Who is most at risk for a choline deficiency?

Choline deficiency can lead to muscle damage, liver damage, and nonalcoholic fatty liver disease. However, clinically evident choline deficiency is very rare, likely due to the contribution of the body’s endogenous choline production.

Choline intakes tend to be below the adequate intake for children and adults, who average an intake of 256 mg per day and 278–402 mg per day, respectively.^[1]

Worldwide choline intakes have been estimated to be 284–468 mg per day for men and 263–374 mg per day for women. In the United States and Canada, adult intakes range from 260–396 mg per day and 292–372 mg per day, respectively.^[2] The United States National Institutes of Health consider adequate intake to be 550 mg/day for men and 425 mg/day for women.^[3]

Pregnant and lactating women need more choline. During pregnancy, choline demand rises due to its role in neural tube formation, brain development, and lipoprotein synthesis. There’s also evidence that choline may prevent neural tube defects, improve offspring cognitive development, and promote maternal well-being.^[4] Most (90%–95%) pregnant women consume less than the adequate intake (AI) for choline,^[5] and prenatal supplements typically don’t contain choline. Women who do not supplement with folic acid, those who have a low vitamin B12 status, or those who have a common variant in the enzyme methylenetetrahydrofolate dehydrogenase are the most at risk for having an inadequate choline status.^[4]

Dietary choline requirements are lower in premenopausal women because estrogen induces the enzyme phosphatidylethanolamine N-methyltransferase (PEMT), which synthesizes phosphatidylcholine. However, women who have a genetic mutation in PEMT have less estrogen-induced choline synthesis and therefore higher choline requirements.^[6]

Finally, adults and infants receiving total parenteral (intravenous) nutrition may need to be supplemented with choline because choline is not routinely added to these solutions. Long-term parenteral nutrition has been shown to reduce plasma choline concentrations in adults and infants and is associated with the development of fatty liver and impaired liver function.^[7] These changes can be attenuated by providing intravenous choline.^[8][9]