Effects of Choline From Eggs vs. Supplements on the Generation of TMAO in Humans (EGGS)

• ClinicalTrials.gov Identifier: NCT03039023
• Recruitment Status: Completed
• First Posted: February 1, 2017
• Results First Posted: May 14, 2021
• Last Update Posted: June 2, 2021
• Sponsor: The Cleveland Clinic
• Information provided by (Responsible Party): Wilson Tang, The Cleveland Clinic

Tracking Information

• First Submitted Date: January 19, 2017
• First Posted Date: February 1, 2017
• Results First Submitted Date: April 21, 2021
• Results First Posted Date: May 14, 2021
• Last Update Posted Date: June 2, 2021
• Actual Study Start Date: September 2, 2016
• Actual Primary Completion Date: April 10, 2018 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: April 21, 2021)

• Changes in Plasma Levels of Fasting Trimethylamine-N-oxide (TMAO), a Choline Metabolite [ Time Frame: Baseline, 28 days ]
  Changes in levels of non-labeled TMAO from baseline to end-of-study (day 28) as measured by established techniques by mass spectrometry.
• Changes in Platelet Function With Increased Choline Intake [ Time Frame: Baseline, Day 28 ]
  The activation and functioning of platelets within a single subject will be compared before and after increased choline intake.

Original Primary Outcome Measures (submitted: January 30, 2017)

• Changes in plasma levels of fasting trimethylamine-N-oxide (TMAO), a choline metabolite [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled TMAO over time will be measured by established techniques by mass spectrometry.
• Changes in plasma levels of fasting trimethylamine (TMA), a choline metabolite [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled TMA over time will be measured by established techniques by mass spectrometry.
• Changes in plasma levels of fasting crotonobetaine, a choline metabolite [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled crotonobetaine over time will be measured by established techniques by mass spectrometry.
• Changes in plasma levels of fasting betaine, a choline metabolite [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled betaine over time will be measured by established techniques by mass spectrometry.
• Changes in plasma levels of fasting gammabutyrobetaine (GBB), a choline metabolite [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled GBB over time will be measured by established techniques by mass spectrometry.

Current Secondary Outcome Measures (submitted: April 21, 2021)

• Changes in Levels of Fasting Trimethylamine-N-oxide (TMAO) in 24-hour Urine Collections [ Time Frame: Baseline, Day 28 ]
  Changes in levels of non-labeled TMAO from baseline to Day 28 measured by established mass spectrometry techniques.
• Changes in Plasma Levels of Fasting Choline [ Time Frame: Baseline, Day 28 ]
  Fasting plasma levels of choline from samples obtained at baseline and at day 28 were compared.
• Changes in Plasma Levels of Fasting Carnitine. [ Time Frame: Baseline, Day 28 ]
  Fasting plasma levels of carnitine from samples obtained at baseline and at day 28 were compared.
• Changes in Plasma Levels of Fasting Betaine. [ Time Frame: Baseline, Day 28 ]
  Fasting plasma levels of betaine from samples obtained at baseline and at day 28 were compared.
• Changes in Lipid Profile, Total Cholesterol [ Time Frame: Baseline, Day 28 ]
  Changes in total cholesterol levels between baseline and Day 28
• Changes in Lipid Profile, HDL [ Time Frame: Baseline, Day 28 ]
  Changes in measured HDL levels between baseline and Day 28
• Changes in Lipid Profile, LDL [ Time Frame: Baseline, Day 28 ]
  Changes in measured LDL levels between baseline and Day 28
• Changes in Lipid Profile, Triglycerides [ Time Frame: Baseline, Day 28 ]
  Changes in measured triglyceride levels between baseline and Day 28

Original Secondary Outcome Measures (submitted: January 30, 2017)

• Changes in urine levels of fasting trimethylamine-N-oxide (TMAO) [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled TMAO over time will be measured by established techniques by mass spectrometry.
• Changes in urine levels of fasting trimethylamine (TMA) [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled TMA over time will be measured by established techniques by mass spectrometry.
• Changes in urine levels of fasting crotonobetaine [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled crotonobetaine over time will be measured by established techniques by mass spectrometry.
• Changes in urine levels of fasting betaine [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled betaine over time will be measured by established techniques by mass spectrometry.
• Changes in urine levels of fasting gammabutyrobetaine (GBB) [ Time Frame: 1 week, 1 month ]
  Changes in levels of non-labeled GBB over time will be measured by established techniques by mass spectrometry.
• Changes in platelet function with increased choline intake [ Time Frame: 1 month ]
  The activation and functioning of platelets within a single subject will be compared before and after increased choline intake.
• Changes in metabolic markers [ Time Frame: 1 week, 1 month ]
  Changes in lipid profile and other markers of metabolism will be measured over time.

• Current Other Pre-specified Outcome Measures: Not Provided
• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Effects of Choline From Eggs vs. Supplements on the Generation of TMAO in Humans
• Official Title: Effects of Choline From Eggs vs. Supplements on the Generation of TMAO in Humans (EGGS)
• Brief Summary: The investigators are interested in learning more about choline, a nutrient required by the body. The body does make some choline, but it does not make enough to support health and the rest must be acquired through diet. Eggs, and especially egg yolks, are a major dietary source of choline. Choline can also be given as a dietary supplement. Ingestion of choline supplements has been linked to an increased concentration of a compound called TMAO (trimethylamine N-oxide). Elevated TMAO levels have been linked to higher heart disease risk. With this study, the investigators hope to learn whether there is a difference in the way your body responds to the ingestion of a choline supplement versus the choline found within eggs.

Detailed Description

The principal goal for the study is to examine whether there is a difference between the ingestion of choline through supplements versus choline found within eggs on plasma TMAO levels. The investigators have previously shown that dietary intake of trimethylamines, including the choline group of phosphatidylcholine (PC), is mechanistically linked to cardiovascular disease risk and that the metabolism of these trimethylamine nutrients in humans is modulated by the intestinal microbes (gut microbes). Additionally, extensive animal studies link an essential role of gut microbiota to the metabolism of choline and the production of metabolites that promote / accelerate atherosclerotic processes. The investigators have also recently shown a 10-fold increase in plasma TMAO levels following supplementation with choline bitartrate supplements. However, another pilot study by a collaborator (unpublished) did not show the same increase in plasma TMAO levels following the ingestion of whole eggs, a major dietary source of choline. Therefore, with this study the investigators wish to examine the differences, if any, between the ingestion of an equivalent mass of total choline in the free form (as bitartrate salt) as a supplement vs. within whole eggs.

Eggs, and specifically the egg yolk, contain a large amount of total choline. However, egg white contains potential anti-microbial peptides that could influence gut microbial composition and function, and therefore impact conversion of choline into TMA and TMAO observed in subjects. Therefore, the investigators hypothesize that the consumption of whole eggs (hardboiled) will not elevate plasma TMAO levels to the same extent as a comparable amount of total choline ingested in capsule form as the choline bitartrate salt. The investigators further hypothesize that the consumption of egg white with choline bitartrate tablets may result in less of a rise in TMAO levels than ingestion of the choline bitartrate supplement alone.

• Study Type: Interventional
• Study Phase: Not Applicable
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: None (Open Label); Primary Purpose: Basic Science
• Condition: Cardiovascular Risk Factor

Intervention

• Dietary Supplement: Choline Bitartrate
  500mg choline bitartrate tablets
• Other: Pre-cooked, pre-peeled whole hardboiled eggs
  Obtained from a commercial source.
• Other: Egg whites from pre-cooked, pre-peeled hardboiled eggs
  Egg whites from pre-cooked, pre-peeled hardboiled eggs. The yolks are removed and discarded.
• Dietary Supplement: Phosphatidylcholine capsules
  420 mg phosphatidylcholine capsules obtained from a commercial source.

Study Arms

• Experimental: Whole Hardboiled Eggs
  Subjects will consume four (4) pre-cooked, pre-peeled whole hardboiled eggs per day for 28 days.
  Intervention: Other: Pre-cooked, pre-peeled whole hardboiled eggs
• Experimental: Choline Bitartrate Tablets
  Subjects will consume two (2) 500mg choline bitartrate tablets per day for 28 days.
  Intervention: Dietary Supplement: Choline Bitartrate
• Experimental: Hardboiled Eggs + Choline Bitartrate Tablets
  Subjects will consume both four (4) whole, pre-cooked, pre-peeled hardboiled eggs and two (2) 500mg choline bitartrate tablets per day for 28 days.
  Interventions:

  • Dietary Supplement: Choline Bitartrate
  • Other: Pre-cooked, pre-peeled whole hardboiled eggs
• Experimental: Egg Whites + Choline Bitartrate Tablets
  Subjects will consume both the egg whites (no yolks) of four (4) pre-cooked, pre-peeled hardboiled eggs and two (2) 500mg choline bitartrate tablets per day for 28 days.
  Interventions:

  • Dietary Supplement: Choline Bitartrate
  • Other: Egg whites from pre-cooked, pre-peeled hardboiled eggs
• Experimental: Phosphatidylcholine Capsules
  Subjects will consume six (6) 420 mg phosphatidylcholine capsules by mouth per day for 28 days.
  Intervention: Dietary Supplement: Phosphatidylcholine capsules

Publications *

• Wang Z, Klipfell E, Bennett BJ, Koeth R, Levison BS, Dugar B, Feldstein AE, Britt EB, Fu X, Chung YM, Wu Y, Schauer P, Smith JD, Allayee H, Tang WH, DiDonato JA, Lusis AJ, Hazen SL. Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. Nature. 2011 Apr 7;472(7341):57-63. doi: 10.1038/nature09922.
• Rebouche CJ, Chenard CA. Metabolic fate of dietary carnitine in human adults: identification and quantification of urinary and fecal metabolites. J Nutr. 1991 Apr;121(4):539-46. doi: 10.1093/jn/121.4.539.
• Bidulescu A, Chambless LE, Siega-Riz AM, Zeisel SH, Heiss G. Repeatability and measurement error in the assessment of choline and betaine dietary intake: the Atherosclerosis Risk in Communities (ARIC) study. Nutr J. 2009 Feb 20;8:14. doi: 10.1186/1475-2891-8-14.
• Wilcox J, Skye SM, Graham B, Zabell A, Li XS, Li L, Shelkay S, Fu X, Neale S, O'Laughlin C, Peterson K, Hazen SL, Tang WHW. Dietary Choline Supplements, but Not Eggs, Raise Fasting TMAO Levels in Participants with Normal Renal Function: A Randomized Clinical Trial. Am J Med. 2021 Sep;134(9):1160-1169.e3. doi: 10.1016/j.amjmed.2021.03.016. Epub 2021 Apr 17.

Recruitment Information

• Recruitment Status: Completed
• Actual Enrollment (submitted: April 21, 2021): 86
• Original Estimated Enrollment (submitted: January 30, 2017): 40
• Actual Study Completion Date: September 3, 2020
• Actual Primary Completion Date: April 10, 2018 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• Men and women age 18 years or above.
• Willing to remain on aspirin or stay off aspirin or aspirin products for 1 week prior to starting the study and throughout the study period.
• Able to provide informed consent and comply with study protocol.
• Able to be off all other supplements during the study period.

Exclusion Criteria:

• Significant chronic illness.
• Active infection or received antibiotics within 1 month of study enrollment.
• Use of over-the-counter probiotic within the past month
• Chronic gastrointestinal disorders, such as ulcerative colitis or Crohn's disease.
• Allergy to eggs or lactose.
• Having undergone bariatric procedures or surgeries such as gastric banding or bypass.
• Pregnancy.
• Any condition that, in the judgment of the Investigator, would place a patient at undue risk by being enrolled in the trial or cause inability to comply with the trial.

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Contacts: Contact information is only displayed when the study is recruiting subjects
• Listed Location Countries: United States

Administrative Information

• NCT Number: NCT03039023
• Other Study ID Numbers: 16-1048
• Has Data Monitoring Committee: No
• U.S. FDA-regulated Product: Not Provided

IPD Sharing Statement

• Plan to Share IPD: No

• Current Responsible Party: Wilson Tang, The Cleveland Clinic
• Original Responsible Party: Same as current
• Current Study Sponsor: The Cleveland Clinic
• Original Study Sponsor: Same as current
• Collaborators: Not Provided

Investigators

• Principal Investigator: W. H. Wilson Tang, MD; The Cleveland Clinic

• PRS Account: The Cleveland Clinic
• Verification Date: May 2021