The importance of choline in pregnancy

Pregnancy

The importance of ensuring adequate choline intake during pregnancy is increasingly recognised. We now know that choline in pregnancy is a critical player in several physiological processes during the prenatal period, as well as the fourth trimester.

The physiological demands for choline increase in pregnancy because it is the precursor for several biomolecules that we need considerably more of:

Acetylcholine – regulates many aspects of early brain development and supports attentional function.
Phosphatidylcholine – a major component of cell membranes in the brain, gut and mitochondria.
Sphingomyelin – the primary constituent of myelin which coats nerve cells and supports rapid cell growth.
Betaine – a methyl donor that has shown lifelong effects on gene expression and is shown to lower homocysteine levels in the blood, which could reduce the incidence of cardiovascular disease and other chronic diseases due to homocysteine’s damaging effect on arterial walls.

What research is there for choline in pregnancy?

As with all research it starts with the rodents! There is over 40 years of research into the effects of maternal choline for the development of their offspring’s cognitive function. Some studies naturally show no clinically significant findings but there is a large body of evidence that supports the benefit of higher levels of choline intake in pregnancy and early life to improve attention and spatial memory in early, adolescent years and thereafter.

Moreover, high choline diets appear to be broadly neuroprotective in offspring born with autism, epileptic predisposition, and down syndrome. It is shown across numerous studies to reduce the detrimental cognitive burden of these disease states.

Human studies on the effects of choline in pregnancy are still slightly limited. However, two randomised controlled studies support a positive correlation between elevated levels of placental cord plasma levels or greater estimated prenatal choline consumption and an increase in a child’s performance on cognitive testing. This is supported by a further two controlled studies showing an increase on an infant’s attention and orienting speed.

By far the most comprehensive however is a recent study out of Cornell University. It is one of the few controlled group studies conducted on humans that showed a clear correlation between the cognitive benefits for children born to mothers who received approximately double (930mg/day) the recommended daily intake of choline in their third trimester compared to those mothers randomised to a dose of 480mg/day.

It followed the babies through to the age of seven where it was showed that the offspring of mothers receiving 930mg choline/day in the third trimester showed a superior performance on the study’s primary endpoint (p=0.02) and a superior ability to maintain correct signal detections across the 12 minute test sessions (p=0.02) in comparison to the offspring of mothers receiving 480mg of choline/day. Find more details of this study here.

This study, albeit it one of few and with a smaller population size than you would ideally want, does suggest that at present pregnant women are advised to consume approximately 70% of the amount of choline that has shown to have an increased and positive effect on a child’s cognition and focus-begging the question, do our recommended guidelines needs to change in light of advancing evidence?

How to increase the amount of choline we take in

We are human and we developed through the nutrition found in our foods first and foremost. Therefore, I have included a table of the foods that contain some of the highest values of choline below. These numbers are taken from the US database of the National Institute for Health as it was difficult to find the UK/European equivalent, therefore numbers may vary slightly but are still a great reference guide.

Given that we have shown that values as high as 930mg of choline/day in the third and fourth trimester have beneficial effects in long-term cognitive health for the growing fetus, it may be necessary for most to supplement with some additional choline, especially those following a vegetarian or vegan diet.

Table 1 – Choline doses (mg) per serving of certain food groups (13).

It's never too late

Women recruited during lactation were also split to 480mg of choline/day vs. 930mg/day. Again it was found that women allocated to the 930mg of choline/day expressed milk with higher choline quantities, beneficial to an infants rapidly developing brain. The effects may be small and there is only one study where this has been tested at present but given very limited side effects of choline supplementation, the benefits appear to outweigh any negatives. At present the recommended intake during lactation is 550mg choline/day (14).

Further study of adults showed potential cognitive benefits and protective effects of increased choline consumption in later age, be it through food or a combination of food and supplements. A positive correlation was found between elevated choline serum levels and decreased brain atrophy and white matter hypersensitivity, two hallmarks of Alzheimer’s disease and memory loss. To note, the upper range of choline found in serum of participants was below the recommended daily intake of 425mg for women and 550mg for men and yet there was still clinical significance (p=0.01).

Are there negative effects of choline in pregnancy?

Choline supplementation is well-tolerated and unlikely to cause harm. Mild adverse effects, such as hypotension, body odour and nausea are only encountered at concentrations more than a magnitude higher than recommended intake levels (>7.5g/day).

Key points about choline in pregnancy

Choline can be synthesised in the body, but not enough to support the needs of a growing life. At present, women are advised to ensure an intake of 450mg of choline per day, increasing to 550mg per day if breastfeeding. This is best obtained through a balanced, healthy diet with oral supplementation if required.
Choline is shown to help reduce neural tube defects, and support the healthy growth of the placenta.
More research is required but studies in both rodent and human populations show long-term, positive effects on cognition in offspring born to mothers with higher choline in their diet.
Choline is also shown to be neuroprotective in conditions that can predispose a child to decreased cognition in later life, as seen in rodent models in autism, epileptics and downs syndrome. This research is yet to be extended to a human population.
A dosing of 930mg of choline in the third and fourth trimester shows positive effects on offspring in humans and rodents, with limited negative outcomes, none of which detrimental long-term to fetus or mother.

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