PREGNANCY

Choline—The Critical Prenatal Nutrient You’ve Never Heard of

by: Alejandra Carrasco, M.D. and Christine Maren, D.O.

by: Alejandra Carrasco, M.D. and Christine Maren, D.O.

Physician founders of Hey mami!

Hey Mami, we know that you are going to go to great lengths to ensure you’re providing the best for your baby, even before he or she is born.

You research, find the right doctor, eat the right foods, avoid what you should, and take the right supplements.

With all this information at our fingertips, would you believe there is a nutrient critical to both mother and child, with long-term scientific credibility, that most mothers (and even their doctors) have never heard of?

That Critical Nutrient is Choline

Our bodies produce some choline, but not enough; common foods contain it, yet much of the population still doesn’t obtain ample amounts.

In fact, 90%–95% of pregnant women consume less choline than necessary.1

But there’s no need to fret! We’re here to keep you informed and provide you with trustworthy, straightforward solutions to support a healthy mami and baby. So, let’s talk choline.

What is Choline?

Choline is an essential micronutrient.2 It wasn’t until the late 1990’s that the Institute of Medicine decided it should be considered “essential”, meaning it must be obtained from the diet because the body can’t make sufficient quantities.

This nutrient enables a wide range of functions and is particularly critical during pregnancy.

What is Choline’s Role During Pregnancy?

A component in numerous processes, choline is central to several, including:

  • Cell membrane integrity
  • Methylation and prevention of neural tube defects
  • Normalization of homocysteine levels and a decrease in adverse pregnancy events
  • Liver and gallbladder health
  • Neurotransmitter functions, memory and sleep
  • Mood and mental health
  • Placental function

Let’s dive into each of these really important roles one by one…

1. Choline is important for cell membrane integrity

Choline is a primary component of the phospholipids which make up the membrane that surrounds every single one of our cells.3 These membranes both protect cells and regulate transport of molecules in and out of them.4

The health and integrity of the cell membrane helps ensure it performs its functions effectively and helps make it resistant to damage.

During pregnancy we are making a whole lot of new cells!

2. Choline supports methylation and decreases neural tube defects

Methylation is a process in the body that produces methyl groups (CH3). Methyl groups are central to a vast number of biochemical reactions which are especially important during pregnancy.

DNA methylation is an action that changes how a gene expresses itself (not the genetic sequence itself). Methylation patterns can be affected throughout life but are constantly in flux during fetal development, and significantly impact reproductive, neurological, and detoxification systems.

Choline, along with folate, plays a critical role in methylation.

In fact, similar to folate, choline plays an important role in preventing neural tube defects (NTDs). Evidence indicates that lower choline levels in mid-pregnancy are associated with an increased risk of NTDs.5,6

Ensuring you get enough choline while you’re pregnant (we’ll talk about how, later) can lend itself to positive lifelong benefits for your child.7

3. Choline helps to normalize homocysteine levels to support a healthy pregnancy

An elevated maternal homocysteine level is a risk factor for several adverse pregnancy events, including preeclampsia, prematurity and very low birth weight.8

Most studies have found an inverse relationship between homocysteine and maternal choline levels. At least one study shows a positive association between maternal choline and total homocysteine during pregnancy, which suggests that high fetal demand for choline increases homocysteine.

9 This supports the use of choline supplementation during pregnancy to help address elevated homocysteine levels.

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4. Choline supports liver and gallbladder health

The liver plays a major role in all metabolic processes. In lipid (fat) metabolism, the liver breaks down fats to be used for absorption of fat-soluble nutrients, to create myelin sheath (the protective covering of your nerves) and to produce energy. Let’s put our nutritional fats to good use!

Choline is phosphorylated to make phosphatidylcholine, which helps move those fats out of the liver and into circulation so it can accomplish its tasks.10

Phosphatidylcholine is also a key component of bile, which is a big deal! Bile not only helps your body absorb fats, it also acts as an antimicrobial in your gut, and helps you detoxify chemicals.11

An insufficient amount of choline, on the other hand, can result in fat and cholesterol buildup in the liver — which can manifest as pain, nausea, fatigue, and toxic overload. This can show up as gallbladder disease in pregnancy,12 and nonalcoholic fatty liver disease (NAFLD).13 In fact, pregnancy in itself is considered a risk factor for gallbladder disease,14 and acute cholecystitis is the second most common non-obstetrical indication for surgery in pregnant women!15

The importance of sufficient lipid metabolism and transport cannot be overstated here.

5. Choline improves neurotransmitter functions, memory and sleep

Choline is a precursor to the neurotransmitter acetylcholine. Acetylcholine is the most abundant neurotransmitter in the body and is responsible for sending and receiving messages within the nervous system.

Acetylcholine has a huge impact on the development and function of the nervous system.

It is key in brain and spinal cord development, learning, cognitive function, focus, and memory. It has even been shown to protect against premature memory decline16…an especially important protective mechanism for new mamis experiencing the phenomenon known as: mommy-brain.

This chemical messenger also plays a role in the signaling of muscle movement, the sensation of pain, and is released in notably higher amounts during the REM (rapid eye movement) cycle of sleep, when the brain is very active.17

6. Choline supports mood and mental health

Choline is important for optimal brain development.  Some evidence suggests that when a sufficient amount of choline is obtained while in-utero and in infancy, a person is less likely to struggle with mental health issues years down the line.18

Conversely, reduced choline levels have been linked to a higher risk of anxiety.19

7. Choline is important for a healthy placenta

Choline is even important for making a healthy placenta in pregnant women.20

In fact, adequate choline improves the vascular (blood flow) function of the placenta, and supplementing mami’s diet with extra choline may decrease the risk of preeclampsia.21

Higher intake of choline can also affect the expression of placental cortisol-regulating genes — this is key to maternal and fetal stress responses, and plays a role in the development of baby’s hypothalamic-pituitary-adrenal (HPA) axis!22

How Much Choline Do You Need During Pregnancy?

Your need for choline increases during pregnancy and lactation because a great deal is passed on through the placenta for baby’s development.23

In fact, choline concentration in amniotic fluid is tenfold greater than that present in maternal blood. 

When available, all needed nourishment goes to baby first, so mami must ensure she gets what she needs, too.24 In fact, 90-95% of pregnant women are deficient in this important nutrient.25

Adequate intake of choline during pregnancy is defined as 450mg a day, which increases to 550mg a day during lactation26. Note that this is the bare minimum necessary.

And certain women need even more, especially those with mutations (SNPs) of the PEMT gene27 (you can learn more about this by testing your nutrigenomics). If you have a variation in PEMT, your need for dietary choline is even greater (especially if you also have variants in MTHFR).

Lab measurement of homocysteine is also an important marker to follow, and can be measured by a simple blood draw. While it is not specific to choline, there is an inverse association between choline levels and homocysteine (meaning, a high homocysteine may indicate a less than optimal level of choline).28

Who knew such an unassuming, under-acknowledged nutrient could have such a big impact?!

So what can you do?

Food sources of choline

There’s some good news and some bad news on this front.

Fortunately, choline can readily be found in several foods.

Unfortunately one of the foods with the greatest choline content is (prepare yourself)…liver. Just what you want to chow down on when you’re pregnant and nauseous, right?

Maybe not.

So what’s next, you might ask?

Choline is most abundant in animal-based foods, especially egg yolk. In fact, eggs are the most concentrated source of choline in the American diet, providing about 125 mg per large egg.29 It’s also found in smaller amounts in meat, poultry, fish, shellfish, and dairy.30

Some plant-based considerations in much lower concentrations are quinoa, toasted wheat germ, cauliflower, almonds, peanut butter and peas.31

Foods high in betaine (also known as trimethyglycine, or TMG) – like beets and spinach – may also be helpful because they can lower choline requirements by bypassing a step in the methylation cycle.32

Whenever feasible, we encourage mamis to get as much of their nutrient requirements from food; however, it’s not always enough (especially if you’re avoiding eggs due to a sensitivity, allergy, dietary or lifestyle preference).

Choline Supplementation While Pregnant

As well-rounded as your diet may be, a high-quality prenatal vitamin should be a staple to fill in any gaps.

In 2017, the American Medical Association voted to increase choline levels in all prenatal vitamins33 stating:

“Adequate levels of choline—an important nutrient that helps a baby’s brain and spinal cord to develop properly—are necessary to maintain normal pregnancy including neural development of the fetus and reducing the incidence of birth defects. Inadequate choline levels during pregnancy are thought to negatively affect cognitive development. Neural tube and hippocampus development also are dependent on adequate choline intake.”

Surprisingly, despite the clear need, prenatals often contain little to no choline (for reals)!34,35…even the most trusted pharmaceutical grade brands. And play close attention to dose here!

Our favorite prenatal uses a mix of Trimethylglycine (TMG) and choline to meet the need for methyl groups in pregnancy.

In our clinical practices, we sometimes add an additional choline supplement depending on patient needs.

What This Means for You

An ample intake of choline is a must for you and your baby. Most people are not getting an optimal amount, and pregnant mamis have a greater need than most.

Make it a priority to increase high-choline foods, check the labels on your current prenatal supplements, and if it seems you’re still not getting enough choline, talk with your practitioner about adding a choline supplement or switching to our favorite prenatal.

And help us spread the word by sharing this article. The more women we can reach with this information, the healthier the next generation will be.

References:

  1. https://www.ncbi.nlm.nih.gov/pubmed/24476840?dopt=Abstract
  2. https://www.ncbi.nlm.nih.gov/pubmed/19906248
  3. https://www.ncbi.nlm.nih.gov/pubmed/16636297
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2441939/
  5. https://www.ncbi.nlm.nih.gov/pubmed/19593156?dopt=Abstract
  6. https://academic.oup.com/aje/article/160/2/102/76495
  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297118/
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782876/#R22
  9. https://www.ncbi.nlm.nih.gov/pubmed/16210714
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113756/
  11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113756/
  12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3394590/
  13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639110/
  14. https://www.ncbi.nlm.nih.gov/pubmed/24002766
  15. https://www.ncbi.nlm.nih.gov/pubmed?term=28881393
  16. hhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3026477/
  17. https://www.ncbi.nlm.nih.gov/pubmed/11208592
  18. https://www.ncbi.nlm.nih.gov/pubmed/27651265
  19. https://academic.oup.com/ajcn/article/90/4/1056/4596992
  20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639110/
  21. https://www.fasebj.org/doi/abs/10.1096/fj.12-221648
  22. https://www.fasebj.org/doi/abs/10.1096/fj.12-207894
  23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639110/
  24. https://www.ncbi.nlm.nih.gov/pubmed/23637565
  25. https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/
  26. https://www.ncbi.nlm.nih.gov/books/NBK114308/#ch12.s53
  27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782876/
  28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782876/
  29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782876/
  30. https://ndb.nal.usda.gov/ndb/nutrients/report/nutrientsfrm?max=25&offset=0&totCount=0&nutrient1=421&nutrient2=&nutrient3=&subset=0&fg=&sort=c&measureby=m
  31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782876/
  32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798916/
  33. https://www.ama-assn.org/delivering-care/public-health/ama-backs-global-health-experts-calling-infertility-disease
  34. https://www.ncbi.nlm.nih.gov/pubmed/20656095?dopt=Abstract
  35. https://clinmedjournals.org/articles/jfmdp/journal-of-family-medicine-and-disease-prevention-jfmdp-2-048.pdf

Our Bio

We are doctors Alejandra Carrasco M.D. and Christine Maren D.O. We’re board-certified through the American Board of Family Medicine, and certified in functional medicine through the Institute for Functional Medicine. We’re on a mission to support women as they navigate mamihood—from preconception through pregnancy, postpartum, and beyond. As mamis of 3 (each!), we got you.

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