Monday, November 29, 2010

Choline and Fatty Liver

I've been writing about non-alcoholic fatty liver disorder (NAFLD) since the early days of this blog, because it's an alarmingly common disorder (roughly a quarter of Americans affected) that is typically undiagnosed. It often progresses into its more serious cousin non-alcoholic steatohepatitis (NASH), an inflammatory condition that causes liver damage and can progress to cancer. In a number of previous posts, I pinpointed excess sugar and seed oil consumption as culprits in NAFLD and NASH (1, 2, 3, 4, 5).

Chris Masterjohn recently published two very informative posts on NAFLD/NASH that add a major additional factor to the equation: choline (6, 7). Choline is an essential nutrient that's required for the transport of fat out of the liver (8). NAFLD can be caused, and cured, simply by removing or adding dietary choline, and it appears to be dominant over other dietary factors including fat, sugar and alcohol. Apparently, certain researchers have been aware of this for some time, but it hasn't entered into the mainstream consciousness.

Could that be because the richest dietary sources are liver and eggs*? Choline is also found in smaller amounts in a variety of whole animal and plant foods. Most people don't get the officially recommended amount. From a recent review article (9):
Mean choline intakes for older children, men, women, and pregnant women are far below the adequate intake level established by the [Institute of Medicine]. Given the importance of choline in a wide range of critical functions in the human body, coupled with less-than-optimal intakes among the population, dietary guidance should be developed to encourage the intake of choline-rich foods.
I've dubbed beef liver the Most Nutritious Food in the World, Nature's Multivitamin, and I'll probably invent other titles for it in the future. Add yours to the comments.

Head over to Chris's blog and read about the classic studies he unearthed. And add The Daily Lipid to your RSS reader, because there's more interesting material to come!

The Sweet Truth about Liver and Egg Yolks
Does Choline Deficiency Contribute to Fatty Liver in Humans?

* For the brave: brain is actually the richest source of choline.


Anonymous said...

Stephan, now I have even more information on how good liver is but still no solution to getting it into the stomachs of my wife and children. Back to the cookbooks.

The only liver I can get them to eat is foie gras, but that's expensive on a weekly basis. I also notice that out here in rural France veal liver is nearly as expensive as foie gras [although beef is cheaper]. The locals know a good thing.

Unknown said...

Thanks Stephan!
Any truth in the known (myth?) that eating liver, being the body main filter, is actually non-healthy due all the harmful left overs ?

Unknown said...

It is a good question that Israel poses. That is why I have always learnt that it is important to emphasise liver from healthy, grass fed and organic animals.

Stipetic said...

The kidneys are a filtering organ. The liver is a efficient detoxing organ. It takes toxic stuff and rapidly metabolises them to something non-toxic, which are then sent to the kidneys (or bile) for elimination. So, unless the animal was in the process of eating toxic stuff when it was killed, it's unlikely its liver was "packing" non-healthy leftovers as it is not a storing facility. Eat your liver, just like your grandma use to say.

woly said...

Is anyone concerned about the high level of copper and/or retinol found in liver?

julianne said...

Lambs brains was one of my favourite meals as a child, soft, sweet, fatty and delicate.

Greg said...

I have 2 approaches to cooking liver- cook in bacon grease with onions, and blend into a pate. In a pate, the liver can be diluted as much is desired.

Yeon said...

Silkworm larva, an acquired taste, are a traditional food here in Korea and are sold in most supermarkets.

They are very high in choline, containing at least 600 mg/100 gr ( Source : Encyclopedia of Entomology, 2th edition)

Other insects are also rich in choline. Locusts, for example, contain 490 mg/100 gr.

Rafael said...

HI for those who can read in spanish I have a similar blog on nutrition issues. Maybe you could combine your spaninsh and nutrition learning in just one session.

trix said...

I've found that I can grind up liver then add it to any ground beef dish. I think that would be a way to start getting it into kids and grownups who weren't raised eating liver (like me).

Ed said...

Kidneys are a great source, too.

I wonder what the "perfect" stew would look like.

Anonymous said...

yummmm... I am not joking, if I have a meal to eat everyday for the rest of my life it would be animal livers. Beef is my favorite by far. i just like it quick seared with salt/pepper and a side of scrambled eggs.

if the choline in related to NAFLD then I would say I am on the right track! i actually made myself stoip eating organs so much and sticking to once a week because i was scared of over vitamin-mineral-ing myself as a few mentioned massive copper and vitamin A

David L said...

I had a friend who died recently from fatty liver. He was definitely on the obese side. However, I looked up fatty liver on Wikipedia, and they did not indicate a high morbidity for this condition. Any thoughts on this?

Scott W said...

Having been convinced by Stephan that liver is the most-nutritious food in the universe, I set about figuring out how to make it palatable enough to eat without a lot of fuss. Throwing it in a frying pan and overcooking it is a sure way to make yourself hate it.

I have no idea if my method makes it less nutritious or not.

First, I start with frozen slices of liver that have already been de-veined. Very cheap. I've seen both beef and veal liver this way. Easier than a container of gloppy fresh liver.

Next, you get the excess blood out. Soaking in milk for a few hours, as recommended by some recipes, is a pain and having a bowl of bloody milk in your fridge will not make your family love it more. I found a better way: I put it in a shallow bowl (carefully, tears easily) and run water from my hot tap around it. Water from an almost boiling teapot would work the same.

I swish it a bit and drain it right away. I repeat this two more times. Don't let it soak; you don't want it to absorb a bunch of water.

The side benefit is that this slightly cooks the liver so it is not mushy and is much easier to handle.

I slide it out onto a paper towel and blot the top with paper towel to dry it.

No breading...hard to get breading right without flour anyway and I don't eat wheat flour. Doesn't need it.

Heat the frying pan on medium high. Favorite oil in the pan. I've been using olive. Could probably skip the seasoning but I like to add some. Browning onions in the oil would be the classic approach, but I find that putting onion powder, salt and pepper directly onto both sides of the liver is just fine.

Brown about 1 minute per side for a 1/4 inch slice, longer for thicker. Just cut into it and you will know. I like mine to have a trace of pink in the middle...all gray and it is shoe leather.

You could also brush it with oil and add spices and broil it close to the element for a similar amount of time.

It is not steak, but after taking a few months to figure out this method and forcing myself to eat my mistakes, I now like it and look forward to it.

Once a week. It is probably psychological, but liver day makes me feel like I'm being really healthy.

Scott W

Anna said...

The weekend before Thanksgiving my sister was hunting in Upstate NY and got a nice buck (my 15 yo neice got her first buck Thanksgiving morning - very exciting). I was "home" this year visiting family and attending my high school 30 year reunion, so I eagerly volunteered to help process the deer the next day.

My sister had saved the liver and the heart for me when she gutted it, before bringing the deer home to hang overnight. That liver was the best I've ever had (I like paté and liverwurst but plain liver is a taste I'm still acquiring). I baked a paté with 1/3 of the liver using a paté recipe with ground pork (though I didn't use enough salt and it was too bland).

I also cut thin slices of the liver and seared them quickly in a pan with caramelized onions and ghee, just enough to barely cook through. Oh, wow, that was the best fresh liver I'd ever had - I even forgot to eat the onions with it. Slightly sweet tasting, and virtually none of the "liver" taste.

I noted that even nearly a week later, the remaining portion of raw liver was still fresh, sweet-smelling, and firm. I left it with my mother (she loves liver) when it was time for me to fly home. Makes me wonder how old the liver in stores really is.

I took the frozen heart with me, which I'll grind and mix with bison meat for meatballs or burgers.

Unknown said...

Hi Stephan - just wanted to add a link to an interesting Choline deficiency and plant-oil induced diabetes post from perfect health diet:

Also, shameless link to my own site where I did a post on phospholipids a while back - choline is a phospholipid and I was able to find some research claiming that increasing phospholipids in the diet seems to decrease the overall hormonal stress response. Not great research, but some research.
I think I'll do an update using choline as a search word rather than phosphotidylcholine or serine.

Might-o'chondri-AL said...
This comment has been removed by the author.
Monica said...,

One thing I do to get liver and other organ meats down my husband is to grind them in my food processor and then mix small amounts with ground beef whenever I make meatballs, hamburgers, meatloaf, etc. Do you have any dishes in France that require the use of ground beef? My husband never notices when the organ meat is only 1 T. per pound or so of muscle meat.

Best wishes in getting some nutrients into your family members!

John said...

Relying on liver for choline is probably not a good idea, as many have mentioned excess vitamin A. The proportional amount of choline in liver [compared to other foods] is nowhere near the vitamin A amount, so this would seem to support eating organ meats (in addition to liver) like kidney, brain, tripe, etc.

sagehill said...

"Beef is my favorite by far. i just like it quick seared with salt/pepper and a side of scrambled eggs."

I've had just about all the species of liver, from chicken to beef and my favorite is rabbit... very delicate and sweet.

Most people overcook liver into a rubbery disgusting mess. Liver is best eaten rare. I sprinkle with thyme and lightly saute with butter and mushrooms; remove the liver to a place, add some dry sherry and cook the liquids into a delicious sauce, pour over the liver and tuck in!

Jack said...

I have been fighting 'liver' forever. It just grosses me out. I know it's psychological, but I just would rather have a sirloin steak with butter. Can you marinate liver and trick yourself into thinking it's steak? I'd hate to miss out on "the healthiest food in the world" but man I just don't know yet.

If I eat beef liver, should I skip the fermented cod liver oil for that particular day?

-Jack Kronk

Diana said...

I always skip the FCLO on days I eat liver, as well as days I have eggs. Just seems to make sense that if you are getting it from food, you shouldn't have to supplement. Just my 2 cents.

David L said...

I'm trying to follow up from an earlier post. What are the best sources of fermented food available at a supermarket? I have been doing sauerkraut, but looking for variety. I tried some pickled beets, but I don't find them terrible savory. On top of that, I guess I'm not sure if pickling counts as fermentation. Any suggestions? (I don't eat bread, so please don't suggest sourdough).

Jack said...


You skip CLO on days you eat eggs? Por qué? I eat eggs every day, and take CLO every day. I don't understand.

-Jack Kronk

David Pier said...
This comment has been removed by the author.
David Pier said...
This comment has been removed by the author.
Unknown said...

Jack -

Liver has a totally different texture than steak, so, unfortunately, it's not something you can "pretend" is something else. I dislike beef liver, but there are ways of cooking that I can eat without gagging.

I find I like it marinated in lemon juice for a day or two, then (very) lightly pan seared (equivalent to rare in a stake) in the in butter or lard. Add some carmelized onions and garlic, and plenty of butter, salt, and pepper, and it's palatable. Not good, but palatable. I imagine yogurt would also be a good marinade.

I can get grassfed liver, so I might try it raw (marinated) with a dipping sauce one of these days.

It's also easy to mask a small amount in ground meat, and much more if the meat dish is heavily spiced (Indian and Ethiopian food work well for this, as does chili).

If you can't get or can't afford pastured eggs, I'd take the CLO anyway. Especially if you eat grain-fed meats otherwise. The ratio is important to some degree, and eggs don't tip the balance if you're getting too much linoleic acid elsewhere.

Take this for what it's worth, but you could still take the CLO if you've eaten liver, the combined vitamin A shouldn't be a problem, especially if the liver is just once a week or less. If you have trouble keeping a habit going with skipping a day here or there, or like routine, I'd keep it. If not, or if you have concerns about the amount of vitamin A, then skip it.

It really depends on what you're comfortable with.

Diana said...

I skip FCLO on days I eat eggs mainly because
1)Eggs have a decent amount of vitamin A, (according to Nutrition Data, 244 iu per 1 large, and I usually eat 4)
2) FCLO is expensive, so if I eat eggs 2 times a week it stretches out my supply.
3) I try not to supplement everything, every day. I try to get as much as I can from whole foods.
That being said, I think FCLO is one of the BEST things you can take for yourself.

Anonymous said...

a lot of spices like mustard, coriander, parsley and garlic have choline too... spice for thought!

Gabriella Kadar said...

I've been buying baby goat pluck these days. Kidneys fried gently in butter with salt, pepper and a late topping of whole grain mustard. Leopold Bloom clearly had it right.

Goat liver and heart, cut up into small pieces added to sauteed onion and paprika, caraway seeds and thyme..... very simple and extremely delicious.

I'm sure that goat 'guts' are at least as nutritious as beef liver. The flavour is less intense for those who find beef liver overpowering.

Stephan Guyenet said...

Hi Israel and Chris,

I agree with Poisonguy, the liver doesn't necessarily accumulate toxins. Still, I think the better the animal was raised, the healthier its liver will be.

Hi Woly,

I'm not concerned about the amount of copper and vit A found in liver, unless you're eating it on a daily basis.

Hi Julianne,

Awesome. My dad grew up eating lamb brain in France. My grandmother said it would make him smart. Well he's smart so I guess it worked.

Hi Yeon,

Thanks, I didn't know that. My impression is that insects are nutritious in general. That's interesting in light of the fact that most contemporary hunter-gatherers eat insects. I think it would be fun to grow a mulberry tree and raise silkworm grubs for food.

Hi David L,

NAFLD can progress to NASH, which can lead to liver failure and cancer, and eventually death. Sorry to hear about your friend.

Stephan Guyenet said...

Hi Mit-o'chondri-AL,

That is a tough screen name to spell. I think what you're getting at is that traditional cultures had ways of mitigating diets that were low in animal source choline by eating whole plant foods that either contain choline or betaine, which spares choline to some degree. I agree.

Hi David L,

Unpasteurized apple cider vinegar is another good one.

Hi Jack,

I used to skip my CLO on days when I ate liver because of the vitamin A. I don't take CLO anymore as I feel I get enough A, D and n-3 as it is (I do supplement D separately in winter). I don't know that taking CLO and liver together is harmful, but I do prefer to keep my A intake in a range that would be reasonable for a hunter-gatherer (excluding arctic groups like the Inuit).

futrzak said...

Hi Stephan,

how does beef, pork and chicken liver compares in terms of amount of choline?

Just curious, because chicken liver seems to be the cheapest one per pound and easiest to get at least where I live.

Chris said...

Awesome, as a student I eat liver and other organ meats almost daily because they are so cheap. Grass-fed heart, liver, brains, oxtail from the farmers market for $2/pound can't be beat. It helps balance out the cost of the organic eggs and bacon :)

Anonymous said...

Its better to go for vegetable rather than going for leaver of animals ! Well thank you Stephan for this gr8 post and looking forward to see you next post!

Sports Nutrition

Chris Masterjohn said...

Long live MNFW!

The only problem with the acronym is it takes a syllable for every letter. Ludwig et al cited one of their most important accomplisments in coming up with the name "NASH" is it's only one syllable. In fact they gave this precedence over the fact that steatosis "isn't strictly a steatohepatitis" but nevertheless classified it as NAFLD and considered it a subdivision of NASH (everyone else does the opposite now!)

So, we need to brainstorm an acronym that appropriately bestows liver with verbose accolades but can be expressed in one syllable. :)


Chris Masterjohn said...

Oops -- and THREE syllables for the dou-ble-you!

TedHutchinson said...

Elucidation of Phosphatidylcholine Composition in Krill Oil
The predominant phospholipid in krill oil is phosphatidylcholine, which is partially composed of choline.

Stephan Guyenet said...

Hi Futrzak,

I don't know off the top of my head, but I suspect they're all good sources.

Hi Chris,

True, we need something catchier but no less superlative.

Hi Ted,

Interesting. Maybe that underlies some of the different effects between fish oil and krill oil.

mike250 said...

unfortunately the taste of beef liver is repulsive and no amount of cooking or herbs can change that. I think I will stick with my eggs.

hazelm said...

I have read here and elsewhere that liver contains large amounts of copper. I have ovarian cancer and have read on various websites that liver is exceptionally high in copper and should be avoided by people with certain types of cancer, including ovarian.

The liver I buy is either lambs or water buffalo and although it isn't organic it comes from a small local Welsh (UK) hill farm where the animals are grass fed.
I always buy/cook it fresh, just seared for about 30 seconds on each side and raw in the middle. Served with caramelized onions it's one of my favourites foods so I'd hate to have to give it up..

Since my diagnosis 18 months ago I've had major surgery, a severe infection and chemotherapy and at present I am eating liver (and other offal) at least once a week in the hope that a good diet, whatever that means, will help to build up my immune system and keep me in remission for as long as possible. I would be grateful if anyone could let me know if they know of a connection between cancer and high liver intake.

Helen said...

I really can't stand beef liver, but I've discovered I like chicken liver. Eggs are not in our house (unfortunately) because of my daughter's serious egg allergy.

Peanuts are actually a good source, too, but those we have to avoid because of a nut allergy, and I've been weirded out by peanuts (which I otherwise love) since reading something by Cordain on peanuts and atherosclerosis.

Eminia said...

Its such a great post...i was looking for something smiler..also looking forward for some more blogs...thanks again Lap band surgery

Yves said...

Hey Stephan. Love the blog, arguably the best out there for health and nutrition. Have incorporated alot of information from here.

I was wondering about the potential for Vitamin A overdose. The last few times I've had liver (from beef/lamb) I've gotten dizzy, had distorted vision, almost vertigo feeling, and just felt odd in general. The first time I didn't make the connection, but when it happened again I threw the liver out. I've never had a problems with this supplier who is a local grass-fed farmer, but figured maybe there was something wrong with it. Unfortunately the same thing happened today when I had some beef liver, although not as severe as I only had maybe .5 oz. I was only having 1-3oz servings before.

I don't ever remember having bad reactions to liver before and always felt like it was a great "power-food", but am wondering if now that I eat 5-10lbs/week of sweet potatoes and 2-4lbs/week of spinach if I am already getting sufficient Vitamin A from plant sources. Even if the conversion rate is paltry 2-5% it should cover me given the massive amount of beta-carotene in these foods. Could it be something to do with the vitamin A-D-K2 triangle? I take 2000iu of D, but don't supplement K2 or eat much dairy (some grass fed butter and some kefir, but small amounts). Is too much of one a problem when there's too little of a another?

Stephan Guyenet said...

Hi Paul,

I don't know what it could be, but I wouldn't assume it's the vitamin A. You could test that by taking high-vitamin cod liver oil or a vitamin A gelcap to see how you react. In any case, if liver makes you feel bad, then I would avoid it. You can get your nutrition elsewhere.

Helen said...

Can I just say you get some of the most hilarious blog-spam I've ever seen?

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Jack said...

"Unless your inner zombie"

That's pretty funny antispirit.

Hey I found a package of 6 lbs of fully grass pasture fed beef liver from Tropical Traditions on sale for $31.50. Is that a good deal?

Grass Fed Beef

-Jack K

Jack said...

My wife made chicken liver patte.

primarily 1/3 chicken liver, 1/3 mushrooms, 1/3 onions with some other variables thrown in for flavor.

is chicken liver good too? (i mean nutritionally speaking)

ramon25 said...

Stephen I know this is an older post and I do apologize but it relates to a question I have. Its in regards to eating brains, Pig brains in particular. I am paranoid or worried that it will have some sort of negative effect on my nervous system. Like kuru or something of that nature. Just scared I guess with alot of what i have read. I know I can eat it, it doesnt disgust me. I am jsut concerned on that note. What do you think?

Puddleg said...

Choline and fatty liver is a truism of biochemistry that goes back at least 50 years; also methionine. Betaine, B12, folate, methionine all help to elevate choline. B12 and methionine from meat, folate from liver and greens, betaine - the very best sources are beetroot (raw or tinned, no difference) and spinach (bran and wheatgerm are equally rich sources, but probably not worth the risk; and one can eat more beetroot by weight).

(USDA Database for the Choline Content of Common Foods)

Anonymous said...

I just ran across a recent study about the association between non-alcoholic fatty liver and vitamin D deficiency:

allison said...

Try the grass fed braunschweiger from US Wellness Meats. I have tried eating liver on numerous occasions, but always exhaust myself fighting the gag reflex while forcing it down. Trying to get children to eat liver is a virtual impossibility. However, I can get them to eat braunscweiger in small quanities if I salt and pepper it sufficiently. The stuff is roughly half liver and half beef trimmings. I eat it a few times a week as a snack.

A u s t r a l i a n A n i m a l said...

So couldn't a person reverse insulin resistance in the liver by having enough choline, thereby allowing glucagon to be used (instead of cortisol) for raising blood sugar levels thru the glucagon/glycogen pathway? And keeping cortisol levels low, will speed up the livers speed of detoxing as well as speeding up the thyroid, also allowing energy to be used quicker? Is this not a well to completely reverse type 2 diabetes?? Or prevent it in the first place? Of course it's more complicated than this, like making sure to try to reverse insulin resistance using chromium, R lipoic acid... And Seriphos to lower cortisol if those levels are high mid afternoon and on... (Also working on correcting other inputs for stimulating or nonstimulating cortisol levels such as neurotransmitter levels, immune th1/2 balancing, hormone balancing) I think a bigger deal should be made of this choline reversing insulin resistance find.

Anonymous said...

My late grandmother Isabell would cook us pork brains with scrambled eggs when she babysat us.