Choline must be integrated into the prenatal supplement regimen, says expert review

A new expert review published in the Journal of Dietary Supplements​ calls choline the “neurocognitive essential nutrient of interest to obstetricians and gynecologists”​, and states unequivocally that “Choline must be integrated into the prenatal supplement regimen”​.

But intakes remain stubbornly low: According to National Health and Nutrition Examination Survey (NHANES) data, 90% of children, adults and pregnant women are not getting enough. The Adequate Intake (AI) for adults is 425 mg/day for women and 550 mg/day of choline for men.

For pregnant women this is a very serious issue, given choline’s importance for the neurodevelopment of the infant. (Recommendations increase to 450 mg for pregnant women and 550 mg for breastfeeding women.)

According to the new review, led by Dr Taylor Wallace from D.C.-based Think Healthy Group, choline has ranked last among common nutrients to recommend for a healthy diet, and fewer than 6% of obstetricians and gynecologists are likely to recommend choline-rich foods to pregnant women.

Prenatal supplements​

Dietary supplements may offer a way to help close this shortfall, but historically very few (if any) prenatal multivitamins were formulated to contain choline.

One of the challenges has been around working with choline - forms like choline bitartrate and choline citrate are hygroscopic – but the biggest hurdle to formulating with meaningful choline doses is finding room in a tablet format that has a broad range of nutrients all competing for space, explained Tom Druke, Director of VitaCholine​​ Brand Development, Balchem Human Nutrition and Pharma.

 “Choline bitartrate is about 40% choline cation by weight and this means that adding a meaningful amount of choline can be a challenge in a single dose,” ​he explained. “To help address this challenge, many companies are formulating a single-ingredient tablet with choline – this approach allows for a standard prenatal multivitamin plus choline in a separate dose, much like the industry did with DHA.”​

The American Medical Association (AMA) recognized the essential role of choline during pregnancy a couple of years ago and proactively recommended that choline be included in all prenatal multivitamins.

A 2016 study found that only eight of the top 25 prenatal vitamins contain choline and none provide more than 55mg per daily dose, or just 12% of the DRI for pregnant women, he said.    

That, thankfully, is now changing.

“It generally takes a little time for brands to reformulate vitamins, but we’ve heard of several who have completed reformulations or are actively working on it,”​ said Druke. “MegaFoods introduced a Baby and Me 2 prenatal​ formulated by Dr. Tierona Low Dog with 300mg of choline.  Also, Nature Made launched a new prenatal gummy SKU with choline​, and SmartyPants has increased the choline levels in their gummy line ​as well."​

There’s also pick-up in the dairy space, he said, with Brainiac fortified yogurt for kids launching earlier in the year with choline, DHA and probiotics for brain health.  Clover Sonoma dairy farm announced at Expo West they would be launching a new fortified organic milk with 50mg of DHA and 100mg of choline.

“Clearly manufacturers are beginning to recognize the potential that choline offers, not only for infant development but also for cognition throughout life,” ​said Druke.

Advocacy​

Building awareness around choline, and educating the healthcare practitioner community is an important issue here.

“Advocacy for choline levels awareness from the medical community intensified in early 2018 with an important policy statement from the American Academy of Pediatrics published in the journal Pediatrics outlining the importance of proper nutrition during the first 1,000 days of life,” ​said Druke. “Choline was noted as one of several substances that this leading medical institution specifically called out as ‘brain-building nutrients’.”​

Druke noted that government agencies are taking action to further the standing of choline in the nutritional field. 

“Choline is the latest nutrient to receive a Reference Daily Intake (RDI) and the Scientific Report of the 2015 Dietary Guidelines for Americans Committee (DGAC) called out choline as one of four ‘shortfall nutrients’ with inadequate intakes across all adult dietary patterns,” ​he said.

“As part of the recent revisions to nutrition labeling, the U.S. Food and Drug Administration (FDA) established 550mg as the RDI for choline for adults, providing for an associated percent Daily Value (% DV) on both Nutrition Facts and Supplement Facts panels as part of the revisions to nutrition labeling.  ​

“We think the 2020 DGA offers the opportunity to introduce choline to Americans as an under-consumed yet important nutrient.”​

Testing ​

It may also be getting easier for people to check their choline levels, added Druke, noting that a significant grant was awarded to UNC Nutrition Research Institute in 2018 to develop and validate laboratory tests able to assess choline status in humans.

“The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), one of the National Institutes of Health, awarded UNC director Steven Zeisel, MD, PhD [one of the authors on the new review] a four-year, $2.6 million grant after he demonstrated that the studies were feasible and likely to succeed based upon proof-of-concept data in a pilot study funded by Balchem Corporation,” ​said Druke.  

Source: Journal of Dietary Supplements​​
Published online ahead of print, doi: 10.1080/19390211.2019.1639875​
“Choline: The Neurocognitive Essential Nutrient of Interest to Obstetricians and Gynecologists”​
Authors: T.C. Wallace, et al.