From the Guidelines
Treatment options for elevated Trimethylamine N-oxide (TMAO) levels primarily focus on dietary modifications and lifestyle changes, with the most effective approach being adopting a plant-based or Mediterranean diet rich in fruits, vegetables, whole grains, nuts, and olive oil. The goal is to limit red meat, processed meats, and full-fat dairy products which contain precursors that gut bacteria convert to TMAO. Increasing fiber intake through foods like legumes, whole grains, and vegetables promotes beneficial gut bacteria that produce less TMAO 1. Some key points to consider:
- Probiotic supplements containing Lactobacillus and Bifidobacterium strains may help rebalance gut microbiota to reduce TMAO production.
- Regular physical exercise has been shown to favorably modify gut microbiota composition and potentially lower TMAO levels.
- For patients with persistently high TMAO despite lifestyle modifications, medications like antibiotics (poorly absorbed ones such as rifaximin) can temporarily reduce TMAO-producing bacteria, though this is not recommended for long-term use due to resistance concerns.
- Some research suggests resveratrol supplements (typically 500-1000mg daily) and DMB (3-dimethyl-1-butanol) may inhibit TMA production, though these remain investigational 1. These interventions work by either reducing TMA precursors in the diet, altering gut microbiota composition to favor bacteria that produce less TMA, or directly inhibiting the enzymatic conversion of dietary precursors to TMA, which is subsequently oxidized to TMAO in the liver. It's worth noting that while other studies discuss various health topics, such as coronary risk evaluation and blood pressure management 1, the most relevant and recent guidance on TMAO levels is focused on dietary and lifestyle interventions.
From the Research
Treatment Options for Elevated TMAO Levels
There are several potential treatment options for patients with elevated Trimethylamine N-oxide (TMAO) levels, including:
- Dietary changes: Reducing or avoiding foods high in choline, L-carnitine, and phosphatidylcholine, such as red meat, fish, and eggs, may help lower TMAO levels 2
- Increasing fiber intake: A high-fiber diet can help promote the growth of beneficial gut bacteria, which may help reduce TMAO production 3
- Probiotics: Certain probiotics, such as those containing Lactobacillus and Bifidobacterium species, may help reduce TMAO levels by altering the gut microbiome 3
- Medications: Certain medications, such as antibiotics and metformin, may help reduce TMAO levels by altering the gut microbiome or improving insulin sensitivity 4, 3
Reducing TMAO Levels to Prevent Cardiovascular Disease
Reducing TMAO levels may help prevent cardiovascular disease, as elevated TMAO levels have been associated with an increased risk of cardiovascular events, including heart attack, stroke, and death 5, 4, 6.
- The relationship between TMAO levels and cardiovascular disease appears to be mediated by renal function, with higher TMAO levels associated with a higher risk of cardiovascular events in individuals with impaired renal function 5
- Reducing TMAO levels may also help improve outcomes in patients with heart failure, as elevated TMAO levels have been associated with a poor prognosis in these patients 4
Monitoring TMAO Levels
Monitoring TMAO levels may be useful in identifying individuals at high risk of cardiovascular disease, as well as in tracking the effectiveness of treatments aimed at reducing TMAO levels 6.
- TMAO levels can be measured using a blood test, and elevated levels may indicate an increased risk of cardiovascular disease 5, 4, 6
- Regular monitoring of TMAO levels may help identify individuals who require more aggressive treatment or lifestyle modifications to reduce their risk of cardiovascular disease 6