There are a lot of nutrients that (rightfully) get extra attention in pregnancy, like iron and folate, but what about the nutrients that don’t get their time in the spotlight? The ones that are not discussed at the doctor’s office, not mentioned in that flimsy pamphlet on prenatal nutrition, and not included in most prenatal vitamins?
This is why I do the work that I do. I aim to highlight the oft forgotten—but equally important—nutrients that deserve our undivided attention and where we find them in real food. If we’re not careful and not specifically including nutrient-dense foods in the diet, these are the very nutrients we can easily miss out on.
I’m a broken record speaking out on the ways in which our prenatal nutrition guidelines can be improved. One such nutrient that needs to be revisted is choline, for which I coined the nickname “folate’s long lost cousin.”
Choline in Pregnancy: Folate’s Long Lost Cousin
Choline is in the B vitamin family, even though it lacks a number next to its name (it’s just “choline,” not vitamin B-85 or B-24) because it was named long after the rest of the B vitamins were discovered. Or who knows? Maybe B vitamin researchers got tired of assigning numerical nicknames?
Choline is involved in many of the same metabolic pathways as folate, including methylation. Everyone knows folate — or its synthetic supplemental version, folic acid — due to its vital role in the prevention of neural tube defects (for the sake of accuracy, folate is far superior to folic acid; more on that in this in-depth article on folate).
Did you know choline is equally as important as folate for preventing neural tube defects?!
Most people don’t. Not most mothers. Not most doctors. Not even most dietitians/nutritionists.
I’ve spoken at dozens of medical conferences and anytime I’m presenting on prenatal nutrition or breastfeeding nutrition, I make sure to include a slide or two on choline. I also ask the audience before I get into the details “How many of you are familiar with the nutrient choline?” Without fail, most people don’t raise their hands. What a tragedy.
This is precisely why I’m such a broken record on the benefits of choline in pregnancy.
Why is no one talking about choline?
The major reason choline is not making headlines in prenatal nutrition is that it’s a new kid on the block, relatively speaking. The first time we had a recommended intake for choline was 1998. The data used to set that recommendation was fairly weak; it was set based on a depletion-repletion study conducted in adult men & set at a minimum level to prevent liver damage. These figures were then adjusted upwards for pregnancy/lactation based on estimates of fetal needs. (In other words, the current recommendations for pregnancy are a SWAG—scientific wild ass guess.)
This also means any medical/nutrition professionals trained before or shortly after 1998 likely didn’t get much information (or any) on choline.
Specifically in the prenatal nutrition field, the past 20-ish years of research has revealed some striking data. Our guidelines are FAR overdue for an update.
This is not just my opinion. This is the opinion of choline researchers:
“The dietary requirement for choline has not been revisited by NAM [Food and Nutrition Board of the National Academy of Medicine] since 1998, despite a growing body of scientific literature. There is a need for dose-response studies across various populations to inform revision of the current Dietary Reference Intakes (DRIs) to include an EAR and RDA, so that accurate assessment of the amounts of individuals who are inadequate can be determined.” (Nutrition Today, 2018)
[By the way, I’ve heard from current dietetics students that choline is now more extensively discussed in their classes and textbooks—hallelujah!]
Data on the Benefits of Choline in Pregnancy
In short, the data is STRONG on the benefits of choline in regards to pregnancy health & brain development.
One review on choline concluded:
“High choline intake during gestation and early postnatal period has been repeatedly described as a robust cognitive enhancing regimen and is neuroprotective in a variety of animal models of neuronal damage. Data showing that maternal choline supply during pregnancy modifies fetal DNA and histone methylation suggest that a concerted epigenomic mechanism contributes to these long-term effects of varied choline intake in utero.” (Clin Chem Lab Med, 2013)
But it’s not just animal studies that has come to these conclusions. Since the above paper was published, we have amassed multiple human studies showing similar benefits.
Choline is one of the few nutrients that we have randomized controlled trials comparing different levels of supplementation on pregnancy health & infant outcomes.
Do you want to take a wild guess at what these studies found?
The gist is that we need MORE choline. A lot more.
Choline intakes at levels more than DOUBLE our current recommended intake optimize placental function, may reduce the risk of preeclampsia, and improve infant cognitive development and reaction time. (Placenta, 2016; FASEB, 2013; FASEB, 2018)
Our current recommended intake for pregnancy is set at 450 mg. Many of the supplementation studies have compared choline intakes of 480 mg (slightly above the recommended intake) to 930 mg per day. The women receiving 930 mg/day consistently show improved outcomes, as do their babies.
Choline also enhances the transport of nutrients across the placenta, including DHA; note the nutrient synergy. (J Nutri, 2017; Metabolism, 2008) Some of the richest food sources of choline also contain DHA, such as egg yolks and salmon.
In children aged 7 years old, those born to mothers with the highest intake of choline during pregnancy have better visual memory compared to those with the lowest intake. Interestingly, this study found that maternal intake of related nutrients, like vitamin B12 and folate, did not have a significant influence on cognitive test performance. (Am J Epidemiology, 2012)
It’s rare to have such a strong consensus among researchers on the necessity and importance of a nutrient. The vital role that choline plays in pregnancy health and fetal development is clear:
“Metabolites of choline are required for synthesis of cell membranes, neurotransmission, and methyl metabolism—processes essential to fetal brain development and tissue expansion. A large body of evidence suggests that periconceptional choline deficiency increases the risk of adverse birth outcomes, including neural tube defects and other congenital abnormalities. In addition, maternal choline status appears to influence cognitive development in infants.” (J Nutr, 2015)
What are the Best Food Sources of Choline?
Choline is widely spread in the food supply, but most concentrated in animal foods. This is an inconvenient thing for folks arguing the adequacy of a vegan diet in pregnancy because the #1 food sources are egg yolks and liver (this is one of many reasons eggs are so good for you in pregnancy).
You’d need close to 4 cups of broccoli OR 2 cups of beans OR 5.75 Tbsp of peanut butter or 3.3 cups of tofu OR 2 cups of shiitake mushrooms (these are among the richest plant sources of choline) to match the choline content of a SINGLE egg yolk.
This is why egg-eaters have, on average, twice the choline intake of non egg-eaters. In an analysis of the National Health and Nutrition Examination Survey data (NHANES) from 2009–2014, only 2.4% of people who don’t eat eggs met the recommended intake for choline, while 57.3% of egg-eaters met the recommendation. (Nutrients, 2017)
Even egg eaters should be aware of their choline intake (57.3% leaves almost half the population at inadequate intake), but a 23.5-fold difference in adequate intake between egg-eaters and egg-avoiders is noteworthy.
The data for pregnant women is particularly dismal; only 6-10% meet the recommended intake for choline. This is partly related to the increased requirements of pregnancy. Once you set the bar higher, many women aren’t going to make the cut. It’s also a side effect the poorly communicated information on food safety resulting in unfairly demonized “foods to avoid” that leaves many afraid to consume eggs.
Aside from egg yolks and liver, other foods rich in choline include: organ meats (like kidney, heart, giblets), fish roe, wild game (especially caribou and venison), fatty fish (especially salmon), pork skin (think chicharones), beef, lamb, pork, poultry, and dairy products. Bacon is actually a surprisingly rich source of choline, too (eggs + bacon anyone?).
In dietary surveys looking at the greatest contributors to choline intake, eggs top the list, followed by meat, poultry, seafood, and dairy products.
According to an extensive data set on US intakes of choline:
“Consumers of eggs had almost double the usual intake of choline as compared to non-consumers (525 ± 5.17 mg/d and 294 ± 1.98; p < 0.0001). Protein food (meat, poultry and seafood) consumption also increased usual choline intakes compared to non-consumers (345 ± 2.21 mg/day and 235 ± 8.81; p < 0.0001).” (Nutrients, 2017)
If you can’t/don’t want to consume eggs, I highly recommend a choline supplement, such as choline bitartrate, phosphatidylcholine, or sunflower lecithin (which is naturally rich in phosphatidylcholine) to meet your needs.
Obtaining Adequate Choline on a Vegetarian Diet
As stated above, choline is widespread in the food supply. However, the concentration of choline is highest in animal foods. This can make it more difficult to obtain enough choline on a vegetarian diet, particularly if one does not consume eggs (such as a vegan diet).
As mentioned above, certain plant foods do contribute to choline intake, especially shiitake mushrooms, beans/legumes, nuts/seeds, and cruciferous vegetables. These still count, but the quantity required to meet choline demands, particularly in pregnancy in lactation, makes it virtually impossible to do with diet alone. In fact, I have yet to see a vegan pregnancy meal plan with adequate choline.
I find it especially worrying that the handout on vegetarian diets in pregnancy from the Vegetarian Nutrition Practice Group of the Academy of Nutrition and Dietetics fails to mention choline as a nutrient of concern. They mention only protein, DHA, iron, folate, zinc, iodine, calcium, B12, and vitamin D (note: there are other nutrients beyond choline this list is missing; see Ch 3 of Real Food for Pregnancy in the section entitled “Challenges of a Vegetarian Diet in Pregnancy”).
A comprehensive nutrient analysis of their sample vegan meal plan shows it provides only 371 mg of choline (80% of the current recommendation for pregnancy or 40% of the level randomized controlled trials show is optimal). This is despite including multiple servings of the richest plant food sources of choline. Their sample meal plan is far better than some I’ve analyzed. Choline researchers note that average choline intake among vegetarians is a mere 192 mg. (Nutrition Today, 2018)
The Academy’s omnivorous sample meal plan in their official policy paper on prenatal nutrition doesn’t fare much better, providing only 374 mg. This is because the only eggs provided in their plan are the tiny amount in low-fat mayonnaise. (Why—why—would you choose oatmeal instead of nutrient-dense eggs for breakfast in this sample meal plan?!)
The dietetics’ field is so focused on complying with the arbitrarily low cholesterol and saturated fat targets in our dietary guidelines, that they compromise the level of choline in the diet. This is a perfect example of the nutritionism trap.
A Real Food Diet for Pregnancy Provides Optimal Levels of Choline
The disappointingly low concentrations of choline in the above examples is due to the low provision of animal-sourced foods—particularly eggs—in these sample meal plans.
In an aptly titled review of choline research, Choline: The Underconsumed and Underappreciated Essential Nutrient, published in 2018, a group of choline researchers argue against dietary policy that excludes animal foods entirely:
“Data indicate that increasing consumption of plant foods may offer health benefits; however, this means that there is a need to include more plant foods in the diet, but not necessarily eliminate nutrient-dense animal-derived foods such as eggs, lean meat, and milk products that contain choline.” [emphasis mine]
The high concentrations of choline in animal foods is one of many reasons I endorse an omnivorous diet for optimal pregnancy outcomes. I’m a proponent of consuming both plants and animals, not arguing in extremes of one versus the other.
The sample meal plans from my book, Real Food for Pregnancy, provide anywhere from 633 to 935 mg of choline—well above the current recommendation and in line with the latest data on optimal intake.
In the section exploring the nutritional considerations of a vegetarian diet, I highly encourage the consumption of eggs for those who otherwise avoid animal products. For those who are averse or allergic to eggs, as stated earlier in this article, a choline supplement is highly recommended.
Read the research. Run a nutrient analysis.
Decide for yourself if you want to EAT your nutrients versus supplement.
It’s not only about what your diet excludes, but what it INCLUDES, hence why I’m constantly talking about nutrient-dense foods.
If you are not sure you’re obtaining enough choline from your diet—or need personalized advice on what level of choline supplementation might be helpful to you (again, if your diet is lacking in choline-rich foods)—I’d recommend working with a real food dietitian with extensive training in prenatal nutrition. They could help run a comprehensive nutrient analysis to check the choline levels in your diet and guide you on the strategies you can take to optimize your intake.
But, but, but… Can’t your body make choline?
There are A LOT of people who are uneducated on choline or being told misinformation about the necessity of this nutrient (several outspoken vegan doctors are decidedly anti-choline). Some of these people argue that your body has the capacity to synthesize all the choline it needs.
This is not true. This is NOT supported by the scientific literature, particularly in pregnancy.
I’ll leave it to the researchers to explain it:
“Despite the potential enhanced capacity for the body to synthesize choline, data from animal models suggest that fetal and infant demand is so high that maternal stores are depleted during pregnancy and lactation. Low maternal choline intakes during pregnancy have been shown to increase the risk of both neural tube defects and cleft palates.” (Nutrition Today, 2018) [emphasis mine]
The above quote comes from an excellent review article on choline, which explores arguments for and against its intake. As of the time of writing, it’s open-access, meaning you don’t have to pay a dime to read it. If you have any lingering questions on choline, I recommend you give it a read (full citation below this article; simply copy and paste the title into a Google search and it’ll come right up).
What About TMAO?
Some people argue that choline should not be a nutrient we emphasize in the diet because it may increase levels of a metabolite known as TMAO (trimethylamine N-oxide). Some studies have linked higher TMAO levels to a higher risk of developing heart disease, however this remains controversial. TMAO levels are not only impacted by diet (and supplements), but also by gut health (both gut bacteria and gut barrier function). (Nutrition, 2018)
Also of interest, is that food-sourced choline doesn’t appear to impact TMAO levels to the same degree as supplemental choline. For example, a number of studies have tested whether the intake of eggs versus supplemental choline have an effect on TMAO levels. Studies ranging from intake of 1 to 4 eggs per day for a minimum of 4 weeks have not shown that they result in elevated TMAO levels, whereas some types of choline do raise TMAO levels (particularly choline bitartrate). Phosphatidylcholine and choline citrate do not seem to raise TMAO levels as significantly. (Am J Med, 2021; J Am Coll Nut,r 2018; Lipids, 2017)
Interestingly, egg-derived supplemental phosphatidylcholine does NOT raise TMAO levels, which brings us full circle in this conversation. (Eur J Nutrition, 2022) If and when possible, eat FOOD to meet your nutrient needs instead of supplements.
Choline and Pregnancy Summary
Let’s sum up the data on choline and pregnancy in bullet points, shall we?
- You need more choline—not less—during pregnancy (and even more when you’re breastfeeding, but that’ll be the topic of another post; or, see Ch 12 of Real Food for Pregnancy). I’ll also be teaching an in-depth webinar on breastfeeding nutrition in the coming months. Stay tuned for details. UPDATE: the nutrition for breastfeeding webinar recording is available here. This presentation focuses on the nutrient transfer into breast milk and how this is affected by maternal nutrient intake/nutrient status.
- Much like folate, choline is most important for placental health & your baby’s brain development (however, keep in mind it’s vital to overall brain function—pregnancy brain, anyone?—and liver health).
- Choline requirements in pregnancy may be DOUBLE the current recommendation; we’re just waiting on prenatal nutrition guidelines to catch up to the research.
- Eggs are the #1 source of choline in the diet; eat them regularly (with the yolks—that’s where the choline is) unless you absolutely cannot tolerate them.
- People who don’t/can’t consume eggs should consider a choline supplement. Don’t count on your prenatal vitamin as most contain none or pixie dust quantities. The two most studied forms of choline used in pregnancy supplementation studies are choline bitartrate and phosphatidylcholine.
If you want to learn even more about choline—and all the other nutrients required for a healthy pregnancy—check out Real Food for Pregnancy. You’ll especially like Ch 3, which explores foods to emphasize based on the latest scientific research on prenatal nutrition.
Before you go, I’d love to hear from you:
– Did your healthcare provider talk to you about choline during your pregnancy?
– Were you aware of this nutrient before reading this article?
I’m really curious to hear your input. I’ve seen a lot more nutrition professionals speaking about choline in recent years, especially since I published Real Food for Pregnancy, so I’m hoping to see this conversation become commonplace.
Until next week,
PS – If you’re new here and want to learn more ways that real food helps to optimize pregnancy outcomes, you can download the first chapter of Real Food for Pregnancy for free below.
- Shaw, Gary M., et al. “Periconceptional dietary intake of choline and betaine and neural tube defects in offspring.” American journal of epidemiology 160.2 (2004): 102-109.
- Wallace, Taylor C., et al. “Choline: The Underconsumed and Underappreciated Essential Nutrient.” Nutrition Today 53.6 (2018): 240-253.
- Blusztajn, Jan Krzysztof, and Tiffany J. Mellott. “Neuroprotective actions of perinatal choline nutrition.” Clinical chemistry and laboratory medicine 3 (2013): 591-599.
- Kwan, Sze Ting Cecilia, et al. “Maternal choline supplementation during pregnancy improves placental vascularization and modulates placental nutrient supply in a sexually dimorphic manner.” Placenta 45 (2016): 130. ; Jiang, Xinyin, et al. “A higher maternal choline intake among third-trimester pregnant women lowers placental and circulating concentrations of the antiangiogenic factor fms-like tyrosine kinase-1 (sFLT1).” The FASEB Journal 27.3 (2013): 1245-1253.
- Caudill, Marie A., et al. “Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study.” The FASEB Journal 4 (2018): 2172-2180.
- Wurtman, Richard J. “Synapse formation and cognitive brain development: effect of docosahexaenoic acid and other dietary constituents.” Metabolism 57 (2008): S6-S10. ; Kwan, Sze Ting, et al. “Maternal choline supplementation modulates placental nutrient transport and metabolism in late gestation of mouse pregnancy.” The Journal of nutrition 11 (2017): 2083-2092.
- Boeke, Caroline E., et al. “Choline intake during pregnancy and child cognition at age 7 years.” American journal of epidemiology 12 (2012): 1338-1347.
- Visentin, Carly E., et al. “Maternal choline status, but not fetal genotype, influences cord plasma choline metabolite concentrations.” The Journal of nutrition 7 (2015): 1491-1497.
- Wallace, Taylor, and Victor Fulgoni. “Usual choline intakes are associated with egg and protein food consumption in the United States.” Nutrients 8 (2017): 839.