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. 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.
• B. High daily alcohol consumption with normal dietary choline intake, because alcohol always masks choline deficiency and is the only cause of steatosis.
• C. Obesity in the absence of supplement trials, since obesity alone proves choline deficiency is the primary cause and no supplementation is informative.
• D. A single low albumin measurement on a basic metabolic panel, because albumin is most specific to choline status and rules out other causes.

Answer: (A)