Continuing Education Elevating Awareness and Intake of Choline An Essential Nutrient for Public Health Marie Caudill, PhD, RD Steven Zeisel, MD, PhD Kerry-Ann da Costa, PhD Betsy Hornick, MS, RD Emerging science has revealed that choline plays important Choline is the newest roles in health throughout the life cycle with potentially essential nutrient. serious health consequences associated with inadequate choline intakes. Recent national consumption data indicate that the vast majority of Americans are falling short of recommended intakes. Increased education, including In 2009, the Choline Science Summit was held in Washington, District of Columbia, bringing together recommendations to consume more choline-rich foods, prominent scientists and researchers along with nutrition is needed to improve choline intakes for optimal health. leaders from organizations including the American Nutr Today. 2011;46(5):235–241 College of Obstetricians and Gynecologists, American Dietetic Association, American Society for Nutrition, International Life Sciences Institute, National WIC Association, and US Department of Agriculture (USDA). holine was discovered as a vitamin in 1862, The symposium addressed the latest science on choline but it was more than a century later that it and gathered insights for helping raise awareness Cwas recognized as an essential nutrient. It was and intake of this essential nutrient, especially among officially recognized as an essential nutrient by the vulnerable populations. It included discussions of Institute of Medicine (IOM) in 1998, and an adequate choline’s critical role in human health and development intake (AI) was established based on estimated throughout the life cycle, the role of genetics in dietary intakes and studies reporting liver damage determining choline requirements, and a closer look with lower choline intakes.1 Choline is essential for at the gaps in choline requirements compared with liver and brain function, lipid metabolism, and for actual intakes. Participants also discussed strategies cellular membrane composition and repair.2 Recent for communicating choline recommendations and advances in the science and understanding of choline including choline in future public health education reveal that it plays a critical role in human health efforts. and development throughout the entire life cycle, A consensus was reached that choline deserves greater beginning with fetal brain and spinal cord recognition in nutrition guidance and public education. development.2,3 Participants agreed that a choline recommendation for Choline was not addressed in the 2005 Dietary special populations, specifically women who are of Guidelines for Americans because consumption childbearing age, pregnant, or lactating, is warranted, data were lacking. However, the development of a and the dietary reference intake for choline should database of the choline content of foods now makes be reevaluated. In addition, they recognized that it possible to evaluate the choline content of diets.4 education among health professionals and consumers At the fourth meeting of the 2010 Dietary Guidelines is needed to elevate awareness of the important Advisory Committee, choline was proposed as a roles of choline and increase intake of this essential shortfall nutrient for certain subgroups.5 However, choline nutrient. The highlights of the Choline Science was not designated as a nutrient of concern in the 2010 Summit, including call-to-action conclusions, are Dietary Guidelines. presented here. Nutrition TodayA, Vo lu me 4 6 Number 5 September/October, 2011 235 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Continuing Education Elevating Awareness and Intake of Choline Choline in the Diet Table 2. Dietary Reference Intakes for Choline Choline is often grouped with the vitamin B complex. Life Stage Group Adequate Intake, mg/d It is available in the diet as free choline, a water-soluble Y form, or it may be bound as fat-soluble esters, such 0 6 mo 125 7Y12 mo 150 as phosphatidylcholine, or sphingomyelin. Although the Y human body can produce a limited supply of choline, 1 3 y 200 4Y8 y 250 consuming choline-rich foods is necessary to meet the Y body’s requirements. 9 13 y 375 Females Choline is found in a wide variety of foods; liver, Y eggs, beef, and pork are among the richest sources. One 14 18 y 400 19Y70+ y 425 Pregnancy 450 Table 1. Selected Food Sources of Choline Lactation 550 Males Choline, 14Y70+ y 550 Food mg/Serving 1 Beef, liver, cooked (3 oz) 355 Source: Food and Nutrition Board, Institute of Medicine. Egg, whole, raw, fresh (1 large) 125 Beef steak, bottom round, cooked (3 oz) 111 egg supplies 125 mg of choline, about one-third to Pork, loin chop, cooked (3 oz) 94 one-half of the daily recommendation.6 Other sources Salmon, chinook, smoked (3 oz) 76 of choline include poultry, salmon, wheat germ, milk, Chicken, breast, cooked (3 oz) 73 nuts, legumes, and some vegetables (Table 1). Data Beef, ground, 85% lean, cooked (3 oz) 70 from the Nurses’ Health Study found animal products, Turkey, light meat, roasted (3 oz) 70 including eggs, milk, chicken, beef, and pork, to be the Salmon, sockeye, cooked (3 oz) 56 largest sources of choline in the diet.7 Choline is Wheat germ, toasted, plain (2 tbsp) 50 available in supplement form, but many multivitamins Milk, 1% low fat, with added vitamins A 43 and prenatal vitamins do not currently contain choline. and D (1 cup) Baked beans, canned (½ cup) 40 Pork, Canadian-style bacon (2 slices) 37 Choline Intake Versus Requirements Lima beans, cooked, boiled, 33 Based on estimated dietary intakes and studies reporting drained (½ cup) liver damage with lower choline intakes, the IOM set the Yogurt, low fat, fruited (8 oz) 32 AI for choline at 425 mg/d for women 19 years or older, Broccoli, cooked, boiled, drained (½ cup) 31 450 mg/d for pregnant women, and 550 mg/d for lactating Potato, baked, flesh and skin (1) 30 women and for men 19 years or older (Table 2).1 Evidence Cauliflower, cooked, boiled (½ cup) 24 was insufficient to set an estimated average requirement Tomato sauce, canned (1 cup) 24 (EAR) and recommended dietary allowance (RDA). Thus, Peas, green, frozen, cooked, 22 the AI serves as a goal for choline intake of individuals, drained (½ cup) and intakes less than this level will not necessarily result Pistachios, dry roasted (1 oz) 20 in deficiency. Bacon, pork, cured, cooked (2 pieces) 20 Peanut butter, creamy (2 tbsp) 20 Corn, sweet, cooked (½ cup) 18 Almonds (1 oz) 15 Increased choline requirements due Frankfurter, beef (1) 15 Pecans (1 oz) 12 to genetic variations are more Banana, raw (1) 12 common than we previously thought. Barley, pearled, cooked (½ cup) 10 Source: US Department of Agriculture Database for the Choline Content of Common Foods, Release 2,4 and US Department of Agriculture 6 National Nutrient Database for Standard Reference, Release 22. These When the AI was established in 1998, it was assumed values may vary slightly depending on the method of processing and preparation. that less than 5% of the population was affected by genetic differences that may result in increased choline 236 Nutrition TodayA, Volume 46 Number 5 September/October, 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Elevating Awareness and Intake of Choline Continuing Education requirements. However, recent research examining Choline in Human Health common variations in genes involved in choline metabolism reveals that a significant proportion of the population Choline’s role in human health begins prenatally carries genetic variants that may increase their requirement and extends into adulthood and old age. Its functions for choline above current recommendations.8,9 Based on this are complex and include neurotransmitter synthesis research, it has been proposed that as much as 50% of the (acetylcholine), cell-membrane signaling (phospholipids), population may have genetic variations that increase their lipid transport (lipoproteins), and methyl-group metabolism 2 choline requirements above current recommendations.9,10 (homocysteine conversion to methionine). In humans, In 2004, a USDA Special Interest Database for choline in dietary deficiency of choline results in liver and muscle foods was created to provide researchers and consumers damage. A more detailed review of choline’s wide-ranging with the means to estimate choline intake; a second roles in human health is published elsewhere.2,3 The release of the database in 2008 provides data for more following overview of key research presented at the summit than 630 foods.4 The database contains values for total emphasizes the role of choline across the life cycle. choline and 6 metabolites of choline: betaine, free choline, glycerophosphocholine, phosphocholine, Pregnancy and Lactation phosphatidylcholine, and sphingomyelin. In 2005, total Demand for choline is especially high during pregnancy choline was included for the first time in the dietary intake 12 and lactation. Recent evidence suggests that pregnancy data collected by ‘‘What We Eat in America’’ (National and lactation present specific windows of opportunity in Health and Nutrition Examination Survey). This survey which adequate choline intake may help improve data revealed that only 10% of individuals had intakes pregnancy outcomes and promote lifelong beneficial at or greater than their AI for choline (A. Moshfegh, 13Y15 effects on memory and learning.