketones:
1. The presence of ketosis can be established by the detection of ketone bodies in
urine by Rothera's test.
2. Supportive evidence may be derived from estimation of serum electrolytes, acidbase parameters, glucose and urea estimation.
3. Rotheras test: saturate 5 ml of urine with solid ammonium sulphate; add a few
drops freshly prepared sodium nitroprusside followed by 2 ml of liquid ammonia
along the sides of test tube. Purple ring indicates ketone bodies.
4. Gerhadt's test for acetoacetic acid: To 5 ml of urine, add dilute ferric chloride
solution drop by drop, till a maximum precipitate of ferric phosphate is obtained.
This is to eliminate the phosphates which may obscure the color in the test. Filter.
To the filtrate add excess ferric chloride. A red color indicates the presence of
acetoacetic acid. This is not a sensitive test. Salicylates will give a false positive
5. There is no specific test for beta hydroxy butyric acid.
6. Differential diagnosis:
1. Urine of diabetic keto acidosis will give positive Benedict and Rotheras
2. Urine of starvation ketosis will give negative Benedict and positive
Rotheras test.
1. Insulin and glucose
2. Bicarbonate and electrolyte maintenance
Significance of ketosis
1. Ketoacidosis is an extension of normal physiological mechanisms that
compensate for starvation. Normally, in the fasting state, the body changes from

metabolism based on carbohydrate, to fat oxidation. Free fatty acids are produced
in adipocytes, and transported to the liver bound to albumin. There they are
broken down into acetate, and then turned into ketoacids (acetoacetate and betahydroxybutyrate). The ketoacids are then exported from the liver to peripheral
tissues (notably brain and muscle) where they can be oxidised.
2. Diabetic keto acidosis (DKA) represents a derangement of the above mechanism.
Despite vast amounts of circulating glucose, this carbohydrate cannot be used
owing to lack of insulin.
3. Insulin normally blocks ketogenesis by inhibiting the transport of FFA derivatives
into the mitochondrial matrix, but ketogenesis proceeds in the absence of insulin.
7. Biochemical basis and consequences of excess production of ketone bodies in diabetes
mellitus and
1. Biochemical basis:
Diabetes Mellitus:
a. Uncontrolled diabetes mellitus is the most common cause for ketosis. Even
though glucose is in plenty, the deficiency of insulin causes accelerated
lipolysis and more fatty acids are released into circulation. This is seen most
often in cases of uncontrolled, type 1 diabetes mellitus.
b. Oxidation of these fatty acids increases the acetyl CoA pool. Enhanced
gluconeogenesis restricts the oxidation of acetyl CoA by TCA cycle, since
availability of oxaloacetate is less.
c. In diabetes mellitus, the blood level of glucagon is increased. Glucagon
inhibits glycolysis, activates gluconeogenesis, activates lipolysis, decreases
malonyl CoA level and stimulates ketogenesis. High glucagoninsulin ratio is
potentially ketogenic.
d. Insulin has the opposite effect; it favors glycolysis, inhibits gluconeogenesis,
depresses lipolysis, increases malonyl CoA level and decreases ketogenesis.
The ketone body formation is regulated at the following 3 levels:
a. the dietary supply of glucose is decreased. Available oxaloacetate is channelled to
gluconeogenesis. The increased rate of lipolysis is to provide alternate source of
fuel. The excess acetyl CoA is converted to ketone bodies.
b. The high glucagon level favors ketogenesis. The brain derives 60-75% of energy
from ketone bodies under conditions of prolonged starvation.
8. Consequences of excess production of ketone bodies:
1. Metabolic acidosis: Acetoacetate and betahydroxy butyrate are acids. When
they accumulate, metabolic acidosis results
2. Reduced buffers: The plasma bicarbonate is used up for buffering of these
3. Kussmaul's respiration: Patients will have typical acidotic breathing due to
compensatory hyperventilation.
4. Smell of acetone in patient's breath.
5. Dehydration due to osmotic diuresis induced by ketonuria
6. Loss of Na and K in urine as they are excreted with ketone bodies.
7. Coma due to hypokalemia, dehydration and acidosis.



1. Compare the metabolic changes in well fed state and starvation. Sep 2002
2. Role of liver in integration of metabolism during post prandial state. Oct
1. In the first stage, digestion in the gastrointestinal tract converts the macromolecules
into small units. For example, proteins are digested to amino acids. This is called
primary metabolism.
2. Then these products are absorbed, catabolized to smaller components, and
ultimately oxidized to CO2. The reducing equivalents are mainly generated in the
mitochondria by the final common oxidative pathway, citric acid cycle. In this
process, NADH or FADH2 are generated. This is called secondary or intermediary
3. Then these reduced equivalents enter into the electron transport chain (ETC, or
Respiratory chain), where energy is released. This is the tertiary metabolism or
cellular respiration.
4. The metabolic pathways, in general, are controlled by four different mechanisms
1. The availability of substrates
2. Allosteric regulation
3. Covalent modification of enzymes
4. Regulation of enzyme synthesis
1. The absorptive state is the 2 to 4 hours period after ingestion of a normal
2. During this period transient increase in plasma glucose, amino acid, and
triacylglycerols occur.
3. Islet tissue of the pancreas responds to the elevation level of glucose and
aminoacids with an increase of insulin and a drop in the secretion of glucagon.
4. It is an anabolic period with increased synthesis of glycogen, triacylglycerols
and protein.
5. During this absorptive period all tissues use glucose as fuel.
Enzyme changes in the fed state:
A. Allosteric effects:
a. Glycolysis in the liver is stimulated following a meal by increase in fructose 2,
6 biphosphate, an allosteric activator of phosphofructokinase.
b. Gluconeogenesis is inhibited by fructose 2,6-biphosphate, an inhibitor of
fructose 1, 6-biphosphate. Allosteric effects work within minutes.
B. Regulation of enzymes by covalent modification
a. Many enzymes are regulated by covalent modification, (phosphorylation and
de phosphorylation).
b. In the fed state most of the enzymes regulated by covalent modification are in
dephosphorylated state and become active. e.g. Pyruvate kinase, Pyruvate
dehydrogenase complex, glycogen synthase HMG CoA reductase and acetyl
CoA carboxylase.
C. Induction enzyme synthesis
a. In the fed state, elevated insulin levels result in an increase in the synthesis of
key enzymes, such as acetyl coenzyme A (CoA) carboxylase and 3-hydroxy-3methylglutaryl- coenzyme A (HMG-CoA) reductase involved in anabolic

Role of various organs in well-fed metabolic state:
1. Liver in integration of metabolism during post prandial state:
1. Carbohydrate metabolism: Hepatic metabolism of glucose is increased
by the following mechanism
a. Increased phosphorylation of glucose: High levels of intra cellular
glucose in the hepatocyte stimulates glucokinase to phosphorylate
glucose to glucose 6-phosphate
b. Increased Glycolysis: The conversion of glucose to pyruvate to
acetyl CoA is stimulated by the elevated insulin to glucagon ratio that
activates the key enzymes of glycolysis
c. Increased activity of the hexose monophosphate pathway
(HMP): The increased availability of glucose 6-phosphate in the wellFed state, combined with the active utilization of NADPH in hepatic
lipogenesis, stimulate the HMP
d. Increased Glycogenesis: Increased glucose -6 phosphate activate
glycogen synthase the key enzyme of glycogensis
e. Decreased gluconeogenesis: The high insulin to glucagon ratio
inhibits enzymes of gluconeogenesis, such as fructose 1,6bisphosphatase
2. Fat metabolism:
a. Increased fatty acid synthesis: Due to increase acetyl CoA and
NADPH the substrates for de novo synthesis of fatty acids
b. Increased triacyl glycerol synthesis: due to increased
availability of fatty acids
3. Amino acid metabolism
a. Increased protein synthesis: stimulated by insulin
b. Increased amino acid degradation: In the absorptive period,
more aminoacids are present than the liver can use in the synthesis
of proteins and other nitrogen compound. The excess aminoacids
are either released into the blood for all tissues to use in protein
synthesis or are deaminated to produce energy. The body cannot
store proteins.
2. Adipose tissue
1. Adipose tissue is regarded as the energy storage tissue.
2. Carbohydrate metabolism : The uptake of glucose is increased. This
follows an increase in glycolysis and hexosemonophosphate shunt.
3. Lipid metabolism : The synthesis of fatty acids and triacylglycerols is
increased. The degradation of triacyl glycerol is inhibited.
3. Skeletal mussle:
1. Carbohydrate metabolism : The uptake of glucose is higher, and glycogen
synthesis is increased.
2. Lipid metabolism : Fatty acids taken up from the circulation are also
important fuel sources for the skeletal muscle.
3. Protein metabolism : Incorporation of amino acids into proteins is higher
4. Brain:
1. Carbohydrate metabolism: In an absorptive state, glucose is the only fuel
source to the brain. About 120 g of glucose is utilized per day by an adult
brain.This constitutesa bout 6O % of the glucose consumed by the body at
2. Lipid metabolism : The free fatty acids cannot cross the blood-brain
barrier, hence their contribution for the supply of energy to the brain is
insignificant. Further, in a fed state, ketone bodies are almost negligible as
fuel source to the brain. However, brain predominantly depends on ketone
bodies during prolonged starvation


Metabolism in starvation
1. In the absence of food, plasma levels of glucose, amino acids, and TAG fall, triggering
a decline in insulin secretion and an increase in glucagon release.
2. The decreased insulin to glucagon ratio, and the decreased availability of circulating
substrates, make the period of nutrient deprivation a catabolic period characterized
by degradation of TAG, glycogen, and protein to :
a. Maintainsufficient plasma levels of glucose for energy metabolism of the brain
and other glucose requiring tissues
b. Mobilize fatty acids from adipose tissue and ketone bodies from liver to supply
energy to all other tissues.
Adaptations in starvation:
1. Fuel stores:
1. caloric stores available in the form of TAG and glycogen.
2. One third of the bodys protein can also be used for energy production
without fatally compromising vital functions.
2. Enzymic changes in fasting
1. In fasting, the flow of intermediates through the pathways of energy
metabolism is controlled by four mechanisms:
i. The availability of substrates;
ii. Allosteric regulation of enzymes;
iii. Covalent modification of enzymes; and
iv. Induction-repression of enzyme synthesis.
2. The metabolic changes observed in fasting are generally opposite to those
described for the absorptive state. For example, most of the enzymes
regulated by covalent modification are dephosphorylated and active in
the fed state, whereas in the fasted state, they are phosphorylated and
3. Metabolic Adaptations During Starvation
Stage 1: Glycogenolysis
i. First glucose is maintained by hepatic Glycogenolysis; this is
sufficient for about 18 hours. Brain needs of glucose are met.
Stage 2: Gluconeogenesis
i. Soon Gluconeogenesis is accelerated using aminoacids from
ii. The amino nitrogen is transferred from aminoacids to pyruvate
to form alanine.
iii. Alanine enters liver and transaminated to pyruvate to enter
Gluconeogenesis: glucose-alanine cycle.
iv. Glutamic acid also serves similar cycle.
v. Muscles use branched chain aminoacids like leucine and
isoleucine from protein breakdown to give energy.
vi. Brain takes up glucogenic valine from blood stream.
vii. The plasma level of branched chain aminoacids peaks on 5th
day of starvation
Stage 3: Lipolysis
1. There is high glucagon-insulin ratio which stimulates cAMP
mediated lipolysis by increasing the hormone sensitive lipase
2. Skeletal muscle, heart and kidney shut down their glucose
utilization and shift to fatty acid cycle for energy needs. This is


Stage 4:

brought by inactivation of pyruvate dehydrogenase by

Glucagon stimulates CAT enzymes to increase the rate of beta
Acetyl CoA and ketone bodies provide source of fuel for skeletal
muscle, heart and kidney and to some extent brain.
Excessive ketone bodies leads to metabolic acidosis
Bicarbonate buffering is exceeded; pH falls and hyperventilation

Stage 5: death
1. Metabolic acidosis and dehydration unless treated lead to death.
Note: Normal person may have fuel reserve for 45-60 days after
which death supervenes.
Metabolic Changes in various organs during starvation:
1. Brain:
1. There is no stored fuel in the brain. Glucose, the preferred fuel for the
brain, should be in continuous supply. Glucose can freely enter the brain
2. The brain is unable to utilize fatty acids as a source of fuel since the fatty
acids complexed to albumin are unable to traverse the blood brain barrier.
But, brain can effectively utilize acetoacetate.
3. During starvation, a significant part (60-70%) of the energy requirement of
the brain is then met by ketone bodies.
2. Skeletal Muscle:
1. During starvation, maximum glucose is spared for the brain. The free fatty
acid (FFA) mobilized from adipose tissue is the preferred fuel for muscle
during starvation. FFA does not require insulin, and during fasting insulin
level is low.
2. During prolonged starvation, muscle protein breakdown occurs and alanine
is released to the blood stream. It is transported to liver to provide
substrate for gluconeogenesis (glucose-alanine cycle).
3. The metabolic fuel during prolonged fasting is ketone bodies. Branched
chain amino acids are utilized by the skeletal muscle.
3. Adipose tissue:
1. During fasting, triglycerides in the adipose tissue are hydrolysed. Cyclic
AMP mediated activation of hormone sensitive lipase occurs in response to
the high glucagon-insulin ratio.

2. Glucocorticoids also have a stimulant lipolytic effect during fasting.
4. Liver:
1. During starvation, liver provides glucose by glycogenolysis and later by
gluconeogenesis so that the obligatory requirements of the brain are met.
2. Moreover, liver also produces the ketone bodies, an alternate source of
fuel. But the liver cannot use ketone bodies as its own fuel.
1. Fatty liver and lipotropic factors. Sep 2002;
2. Alterations in biochemical investigations in cirrhosis of liver. Oct 203
1. Fatty liver refers to the deposition of excess triglycerides in the liver cells.
2. Liver is not a storage organ of fat. In the normal liver, Kupffer cells contain lipids in the
form of droplets. In fatty liver, droplets of triacylglycerols are found in the entire
cytoplasm of hepatic cells. This causes impairment in metabolic functions of liver. Fatty
liver is associated with fibrotic changes and cirrhosis.
3. Causes of Fatty Liver
1. Excess fat deposition in liver
i. Mobilization of NEFA from adipose tissue.
ii. Excess synthesis of fatty acid from glucose.
2. Reduced removal of fat from liver
1. Toxic injury to liver. Secretion of VLDL needs synthesis of apo B-100 and
apo C.
2. Decreased oxidation of fat by hepatic cells.
4. Excessive mobilization of fat:
The capacity of liver to take up the fatty acids from blood far exceeds its capacity for
excretion as VLDL. So fatty liver can occur in diabetes mellitus and starvation due to
increased lipolysis in adipose tissue
5. Excess calorie intake:
Excess calories, either in the form of carbohydrates or as fats, are deposited as fat.
Hence fatty liver may accompany obesity.
3. Toxic injury to liver:
1. Poisoning by compounds like carbon tetrachloride, arsenic, lead, etc. can
decrease the capacity to synthesise VLDL leading to fatty infiltration of liver
2. In protein energy malnutrition (PEM) fatty live is due to defective apoprotein
3. Hepatitis B virus infection reduces the function of hepatic cells.
4. Alcoholism
1. It is the most common cause of fatty liver and cirrhosis in India.
2. Alcohol is oxidized to acetaldehyde. This reaction produces increased quantities of
NADH, which converts oxalo-acetate to malate. As the availability of oxaloacetate is reduced, the oxidation of acetyl CoA through citric acid cycle is reduced
3. So fatty acid accumulates leading to TAG deposits in liver.
5. Nonalcoholic Fatty Liver Disease (NAFLD) and Nonalcoholic Steatohepatitis (NASH)
1. NAFLD is the most common liver disease, where fat is accumulated in
2. High fat diet and uncontrolled diabetes mellitus are the most common causes.
3. As the disease progresses, inflammatory reaction occurs, which is then termed as
6. Fatty liver progresses to cirrhosis
1. Fat molecules infiltrate the cytoplasm of the cell (fatty infiltration). These are seen
as fat droplets, which are merged together so that most of the cytoplasm
becomes laden with fat.
2. The nucleus is pushed to a side of the cell, nucleus disintegrates (karyorrhexis),
and ultimately the hepatic cell is lysed.

3. As a healing process, fibrous tissue is laid down, causing fibrosis of liver,
otherwise known as cirrhosis. Liver function tests show abnormal values when
chronic liver damage occurs.
Lipotropic Factors
1. They are required for the normal mobilisation of fat from liver. Therefore,
deficiency of these factors may result in fatty liver. They can afford protection
against the development of fatty liver.
2. They act by anti-oxidant effects and favouring synthesis of apoprotein and
methyl groups for Carnitine and hence they protect against fatty changes of
4. Lecithin and methionine. They help in synthesis of apoprotein and choline
formation. The deficiency of methyl groups for carnitine synthesis may also hinder
fatty acid oxidation.
5. Choline deficiency and fatty tiver: Feeding of choline has been able to reverse
fatty changes in animals. Several explanationsa re offeredt o understand choline
deficiency causing fatty liver :
1. Decreased phospholipid synthesis
2. lmpaired formation of lipoprotein memorane
3. Reduced synthesis of carnitine due to insufficient supply of methyl groups
4. lmpairment in fatty acid oxidation
6. Vitamin E and selenium give protection due to their anti-oxidant effect.
7. Omega 3 fatty acids present in marine oils have a protective effect against fatty
8. Severe protein deficiency (e.g. kwashiorkor) causes fatty liver. This is due to a
defect in the synthesis of choline as a result of insufficient amino acid (par t icular
lym ethionine) supply. In other words the non-avai labi l i tyo f methyl groups may
lead to fatty liver
1. The adipose tissue serves as a storage site for excess calories ingested. The
triglycerides stored in the adipose tissue are not inert.
2. They undergo a daily turnover with new triacyl glycerol molecules being synthesized
and a definite fraction being broken down.
Adipose Tissue in Well-fed Condition
1. Under well-fed conditions, active lipogenesis occurs in the adipose tissue.
2. The dietary triglycerides transported by chylomicrons and the endogenously
synthesized triglycerides from liver brought by VLDL are both taken up by adipose
tissue and esterified and stored as TAG.
3. In well-fed condition, glucose and insulin levels are increased. GluT4 in adipose
tissue is insulin dependent. Insulin increases the activity of key glycolytic
enzymes as well as pyruvate dehydrogenase, acetyl CoA carboxylase and glycerol
phosphate acyl transferase. The stimulant effect of insulin on the uptake of
glucose by adipose tissue, on the glycolysis and on the utilisation of glucose by
HMP pathway also enhances lipogenesis.
4. Insulin also causes inhibition of hormone sensitive lipase, and so lipolysis is
Adipose Tissue in Fasting Condition
3. The metabolic pattern totally changes under conditions of fasting. TAG from the
adipose tissue is mobilised under the effect of the hormones, glucagon and

4. The cyclic AMP mediated activation cascade enhances the intracellular hormone
sensitive lipase. The phosphorylated form of the enzyme is active which acts on
TAG and liberates fatty acids.
5. Under conditions of starvation, a high glucagon, ACTH, glucocorticoids and
thyroxine have lipolytic effect.
6. The released free fatty acids (FFA) are taken up by peripheral tissues as a fuel.
Adipose Tissue and Diabetes Mellitus:
1. Lipolysis is enhanced and high FFA level in plasma is noticed in diabetes mellitus.
2. The insulin acts through receptors on the cell surface of adipocytes. These
receptors are decreased, leading to insulin insensitivity in diabetes. In type 2
diabetes mellitus, there is insulin resistance and the different insulin signaling
pathways are affected differently.
3. Hepatic gluconeogenesis occurs uninhibited leading to hyperglycemia. However,
increased mobilization of fatty acids from adipose tissue and the persistently high
free fatty acid levels in the presence of hyperinsulinemia stimulate synthesis of
triacyl glycerol.
4. The overproduction of TAG leads to increased release of VLDL from liver causing
hypertriglyceridemia. The excess deposition of TAG in adipose tissue accounts for
the obesity prevalent in type 2 diabetes patients.
Adipose Tissue and Obesity:
1. The fat content of the adipose tissue can increase to unlimited amounts,
depending on the amount of excess calories taken in. This leads to obesity.
2. Plasma insulin level is high. But the insulin receptors are decreased; and there is
peripheral resistance against insulin action.
3. When fat droplets are overloaded, the nucleus of adipose tissue cell is degraded,
cell is destroyed and TAG becomes extracellular. Such TAG cannot be
metabolically reutilised and forms the dead bulk in obese individuals.
Adipokines (Adipose Tissue Derived Hormones):
1. Adipokines are a group of active factors involved in maintenance of energy
homeostasis as well as resistance to insulin.
2. The important adipokines are leptin, adiponectin, resistin, TNF-alpha (tumor
necrosis factor) and IL-6 (interleukin-6).
3. Leptin is a small peptide, produced by adipocytes. Leptin receptors are present in
specific regions of the brain. The feeding behavior is regulated by leptin. A defect
in leptin or its receptor, can lead to obesity. Leptin also prepares body to adapt for
starvation. Leptin regulates energy balance and exerts an insulin sensitising
effect. Decreased level of leptin increases the occurrence of obesity.
4. Adiponectin is another polypeptide which increases the insulin sensitivity of
muscle and liver and exerts an antiatherogenic effect. Low levels of adiponectin
will accelerate atherosclerosis. Low levels are also observed in patients with
metabolic syndrome.
5. Increased secretion of TNF-alpha and IL-6 will decrease insulin action on muscle
and liver.
White Adipose Tissue
1. It is mainly concerned with energy storage. It is made up of spherical cells, with
very few mitochondria.
2. The triglycerides form the major component of white adipose tissue (about 80%)
with oleic acid being the most abundant fatty acid (50%).
Brown adipose tissue is involved in thermogenesis.

1. Brown adipose tissue cells are polygonal with more abundant cytoplasm. The
brown color is due to the presence of numerous mitochondria. It is primarily
important in newborn human beings and adult hibernating animals.
2. Thermogenesis is a process found in brown adipose tissue. Heat is liberated by
uncoupling oxidation from phosphorylation. So energy is released as heat, instead
of trapping it in the high energy bonds of ATP.
Liver-Adipose Tissue Axis
1. Liver produces fatty acid and TAG (triacyl glycerol), which is transported as VLDL
(very low density lipoprotein) in the blood. The fatty acids from VLDL are taken up
by adipose tissue with the help of lipoprotein lipase, and stored as TAG. This
neutral fat is hydrolysed by hormone sensitive lipase into NEFA, which is carried
by albumin in blood.
2. The NEFA is utilised by the peripheral tissues, excess of which can be taken up by
liver cells. Thus there is a constant flux of fat molecules from liver to adipose
tissue and back.