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

Study Description

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.

Condition or disease	Intervention/treatment	Phase
Cardiovascular Risk Factor	Dietary Supplement: Choline Bitartrate; Other: Pre-cooked, pre-peeled whole hardboiled eggs; Other: Egg whites from pre-cooked, pre-peeled hardboiled eggs; Dietary Supplement: Phosphatidylcholine capsules	Not Applicable

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 However, another pilot study by a collaborator (unpublished) did not show the same increase in plasma TMAO levels following the ingestion of whole eggs, a major dietary source of choline.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 Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 86 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Basic Science
• Official Title: Effects of Choline From Eggs vs. Supplements on the Generation of TMAO in Humans (EGGS)
• Actual Study Start Date: September 2, 2016
• Actual Primary Completion Date: April 10, 2018
• Actual Study Completion Date: September 3, 2020

Arms and Interventions

Arm	Intervention/treatment
Experimental: Whole Hardboiled Eggs; Subjects will consume four (4) pre-cooked, pre-peeled whole hardboiled eggs per day for 28 days.	Other: Pre-cooked, pre-peeled whole hardboiled eggs; Obtained from a commercial source.
Experimental: Choline Bitartrate Tablets; Subjects will consume two (2) 500mg choline bitartrate tablets per day for 28 days.	Dietary Supplement: Choline Bitartrate; 500mg choline bitartrate tablets
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.	Dietary Supplement: Choline Bitartrate; 500mg choline bitartrate tablets; Other: Pre-cooked, pre-peeled whole hardboiled eggs; Obtained from a commercial source.
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.	Dietary Supplement: Choline Bitartrate; 500mg choline bitartrate tablets; 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.
Experimental: Phosphatidylcholine Capsules; Subjects will consume six (6) 420 mg phosphatidylcholine capsules by mouth per day for 28 days.	Dietary Supplement: Phosphatidylcholine capsules; 420 mg phosphatidylcholine capsules obtained from a commercial source.

Outcome Measures

Primary Outcome Measures :

1. 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.
2. 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.

Secondary Outcome Measures :

1. 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.
2. 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.
3. 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.
4. 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.
5. Changes in Lipid Profile, Total Cholesterol [ Time Frame: Baseline, Day 28 ]
   Changes in total cholesterol levels between baseline and Day 28
6. Changes in Lipid Profile, HDL [ Time Frame: Baseline, Day 28 ]
   Changes in measured HDL levels between baseline and Day 28
7. Changes in Lipid Profile, LDL [ Time Frame: Baseline, Day 28 ]
   Changes in measured LDL levels between baseline and Day 28
8. Changes in Lipid Profile, Triglycerides [ Time Frame: Baseline, Day 28 ]
   Changes in measured triglyceride levels between baseline and Day 28

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: Yes

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.

Contacts and Locations

Locations

United States, Ohio

Cleveland Clinic Foundation

Cleveland, Ohio, United States, 44195

Sponsors and Collaborators

The Cleveland Clinic

Investigators

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

  Study Documents (Full-Text)

Documents provided by Wilson Tang, The Cleveland Clinic:

Study Protocol and Statistical Analysis Plan  [PDF] November 2, 2017

More Information

Additional Information:

Patterson K, Bhagwat S, Williams J, Howe J, and Holden J. USDA Database for the Choline Content of Common Foods, Release Two. January 2008. 

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.

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

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.

• Responsible Party: Wilson Tang, Staff, Cardiovascular Medicine, The Cleveland Clinic; Staff, Cellular and Molecular Medicine, The Cleveland Clinic Lerner Research Institute, The Cleveland Clinic
• ClinicalTrials.gov Identifier: NCT03039023
• Other Study ID Numbers: 16-1048
• First Posted: February 1, 2017
• Results First Posted: May 14, 2021
• Last Update Posted: June 2, 2021
• Last Verified: May 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

Keywords provided by Wilson Tang, The Cleveland Clinic:

TMAO; choline; eggs; gastrointestinal microbiome; healthy volunteers

Additional relevant MeSH terms:

Choline; Lipotropic Agents; Hypolipidemic Agents; Antimetabolites; Molecular Mechanisms of Pharmacological Action; Gastrointestinal Agents; Lipid Regulating Agents; Nootropic Agents