A clinician suspects a patient’s fatty liver results from inadequate choline. Which piece of evidence would best support that diagnosis over alternative causes such as alcohol or obesity?

A history of very low dietary choline intake (e.g., avoidance of eggs, liver, and peanuts) accompanied by normal alcohol intake and BMI, plus improvement of liver enzymes after choline supplementation.

High daily alcohol consumption with normal dietary choline intake, because alcohol always masks choline deficiency and is the only cause of steatosis.

Obesity in the absence of supplement trials, since obesity alone proves choline deficiency is the primary cause and no supplementation is informative.

A single low albumin measurement on a basic metabolic panel, because albumin is most specific to choline status and rules out other causes.