Gut flora metabolism of phosphatidylcholine promotes cardiovascular disease. [, Brunst KJ, Wright RO, DiGioia K, Enlow MB, Fernandez H, Wright RJ, et al. Use healthy oils (like olive and canola oil) for cooking, on salad, and at the table. Explore the downloadable guide with tips and strategies for healthy eating and healthy living. An introduction to the nutrition and metabolism of choline. Choline can be found naturally in foods including eggs, liver, beef, salmon, cauliflower, Brussel sprouts and breast milk. Choline is a source of methyl groups needed for many steps in metabolism. Includes a variety of vegetables; fruits; grains (at least half whole grains); fat-free and low-fat milk, yogurt, and cheese; and oils. Many studies do not assess the status of all B vitamins, which can confound results and obscure the true relationship between choline and the observed outcome. U.S. Department of Agriculture, Agricultural Research Service. An analysis of 72,348 women in the Nurses Health Study and 44,504 men in the Health Professionals Follow-up Study showed no association between choline intake and risk of peripheral artery disease in men or women [35]. For a reader-friendly overview of Choline, see our consumer fact sheet on Choline. Choline and folate are known to be key nutrients involved in the methyl group processes, which the body uses to form genetic material that helps build every system within the body. As you can see, there are plenty of other sources of choline that offer many more health benefits without the risks, including wild salmon, cage-free eggs and even certain vegetables, so why not obtain most of your choline from these foods? It is believed that circulating TMAO may promote atherosclerosis by preventing the removal of cholesterol in the liver. And the best way to promote healthy genetic expression is to avoid chemicals and other contaminants and give your body the nutrients it needs. AI: The Adequate Intake for men and women ages 19+ years is 550 mg and 425 mg daily , respectively. The main dietary sources of choline in the United States consist primarily of animal-based products that are particularly rich in cholinemeat, poultry, fish, dairy products, and eggs [4,5,8-10]. For example, premenopausal women may have lower requirements for dietary choline because higher estrogen levels stimulate the creation of choline in the body. Benefits, How to Follow, Risks & More, What is Betaine? The DV for choline is 550 mg for adults and children age 4 years and older [12]. The exact mechanism of this association is unclear and warrants further research. FLD is a chronic condition that usually goes on without notice or gives away very few symptoms or none at all. Neuron synapses are being formed in the brain of fetuses and infants at a very rapid rate, so choline plays a major part in helping to build the foundation of the brains structure. WebChristie, J. G. Blackburn 1. An alcohol recovery program can help you achieve this goal. This amount can be from food, supplements, or a combination of the two. Its also important for the functioning of a key neurotransmitter called acetylcholine, which similarly helps nerves to communicate and muscles to move, acts as ananti-agingneurotransmitter, and performs other basic processes. In healthy adults, the concentration of choline in plasma ranges from 7 to 20 mcmol/L [2]. This post may contain affiliate links. Prague Med Rep 2015;116:5-15. Choline is especially presentin animal products, so vegetarians and vegans are more prone to experiencing a deficiency in choline. 1-888-75-LIVER. 2016, Beef top round, separable lean only, braised, 3 ounces, Beef, ground, 93% lean meat, broiled, 3 ounces, Fish, cod, Atlantic, cooked, dry heat, 3 ounces, Potatoes, red, baked, flesh and skin, 1 large potato, Broccoli, chopped, boiled, drained, cup, Mushrooms, shiitake, cooked, cup pieces, Fish, tuna, white, canned in water, drained in solids, 3 ounces, Cauliflower, 1" pieces, boiled, drained, cup, Bread, pita, whole wheat, 1 large (6 inch diameter), Tangerine (mandarin orange), sections, cup, Apples, raw, with skin, quartered or chopped, cup. The forms of choline in dietary supplements include choline bitartrate, phosphatidylcholine, and lecithin. Create healthy, balanced meals using this visual guide as a blueprint. Choline deficiency can cause harm, especially for your liver. Choline is an essential nutrient that is naturally present in some foods and available as a dietary supplement. In: Coates PM, Betz JM, Blackman MR, et al., eds. [1]. And so, theres a lot of things you can do to glutathione. (9). Choline is needed to properly transport fat from the liver to cells throughout the body. Choline. Eggs. There is not enough data to establish a Recommended Dietary Allowance for choline. And they have been shown to reduce inflammation and boost detoxification. Foods providing 20% or more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet. However, a more recent analysis of data on 80,978 women from the Nurses Health Study and 39,434 men from the Health Professionals Follow-Up Study found an increased risk of mortality in those consuming higher levels of choline [33]. Maternal choline concentrations during pregnancy and choline-related genetic variants as risk factors for neural tube defects. But what will reverse your fatty liver is cutting out alcohol, soda and sugar, reducing all carbs in your diet and eliminating processed foods. [7,8]. [, Brody LC, Conley M, Cox C, Kirke PN, McKeever MP, Mills JL, et al. And well also show you a super-tasty way to add liver to your familys diet and have every person at the table coming back for seconds! Zeisel SH, Corbin KD. 3rd ed; 2012:565-608. Specifically, a cross-sectional study of 56,195 Chinese adults aged 4075 years found an inverse relationship between dietary choline intakes and risk of NAFLD based on 24-hour dietary recall [47]. It is also food for beneficial gut bacteria. They are one of the top choline-rich foods available, with one serving providing 147 milligrams. Lecithin itself has important roles in the body, including to help maintain cell membranes, transmit nerve impulses, process fat and cholesterol, and perform other tasks. Choline, along with the B vitamin folate, helps to lower blood levels of homocysteine by converting it to methionine. [11] Although some observational studies have found that higher intakes of choline are associated with higher levels of cognitive function like memory, clinical trials have not found that choline supplementation significantly improves these cognitive measures. We recommend you obtain a copy of Dr Cabots wonderful book Fatty Liver You Can Reverse It as it provides a complete eating plan with recipes. A landmark study showed that losing 10% of ones body weight can reduce liver fat, resolve inflammation, and potentially improve scarring. Our bodies are able to make a small amount of choline on their own, but the rest we must obtain from food sources. The U.S. Department of Agricultures (USDAs) FoodData Central [11] lists the nutrient content of many foods and provides a comprehensive list of foods containing choline arranged by nutrient content. The researchers found that women who consumed more choline switched on genes that beneficially affect hormone production in the fetus. People who are pregnant or lactating need even more. Benefits, Signs of Deficiency and Food Sources, Daniel Fast: Benefits for Your Spiritual, Emotional and Physical Health, 15 Fermented Foods for a Healthy Gut and Overall Health, 9 Proven Black Seed Oil Benefits that Boost Your Health, L-Glutamine Benefits Leaky Gut & Metabolism, Chia Seeds Benefits: The Omega-3, Protein-Packed Superfood, Apple Cider Vinegar Benefits for Weight Loss, Skin Health, Cholesterol & More. Choline and folate assist in the conversion of homocysteine, which prevents the body from accumulating too much fat and may be beneficial in cutting down on the risk of having a heart attack or stroke. WebSo what drugs do you take with grade 1 fatty liver? Dont Drink Alcohol. The remaining fat-soluble phospholipids (phosphatidylcholine and sphingomyelin) are absorbed intact, incorporated into chylomicrons, and secreted into the lymphatic circulation, where they are distributed to tissues and other organs, including the brain and placenta [1,6]. Am J Clin Nutr 2016;104:173-80. In fact, at this stage, the patient can or does not need to take medicine. J Nutr Biochem 2008;19:158-65. WebSo what drugs do you take with grade 1 fatty liver? Br J Nutr 2014;112:1858-72. The richest sources of this vital nutrient include liver, beef, eggs, poultry and seafood. Several food sources of choline are listed in Table 2. [, Resseguie ME, da Costa KA, Galanko JA, Patel M, Davis IJ, Zeisel SH. Choline helps to improve mental energy, focus and concentration, which are all important for physical activity and athletic performance. Our team includes licensed nutritionists and dietitians, certified health education specialists, as well as certified strength and conditioning specialists, personal trainers and corrective exercise specialists. Although soy lecithin is considered safe by the FDA, at times it can result in negative reactions including nausea, bloating, constipation, rashes on the skin, abdominal pain and other digestive problems. Choline deficiency causes reversible hepatic abnormalities in patients receiving parenteral nutrition: proof of a human choline requirement: a placebo-controlled trial. [, Wu BT, Dyer RA, King DJ, Richardson KJ, Innis SM. Am J Clin Nutr 2011;94:1584-91. [, Veena J, Muragundla A, Sidgiddi S, Subramaniam S. Non-alcoholic fatty liver disease: need for a balanced nutritional source. A key component to reverse fatty liver with choline is by eating a diet high in choline, which is required by the PEMT gene to make Phosphatidylcholine. WebConsuming too much alcohol can cause inflammation and swelling in the organs, which can lead to pain. [, Fischer LM, daCosta KA, Kwock L, Stewart PW, Lu TS, Stabler SP, et al. An analysis of data from the 20132014 National Health and Nutrition Examination Survey (NHANES) found that the average daily choline intake from foods and beverages among children and teens is 256 mg for ages 219 [14]. Multivitamins do not typically contain choline. The U.S. Food and Drug Administration (FDA) developed DVs to help consumers compare the nutrient contents of foods and dietary supplements within the context of a total diet. Choline, its potential role in nonalcoholic fatty liver disease, and the case for human and bacterial genes. Choline is nutrient that helps your body detoxify. Whey protein, shown to reduce liver fat by up to 20%. [2] The Food and Nutrition Board established an Adequate Intake (AI) for choline based on the prevention of liver damage. Some studies have shown that choline and lecithin can help to reduce blood cholesterol and risk for heart disease, but different studies have yielded inconsistent results, so more research is still needed before doctors will begin to prescribe choline for its ability to lower LDL (bad) cholesterol and trigylcerides. The nutrigenetics and nutrigenomics of the dietary requirement for choline. Choline is a key component of lecithin (phosphatidylcholine), which is a fat-like substance found in our cells. As a result, humans must obtain some choline from the diet. Its not recommended to take more than 3,500 mg of choline per day during pregnancy. (A single drink [e.g., 12 oz beer, 5 oz wine, or 1.5 oz hard liquor] contains about 1214 g alcohol.) The richest plant sources are collards, Brussels sprouts, broccoli, crimini mushrooms, asparagus and cauliflower (although these foods provide only about 17-60 mg per cup). Need Help? Best Choline For Fatty Liver Resources https://my.clevelandclinic.org/health/drugs/22202-choline-supplement In fact, according to the Institute of Medicine only 10% of Americans consume an adequate amount of choline. Includes a variety of protein foods such as lean meats; poultry; eggs; seafood; beans, peas, and lentils; nuts and seeds; and soy products. Millard HR, Musani SK, Dibaba DT, Talegawkar SA, Taylor HA, Tucker KL, Bidulescu A. Dietary choline and betaine; associations with subclinical markers of cardiovascular disease risk and incidence of CVD, coronary heart disease and stroke: the Jackson Heart Study. Am J Clin Nutr 2007;85:1275-85. Your healthcare provider can help you figure out the best way to get the choline you need. 10 Evidence shows that even if alcoholic fatty liver has progressed to fibrosis, the liver can repair and regenerate itself if alcohol consumption is stopped. Zheng Y, Li Y, Rimm EB, Hu FB, Albert CM, Rexrode KM, Manson JE, Qi L. Dietary phosphatidylcholine and risk of all-cause and cardiovascular-specific mortality among US women and men. These values, which vary by age and sex, include: Insufficient data were available to establish an EAR for choline, so the FNB established AIs for all ages that are based on the prevention of liver damage as measured by serum alanine aminostransferase levels [2]. Choline deficiency: a cause of hepatic steatosis during parenteral nutrition that can be reversed with intravenous choline supplementation. Choline was shown to completely reverse fatty liver in a small Zeisel SH. Food and Nutrition Board. Food
In a study of 100 African, Asian, Caucasian, and Mexican Americans, individuals of European ancestry had a higher prevalence of four SNPs that increased the risk of organ dysfunction when these individuals consumed a low-choline diet [27]. WebA healthy liver typically has a small amount of fat, and medical criteria establish fatty liver disease when around 5% of the liver mass is made up of fat. Corbin KD, Zeisel SH. Baltimore, MD: Lippincott Williams & Wilkins; 2014:416-26. Choline acts like a precursor to certain important neurotransmitters, including acetylcholine, which is used in healthy nerve and muscle function. Gastroenterology 2009;137:S119-28. Sometimes its possible to reverse nonalcoholic fatty liver disease, especially in the early stages. It can lead to much more serious conditions including cirrhosis and liver failure.. [, Zheng Y, Li Y, Rimm EB, Hu FB, Albert CM, Rexrode KM, et al. Choline is considered to be a safe nutrient and rarely causes negative side effects. [, Guerrerio AL, Colvin RM, Schwartz AK, Molleston JP, Murray KF, Diehl A, et al. Fatty liver disease. This article is based on scientific evidence, written by experts and fact checked by our trained editorial staff. Institute of Medicine. [, Abratte CM, Wang W, Li R, Moriarty DJ, Caudill MA. WebCan choline reverse fatty liver? In some cases, fortified foods and dietary supplements are useful when it is not possible otherwise to meet needs for one or more nutrients (e.g., during specific life stages such as pregnancy).". This Dr. Axe content is medically reviewed or fact checked to ensure factually accurate information. Encyclopedia of Dietary Supplements. Choline. It can also help you absorb more nutrients. Yes. Low blood levels of choline can cause fat to accumulate in the liver. [. Furthermore, having diabetes heightened that risk. Avoid sugary drinks. No reproduction, transmission or display is permitted without the written permissions of Health-e Enterprises, LLC. Your email address will not be published. Precise estimates of the percentage absorption of the different forms of dietary choline in humans are not available [2,3]. Tolerable Upper Intake Level (UL): Maximum daily intake unlikely to cause adverse health effects. [, Buchman AL, Moukarzel A, Jenden DJ, Roch M, Rice K, Ament ME. Updated:
(5), On the other hand, there are potential health benefits of soy lecithin, including its ability to help lower cholesterol, improve cognitive function, relieve menopause symptoms and help the body deal with stress. It commonly develops with people who have an excessive alcohol intake, are obese, suffer withdiabetes or a form of insulin resistance, and haveother diseases that influence fat metabolism. women who ate 930 mg of choline per day had 33% lower levels of cortisol compared to women who ate only 430 mg daily. Higher blood levels of TMAO have been associated with a higher risk of CVD in animal studies. High intakes of choline are associated with a fishy body odor, vomiting, excessive sweating and salivation, hypotension, and liver toxicity [1,2]. Food and Nutrition Board. For pregnancy and lactation, the AI is 450 mg and 550 mg daily, respectively. The study found that 77% of postmenopausal women and 80% of men developed fatty-liver disease in the six weeks of choline deprivation (<50mg/day). FDA does not require food labels to list choline content unless choline has been added to the food. Yes, You Can: Repair and Reverse Your Fatty Liver Disease 1 Take It Easy On The Sugar. According to Dr. 2 Eat More Liver and Eggs. Liver and eggs are the highest known food source 3 Supplement With Choline and B-Vitamins. If youre not able to get enough choline through dietary The most important thing is to change the diet, quit alcohol, smoke, should not eat greasy food. Plasma homocysteine, dietary B vitamins, betaine, and choline and risk of peripheral artery disease. Am J Clin Nutr 2014;100:1069-74. Prospective study on dietary intakes of folate, betaine, and choline and cardiovascular disease risk in women. Choline is a water soluble nutrient that is related to other vitamins, such as folate and those in the B vitamin complexfamily. Nutr Rev 2015;73:500-22. [, Yu D, Shu XO, Xiang YB, Li H, Yang G, Gao YT, et al. Note that the numbers in parentheses (1, 2, etc.) Eat a variety of whole grains (like whole-wheat bread, whole-grain pasta, and brown rice). Chan School of Public Health, https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/, Academic Departments, Divisions and Centers. Choline metabolism provides novel insights into non-alcoholic fatty liver disease and its progression. read my affiliate policy. [10] NAFLD occurs most often in individuals with excess weight or obesity, and the main treatment is to reduce body fat with calorie restriction and exercise. JPEN J Parenter Enteral Nutr 2001;25:260-8. The Institute of Medicine (IOM) recommends that women consume at least 425 mg daily. 1. In fact, eggs are sometimes called brain food because they are known for supplying high amounts of choline. This may be due to the hydrolysis of membrane phospholipids, a source of choline, to maintain plasma choline concentrations above this minimal level, or to endogenous synthesis [2]. Folate intake and the MTHFR C677T genotype influence choline status in young Mexican American women. Webcisco a-flex-3 datasheet; get element from array java; kimchi prostate cancer; most reliable luxury suv consumer reports You should seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. (1) Choline is still being studied in order to learn more about its potential benefits and uses, but at this time, most experts agree that the amounts listed below are sufficient for producing optimal benefits without causing any harm: Some experts recommend getting even higher levels of choline in order to boost brain function and to retain memory. (16). 2. [, Mills JL, Fan R, Brody LC, Liu A, Ueland PM, Wang Y, et al. For example, in a study of 57 adults who consumed a diet that included less than 50 mg choline per 70 kg body weight per day (<10% of the AI) for up to 42 days, 37 of the participants developed liver dysfunction [45]. (15) Other studies show that pregnant women with a low blood level of choline have been shown to be at a higher risk for having children with neural tube defects and developmental problems. Similarly, a 2003 Cochrane review of 12 randomized trials in 265 patients with Alzheimers disease, 21 with Parkinsonian dementia, and 90 with self-identified memory problems found no clear clinical benefits of lecithin supplementation for treating Alzheimers disease or Parkinsonian dementia [38]. AI: The Adequate Intake for men and women ages 19+ years is June 2, 2022
When the liver you eat comes from animals raised on a pristine natural diet, it can be one of the most powerful superfoods around. Read Next:What is Betaine? Avoid more harmful fat sources such as saturated or trans fats. A monthly update filled with nutrition news and tips from Harvard expertsall designed to help you eat healthier. [, Sanders LM, Zeisel SH. Corbin KD, Zeisel SH. Thats key since the liver uses choline to break down fat. Additionally, choline is used in muscle nerve functioning and may be useful in preventing fatigue and muscle aches or pains following exercise. Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy; established when evidence is insufficient to develop an RDA. It also gives our cell membranes the ability to transfer both water-soluble and fat-soluble molecules. AI: The Adequate Intake for men and women ages 19+ years is 550 mg and 425 mg daily, respectively. What is choline found in? Click here to
Limit refined grains (like white rice and white bread). It helps your cells to communicate. Nutrition and the brain 1979;5 Its believed that cholines effect on your metabolism and neurotransmitters in the brain can produce quicker reaction times and cut down on the amount of time needed for mental processing. Limits foods and beverages higher in added sugars, saturated fat, and sodium. Therefore, in choline deficiency, fat accumulates in the liver, which can result in NAFLD [44,45]. The biggest benefit of choline for the liver is that it helps remove fat from the liver which in turn may help prevent non alcoholic fatty liver disease (NAFLD) and liver damage (8, 10). Additional research is needed to determine the relationship between choline intakes and cardiovascular and peripheral artery disease as well as the potential risks and benefits of choline supplementation to reduce the risk of these diseases. This ultimately interferes with normal liver function. Its also worth noting that choline can be found in soy products, especially soy lecithin. It may also lead to the excess production of TMAO, which is associated with a higher risk of cardiovascular disease. Humans have variations in the DNA sequences for these genes (single nucleotide polymorphisms [SNPs]), and these SNPs can have a strong influence on demands for dietary choline. WebDerived from chylomicrons, VLDLs or extrahepatic tissues (reverse PC transport) (10. van der Veen JN , can lower the amount of dietary choline required, because it reduces the need to convert choline potentially predisposing one to fatty liver. Table 1 lists the current AIs for choline [2]. [, Poly C, Massaro JM, Seshadri S, Wolf PA, Cho E, Krall E, et al. Choline is converted by gut bacteria into a byproduct called trimethylamine (TMA), which is then converted in the liver to trimethylamine-N-oxide (TMAO). People with certain genetic alterations
A large cohort of men and women from the Nurses Health Study and Health Professionals Follow-up Study, followed for 20-25 years, found that higher phosphatidylcholine intakes were associated with an increased risk of deaths from CVD and other causes. [1]. As a result, adults and infants receiving total parenteral nutrition (TPN) over the long term have low plasma choline concentrations (approximately 5 nmol/ml in adults and 5.7 nmol/ml in infants), which can result in hepatic abnormalities, including NAFLD [30-32]. Washington, DC: National Academy Press; 1998. (8). Potatoes and French fries dont count. [10] A true choline deficiency can lead to muscle or liver damage, and nonalcoholic fatty liver disease. Liver function returned to normal in 29 participants in this study after they were fed a diet containing 25%75% of the choline AI and in 8 who consumed an ad libitum diet. (17), As children grow older, choline is needed to help develop brain function since it plays a role in learning, remembering, logical thinking and concentration abilities. Have a question? How much choline should I take for fatty liver? *Not possible to establish; breast milk, formula, and food should be the only sources of choline for infants. WebCholine: The Forgotten B Vitamin. A.S.P.E.N. Extra sweating. People with Alzheimers disease have lower levels of the enzyme that converts choline into acetylcholine in the brain [38]. Sherriff JL, OSullivan TA, Properzi C, Oddo JL, Adams LA. The most common sources of choline in foods are the fat-soluble phospholipids phosphatidylcholine and sphingomyelin as well as the water-soluble compounds phosphocholine, glycerolphosphocholine, and free choline [1]. Another one of the benefits of choline is its ability to keep your mind mentally sharp as you age. As we age, our brain becomes less elastic. Choline intakes also had no association with cardiovascular disease risk in a study of 16,165 women participating in the European Prospective Investigation into Cancer and Nutrition [37]. The risk of inadequate choline status might be greater in pregnant and lactating women who do not take folic acid supplements, those with low vitamin B12 status, and those with a common variant in methylenetetrahydrofolate dehydrogenase (an enzyme that can affect folate status), all of which reduce the bodys pool of methyl groups needed for metabolism [17-20]. Present Knowledge in Nutrition. *DV = Daily Value. Soy lecithin contains choline and other molecules, including fatty acids, glycerol and phosolipids. London and New York: Informa Healthcare; 2010:136-43. [, Higgins JP, Flicker L. Lecithin for dementia and cognitive impairment. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, eds. Nonalcoholic fatty liver disease (NAFLD) is a health condition where you have too much fat in your liver. [6] There was a 26% increased risk of CVD deaths when combining data from both cohorts comparing the highest intakes of phosphatidylcholine with the lowest. It is also a rich source of choline and allows you to add a significant helping of liver, without changing the taste. J Biol Chem 2011;286:1649-58. This amount can be from food, supplements, or a combination of the two. Lose Weight. Tang WW, Wang Z, Levison BS, Koeth RA, Britt EB, Fu X, Wu Y, Hazen SL. However, it was noted that TMAO blood levels were not measured in this study, only choline from foods reported in diet questionnaires. Pregnant womenIn addition to low average dietary intakes in the general public, prenatal supplements do not typically contain choline. Choline, especially phosphatidylcholine, is essential for transporting lipids from the liver [1]. These are potent types of choline that produce the most benefits in the body, according to some sources, because they closely mimic the way that choline is found naturally in food sources. 1. It was originally studied for its ability to prevent fat and cholesterol from building up in the liver. Choline is found in a variety of foods. In: Erdman JW, Macdonald IA, Zeisel SH, eds. Intestinal microbial metabolism of phosphatidylcholine and cardiovascular risk. WebYou also need choline to form the membranes that surround your bodys cells. And its not because genetic mutations are passed down (although that can happen). Enjoy the Most Delicious Dinners You've Ever Set on the Table, 2614 Tamiami Trail North, Ste #219, Naples, FL 34103. Ask ODS
Some experts have pointed to the fact that the types of choline that is best used by the body are CDP choline, also called Citicoline, or Alpha GPC choline. Her passion is educating on how foods promote health and protect against disease and creating simple and delicious recipes for vibrant health and enjoyment. Although most people in the United States consume less than the AI of choline, frank choline deficiency in healthy, nonpregnant individuals is very rare, possibly because of the contribution of choline that the body synthesizes endogenously [1,5]. Neurological disorders
[, Buchman AL. Choline metabolism provides novel insights into nonalcoholic fatty liver disease and its progression. Impacts and Outlook of Alcoholic Fatty Liver Disease. The FNB has established ULs for choline from food and supplements based on the amounts of choline that are associated with hypotension and fishy body odor (see Table 3) [2].