90% of Americans don't get enough choline. So why isn't it higher up the food policy agenda?

By Elaine Watson

- Last updated on GMT

Dr Steve Zeisel:  “In pregnancy we know that low choline diets are associated with increased rates of birth defects."
Dr Steve Zeisel: “In pregnancy we know that low choline diets are associated with increased rates of birth defects."

Related tags Nutrition

As the 2015 Dietary Guidelines for Americans are developed, there has been a lot of heated debate about saturated fat (not the nutritional bogeyman we always thought?) and protein (it’s a hot trend, but do we really need more?). But what about choline?

In 1998, the Institute of Medicine (IOM) recognized choline - found naturally in beef and chicken liver, egg yolk, salmon, milk, and soybeans among other things - as an essential nutrient and set an adequate intake at 550 mg/day for men and 425 mg/day for women (rising to 450 mg for pregnant women and 550 mg for breastfeeding women).

Yet according to National Health and Nutrition Examination Survey (NHANES) data,​ while American infants are doing OK (choline is in breast milk and is added to infant formula), a whopping 90% of children, adults and pregnant women are not getting enough.

Low choline diets in adults present with fatty liver   

But while the 2010 DG advisory committee identified choline as a "shortfallnutrient​”, it did not make any particular recommendations about the importance of increasing intake, something which has frustrated Steven H. Zeisel, MD, PhD, a leading researcher on choline (click HERE​ for an overview of choline research from Dr Zeisel)

 “In pregnancy we know that low choline diets are associated with increased rates of birth defects," ​Dr Zeisel told FoodNavigator-USA.

"And we know that low choline diets in adults present with fatty liver and sometimes muscle damage that is reversed when choline restored  ​(click HERE​), added Dr Zeisel, who has written to the DG advisory committee urging them to actively encourage the intake of choline-rich foods in the 2015 guidelines.

Given the importance of choline in making a healthy baby, pregnant women should be the target.  As more data develops, fatty liver in older men and women may develop as a second important target for increasing choline.”

And given that 50% of the population has genetic variations that make it necessary to consume choline at levels even greater than the AI, there is an immediate need to increase awareness of the critical role it plays throughout life, he said, noting that only a fraction of doctors are likely to recommend foods containing choline for healthy pregnant women.

“The 1998 IOM report moved recognition of choline forward, but still few clinicians understand that it is important. But there is a great deal of data as to the importance of choline.”

As for adults, “25% of the US population has fatty liver,” ​he added.“[But as] we do not know if we have fatty liver without special testing, most people do not realize they have it.  Probably this is why there is less pressure to set policy on choline.”

Foods rich in choline

Few clinicians understand that it is important

As for fetal development, he said: “Women in California in the lowest quartile for choline intake during pregnancy have four times the risk of having a baby with a neural tube defect, and 1.7 times risk of having baby with a cleft palette​.

“Choline intake in the last two trimesters of pregnancy is also correlated with memory function in seven year olds [and] animal studies show that choline during pregnancy is needed for brain (memory) development.”

Meanwhile, a 2005 study ​found that giving phosphatidylcholine supplements to men aged 50-71 with elevated homocysteine levels was as effective as folic acid in lowering fasting homocysteine levels, suggesting that choline intake may reduce cardiovascular disease risk, he added.

FDA is proposing to set RDI for choline and allow it to be voluntarily listed on the NF panel

That said, it looks like things might be beginning to change, with the FDA now proposing to set an RDI of 550 mg for choline based on the AI as part of its overhaul of the Nutrition Facts panel (click HERE​).

Man shopping
Most consumers don't know much about choline, says Dr Catherine Adams-Hutt: "Given the strength of the body of scientific literature, this nutrient begs for a champion."

It is also proposing to permit the voluntary declaration of choline on the Nutrition Facts label, and says it would not object to nutrient content-type claims about choline (click HERE​) based on a 550mg RDI (so 55mg/serving is a good source, 110mg is an excellent source).

And all of these factors could start to generate more interest from food and supplement companies, said Dr Catherine Adams-Hutt at Sloan Trends (which as a disclaimer has worked with Balchem, which supplies the Vitacholine brand of choline).

“Given the strength of the body of scientific literature, this nutrient begs for a champion," ​she said. "It really is unusual for such a widespread deficiency of a nutrient to go unaddressed by the nutraceutical and functional food industries for so long”.

Eggs are one of the richest dietary sources of choline

But how do we get more choline? And are supplements or fortified products advisable for some groups?

“Intake of diets that contain foods rich in choline is the best way to increase intake,”​  according to Dr Zeisel. “For vegetarians it can be done but will be difficult. If they supplement then I would suggest phosphatidylcholine.”

Dr Mitch Kanter: "Eggs are one of the richest dietary sources of choline, with an average whole large egg containing approximately 147mg choline."

While the likelihood of Americans developing a renewed enthusiasm for chicken liver seems fairly slim, eating more eggs - a key source of choline - is more achievable, however, said Mitch Kanter, Ph.D, executive director at the Egg Nutrition Center, who has also penned a letter to the DG advisory committee about choline.

Eggs are one of the richest dietary sources of choline, with an average whole large egg containing approximately 147 mg choline, in addition to varying amounts of nutrients pregnant women need most: high-quality protein, iron, and folate, according to the USDA database​.”

But while eggs are currently enjoying a bit of a renaissance thanks to the high-protein craze, choline is not really on the radar of most consumers, although this could change if companies start talking about it on food labels, said Dr Kanter.

“Once people see it on the label, then people will start talking about it.”

Raising awareness about choline could also serve as a reminder that the new wave of plant-based egg replacers might be able to replace the functionality of eggs, but do not always match the nutritional benefits, particularly when it comes to choline, he added.

There was a national program for folate fortification. What are we doing about choline?

Dr Adams-Hutt, meanwhile, reckons that choline could and should become the next folate: “The effect of choline deficiency in pregnant women is similar to that of folate; and there was a national program that included folate fortification of bread and cereals to correct it. What are we doing about choline​?

“Choline has been effectively sidelined as a nutrient of key importance for no apparent reason.”

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Choline Intake

Posted by Chris,

According to the Institute of Medicine, the tolerable UL for choline is 1,000mg for age 1 - 9, 2,000 for 9-13, 3,000 for 13 - 18 and 3,500 for adults 18+. At 7.5 grams of choline/day, some people experienced a slight blood pressure lowering (hypotensive) effect, which could result in dizziness or fainting. Choline at levels of 10,000mg or above will frequently cause a fishy body odor, though it may appear at lower levels in people who suffer from trimethylaminuria due to their lower tolerance for trimethylamine, a metabolite of choline. To reach the adult UL, you'd need to eat the equivalent of almost 2 lbs of beef liver or 28 eggs in one day (those are two of the foods with the highest amount of choline). This information was all sourced from Oregon State University's Linus Pauling Institute for micronutrient research.

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Too much choline?

Posted by Deborah Collins,

What is the result of ingesting too much choline? I currently supplement my choline-rich diet with powdered choline bitartrate. Thanks for any answers.

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Choline important. Fortification dangerous.

Posted by Dr Ben Lynch,

While I wholeheartedly agree with the overall tone of this article, emphasizing the importance of choline in the diet, I absolutely disagree with suggesting fortifying foods with choline.

Folic acid fortification has been a nightmare and continues to be so. Neural tube defects have reduced in some areas due to folic acid fortification; however, folic acid itself is the inferior form of folate. What is really needed is L-5-MTHF also known as methylfolate.

If the government begins fortifying foods with choline, they no doubt will use GMO soy derived choline which will do more harm than good.

Also - some populations get plenty of choline and higher amounts may lead to issues like higher acetylcholine levels.

All for eating natural, healthy forms of choline. Teach this to the public - do not fortify foods.

Getting rid of farm subsidies would also help...

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