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In the past, research on the carnitine pool focused mainly on FAO, but it has now expanded to many biological fields, including energy metabolism, mitochondrial homeostasis, epigenetic regulation, inflammatory and immune homeostasis, endocrine regulation, cell signaling, neuroprotection, and tumor biology

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While research into this topic is currently limited, current studies indicate that the microbiota has a decisive role in the synthesis of TMAO from dietary choline and carnitine

The link below is the American Heart Associations simple animation of how atherosclerosis develops