The association between TMAO and worse cardiometabolic health outcomes may be due to reverse causality or confounding.

“assessment of causal direction you don't know which direction the arrow of causality is going here between gut microbiota dependent metabolites that's choline and carnitine and cardiometabolic health this is a bi-directional mendelian randomization analysis if you read this abstract what you'll find is that there are men our mendelian randomization findings support that type 2 diabetes and kidney disease increase tmao levels in evidence for cardiovascular diseases may be due to confounding or reverse causality”