There are a lot of nutrients that (rightfully) get extra attention in pregnancy, like iron and folate, but what about the nutrients that don’t get their time in the spotlight? The ones that are not discussed at the doctor’s office, not mentioned in that flimsy pamphlet on prenatal nutrition, and not included in most prenatal vitamins?
This is why I do the work that I do. I aim to highlight the oft forgotten—but equally important—nutrients that deserve our undivided attention and where we find them in real food. If we’re not careful and not specifically including nutrient-dense foods in the diet, these are the very nutrients we can easily miss out on.
I’m a broken record speaking out on the ways in which our prenatal nutrition guidelines can be improved. One such nutrient that needs to be revisted is choline, for which I coined the nickname “folate’s long lost cousin.”
Choline in Pregnancy: Folate’s Long Lost Cousin
Choline is in the B vitamin family, even though it lacks a number next to its name (it’s just “choline,” not vitamin B-85 or B-24) because it was named long after the rest of the B vitamins were discovered. Or who knows? Maybe B vitamin researchers got tired of assigning numerical nicknames?
Choline is involved in many of the same metabolic pathways as folate, including methylation. Everyone knows folate — or its synthetic supplemental version, folic acid — due to its vital role in the prevention of neural tube defects (for the sake of accuracy, folate is far superior to folic acid; more on that in this in-depth article on folate).
Did you know choline is equally as important as folate for preventing neural tube defects?!
Most people don’t. Not most mothers. Not most doctors. Not even most dietitians/nutritionists.
I’ve spoken at dozens of medical conferences and anytime I’m presenting on prenatal nutrition or breastfeeding nutrition, I make sure to include a slide or two on choline. I also ask the audience before I get into the details “How many of you are familiar with the nutrient choline?” Without fail, most people don’t raise their hands. What a tragedy.
This is precisely why I’m such a broken record on the benefits of choline in pregnancy.
Why is no one talking about choline?
The major reason choline is not making headlines in prenatal nutrition is that it’s a new kid on the block, relatively speaking. The first time we had a recommended intake for choline was 1998. The data used to set that recommendation was fairly weak; it was set based on a depletion-repletion study conducted in adult men & set at a minimum level to prevent liver damage. These figures were then adjusted upwards for pregnancy/lactation based on estimates of fetal needs. (In other words, the current recommendations for pregnancy are a SWAG—scientific wild ass guess.)
This also means any medical/nutrition professionals trained before or shortly after 1998 likely didn’t get much information (or any) on choline.
Specifically in the prenatal nutrition field, the past 20-ish years of research has revealed some striking data. Our guidelines are FAR overdue for an update.
This is not just my opinion. This is the opinion of choline researchers:
“The dietary requirement for choline has not been revisited by NAM [Food and Nutrition Board of the National Academy of Medicine] since 1998, despite a growing body of scientific literature. There is a need for dose-response studies across various populations to inform revision of the current Dietary Reference Intakes (DRIs) to include an EAR and RDA, so that accurate assessment of the amounts of individuals who are inadequate can be determined.” (Nutrition Today, 2018)
[By the way, I’ve heard from current dietetics students that choline is now more extensively discussed in their classes and textbooks—hallelujah!]
Data on the Benefits of Choline in Pregnancy
In short, the data is STRONG on the benefits of choline in regards to pregnancy health & brain development.
One review on choline concluded:
“High choline intake during gestation and early postnatal period has been repeatedly described as a robust cognitive enhancing regimen and is neuroprotective in a variety of animal models of neuronal damage. Data showing that maternal choline supply during pregnancy modifies fetal DNA and histone methylation suggest that a concerted epigenomic mechanism contributes to these long-term effects of varied choline intake in utero.” (Clin Chem Lab Med, 2013)
But it’s not just animal studies that has come to these conclusions. Since the above paper was published, we have amassed multiple human studies showing similar benefits.
Choline is one of the few nutrients that we have randomized controlled trials comparing different levels of supplementation on pregnancy health & infant outcomes.
Do you want to take a wild guess at what these studies found?
The gist is that we need MORE choline. A lot more.
Choline intakes at levels more than DOUBLE our current recommended intake optimize placental function, may reduce the risk of preeclampsia, and improve infant cognitive development and reaction time. (Placenta, 2016; FASEB, 2013; FASEB, 2018)
Our current recommended intake for pregnancy is set at 450 mg. Many of the supplementation studies have compared choline intakes of 480 mg (slightly above the recommended intake) to 930 mg per day. The women receiving 930 mg/day consistently show improved outcomes, as do their babies.
Choline also enhances the transport of nutrients across the placenta, including DHA; note the nutrient synergy. (J Nutri, 2017; Metabolism, 2008) Some of the richest food sources of choline also contain DHA, such as egg yolks and salmon.
In children aged 7 years old, those born to mothers with the highest intake of choline during pregnancy have better visual memory compared to those with the lowest intake. Interestingly, this study found that maternal intake of related nutrients, like vitamin B12 and folate, did not have a significant influence on cognitive test performance. (Am J Epidemiology, 2012)
It’s rare to have such a strong consensus among researchers on the necessity and importance of a nutrient. The vital role that choline plays in pregnancy health and fetal development is clear:
“Metabolites of choline are required for synthesis of cell membranes, neurotransmission, and methyl metabolism—processes essential to fetal brain development and tissue expansion. A large body of evidence suggests that periconceptional choline deficiency increases the risk of adverse birth outcomes, including neural tube defects and other congenital abnormalities. In addition, maternal choline status appears to influence cognitive development in infants.” (J Nutr, 2015)
What are the Best Food Sources of Choline?
Choline is widely spread in the food supply, but most concentrated in animal foods. This is an inconvenient thing for folks arguing the adequacy of a vegan diet in pregnancy because the #1 food sources are egg yolks and liver (this is one of many reasons eggs are so good for you in pregnancy).
You’d need close to 4 cups of broccoli OR 2 cups of beans OR 5.75 Tbsp of peanut butter or 3.3 cups of tofu OR 2 cups of shiitake mushrooms (these are among the richest plant sources of choline) to match the choline content of a SINGLE egg yolk.
This is why egg-eaters have, on average, twice the choline intake of non egg-eaters. In an analysis of the National Health and Nutrition Examination Survey data (NHANES) from 2009–2014, only 2.4% of people who don’t eat eggs met the recommended intake for choline, while 57.3% of egg-eaters met the recommendation. (Nutrients, 2017)
Even egg eaters should be aware of their choline intake (57.3% leaves almost half the population at inadequate intake), but a 23.5-fold difference in adequate intake between egg-eaters and egg-avoiders is noteworthy.
The data for pregnant women is particularly dismal; only 6-10% meet the recommended intake for choline. This is partly related to the increased requirements of pregnancy. Once you set the bar higher, many women aren’t going to make the cut. It’s also a side effect the poorly communicated information on food safety resulting in unfairly demonized “foods to avoid” that leaves many afraid to consume eggs.
Aside from egg yolks and liver, other foods rich in choline include: organ meats (like kidney, heart, giblets), fish roe, wild game (especially caribou and venison), fatty fish (especially salmon), pork skin (think chicharones), beef, lamb, pork, poultry, and dairy products. Bacon is actually a surprisingly rich source of choline, too (eggs + bacon anyone?).
In dietary surveys looking at the greatest contributors to choline intake, eggs top the list, followed by meat, poultry, seafood, and dairy products.
According to an extensive data set on US intakes of choline:
“Consumers of eggs had almost double the usual intake of choline as compared to non-consumers (525 ± 5.17 mg/d and 294 ± 1.98; p < 0.0001). Protein food (meat, poultry and seafood) consumption also increased usual choline intakes compared to non-consumers (345 ± 2.21 mg/day and 235 ± 8.81; p < 0.0001).” (Nutrients, 2017)
If you can’t/don’t want to consume eggs, I highly recommend a choline supplement, such as choline bitartrate, phosphatidylcholine, or sunflower lecithin (which is naturally rich in phosphatidylcholine) to meet your needs.
Obtaining Adequate Choline on a Vegetarian Diet
As stated above, choline is widespread in the food supply. However, the concentration of choline is highest in animal foods. This can make it more difficult to obtain enough choline on a vegetarian diet, particularly if one does not consume eggs (such as a vegan diet).
As mentioned above, certain plant foods do contribute to choline intake, especially shiitake mushrooms, beans/legumes, nuts/seeds, and cruciferous vegetables. These still count, but the quantity required to meet choline demands, particularly in pregnancy in lactation, makes it virtually impossible to do with diet alone. In fact, I have yet to see a vegan pregnancy meal plan with adequate choline.
I find it especially worrying that the handout on vegetarian diets in pregnancy from the Vegetarian Nutrition Practice Group of the Academy of Nutrition and Dietetics fails to mention choline as a nutrient of concern. They mention only protein, DHA, iron, folate, zinc, iodine, calcium, B12, and vitamin D (note: there are other nutrients beyond choline this list is missing; see Ch 3 of Real Food for Pregnancy in the section entitled “Challenges of a Vegetarian Diet in Pregnancy”).
A comprehensive nutrient analysis of their sample vegan meal plan shows it provides only 371 mg of choline (80% of the current recommendation for pregnancy or 40% of the level randomized controlled trials show is optimal). This is despite including multiple servings of the richest plant food sources of choline. Their sample meal plan is far better than some I’ve analyzed. Choline researchers note that average choline intake among vegetarians is a mere 192 mg. (Nutrition Today, 2018)
The Academy’s omnivorous sample meal plan in their official policy paper on prenatal nutrition doesn’t fare much better, providing only 374 mg. This is because the only eggs provided in their plan are the tiny amount in low-fat mayonnaise. (Why—why—would you choose oatmeal instead of nutrient-dense eggs for breakfast in this sample meal plan?!)
The dietetics’ field is so focused on complying with the arbitrarily low cholesterol and saturated fat targets in our dietary guidelines, that they compromise the level of choline in the diet. This is a perfect example of the nutritionism trap.
A Real Food Diet for Pregnancy Provides Optimal Levels of Choline
The disappointingly low concentrations of choline in the above examples is due to the low provision of animal-sourced foods—particularly eggs—in these sample meal plans.
In an aptly titled review of choline research, Choline: The Underconsumed and Underappreciated Essential Nutrient, published in 2018, a group of choline researchers argue against dietary policy that excludes animal foods entirely:
“Data indicate that increasing consumption of plant foods may offer health benefits; however, this means that there is a need to include more plant foods in the diet, but not necessarily eliminate nutrient-dense animal-derived foods such as eggs, lean meat, and milk products that contain choline.” [emphasis mine]
The high concentrations of choline in animal foods is one of many reasons I endorse an omnivorous diet for optimal pregnancy outcomes. I’m a proponent of consuming both plants and animals, not arguing in extremes of one versus the other.
The sample meal plans from my book, Real Food for Pregnancy, provide anywhere from 633 to 935 mg of choline—well above the current recommendation and in line with the latest data on optimal intake.
In the section exploring the nutritional considerations of a vegetarian diet, I highly encourage the consumption of eggs for those who otherwise avoid animal products. For those who are averse or allergic to eggs, as stated earlier in this article, a choline supplement is highly recommended.
Read the research. Run a nutrient analysis.
Decide for yourself if you want to EAT your nutrients versus supplement.
It’s not only about what your diet excludes, but what it INCLUDES, hence why I’m constantly talking about nutrient-dense foods.
How do I know how much choline I’m eating? Do I need a supplement?
If you are not sure you’re obtaining enough choline from your diet — or need personalized advice on what level of choline supplementation might be helpful to you (again, if your diet is lacking in choline-rich foods) — I’d recommend working with a real food dietitian with extensive training in prenatal nutrition. They can help run a comprehensive nutrient analysis to check the choline levels in your diet and guide you on the strategies you can take to optimize your intake. I recommend the practitioners who have personally mentored with me via the Institute for Prenatal Nutrition (check our Specialist in Prenatal Nutrition graduate directory).
If a supplement is warranted, you can check my Fullscript (see the recommendations category for choline) for options there. Some of the more comprehensive prenatal vitamins include choline as well, such as Fullwell and Seeking Health Optimal Prenatal (most prenatals don’t because choline takes up a LOT of capsule space, so a 1-a-day or even a 3-a-day is unlikely to have significant quantities of choline, just FYI).
But, but, but… Can’t your body make choline?
There are A LOT of people who are uneducated on choline or being told misinformation about the necessity of this nutrient (several outspoken vegan doctors are decidedly anti-choline). Some of these people argue that your body has the capacity to synthesize all the choline it needs.
This is not true. This is NOT supported by the scientific literature, particularly in pregnancy.
I’ll leave it to the researchers to explain it:
“Despite the potential enhanced capacity for the body to synthesize choline, data from animal models suggest that fetal and infant demand is so high that maternal stores are depleted during pregnancy and lactation. Low maternal choline intakes during pregnancy have been shown to increase the risk of both neural tube defects and cleft palates.” (Nutrition Today, 2018) [emphasis mine]
The above quote comes from an excellent review article on choline, which explores arguments for and against its intake. As of the time of writing, it’s open-access, meaning you don’t have to pay a dime to read it. If you have any lingering questions on choline, I recommend you give it a read (full citation below this article; simply copy and paste the title into a Google search and it’ll come right up).
What About TMAO?
Some people argue that choline should not be a nutrient we emphasize in the diet because it may increase levels of a metabolite known as TMAO (trimethylamine N-oxide). Some studies have linked higher TMAO levels to a higher risk of developing heart disease, however this remains controversial. TMAO levels are not only impacted by diet (and supplements), but also by gut health (both gut bacteria and gut barrier function). (Nutrition, 2018)
Also of interest, is that food-sourced choline doesn’t appear to impact TMAO levels to the same degree as supplemental choline. For example, a number of studies have tested whether the intake of eggs versus supplemental choline have an effect on TMAO levels. Studies ranging from intake of 1 to 4 eggs per day for a minimum of 4 weeks have not shown that they result in elevated TMAO levels, whereas some types of choline supplements do raise TMAO levels (particularly choline bitartrate). Phosphatidylcholine and choline citrate do not seem to raise TMAO levels as significantly. (Am J Med, 2021; J Am Coll Nut,r 2018; Lipids, 2017)
Interestingly, egg-derived supplemental phosphatidylcholine does NOT raise TMAO levels, which brings us full circle in this conversation. (Eur J Nutrition, 2022) If and when possible, eat FOOD to meet your nutrient needs instead of supplements.
Choline and Pregnancy Summary
Let’s sum up the data on choline and pregnancy in bullet points, shall we?
- You need more choline—not less—during pregnancy (and even more when you’re breastfeeding, but that’ll be the topic of another post; or, see Ch 12 of Real Food for Pregnancy). I’ll also be teaching an in-depth webinar on breastfeeding nutrition in the coming months. Stay tuned for details. UPDATE: the nutrition for breastfeeding webinar recording is available here. This presentation focuses on the nutrient transfer into breast milk and how this is affected by maternal nutrient intake/nutrient status.
- Much like folate, choline is most important for placental health & your baby’s brain development (however, keep in mind it’s vital to overall brain function—pregnancy brain, anyone?—and liver health).
- Choline requirements in pregnancy may be DOUBLE the current recommendation; we’re just waiting on prenatal nutrition guidelines to catch up to the research.
- Eggs are the #1 source of choline in the diet; eat them regularly (with the yolks—that’s where the choline is) unless you absolutely cannot tolerate them.
- People who don’t/can’t consume eggs should consider a choline supplement. Don’t count on your prenatal vitamin as most contain none or pixie dust quantities. The two most studied forms of choline used in pregnancy supplementation studies are choline bitartrate and phosphatidylcholine.
If you want to learn even more about choline—and all the other nutrients required for a healthy pregnancy—check out Real Food for Pregnancy. You’ll especially like Ch 3, which explores foods to emphasize based on the latest scientific research on prenatal nutrition.
Before you go, I’d love to hear from you:
– Did your healthcare provider talk to you about choline during your pregnancy?
– Were you aware of this nutrient before reading this article?
I’m really curious to hear your input. I’ve seen a lot more nutrition professionals speaking about choline in recent years, especially since I published Real Food for Pregnancy, so I’m hoping to see this conversation become commonplace.
Until next week,
Lily
PS – If you’re new here and want to learn more ways that real food helps to optimize pregnancy outcomes, you can download the first chapter of Real Food for Pregnancy for free below.
References
- Shaw, Gary M., et al. “Periconceptional dietary intake of choline and betaine and neural tube defects in offspring.” American journal of epidemiology 160.2 (2004): 102-109.
- Wallace, Taylor C., et al. “Choline: The Underconsumed and Underappreciated Essential Nutrient.” Nutrition Today 53.6 (2018): 240-253.
- Blusztajn, Jan Krzysztof, and Tiffany J. Mellott. “Neuroprotective actions of perinatal choline nutrition.” Clinical chemistry and laboratory medicine 3 (2013): 591-599.
- Kwan, Sze Ting Cecilia, et al. “Maternal choline supplementation during pregnancy improves placental vascularization and modulates placental nutrient supply in a sexually dimorphic manner.” Placenta 45 (2016): 130. ; Jiang, Xinyin, et al. “A higher maternal choline intake among third-trimester pregnant women lowers placental and circulating concentrations of the antiangiogenic factor fms-like tyrosine kinase-1 (sFLT1).” The FASEB Journal 27.3 (2013): 1245-1253.
- Caudill, Marie A., et al. “Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study.” The FASEB Journal 4 (2018): 2172-2180.
- Wurtman, Richard J. “Synapse formation and cognitive brain development: effect of docosahexaenoic acid and other dietary constituents.” Metabolism 57 (2008): S6-S10. ; Kwan, Sze Ting, et al. “Maternal choline supplementation modulates placental nutrient transport and metabolism in late gestation of mouse pregnancy.” The Journal of nutrition 11 (2017): 2083-2092.
- Boeke, Caroline E., et al. “Choline intake during pregnancy and child cognition at age 7 years.” American journal of epidemiology 12 (2012): 1338-1347.
- Visentin, Carly E., et al. “Maternal choline status, but not fetal genotype, influences cord plasma choline metabolite concentrations.” The Journal of nutrition 7 (2015): 1491-1497.
- Wallace, Taylor, and Victor Fulgoni. “Usual choline intakes are associated with egg and protein food consumption in the United States.” Nutrients 8 (2017): 839.
I am new to your blog and havent read your book yet, but I have had the chance to read the first chapter. Before learning about you and your work, I have never heard of choline. My prenatal care was extremely hands off in terms of what supplements to take and nutrition in general. Then, once my daughter arrived, she had an egg and dairy intolerance and I pretty much became vegan due to me not being a big meat eater. But, I loved eggs. She is now 1 year old, still breastfeeding, and starting to outgrow the egg intolerance, but I worry that I messed up by not supplementing properly. I am so glad I found your page, AND I am really looking forward to reading your book especially since there’s info on nursing nutrition
If you loved eggs, it’s unlikely your choline intake was severely lacking. 2 eggs/day meets approximately half of the daily recommendation for choline in pregnancy (based on the current recommended intake level anyways).
Yes, you’ll love the last chapter, which is all about the 4th trimester, postpartum recovery, and breastfeeding nutrition. <3
Has there been any research done to determine the upper limit of choline? Wondering if there are any adverse effects of having TOO much choline, although it sound like this is not a common problem for most people. Thanks Lily!!
They set the upper limit at 3500 mg, but virtually no one consumes that much. The only way to reach those levels is high dose supplementation. The second reference below this article goes into details on this.
Thanks Lily – Great article (and builds on what I’ve learned in your EXCELLENT book). None of my healthcare providers have mentioned choline – I find that it’s just a generic question of “are you taking a pre-natal vitamin.”
As far as dietary sources – one big lesson learned for me (with business travel) was that the liquid egg product often used to make large batches of scrambled eggs contains essentially NO choline! I do find variety to be a bit challenging in working toward the higher recommended choline targets day in and day out during pregnancy.
On the topic of supplementation, have studies to-date found similar results/outcomes with dietary choline vs. supplements?
Yeah, fake eggs, like the ones often used for making massive batches of scrambled eggs in cafeterias or hotels won’t contain choline unless the manufacturers specifically add it in. Egg Beaters, for example, does NOT have choline. I try to order fried eggs in situations like that to ensure I’m getting *actual* eggs.
The data from choline supplementation trials is reassuring, but there are some studies showing markers of choline status are improved when they test eggs versus a choline supplement, even when the dosage of choline from the two is equivalent. I’m always a fan of “food first” if it’s possible. There’s a lot we don’t know about nutrient synergy. The choline-DHA connection is a perfect example.
Lily,
I first heard of you during your interview on the Whole Mamas podcast and likely replayed it at least 3 times to try to soak in everything that you said. I’ve since bought your Real Food for Pregnancy book to have a hard copy because the data you put forward has been astounding to say the least!
I’ve been on a journey over the last year and a half to learn a lot more about nutrients and supplements as I prepared to conceive. Needless to say, working with a natural path, a fertility OB, an endocrinologist specializing in fertility and now that I am pregnant, a midwife practice near Toronto, Canada – no practitioner ever recommended choline despite all being very open to supplements and taking a more natural approach. After conceiving, when I was asked what supplements (by all of those groups) I am using, when I mentioned choline, only the natural path commented on it that she was surprised I knew about it since it’s a ‘new thing’.
Thank you so much for your research! I must admit I have a hard time not throwing your book into the hands of pregnant friends and “forcing” them to read it! It’s so frustrating to hear comments like “I think I need to eat more carbs to manage my borderline gestational diabetes” or “I’m avoiding eggs while pregnant in case they are undercooked”.
Keep fighting the good fight!
Glad my book has been helpful to you and thank you for sharing with your friends!
That’s funny about them saying choline is a “new” nutrient. It’s only new to the people who haven’t been following the research.
This is really interesting! What about choline when breastfeeding? I’m not planning to have any more children but am currently breastfeeding my 4-month-old. Thanks!
Choline needs are even higher when breastfeeding and choline transfers readily in breast milk. See the section on choline in Ch 12 of Real Food for Pregnancy!
Thank you! I have your book (and love it) and will look it up.
How much is in one egg / how many eggs do we need to eat to get our daily recommended requirements?
An egg is approximately 115 mg of choline, but it depends on the size of the chicken egg (larger egg = larger yolk = more choline). Remember, eggs aren’t the ONLY source of choline in the diet, but the major contributor.
Love this! Thank you for all that you’re doing!
When I found out I was pregnant and spoke to my NP, all she wanted to make sure I was taking was folic acid. No mention of choline at all.
Prior to being pregnant, I had heard of choline but had no idea the benefits it had on pregnancy. I’m just over 12wks pregnant with twins and consuming 2 eggs every morning with the odd side of bacon.
Oy, and the folic acid instead of folate. This type of bland prenatal nutrition advice makes me cringe, but it all too common.
Congratulations on twins!!!
Hi Lily! Do you have a recommended supplement company to start with for those who do chose to supplement? I find the options overwhelming when it comes to finding a high-quality supplement. Any harm in supplementing with Phosphatidyl Choline in lieu of Choline Bitartrate? Thank you!
I’m using Phosphatidyl Choline from Thorne Research. I messaged Lily on instagram and she very kindly responded and said it was okay to use 🙂
Lily,
Thank you for the work you do and for your books on Real Food – I keep telling everyone that you should have titled it Real Food for Everyone because the information is good for everyone, not just pregnant women! I’m a CNM (I won your book from EBB when they did a webinar with you) and couldn’t put it down – read it cover to cover like a novel. I am so happy to have that resource and be able to share it with the pregnant women I have access to!
I’m do glad you enjoyed it! Love all the work that Evidence Based Birth puts out and have been happy to contribute to some of their content.
My provider never talked to me about choline and I never heard of it before! It is interesting to note though, that I developed preeclampsia and my placenta was “calcifying” with my most recent baby. I’ve never had this problem before with 7 kids…but I was egg free this last pregnancy because I didn’t tolerate eggs. I don’t think that is a coincidence!
Great write up, thank you! I ate 2 eggs daily while pregnant based on your recommendation. I have a question unrelated to this topic. Do you have any advice on restoring gut health with diet after the antibiotics of a csection? My stomach hasn’t been the same since and I’m suspecting some other issues are related like puffy eyes and general swelling. I’m breastfeeding and I’m not familiar with how diet could effect supply. Thanks!
Dear Lily,
Im 2 months pregnant and already read your book twice in one month! Its like a bible for pregnant women. I ve been trying to eat an egg or two almost every day and chicken/meat liver twice a week but im afraid im still not getting the recommended 930 mg of choline daily and was considering taking a supplement just to be on the safe side. Looking at choline bitartrate supplements, most of them are in a combined form with something called “inositol” (250/250 mg). Is there a reason for that like better absorption of choline or should i get a supplement that only includes choline bitartrate?
Glad you enjoyed Real Food for Pregnancy! You might consider running a nutrient analysis to check your choline intake if you’re concerned. Eggs + liver are the #1 most concentrated sources, but not the ONLY sources of choline in the diet.
As far as inositol, it’s another nutrient in the B vitamin family and is generally considered safe for pregnancy. I’m not legally able to give personalized supplement advice in this format, so I’d recommend talking it over with your healthcare provider.
I like eggs.
Egg-celent.
I’m a lover of eggs. Ate a ton during pregnancy and after. Unfortunately 2 of my 4 kids are severely allergic (can’t even have them baked without severe reaction).
I try to give them sunflower lecithin whenever I can figure out a way of squeezing it into their diet, but it’s not always easy. Can you recommend a choline supplement that doesn’t contain eggs? And what the heck happens to kids who don’t get enough? Lots of bacon eaten over here, but probably not nearly enough.
Lily, any idea how much choline is in sunflower lecithin? I can’t find this information anywhere!
Chris Masterjohn says that 1 tablespoon of sunflower lecithin is equivalent to 1 egg yolk as far as choline content. Hope this helps!
I read your book a year ago, and I have since reread it and shared with a friend. I think I’ve also listened to every podcast you appear on (I’m a super fan of your work). I am not pregnant nor have I ever been, but I want my body to be ready when the time comes.
I was on the Autoimmune Protocal last year and when I tried reintroducing eggs I found I got terrible headaches and body aches every time I ate them. Of course I was so sad after reading your book, but this is why I’m here commenting. A local farmer suggested I try duck eggs since they have a different set of proteins. I’ve been eating them for about a month with no problems. I’m not sure on the actual amounts of choline in duck eggs, but I wanted to mention this in case there are other people out there wishing they could tolerate chicken eggs. I’ll leave it up to Lily Nichols and other real food educators like her to tell us how duck eggs compare to chicken eggs. Thanks so much for all of your work and contributions to this field! Yay for healthy babies and mamas!
Actually duck eggs are excellent nutrition-wise, even for choline. Since they are larger than chicken eggs, their choline content is higher as well. 1 duck egg has 184 mg of choline compared to 115mg in a large chicken egg.
Your book was the first and only place I’d heard about choline. Since I’m intolerant to eggs (stomach pain, rashes) and rarely eat liver, I decided to supplement. I recently changed practitioners and my old doc said “I didn’t even know they made choline supplements” although he at least seemed aware of it. New doc office didn’t have it in their system as a supplement to choose from… they had to write it in! Nobody talked to me about it and the nutrition info I was given was standard stuff… don’t eat lunchmeat, stick to low fat (!!) dairy, etc. Your book has been so empowering and a lifesaver! The only thing I do differently than your book is eat higher carb (by a lot) but I was already doing that in a healthy way with a nutrition coach due to my crossfitting and weightlifting along with the stress of being a business owner. I haven’t changed that since being pregnant. SO EXCITED for your breastfeeding webinar!!
Glad to hear you learned about choline and have been able to share this info with your provider. Hopefully more will be up-to-date on this nutrient in 5-10 years. As they say, it takes 17 years for research to make it into practice.
And, YES to adjusting your macros to what your body needs. As I try to stress in Real Food for Pregnancy, folks with much higher exercise levels usually have more wiggle room for carbs. Glad you’re listening to your body!
Really interesting article. You say Sunflower lecithin is a vegetarian source. I hear lots of lactating mothers who are taking it to help with supply, any speculation that it might be low choline that’s impacting their supply?
p.s. I’m not even pregnant yet and Real Food for Pregnancy has been an amazing book to help me eat more nutrient dens foods. I was already keto but no have upped my eggs and liver based on your recommendation. Wish you could do a general Real Food for Life book!
People take sunflower lecithin while breastfeeding to reduce the odds of developing a clogged duct – typically only those that have experienced recurrent clogs do this. It’s not used for increasing milk supply.
My doctors did not say anything about choline at all. Or any nutrients for that matter. They just asked if I was taking a prenatal, said not to eat sushi, and sent me on my way. I’m glad I read Real Food for Pregnancy before becoming pregnant.
Hi. Since you asked, just thought I would tell you about my pregnancy, the only one I wanted, which happened over 47 years ago. I had a very healthy son, who weighed 6 pounds, 7 ounces, and a bit on the thin side but otherwise perfectly normal. He is still alive and well. I’m 66 and also quite healthy. Before he was born I had never even tasted and egg and wasn’t big meat eater. I was given prenatal vitamins but quickly realized they (nor anything else) was going to stay down as I was suffering from hyperemesis, otherwise known as extreme vomiting. It lasted the whole nine months of my pregnancy and I lost 30 pounds that I didn’t need to lose. After he was born, I breastfed him for over 6 months, with no other supplemental food. I have to think that my body somehow made all the nutrients we needed. The only thing I ingested during the whole pregnancy was cream soda (pop) because I quickly learned that it didn’t taste too bad coming back up. Sorry to be so graphic but that is my story, since you asked.
I eat eggs almost daily and am attempting to eat liver weekly. (any recipe ideas are appreciated!), but I am still considering a Choline supplement due to not hitting the 930mg dosage each day. Should I consider the Choline Bitartrate or Phosphatidyl Choline? I also take a DHA supplement and I was wondering what the daily recommendations are for that?
I just started your book, it is AMAZING!!!
I ate tons of eggs during my three pregnancies (I LOVE eggs) but in my last pregnancy I was so sick but eggs settled my stomach. I remember counting up six eggs a day sometimes! I did have three healthy pregnancies and have three healthy smartie-pants kids, so I wonder how much of this has to do with my morning-sickness induced egg intake.
I never got any information about choline during my pregnancy. I also find it very difficult to find a prenatal here in Sweden that has choline. The only one I have found is Innate Respons “Baby and me”. It has 300 mg choline. Is this a prenatal you have heard of or would recommend? Btw, just started reading your book Real food for pregnancy and I’m so thankful for your work.
My recommendations on prenatal vitamins & other supplements are detailed in Ch 6 of Real Food for Pregnancy.
Hi Lily quick question! I do have Real Food for Pregnancy but don’t think this is exactly addressed there or in this blog post.
I eat meat and eggs, but in the first trimester I’m not able to get either down currently. Veggies are also a struggle. My prenatal includes 300 mg of choline, which sounds like it is not adequate. Once my morning sickness resolves I plan to resume eating eggs and meat, but in the meantime would you recommend a choline supplement? My only hesitation is that many of them seem to have 500 or more mg so I would be over the recommendation…but per this article it sounds like that’s probably fine. Just wanted to see what your thoughts would be!
Hi Lily,
Thank you for sharing your research. Unfortunately I’m very allergic to eggs, I eat fish, but otherwise wonder if adding a choline supplement would be good for me. Do you mind if I ask, is this a good form of it, and what measurement do you recommend daily? https://nootropicsdepot.com/choline-l-bitartrate-powder/?gclid=Cj0KCQjwv8nqBRDGARIsAHfR9wD1IsjhypAW6AJhh0J6Sti3WiPa3e0Pwb9BXUIvsZYQe6UAsbNJM-4aAli0EALw_wcB
Also, to answer your above question, no doctor has ever mentioned choline, and I wasn’t aware of choline before hearing your episode on Fertility Friday Podcast.
Thanks!
Aleya
Great no-nonsense post on choline and it’s HUGE value during pregnancy. During my first pregnancy I had shocking news at the 20 week anatomy scan. Baby was in the 13th percentile! My midwife said eat 2-3 eggs EVERY day and we will rescan at 30 weeks. At the second scan babe was in the 75th percentile. I suspect I wasn’t getting enough protein but certainly choline from the eggs helped.
I’ve never been tested but my husband’s sister has the MTHFR snip, likely it’s also affecting the genetics of our kiddos and therefore their methylation, need for choline.
Thanks Lily!!!
First off, I want to say I love your book. So glad someone is combing through research for pregnancy!!! I guess I just don’t understand the obsession with eggs… You said one egg is about 115mg of choline and you acknowledge that there are other sources… why not just give a list? (Or did you give a list? I only have the audio version of your book) Especially from non-animal products? I don’t disagree that animal products provide more choline, but it felt like you could’ve given a little more options to vegans/vegetarians besides a supplement.
I got these numbers from nutritiondata.self.com. Are they wrong?
100g sundried tomatoes – 105 mg of choline
100g ready to eat cereal, with wheat germ – 124-178 mg of choline
1 piece of chocolate cake, without frosting 🙂 – 122 mg
2 oz of shiitake mushrooms – 113mg
1/2 cup soybeans – 214 mg
100g of soy chips – 111mg
1 can of grapefruit juice – 50.7 mg of choline
(any many more of course!)
Thanks!
Not all of those numbers are correct. Soybean choline content, for example, must have been from UNCOOKED soy beans. 1/2 cup of COOKED soy beans provides only 40 mg of choline. 2 oz of shiitake mushrooms is actually referring to DRIED shiitake mushrooms, not fresh. 2 oz of FRESH shiitake mushrooms provides 13mg.
For other values, you want to consider the actual quantity of food needed to provide those doses of choline. For example, 100g of dried tomatoes is nearly 2 CUPS of dried tomatoes. That’s a LOT of tomatoes and an unrealistic portion to consume on a daily basis. For reference 100g of egg is approx 2 large eggs.
Be very careful with units and taking into account a realistic portion size when assessing choline concentrations. This is discussed in depth in many of the references cited in this post. These foods DO contribute to overall choline intake, just not in a substantial way when compared to eggs.
In relation to your first reference (1), I’ve found a more recent study.
2014 research “Maternal choline concentrations during pregnancy and choline-related genetic variants as risk factors for neural tube defects,” says, quote, “maternal betaine and choline concentrations are not strongly associated with NTD risk”.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163794/
Hi Lily!
I’m 5 weeks pregnant and would like to take a choline supplement. I found two: Thorne Phosphatidylcholine and Vital Nutrients Choline Bitartrate. Which would you recommend? I’m worried that the Bitartrate isn’t absorbed as well, but I’m also worried that the Phosphatidylcholine is derived from soy. I’d love your opinion! I want to make sure my little one is getting enough choline! Thank you!!
Great article! I’m taking a choline supplement as I can’t stomach eggs at the moment- here is the question though- you recommend choline bitatrate but lots of info on the web suggests that isn’t as effective as the other two forms. I’m taking a citicoline supplement at the moment but read an article saying that was not safe in pregnancy and I should be taking alpha gpc- I asked my midwife and she had never heard of choline! Grateful for your comments on the different forms of supplement and any dangers to be aware of in the evidence of each(and also how much to take if I continue not to be able to stomach whole eggs…). Thanks!
Dear Lily,
I have purchased your book through Audible and it provides such a wonderful wealth of information that I am so grateful for!
I would like to ask a question about Choline – as you mention that it can help to optimize placental function and may reduce the risk of preeclampsia. I am almost 15 weeks and have been told that I have low Papp-A levels, a hormone produced by the placenta which can be associated with low birth rate, early deliveries and pre-eclampsia. I have been told I need to take aspirin every day until the birth, which I feel uncomfortable about.
I was wondering if you know of any links between Choline and Papp-A levels? As it supports the transfer of nutrition to the placenta, perhaps it will help me raise my levels? I try to eat Choline rich foods as often as I can stomach them, but I definitely want to up my intake through a supplement.
Thank you for the work you do!
I’m not aware of any research on this specific topic.
Hi Lily, I just read your Real Food for Pregnancy book and I’m hooked. Ive always been very, very conscious about the food that I eat and now that I’m 6 weeks pregnant (only took 3 years via IVF, ha!), i find my self slightly obsessing about every single thing. My prenatal has 100mg of choline. I really want to reach the 900+ mg goal a day because I have read so many benefits. I eat well, and usually have 1-2 eggs a day.. I just bought a 500mg choline supplement as well. Should I take that? Or maybe just cut that in half and take the 250 mg (2 capsules=500mg)?? My husband doesnt want me to OVER do the choline in my body! But I’m not sure that’s possible? What are you thoughts?
I can’t provide medical/supplement advice outside of a formal client-dietitian relationship. For general informational purposes, the upper limit for choline is set at 3500 mg for adults.
Hi Lily!
Super interesting all of this! I’m a little confused to why you say choline bitartrate is the most used one (in supplements, yes. But in actual studies of choline – no?) from what I can see, all studies on pregnant women have used Phosphatidyl Choline? (apologies for my spelling?)
Could you please clarify?
I bought choline bitartrate but now very unsure of its efficacy as it doesn’t seem to have been used in those trials?/no studies of its bioavailability?
Both forms of choline have been used in studies, but the recent RCTs showing positive results used choline bitartrate. Either form is good, though.
Any input on the seeking health optimal PC (phospholipid complex)?
I know it is a great brand but I am unsure what some of the ingredients are such as Phosphatidylethanolamine and Phosphatidylinositol..
Phosphatidylcholine is only part of the complex which isn’t that the most important? Or are they all important?
I’m forever grateful for the work you’ve done. I’ve always been one to eat my eggs, cod liver oil and liver (well, once I’ve quit my experiment with vegetarianism), and I’ve supplemented with extra choline during my pregnancy. I made a concerted effort to meet the 930 mg target.
My son was born at full term and was well-built and quite large, weigning in at over 4 kg (mainly due to his body type and head circumference). O continued my choline rich diet all 16 months I breastfed him.
I always got comments from our pediatrician and other doctors about how neurologically advanced and alert he seemed.
I’m so glad I read your book before I even conceived. I’ve been trying for baby number two now, and I’ve added a krill oil supplement and wild salmon roe, both rich in choline.
Hi Lily,
I am curious about your thoughts on this study pubmed.ncbi.nlm.nih.gov/33872583/ which shows that participant’s plasma TMAO levels increased significantly in all three intervention arms containing choline bitartrate supplementation. The great news from this study is that despite the high choline content of eggs, they had no impact on plasma TMAO levels. Only choline supplements did, and specifically choline bitartrate (not phosphatidylcholine). For someone who does not consume eggs but is conscious of meeting pregnancy’s pregnancy choline requirements, would you suggest avoiding choline bitartrate and opting for phosphatidylcholine or sunflower lecithin instead? Thanks!
My provider (midwife) didn’t talk to me about choline and even when I asked my naturopath, she was uninformed. I had come across the importance of choline in the CSNN Natural Nutrition program and decided to go for a phos choline supplement as I eat a more plant based diet and had done so for years prior to pregnancy. I’m glad I followed my instinct a different appreciate you collecting the research that validated that choice. Looking forward to reading your research on breastfeeding now that my son is here!
I am studying midwifery (cpm, out of hospital) and i have never heard one of my three preceptors talk to clients about choline in pregnancy. They talk about folate with everyone, but I had never heard about choline until listening to a podcast you did that my school (National Midwifery Institute) assigned us to listen to in our nutrition module.
Hi Lily,
Great research.
Is there any current research stating the safety of consuming sunflower lecithin during pregnancy?
More information coming out about the importance of choline and vitamin D in the prevention of cholestasis of pregnancy.
Hi Lily,
I love your book and thank you for everything you do!! I’m trying to figure out how much phosphatidylcholine to supplement. I’ve been reading that phosphatidylcholine only contains about 13% actual choline. My question is, if we need 450mg choline, would we need over 2000mg of a phosphatidylcholine supplement to reach 450mg? I’m a little confused.
Hi Lily,
I’m extremely obsessed with understanding choline and how to get a lot of it in my pregnancy because I have recently learned that my baby will have Down syndrome. I’ve read studies that show choline can improve the outcome for DS babies, in addition to the already known facts about how it supports a growing fetus. I’m so confused about what supplement to take. I know real food is best but it seems difficult to get an optimal amount. I’ve been trying your recipes and that makes me feel good about my effort but with young ones and tge chaos of life, I want a supplement for days that i don’t feel I’ve done well. I read an article that recommended Cognizin Citacoline for pregnancy, so i bought it; however, I’m not sure if i want to use it. Any thoughts on that particular version or on choline intake and DS? I feel like you are the only person to talk about choline in pregnancy and i don’t know where else to turn for information.
Did my OB care team mention choline during any of my appointments? Ya right. They probably don’t even know what choline is. Healthcare in this country is a joke.
Hi, this was a really great read.
I read that choline bitartrate doesn’t cross the blood brain barrier. So will it be effective in enhancing the cognition of the fetus?
Are other forms of choline like phosphatidylcholine, gpc choline, citicoline better than choline bitartrate?
Hi Lily!
I’ve only ever heard about Choline from you! A shocking lack of information on it everywhere else.
Thank you so much for your book and blogs. My now 16 month old is one smart little boy! And you motivated me to eat plenty of eggs, fish and liver during pregnancy and lactation. 🙂
Love!
Jolanthe x
Thank you so much for your excellent work, Lily! I’ve recently discovered you. Forgive me if this has been addressed, as I didn’t read all the questions, but can you speak to concerns around choline bitartrate?
I have been looking into FullWell but am concerned by their choice of choline bitartrate in such huge amounts. At this point it has me sticking with SeekingHealth and eating a lot of eggs.
Yes, I touch on choline bitartrate in this article. It’s actually the form of supplementation used in the RCT trials showing improved cognitive function in children from higher maternal intake in pregnancy.
Thank you so much Lily! Do you know how much choline is in a cup of beef or chicken bone broth? I know you’ve mentioned that bone broth is an excellent source of choline, but it’s been hard to find the amount for some reason!
I have a feeling you may be mixing up choline and glycine. Bone broth is not a rich source of choline; it’s a rich source of glycine. I talk more about glycine in this article on protein and pregnancy.
Hi Lily,
I was wondering if choline chloride is the same as choline bitartrate? I need to supplement choline in my diet during pregnancy due to having hyperemesis gravidarum.