Abstract: Choline(or vitamin b4) is relatively new to the attention of prenatal nutrition. However, it is a critical nutrient for cell health, brain health, lipid transport, and metabolic processes. Choline also plays a role in preventing neural tube defects in your baby. Even though choline is made by the body and is present in many foods, many women are deficient in choline. The ideal amounts for choline during pregnancy may be well above the Adequate Intake. Thus, it is critical to consider all the various factors that lead to an increased risk for choline deficiency to determine the proper dietary and supplementation amount for you. 

What is Choline? Why Do I Need It? 

Choline (or vitamin b4) is critical for a number of physiological processes during pregnancy with roles in membrane biosynthesis and tissue expansion, neurotransmission,  brain development, and methyl group donation and gene expression. Relative to other nutrients, choline is new to the prenatal discussion but not any less critical. Even though the American Medical Association didn't acknowledge the importance of choline during pregnancy until 2017, scientists now know that choline is vital to proper embryo development, fetal brain development, and placental function. It is also not just folate's job to prevent neural tube defects. Choline plays a role in that too. In 2018, the American Academy of Pediatrics recognized choline as a “brain-building” nutrient and called upon pediatricians to ensure pregnant women and young children have adequate intakes of choline. 

Have you ever heard of choline? Well, listen up.  

Choline affects all aspects of the fertility journey, starting with the ability to conceive, the placenta's health, the prevention of serious pregnancy complications, including neural tube defects, and the baby's brain development. 

The demands for choline during pregnancy and lactation are exceptionally high as the female body ensures that the fetus is exposed to very high choline concentrations. Choline concentrations during pregnancy in amniotic fluid are tenfold greater than in maternal blood. Choline supports the placenta, forming the cell structure of this new organ, promoting the formation of needed blood vessels, and facilitating nutrient transport to feed the hungry and growing fetus. To fulfill these neonatal demands, maternal choline stores can become depleted. And even though you can synthesize some choline in your body from estrogen, you need enough dietary and supplemental choline to ensure you receive adequate choline levels for yourself to stay healthy. 

Our overall health relies on enough choline for brain health, high-functioning cells with healthy membranes, lipid transport, and efficient metabolic processes. Maternal brain health and fetal brain development is reliant on choline intake. The choline derived neurotransmitter acetylcholine influences many processes in the developing brain and supports normal development of the hippocampus, a region of the brain with roles in learning, memory, and attention. Acetylcholine functions as a neurotransmitter in both the central nervous system and the peripheral nervous system and is heavily involved in brain functioning. One research study found that concentrations of maternal plasma choline at 16 weeks of gestation were positively associated with infant cognitive test scores at 18 months. Another study observed an association of better visual memory among 7 year old children of mothers with choline intakes in the top versus the bottom quartile during the second trimester of pregnancy.  

Research suggests that elevated homocysteine levels during pregnancy are associated with large amounts of choline synthesized in the liver as the body tries to keep up with high prenatal demands. The more supplemental or dietary choline consumed the less pressure on the liver to make enough choline and the lower the plasma homocysteine levels. Elevated plasma homocysteine levels are an independent risk factor for cardiovascular disease and stroke in humans. Thus, even though our bodies can create choline, it is critical that women, especially those pregnant, also consume dietary and supplemental sources of choline. Lastly, insufficient choline levels can cause liver damage, muscle damage, and neurodegenerative diseases! 

Choline Deficiency

Choline deficiency causes muscle damage and abnormal deposition of fat in the liver, which results in nonalcoholic fatty liver disease. Genetic predispositions and gender can influence individual variations in choline requirements and thus the susceptibility to choline deficiency-induced fatty liver disease. 

Choline Supplementation During Pregnancy: What Form is Best? 

Currently, there aren't any research studies on the various forms of supplemental choline that suggest one type over the other. Since almost all women are deficient in choline, dietary intake and supplementation are important. However, not all prenatal vitamins contain choline or have enough choline. No studies have compared the relative bioavailability of choline from the various forms (choline bitartrate, phosphatidylcholine, and lecithin). So, in this case, ensuring enough choline is present is more important than deciphering between different forms. 

How Much Choline Do I Need?

Currently, approximately 90-95% of women consume less than the Adequate Intake recommendation formulated by the National Academy of Sciences for choline(or vitamin b4). Furthermore, current research shows that consuming amounts near double the AI for choline is beneficial. And consequently, the demand for folate is increased when the dietary supply for choline is limited. While the recommended target for pregnant women is 450 mg/day of choline, choline intakes that exceed dietary recommendations during pregnancy may improve maternal and child health outcomes. Studies that used 930 mg of supplemental daily choline demonstrated benefits on fetal development and placental function, specifically on the fetus' brain development. In a randomized controlled feeding study, faster processing speed was observed among infants born to mothers consuming 930 mg versus 480 mg choline per day during their third trimester of pregnancy. Another study showed that children whose mothers consumed 930 mg of choline per day performed significantly better on a task of color location memory at 7 years of age. This suggests a long-term beneficial impact of high choline supplementation. 

Adequate Intake Female: 425 mg/day Pregnancy 450 mg/day Lactation 550 mg/day

Research showing that high amounts of choline are ideal may be due to the high variability of need across women: genes, the gut microbiome, hormone, and nutrient levels, all impact dietary requirements. If you know the below scenarios apply to you, you may have a higher risk for choline deficiency. 

Genetic variation and single nucleotide polymorphisms (SNPs) influence choline metabolism through various pathways. Genetic mutations in the folate pathway could limit the amount of bioavailable folate, increasing the need for choline as a methyl donor in the body. Genetic mutations in the PEMT gene could influence the amount of choline synthesized in the body from estrogen. Lastly, it is estimated that women who have the common MTHFR mutation, which affects up to 60% of the population, may have substantially higher choline needs than the recommended level.

Gut microbiome health impacts choline needs as choline utilizing bacteria constitutes less than 1% of the gut bacteria community and can easily be altered through lifestyle such as dietary patterns, antibiotic use, and probiotics. 

Variability in Vitamin B12, folate, and estrogen levels influence the individual's need for choline. 

Lastly, the tolerable upper intake level of choline is 3,500 mg/day for adults. None of the research studies have documented any adverse effects of choline supplementation at levels ranging from 550-900 mg/day. 

Am I Getting It From Food? What Food Sources Contain Choline? 

Yes! The good news is many foods contain choline(or vitamin b4). Animal-based products such as meat, poultry, fish, dairy, and eggs are all rich in choline. Three ounces of beef liver at 350 mg of choline and one egg constituting approximately 150 mg of choline are your strongest dietary sources of choline. Animal source foods typically contain more choline per gram of food. Smaller amounts of choline can be obtained from cruciferous vegetables, mushrooms, certain beans, grains, nuts, and seeds. Roast up some cauliflower, broccoli, and brussels sprouts each week to keep your choline levels humming along smoothly!

Various forms of choline are found in food. The most prominent dietary form of choline is usually phosphatidylcholine (PC) with smaller amounts of free choline, phosphocholine, sphingomyelin, glycerophosphocholine, and lysophosphatidylcholine (LPC). All of these choline forms are interchangeable within the body and contribute to an individual’s “total” choline intake. 

Prenatal Vitamin Brands: What's the Choline Amount and Type in Popular Prenatal Brands?

Prenatal Analysis:

It is good to see a majority of these prenatal brands including choline in their supplement. These supplements ranging from 50 mg to 300 mg offer a range of amounts, making it a personal decision based on your dietary habits and individual needs on how much choline is appropriate for you in your supplement. 

Resources: 

1. Office of Dietary Supplements - Choline. Accessed February 25, 2022. https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/

2. Goh YQ, Cheam G, Wang Y. Understanding Choline Bioavailability and Utilization: First Step Toward Personalizing Choline Nutrition. J Agric Food Chem. 2021;69(37):10774-10789. doi:10.1021/acs.jafc.1c03077

3. Zeisel SH, da Costa KA. Choline: An Essential Nutrient for Public Health. Nutr Rev. 2009;67(11):615-623. doi:10.1111/j.1753-4887.2009.00246.x

4. Korsmo HW, Jiang X, Caudill MA. Choline: Exploring the Growing Science on Its Benefits for Moms and Babies. Nutrients. 2019;11(8):1823. doi:10.3390/nu11081823

5. Zeisel SH. Choline: Critical Role During Fetal Development and Dietary Requirements in Adults. Annu Rev Nutr. 2006;26:229-250. doi:10.1146/annurev.nutr.26.061505.111156

6. Nichols L. Real Food for Pregnancy: The Science and Wisdom of Optimal Prenatal Nutrition. First edition. Lily Nichols; 2018.