Morning everyone!

Welcome to another edition of the Doctor’s Note where we talk about what’s on our minds when it comes to your health. This week we’re going to talk about a blood marker that we include on our Cleveland Heart Panel called a TMAO (Trimethylamine N-Oxide).  

TMAO is an important marker to assess your risk of heart disease and stroke. A very interesting topic that we should take note of.


Risks of High Level TMAO


TMAO is a metabolite derived from your own gut bacteria, a powerful predictor of heart attacks and strokes. This blood level is produced from the liver after your intestinal bacteria digests a few things: 

  • L-Carnitine (this is high in red meat)
  • Lecithin 
  • Choline (found more in egg yolks, some meats, and full fat dairy) 

Note: TMAO can also be produced naturally in your bile. 

If you have a high TMAO marker it can almost double (2.5x) your risk of heart attack or stroke. Even without smoking, hypertension, and diabetes, an increased level can be a real risk factor. 

A high TMAO level turns on an inflammatory cascade that damages your arteries by making it easier for the cholesterol to burrow into the arterial walls and form plaque (which is what causes heart attacks and strokes for the most part). 

It also reduces the body’s ability to get rid of LDL (the bad cholesterol). This may explain why saturated fats in animal foods were thought to be the main culprits in cardiovascular disease. It may be that this inflammatory cascade, turned on by eating certain types of foods, can elevate this TMAO level in some people, causing heart attacks and strokes. 


So what do you do? 


I always go back to the gut when looking at patients. It’s where most of your immune system is located, as well as where most inflammation starts. 

The gut microbiome is so important to your overall health. We talk about it all the time with autoimmune disease, gut problems, and weight gain. Some people have great microbiomes, but most don’t. 

I checked my TMAO level a year ago and it was elevated. That’s why I don’t eat red meat or eggs anymore. For some people those might be perfect foods, but for me they’re not. My brother has been a vegan for about a year now, and just recently the two of us went to the office and got a Cleveland Heart Panel. It will be interesting to compare his TMAO to mine to see if a vegan diet produces a lower TMAO versus one that doesn’t eat red meat or eggs, but eats fish. Stay tuned for those results! 

Note: Seafood can have some carnitine in it. 

Some people are more predisposed to having an increased TMAO because of a particular gut microbiome. When you eat L-Carnitine, or consume Choline or Lecithin, your intestinal bacteria turns it into TMA, which is processed by the liver, which turns it into TMAO (an oxidized form of TMA). 

When you take a deep dive, it becomes controversial whether or not TMAO will activate that inflammatory cascade. In my research, it does seem that you don’t want a high level. Some suggestions to avoid that are: (a) adjust your diet (b) cut out red meat and eggs, and (c) cut out energy drinks because some have L-Carnitine (plus they are bad for you anyway!). You can also look at a plant based diet, or a Mediterranean diet (a great way to eat heart healthy). 

Also, look at your other risk factors: 

  • Obesity
  • Hypertension
  • Diabetes
  • Smoking
  • Lack of exercise
  • Poor sleep
  • Stress
  • Sleep apnea  

Note: Increases in TMAO can cause kidney disease (even Diabetes and Colon Cancer). 

Avoid L-Carnitine and Extra Choline supplements if your TMAO is high. Phosphatidylcholine supplements are OK. Choline by itself is probably not okay. 


Supplements to Decrease TMAO


  • Vitamin D
  • Vitamin C (buffered)
  • B-Complex 
  • Resveratrol 
  • Berberine
  • Hawthorne
  • Quercetin
  • Soluble fiber 
  • Pre and Probiotics 

Note: Pistachio nuts and brussel sprouts have also been found to decrease TMAO levels. 

The key is to bring down inflammation in your body and be as disease free as you can. 

Eat more plants. Get a Cleveland Heart Panel and check the TMAO marker. Look at other inflammatory markers as well and assess your health from that standpoint.  

Achieving optimal health requires you to be proactive. Now is the time to see where you are health wise.