Carnitine, Choline, Cancer, & Cholesterol: The TMAO Connection

Carnitine, Choline, Cancer, & Cholesterol: The TMAO Connection
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Expanding on the subject of my upcoming appearance on The Dr. Oz Show, a landmark new article in the New England Journal of Medicine shows that choline in eggs, poultry, dairy, and fish produces the same toxic TMAO as carnitine in red meat—which may help explain plant-based protection from heart disease and prostate cancer.

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Earlier this month, a research team at the Cleveland Clinic offered a novel explanation as to why meat intake may be related to mortality. “Numerous studies have suggested a decrease in atherosclerotic disease risk [heart disease, our #1 killer] in vegan and vegetarian individuals compared to omnivores; [but, we’ve just assumed this was due to reduced intake] of dietary cholesterol and saturated fat…”

But, what these researchers found was that within 24 hours of carnitine consumption—eating a sirloin steak, taking a carnitine supplement—certain gut bacteria metabolize the carnitine to a toxic substance called trimethylamine, which then gets oxidized in our liver to TMAO (trimethylamine-n-oxide), which then circulates throughout our bloodstream.

The way we know it’s the gut bacteria that’s doing it, is that if you give people antibiotics to wipe out gut bacteria, you can apparently eat all the steak you want without making any TMAO. But then, if you wait a couple weeks, until your gut bacteria grows back, you’re back to the same problem. 

What’s so bad about this TMAO stuff? Well, it may increase the risk of buildup of cholesterol in the inflammatory cells in the atherosclerotic plaques in our arteries, increasing our risk of heart attack, stroke, death—and, if that isn’t enough, cardiac surgery, as well.

So, how do you stay away from carnitine? Well, there’s zero dietary requirement; our body normally makes all that we need. The problem is that the bodies of other animals also makes all that they need, so when we eat them, their carnitine can end up in our gut for those bacteria to feast upon—resulting in TMAO. Some animals make more than others; carnitine is concentrated in red meat. So, then, why is there also clip art of white meat, dairy, and eggs?

That is what most media reports missed—even though it’s the very first sentence of the paper. How do you think the researchers even thought to look into carnitine? Because gut bacteria can turn choline into TMAO, too! Given the similarity in structure between carnitine and choline, they figured that the same kind of transformation would occur into TMAO. And, that’s exactly what they found.

“Eggs, milk, liver, red meat, poultry, shell fish, and fish,…[all] believed to be major dietary sources of choline, and, hence TMAO production.” So it’s not just red meat. The good news is that this may mean a new approach “to prevent or treat heart disease,” the most obvious of which would be “to limit dietary choline intake.” But, if that means decreasing egg, meat, and dairy consumption, then the new approach sounds an awful lot like the old approach.

Unlike carnitine, we do need to take in some choline, so should vegans be worried about the choline they’re getting from beans, veggies, grains, and fruit? And, same question with carnitine. There’s a small amount of carnitine found in fruits, veggies, and grains, as well. Of course, it’s not the carnitine itself we’re worried about, but the toxic TMAO, and you can feed a vegan a steak—literally, an eight-ounce sirloin (anything in the name of science). Same whopping carnitine load, but, essentially no TMAO was produced.

Apparently, the vegans don’t develop those TMAO-producing bacteria in their gut. And, why should they? It’s like the whole prebiotic story. You eat a lot of fiber, and you select for fiber-consuming bacteria.  And, some of the compounds they make with fiber are beneficial, like the propionate I’ve talked about, that appears to have an anti-obesity effect.

So, eat fiber; select for fiber-eating bacteria. Well, if we eat a lot of animal products, we may instead be selecting for animal product-digesting bacteria, and it appears some of those waste products, like the trimethylamine, may be harmful.

Even if you eat vegan, though, you’re not necessarily out of the woods. If you regularly drink carnitine-containing energy drinks, or take carnitine supplements, or lecithin supplements, which contain choline, presumably you’d foster and maintain those same kinds of TMAO-producing bacteria in your gut, and increase your risk of heart disease and, perhaps, cancer.

About two million men in the U.S. are living with prostate cancer, but that’s better than dying from prostate cancer. Catch it when it’s localized, and your five-year survival is practically guaranteed. But, once it really starts spreading, your chances drop to about one in three.

“Thus, identification of modifiable factors that affect the progression of prostate cancer is [something that deserves study].” So, researchers at Harvard took more than a thousand men with early stage prostate cancer, and followed them for a couple years to see if there was anything in their diet associated with a resurgence of the cancer, such as a spread to the bone.

Compared to men who hardly ate any eggs, men who ate even less than a single egg a day had “a significant 2-fold increased risk of prostate cancer progression.” And, maybe it’s the choline.

“A plausible mechanism that may explain [the]…association between eggs and prostate cancer progression is high dietary choline.” Egg consumption is a determinant of how much choline you have in your blood, and higher blood choline has been associated with “a greater risk” of getting prostate cancer in the first place. So, the choline in eggs may both increase one’s risk of getting it, and then, having it spread, and, also, having it kill you.

“Choline intake and [the] risk of lethal prostate cancer.” Choline consumption is associated not just with getting cancer, and spreading cancer, but also with a significantly increased risk of dying from it. Those who ate the most “had a 70% increased risk of lethal prostate cancer.”

Another recent study found that men who consumed two and a half or more eggs per week—that’s just like one egg every three days—”had an 81% increased risk of lethal prostate cancer.” Now, it could just be the cholesterol in eggs that’s increasing fatal cancer risk, but it could also be that choline.

Maybe that’s why meat, milk, and eggs have all been associated with advanced prostate cancer, because of the choline. In fact, choline is so concentrated in cancer cells, if you follow choline uptake in the body, you can track the spread of cancer throughout your body.

But why may dietary choline increase the risk of lethal prostate cancer? It may be the TMAO, the trimethylamine oxide. The Harvard researchers speculated that the TMAO from the “high dietary choline [intake] may increase inflammation, and this may promote progression of prostate cancer to lethal disease.”

In fact, just yesterday, in the New England Journal of Medicine, that same Cleveland Clinic research team that did the carnitine study repeated the study. But, this time, instead of feeding people a steak, they fed people some hard-boiled eggs. And, just as they suspected, a similar spike in that toxic TMAO. So, it’s not just the red meat. And the link between TMAO levels in the blood and strokes, heart attacks, and death was seen even in low-risk groups like those with low-risk cholesterol levels. So, eating eggs may increase our risk regardless what our cholesterol is, because of the choline. 

It’s ironic that the choline content of eggs is something the egg industry actually boasts about. And, the industry is aware of the cancer data. Through the Freedom of Information Act, I was able to get my hands on an email from the executive director of the industry’s Egg Nutrition Center to an American Egg Board executive talking about how choline may be a culprit in promoting cancer progression: “Certainly worth keeping in mind as we continue to promote choline as another good reason to consume eggs.”

Please consider volunteering to help out on the site.

Image thanks to Nature

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Earlier this month, a research team at the Cleveland Clinic offered a novel explanation as to why meat intake may be related to mortality. “Numerous studies have suggested a decrease in atherosclerotic disease risk [heart disease, our #1 killer] in vegan and vegetarian individuals compared to omnivores; [but, we’ve just assumed this was due to reduced intake] of dietary cholesterol and saturated fat…”

But, what these researchers found was that within 24 hours of carnitine consumption—eating a sirloin steak, taking a carnitine supplement—certain gut bacteria metabolize the carnitine to a toxic substance called trimethylamine, which then gets oxidized in our liver to TMAO (trimethylamine-n-oxide), which then circulates throughout our bloodstream.

The way we know it’s the gut bacteria that’s doing it, is that if you give people antibiotics to wipe out gut bacteria, you can apparently eat all the steak you want without making any TMAO. But then, if you wait a couple weeks, until your gut bacteria grows back, you’re back to the same problem. 

What’s so bad about this TMAO stuff? Well, it may increase the risk of buildup of cholesterol in the inflammatory cells in the atherosclerotic plaques in our arteries, increasing our risk of heart attack, stroke, death—and, if that isn’t enough, cardiac surgery, as well.

So, how do you stay away from carnitine? Well, there’s zero dietary requirement; our body normally makes all that we need. The problem is that the bodies of other animals also makes all that they need, so when we eat them, their carnitine can end up in our gut for those bacteria to feast upon—resulting in TMAO. Some animals make more than others; carnitine is concentrated in red meat. So, then, why is there also clip art of white meat, dairy, and eggs?

That is what most media reports missed—even though it’s the very first sentence of the paper. How do you think the researchers even thought to look into carnitine? Because gut bacteria can turn choline into TMAO, too! Given the similarity in structure between carnitine and choline, they figured that the same kind of transformation would occur into TMAO. And, that’s exactly what they found.

“Eggs, milk, liver, red meat, poultry, shell fish, and fish,…[all] believed to be major dietary sources of choline, and, hence TMAO production.” So it’s not just red meat. The good news is that this may mean a new approach “to prevent or treat heart disease,” the most obvious of which would be “to limit dietary choline intake.” But, if that means decreasing egg, meat, and dairy consumption, then the new approach sounds an awful lot like the old approach.

Unlike carnitine, we do need to take in some choline, so should vegans be worried about the choline they’re getting from beans, veggies, grains, and fruit? And, same question with carnitine. There’s a small amount of carnitine found in fruits, veggies, and grains, as well. Of course, it’s not the carnitine itself we’re worried about, but the toxic TMAO, and you can feed a vegan a steak—literally, an eight-ounce sirloin (anything in the name of science). Same whopping carnitine load, but, essentially no TMAO was produced.

Apparently, the vegans don’t develop those TMAO-producing bacteria in their gut. And, why should they? It’s like the whole prebiotic story. You eat a lot of fiber, and you select for fiber-consuming bacteria.  And, some of the compounds they make with fiber are beneficial, like the propionate I’ve talked about, that appears to have an anti-obesity effect.

So, eat fiber; select for fiber-eating bacteria. Well, if we eat a lot of animal products, we may instead be selecting for animal product-digesting bacteria, and it appears some of those waste products, like the trimethylamine, may be harmful.

Even if you eat vegan, though, you’re not necessarily out of the woods. If you regularly drink carnitine-containing energy drinks, or take carnitine supplements, or lecithin supplements, which contain choline, presumably you’d foster and maintain those same kinds of TMAO-producing bacteria in your gut, and increase your risk of heart disease and, perhaps, cancer.

About two million men in the U.S. are living with prostate cancer, but that’s better than dying from prostate cancer. Catch it when it’s localized, and your five-year survival is practically guaranteed. But, once it really starts spreading, your chances drop to about one in three.

“Thus, identification of modifiable factors that affect the progression of prostate cancer is [something that deserves study].” So, researchers at Harvard took more than a thousand men with early stage prostate cancer, and followed them for a couple years to see if there was anything in their diet associated with a resurgence of the cancer, such as a spread to the bone.

Compared to men who hardly ate any eggs, men who ate even less than a single egg a day had “a significant 2-fold increased risk of prostate cancer progression.” And, maybe it’s the choline.

“A plausible mechanism that may explain [the]…association between eggs and prostate cancer progression is high dietary choline.” Egg consumption is a determinant of how much choline you have in your blood, and higher blood choline has been associated with “a greater risk” of getting prostate cancer in the first place. So, the choline in eggs may both increase one’s risk of getting it, and then, having it spread, and, also, having it kill you.

“Choline intake and [the] risk of lethal prostate cancer.” Choline consumption is associated not just with getting cancer, and spreading cancer, but also with a significantly increased risk of dying from it. Those who ate the most “had a 70% increased risk of lethal prostate cancer.”

Another recent study found that men who consumed two and a half or more eggs per week—that’s just like one egg every three days—”had an 81% increased risk of lethal prostate cancer.” Now, it could just be the cholesterol in eggs that’s increasing fatal cancer risk, but it could also be that choline.

Maybe that’s why meat, milk, and eggs have all been associated with advanced prostate cancer, because of the choline. In fact, choline is so concentrated in cancer cells, if you follow choline uptake in the body, you can track the spread of cancer throughout your body.

But why may dietary choline increase the risk of lethal prostate cancer? It may be the TMAO, the trimethylamine oxide. The Harvard researchers speculated that the TMAO from the “high dietary choline [intake] may increase inflammation, and this may promote progression of prostate cancer to lethal disease.”

In fact, just yesterday, in the New England Journal of Medicine, that same Cleveland Clinic research team that did the carnitine study repeated the study. But, this time, instead of feeding people a steak, they fed people some hard-boiled eggs. And, just as they suspected, a similar spike in that toxic TMAO. So, it’s not just the red meat. And the link between TMAO levels in the blood and strokes, heart attacks, and death was seen even in low-risk groups like those with low-risk cholesterol levels. So, eating eggs may increase our risk regardless what our cholesterol is, because of the choline. 

It’s ironic that the choline content of eggs is something the egg industry actually boasts about. And, the industry is aware of the cancer data. Through the Freedom of Information Act, I was able to get my hands on an email from the executive director of the industry’s Egg Nutrition Center to an American Egg Board executive talking about how choline may be a culprit in promoting cancer progression: “Certainly worth keeping in mind as we continue to promote choline as another good reason to consume eggs.”

Please consider volunteering to help out on the site.

Image thanks to Nature

Doctor's Note

The TMAO story is such a fascinating twist. It helps explain, for example, Harvard’s Meat & Mortality Studies. The role of the inflammatory “foam” cells (so-called because they’re so packed with cholesterol they look foamy under a microscope) affected by TMAO is explained in my video series that begins with Arterial Acne, and continues in Blocking the First Step of Heart Disease.

When I say we normally make all the carnitine we need, there’s a rare genetic inborn error of metabolism that affects as many as one in 40,000 births, which can result in a need for dietary carnitine. Learn more in When Meat Can Be a Lifesaver.

What does carnitine do? It’s involved in energy production in the mitochondria (“power plants”) in our cells. The enzyme that uses carnitine to help us burn fat (carnitine palmitoyl transferase) is actually upregulated by about 60% in those eating meat-free diets—which may help explain why those eating plant-based diets tend to be slimmer. More details in How to Upregulate Metabolism.

For more on TMAO see:

The prebiotic videos I feature are Fawning over Flora and Boosting Good Bacteria in the Colon without Probiotics, though other videos describing the beneficial products our friendly flora make from the plants we eat include:

And for another behind-the-curtain peek at the egg industry, see Eggs vs. Cigarettes in Atherosclerosis and Egg Industry Blind Spot.

For more context, check out my associated blog posts: Avoid Carnitine & Lethicin SupplementsWhy are Eggs Linked to Cancer Progression?; and Top 10 Most Popular Videos of 2013.

If you haven’t yet, you can subscribe to my videos for free by clicking here.

188 responses to “Carnitine, Choline, Cancer, & Cholesterol: The TMAO Connection

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  1. And the answer is NOT to pollute the meat further with antibiotics in the hope of wiping the bad-meat-eating-bacteria out. Probably the next suggestion from the meat industriy…




    3
    1. Don’t give them any ideas! But it does make you wonder if, in a lot of these studies, they will need to start enterotyping the test subjects and the food contaminants to make sense of the data.




      1
      1. Enterotyping seems logical enough, given Hazen was able to introduce a vegan (at least one-year of vegan diet) to the omnivore diet, and start TMA / TMAO production– but only after his GI tract had been populated with TMA-producing bacteria.




        1
    2. Isolating human omnivores from TMA producing bacteria is most effectively done by adopting a vegan diet, one which does not feed the bacteria. TMAO is not the only risk factor in cardiovascular disease, only a major risk.




      2
    3. The authors of the Mayo Clinic study found carnitine supplementation was associated with a 27% reduction in all-cause mortality, a 65% reduction in ventricular arrhythmias, and a 40% reduction in angina symptoms in patients experiencing a heart attack.1

      People with angina, an early sign of impaired blood flow (ischemia) to the heart muscle, benefited from carnitine supplements. A natural derivative of L-carnitine, propionyl-L-carnitine, at a dose of 500 mg 3 times daily , increased the average time patients could exercise without EKG signs of ischemia by an impressive 450%.10 That result indicated improved blood flow to heart muscle cells following ischemia, an effect amply demonstrated in animal studies.13,14

      http://www.lifeextension.com/magazine/2013/8/rebuttal-to-attack-against-carnitine/page-01




      2
  2. WOW!! I was all set to buy L-Carnitine supplements online! Thanks Dr.Greger!! What about about carnosine? I know it has documented affects againts AGE’s.




    0
  3. WOW!! I was all set to buy L-Carnitine supplements online! Thanks Dr.Greger!! What about about carnosine? I know it has documented affects againts AGE’s.




    0
    1. I’ve been taking carnitine and lecithin for several years- but today is the day I stop! I wonder how many of the 35 or so other supplements I take are harmful. From previous videos here, vitamins B-12 and D are okay, but I think I may not renew my subscription to Life Extension. By the way, instead of taking carnosine, you can take beta alanine which is much less expensive and produces carnosine in your body. Carnosine is broken down to beta alanine by your digestion anyway.




      1
      1. The only supplement I routinely recommend for patients is Vitamin B12. In my experience Life Extension can be a great way to get laboratory testing done. We used their services in the last Meals for Health program in the Berkeley/Oakland area. I avoid any other supplements unless a deficiency is documented. Unfortunately given the distribution of normal laboratory values in the normal population it is easy for medicine to change recommendations and to start recommending supplements or medications for people who are normal. If your Vitamin D level is low the best Rx is sunlight. Taking vitamin D supplement doesn’t improve the arterial system by the liberation of Nitrous Oxide from subcutaneous stores. Dr. Greger has yet to run a video on this subject… see the TED.com talk: Richard
        Weller: Could the sun be good for your heart? Of course their are times I recommend Vit D but very few.

        See




        0
        1. How can we “test” for choline deficiency? If you have access to full articles what where the actual dietary levels measured that correlated to increased prostate cancer risk? I am nervous only getting 300-400 mg/day as an adult male. But supplementing to the AI also makes me nervous.




          0
        2. Did you make the viewers aware it is not all sources of Choline that does this? I read the paper awhile ago and while eggs and other sources do cause these bad symptoms of increased cancer risk and increased prostate lethal cancer risk, not all of them do, and it is vital for our memory. Just be aware of the source you get it from. Like CDP Choline does not have this negative effect.




          1
            1. Hi Name, this is Dr. Daniela Sozanski PhD, Moderator with Nutritionfacts. My take on this is that since we do need about half a gram of choline daily, we are probably more safe in getting it from chickpeas, split peas, navy beans and cruciferous vegetables and not animal food. Regards, Daniela




              1
        3. What about iodine supplement? There is nowhere close to enough iodine in a regular vegan diet to meet the recommendations. The added iodine to salt is just a drop in the ocean.




          0
          1. it all depends on where you live and how much iodine is naturally in the soil. if you are concerned about it a blood test should be able to tell you whether you are getting enough. If you want to supplement I would suggest introducing a few sea vegetables like Kelp to your diet. However you can overdose on iodine as well so don’t go crazy.
            I agree that salt is not a good place to get your iodine from.




            1
      2. Beta alanine will reduce taurine. Taurine has a lot of healthy benefits. However, if you try taurine, start slow and give your body time to get used to it. Taurine will facilitate the removal of some toxins from cells. You don’t want a fast detox reaction.




        0
  4. Glad to hear you’re going to be on Dr. Oz. Not only will that help you to get the word and science out, but hopefully help Nutritionfacts.org with their fundraising!




    0
      1. Yeah, I was kind of surprised he didn’t take a more aggressive stance, but I guess he was either being diplomatic as to not alienate the audience, or the show had “policies” about what and how it was handled?




        0
  5. I saw something about this on CBS news earlier this week. INSTEAD of taking the opportunity to promote a plant-based diet they talked about drug companies hopefully being able to make a new drug to treat TMAO (insert face palm here). When are they going to figure this out. I wish HLN’s evening new show would include Dr. Greger several times a week. A reoccurring nutrition segment on national news would be wonderful and Dr. Greger keeps his information short and concise and throws in a little humor. It would be perfect for the masses!




    0
  6. I am currently taking the more bio available Acetyl-L Carnitine as a supplement for some of the studies dealing with it’s protective qualities toward hearing loss. Being a 25 year low fat eating Vegan, can I assume that I am fairly safe from the TMAO production and it’s effects you are referring to?




    0
  7. Don’t do this Michael. You are falling into the same trap they have.

    It is not the specific ingredients, either carnitine or lecithin, that is the problem. It is the gut flora that has developed in response to a refined ingredient and high sugar diet.

    Remember the 1875 patients were referred to their heart clinic because they already were really sick. Their gut flora was mainly firmicutes and some tenericutes, species that are not resident in a healthy gut flora.

    Restoring a healthy flora is the key here, not blaming highly processed ingredients that merely feed the bad bacteria. The liposaccharides from healthy flora does not raise TMA.

    Consuming polyphenols in veggies and fruits are the natural way to decrease firmicutes and support bacteroidetes and decrease heart disease. Antibiotics are not.




    0
    1. Yes, it’s more about the gut flora than isolated ingredients. Japan has one of the lowest rates of heart disease, South East and South Central Asia have the lowest rates of prostate cancer. They eat fish and eggs. But their gut bacteria is different to begin with. US microbiomes are more focused on degrading amino acids, while, for example, Malawian microbes are focused on digesting starches.




      0
    2. Douglas, are you suggesting that meat consumption is not the culprit here? Thank you for more clarity on your previous comments.




      0
      1. My thought as well. Japanese eat lots of sugar. Meat, not so much. Sugar is likely an issue here in the US because of the lack of whole plant foods in the diet and the excess calories sugar contributes here. In other words, portion sizes count.




        0
    3. Dr Greger is in no way advocating the use of antibiotics to treat CVD. Antibiotics merely confirmed the hypothesis that gut bacteria were involved in the conversion of carnitine and lecithin to TMAO. Which bacteria involved has not yet been determined.

      By now, I think it can be safely stated that pretty much anything we put down our gullets affects the ecosystem in our digestive tract.




      0
    1. AileenO: Friendly tip: Dr. Greger has a ‘Doctor’s Note’ under each of the videos. Above, you can see that Dr. Greger gives a link to a Facebook page where he will announce his Dr. Oz showing when he knows it. Hope that helps.




      0
  8. This was an awesome video Dr. Greger. Your research is so up-to-date and wide-reaching. Your presentation is engaging and succinct. Thank-you for this and so many excellent videos.




    0
  9. I think you should not say compared to omnivores but compared to meat
    eaters or vegetarians. As it gives the false idea that people are
    omnivores when really we are herbivores. So really people are not
    omnivores but herbivores that eat meat. Just like Panda’s are carnivores
    that eat bamboo.




    1
    1. The similarity of our body design to that of the great apes make me wonder if we’re not actually frugavores. Apes eat mostly fruit and greens. Some eat grains- raw. Since we produce more amylase that most apes, it seems that we’re adapted to grains too. Chimps seem to be an exception. They also eat an occasional monkey, perhaps as a ritual to show dominance. Herbivores eat mostly grass, I’ve tried it in juice form once or twice (as wheat grass) and I find it to be disgusting. So, I’m afraid I wouldn’t make a good herbivore.




      0
      1. Humans are certainly capable of living on an omnivore diet, but human/primate anatomy and biochemistry evolved over tens of million years as a plant eater. Optimal health is achieved by eating a diet of plant food and avoiding animal food.

        In case an open minded person who is curious and/or unconvinced wants more information, here are two links:

        http://michaelbluejay.com/veg/natural.html
        https://www.scribd.com/doc/94656/The-Comparative-Anatomy-of-Eating




        1
  10. I think you should not say compared to omnivores but compared to meat eaters or vegetarians. As it gives the false idea that people are omnivores when really we are herbivores. So really people are not omnivores but herbivores that eat meat. Just like Panda’s are carnivores that eat bamboo…




    0
    1. No need to seek these nutrients. Carnitine is produced by our own body and choline is available in a variety of plant foods in adequate amounts. Choline deficiency is quite rare in healthy populations.




      0
      1. I recently tracked my diet and found that I average 221 mg choline a day from plant sources, as opposed to the 400 mg RDA. Is there any reason I should work to boost intake from whole grains, beans, and peas?




        0
    1. With reference to your second citation, the major weakness I see in the Hazen studies at the heart of this video is that cold water fish can contain significantly greater TMAO than the carnitine content of red meat, yet fish consumption has a far weaker correlation with cardiovascular disease than red meat consumption.

      I suspect that red meat’s combination of numerous inflamatory hazards (carnitine/TMAO, saturated fat, cholesterol, endotoxins, AGEs, Neu5gc, heterocyclic amines, persistant organic pollutants, etc) acting in concert after every meal, and its lack of significant anti-inflammatory components like omega-3 fatty acids, may result in it being a particularly potent cause of cardiovascular disease. More so than any one of its components in isolation.

      Serum TMAO levels in a cohort of Western omnivores are very strongly correlated with cardiovascular risk (http://content.onlinejacc.org/article.aspx?articleid=1665659), but its also possible that that the TMAO is serving as a biomarker for consumption of a whole range of hazards, rather than a singular risk. At present, there aren’t any studies on other populations (ie. those on traditional Japanese diet) where serum TMAO may arise mostly from non-red meat sources.

      To tease out whether TMAO alone is a dominant cause of atherosclerosis in humans might require an impractical or unethical study like feeding Monster energy drinks (more carnitine than a Porterhouse steak) to vegans for an extended period.




      2
      1. Darryl: re: “I suspect that red meat’s combination of numerous inflamatory hazards … acting in
        concert after every meal… More so than any
        one of its components in isolation.”

        That makes sense to me and is quite in line with the approach that is presented in the book The China Study. The idea is that we can work on understanding individual mechanisms on how things work, but diseases rarely operate on a single mechanism. It is the whole system that comes together to create effects. At least, that’s my understanding of the point of the book.

        Anyway, I was moved to reply to your statement, because literally hours before seeing this video, I had found what looks like the best recipe in the world for making vegan butter!!:
        http://www.veganbaking.net/fats/vegan-butters/735-vegan-butter#.UX2W_dtTVoP
        BUT it has lecithin.

        I wouldn’t be using the vegan butter (fat/pure oil) all the time anyway. I am trying to go in a generally more healthy direction. But I still want the occasional treat and say butter on pancakes would be a real treat.

        Thus, the vegan butter idea was really exciting. This
        video raised the question in my head about how harmful the lecithin would be in the vegan butter. Which gets to your point: I’m hoping that by itself, as part of vegan butter in a vegan diet, that the lecithin wouldn’t be so bad – at least no more bad than any plant-based fat.

        That’s what I’m going with anyway, because when
        I get all of the ingredients, I’m going to give it a try. Thanks for posting your thoughts. You helped me put things into perspective.




        0
  11. Very interesting. I have two questions.
    First, if vegans, not having the gut flora that produce TMAO, are somewhat protected, would not this same protection apply to eating eggs as well?
    Second, does it make any difference if the eggs come from pastured, naturally fed hens?




    0
    1. Nope – eggs are eggs. Some come from happy chickens, some from battery chickens and some come from organic chickens (which BTW can be battery chickens), but the composition of the egg is similar. If you are lucky – a little less dioxin….




      0
    2. I could be misunderstanding your question, but eating eggs regularly will change your gut flora. You will no longer have the gut flora of a vegan i.e. you would no longer be a “protected” vegan.




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  12. Hi, Dr Greger. Does this means we have to stay away from cauliflower, almond, and peanuts too? Last time I check 100g of cauliflower contains 45.2mg of choline. That’s close to 1/2 of an egg.




    0
    1. My guess is that further studies will be completed on choline and we will have a better picture of it’s effects on intestinal microflora. My experience is that most egg based entrees, use 2 to 4 eggs per serving. So some people are consuming a lot of choline and quite frequently. Compounds in cauliflower (like glucosinolates) have an anti-cancer effect and are cardio-protective. So I’m just avoiding eggs and keeping cruciferous vegetables on my plate and flax seeds in my smoothies…I’m not a huge fan of peanuts, I like the taste..however I think there are options with more nutrients.




      1
  13. Here’s the problem I have. The big issue with eggs seems to that the bacteria in the gut break down the lecithin in eggs and produce TMAO–which causes damage to the artery walls. Just this past week we saw the research promoting fenugreek as an herbal wonder which helps with everything from body building to sexual health. But fenugreek is high in lecithin. Why is the lecithin in fenugreek good for us and the lecithin in eggs a killer?




    1
  14. I take 650 mg of betaine per meal for protein digestion. Does this pose a risk insofar as choline is converted into betaine? Is is that choline itself to excess is dangerous or is it the betaine as an end product?




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  15. Der Dr. Gregor,
    Outstanding video! I had totally missed the choline connection!
    It would be interesting to do some self experimentation by altering our diet in various ways for a few months and then testing our blood levels of TMAO, choline, & L carnitine, Do you know anything about the availability of blood tests for TMAO for the everyday person not in a research study? It would be interesting also to find out if supplementation with various kinds of probiotics and fiber might affect the proliferation of L-carnitine and choline metabolizing bacteria in people who do eat specific amounts of meat, and to answer the question of to what degree can competing bacteria reduce the populations of the L-carnitine & choline loving bacteria.
    Lastly, some of the other commenters raised some very good questions. We would love to hear your response to them. So far most of these questions have not been addressed.




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  16. I am so happy to see this video. I was vegetarian and now I am full vegan, but I kept wondering if I should supplement choline to get the brain boost. Now I know it is not necessary. Will you make a video about taurine in vegans? I saw in another video that taurine helps to protect against AGE’s. Thank you for these videos!




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  17. Why restrict your Dr Oz airdate announcement to Facebook? Some of us value out privacy too much to entrust it to Zuckerberg and Company. Please widen out your announcements to other communication channels.




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  18. It boggles my brain cells why anyone would eat meat, drink milk, consume cheese and eggs once scientists are finding these links to diseases that are preventable just by NOT eating this stuff. Is it the same idea as when people smoke? They know it causes disease but keep doing it? I still cannot figure that one out, except for the addictive properties, but are some humans addicted to meat, milk, eggs and cheese or is it just an unfortunate quirk of our current society? Why don’t doctors just tell people to STOP eating stuff that causes disease? Are they afraid of the meat and dairy industry?




    1
    1. When it comes to diet and disease most docorts are ignorants. I dont think they are afraid, they just dont know the abundance of science that backs up a whole food plant based diet. In the medical community you dont hear much about nutrition. My mother (type 2 diabetic) says that I am the only doctor ever, who has told her that she is to fat. The only one! I have heard about a GP who recommended more read meat to a patient, because she allegedly lacked proteins in the blod (the story made no sense)! I know a person who went to his doctor to get some help to loose weight, because he was just diagnosed with type 2 diabetes, and the doctor replyed “you are not overweight” – despite the obvious fact that the man was at least 20 kg overweight. I was actually searching for something else, but found informations about this topic by chance.




      1
    2. so many rhetorical questions! here is my take as an informed consumer who didn’t know this stuff until seeing ‘Forks Over Knives’ despite ‘paying attention’ to nutrition for many years. ordinary people don’t know this stuff. Dr. Greger’s recent video on the McGovern Report was an eye-opener. doctors don’t know this stuff! there is very little attention paid to nutrition in medical school and the pharmaceutical industry ‘friends’ them after school. lastly, there is inertia, a HUGE factor in why people don’t change.




      2
    3. Through its favorite, pliant congresspeople, the corporate food industry struggles feverishly to control not only consumer legislation but funding of nutritional research. Industry also perfects its many channels of access to public policy decisions through the revolving doors of EPA and Agriculture.

      That same congressional and agency influence serves industry well as an effective firewall against bad news from scientists. No scientist wants to create a profile of industry-perceived hostility, especially with FDA and Agriculture funding literally under the thumb of “former” executives from Monsanto, etc.




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  19. I’m vegan and took a 500 mg carnitine supplement for a few months to see if I felt any different. No difference at all. I did the same with 250 mg choline (and 250 mg inositol in the same pill) and also felt no difference. Seeing as now it may be harmful to use these supplements, I don’t plan on buying them again. What is your suggested intake of choline from food? What about carnitine, which I assume our body makes from eating foods high in lysine and methoinine?




    0
    1. Update: Before I saw this video I bought a small bottle of acetyl-l-carnitine to test out. I’ve taken acetyl-l-carnitine at the levels from 250 mg – 750 mg daily for the last 8 days and, unlike l-carnitine which I didn’t feel anything, the acetyl form makes me feel bad. It’s causing heart palpitations and I have no history of any heart problems. I’m stopping this now and dumping the rest of the bottle. I will go the safe (and free!) route of just eating food and having my body produce whatever carnitine is needed on it’s own.




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    1. Your link doesn’t appear to have worked; you’ve included the link to this video.

      Regarding Weston Price and Mercola, I would find it hard to critique either of them because they just can’t be taken seriously. In the blog world maybe, but in the world of peer-reviewed research, they’re just not considered legitimate sources. The few Mercola articles I’ve read, when I actually checked his sources, stated completely different conclusions than what he was peddling in his article. The Weston Price Foundation is based on the idea that we should ignore all of the clinical, epidemiological, and basic science research that has been done to date, and base our nutrition decisions on what a dentist from the 1920’s thought.

      However, if your friend has peer-reviewed modern research articles that they wish to share (since that is what this site is based on), I’m sure many would be happy to discuss them.




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      1. I am posting here only because I searched in vein for a reference and found none. Dr. Greger, what is your opinion of coenzyme Q10 supplementation?




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  20. Dr Gregor,
    Not to change the subject, I was wondering if and when you might discuss
    Chromium and linoleic acid. I would be interested in that topic.
    Thank you and I enjoy reading all your presented research online.




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  21. Please take a look at yet another study (“L-Carnitine in the Secondary Prevention of Cardiovascular Disease: Systematic Review and Meta-analysis”)

    Now, another study delivered by the Scarecrow from the Wizard of Oz delivers a study asserting that Carnitine, a compound found in red meats, appears to be cardioprotective in a systematic review — a finding that comes barely a week after a Nature Medicine study sounded an alarm about the heart risks of carnitine in the form of derivative TMAOs.

    OK….is this a case where the substance (LCar) itself is beneficial, but the by-products are not? Or…
    And if so, how does one balance or even evaluate the balance between the two effects.

    Thanks…




    0
    1. Thanks for the question foxfyr! The study to which you’re referring can be found here.

      We’ve known for over 20 years (http://1.usa.gov/19s7dLe) that large doses of carnitine given intravenously in people within hours of a heart attack may have an antiarrhythmic effect, presumably by facilitating glucose oxidation in the failing heart muscle. Because it’s given directly into the bloodstream, it enters our body the way our own body creates it (bypassing the gut). Only when carnitine enters the gut could that toxic TMAO be made by the gut bacteria. In the context of a heart attack, even carnitine supplements given orally could help the patient live through that critical first post-MI period by lowering risk of ventricular arrythmia even if it might be contributing to further plaque progression elsewhere in the heart. Hopefully we will all never be placed in that situation by preventing the heart attack in the first place by decreasing our intake of carnitine, choline, cholesterol, saturated fat, and trans fats found in animal foods and junk. Check out my video series starting with Arterial Acne.




      1
  22. I just read in Healthy at 100 by John Robbins that he recommends L-Carnotine for vegans, and I started taking supplements, so I guess I should stop taking it??

    –Neal




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  23. I don’t want to be a pest, but people refer me to Weston Price inst. analysis(Chris Masterjohn) of the studies above. I don;t have the tools or knowledge to refute any of it. I was wondering if there was any data pertaining to this “rebuttal”
    http://www.westonaprice.org/blogs/cmasterjohn/2013/04/10/does-carnitine-from-red-meat-contribute-to-heart-disease-through-intestinal-bacterial-metabolism-to-tmao/
    I personally can’t take the Weston Price Institute seriously, but Mr Chris Masterjohn seems to have a following, and giving it a flick and wishing it away doesn’t seem responsible.




    0
    1. abeleehane: Perhaps this will help you: Plant Positive on You Tube has several videos that competently address several of the problems with Weston Price information. I would guess that there are also other sources of information refuting what Price sells as good science. I just haven’t bothered to look further myself.

      Here’s one link that will get you started:
      http://www.youtube.com/watch?v=jaiU6RVC2Jk

      Plant Positive posts a series of videos. The above link is just to one of video in the series. If you (or others you want to educate) are interested, I recommend watching as much of the series as you can. Plant Positive addresses all sorts of claims by paleo and other types of diets.

      Good luck!




      1
        1. PlantPositive is an Excellent Resource! FWIW Dr. Greger wrote the book debunking low carber truthiness, titled Carbophobia, and you can get a copy free or at very low cost, check out atkinsexposed.org. Don’t expect Dr. G to go over everything again on this message board, and if you watch just a fraction of his 1600+ videos you’ll see he already has.




          1
  24. Dr. Greger, thank you for this valuable information. It does, however, present a personal problem for me. I had been vegan for a few years but for some reason could not stop eating all day long. I believe this has to do with undiagnosed hypoglycemia. At any rate, I find that the only dish that fills me up and prevents me from grazing and experiencing massive food cravings is stir-fried brown rice, veggies, and eggs in the morning. I eat vegan food for the rest of the day. I have tried protein powders, nuts, tofu, beans, etc. and none of the vegan sources of protein have the blood-sugar leveling effect of the eggs and rice. Do you have any suggestions? Is there some magical combination of vegan foods I could eat in the morning that would help keep my blood sugar level throughout the day?




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  25. Interesting! Just curious – if, when vegans eat a steak it doesn’t increase their TMAO levels, because they lack the gut bacteria to metabolized carnitine or choline into TMAO – then why would vegans, who eat foods or take supplements containing choline, be at increased risk for heart disease and cancer due to TMAO’s?




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  26. This study you cite has a number of serious flaws, and the connection between carnitine and heart disease is weak at best:

    http://chriskresser.com/choline-and-tmao-eggs-still-dont-cause-heart-disease?inf_contact_key=e5459684e0bea63561b832db0b48f32cba2c91715a3399db4c32b1052d801833

    http://www.forbes.com/sites/larryhusten/2013/04/12/is-red-meat-a-fish-story-why-you-should-never-believe-health-headlines/

    http://www.humansarenotbroken.com/red-meat-tmao/

    Sometimes it’s best to examine the methodology of the research a bit closer as well as the results to see if all extraneous variables are accounted for. Instead, it appears you are agreeing with it’s conclusions prematurely as a result of your own particular bias on nutrition. Not that I don’t agree with the majority of your input, but in this particular case it is flawed.




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  27. These data raise good questions. More data need to address additional factors possibly associated with TMAO increases and then begin to narrow the correlates down to plausible causal factors. There are so many “maybe’s” and words like “plausible” and “presumably” in this article to have confidence in the conjectured causalities. No sense changing diet based on associational relationships alone. So many possible paradoxical effects to account for first.




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  28. Dear Dr.Greger, thank you so much for all your interesting lectures and presentations. I enjoyed one at the SF Vegetarian Festival a week ago.
    Recently I came across this article http://www.huffingtonpost.com/dr-jonny-bowden/red-meat-health_b_3119520.html where the author suggests (like some people were predicting that the reaction from those, who don’t want to part with animal products, and the industry, of course would be like it) that it might be factory farming toxins that are to blame for the TMAO producing bacteria not the meat and animal products themselves”.
    Since the body can be cleaned from any bacteria with the help of antibiotics, and it takes only 2 weeks to restore the intestinal flora – then it seems that it should not be difficult to check whether “clean” start with the “organic”, or non factory farm animal products would bring back the TMAO causing bacteria or not.




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  29. You’ve pretty much demonized choline here without saying why the body needs choline, especially athletes who train heavily. While I’m not a vegan nor will I ever be one, I find your website helpful in balancing my diet and it has even led me to incorporate more veggies into it. Keep up the good work.




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  30. Dr. Oz had a show on last week where he recommended CLA supplement of 1500 mg twice a day. I have bought at GNC and started taking now I read this article?? Should I discontinue?




    0
    1. Before following recommendations from TV shows such as Dr. Oz I would check out more reliable free websites such as NutritionFacts or Dr. John McDougall. I have not seen any credible science which shows that recommending for the general population to take CLA at 1500 mg twice a day is beneficial.




      0
    2. Evidence from randomized controlled trials (RCT), do not convincingly show that CLA intake produces clinically relevant effects on long-term body composition. (1) Moreover, there is some concern that taking conjugated linoleic acid may worsen diabetes.

      Martha Belury and her Ohio State research team
      “found that CLA supplementation significantly decreased body fat in the first group of mice, but at the same time excessive amounts of fat accumulated in the animals’ livers. Belury linked this accumulation of fat in the liver to increased insulin resistance.” (2)

      A healthy lifestyle and a whole food plant-based diet along with exercise is the only proven method for long-term weight loss and weight maintenance.

      1) http://www.ncbi.nlm.nih.gov/pubmed/21990002
      2) http://researchnews.osu.edu/archive/cladiet.htm




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  31. This is all bad news for me. I eschew meat but take carnitine supplements because I have heart failure that entails a significantly enlarged heart. The carnitine has allowed me to go about normal everyday activities without having to stop to catch my breath and without pooling of blood in my feet. Are there any alternatives that would provide the same coronary benefits as the carnitine supplements?




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  32. Thank you. Being a descendant of early American settlers, I now know it was not my ancestors that killed off the natives, it was the natives high meat consumption! :)




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  33. I have two questions:
    1) the lecithin in eggs and TMAO – what about eating egg white only?
    2) avoiding Lecithin supplements: soy protein shakes do include Lecithin. Is this critical or is the dose so small that it does not really matter?




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  34. Now this video obviously answers my question can we safely consume eggs by adding flax and or/ garlic. However, choline is so prevalent in the vegetable kingdom that it is impossible to avoid. Even with broccoli a pound (180 mg) the concentration is higher than 2 eggs as two eggs. Furthermore, betaine and choline are protective in control of homocysteine levels. This situation as it seems makes it hard to eat healthily. I do comprehend that vegans can handle a steak because their gut flora has already been transformed to non choline-phil. What about an occasional egg after our transformation? I sound like an egg glutton! Seriously, I have nothing against veganism however most of the world especially in colder climates consume a small percentage of their diet animal products.




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  35. this video is superb. my first thought was about phosphatidylserine (made from cow brains and soy beans) is sold in supplemental form to those with memory problems and to increase athletic performance. however, this research discusses phosphatidylcholine. yet when i researched the similarity between these two, it seems phophatidylcholine comes from the sames sources…i wonder if phosphatidylserine is bad for us as well??? gasp! anyone have any research or thoughts on this….if so please do share…thanks so much again dr. greger for this great presentation…




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  36. Since Choline is a nutrient that is a precursor of the phosphatidylcholine and sphingomyelin, both major components of cell membranes and inadequate amounts can affect memory especially in an unborn developing fetus. What would you recommend as a suitable choline source?




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  37. This doesn’t make sense.

    So choline and carnitine are converted by TMAO by “animal product-consuming gut bacteria” but not by “fiber-consuming gut bacteria”. This is why vegans produced no TMAO in the study by meat eaters did.

    Therefore choline and carnitine are safe for vegans with respect to TMAO.

    Why the need to avoid not just all animal products but also lecithin and energy drinks? If someone eats vegan then they should be able to drink all the carnitine drinks and take all the choline supplements they want and produce no TMAO.

    Right?




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  38. In my opinion that really does not make sense for several reasons.

    First
    of all as a fat emulsifier the lecithin is going to aid in the
    absorption of fats in the diet and in the process will be absorbed
    itself. Therefore little if any of the lecithin would reach the
    majority of the flora, which is in the colon.

    Secondly, bile is
    released in to the intestines all the time as part of the natural
    digestive process. Bile is about 80% lecithin, which is why bile is an
    emulsifier. So how does Greger explain this lecithin not interacting
    with these bacteria?

    Third, lecithin is a component of cell
    walls. So why don’t these bacteria use the lecithin from dead cells
    being excreted in the feces?

    Any why don’t more people have heart
    disease from the TMAO since these processes in which TMAO is being
    produced occur from the beginnings of life? If TMAO was such a danger we
    would have all died by the age of 5 from heart disease.

    This
    sounds like one of those cases where someone is taking a little
    unverified information they read in a medical study and are blowing it
    out of proportion by ignoring things such as the body’s ability to deal
    with certain harmful substances.

    For example, someone could read
    some medical journal article on how cyanide can kill you and then
    exaggerate the claim that the cyanide found in the seeds of some foods
    will kill you if you ingest them overlooking the fact that we also
    produce an enzyme that convert this cyanide in to a harmless
    thiocyanate.

    So I am not going to accept Greger’s the sky is
    falling scenario over lecithin until he can explain why bile and dead
    cells containing lecithin and do come in to contact with these bacteria
    are not killing us with heart disease.




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  39. Dr, As a 24 year old male who has been consuming at least 3 eggs a day, red meat and milk everyday, I am thinking of switching to a healthier lifestyle. What are the supplements that I should take to be healthy and gain muscle, in junction to a heavy intensity exercise and medium-lifting routine, while avoiding prostate cancer?




    0
    1. …I was thinking of consuming the following supplements; I would like to ask your opinion on whether or not those are healthy or dangerous to take.

      1. Krill oil (Source Naturals ArcticPure Krill Oilr 500mg)
      2. Astaxanthin (Nutrex hawaii Bioastin Hawaiin Astaxanthin -12mg)
      3. Probiotic supplement (Nutrition Now PB 8 Pro-Biotic Acidophilus)
      4. A multivitamin (rainbow light men’s organic multivitamin)
      5. Whey protein powder




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    2. I_O: The following is a link to Dr. Greger’s overall nutrition recommendations that apply just as much to body builders as anyone else. The page includes Dr. Greger’s suppliment recommendations. But also note what is *not* included in recommended foods: meat, diary or eggs.
      http://nutritionfacts.org/2011/09/12/dr-gregers-2011-optimum-nutrition-recommendations/

      The above diet is great for avoiding prostate and other cancers, heart disease, T-2 diabetes and much more!

      Let me know if you would like some advice on how to transition from your current diet to a healthy one. I’ll just say up front that one of the moderators on this site does some serious rock climbing. He generally follows Dr. McDougall’s The Starch Solution diet with great results. That book, which includes recipes, could be a good starting place for you:
      http://www.amazon.com/Starch-Solution-Regain-Health-Weight/dp/1623360277/ref=sr_1_1_twi_1?s=books&ie=UTF8&qid=1423698879&sr=1-1&keywords=the+starch+solution




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  40. From nutritionfacts videos I am sold to the idea that ingesting excessive choline is bad for us. But I am wondering how much would be an adequate amount of choline to eat daily.

    Official recommendations are 550mg/day for men over 19yo and 425mg/day for women over 19yo, but I’ve read that the need for dietary choline may also be dependant on the intake of folate.

    Working on data taken from nutritiondata.self.org, I found it somewhat hard to reach 550mg/day on a eucaloric vegan diet.

    Could someone please share some thought on this subject?

    Many thanks!




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    1. I use peacounter.com and used to worry about this, too. Then I asked Jack Norris about it and he added this to the FAQ page there:
      —–
      “My diet seems to be far below the RDA for choline. Why would that be?

      As of February 2014, the USDA database still doesn’t have the choline amount listed for many of the foods. It’s likely that your choline intake is much higher than listed.”
      —–




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      1. Thanks Brandon!

        I looked at my table and, in fact, I wasn’t considering any value for oats (which I found out under another entry that has 40mg/100g) and due to a formula error I wasn’t including in the sum the choline from Soy Protein Isolate (191mg/100g).
        With everything corrected, I’m getting ~580mg/day.

        But still, I must say it wasn’t easy. I am able to eat 3500kcal/day because I work out a lot and I am trying to pack up some muscles, but if I were to eat 2500kcal/day, it would be a difficult challenge to reach the 550mg/day mark…




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  41. Question: Does Coenzyme Q-10 have any similarity to carnitine and choline? I’m wondering if CO-Q10 could lead to similar harmful TMAO generation. It is commonly suggested as a supplement when taking statins and I see it sold with red yeast rice.




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  42. I developed secondary TMAU in 2009 and at the time I was eating eggs every single day and red meat. I’m not sure if I developed this due to my diet at the time but I was also under severe stress and stress and diet can developed into this horrible disease.




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    1. Hi Paul, Thanks for being patient. Dr. Greger does mention a few of the studies mentioned from that article you referenced, such as Koeth RA, Wang Z, Levison BS, et al. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. Apr 7, 2013

      I don’t think he is overlooking the study. It is fine to talk about the benefits of the Mayo clinic study, but it is just as important to discuss the potential harmful affects of TMAO.




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  43. When you Google “are eggs bad for you” the top 10 sites all say yes. From places like Mayo Clinic, WebMD, Harvard Nutrition, ect. What gives?




    0
    1. Thanks for your patience. I responded below. Again, it may not be so much concern with carnitine, but the potential TMAO that is produced from ingestion. It may very based on foods vs. supplements.

      In response to your question about this study http://www.plosone.org/article/fetchObject.action?uri=info:doi/10.1371/journal.pone.0088278&representation=PDF I am not sure what the diet looked like for the vegetarians and I did see the study had many limitations. Nonetheless it is important to consider. Thanks for sharing it!

      Best regards,
      Joseph




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  44. Does a pregnant woman eating only plant foods risk neural tube development problems in the fetus? Is it worth eating some Wild Shrimp daily/weekly to ensure the requirements are satisfied? Are levels of 200mg/day enough to avoid complications in the womb? How about during nursing? Thanks.




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  45. Do they know yet if vegans can eat eggs and not have TMAO in the blood? And, have they looked to see if quality of meat/eggs matter yet? In other words, is there TMAO in the blood after eating grassfed red meat or pastured eggs? And, not sure why only propionate bacteria in vegan gut is mentioned… there’s much microbiome to discuss.




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  46. > “It was such an honor to be on The Dr. Oz Show last week”

    That really gives me the willies. I understand the importance of educating the masses, even if you have to go on a show that promotes quackery like homeopathy. But calling it an “honor”? More like a strategic opportunity.

    I wanted to share this page on FB, but the moment a lot of my friends see that you call appearing with Oz an “honor”, they will dismiss you as they do him. And they are right to dismiss him. He flip-flops on GMOs and shills like a late-night QVC salesman.

    I encourage you to rephrase the opening line.




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  47. So, it is important to also note that dietary choline seems essential for liver function and cognitive function. I’d like more information because it could be that the right kind of choline intake in your diet is perfectly healthy and including things like soy lecithin won’t promote the growth of gut bacteria that will produce TMAO. Also, we need more information about how much choline is actually needed in our diet. It seems that maybe dietary choline is unnecessary if you have enough folate or methionine in your diet too. It is all pretty confusing, but the thing that is really weird was that the choline from less than an egg a day seemed to be correlated with increased prostate cancer risk while your average vegan diet will give you more than the amount of choline in an egg in a day. I feel like that probably means that it either isn’t the choline or maybe somehow the choline you get from vegan sources does not have the same effect.




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  48. In December 2015, Cleveland Clinic announced discovery that naturally-occurring DMB (3,3-dimethyl-1-butanol, found in cold-pressed extra virgin olive oil and grapeseed oil) can interrupt the production of TMA (and eventually TMAO, after liver processing).

    This news may have driven many to conclude it was safe, once again, to return to a “traditional” American meat-based diet.

    However, what Cleveland did not claim is DMB prevents cardiovascular risk associated with regular intake of carnitine and choline. Instead, researchers made the more modest suggestion that DMB should reduce CV risk, and that by implication.

    In fact, the news from Cleveland remains small comfort for the population of red meat lovers who might imagine years of DMB-assured protection while indulging their favorite saturated fat-laden diet. And as it turns out, study principal Dr. Stanley Hazen, is not one of them.

    Although a self-confessed steak aficionado, Dr. Hazen is considerably more restrained about the discovery. Hazen, who had announced shortly after his initial, ground-breaking study of signal risk from carnitine and choline in red meat that what researchers needed to find, now, was a drug which would interdict the TMA-generating process, Hazen understands DMB is not revealed as a silver bullet of any kind.

    For Dr. Hazen, at least, the matter of dietary risk from red meat remains anything but academic.




    0
    1. This is very interesting, because studies from as far back as the 1950’s have suggested that olive oil could protect against heart disease. There was, for example, the 5 Country Study in the 1950’s in which it was found that of the 5 countries studied ( US, Japan, Finland, Greece and one other) Greece had the lowest rate of heart disease, but also the most risk factors. Then in the 1980’s, 1984 or 1989, I don’t remember exactly, the University of Crete looked at heart disease in rural Crete and found that heart disease was almost non-existent even though the population studied had many risk factors. I think that 40% of the men smoked and a large % of the women, obesity was prevalent and cholesterol levels were through the roof. In 2012, the University of Crete looked at 200 of the same individuals it had studied in the 1980’s and again found virtually no heart disease, even though risk factors stayed the same. This is my recollection. No cause and effect relationship was established, but Greece consumes more olive oil than any other country in the world. It’s interesting that deaths from Alzheimer’s is also very low. I use olive oil liberally and will continue to use it.




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  49. Your book “How Not to Die” warns against choline, which can lead to heart disease. What about choline as ch-OSA (in products like Regenemax) for hair, skin, and nails? Is this the same choline?




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  50. Yesterday at the NYC Vegetarian Food Festival Dr. Robert Ostfeld mentioned that those who switch from a standard American diet to a wfpb diet may experience a lowering of their HDL and that he is not concerned about this because of research showing that people on a wfpb diet may have better HDL efflux capacity. So even though the good cholesterol is lower, it is more efficient at removing the bad cholesterol from the blood. I was wondering if Dr. Greger could comment on this and perhaps provide a reference.




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    1. Hello! This is something I found from Dr. Esselstyn that you might be interested in: “It is not uncommon for HDL to fall when consuming plant based nutrition. Do not be alarmed. The capacity of HDL to do its job has been shown recently by scientific research that there is no relationship between the capacity of the HDL molecule to function optimally and its blood level. Recent research has confirmed that the HDL molecule can be injured and weakened when one is ingesting a pro inflammatory western diet and conversely it appears despite a lower than normal level to be optimized by anti inflammatory plant based-nutrition.” Dr Esselstyn’s FAQ

      Let me see if I can find you a reference…




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  51. how do you explain high soy consumption among Asians and lower mortality rates from cancers? Wouldn’t soy contain lecithin —> —> choline as well as sunflower seeds, cauliflower?




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  52. so, I may not have followed through with the logic in the video, but the Dr. mentioned that vegetarians don’t get TMEO despite intake on choline. So, choline maybe the innocent bystander ??




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  53. Was just wondering if anyone could comment on this preliminary study that was discussed on Medscape re choline supplements in pregnancy for preventing mental health conditions including schizophrenia.

    Can a Prenatal Supplement Prevent Mental Illness?
    Bret S. Stetka, MD; Robert Freedman, MD
    http://www.medscape.com/viewarticle/871311#vp_2

    They recommend at least getting the RDI which seems almost impossible on a vegan diet.

    It seems most people here think supplementing in general is a bad idea, but what about for wfpb dieters in times of additional requirements like pregnancy?
    It seems the choline may also be important for other aspects of neurological development in the foetus like long term memory.
    I have read others around the web who suggest small dose choline supplements for pregnant vegans.
    Would really like some input on this, from anyone but hopefully someone from Nutrition Facts?
    Thanks in advance.




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    1. Romi: Dr. Greger has recommended the book, Becoming Vegan, for when people have questions about specific nutrients. The Express Edition of the book has this to say on page 118:
      .
      “Choline has hopped back and forth across the line between vitamin–and therefore essential–and nonvitamin. That’s because the body can produce sufficient choline unless a person’s diet is short on folate, vitamin B12, and the amino acid methoionine. … Women should bet 425 mg choline per day, and men should bet 500 mg. … There are plenty of good sources of choline. A few that are particularly rich are beans, broccoli, peas, quinoa, and soy foods.”
      .
      In other words, even if you are relying on getting choline from your diet, there are safe and healthy foods for consuming it. One *generally* does not have to resort to eating eggs or any other animal product.
      .
      On the other hand, your raise an interesting point about pregnancy. I don’t know the answer to that and hope that someone else will be able to jump in and offer some thoughts. I just thought that the above information would be helpful for you as a starting place.




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      1. Thanks Thea, I will check out Becoming Vegan.
        Seems like pregnancy is a tricky area with most research, and very hard to prove causation with so many variables!




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    2. Hi, Romi. I am Christine, a NF Volunteer Nutrition Moderator. The link you supplied is to an interview, not a research study. In my opinion, Dr. Freedman makes a lot of leaps that are not necessarily supported by evidence. The table, Dietary Reference Intakes (DRIs): Vitamins, published by the Food and Nutrition Board, Institute of Medicine, National Academies of Science, includes the following note regarding choline: “Although AIs have been set for choline, there are few data to assess whether a dietary supply of choline is needed at all stages of the life cycle, and it may be that the choline requirement can be met by endogenous synthesis at some of these stages.” AI stands for Average Intake, which is an estimate of the amount of a nutrient most healthy people consume. This comment states that people may not need to consume any choline at all, because their bodies may be able to make as much as they need. This is coming from the people who set the intake requirements for all nutrients. If you are concerned, peanuts are a good plant-based source of choline. I hope this helps!




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      1. Thanks Christine,
        I probably wasnt clear about that when I posted- I did realise it was an interview, but I thought it was interesting that they were suggesting that the preliminary study results were significant enough to suggest that pregnant women start supplementing.
        It seems like the more you read, the less clear it is!
        Thanks for the info about the AIs- does make it interesting given most people who are included and presumed healthy may be consuming a SAD, which leaves us pretty grey as to what a ‘healthy’ intake of choline may look like. On the other hand, mental illness like schizophrenia can cause a lot of suffering, and if there are potential preventative measures that may do little harm (although this is also unknown), it seems worth taking note.
        I guess maybe just focusing on plant sources and getting as close as you can to recommended levels!




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  54. As I understand it, Dr. Greger is saying that a different kind of gut bacteria is produced from eating animal products (eggs, meat, fish and dairy) than is produced from eating a vegan diet. It is the gut bacteria produced from these animal products that converts choline to trimethylamine (TMA), which is then converted to TMAO (trimethylamine oxide) by the liver and which predisposes one to heart disease and in some cases to cancer. He indicates that if a vegan were to consume animal products containing choline (and carnitine), his gut bacteria, which differs from that of omnivores, would not convert the choline or carnitine into TMAO.

    However, he states that “eggs, milk, red meat, poultry, shell fish and fish, are believed to be the major sources for choline and HENCE [emphasis added] TMAO production,” suggesting that it is the choline itself, rather than the change in gut bacteria from the consumption of animal products, that is initially responsible for the TMAO production. Elsewhere in the video, he adds, “Even if you eat vegan, though, you’re not necessarily out of the woods. If you regularly drink carnitine-containing energy drinks, or take carnitine
    supplements, or lecithin supplements which contain choline, presumably you’d foster and maintain those same kinds of TMAO-producing bacteria in your gut and increase your risk of heart disease and perhaps cancer.”

    Here he appears to be saying that it is the carnitine and choline themselves, irrespective of their presence in animal products, that foster and maintain the TMAO-producing bacteria, especially since lecithin supplements are produced from soy and sunflower seeds, which should not (according to this theory) contribute to the TMAO-producing bacteria.

    So my question is: Is it the gut bacteria from the consumption of animal products that are primarily responsible for the TMAO that’s produced from the consumption of choline or carnitine, or is it simply the choline or carnitine itself? If the former, then vegans should not be risking TMAO production simply from consuming carnitine or choline supplements.




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  55. If you stop the video and read the memo that he is referencing, you find that they are stating that the study was a poorly done studying and that earlier studies of the same type have not demonstrated this same result. So it does make me question Dr. Gregor if this is a valid point that can be made based on that study




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  56. In articles I’ve read regarding heart disease, lecithin is sometimes mentioned along with choline and carnitine as a substance linked to the production of artery damaging TMAO. Many of the nut milks consumed by vegetarians contain added lecithin. In fact, it’s downright difficult to find a milk alternative that doesn’t contain lecithin or carrageenan. Should vegetarians avoid beverages containing lecithin? I’m not able to find information to determine whether it’s the consumption of choline/carnitine that results in TMA forming bacteria in the gut, or whether it’s something else about meat/egg consumption that results in the TMA bacteria. In any case, as a vegan with heart disease, I have a concern about drinking alternative milks that contain lecithin. Might someone have information to shed some light on this issue?




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    1. Michael Moritko: I forwarded your question to our volunteer medical moderators. We don’t have enough volunteers to answer every question, but at least your question is in the pile.

      In the meantime, I thought I would ask if you have considered making your own plant based milks? It’s pretty easy if you have a blender. Even a cheap blender will do. Let me know if you are interested in how to make your own.




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      1. Thea: Thanks for your reply. Yes…..I would like to try making my own dairy milk alternative. I have a Vitamix so that should do the job. I go through at least one container of almond milk per day but I am concerned that the lecithin contained in all the almond milks on the market results in increased production of TMA. Again, thanks for resonding.




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        1. Michael Moritko:
          When it comes to making your own nut milks, I like to show posts from two other people. Note that the posts below talk about almond milk, but the concept can apply to just about any nut or seed milk. Maybe even some grains. Have you tried oat milk?

          This first post is from Jim Felder, an awesome NutritionFacts participant:
          “Home made almond milk is justification all by itself for buying a Vitamix. A cup (5 ounces) of almonds (soaked for at least an hour), 3-4 cups water (depending on how rich you like it), some madjool dates (if you want a bit of sweet), vanilla extract (if that floats your boat), a length of cheesecloth or better yet a nut-milk bag and 1 minute in a Vitamix and you have almond milk. Just strain out the solids and put the milk in the frig to chill. And as a bonus you get left-over high fiber almond pulp which can be used with beans, oats and brown rice to make veggie burgers. If not using the pulp right away, it can be frozen and defrosted at need. Angela Liddon on her Oh She Glows blog has a nice recipe.

          If you are using the almond milk in a recipe you could likely just skip the straining step and leave the solids in with the liquid.

          If you really get into it making almond milk, there are places on-line (like justalmonds.com) where in larger amounts almonds can be as cheap as $6.50/lb. Assuming that 5 ounces of almonds gets you a quart of almond milk, then the price of home made can be as little as $4/half gallon. That isn’t a whole lot less than commercial, but here you control what does and more importantly doesn’t go into your milk, and you can just make the amount you want/need.”

          This second post is from NutritionFacts volunteer moderator Stephanie:
          “A tip if you want your homemade almond milk super smooth: buy raw almond butter (only ingredient is almonds) and blend about 2 Tbsp with 3 C water until smooth. May add some vanilla extract. No need to strain anything. I find raw, creamy almond butter at Trader Joe’s, but I’m sure you can find it at other places too.”

          My own notes: The second idea, using a nut butter as opposed to grinding the whole nut, is the easiest option if convenience is your primary goal. Also note that a powerful blender like a Vitamix can pulverize the nuts so small that they go right through even small colanders and you really need a milk bag. Or just don’t let the Vitamix go so much. For those people who don’t mind a little grit in their milk (who let those people on the planet?), they can just drink the Vitamix-blasted milk without any straining. I’ve met people like that, and they were perfectly happy.

          I hope this helps. If you give it a try, let us know how it goes.




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          1. Thea: Forgot to mention…..yes, I do drink Pacific brand oat milk. It’s the only dairy milk alternative I know of (besides home made) that contains neither lecithin nor carrageenan, and also has no added sugar. It does, however, have a pretty strong flavor so I prefer a slightly sweetened almond milk. I find it curious that Dr. Esselstyn (I’m on his whole food plant based diet) allows almond milk but absolutely no nuts. In any case, thanks for your help.




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            1. Michael Moritko: re: the Pacific brand oat milk. That’s the one that I have tried too. I didn’t like it at first, but then it quickly grew on me. I decided I liked it for specific applications.

              re: “I find it curious that Dr. Esselstyn (I’m on his whole food plant based diet) allows almond milk but absolutely no nuts.” My understanding of Dr. Esselstyn’s concerns regarding nuts is that the nuts are so high in fat AND it is really easy to over-due nuts. I would say that almond milk has relatively little fat and is hard to over-due.




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            2. Oatly’s oat drink and Rice Dream’s rice drink doesn’t contain any lecithin or carrageenan. Alpro oat drink doesn’t either, but does contain more ingredients than ideal.




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  57. As a moderator for NutritionFacts.org, I see you had a question about choline from vegetarian sources and it that is good for the liver. In reviewing the transcript of the video you watch, I see Dr. Greger states that we do need to take in some choline so vegetarian sources presumably are good for us. However, it can seeconfusing. His comments below may make it clearer…”…so should vegans be worried about the choline they’re getting from beans, veggies, grains, and fruit? And, same question with carnitine. There’s a small amount of carnitine found in fruits, veggies, and grains, as well. Of course, it’s not the carnitine itself we’re worried about, but the toxic TMAO, and you can feed a vegan a steak—literally, an eight-ounce sirloin (anything in the name of science). Same whopping carnitine load, but, essentially no TMAO was produced” Apparently, the vegans don’t develop those TMAO-producing bacteria in their gut so you can indulge in vegetarian sources of choline without worry.
    I hope this helps.




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  58. Pardon my fibromyalgia-fogged brain, but I couldn’t quite figure out if acetyl l-carnitine and l-carnitine act the same way here. I ask because a naturopath recommended I take acetyl l-carnitine to help my energy. I’m 99% vegan (or so). But if that is a bad idea, I won’t.




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  59. Hello Dr Greger and the team, could you please talk about the daily recommended intake of choline? It stands now on about 500 mg, but this is based on just one study that checked 50 mg and 500 mg and nothing in between (so I read). 500 mg is normal for carnistic diet but hard to reach in vegan diet. It also creates TMAO in th carnistic diet. Thank all very much
    Judy (Israel)




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    1. Hi Judy and thank you for the excellent question. You’re right, the study comparing 50mg to 500mg has flaws. In addition, betaine needs to be accounted for because it acts as a methyl group donor, similar in function to choline, with many whole food vegan sources as outlined here: http://advances.nutrition.org/content/1/1/46.full

      All available evidence suggests that a whole food vegan does not need to supplement with choline. If you are concerned, your first step would be to keep a complete food log with weights of food eaten, for at least a week, and then calculate your choline and betaine intake. If your intake is low as compared to the guidelines, then you could supplement whole vegan foods that are richer in betaine and choline.

      Supplements would not the first choice as outlined by Dr. Greger in this great video: https://nutritionfacts.org/video/dangers-of-dietary-supplement-deregulation/

      Thanks for reading!
      Dr. Ben




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  60. Hello,
    I’ve sworn off meat and eggs to avoid ingesting carnitine and choline and the subsequent TMAO that my gut bacteria will produce. But just the other day I was taking a closer look at the ingredients of the multi-vitamin I take and noticed, to my chagrin, that it contains L-Carnitine (as L-Carnitine Tartrate) and 10 mg of Choline (as Choline bitartrate). Should I find a new multi? Is this the same as eating eggs and meat?

    Thanks!
    -Zach




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  61. Hello,

    Don’t know if it makes sense to ask this question in this forum, but I have a great concern in regards to carnitine supplements and the contradiction facts experts have to say about this topic.

    During the last two months I have switched to a whole food plant based diet, but due to carnetine deficiency I have taken daily carnitine supplements. Many people from where I come from (the Faroe Islands) suffer from CTD, Carnitine Transporter Deficiency, and are required to take carinitine supplements to prevent sudden death (See article: http://goo.gl/oHofN80). Even though I am not diagnosed with CTD, my numbers are relatively low in comparison to other people. Would you still recommend discarding carnitine supplements or is it possible to increase the numbers in other ways? CTD is a relatively rare disease worldwide but for some reason this is not the case in the Faroe Islands.




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  62. Hi Rógvi. Thank you for reaching out to us. I am a volunteer moderator and would be happy to answer your question. This video, When Meat Can Be a Lifesaver, answers your question. There are some cases where individuals with a inborn metabolic error birth defect such as CTD are required to take carnitine to treat the disorder. I hope that helps.




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  63. Hello,
    in the video there was the talk about choline,
    i wonder if Acetylcholinesterase inhibitor medication is linked to prostate cancer because of an increase of choline in the bloodstream?? Anyone has an answer?
    Thanks,
    Karl




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