Egg Industry Response to Choline & TMAO

Egg Industry Response to Choline & TMAO
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How the egg industry funded a study designed to cover up the toxic trimethylamine oxide reaction to egg consumption.

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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.

Metabolomics is a term used to describe the measurement of multiple…metabolites in biological specimens, [like] bodily fluids,” with the goal of “identifying the molecular signatures.”

For example, if we compare the metabolic profile of those with severe heart disease to those with clean arteries, maybe we could come up with a cheap, simple, noninvasive way to screen people. If heart patients happen to have something in their blood that healthy people didn’t, we could test for that. And, maybe, it would even help us understand the mechanisms of disease. “To refer to metabolomics as a new field,” though, is to do “injustice to ancient doctors who used ants to diagnose…[people with] diabetes”—because the ants could detect the sugar in their urine.

The first modern foray discovered hundreds of substances in a single breath: for example, thanks to the development of computer technology that made it possible to handle large amounts of information. And, that was in 1971, a time when computers looked like this. “[N]ew…technologies have allowed researchers to measure hundreds, or even thousands, of metabolites at a time”—which is good, since more than 25,000 compounds may be entering our body through our diet alone.

The data come out looking like this, which computers can turn into maps that allow researchers to try to piece together connections. Metabolomics is where the story of TMAO started.

“Every[one] knows that a bad diet can lead to heart disease. But which dietary components are the most harmful?” So, researchers at the Cleveland Clinic screened blood from patients who had experienced a heart attack or stroke, and compared the results with those from blood of people who had not.

Using all sorts of fancy technology, they identified a compound called TMAO, which stands for trimethylamine oxide. The more of this TMAO stuff people had in their blood, the greater the odds they had heart disease, and the worse their heart disease was.

Where does this TMAO stuff come from? Our liver turns TMA into TMAO. Okay, where does TMA come from? Certain bacteria in our gut turn something in our diet called choline into TMA. Where is the highest concentration of choline found? Eggs, milk, and meats, including poultry and fish. So, when we eat these foods, our gut bacteria may make TMA, which is absorbed into our system, and oxidized by our liver into TMAO, which may then increase our risk of heart attack, stroke, and death.

But, just because at a snapshot in time, people with heart disease tend to have higher TMAO levels doesn’t mean having high TMAO necessarily leads to bad outcomes. We’d really want to follow people over time—which is what they did next. 4,000 people followed for three years, and those with the highest TMAO levels went on to have significantly more heart attacks, strokes, or death.

Wait a second, though. If high TMAO levels come from eating lots of meat, dairy, and eggs, then maybe the only reason people with high TMAO levels have lots of heart attacks is they’re eating lots of meat, dairy, and eggs. Maybe having high TMAO levels is just a marker of a diet high in “red meat, eggs, milk, and chicken,” that’s killing people by raising cholesterol levels, or something, and has nothing to do with TMAO at all. “Conversely, [the reason] a low TMAO level” seems so protective may just be because it’s “indicative of a [more] plant-based diet.”

One of the reasons we think TMAO is directly responsible is that “TMAO levels predict the risk of [heart attacks, strokes, and death] independently of traditional cardiovascular risk factors”—meaning whether or not you have high cholesterol or low cholesterol, high blood pressure or low blood pressure, having high TMAO levels appeared to be bad news. This has since been replicated in other studies: up to nine times the odds of heart disease at high TMAO blood levels, even after controlling “for meat, fish, and cholesterol intake—[which is a] surrogate for egg intake.”

But, what about the rest of this sequence? How can we be certain that our gut bacteria can take the choline we eat, and turn it into trimethylamine in the first place?  Easily—they’d just have to administer a simple dietary choline challenge. How do you do that? Just give ’em some eggs.

Have people eat two hard-boiled eggs, and you get a bump of TMAO in their blood within about an hour of consumption. Ah, but what if you then gave them antibiotics, to wipe out their gut flora? Then, you can give ’em eggs, and nothing happens. In fact, their TMAO levels are down at zero, showing gut bacteria plays a critical role. But if you wait a month, give their gut some time to recover from the antibiotics, TMAO levels come creeping back up.

These findings did not thrill the egg industry. Imagine you work for the American Egg Board, tasked with designing a study to show no effect of eating nearly an egg a day. How could you rig it to show no difference? Well, if you look at the effect of an egg meal, you get a bump in TMAO levels. But, your kidneys are so good at getting rid of this nasty stuff, by hours 4, 6, 8, you’re back to baseline.

So, all you have to do is just make sure they hadn’t eaten those eggs in the last 12 hours, and you can show no effect and get your study published in the Journal of the Academy of Nutrition and Dietetics, and collect your paycheck.

Please consider volunteering to help out on the site.

Image credits: Magnus Manske via Wikimedia and Thinex via pixabay. Images have been modified.

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.

Metabolomics is a term used to describe the measurement of multiple…metabolites in biological specimens, [like] bodily fluids,” with the goal of “identifying the molecular signatures.”

For example, if we compare the metabolic profile of those with severe heart disease to those with clean arteries, maybe we could come up with a cheap, simple, noninvasive way to screen people. If heart patients happen to have something in their blood that healthy people didn’t, we could test for that. And, maybe, it would even help us understand the mechanisms of disease. “To refer to metabolomics as a new field,” though, is to do “injustice to ancient doctors who used ants to diagnose…[people with] diabetes”—because the ants could detect the sugar in their urine.

The first modern foray discovered hundreds of substances in a single breath: for example, thanks to the development of computer technology that made it possible to handle large amounts of information. And, that was in 1971, a time when computers looked like this. “[N]ew…technologies have allowed researchers to measure hundreds, or even thousands, of metabolites at a time”—which is good, since more than 25,000 compounds may be entering our body through our diet alone.

The data come out looking like this, which computers can turn into maps that allow researchers to try to piece together connections. Metabolomics is where the story of TMAO started.

“Every[one] knows that a bad diet can lead to heart disease. But which dietary components are the most harmful?” So, researchers at the Cleveland Clinic screened blood from patients who had experienced a heart attack or stroke, and compared the results with those from blood of people who had not.

Using all sorts of fancy technology, they identified a compound called TMAO, which stands for trimethylamine oxide. The more of this TMAO stuff people had in their blood, the greater the odds they had heart disease, and the worse their heart disease was.

Where does this TMAO stuff come from? Our liver turns TMA into TMAO. Okay, where does TMA come from? Certain bacteria in our gut turn something in our diet called choline into TMA. Where is the highest concentration of choline found? Eggs, milk, and meats, including poultry and fish. So, when we eat these foods, our gut bacteria may make TMA, which is absorbed into our system, and oxidized by our liver into TMAO, which may then increase our risk of heart attack, stroke, and death.

But, just because at a snapshot in time, people with heart disease tend to have higher TMAO levels doesn’t mean having high TMAO necessarily leads to bad outcomes. We’d really want to follow people over time—which is what they did next. 4,000 people followed for three years, and those with the highest TMAO levels went on to have significantly more heart attacks, strokes, or death.

Wait a second, though. If high TMAO levels come from eating lots of meat, dairy, and eggs, then maybe the only reason people with high TMAO levels have lots of heart attacks is they’re eating lots of meat, dairy, and eggs. Maybe having high TMAO levels is just a marker of a diet high in “red meat, eggs, milk, and chicken,” that’s killing people by raising cholesterol levels, or something, and has nothing to do with TMAO at all. “Conversely, [the reason] a low TMAO level” seems so protective may just be because it’s “indicative of a [more] plant-based diet.”

One of the reasons we think TMAO is directly responsible is that “TMAO levels predict the risk of [heart attacks, strokes, and death] independently of traditional cardiovascular risk factors”—meaning whether or not you have high cholesterol or low cholesterol, high blood pressure or low blood pressure, having high TMAO levels appeared to be bad news. This has since been replicated in other studies: up to nine times the odds of heart disease at high TMAO blood levels, even after controlling “for meat, fish, and cholesterol intake—[which is a] surrogate for egg intake.”

But, what about the rest of this sequence? How can we be certain that our gut bacteria can take the choline we eat, and turn it into trimethylamine in the first place?  Easily—they’d just have to administer a simple dietary choline challenge. How do you do that? Just give ’em some eggs.

Have people eat two hard-boiled eggs, and you get a bump of TMAO in their blood within about an hour of consumption. Ah, but what if you then gave them antibiotics, to wipe out their gut flora? Then, you can give ’em eggs, and nothing happens. In fact, their TMAO levels are down at zero, showing gut bacteria plays a critical role. But if you wait a month, give their gut some time to recover from the antibiotics, TMAO levels come creeping back up.

These findings did not thrill the egg industry. Imagine you work for the American Egg Board, tasked with designing a study to show no effect of eating nearly an egg a day. How could you rig it to show no difference? Well, if you look at the effect of an egg meal, you get a bump in TMAO levels. But, your kidneys are so good at getting rid of this nasty stuff, by hours 4, 6, 8, you’re back to baseline.

So, all you have to do is just make sure they hadn’t eaten those eggs in the last 12 hours, and you can show no effect and get your study published in the Journal of the Academy of Nutrition and Dietetics, and collect your paycheck.

Please consider volunteering to help out on the site.

Image credits: Magnus Manske via Wikimedia and Thinex via pixabay. Images have been modified.

246 responses to “Egg Industry Response to Choline & TMAO

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  1. Excellent video! I find it fascinating how increased computing power has allowed us to tease out relationships that weren’t possible before. And this TMAO connection may go a long way in explaining why the cholesterol – atherosclerosis discussion is so confusing. Quoting from the video: “TMAO levels predict the risk of [heart attacks, strokes, and death] independently of traditional cardiovascular risk factors”—meaning whether or not you have high cholesterol or low cholesterol, high blood pressure or low blood pressure, having high TMAO levels appeared to be bad news. This has since been replicated in other studies; up to nine times the odds of heart disease at high TMAO blood levels, even after controlling “for meat, fish, and cholesterol intake”. Seems like TMAO is a fascinating piece of the puzzle.




    2
    1. https://www.youtube.com/watch?v=yeDY3OkUl_Y

      This is a presentation by the Cleveland Clinic who authored this study (I think). What was an eye-opener for me, in wading through this technical stuff, is that TMAO increases the rate of cholesterol plaque buildup and decreases the rate that the body clears plaques. Reducing TMAO gives the body a fighting chance in repairing the damage and slows down the creation of new damage – a most welcome twofer.




      0
      1. Great video. This is one of the most important videos on health issues I´ve ever watched. Clearly explains many missing links. And gives lots of insights on new avenues for interventions to improve our health previously unexplored. Thanks for sharing.




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    2. I am not buying it. The best researchers in the field of nutrition/metabolism/and life extension such as Drs. Peter Attia and Dominik D’Agostino, do not have a problem with eggs. In fact, they include them as part of their daily diet. They are not working for the meat or egg industry, and are some of the most brilliant minds in medicine and nutrition science. They are interested in life extension and are very “self preserving”, so they wouldn’t eat eggs if they were “bad for you”.
      This goes to show that nutrition is a VERY COMPLEX topic, for example saturated fat in the context of a high fat or ketogenic diet may not be bad, while in the context of a mod-high fat and mod-high carbohydrate diet (such as the SAD), IS very bad. I don’t think one food can be studied in isolation (let alone one chemical in one food), without giving proper context to diet type, macronutrients, genetic and microbiome profile of the recipients etc. etc.
      To reiterate, the scientists (M.D.s/Ph.Ds) I mentioned are very accomplished and are credited as the pioneers in the discovery of mTOR, IGF-1 etc. So I don’t think its a wise or correct statement to just say “eggs are bad”, without a (pardon my French) sh** ton of further explaining to do. Unfortunately, the average layperson does not have the physiology or biochemistry background to even be able to piece some of the critical components together. So like I said, I am not buying it. You shouldn’t buy it either without the proper context. I know people on this site do not like to hear anything like this, which I can’t say surprises me.




      16
      1. Well, continue eating eggs and dairy then. You should wait for 20-30 years for the general consensus to reach to a convincing level. I hope that it works for you.




        0
      2. I am interested in your alternate view on this. Could address for the layman why the compilation of studies in this video showing TMAO levels predict the risk of heart attacks, strokes, and death independently of traditional cardiovascular risk factors, does not amount to a s***ton of data? I don’t think I’m out of line is saying that most readers here find independent predictive variables convincing evidence.

        Perhaps you could provide some insight rather than just pointing to other smart minds who disagree and without the counter evidence?

        Cheers




        0
        1. Hi Casey and thanks for your question. Omnivores will have higher TMAO levels as compared to vegans or vegetarians (Woolston C: Red meat + wrong bacteria = bad news for hearts. 2013. Nature. http://www.nature.com/news/red-meat-wrong-bacteria-bad-news-for-hearts-1.12746. Accessed April 12, 2013.; Koeth RA, Wang Z, Levison BS, et al: Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med 2013.; Tang WH, Hazen SL: Microbiome, trimethylamine N-oxide, and cardiometabolic disease. Transl Res 2017;179:108-115) due to alterations in gut flora and this can certainly precede the clinical diagnosis of cardiovascular disease, stroke and their corresponding risk factors. As an emergency medicine doctor, I often treat patients with their first heart attack or stroke, many of whom do not seemingly have documented risk factors such as hypertension, high cholesterol or diabetes. TMAO may be a more helpful clinical predictor in the future, especially if health care providers can agree to improve upon diet and lifestyle factors before medications and procedures in the prevention and treatment of these conditions.




          0
      3. Andrey,

        I’m “not buying” most of your post. It’s not so much that “people on this site do not like to hear anything like this,” but–rather–it is mainly because they question the credibility of the “experts” you’re citing, and their peculiar, niche ketogenic “diet” (best left for treatment of epilepsy). Rather than go into detail, here, for example, is an excellent overview of the problems with buying into high-fat proponents such as Attia, who is apparently a disciple of Gary Taubes: http://carbsanity.blogspot.com/2012/12/stossels-food-bunk-i-paging-dr-attia.html

        And, as you note, nutrition is very complex. Attia and D’Agnostino, for example, exercise a great deal. If anyone cuts out processed oils and sugars, refined grains, reduces caloric intake generally, and greatly increases cardio and weight training, as Attia did, then that person is going to lose weight, regardless of whether they eat a couple eggs or substitute those calories for a couple of slices of whole-grain bread with hummus and avocado. The ketogenic diet, which Attia and D’Agnostino espouse, is not the only–much less the best–way to lose weight (http://sciencedrivennutrition.com/the-ketogenic-diet/). Furthermore, regardless of what Taubes (an overweight journalist, and Attia’s inspiration) and his ilk claim, losing weight comes down to calories in, calories out (https://ed.ted.com/on/dgLmO0cP). You, however, as an M.D., understand that losing weight is not the only metric for whether a diet is healthy, especially in the long-term, i.e., losing weight is not the end game. That is where nutritionfacts.org comes in, and what this video on eggs was illuminating: whether eggs part of a healthy diet. The video was not on whether eating one’s calories from eggs rather than plants will result in weight loss.

        That said, the human body is versatile, and humans have evolved for 2 million years on an omnivorous/opportunistic diet. Eggs are very dense, calorically, and would have been sought after by humans. But we did not consume eggs and meat for every meal, all day, every day. Furthermore, there were days, weeks, or months with feast or famine/starvation, where the body was forced to go into ketosis. But it is without dispute–especially now as science is able to analyze substances such as ancient dental plaque–that humans ate primarily a plant-based diet, which included grains.
        https://www.ncbi.nlm.nih.gov/pubmed/28273061
        https://www.ncbi.nlm.nih.gov/pubmed/21187393
        https://www.ncbi.nlm.nih.gov/pubmed/23733965
        http://www.npr.org/sections/thesalt/2015/09/14/440292003/paleo-people-were-making-flour-32-000-years-ago
        https://www.ncbi.nlm.nih.gov/pubmed/?term=ancient+grain+consumption+stone

        Even the current longest-living human populations eat a primarily plant-based diet, heavy on carbohydrates.
        https://bluezones.com/recipes/food-guidelines/

        In sum, the human body (especially one that is engaged in regular, strenuous exercise or physical activity) can obviously survive for periods, and lose weight on, the ketogenic diet, but it is not an ideal, healthy, diet for the long-term.

        Neil




        0
      4. Not sure if I care if the Pope eats eggs daily….It shoots up the TMAO which is not a good thing because of its well known association just like a non diabetic who drinks a quart of apple juice and a few hours later has a descent blood sugar reading. It was still bad when the blood sugar shot with a corresponding jump in insulin up whether or not it came down ok. It’s just a more lasting injury for a diabetic than for a normal person.




        0
  2. I hope we get an update about choline and cancer.

    I remember way back in the era of “Life Extension” by Durk Pearson and Sandy Shaw, when they recommended massive doses of choline supplements to protect the brain from aging. Good times…not.




    0
      1. susan, the link you shared states that an important function for choline is reduction of homocysteine. It also states that folate, through a second pathway, also reduces homocysteine levels. Folate is found in the highest concentration in green leafy vegetables. How much do you think that RDI value for choline are affected by the low level of vegetable consumption in the US? Are you aware of any estimates of choline requirements in populations that do in fact consume a largely plant based diet with lots of greens and thus have a very high dietary intake of folate?

        I would have to think that we might not need so much choline, found in significant amounts only in animals, if we didn’t as a population eat a diet with very little natural folate, found in significant amounts only in plants.




        1
        1. Thank you Jim Felder! I always enjoy reading your posts – never fail to learn something. Your questions are right on the mark, and in fact I went for a brief search for some historical data on vegans, or anything that mentioned we have an issue with not meeting requirement guidelines. I did not find anything.. nada. In fact I did find mention along the way that perhaps the guidelines were too high. I believe that was on the american journal of clinical nutrition / choline site.
          Its so interesting to me Jim.. and it seems the more we dig, the more simple it becomes. WFPB!




          0
        2. Choline is an essential nutrient. Humans can make choline but not in sufficient quantities, which is why it is classified as a vitamin (a member of the vitamin-B family.). Choline has many functions. The ones i remember are 1) Acetylcholine, a major neurotransmitter, is made from choline. 2) It’s a constituent of many a lipid. 3) Trimethylglycine, required for one of the three ways to remove homocysteine, is made from choline. A lot of plant food contain choline, but the AI of choline for adults is 400-500 mg range, so I don’t know how practical it is to obtain enough choline from plants, and I’m concerned about it. I remember reading somewhere that the guts of vegans don’t harbor the bacteria that convert choline to trimethylamine but I haven’t seen any evidence to support this claim.




          0
          1. George, I agree it is indeed an essential nutrient. What has not been established is exactly how much we need to be healthy. The DRI looks like it was established from a very small and not a lot of fidelity or insight in adequate or healthy levels of dietary choline. Studies at UNC Chapel Hill fed subjects an artificial diet with less than 50 mg of choline a day which was sufficient to induce symptoms of choline deficiency (elevated liver enzymes, fatty liver, etc) in 50% of premenopausal women and 75% of postmenopausal women and men. They then step the subjects back to the DRI in a single step and the symptoms of deficiency went away. So these trials were able to establish that deficiency could be induced in a majority of subjects and that returning to the DRI will eliminate it. What they don’t say is where between 50 and 425-500 mg/day is the threshold of deficiency. My guess, and that is all it is, is that to avoid acute deficiencies only slightly more than 50 mg/day is required. I say that because 50% of the premenopausal women and 25% of the men and postmenopausal women didn’t developed an overt deficiency. That means that it was adequate for at least some of the subjects, if only just. So doubling that to 100 mg/day should probably eliminate overt deficiency. That still might not be enough to ensure optimal health. But I would be very surprised if the level had to rise to the DRI in order to see no more improvement in health.

            Here is the source of the data used in my opinion.

            http://www.veganhealth.org/articles/choline




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          2. I have been taking choline in the form of LECITHIN from non-gmo soy and organic sunflower seed for decades. I use it everyday in my smoothie. TOO MUCH choline from animal sources is likely the issue here, not the nutrient itself, especially from plant sources.




            0
            1. I have taken lecithin before..but not now. I do take a supplement callled Cognitex which includes….

              Phosphatidylserine (PS) is required for normal
              cellular structure and function. Brain tissues are especially rich in
              phosphatidylserine, but aging causes a decline in the PS content of
              cells throughout the body.

              Research has shown that in addition to improving neural
              function, PS enhances energy metabolism in all cells, memory,
              concentration, learning and word choice. In the brain, PS helps
              maintain cell membrane integrity and brain-cell-to-brain-cell
              connections.34-42

              Additionally, phosphatidylserine helps the brain use its fuel
              efficiently. By boosting glucose metabolism and stimulating production
              of acetylcholine, supplemental phosphatidylserine has been shown to
              improve the condition of patients experiencing age-associated memory
              impairment or cognitive decline.43-46

              * I’ve checked…and all my brain cells are interconnected….. ;-)

              IF they can use a dose of lecithin to raise TMAO levels…I’d avoid too much of it….




              0
              1. I too would be curious to know if choline from plant sources, as opposed to animal sources, would have the same effect on the production of TMAO. I have a young son with ADHD and he does much better with supplemental choline (in a vegan form). It’s exceptionally difficult for him to meet the minimum RDI by diet alone (picky eater). My husband (also ADHD) has seen a benefit with sunflower lecithin.




                1
          3. I have been giving a choline supplement to my wife for her pregnancy. Like you say, not easy to get enough, especially if you are pregnant with morning sickness.




            0
        3. This may sound incredibly simplistic and naive, but it seems that our bodies always do better with plants and their intrinsic balance of nutrients, and seem to take what we need without so much danger of getting too much or too little, as with animal sources like choline, iron, etc.. Maybe someday there will be enough people eating a WFPB diet to do some actual comparison studies on healthy populations to differentiate from the current western diet medicine seems based on.




          0
          1. Well I would estimate that there has to be at least a million people eating a WFPB diet or at least 95+% of the time in just the United States to form a very large cohort. We could use the general population as a control, but it would be better if there were cohorts following other lifestyles like Paleo and Low-carb. We just need a group of researchers to get on board and write the grant requests and recruit the subjects and then follow it for years and perhaps decades. Of course if the results are as stunningly positive as all the data is indicating it would be, a large measure of fame and fortune could also “befall” the researchers wise enough to undertake it. In fact they probably would need to follow the diet themselves so that they could live long enough to see the study through all the decades that it is likely to run.




            0
          2. I always found it kind of telling that carnivores don’t developer atherosclerosis. Ever. Only herbivores can get arteries clogged from cholesterol. Also name any meat eater than has to cook it’s food or risk dying from food poisoning lol.

            I think that you’re absolutely right that people do much better on plants. That’s just what we have evolved to thrive on.




            0
              1. I didn’t say that they didn’t die from it. I said that they didn’t get it. In humans you can see fatty streaks by age ten at the start of atherosclerosis. There are many carnivores that live past ten years and we don’t even see the start of atherosclerosis in them. It’s also experimentally impossible to produce atherosclerosis plaques in carnivores https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1312295/ unless you cut out their thyroid gland




                0
                    1. I too thank you for posting that article Ryan, it was well worth reading. I also looked up the biography of William C Roberts MD, the author, and was totally amazed at the man’s lifetime achievements. In the article, my favorite part was at the end under the question of taking statins for the rest of our lives..unless a person was a pure vegetarian fruit eater. Sadly, Dr Roberts admits that very few are willing to do that.

                      I was going to ask a question about thyroid and heart disease if I may.. if a person has hashimoto’s in their family, but does not have clinically low thyroid yet, can that impact heart disease ie make it worse or make it more likely ? Thanks again




                      0
                    2. I saw that line about the vegetarian fruit eater too! It made me wonder if Dr. Greger has ever referenced it in one of his videos. I feel like more people would choose that option if they were told that it was a choice and that they could get off of most of their medicines that way.

                      About your question, I found ‘Reduced serum T3 is a strong predictor of all-cause and cardiovascular mortality and, in fact, is a stronger predictor than age, left ventricular ejection fraction, or dyslipidemia’ and ‘In addition, atherosclerosis, coronary heart disease, and myocardial infarction risk are increased in women with subclinical hypothyroidis’ all from http://circ.ahajournals.org/content/116/15/1725#sec-13

                      I’m just a lay person but this suggests to me that if Hashimoto’s is decreasing your family member’s thyroid output even subclinically, it probably will increase their risk of heart disease.




                      0
                    3. Wow Ryan! Im glad I asked… for me it means added vigilance on the diet and exercise, and to keep on top of the thyroid testing. It explains a lot about my family’s struggle with heart disease. Thank you for taking the time to answer, and to supply the link. Very much appreciated!




                      0
        4. I thought that it was Folate + B12 that reduced homocysteine; not just Folate. I was going to rewatch the 40 yr old vegan dies of a heart attack video again recently, but didn’t have time.




          0
      2. I found this interesting discussion about choline

        http://www.veganhealth.org/articles/choline

        From the discussion in this article it doesn’t look like there has been much if any research into the minimum amount of choline required to maintain normal liver functioning. The studies to date only establish that most people will develope symptoms of choline difficiency if they consume less than 50 mg/day and that returning to the DRI values (550 mg/day for men, 425 mg/day for women) will eliminate those symptoms. It would be very interesting to see where the minimum required amount actually is.




        0
        1. Interesting, Jim. Eating WFPB I have trouble getting over 330 mg of choline per day. it would ease my mind if the 550 mg/day requirement had no science behind it.




          0
          1. I would to. I take comfort from the fact that there are very long lived populations both as a culture and as individuals who get less than 5% of their calories from animal sources. As such they have to be getting the large majority of their choline from plant sources. If they don’t have widespread and chronic a problem with liver dysfunction, elevated homocysteine levels and whatever else goes wrong if you don’t get enough choline, then I think we are good.




            0
    1. Science can be bought, just like you saw with this grant for the egg board. People like studies with new results or results that favor their cause. Eventually they believe their reputation doesn’t matter as long as they gain readers and funding. Maybe the peer review group was swayed or unaware of TMAO not being present after fasting and urination from participants cleaning out their system.




      0
      1. Also scientists aren’t immune from confirmation bias, and a lot of confirmation bias operates at the unconscious level. Most people in the western world already “know” that eggs are healthy. So when setting up an experiment that “knowledge” can guide researchers to a structure that avoids results that would cause them to have to question their biases.

        For an example the researchers setting up these studies would know that substances like TMAO are necessarily low-grade toxins (we don’t become acutely ill or die when blood levels rise) and so it is only through long term exposure to chronically elevated levels that TMAO would have an impact. The standard way for decades to measure this is to look for elevated baseline levels to show that long term exposure is increasing. This makes it easy to dismiss the short term spikes since they aren’t concerned with acute toxicity. When the results come back that single exposure challenge tests do not result in any increase in baseline TMAO, guided by your biases coming in, you would conclude that eggs and their choline levels are not responsible for raising TMAO levels. And of course this is exactly the same logic they use when claiming that dietary cholesterol has not effect on blood cholesterol.

        And of course this is missing seeing the forest for the trees. Chronic, long term exposure can happen just as readily from continuous and frequent exposure to TMAO spikes regardless of changes in baseline levels if the damage caused during the spikes is not completely and immediately reversible, but rather persists until the next time TMAO spikes and starts reinjuring the body. In those cases what matters is the accumulated damage due to the time averaged values of TMAO.

        In an example from my area of experience, all this is a little like saying that an A/C electrical current can’t be dangerous because if you average the voltage over a long period of time it comes out to zero. (BTW, it is zero because with alternating current the voltage value follows a sine wave sweeping continuously from a maximum positive voltage to a minimum negative voltage). This of course completely ignores the fact that anytime the voltage is not zero there is current flowing in the line and it is the time averaged voltage and current that presents a danger.




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        1. My family member was an Olympian in 1936 with Jesse Owens. He raises most of his vegetables and fruits. He is not a vegetarian and has always eaten meats chicken and fish plus venison and wild salmon and trout. He has always chopped wood or gotten exercise. Never had cancer or a heart attack and sits in the sun every day ever since i can remember and water skied fpr 27 years,hiked many trails. He is 102 still sharp and walks with a cane. He has always eaten eggs and makes chicken soup every week.I met a lady who came from a family of 10 children and said they were poor so her Mother fixed eggs everyday in a different and delicious way.?? Doctors don’t know everything and are guessing.




          1
          1. We as humans are great at zeroing in on events that match our biases while ignoring many many others that do not. So you have an example of someone living a very long time while not following the dietary guidance emerging from the last half century of scientific research and feel that that casts doubt on that entire body of research. However, I am sure that there are many other people in your extended family who suffer from diet induced diseases like high blood pressure, diabetes, heart disease, kidney disease, and most of the common cancers which will result in their living diminished lives and dying years or decades sooner than they would have if the didn’t eat their current diet.

            Good science looks at large numbers of people in order to find the larger trends. In every population eating a specific diet there will be a distribution typically shaped like an upside down bell with few on the left dying far earlier that the rest and a few on the far right seemingly unaffected and living a very long time with the peak of the curve being at a particular age between. What the science is looking at is how does the shape and peak of this curve shift in populations eating different diets. So if a diet moves the peak to the right (older age) and reduces the width, then that diet can be said to on average increase lifespan. And this shift of the curve to the right with the peak at an older age and fewer people dying prematurely is exactly what scientist see when the compare populations who eat more whole plant and less animal foods and refined plant foods.

            So while it is wonderful that your relative lived such a long and healthy life he is an outlier of tiny percentage of people who eat a diet with significant amounts of animal products who reach the century mark, the facts are crystal clear that eating his diet will again on average result in reduced longevity compared to people who eat a more whole plant diet.




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    1. Perhaps a better question would be: How can we measure our health by measuring TMAO?, and perhaps Can we measure kidney health by measuring its clearance? When would be the best time to measure, at 4 hours?




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    2. If TMAO causes small non-reversible or slowly reversing changes/damages to the body, then the important factor is the time-averaged TMAO levels since damage is being caused when the levels are high and those damages accumulate over time. I don’t know what those changes might be, maybe other can help me out, but accumulation of small insults is a mechanism where transient increases can have an effect in the absence of chronic elevation of the baseline level.




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    3. I really have no legit clue, but I would imagine akin to the way repeated excess glucose spikes can do damage, even if your blood sugar drops when you fast. The kidneys can only take so much abuse, so their effectiveness would be compromised over time, and in a closed system that would spell trouble downstream too.




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    4. It works by having enough time for the TMAO to be elevated to do the damage but then never enough time for the TMAO levels to be low enough to heal said damage. If TMAO is the driving force behind cholesterol plaques being laid down and 2 or 3 x TMAO elevating meals a day are eaten (quite normal in our societies) then the plaques can establish and build but there is never an opportunity for them to be diminished.

      The whole medical industry is set up to mess with the science. Why do people have fasting blood tests after not eating for 12 hours? Why not during the middle of the afternoon when they’ve eaten their normal diet? Because they don’t want the real results of what people are truly doing to their bloodstreams.




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    5. Please refer to an earlier video http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ that discusses choline and carnitine forming TMAO. One statement is that the TMAO causes the inflammation that we see associated with heart disease and cancer. Like the posters below mentioned the continuing assaults on the body with continued ingestion of the offending molecule, the residual inflammatory response initiated by the TMAO that may well continue long after the measurable amounts of TMAO have been cleared by the kidneys. Great question.




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    1. From http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ :

      “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.”




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        1. See the video posted in the comments. In it, they tested vegans and omnivores. The vegans had virtually no microbes to transform choline into TMAO. It is a 30 minute presentation and that bit is toward the end.




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          1. are you talking about the video, “Gut Microbiota as a Participant and Therapeutic Target in Atherosclerosis and Vascular Inflammation”?
            i’m sorry but i’m having a real problem finding things on Disqus these last few days. i look for a comment that i know was there, can’t find it and then i find it by accident, lol. it’s making me crazy.




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      1. I am trying to find out whether soy lecithin is less harmful than egg lecithin. It stands to reason that, in the absence of carnitine, soy lecithin would not be a problem. Can anyone substantiate or refute this?




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      2. Then there is this:

        http://www.vincegiuliano.name/10topsupplements.htm

        Actyl-l-carnitine –
        a key substance related to cell metabolic processes that can also penetrate mitochondria and mitigate various
        pathologies that can affect cell metabolism. A powerful antioxidant,
        also helps clear lipofuscin and fight tissue glycation.

        The combination of r-alpha lipoic acid and Actyl-l-carnitine is particularly powerful, impacting
        the mitochondrial health of all cells in the
        body. The combination can repair damaged
        mitochondrial and restore functionality to what otherwise would be compromised
        cells. Health implications include
        eyesight and hearing improvement, enhanced vitality and sexual drive.

        Feeding these supplements to mice and lower
        life forms extends lifespans 20% to 30%
        compared to control groups. I suggest
        taking 200mg of r-alpha lipoic acid and 500mg of Actyl-l-carnitine twice daily.

        * I take 500 mg ALC in the morning along with some AlphaLipoicAcid.

        ** IF ALC is so damaging…why the increase in lifespan as seen above?




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    2. The problem is not choline. Although choline is the starting material for the production of TMAO, the real villains are TMAO and the TMAO-producing bacteria associated with meat-eating. Many plant foods (e.g., soy beans) contain almost as much choline as eggs, yet because the microbiome of 100% plant-eaters contains a different profile of bacteria, we do not see high levels of TMAO in this population.




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    3. Good question. Another video Dr. G did on choline and TMAO gives a comprehensive answer regarding the association between gut bacteria and formation of TMAO. It essentially says what you do in that the formation is dependent upon the bacteria in the gut and that meat eaters have a different flora than veg eaters and those that avoid animal products do not have the bacteria to form TMAO.




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  3. Erm..how shall i put this..Doctor Mcgreger, you’re a legend lol or to put it more simply
    Dr Mcgreger :10/ egg industry: 0
    Next please!!!
    ;-)




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  4. LOL, this is completely misleading. So cholesterol, high blood pressure are no longer the problem but it’s TMAO now? Is it cherry picking for the usual agenda?




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    1. You sir are not fooling anybody. With such a blatant display of biased interpretation of this video, accusing Dr. Greger of cherry picking look a whole lot like you projecting your own issues with an agenda driven approach to the science.




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    2. Cholesterol no longer a problem? Only in the minds of the misguided. TMAO acts on at several sites: enterocytes (cells lining the intestines), hepatocytes (liver cells), macrophage foam cells of atherosclerotic plaques, and vascular endothelial and smooth muscle cells. TMAO is atherogenic for at least several reasons, some that directly involve cholesterol. TMAO decreases reverse cholesterol transport (net movement of cholesterol from the peripheral tissues to the liver), elevates cholesterol accumulation in macrophages, and causes inflammation in vascular endothelial and smooth muscle cells. Here are just 2 citations that will lead the willing reader (probably not frank) to others articles.
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650111/
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802459/




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    3. I think you may have missed the point of the video. The point is that it is less invasive to determine heart disease by a blood test (TMAO might be that possibility if research pans out) than it is by an angiogram where one has to have their body cut into and a camera threaded into the heart to look for disease. These invasive procedures have certain elements of danger to them. My Father had one done and it didn’t go well. If a blood test could tell us more without the invasive procedures then its easier on everyone.
      Thank you.




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  5. Looks like Dr. G struck a nerve. Are some of the snarky posts below people trolling from the egg board? Do tell!
    Thanks for another eye-opening and informative video, Dr. G.




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    1. Heh heh, the opposite thing happened to me when I posted about my success with a WFPB diet on the ADA forum, I got blasted with nastiness by their staff of trolls for exposing reality! Wow, sure made me rethink the real purpose of that agency…keep em from dying, but sick enough to fund the system?




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      1. I assume you refer to American Diabetes Association. Perhaps I need to look at their site more. I’ve never found much there to be of much value though.




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        1. I don’t know how anybody would find useful information at their website. Their basic message is”

          1) You’re screwed! You have this disease and you will for life and there is no getting better, let alone curing it. Better get used to it.
          2) You will only get worse and worse and you will likely go blind, develop neuropathy in your extremities, possibly lose limbs, destroy your kidneys, and vastly increase your chances of having a heart attack
          3) But if you spend huge amounts of money buying drugs from our patrons you can somewhat slow your slide into oblivion.
          4) You will spend the rest of your life counting the number of grams of carbohydrates in ever bite of food you eat (if you know what is good for you) in an constant struggle to keep your blood sugar and especially A1c under control to stave off the worst of the effects of the disease. But hey, at least you get to eat lots of butter, meat, full fat dairy and olive oil poured over literally everything just as long as you avoid the evil carbs
          5) Did we mention that you are screwed.

          What’s that you say, you think a whole plant based diet without all those yummy fats and meat will actually reverse your diabetes! Don’t be rediculous, there is no cure for you, just drugs for ever. Besides that would be such an extreme diet that nobody would ever stick with it. No, no, no more objections, just go back to sleep. We’ll let you know if we think you need to know anything.




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          1. Clearly you have looked more recently that I. It has been almost 20 years since I looked and found nothing of use. Your characterization is really spot on as I recall. Their damage is I think particularly egregious as in the following example: I’ve a friend in his late 60s who I met at a dance studio. He mentioned that he is probably going to need to quit dancing because he had just been diagnosed with diabetic nephropathy which in turn would further limit his activities. I explained some of the dietary factors that could be changed to arrest the progression of the nephropathy and possibly reverse the diabetes. He looked sad and noted that he just could not do that.

            Now the issue is that while I gave very good information that could save his life, I was just some guy. The “real authorities” like his doctor and the ADA never mention any such thing as dietary changes other than being consistent and regular in exactly the ways you mentioned.

            Your reply suggests that you or a family member has a direct history with diabetes? I developed diabetes 46 years ago at the age of 21 and within 10 years had learned to never believe a medical professional without double checking what they told me. Even the little I knew about fats in the diet had led me to regard most of the ADA as nonsense before I ever heard of Michael Greger.




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  6. I see a lot of confusion regarding this topic from the comments. Here is my understanding: Number 1 killer for adults in the USA is heart disease. Risk factors such as cholesterol levels, smoking, sedentary lifestyle, and high blood pressure are still the same risk factors.

    Goal of identifying blood markers such as TMAO is to improve ability to identify people at higher risk for cardiac disease.
    TMAO is not to see if our overall state of health is better or to measure health of our kidneys.
    It is just to see if we are at risk for heart disease.

    “Omnivorous human subjects produced more TMAO than did vegans or vegetarians following ingestion of L-carnitine through a microbiota-dependent mechanism.” Source: http://www.nature.com/nm/journal/v19/n5/full/nm.3145.html

    My impression is we are selecting certain gut bacteria by our diet. A diet composed of WFPB food is better from cardiac disease perspective (reduced risk). It happens to also be better for diabetes, hypertension, and weight. Adapting our diets to WFPB food is a personal choice. It makes sense to me however that we would want to have overall healthier lives.




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  7. Excellent video, but it’s not clear if the elevation of TMAO following recovery from antibiotics was due to continued egg consumption or to the residual effect from the initial consumption 2 hard boiled eggs. Also, what might be the effect on TMA/TMAO when probiotics are consumed, rather than antibiotics? Perhaps Lisa can help answer.




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    1. The bout of antibiotics lasted 1 week. Subsequently, subjects were allowed to recovery their gut flora for at least 3 weeks before receiving another challenge of labeled d3-L-carnitine.




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    2. Since the second challenge occurred a month after the initial one it would be a stretch to think there were still portions of the two hard boiled eggs in the intestine. Here is a link to the full text of the article and in the methods section it mentions a second choline challenge which is interpreted as the same ingestion of eggs as the first. http://www.nejm.org/doi/full/10.1056/NEJMoa1109400




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  8. Preface: I am a PBWF advocate but with lapses, enthusiastically embrace plant protein/fat rather than animal, especially egg yolks, and an ardent follower of NutritionFacts.org and Dr. Greger’s amazing work–really a national treasure…
    And, I appreciate and admire the excellent work Dr Hazen et al and other workers have done re TMAO and atherosclerosis, especially metabolomics studies. Agreed, large amounts of extra offenders here–choline, lecithin, carnitine–are certainly to be avoided.
    However, I think there is more to the story than is known… First, how come populations consuming high amounts of fish do not have high rates of new cases of coronary events? Second, from a teleological and physiological standpoint, choline is essential for all membranes, and age-related losses are accompanied by cognitive impairment, which is reversible. As is mentioned in another comment, choline-betaine deficiencies cause disease per se, and choline deficiency has been cited as a cause for concern. Third, details of conversion to TMAO by gut microbiota are not well understood. In the healthy gut, as rare as this may be in modern society, what is the degree of association with TMAO and heart disease?
    While this pathway is a remarkable contribution to our understanding, the last word has definitely not been written, but certainly enough to avoid unnecessary amounts without cause.




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      1. Exactly, I think there is more to the diet-TMAO story.

        Fish elevates blood TMAO more than most other foods – https://www.ncbi.nlm.nih.gov/pubmed/27377678.

        Yet fish consumption is overwhelmingly associated with lower risk of CVD – http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3705336

        I think the difference between postprandial and fasting TMAO is crucial. The diet studies show you can elevate postprandial TMAO, but the metabolomic studies show that fasting TMAO predicts CVD – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086762/.

        Since the body can normally clear TMAO pretty quick, elevated fasting TMAO suggests clearance/kidney problems. So perhaps in the long run, dietary modulation of kidney function and TMAO clearance is important. Another area plant-based diets may help.




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        1. “Yet fish consumption is overwhelmingly associated with lower risk of CVD”

          That really, is not a given!

          There are confounders to studies showing this, and consuming fish is usually higher among people who are into their overall health. The possibility is that despite consuming fish, a WFPB diet can still produce benefit. A likely diet in people who are interested in better health. Take the reverse of that, a diet of fried food, red meats, smoking, and sedentary lives likely would not benefit from adding more fish to their diet. The ratio of WFPB diet to fish maybe the real question waiting to be answered.




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          1. Fair points. I agree, nothing is given, hence why I’m poking around :).

            Still, fish (cod fillets) increased blood TMAO around 50x more than eggs/beef. The fish contained lots of preformed TMAO and likely increased blood levels independent of gut microbiota, unlike egg/beef. Interestingly, in the same study fruit (apple sauce) actually decreased postprandial TMAO.
            https://www.ncbi.nlm.nih.gov/pubmed/27377678

            Since fish can so profoundly increase blood TMAO, it seems odd there is a negative association between fish consumption and CVD, even with some potential confounders (esp since most fish-CVD studies were observational).
            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705336/

            I wonder if diet might also modulate TMA oxidation (FMO3), TMAO clearance or TMAO athrogenicity?




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    1. TMAO is produced as a metabolic byproduct by bacteria that use carnitine and choline as a food source. In order to keep TMAO from being produced you have to eliminate this type of bacteria from the gut. Since it appears to depend on there being a steady supply of carnitine in the food consumed. Carnitine is only found in animal foods. Thus a proven way for the meat and egg industry to prevent TMAO from being produced is to encourage people to stop eating their products!

      Oh, and we know that these bacteria dependent on carnitine is that they are not present in the guts of long term strict vegetarians (vegans) who do not consume any food that comes from animals. However, plants can be high in choline, and so choline by itself is not sufficient for these bacteria to survive. They need carnitine. This was tested as part of the Cleveland Clinic study referenced in the video by having a long term vegan who had not been treated with antibiotics eat a steak. In the average habitual animal food eater, the steak would have caused a clearly visible spike in TMAO. In the vegan there was not TMAO response. Of course this was just one person, but and would have to be replicated with more vegans to be absolutely sure. However, reinforcing this is that plant based choline does not cause a spike in TMAO in vegan, but does in carnists.




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  9. Excellent video, in the end, showing how Industry manipulates science, not in the interest of public health, but rather their bottom line! This one will definitely be added to my “Industry-biased Research” folder, ( which grows thicker every day).




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  10. Did they address the association between TMAO and plant based diet eaters? I heard it mentioned but didn’t hear if there was actually any study done on the amount of TMAO that might be found in those eating plant based diets. I’m guessing there was no study done on that at least by the Egg board ….. does anyone know if there have been studies on TMAO and plant based diet eaters? Just curious.




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  11. I think there is more to the story than is known… First, how come populations consuming high amounts of fish, which contains much higher amounts of TMAO precursors than meat, do not have high rates of new cases or prevalence of coronary events? Second, from a physiological standpoint, choline is essential for all membranes. Synthesis of choline in humans is insufficient to meet requirements for health. Third, choline-betaine deficiencies cause disease per se, and choline deficiency (actually not uncommon) has been cited as a cause for concern. Teleologically, it makes no sense. Age-related (and other) losses are accompanied by cognitiveimpairment, which is reversible through replacement. Fourth, details of conversion to TMAO by gut microbiota are not well understood. Fifth, the intestinal bacterial that produce trimethylamine remain unknown (Falony, 2015). Sixth, determinants of TMAO levels are not simple, and depend upon ability to methylate, are inversely proportional to plasma phosphatidylcholine levels, and associated with low levels of high-density lipoproteins (HDL)–itself another complicated molecule (Obeid et al, 2016). One fascinating feature is the diabetes-TMAO connection, but that would be expected for a number of reasons.

    In the healthy gut, as rare as this may be in modern society, what is the degree of association with TMAO and heart disease? Even though TMAO is a predictive biomarker, the question is whether it is a proxy for other atherogenic processes, mediates atherosclerosis itself, or is a bystander (Velasquez et al, 2016). Since TMAO levels are part of several intersecting biochemical pathways, we need to be sure that TMAO is not a marker of other processes that predict atherosclerosis. More work is needed to explain some epidemiological and molecular gaps in knowledge, and then clinical significance can be directly explored (Cho & Caudill, 2016).

    So, while the choline-TMAO pathway is a remarkable contribution to our understanding of the players, current evidence
    suggests the last word has not been written about it.

    References
    Cho CE, Caudill MA. Trimethylamine-N-Oxide: Friend, Foe, or Simply
    Caught in the Cross-Fire? Trends Endocrinol Metab. 2016 Epub Nov 4. pii:
    S1043-2760(16)30144-8. doi: 10.1016/j.tem.2016.10.005
    Falony G, Vieira-Silva S, Raes J. Microbiology Meets Big Data: The Case of Gut
    Microbiota-Derived Trimethylamine. Annu Rev Microbiol. 2015;69:305-21. doi:
    10.1146/annurev-micro-091014-104422
    Obeid et al. Plasma trimethylamine N-oxide concentration is associated with
    choline, phospholipids, and methyl metabolism Am J Clin Nutr. 2016
    Mar;103(3):703-11. DOI:10.3945/ajcn.115.121269
    Velasquez MT, Ramezani A, Manal A, Raj DS. Trimethylamine N-Oxide: The Good,
    the Bad and the Unknown. Toxins (Basel). 2016 Nov 8;8(11). pii: E326.
    10.3390/toxins8110326




    1
    1. Richard Kones, MD: You wrote: “First, how come populations consuming high amounts of fish, which contains much higher amounts of TMAO precursors than meat, do not have high rates of new cases or prevalence of coronary events?” I’m wondering: a) what populations you are referring to, b) what counts as “high amounts”, and c) what the coronary event numbers are comparing these populations to other populations which are largely plant based in their diets.
      .
      You also wrote, “Second, from a physiological standpoint, choline is essential for all membranes.” That’s irrelevant. That’s like saying, “Water is essential for human life.” Yes, it is. But too much water can kill you… Or if water had a way to morph into something bad in our guts when consumed from certain sources, then that would mean we might be wise to watch where we get our water from.
      .
      I’ll let other people tackle your other points if interested. I’ll just make a general comment on the topic. 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 does not have to resort to eating animal products. You can get the benefits of the choline without the harms of the animal products like fish.




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      1. This still does not address the issue of why eating fish is not associated with atherosclerosis through elevated TMAO levels.
        –We agree about eggs and meat for many reasons too long to discuss. The question is if TMAO is high fro one source, and produces an ill effect, why doesn’t the same effect arise from other sources.
        –High amounts for fish depend upon the fish, whose carnitine (which also produces TMA and TMAO) content may exceed several-fold that in meat. So 1-2 portions should do more to raise TMAO than the equivalent of red meat, by far.
        –By populations, I mean any of the modern-day hunter-gatherer fishing peoples, but also coastal dwellers, in view of the content in fish generally.
        –By c) I mean exactly what is posed. There are numerous references about fish-rich diets associated with proportionally fewer major cardiac events. Consuming those diets should lead to equally high incidences of major events. They do not, so I simply cite this as an inconsistency that TMAO is solely responsible.
        –The need for phosphocholine in all membranes is not trite or irrelevant. That is why the minimum requirement does exist, as you quoted from page 118. There is no argument that choline can be consumed in a WFPB diet–there is certainly no need to consume fish, fowl, or meat to obtain dietary needs.
        –The point made is that TMAO may not be responsible for atherosclerosis alone–there is a difference between a biomarker, predictor, and being a cause of an effect. C-reactive protein, for instance, is a powerful predictor and biomarker for future events and illness, yet is not itself a cause, ie, involved in the production of the illness.
        –The other items remain as questions research needs to answer. There is a definite tension between a need for choline that is typically not synthesized sufficiently in humans for health and the over-interpretation that we need to lower our consumption of choline urgently. Choline is used for the neurotransmitter acetylcholine humans need. Cognitive impairment can be mitigated with ingestion of choline derivatives. Importantly, there are a large number of drugs which have anticholinergic actions (block the action of choline) that are dangerous in the elderly, consistent with the need for sufficient choline for the brain and intact executive function.
        Thea, I am on your side here about the essential philosophy about plant based diets, but my point is not that not that choline/carnitine is necessary so go eat eggs, but that TMAO as a molecular needs further work before clinical action is taken. If choline is restricted unnecessarily (whether it is from plant sources as well), unforeseen but serious consequences may result.




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        1. Richard Kones, MD: Thank you for clarifying your thoughts. You raise some interesting points. In reading your posts, it’s clear to me that I don’t know enough about this topic to have a conversation with you about the main points you raise. There may be no more that needs to be said, but maybe someone will have some additional thoughts to share with you.
          .
          While not negating perhaps the main gist of your post, I would like to clarify two points of my own. :-) One is that when I asked about which populations you were thinking about, I was hoping for some particulars. The reason I bring this up is that many posters often refer to the old/traditional Inuit (Eskimo in outdated terminology) as a people who eat a lot of fish and do not get heart disease. But this is actually not true. Even ancient Inuit mummies show signs of heart disease. It’s been a long time since I looked at the following references and don’t have time to filter right now, but I’m pretty sure that at least one of the following references backs up my claim.
          http://www.ncbi.nlm.nih.gov/pubmed/12535749
          http://nutritionfacts.org/video/omega-3s-and-the-eskimo-fish-tale/
          http://aje.oxfordjournals.org/content/95/1/26.short
          .
          The point I’m making is that I’m not aware of any actual heavy fish eating populations which have good evidence to show that they do not suffer from heart disease.
          .
          The only other comment I have is that you wrote, “If choline is restricted unnecessarily (whether it is from plant sources as well), unforeseen but serious consequences may result.” Who is talking about restricting below recommended daily amounts? Is this a concern?




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          1. Yes, what you say about the Intuit is true–they had more heart disease than usually quoted, even before some Westernization.
            I just posted what I called corollary to my original post–that keeping one’s gut bacteria in the best shape possible is what’s called for, aside from consuming excess TMAO generating foods.
            About restricting choline intake–yes, this has been mentioned. And, there is also a drug in the works to counteract TMAO production, which to me is ridiculous when compared to a WFPB diet. People will do anything to enable unhealthy habits, it seems, as you know.
            I advocate a WFPB diet, and certainly not eggs. In addition to the lecithin in the yolk, egg protein is less healthy, in my opinion, than plant-based protein, which has been discussed before by Dr Greger. I admire your enthusiasm, Thea.




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              1. It appears the “Blue Zone” Ikarians eat small amounts of fish and have very little heart disease. See http://www.npr.org/sections/thesalt/2015/04/11/398325030/eating-to-break-100-longevity-diet-tips-from-the-blue-zones –and of course the same is true of some of the Loma Linda Adventists. It’s interesting that one of the top foods listed for Loma Linda is salmon. I haven’t read the book, but based on the NPR summary, the Blue Zoners average about a pound of “meat” a month. It doesn’t say whether “meat” in this context includes fish. If it does, then the fish component would likely be a fraction of that small total, with the possible exception of the Loma Linda Adventists, who are (in my experience) more likely to avoid all meats other than fish. Ellen White, the founder of Adventism and the original source of many of their dietary practices, apparently ate fish sometimes, although later in life she became reluctant to do so. Her reasons, however, were mainly about contamination and pollution of the seas near the cities, where a lot of fishing was done. And this was in 1905! My Adventist grandmother ate fish maybe once a month.

                It’s interesting, though not on topic, that the Ikarians and Sardinians also use goat or sheep milk/cheese. They mention 15 lbs of cheese a year, per person, for the Sardinians. That’s only 4.6 ounces per week, a very small amount.




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                1. Good morning Todd
                  The overriding theme in the Blue Zone is that the longest living populations eat meat/fish occasionally–as you said. Richard is talking about “high consumption populations” and I was wondering what group he was talking about. We know in the United States the FDA recommends fish 2-3 times per week and no more due to pollutants. And this pollution is world wide unfortunately. Many of the toxins from industry are carried in the air, landing in the rivers and polluting the fish. (Very sad)

                  But you are right. Small amounts are the key. Not the way we do it in the United States-3 meals a day of meat or dairy.




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                  1. My personal guess is that in these Blue Zone places, the occasional consumption of meat and fish is how they avoid B12 deficiency, since they probably don’t take supplements. The amount needed for this purpose is probably quite small, so the best strategy is to eat only as much as needed for that purpose. I also have the suspicion that K2, another micronutrient made by bacteria, may play a role, but that’s even more conjectural. I’m convinced, however, that K2 is important for (cardio)vascular health. At the moment, however, there’s no simple way to test K2 levels.




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                2. Legumes–beans, peas and lentils — are the #1 key to longevity, says Dan Buettner, the bestselling author who’s been studying those Blue Zones. http://www.independent.ie/life/the-man-who-knows-what-to-eat-to-live-longer-and-it-involves-beans-31550139.html In a study on animal models with breast and prostate cancer, longevity researchers Drs. Valter Longo and Luigi Fontana suggest that if you keep dietary protein low (below 10% of calories), a little animal protein may be fine. “Interestingly, there was no additive effect of switching from animal to plant proteins when dietary protein content was 10%, suggesting that a threshold exists below which the amino acid composition is less important than the protein content of the diet,” the authors said. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3926840/




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          2. I also wonder that if TMAO precursors play such a strong causative role in adverse cardiac outcomes, why wouldn’t fish carry more risk than other meats? Instead, we find the opposite is true, and fish are provisionally recommended as part of a cardioprotective diet (whereas red meat, etc., is not) based on a whole host of research.




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            1. rizumu: I don’t know. This is definitely an area that I don’t know that much about. Some speculation: If what you are saying is true, perhaps it is because fish contain other counter/helpful substances. Fish, as a whole food, would have a complex set of interactions with our bodies just like any other whole food. That’s my completely uneducated speculation.




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        2. I agree with you that TMAO needs more research. Currently it is a research topic rather than a clinical marker.
          C-reactive protein, on the other hand, is a clinical marker.

          A quick google search on highest fish consumption by Capita shows Iceland and Malaysia as 2 countries with high consumption but very different rates of heart disease. Iceland has been working hard to change risk factors such as cholesterol levels, smoking, blood pressure, and sedentary lifestyle since the 1980s. It paid off. Malaysia has high rates of heart disease and that did not decrease.

          Another point was that I was unable to locate levels of TMAO in Icelandic subjects following their diet.
          Do you know of any such study?

          Choline itself is not the issue as Choline is found in WFPB diet.
          Whether WFPB diet is better augmented with fish or not brings a different piece to the table: Is fish consumption by 7.5 billion individuals sustainable? Likely not at the rates fish is currently consumed.

          Are we losing anything by following WFPB diet?
          Again, likely not as we currently know, and in the process we decrease cholesterol levels, weight (and likely increased activity as weight is reduced), and risk for insulin resistance among other yet unknown benefits.




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  12. Excellent discussion. Thank you Dr. Greger for addressing this topic. Only have one question…..what is a WFPB diet? Not familiar with that acronym.




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    1. Wildbot: I hope you stick around. If you do, you will see that WFPB acronym used a lot. It means “Whole Food Plant Based” diet. It refers to a diet that is *largely* made up of (the *vast* majority of calories come from) whole plant foods – as opposed to animal foods or processed plant junk (like oils, while flours, etc).
      .
      The WFPB diet comes in various forms/details. Dr. Greger recommends what he calls the Daily Dozen, which you could look up (or get details from Part 2 of Dr. Greger’s book How Not To Die). An older form of Dr. Greger’s recommendations are on this page: http://nutritionfacts.org/2011/09/12/dr-gregers-2011-optimum-nutrition-recommendations/
      .
      Note that unlike most people offering nutrition information, there is no conflict of interest here. Dr. Greger does not make a single penny off of this website, his books, his DVDs or his speaking engagements. It is a “labor of love” that he donates his time to share this information with people.
      .
      I recommend watching the summary videos (found at the bottom of the home page) for a great overview of the type of information presented on this site. We also have a series of introductory videos that you might find helpful. You can find those videos here: http://nutritionfacts.org/topics/introductory-videos




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      1. Thank you Thea for your detailed response. Will definitely follow up on your suggestions for further reading. I’ve also ordered a copy of Dr. Greger’s book “How Not to Die”.




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        1. make sure and listen to, pay attention to and hang onto every single word that thea says.
          like rush always says, “don’t doubt me” but in this case, don’t doubt thea !!
          she’s an incredibly knowledgeable moderator amongst incredibly knowledgeable moderators.
          this is the best medical information site in the world, literally.
          donald.




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          1. AZ DONALD: That’s such a kind thing to say. You have made my day!
            .
            I do make a point of making sure people understand that I’m just a lay person. I’m not nearly as knowledgeable as many of the other participants on this site. Feel free to doubt all you want. :-) I couldn’t agree with you more though that this site is top notch. I feel very proud to be part of the NutritionFacts volunteer team. I’m also grateful to be able to converse with people like you, whom I learn so much from and gain inspiration from every day.




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      2. Thea, AZ Donald beat me to our and said things better than I am here. I’ll simply say that you, Thea, are a gem! I appreciate all the time and knowledge you share with us here at Nf.org




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  13. Saw this video earlier in the day and just returned from a late afternoon trip to the grocery store. Saw an older, white-haired fellow with a shopping cart full of eggs. And by full I mean 24 cartons. I literally stood there looking and counting – 8 piles, each 3 cartons deep. 288 eggs. I gathered there must have been a sale on eggs, although I didn’t bother checking.

    Now this was a frail, old fella who could barely push his cart, so doubt he was buying them for his catering business. I have no idea what the shelf life of eggs is – 3 weeks? Even assuming his wife was still alive and indulging as much as her husband, they’d each have to put away 7 eggs a day each day to finish off that stash before it goes bad.

    This is in Canada, so the Egg Board isn’t the culprit when it comes to passing off eggs as health food. Nope, it’s actually the government itself. Agriculture and Agri-Food (whatever that is) Canada:

    “The egg, therefore, has been re-born not only as a Functional Food i.e. one which by virtue of the presence of physiologically active components is efficacious in the prevention and/or treatment of disease and the promotion of optimal health, but as a food containing a treasure chest of products which can be utilized in many areas.”
    http://www.agr.gc.ca/eng/industry-markets-and-trade/statistics-and-market-information/by-product-sector/poultry-and-eggs/poultry-and-egg-market-information/sub-sector-reports/table-and-processed-eggs/little-known-uses-for-eggs/?id=1384971854397

    Yep, eggs for the “prevention and/or treatment of disease and the promotion of optimal health”. So says the Government of Canada.




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      1. Canada is as backwards as the US, if not more so, when it comes right down to it. The only way the international community buys into Canada’s faux progressiveness is just good PR on the part of the federal government. That and the fact Canada’s not really important enough globally for anyone to take the time to look into whether the PR holds up to the reality.

        For example, the national media in Canada, including the federal government funded national broadcaster, the Canadian Broadcast corporation, not only downplayed the significance of the World Health Organization’s classification of red and processed meat as known carcinogens, but actually characterised the report as “an attack” on the meat industry in Canada.

        https://www.youtube.com/watch?v=j9QCMjV2ePM

        And Canada’s Senate produced a report around the same time touting the need to adopt a national strategy to combat obesity. Its proposed solution:A tax on soda.

        Informed Canadians aren’t any more proud of their government than Americans are of theirs.




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    1. Don’t get me started on industry’s snowjob here in Canada. Several years ago, I did a piece for CBC’s investigative show “The Fifth Estate” exposing Canada’s Heart and Stroke Foundation for taking money from a major food maker and putting its seal of approval on the company’s products– despite that the products were unhealthy. For years, the Dairy Board published advertorials in a medical newspaper but those promo pieces were not labelled as advertising. Everything in moderation? What industry exec came up with that one?




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  14. The corollary of my earlier post is that following a plant-based diet may be an appropriate defense against TMAO according to current evidence.

    Since TMA is produced by restricted, nondiverse, and unhealthy gut microbiota, a main thrust is to restore the gut flora back to a healthy profile. Healthier bacteria, less TMA, less TMAO. This is not an easy task. Rather than restrict choline at the moment, preventing its conversion to TMAO by promoting “good” intestinal bacteria is reasonable. Lifestyle–diet and exercise–is the way to go.

    As mentioned earlier, seeking to lower choline levels may only reproduce what happens when choline is inappropriately blocked through the use of drugs, and/or what occurs during choline deficiency diseases occur. This has little to do with choline intake, which may be through beans, broccoli, tofu, greens, potatoes, nuts, grains, and fruit https://www.ars.usda.gov/northeast-area/beltsville-md/beltsville-human-nutrition-research-center/nutrient-data-laboratory/docs/usda-database-for-the-choline-content-of-common-foods-release-2-2008/.




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    1. I see that Cornell has been asking similar questions to those which you posed, based on the apparent “fish paradox”..

      They too suspect that TMAO may simply be a marker for gut microbiota composition rather than a direct causal factor. However, this work appears to be funded by the meat and egg industries so we can’t be sure that they are looking at all the relevant questions.
      https://www.ncbi.nlm.nih.gov/pubmed/27377678
      http://www.fasebj.org/content/30/1_Supplement/406.6.short




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    2. Personally, I’m going to continue to eat a diet exclusively (well, as exclusive as I can) of whole plant foods and not worry about choline, carnitine, “carnephilic” bacteria, or TMAO. [But I am still interested in the biochemistry.]

      As the short position paper (pdf) below suggests:
      “In summary, it appears that the AI for choline of 550 mg/day for men and 425 mg/day for women is more than adequate and, based on associations with chronic diseases, might even be higher than ideal. A range of 300 to 350 mg appears ideal for the long-term prevention of disease …”
      and
      “Eating a well-balanced vegan diet with plenty of whole foods should ensure you are getting enough choline.”
      extension.oregonstate.edu/coos/sites/default/files/FFE/documents/choline-rd.pdf




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    3. Carnitine appears to be an essential nutrient to the TMA producing bacteria. In the Cleveland Clinic study long term vegans challenged with a steak did not see any increase in their serum TMAO levels indicating low levels of these bacteria in their guts. As you say, a plant based diet provides plenty of choline, so choline can’t be sufficient for these bacteria, though they can obviously metabolize choline to TMA when they are present in the gut and receiving sufficient carnitine.

      So there appear to be no need to worry about choline intake from plants being converted to TMA when consuming a strict vegetarian diet since there does not appear to be sufficient numbers of the bacteria capable of converting choline into TMA present in people who strictly plant based.

      While single meal challenges of meat don’t have any effect, I am sure that at some level and probably more importantly frequency of meat consumption the portion of the gut bacteria capable of producing TMA will start to rise and the choline from not only the small amount of animal foods but also the choline from plants will start to represent a potential source for these bacteria. I have no idea what that level and frequency is and have not real desire to find out, so I’ll not take any chances and stay plant based.




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  15. Harvard heath, Mayo, American Heart Assoc and myriad other prestigious organizations indicate that diets high in fish and seafood such as that of the Japanese result in reduced cardiovascular disease. Fish have very high levels of TMAO.




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  16. Raw Cauliflower, Broccoli, Cooked Shiitake mushrooms, Beet Greens, Asparagus are also high in Choline. So are these vegetable food sources also bad? Is Choline a problem?




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    1. Look through the comments a bit and you’ll find that the problem isn’t the choline per se, but the choline being digested by harmful flora in our guts. The bacteria that feeds on carnitine (only found in mea, dairy, and energy drinks) turn the choline into TMAO. So if we feed our gut bacteria only WFPB, we selectively breed for the bacteria that won’t turn choline into a problem.




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  17. Perhaps worth noting, the metabolomics studies which associated TMAO with CVD were done on fasting blood samples. Elevated fasting TMAO may particularly suggest impaired kidney clearance from blood, of course not helped by chronic diet-induced TMA exposure.

    I wonder if diet might modulate TMAO production and clearance by other means, beyond simply supplying precursors. Interesting that high-fat diets also increase postprandial TMAO – https://www.ncbi.nlm.nih.gov/pubmed/?term=high+fat+diet+tmao




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    1. not necessarily. Ever had to do a diabetes test with that syrup? Blood test start before drinking the syrup and then every half an hour from drinking that syrup.




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    1. Thanks for your comment.

      Interesting find. While I haven’t fully had time to analyse the study (it can take 2 hours or more), I did think they mentioned some interesting points which will certainly enlighten the role of a vegetarian diet in cancer prevention. But here’s the conclusion from this paper:

      “In conclusion, plant-based and fish-based dietary patterns represent a healthy dietary choice compared to meat-based dietary patterns when considering cancer as an outcome.”.

      However, looking at the recently published position statements by the ADA, here’s what we truly know about vegetarians at this point in time (2016):

      “It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. Plant-based diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage. Vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. Low intake of saturated fat and high intakes of vegetables, fruits, whole grains, legumes, soy products, nuts, and seeds (all rich in fiber and phytochemicals) are characteristics of vegetarian and vegan diets that produce lower total and low-density lipoprotein cholesterol levels and better serum glucose control. These factors contribute to reduction of chronic disease. Vegans need reliable sources of vitamin B-12, such as fortified foods or supplements.”

      Hope this answer helps.




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    2. Thanks for your comment.

      I have not read the study to full extent and there are certainly interesting points to consider and I hope in the future we will have more accurate information about the role of vegetarian diets on cancer prevention but here is the quote from this paper:

      “In conclusion, plant-based and fish-based dietary patterns represent a healthy dietary choice compared to meat-based dietary patterns when considering cancer as an outcome.”

      The authors admit that:

      “the limited evidence retrieved regarding pure vegetarian diets highlights the possibility that very low meat intake can be associated with a lower risk of cancer, despite there being no strong evidence that a total depletion of sources of protein from the diet improves the outcome under consideration.”

      However, to date (2016), here’s what we know about Vegetarian diets according to the ADA:

      “It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. Plant-based diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage. Vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. Low intake of saturated fat and high intakes of vegetables, fruits, whole grains, legumes, soy products, nuts, and seeds (all rich in fiber and phytochemicals) are characteristics of vegetarian and vegan diets that produce lower total and low-density lipoprotein cholesterol levels and better serum glucose control. These factors contribute to reduction of chronic disease. Vegans need reliable sources of vitamin B-12, such as fortified foods or supplements.”

      As you can see the potential benefits of a plant based diet far outweigh of a conventional diet.

      Hope this answer helps.




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      1. thanks, but I think it is also important to the quality of animal protein
        for example goat’s milk and fresh sardines may have positive health effects




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        1. That is certainly true, goat milk and fresh sardines can have some nutrients that may benefit our health. But they also have compounds that can harm our health (saturated fat and hormones in the milk and contaminants in fish). It is the overall balance that matters.

          When it comes to quality of animal protein, the latest review has concluded that replacing animal protein with plant-based sources of protein lowers risk for mortality.

          And like Dr Katz wrote in this publication:

          “Although the focus here is on health effects, a diet that cannot be generalized or sustained is unlikely to confer the greatest health benefits at the population level over time.”

          When it comes to the example you mentioned, it clearly seems that both current fish recommendations are unsustainable (see here) and in case of goat milk (which is an animal food), it may have an important water, land and resource usage inefficiency (see here).

          Hope this answer helps.




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              1. from Blue Zones Solution, Dan Buettner
                Diet From the World’s Longest-Lived Men: Sardinia, Italy
                … Fat accounted for about 20 percent of their diet, mostly from animal sources such as goat’s milk or sheep’s cheese but also from olive oil ….




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    3. Thanks for your comment.

      I have not read the study to full extent and there are certainly interesting points to consider and I hope in the future we will have more accurate information about the role of vegetarian diets on cancer prevention but here is the quote from this paper:

      “In conclusion, plant-based and fish-based dietary patterns represent a healthy dietary choice compared to meat-based dietary patterns when considering cancer as an outcome.”

      The authors admit that:

      “the limited evidence retrieved regarding pure vegetarian diets highlights the possibility that very low meat intake can be associated with a lower risk of cancer, despite there being no strong evidence that a total depletion of sources of protein from the diet improves the outcome under consideration.”

      However, to date (2016), here’s what we know about Vegetarian diets:

      “It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits for the prevention and treatment of certain diseases. These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes. Plant-based diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage. Vegetarians and vegans are at reduced risk of certain health conditions, including ischemic heart disease, type 2 diabetes, hypertension, certain types of cancer, and obesity. Low intake of saturated fat and high intakes of vegetables, fruits, whole grains, legumes, soy products, nuts, and seeds (all rich in fiber and phytochemicals) are characteristics of vegetarian and vegan diets that produce lower total and low-density lipoprotein cholesterol levels and better serum glucose control. These factors contribute to reduction of chronic disease. Vegans need reliable sources of vitamin B-12, such as fortified foods or supplements.”

      As you can see the potential benefits of a plant based diet far outweigh of a conventional diet.

      Hope this answer helps.




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  18. I went on a strict vegetarian diet in 2013, and not only lost a lot of weight, but also ended up in the hospital with renal insufficiency, high blood pressure and cardiomyopathy. Over the past year, I have slowly switched back to a Paleo lifestyle for my blood type, and have started to recover. I’d like to resume a vegetarian lifestyle, however, I’m skeptical because of how my body previously reacted to it. I still eat lots of vegetables, some fruit as well as chicken, beef and eggs a few times a week. Everything I eat is organic.




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    1. DB: I’m not an expert, but I wonder if you were getting too few calories? There are several great programs for learning how to eat a healthy diet. Dr. Greger’s Daily Dozen is one good place to start. The book How Not to Die explains the system in detail. Another is the free on line “21 Day Kickstart” program from PCRM. Or following the diet in Dr. McDougall’s the Starch Solution. Good luck.




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    2. For what it is worth, here is my take. Renal insufficiency, hypertension, and cardiomyopathy occurring during the same period suggest a vascular problem such as atherosclerosis. Renal insufficiency and atherosclerosis share the same risk factors. The term cardiomyopathy is ambiguous and can be due to many causes, including hypertension, and often the cause in unknown. Unless your vegetarian diet included a high consumption of eggs, cheese, butter, ice cream, and other high fat foods it is highly unlikely that a vegetarian diet caused your problems. (By the way, low carb and Paleo people love to say correlation does not prove causation, but only when doing so advances their argument.)

      You said you switched back to Paleo, so that implies you were Paleo before you tried vegetarian. I’m guessing that you ate the standard western (or American) diet (SAD), that is high fat, high protein, lots of simple refined carbs before going Paleo. Thus, it is my contention that you ate atherogenic diets (SAD and Paleo) for a long time and that your circulatory problems were well advanced before you went vegetarian. The fact that you had the poor health when you were eating vegetarian was probably just coincidence.

      You say that you are now on a Paleo diet for your blood type. (FYI, we know that diets based on blood type are a sham.) Be that as it may, any Paleo diet is generally an improvement on the SAD diet, so that is a step in the right direction.

      If you are still concerned about going WFPB how about slowly transitioning by phasing in move veggies and phasing out the meat. In the process, lose the Paleo fear of legumes and whole grains.




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    3. Hi DB – Looks like you’ve already received a number of nice response, but I wanted to add in a few thoughts. I agree with Thea that maybe you weren’t taking in enough of the right calories. Some of the medical conditions you described also could have been underlying before you even changed your diet. It’s also important to remember that just because something is labeled as “vegetarian” or “vegan” doesn’t automatically mean it’s healthy. If you’re interested in making the switch again, try sticking to a wholesome, minimally processed, plant-based diet. Dr. G’s Daily Dozen is a great place to start. You might also have some luck using Lighter to help with meal planning and grocery shopping lists – Lighter




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  19. I have a genuine question that I would really like answered: If the fat you eat is the fat you wear, like Dr. McDougall says, then why are there many low carb, high fat dieters who are trim? I do not buy the low carb hype at all and believe that plant based is best. I just can’t seem to understand why there are many with whom I interact regularly who eat ALOT of fat but also are low carb; mostly very fit and trim people…some just trim not so fit. Thanks for any insight.




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    1. They lose weight on a high fat diet because they actually eat less calories overall. Fat and animal protein lower our hunger pangs and reduce our cravings for food. But that doesn’t make them good for you.

      The problem is that while they can appear trim and fit, they’re not healthy. All those calories from fat that comes with no fibre will eventually destroy their health. If all people are interested in is short term losses then have at it, but a high fat low carb diet is a recipe for long term chronic disease. Fibre is a carbohydrate and we need lots of fibre.

      And then there’s all the animal protein that comes with all those fats that they’re eating. No thank you!




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    2. Hi becca – these people are likely in a state of ketosis. Ketogenic diets are high fat, moderate protein and very low carb which forces the body to burn fat for energy. However, since the ketone byproducts are toxic, these folks often have bad breath – acetone smelling breath – one way our body rids itself of these toxins. It’s really kind of sad what people do to be slim …. we know that being slim does not necessarily equate good health.




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      1. Thank you Joanne and Growing Young. Based on lots of research, I firmly believe that high fat/high animal protein low carb diets are just plain bad on many levels. It’s sometimes so deceptive as I know a person with several health issues who lost 100 pounds on the ketogenic diet. I am trying to lose additional weight on a wfpb diet and find it a bit of a struggle. I know I will get to my goal somehow but it’s mind boggling to watch these people eat butter and bacon in large amounts while losing weight. Obviously we can see their arteries. I am thinking I may need to count calories while being wfpb; is that something dr. greger recommends.




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        1. becca: Dr. Greger recommends paying attention to calorie density for losing weight. Using this method does not require calorie counting, but does require tweaking what you eat. Below is the information I typically share with people who are interested in losing weight the healthy way. I hope it helps.
          ******************
          The nice thing about your situation is that you already understand half the battle. I’m guessing from your post that you already understand about the importance of a whole plant food diet and have at least a sense of how to implement it. That’s half the learning curve. The other half is understanding the concept of calorie density and how to apply it to weight loss so that you don’t get hungry and you still get all the nutrients you need.
          .
          Dr. Greger covers calorie density (http://nutritionfacts.org/video/eating-more-to-weigh-less/ ), but not in enough detail in my opinion for someone who wants to apply it for the first time. Doug Lisle, one of the experts in the Forks Over Knives documentary, gives a great ‘calorie density 101’ talk officially called: How To Lose Weight Without Losing Your Mind. I have watched the following talk from Doug Lisle several times and think very highly of it. And it’s free!!! And it’s entertaining! https://www.youtube.com/watch?v=xAdqLB6bTuQ
          .
          As good as Doug Lisle’s talk is, it pretty much just gives you a solid understanding of the concept, but not enough practical information in my opinion. For starting to get the practical information, I recommend a talk from Jeff Novick,Calorie Density: “How to Eat More, Weigh Less, and Live Longer,” http://www.jeffnovick.com/RD/Calorie_Density.html If talks aren’t your thing, the following article from Jeff covers a lot of the same information: http://www.jeffnovick.com/RD/Articles/Entries/2012/5/20_A_Common_Sense_Approach_To_Sound_Nutrition.html
          Be sure to pay attention to the charts.
          .
          Chef AJ tells people who want to lose weight to eat “left of the red line”, where I believe the red line is on a diagram of hers representing is about 650 (or so) calories per pound. And “left of the red line” is all the whole plant foods which are below 650 calories per pound. The above article from Jeff Novick gives you a good sense of which foods are “left of the red line” by food category. But if you want to look up the calorie density of specific foods, you can find many foods on the following site: http://nutritiondata.self.com/ Most foods on that site have the option of choose an ‘ounce’ as a size. Then you can multiply by 16 to get the calories per pound.
          .
          It would be perfectly respectable if you are one of those people who are just not interested in the theory. You just want to dive right in and want straight how-to information. If you would rather not think about any of that (or start with the theory and then move onto this step), I have one more suggestion that Dr. Greger also recommends in his book, How Not To Die. Consider going through the free program from PCRM (Physician’s Committee For Responsible Medicine) called 21 Day Kickstart. The program will “hold your hand” for 21 days, including meal plans, recipes, videos, inspirational messages, and a forum (moderated by a very respected RD) where you can ask questions.
          http://www.pcrm.org/kickstartHome/
          (Click the green “Register Now” button.)
          At the end of the program, you will have a very good practical knowledge about how to eat with healthy and “low” (normal for most people) calorie density.
          .
          Another recommendation that Dr. Greger and I share is to get Jeff Novick’s Fast Food videos for tasty, affordable, fast and healthy calorie density recipes. Also, on-line and free is a YouTube series of recipes/cooking shows called something like Chef AJ and The Dietician. I know that Chef AJ will not steer you wrong in terms of weight loss and providing accurate nutrition information.
          .
          How’s that for some tips? If you give these ideas a try, please report back and let us know how it went.




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          1. Thank you for all the links and input; you’re an amazing help! The way some of the info is presented just makes better sense to me. Not hard to fill half my plate with a salad and then add some cooked veggies and a starch. Thanks!




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  20. I’m curious: If seafood is associated with producing varying dangerous compounds in the body, such as the TMA, then why is it that the Japanese people are the longest living people in the world (or have been for a while)? They consume seafood like its the last thing on earth! Or is it because they incorporate more vegetables into their diet unlike the West?




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  21. In view of the published findings reviewed and the valuable insight and benefits of a vegan diet, I would like to understand how can the following can be rationalised:

    Ms Morano’s longevity, she admits, is partly down to genetics – her mother reached 91 and several sisters reached their centenary – and partly, she says, down to a rather unusual diet of three eggs – two raw – each day for more than 90 years

    It does defy all accepted advice on healthy living, her doctor of 27 years, Carlo Bava, told AFP news agency:
    “Emma has always eaten very few vegetables, very little fruit.
    “When I met her, she ate three eggs per day, two raw in the morning and then an omelette at noon, and chicken at dinner.”
    Despite this, he noted, she seems to be “eternal”.

    Ms Morano herself has not left her two-room flat for 20 years but she was surrounded by well-wishers on Tuesday who took part in her birthday celebrations

    http://www.bbc.co.uk/news/world-europe-38134004

    – pure genetics?




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    1. We know from the blue zones that your best chance of reaching a ripe old age is a WFPB diet with minimized quantities of meat and dairy. That being said there are statistical flukes for every type of sub-optimal behavior. We know how bad cigarettes are for your longevity in every way but there are centurians who smoke a pack a day. Some people are lucky enough to get away with those types of behavior but they are a small minority.




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  22. @Gatherer, Your post got caught in the automated SPAM filter. I rescued it. I’m making a point of this, because your post is so good, I want to make sure that @Anaemiac99 sees your reply.




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  23. Let’s see: One medium egg (44 grams) has 110 mg of choline, but 3/4 of a cup of blackeyed peas (125 grams), which I eat every day, has 120 mg of choline; a half cup of steel-cut oats (84 grams), which I also eat every day, has 34 mg of choline; a bowl of split pea soup, containing a half cup of split peas (100 grams), has 95 mg of choline, an ounce and a half of almonds (42 grams) (which Dr. Greger recommends to prevent bone loss) contains 22 mg of choline. One could go on citing other plant foods that contain similar amounts of choline.

    So let’s add up the amount of choline that I would be getting daily from a strictly plant-based diet: 120 mg (from blackeyed peas), 34 mg (from steel-cut oats), 95 mg from split pea soup, and 22 mg from an ounce and a half of almonds. The total comes to 271 mg of choline.

    So let me get this straight: It’s specifically the CHOLINE in an egg (110 mg) that causes TMAO and atherosclerosis, but NOT the choline in plant foods (271 mg)? Hello?!! Earth to Dr. Greger — come in, please. :-)




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    1. William Dwyer: It’s not the amount of choline that is the problem. Arguably, you need some choline in your diet. The problem is what the bacteria in your gut does to the choline that determines whether there is a potential problem or not. If you eat a diet free of meat, dairy and eggs, you don’t have the “bad” bacteria in your gut that will turn that choline into a problem. See if the following NutritionFacts video clarifies it for you: http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/




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      1. Okay, I’ll listen to it, but Dr. Greger doesn’t explain that in this video. He simply cites choline as the culprit without mentioning anything about the so-called bad bacteria in your gut. So it’s not the choline (which you can get plenty of in plant foods), but the bad bacteria acting on the choline?

        Very well, then one has to explain the connection between the egg and the bad bacteria. Is it something else in the egg besides the choline that causes the bad bacteria? If so, what is it? That needs to be demonstrated; otherwise, merely eating an egg would have no effect on TMAO, regardless of the choline in the egg. He focuses solely on the choline, which if what you say is true, can be misleading.




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  24. I’m confused. I was under the impression that I should be getting at least 450 mg of choline per day from my diet. As far as I can tell I’m getting less than half that much, so I started taking a supplement of 250 mg of choline bitartrate each day. I mostly eat a vegan diet but I do eat small amounts of meat, milk or eggs two or three times a month (when I visit my parents). Should I stop taking the choline supplement?




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    1. hi Isolda_r, this video may clarify more http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ If you check the transcript at the paragraph starting with ‘vegans are not out of the woods ‘ you will see that supplements of carnitine or lecithin containing choline, or choline fosters and maintains tmao producing bacteria.
      Given your substantial /frequent intake of animal products, it would seem your choline supplements just add fuel to the fire in maintaining those populations imo. In any event you may find the video clarifies some issues for you. All the best to you,




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  25. As I understand it, from a previous video — http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ — 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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    1. hi William Dwyer, its a fascinating process for sure. I remembered this video that Dr Greger had done on the TMAO connection and that it might clarify some questions for you. http://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/ Its been a while since I have seen it but I recall Dr Greger saying that you can feed a vegan a steak and tmao will not be produced. The necessary microbes are not there to produce it. Anyway, hope this helps




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  26. I would have expected some discussion on Probiotic relating to this issue. Only mentioned once. (Also, what might be the effect on TMA/TMAO when probiotics are consumed) I take a Probiotic with 10 strains, 30 billion live cultures.




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        1. A healthy microbiome is not made by 10 laboratory produced strains, but you keep piling those 10 strains in starving thousands of natural healthy strains out.

          Add to that the chemical crap that they pack the microbes in – what does that do to your natural microbiome, gut and body?

          So the question remains, why would you do this?




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    1. Birgit… there was no plant based diet in the four groups. The vegetarians were all eating fish and dairy. The traditional group were listed as not consuming dairy at all, just meat, eggs, rice or flour, aquatics, vegetables, and poultry. The sweet group ate no meat or fish at all, just soft drinks, sugar strengthened beverages, fried food, cakes, milk, coffee, and fresh juice??? If you look at each group it beggars belief to think that each person in those groups were only eating the things listed for those groups. This is a hugely flawed study.




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    2. Hi Birgit! Great question — first off, the study design is poor on a few counts. Just keep in mind that this is an observational case-control study meaning they are looking at what people self-report and do not even have a plant-based group. This study would be held quite low in the hierarchy of evidence as far as optimal health goes.
      To health!




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  27. Interesting, but unfortunately misguided.
    It’s not the food item per se (ie, meat, eggs, dairy, fish) but the source of the food item. Industrially produced foods, specifically for this example animals raised eating corn and not their natural diet) are well known to be high in inflammatory omega-6 fatty acids and when this forms the foundation of a person’s diet, they develop metabolic and mitochondrial dysfunction and disease.

    If, however, the foundation of your diet contains food products – especially animal protein – that is from “happy” animals who are fed their natural diet and live in the sun eating grass, roots, bugs, etc…then these foods (ie, meat, eggs, dairy, fish) have been shown in studies to contain higher amounts of the anti-inflammatory omega-3 fatty acids.

    Although I did not evaluate this particular “egg” study, I have spent over 20 years evaluating medical studies – I would bet my sweet bippy that they did NOT use eggs from “happy” pasture-raised hens.

    Additionally, people who consume an industrial food diet (instead of a natural diet from which we originate) have a very dysfunctional gut microbiome that contains communities of organisms that create problems and diseases in humans.

    You are not “what you eat” …. you are “what you eat, eats.”

    To your health & happy genes!
    http://www.IsDiseaseHereditary.com
    http://www.HealthyFoodHappyGenes.com




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    1. Omega-3 EFAs from happy eggs won’t negate the pro-inflammatory action of the animal protein via mTOR/IGF-1 signalling.
      It is you who is misguided in thinking ad libitum animal protein intake is fine.




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      1. I haven’t seen that study…perhaps you could forward it to me.
        Did they compare consumption of protein from naturally-fed to feed-lot animals? or naturally-fed vs corn-fed commercial salmon?

        likely not.
        I’m also curious as to your credentials…just so I can better understand the source of your input.




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        1. My point was the liberal consumption of animal protein, not organic vs industrial foods – as this distinction has no bearing to the issue at hand.

          You don’t need to take my word for it. See:
          https://youtu.be/Yv-M-5-s9B0?t=4m1s

          A few studies on the subject:
          H. Noto, A. Goto, T. Tsujimoto, M. Noda. Low-carbohydrate diets and all-cause mortality: A systematic review and meta-analysis of observational studies. PLoS ONE 2013 8(1):e55030.
          Just look at what you’re doing to your arteries and heart:

          Fung TT, van Dam RM, Hankinson SE, Stampfer M, Willett WC, Hu FB. Low-carbohydrate diets and all-cause and cause-specific mortality: two cohort studies. Ann Intern Med. 2010 Sep 7;153(5):289-98.
          Jenkins DJ, Wong JM, Kendall CW, Esfahani A, Ng VW, Leong TC, Faulkner DA, Vidgen E, Greaves KA, Paul G, Singer W. The effect of a plant-based low-carbohydrate
          “R. M. Fleming, L. B. Boyd. The effect of high-protein diets on coronary blood flow. Angiology 2000 51(10):817 – 826.
          J. Merino, R. Kones, R. Ferré, N. Plana, J. Girona, G. Aragonés, D. Ibarretxe, M. Heras, L. Masana. Negative effect of a low-carbohydrate, high-protein, high-fat diet on small peripheral artery reactivity in patients with increased cardiovascular risk. Br. J. Nutr. 2013 109(7):1241 – 1247.

          I think there is no debate among serious unbiased scientists that high protein diets are not health-promoting.

          As to my credentials, I am an autodidact who likes to read as are many here on NF who seem more knowledgeable than the average MD when it comes to nutrition and metabolomics.




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          1. agreed. liberal protein consumption is unhealthy. i was not advocating ad libitum intake. I was advocating against veganism.
            I also respect the fact that many people with a strong interest in a particular topic are more knowledgeable than others who have professional degrees.
            My inquiry into your background was one of sincere interest as it was unclear from your username….and understanding that, for me, ads validity to your comments.
            No disrespect was intended.




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            1. How do you address and, more importantly, mitigate the issues brought up surrounding animal protein in the context of omnivorous diet you supposedly advocate?

              I haven’t seen adequate countermeasures to date, except perhaps rapamycin intake which is not very well studied in healthy, non-cancer patients.




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              1. Could you be more specific about what ‘issues’ your talking about regarding animal protein?

                In general, the issues that I’ve come across thus far were all related to cellular stress (from inflammatory molecules) that prevented proper transcription of the DNA to make proteins properly and initiated metabolic dysfunction and ‘misfolded proteins’ (eg, the infamous ‘tau’, as well as misfolded insulin, etc).
                “Happy” animal protein is anti-inflammatory – unfortunately it is a bit more expensive.
                Unhappy animal protein is inflammatory.

                So animal protein should play a part, but a small part, in the majority of humans’ diet in the context of a plant-based diet of 2-3 cups of a variety of plants at every meal plus healthy fats.
                (genetically, some people are more capable of extracting healthy fatty acids from plants than others – it’s related to the variant of the FADS1 gene that you have.)

                Reducing foods that have a tendency to not be gene-friendly for the majority of humans (ie, grains, legumes) and trying to eliminate all ‘added’ sugars and sweeteners (even the so-called ‘natural ones like Stevia and agave) is the other important way to mitigate other environmental factors.
                Your body gets sufficient sugar from vegetables and a little fruit if you eat vegetables 3 meals a day.

                I hope that is helpful.




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                1. The main issue is the high methionine (Met) content of animal protein which is known to be leading to hyperhomocysteinemia, triggers gut dysbiosis, activates mTOR/IGF-1 and thus causes inflammation, promotes atheroclerosis and overall accelerated aging.

                  Many studies suggest Met restriction yields the benefits of caloric restriction without the constant hunger.

                  I seriously doubt that happy and unhappy animal protein has wildly differing levels of Met and thus differing inflammatory action – in particular, that the happy animal protein is so low in Met that it is acting anti-inflammatorily.
                  I would love to see the scientific evidence.

                  Yes, most grains are inflammatory due to their gluten and lectin content. Quinoa and amaranth are notable exceptions in the grains family.

                  Which are the genes that are shown to be legume-unfriendly?

                  As to the sweeteners, I agree on the agave syrup, am neutral on stevia but disagree on the sugar alcohol-based ones – xylitol and erythritol are shown to be net positive.

                  Met references:
                  Sugiyama, Kimio, Shin-ichiro Fukada, and Tatsuya Morita. “Effects of various amino acids on methionine-induced hyperhomocysteinemia in rats.”Bioscience, biotechnology, and biochemistry 72.7 (2008): 1940-1943.

                  “Mullin JM et al. 2015. Methionine restriction fundamentally supports health by tightening epithelial barriers. Annals of the New York Academy of Sciences.

                  Gomez, J., Caro, P., Sanchez, I., Naudi, A., Jove, M., Portero-Otin, M., … & Barja, G. (2009). Effect of methionine dietary supplementation on mitochondrial oxygen radical generation and oxidative DNA damage in rat liver and heart.Journal of bioenergetics and biomembranes, 41(3), 309-321.

                  Lees, E. K., Król, E., Grant, L., Shearer, K., Wyse, C., Moncur, E., … & Delibegovic, M. (2014). Methionine restriction restores a younger metabolic phenotype in adult mice with alterations in fibroblast growth factor 21. Aging Cell.

                  Zhou, J., Møller, J., Danielsen, C. C., Bentzon, J., Ravn, H. B., Austin, R. C., & Falk, E. (2001). Dietary supplementation with methionine and homocysteine promotes early atherosclerosis but not plaque rupture in ApoE-deficient mice.Arteriosclerosis, thrombosis, and vascular biology, 21(9), 1470-1476.

                  Zhang, R., Ma, J., Xia, M., Zhu, H., & Ling, W. (2004). Mild hyperhomocysteinemia induced by feeding rats diets rich in methionine or deficient in folate promotes early atherosclerotic inflammatory processes. The Journal of nutrition, 134(4), 825-830.

                  Virtanen, J. K., Voutilainen, S., Rissanen, T. H., Happonen, P., Mursu, J., Laukkanen, J. A., … & Salonen, J. T. (2006). High dietary methionine intake increases the risk of acute coronary events in middle-aged men. Nutrition, metabolism and cardiovascular diseases, 16(2), 113-120.

                  Troen, A. M., Lutgens, E., Smith, D. E., Rosenberg, I. H., & Selhub, J. (2003). The atherogenic effect of excess methionine intake. Proceedings of the National Academy of Sciences, 100(25), 15089-15094.

                  Yalçınkaya, S., Ünlüçerçi, Y., & Uysal, M. (2007). Methionine-supplemented diet augments hepatotoxicity and prooxidant status in chronically ethanol-treated rats. Experimental and Toxicologic Pathology, 58(6), 455-459.

                  Park, C. M., Cho, C. W., Rosenfeld, M. E., & Song, Y. S. (2008). Methionine Supplementation Accelerates Oxidative Stress and Nuclear Factor κ B Activation in Livers of C57BL/6 Mice. Journal of medicinal food, 11(4), 667-674.

                  Yalçinkaya-Demirsöz, S., Depboylu, B., Doğru-Abbasoğlu, S., Ünlüçerçi, Y., & Uysal, M. (2009). Effects of high methionine diet on oxidative stress in serum, apo-B containing lipoproteins, heart, and aorta in rabbits. Annals of Clinical & Laboratory Science, 39(4), 386-391.

                  Song, Y., Cho, M., Cho, C., & Rosenfeld, M. E. (2009). Methionine-induced hyperhomocysteinemia modulates lipoprotein profile and oxidative stress but not progression of atherosclerosis in aged apolipoprotein E knockout mice.Journal of medicinal food, 12(1), 137-144.

                  Zulli, A., & Hare, D. L. (2009). High dietary methionine plus cholesterol stimulates early atherosclerosis and late fibrous cap development which is associated with a decrease in GRP78 positive plaque cells. International journal of experimental pathology, 90(3), 311-320.

                  Aissa, A. F., Gomes, T. D. U. H., Almeida, M. R., Hernandes, L. C., Darin, J., Bianchi, M. L. P., & Antunes, L. M. G. (2013). Methionine concentration in the diet has a tissue-specific effect on chromosomal stability in female mice. Food and Chemical Toxicology, 62, 456-462.




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                  1. am not familiar with Met in pastured vs commercial.
                    yes, have recently read some support on erythritol.
                    have not yet come across (or looked for) gene-based legume metabolism associations, problems have mostly been oriented around phytates, anti-nutrients and overall low bioavailability of nutrients relative to veggies-so just less nutritious.
                    As with whole grains, probably fine if consumed as a very small portion of the diet.




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                    1. What have you based your assertion that “happy” animal protein is anti-inflammatory on?
                      Can you provide references backing this up?




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                    2. I use the term “happy” meaning eating a diet natural to that animal (not corn) and raised in an environment that is as low stress as possible (usually pastured or wild-caught).
                      As with us, poor diet and stress leads to metabolic dysfunction and nutritional genomic issues (maybe too high or too low methionine? Not sure.).
                      An evidence-based nutritional genomics site that has great summaries is called GB Healthwatch.
                      They have some reviews on methionine and the MTHFR gene.
                      http://www.gbhealthwatch.com/search.php?search=methionine

                      Yes, all of my comments are evidence-based (I can’t help myself).
                      Interestingly, the other day I came across and a study published in an agricultural journal where they documented the nutrigenomic impact and fatty acid profile on feed-lot cattle fed varying diets (PUFA-rich, starches, high and low foraging ratios) and determined the importance of these elements in the beef and it’s fat.
                      PMID: 27294923

                      I’ll pull together some refs for you later this week…right now I’m working against a deadline to get a project done tonight so will respond with them in the next 2-3 days, once my project is launched.




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                    3. Your last statement showed a fundamental misunderstanding of methionine’s role in metabolism.
                      It is an amino acid contained in very high amounts in all meat and eggs (and Brazil nuts), regardless of the type or method of raising.

                      It cannot ever be too low to exercise the purported anti-inflammatory action. In fact, it is nearly impossible to achieve Met restriction with vegan diet (1.5x the required amount) let alone with omnivorous one which averages 3x the required Met amount.

                      As per WHO, the Met requirement for humans is 10 mg/kg. That’s just 0.7 g Met or somewhere around 0.15% of calories (in a 2000 kcal/d diet). If the NHANES III study is any guide, the median methionine intake among Americans was about 1.76 grams. Add that methionine and cysteine can replace each other and the figure goes to 2.65g/d. or over 250% above the requisite daily Met or Met+Cys amount, respectively.

                      The supposedly improved FA profile of organically vs conventionally grown meat cannot negate/counteract the harmful effects of the Met excess. It is like picking to be bludgeoned to death or shot – the result is the same.

                      Your link regarding the methionine and MTHFR confirms my earlier statement that too much Met causes hyperhomocysteinemia and it is mostly governed by the methylfolate intake and the gene variations.

                      It appears that additional personal reading is necessary before deciding to provide nutritional advice to others (as it seems to be your occupation as per your websites).




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                    4. wow.
                      I thought we were having an honest, friendly sharing of information and ideas…evidently that was only from my side. I was enjoying scanning through the methionine studies you cited…I find it interesting to broaden my perspective.
                      I already stated that I was not familiar with methionine issues..so good on ya’, you validated a previous declared ignorance. And I won’t bother commenting on all of the other assumptions that you erroneously associated with my comment on methionine. You’re obviously on a mission to prove me wrong rather than confab about the uncertainties of science.

                      Considering the critical and prevalent role that industrial food has in disease of developed countries, I suggest that the methionine issue pales in comparison. And considering that I am but one messenger among hundreds if not thousands of clinicians who are helping people actually reverse disease and symptoms and live healthier, happier lives on fewer to no medications, (based on evidence and actual results from the way of eating I stated earlier) then I suggest that my ‘simple’ practical dietary advice is not only well-founded but effective.

                      you’ve taken the fun out of this exchange now that I understand your agenda.
                      good night.




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                    5. I don’t consider funny your spreading misinformed opinions and I just refuted them based on science.
                      My “agenda” is what the science said on Met and, by extension, to animal protein intake.

                      When your advice flies in the face of the body of scientific evidence it is not “well-founded” nor “evidence-based”.
                      Of course, if your switch patients from SAD to a bit cleaner, but still something-left-to-be-desired, diet it will be effective but it is not the best possible one based on science. That is my “agenda”. You started off passive-aggressive when trying to question my knowledge and the “validity of my comments” by asking for credentials and I showed what I “base my input” on.
                      You later showed yours and it is woefully inadequate so yes, better acquaint yourself with mTOR, IGF-1, Met metabolism before posting nutritional opinions.
                      As you can see, proper nutrition goes a bit deeper than eating organic to be healthy.




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                    6. There is no diet natural to those animals as those animals aren’t natural – they’re man made creations from selective breeding. None of our farm animals exist in Nature, they are only able to live in controlled environments that humans have created by eradicating Nature from the land in use because we created them that way. Being selectively bred to be docile does not mean an animal is content and ‘happy’.

                      If you’ve ever killed an animal you would know that none of them are ‘happy’ about it regardless of whatever lifestyle they were born and raised in. Your term ‘happy’ is utterly sickening. No animal that is selectively bred and farmed for it’s meat is ‘happy’.




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    2. Renee,

      Love your response…indeed our industrialization of food leads to the consequences you discuss and more……I too would suggest that it would be an interesting study to take the free range chicken’s eggs and see what happens in a controlled manner. Can you imagine the uproar if someone did this testing and showed substantially better health responses ?

      My suspicion is that we would still see some if not most of the adverse effects from the animal products intakes, as the rest of the environmental impacts are still present, ie, typical household and vocational toxins….. from the parabens to the ….. so perhaps, we should think of the higher plant based diets as a means of addressing our current environment, unlike those who in the past had less/different confounding factors. Eat as minimally processed should obviously be our mantra ……keeping our genes and cells much happier. Dr. Alan Kadish moderator for Dr. Greger




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      1. Thanks Alan.
        Whole food (and holistic) studies seem to be slowly gaining support, Liebert Publishing is an interesting resource in this regard.

        I agree that plants need to be the foundation of our diet (lots and lots of plants), however veganism does appear to cause health problems in a significant portion of the population. My clients have had some inspirational disease and symptom reversal with a plant-based whole foods diet that includes a small portion of “happy” animal protein and healthy fats.
        Other environmental toxins are certainly adding to the problem.

        The epigenetic story that is unraveling is an amazing one to be a part of.

        This is truly an interesting time in global health.




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    3. This thread is disappointing on several levels. Sure animals raised in the wild are less harmful to eat than animals grown in deplorable industry settings, but that doesn’t make them a healthy source of food. Flesh, dairy, and eggs are unhealthy foods for a variety of reasons, not just for the (as yet incomplete) TMAO/gut bacteria story. Sure the microbiome of our GI tract is more healthy when we eat a diet natural for humans, but a significant amount of animal flesh or eggs isn’t a natural diet for humans whether those animals are grown in the wild on grass or in the pen on grain. Evidence suggests that the human ancestral diet consisted of 3% or less non-plant food (e.g., insects, rodents, eggs). Eggs produced by chickens grown in the wild may be great food for dogs, but humans aren’t dogs (the way cholesterol is handled, for example).

      Further, this fad of eating grass fed animals is elitist. Most people cannot afford that type of food. Additionally, with the present high global human population and that population expanding rapidly, how many acres of land would be required to the raise animals on the open range to feed the world? How much more land would have to cleared and how much more water required? The environmental damage in the face of global warming is mind numbing.

      Yes, there are junk food vegans that eat unhealthy diets and there are vegans that don’t take a Vit B12 supplement. But that type of veganism is warned against at NF.org. Can you cite any properly performed studies in well regarded scientific journals that conclude that a WFBP diet causes “health problems in a significant portion of the population”?

      Trying to trump one person’s point of view with higher credentials is not appreciated. I can play that game, too, but so far I haven’t and don’t plan to. There are a number of people who post here with impressive degrees and experience. Occasionally, some highly credentialed people put forth unhealthy, unsubstantiated statements.

      The two links provided at the end of the first comment of this thread go to commercial sites that promote the business of the author of this thread. This unsolicited advertising seems out of place to me at this non-profit site.

      Finally, the response by the NF Moderator reads like an endorsement of the original comment, and I don’t think it reflects the overall message of NutritionFacts.org. Correct me if I am wrong.




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      1. It’s interesting that you interpreted my inquiry into the credentials of the other as an attempt to “trump”…I am the least likely person to ever do that, but that of course is the disadvantage of communicating via text.

        and regarding “supplementation of vitamn B12” – does it not seem incongruent with our evolution to need a supplement for a vitamin that is prevalent in other available food sources? [nothing personal…simply one that I ponder]

        I try and use every opportunity to share the information that I have gleaned from 20 years of evaluating medical studies, especially the last 2 years focused on nutritional genomic studies. Thus the inclusion of my websites. The first is informational, the second is commercial.
        My apologies their inclusion overstepped the boundaries of this site’s etiquette.




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        1. “regarding “supplementation of vitamn B12″ – does it not seem incongruent with our evolution to need a supplement for
          a vitamin that is prevalent in other available food sources?”

          It may seem incongruent on first consideration. However, the fact that modern strict plant eaters (vegans) don’t get enough Vit B12 (unless they supplement) is a product of living an unnaturally sanitary life. B12 is produced by anaerobic bacteria and archaea. The gut microbes of ruminant animals, for example, produce B12 and that B12 is absorbed into the body by their distal GI tract. When carnivores eat those animals they obtain B12. (By the way, a lot of industrial meat and dairy is “fortified” with B12 and that isn’t natural.) Human gut microbes also make B12 but too far down our GI tract to absorb it. The B12 we make is excreted in our feces, of which our ancestors, similar to the behavior of other animals, very likely ate a small amount.

          Our requirement for B12 is pretty low, only about 4-7 micrograms a day (revised up from 2.4 micrograms).
          http://nutritionfacts.org/video/vitamin-b12-recommendation-change/
          Primates living in the wild get their B12 by consuming dirt and the bacteria living within, unwashed fruits and vegetables, insects, non-sterile drinking water, and feces (their own or other animals either intentionally or not). When backpacking in the Wind River Mountain Range in Wyoming a few years ago I was surprised to see how much elk poop there was covering the ground. The animal density during the time of our primate ancestors was probably much higher than that of the relatively food scarce Wind Rivers, so unintentional consumption of poop may have been unavoidable.

          Human intestinal receptors for intrinsic factor-vitamin B12 complexes saturate at about 1.5 to 2 micrograms of B12, which is a consideration for infrequent supplementation. But since primates in the wild eat throughout the day, getting enough B12 was no problem for them. In summary, the consumption of meat was not required by our ancestors for the attainment of B12 and a “strict” plant based diet is congruent with the roots of our evolution. Nowadays even the 1-3% non-plant sources are unnecessary with simple B12 supplementation costing a few dollars a year.




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        2. Renee, if you knew anything about nutrition you would not be writing what you have written about B12. Animals do not make B12 it comes from soil bacteria. And the reason most wholefood vegans need to supplement it is because those bacteria have mostly been eradicated from the soil our plants are now grown in and it’s also been eradicated from our drinking water – another original source of B12 for early humans.

          And B12 is not prevalent in other food sources for the same reason as above unless those food sources are fortified or it’s added to the animal’s feed stuff.

          Just to make it very clear…. animals do not make B12. Animals are not a source of B12 unless they are farmed on land that has the bacteria in the soil that makes it, and that’s the same for vegetables.

          Therefore, it makes common sense to take a B12 supplement no matter what diet you are on. You can’t have too much, you expel any excess, and it’s incredibly cheap.

          I would suggest that you go away and do some proper unbiased studying.




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      2. Gatherer: Thank you for this comment. As we have seen time and again, it really doesn’t matter how an animal is raised. There are inherent aspects to animal products that make them unhealthy in the big picture/compared to whole plant foods in general. As you say, wild animals affect our health in a less bad way, but that doesn’t make them health promoting. http://nutritionfacts.org/video/modern-meat-not-ahead-of-the-game/ , http://nutritionfacts.org/video/paleo-diet-studies-show-benefits/
        .
        Then there is the misleading label of “happy” animals. Bite Sized Vegan recently did an investigative piece on animals in a country that prides itself on treating animals well–on having the some of the best animal protections in the world. As we see, there is no such thing as happy animals in any sort of scale operation when it comes to raising them for food. Here’s the talk for anyone interested: It’s Not Like There Here! The Best We Have To Offer: http://bitesizevegan.us8.list-manage2.com/track/click?u=365bb475e8fd79d689d354767&id=22b55f72fc&e=d1a0317659




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    4. My curtness inadvertently created misperceptions. My apologies.

      Let me more carefully clarify my thoughts behind why I believe the review of the data presented in the video is misguiding viewers.

      I think it is misleading to associate a disease process / metabolic dysfunction (ie, related to the increase in mtor that was shown to be related to consumption of animal protein in this particular review) to consumption of a food when the ‘source’ of the food is undefined.
      Especially when the source of the majority of foods in civilized societies conducting research is industrial and extremely high in inflammatory fats and sugars – a proven source of cellular inflammation and metabolic dysfunction.

      Nature maintains balance.
      mTor plays an important role in immunological responses, as does oxidation, as do cannabinoids.

      It is possible that consumption of “happy” animal protein that contains anti-inflammatory substances may very well balance the actions of inflammatory molecules in animal protein – so it is not the protein per se, but the source of it.

      Plants should, of course, play the predominant role in the human diet.




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      1. There are differences in the amino acid profile found in animals as compared to plants. http://nutritionstudies.org/animal-vs-plant-protein/

        There are many studies showing health benefits from vegan diet:
        Vegetarian Diets and Weight Reduction: a Meta-Analysis of Randomized Controlled Trials.:https://www.ncbi.nlm.nih.gov/pubmed/26138004
        Vegans report less stress and anxiety than omnivores.:https://www.ncbi.nlm.nih.gov/pubmed/25415255

        It is important to also dispel the myth of “happy” meats. Omega 3 to omega 6 ratio is far from ideal in these sources, in addition to them being costly and out of reach for most consumers.

        The implication of advocating against a healthy vegan diet is what we have now. 7.5 billion people can not be fed with grass fed animals period. Not enough earth to sustain this recommendation.

        Healthiest diets to date contain less than 4 percent of total calories come from animal products.

        We can not in good conscience promote Vegan diets as unhealthy when we see benefit in heart disease, hypertension, diabetes, obesity, Cholesterol levels, and sustainability all tilt in Vegan diets favor.




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  28. I do not completely understand. It looks to me like TMAO levels drop to baseline four hours (or less) after consumption. If so, is it in fact dangerous? Are we saying that a single egg, which doubles TMAO levels for four hours but then TMAO levels return to baseline, is dangerous?

    I am not trying to be argumentative: I am adopted a vegan lifestyle two years ago and don’t consume eggs, but there is a leap here that I am unable to make.




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    1. Drop a brick on your foot once every 12 hours. For 11:59:59 you are not inflicting any blunt force trauma on your foot, it’s only for that 1 second every 12 hours. Yet your foot will never recover from the damage done in those 1 seconds.

      And people aren’t just elevating TMAO levels every 12 hours, it’s 3 or 4 times during the average day. Too much time to do the damage but never enough time to allow to heal that damage.




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    2. Since TMAO levels drop back to nil after several hours due to clearing by the kidneys, is it clear that an egg per day will lead to any atherosclerosis at all? Haven’t seen any such study.




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      1. Hi, Dave. Thanks for contributing to the conversation on TMAO. This article reaffirms earlier studies linking TMAO with atherosclerosis, and finds that atherosclerosis risk can be transmitted by fecal transplantation:
        https://www.ncbi.nlm.nih.gov/pubmed/25550161
        This article discusses an attenuating effect for resveratrol on TMAO-induced atherosclerosis:
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4817264/
        Wouldn’t it be better not to have the TMAO-induced atherosclerosis in the first place?
        You might be interested in this article on the effect of TMAO on kidney function:
        https://www.ncbi.nlm.nih.gov/pubmed/25599331
        Or this one on TMAO and thrombosis risk:
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4862743/
        That’s just the tip of the iceberg. I hope it helps!




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    1. the only studies i trust are done on rural, indigenous peoples or no fat vegans which there aren’t many of.

      all other studies are done on fat, sick, medicated people on the standard american diet and therefore unreliable.

      when you see studies conclude that “OLIVE OIL IS HEART HEALTHY” because of a study which replaced a bad fat with a lesser bad fat then you will understand where i’m coming from.

      .




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      1. I’m not arguing that eggs are healthy. A friend brought this study to my attention, and I wasn’t sure what to make of it. There are several articles written that cite this study as being proof that eggs are good for you. There is also another study showing that cholesterol that is consumed causes your liver to produce less cholesterol, and that study is also being used in articles to promote the health benefits of eggs. I was just wondering if this is like the twinkie example in another video, where they took out something even more unhealthy and replaced it with an egg, and are now claiming the eggs are healthy because there is less health problems while eating an egg as opposed to whatever else the people were consuming.




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        1. Dr. Greger in this video shows that dietary cholesterol increases your blood cholesterol for a number of hours after it is consumed. The body then works to bring the cholesterol level back down to baseline, which it finally does about 8-10 hours. From this you can clearly see why all studies that purport to show that dietary cholesterol has no impact on blood cholesterol all give blood cholesterol after a 12 hour fast. But as Dr. Greger says that for people who regularly consume cholesterol containing foods at most meals, this lower fasting level is only experienced by the body for a few hours in the middle of the night. The majority of time is spent with this elevated postprandial blood cholesterol.




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  29. Could someone comment on these two publications regarding the effects of eggs:
    PMID: 28052883 DOI: 10.3945/ajcn.116.146753 Am J Clin Nutr doi: 10.3945/ajcn.116.146753. Printed in USA. ! 2017 American Society for Nutrition

    &

    PMID: 27928124 DOI: 10.3177/jnsv.62.361 J Nutr Sci Vitaminol, 62, 361–365, 2016

    Thank you for your time.




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  30. For the past five years, eggs have been my go to breakfast. Their protein is the only thing that really satiates my appetite until noon and even one or two o’clock. Watching your egg videos has me really scared. Question. These egg studies. Is there a difference between eating the whole egg versus the egg white? Is there a difference between eating the yolk as opposed to just the egg whites? Thanks.




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    1. Outdoorguy2001: Have you tried eating a hearty bowl of beans and barley for breakfast? I ask, because the health problems of egg whites are just as significant and well known as the yolk.
      .
      There are two problems with eggs, the yolk and the white. (To paraphrase Dr. Barnard.) Egg whites are likely a big problem health-wise, just like the yolks. It is true that egg whites do not have cholesterol. But egg whites are essentially all animal protein. Here’s what we know about animal protein in general and egg whites in particular:
      .
      Dr. Barnard links potential kidney problems to animal protein (though I don’t have the details on that). And Dr. Greger talks about the problems of animal protein in general in his annual summary video, “Food as Medicine: Preventing and Treating the Most Dreaded Diseases with Diet” http://nutritionfacts.org/video/food-as-medicine
      .
      Here on NutritionFacts, you can get a great education on how animal protein is linked to the body’s over-production of a growth hormone called IGF-1. IGF-1 helps cancer to grow. To watch the series about IGF-1, click on the link below and then keep clicking the “next video” link on the button to the right until you get through the bodybuilding video. Then you will have seen the entire series.
      http://nutritionfacts.org/video/igf-1-as-one-stop-cancer-shop/
      .
      Here’s another great tidbit from NutritionFacts on another mechanism linking egg whites to cancer as well as increased virus infections: “why would animal protein and fat increase cancer risk? Well, as I noted in Bowel Wars, if you eat egg whites, for example, between 5 and 35% of the protein isn’t digested, isn’t absorbed, and ends up in the colon, where it undergoes a process called putrefaction. When animal protein putrefies in the gut, it can lead to the production of the rotten egg gas, hydrogen sulfide, which, over and above its objectionable odor, can produce changes that increase cancer risk. Putrefying protein also produces ammonia.”
      To learn more details about the process, check out:
      http://nutritionfacts.org/video/putrefying-protein-and-toxifying-enzymes/
      .
      Darryl at one point reminded me of the methionine issue. Egg whites have *the* highest concentration of methionine of any food:
      http://nutritiondata.self.com/foods-000084000000000000000.html?categories=1,18,9,0,13,14,5,4,42,16,17,15,6,3,2,11,7,19,21,12,10,8,22
      Dr. Greger did a nice video showing the link between methionine and cancer.
      http://nutritionfacts.org/video/starving-cancer-with-methionine-restriction/
      .
      Darryl also pointed out that, “…high methionine diets increase coronary risk in humans. In its associations with cardiovascular disease and other disorders, homocysteine may be functioning partly as a marker for the major culprit, excess methionine.”
      http://www.sciencedirect.com/science/article/pii/S0939475305001092
      .
      Dr. Greger recently posted some videos on how animal protein can raise insulin levels. The first of the following videos even specifically addresses egg whites.
      http://nutritionfacts.org/video/paleo-diets-may-negate-benefits-of-exercise/#comment-1978464793
      http://nutritionfacts.org/video/if-white-rice-is-linked-to-diabetes-what-about-china/
      .
      In summary: there are at least three pathways potentially linking animal proteins, especially egg whites, to cancer: the IGF-1, methionine, and putrefaction. And there is some good evidence that egg white consumption contributes to heart disease and potential problems with T2 diabetes by raising insulin levels in a bad way. All of these reductionist-type studies lend support the bigger general population studies showing that the healthiest populations on earth are those which eat the least amount of animal protein.
      .
      With all of the information we have about the harmful effects of animal protein in general and egg white in particular, I think it’s best to stay away from egg white. Why not get your protein from safe sources? IE: Sources which are known to have lots of positive health effects and will naturally give you a balanced amount of protein? (ie: whole plant foods) Make sense?




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  31. Dr. Greger and Staff,

    Please address this new meta-analysis: https://www.ncbi.nlm.nih.gov/pubmed/27710205
    Meta-analysis of Egg Consumption and Risk of Coronary Heart Disease and Stroke, J Am Coll Nutr. 2016 Nov-Dec;35(8):704-716. Epub 2016 Oct 6.

    It concludes: “A comprehensive meta-analysis of prospective cohort studies that reported risk estimates for egg consumption in association with CHD or stroke was performed on the peer-reviewed epidemiologic literature through August 2015. • Overall, summary associations indicate that intake of up to 1 egg daily may be associated with reduced risk of total stroke. • Overall, summary associations show no clear association between egg intake and increased or decreased risk of CHD. • Eggs are a relatively low-cost and nutrient-dense whole food that provides a valuable source of protein, essential fatty acids, antioxidants, choline, vitamins, and minerals.”

    The egg industry and egg proponents are getting a lot of mileage out of it: http://www.enc.org.au/position-statements/eggs-and-cardiovascular-disease/

    Thanks!
    Neil




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    1. Hi there —

      Great question, and thank you for bringing this to my attention.
      I wanted to find the funding sources for this study and had I hard time.

      I glanced over the work done at EpidStat Institute and Dominik D. Alexander.
      The work I saw from them is funded by industry and typically produces favorable results for industry.

      A recent paper from EpidStat by DD Alexander found no association between red meat and colorectal cancer — it was funded by the Cattlemen’s Beef Association, Meat & Livestock Australia, etc.

      The conclusion of their industry-funded study contradicts the findings of the WHO International Agency for Research on Cancer, which finds processed meats to be carcinogenic, and red meat to be a probable carcinogen.

      I generally take results from industry-funded studies lightly.
      I did not dig deep into their methodology, etc. just because of time — I would love to learn more in regards to your question.

      Thanks for the question once again — To health!




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  32. Dr. Greger, thanks for all you do to try and clear up the sometimes confusing and contradictory issues on nutrition. I have recently seen two studies regarding eggs and cholesterol showing that there is no affect on CVD risk. One was in a young asymptomatic group (mean age 40) and the other from the Eastern Finland Institute of Public Health. Both seem to show that there is little effect from the Cholesterol consumed in eggs and TMAO. I have listed the references below and wondered if you could comment on these. Thank you for your time.

    1) “Association of dietary cholesterol and egg intakes with risk of incident dementia and Alzheimer’s disease: The Kuopio Ischemic Heart Disease Risk Factor Study”., Maija P.T., etc all; The American Journal of Clinical Nutrition; January 2017

    2) Meyer KA, Benton TZ, Bennett BJ, Jacobs DR, Lloyd-Jones DM, Gross MD, Carr JJ, Gordon-Larsen P, Ziesel SH (submitted. The microbiota-dependent metabolite TMAO and Coronary Artery Risk Development in Young Adults Study (CARDIA). Journal of The American Heart Association.




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  33. What about the plant based choline (like soy lecithin)? Does it work in the same way, raising the levels of TMAO? Liposomal vitamin C, among other supplements, is becoming very popular and it is based on soy lecithin choline. I would appreciate your comments in this Lypo-based supplements and the risks, if any, they might pose due to their choline content
    Thank you




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    1. Clara, what the research shows is that in the absence of carnitine that TMA is not oxidized into TMAO. Therefore it appears that the plant based choline does not have same negative effects as the animal based choline.

      “Health may not be everything but without health everything is nothing”
      – Dr. Hans Diehl, CHIP Founder




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  34. Hi, Clara. You might want to watch this video, which should answer your question:
    https://nutritionfacts.org/video/carnitine-choline-cancer-and-cholesterol-the-tmao-connection/
    The key is gut flora, which are determined by usual diet. The gut flora of those who regularly consume animal products turn choline into TMAO, whereas the gut flora of vegans is made up of different organisms, which do not. Eating plant-based means the choline you get from whole plant foods should not be converted to TMAO. I hope that helps!




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  35. Thanks Chistine. OMG, I have been doing an IV vit C treatment and taking up to 5 gr of vit C in the lyposomal form the days I don’t do IV, so an average of 3.5 days a week. Each gram contains 500 mg of phosphatidylcholine, So i’ve been taken more than 2500 gr of choline daily 3.5 days a week. It’s just amazing that they advertise this form of vit c as the best because of the choline content. It’s so freaking confusing. I’m so upset right now! Could you please comment in Lyposomal vit C? is there anything that makes it better or not as harmfull as it seems it is. Just for my peace of mind…You guys do an amazing job !




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    1. Hi Clara- I’m Dr Anderson, a volunteer with Dr Greger. We know from this study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915787/ that liposmal Vit C causes higher Vit C blood levels than non-liposomal Vit C. But if you are an omnivore, the excess choline in this formation would lead to higher TMAO, which is toxic to blood vessels. IV Vit C leads to the highest plasma levels of Vit C. I cannot find evaluation of long term safety of oral liposomal Vit C. While high amounts of Vit C MAY be useful in certain specific clinical settings (after a heart attack has been treated with a stent), it’s not clearly of benefit in a general population. While the high blood levels of Vit C won’t occur with Vit C naturally from foods like oranges, peppers, kale, it’s not proven that very high blood levels are helpful. If you’re eating a diversity of fruits and vegetables, including cruciferous vegetables like broccoli and kale, you’re going to get plenty of Vit C without needing to sit with an IV several times a week, and without taking in excess choline. Best luck to you!




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