When certain gut bacteria encounter choline (found in eggs and liver) or carnitine (found in meat, especially red meat), some of it is converted to trimethylamine, or TMA. TMA is the compound that gives fish its “fishy odor.” Fish is actually extremely high in TMA, which I’ll discuss later on. Then, the liver converts a portion of the TMA to TMAO. Studies have shown that elevated serum levels of TMAO are linked to heart disease, type 2 diabetes, kidney disease, and even all-cause mortality. There’s definitely some heterogeneity among the studies, but enough have found a strong connection between TMAO and all manner of poor health conditions that researchers have focused on this compound.
Okay, so anything that contains choline or carnitine will increase TMAO, which should in theory increase your risk of heart disease. Right? Let’s go down the list.
Dietary TMAO Precursors and Their Effects On Health
Eggs. The best source of TMAO-precursor choline in our diet—eggs—should absolutely skyrocket TMAO levels. Except it doesn’t happen.
Okay, so maybe the choline slipped past the TMA-producing gut bacteria in that study, but what about if you quickly switch people from eating oatmeal for breakfast to eating eggs. Surely bad things will happen, right?
Nope. TMAO skyrockets, an indication that these ladies’ gut bacteria are converting carnitine to TMA and TMAO, but serum C-reactive protein, interleukin-6, L-selectin, P-selectin, vascular cell adhesion molecule-1, intercellular adhesion molecule-1 and lipid profile markers are completely unaffected. If gut bacterial conversion of carnitine to TMAO is the preeminent risk factor for heart disease, you’d think some of these ladies’ cardiovascular risk factors would have responded. They had half a year to respond. They did not.
Okay, but maybe there’s lag time between TMAO increases and deleterious changes to health. Nope. They followed those same ladies after cessation of carnitine supplementation. Their TMAO levels dropped, but their health markers stayed the same. No change.
Seafood. As I mentioned earlier, fish and shellfish come pre-contaminated with the TMAO precursor TMA. It’s what gives the characteristic fishy odor, and it definitely gets converted to TMAO. In fact, a human study from a few years ago found that feeding people fish spiked TMAO levels by 60 times. A more recent study even concluded that elevated TMAO levels are a reliable marker for cod intake. The more fish you eat, the more TMAO your body will process.
The connection is there. And in animal models, TMAO even appears to mechanistically increase atherosclerosis. The mice they dosed with TMAO to increase atherosclerosis were genetically engineered to be ApoE knockouts, a strain of lab mouse that gets heart disease from almost everything, but still.
The connection isn’t causal. It’s an observation. There are no controlled studies giving people foods (or even supplements) that raise TMAO and increase disease or death. There aren’t even prospective observational studies where they track a group’s food intake, TMAO levels, and death/disease over time.
You know what I think (and have always thought)?
High TMAO can be a marker for metabolic disease. It could indicate inhibited kidney function, as the kidneys are response for disposing of excess TMAO. It could indicate poor health in general.
The latest evidence is confirming what I’ve long suspected: the reason high TMAO levels are linked to cardiovascular disease and overall mortality is that both type 2 diabetes and chronic kidney disease cause elevated TMAO levels. The causality is reversed.
What’s one of the kidney’s primary jobs? Excreting waste materials and toxins. What’s going to happen if the kidney begins to fail or lose its functioning? The stuff that used to be excreted starts backing up. TMAO is supposed to be excreted in the urine via the kidneys. If the kidneys aren’t working, TMAO levels skyrocket.
But even then, high TMAO isn’t even necessarily a bad thing. Check out that study I linked to earlier where women were given carnitine every day. Their TMAO levels skyrocketed but nothing bad happened. No health markers worsened. In one study, they even improved.
That’s the thing with biology. There are dozens of reasons TMAO could be elevated, some of them bad, some of them harmless, some of them good.
There simply exists no credible evidence that increased TMAO because you’re eating fish, or eggs, or liver, or meat, does anything untoward to your health. I’m not ruling it out. But the evidence just isn’t there. There’s far more evidence that eating fish, eggs, liver, and meat improve your health.
That’s it for today, folks. If you have any further questions about TMAO, leave them down below. Until then, enjoy your choline and carnitine!
Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.