During a satellite symposium* at the 13th Congress of the European Society of Gynecology, a group of scientific leaders and experts, chaired by Professor Marie Caudill, PhD, RD from Cornell University/ Division of Nutritional Sciences, gathered to discuss the overlooked importance of choline during the pre- and postnatal period.
Whilst choline was recognised as an ‘essential nutrient in 1998’ (1) and despite the fact that the European Food Safety Authority, the American Medical Association, and the American Academy of Pediatrics have highlighted its importance during pregnancy and breast-feeding (2,3,4), this recent progress has not been translated in concrete recommendations in Europe. Specifically, there was no further guideline or recommendation shared by European gynaecologist or paediatrician associations with regards to choline intake for pregnant and breastfeeding women.
This lack of guidance is a true problem. Given the low public awareness of choline’s benefits, expectant mothers and lactating women need advice from their health advisors to appreciate the importance of choline and consider eating choline rich food.
Did you know? Large amounts of choline are delivered from the mother to the fetus. The choline concentration in the placenta is 50 times higher compared to the maternal choline blood concentration. (5)
What is choline?
Choline is an important vitamin-like nutrient required for normal bodily function. Choline can be synthesized de novo in humans, but this may become insufficient to meet the body’s needs, meaning that dietary choline is getting essential3- meat, eggs, fish and milk are particularly good sources of choline (6).
Did you know? Additionally to choline acquired through diet, supplementation is recommended in some cases: the American Medical Association announced in 2017 that prenatal vitamin supplements should contain ‘evidenced-based’ amounts of choline.
The science around choline benefits
Choline plays an important role in cell membrane structure and function3, nerve fibre myelination (5), homocysteine metabolism (7) and neurotransmission (8). More recently, evidence has suggested that choline is of great importance during pregnancy. Even modest increases in maternal choline intake during pregnancy may produce cognitive benefits to the offspring.(9)
Further benefits of choline, suggested by research, include reduced risk of some pregnancy complications: the role of folic acid in preventing neural tube defects (NTD) (10) and other birth defects (11) is well established. Findings from clinical studies indicate that supplementing choline may: improve placental angiogenesis and mitigate some of the pathological antecedents of preeclampsia (12) and play an important role in baby’s stress response by decreasing the expression of a placental stress-related hormone (13).
Choline’s benefits may go beyond improving some pregnancy outcomes. Choline may also play an important role in determining future lasting health effects through epigenetic mechanisms that modify gene expression without modifying the genetic code (14) and they are characterised by the ‘switching on and off’ of genes by environmental factors, such as maternal nutritional and lifestyle (e.g. stress, smoking, etc.) (15).
According to Prof. Rima Obeid, BSc, PhD, Saarland University Hospital (DE), presenting during the satellite symposium, “The epigenetic fingerprint of the growing fetus is maintained for many years after birth. Maternal intake of dietary methyl donors like choline has been linked to foetal growth, placental function, and liver and brain function via several mechanisms including epigenetics.”
Educating healthcare professionals about the importance of choline during critical period
With strong evidence supporting the benefits of choline in pregnant and lactating women, experts insist that now is the time that choline should be given prominence for pregnant women.
Dr. Emma Derbyshire, BSc, PhD, RNutr (Public Health), Nutritional Insight Ltd. (UK) shared her insights regarding the forgotten yet crucial nutrient for women during the satellite symposium and confirmed the need to act with urgency: “Although choline is likened to an ‘essential nutrient’, it is generally under consumed in Europe. Especially pregnant and lactating women have much higher needs than the general population. Although the EFSA makes recommendations regarding dietary choline intake, this is not widely known in Europe. The current choline situation needs to be addressed.”
1) Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes and its Panel on Folate OBV, and Choline. Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington (DC): National Academies Press (US); 1998
2) Berg S. AMA Wire. 2017 AMA backs global health experts in calling infertility a disease. https://wire.ama-assn.org/ama-news/amabacks-global-health-experts-calling-infertility-disease
3) European Food Safety Authority (EFSA). 2016 Scientific Opinion on Dietary Reference Values for Choline. EFSA Journal. 14(8):4484-4554
4) Schwarzenberg SJ, Georgieff MK. Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics. 2018;141(2)
5) Caudill MA. 2010 Pre and postnatal health; Evidence of increased choline need. J Am Diet Assoc. 110:1198-1206US National
6) US National Institutes of Health, Fact Sheet on Choline for Health Professionals, July 2019. https://ods.od.nih.gov/factsheets/CholineHealthProfessional/.
7) Zeisel SH. 2006 Choline: Critical Role during Fetal Development and Dietary Requirements in Adults. Annu Rev Nutr. 26: 229–250
8) McCorry LK. Physiology of the autonomic nervous system. American journal of pharmaceutical education. 2007;71(4):78.
9) Caudill MA, Strupp BJ, Muscalu L, Nevins JEH, Canfield RL. Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study. FASEB journal : official publication of the Federation of American Societies for Experimental Biology. 2018;32(4):2172-80.
10) Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Folic Acid Supplementation for the Prevention of Neural Tube Defects: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(2):183-189.
11) Liu S, Joseph KS, Luo W, et al. Effect of folic acid food fortification in Canada on congenital heart disease subtypes. Circulation 2016;134:647-55
12) Feng Y, Wang S, Chen R, Tong X, Wu Z, Mo X. Maternal folic acid supplementation and the risk of congenital heart defects in offspring: a meta-analysis of epidemiological observational studies. Sci Rep. 2015;5:8506.
13) Jiang X, Yan J, West AA, et al. Maternal choline intake alters the epigenetic state of fetal cortisol-regulating genes in humans. FASEB J. 2012;26(8):3563-74.
14) Zeisel SH. 2017 Choline, Other Methyl-Donors and Epigenetics. Nutrients. 9(5):445
15) Zeisel, S.H. Epigenetic mechanisms for nutrition determinants of later health outcomes. Am. J. Clin. Nutr. 2009, 89, 1488S–1493S