Choline
What is Choline?
Choline is an essential dietary nutrient that is important for normal brain, nervous system, and cellular function. Evidence suggests that children with autism have higher levels of choline deficiency, and supplementation may improve their receptive language skills.
Although choline is not classified as a vitamin or mineral, it is an essential nutrient that has structural, metabolic, and regulatory roles within the body. [1]
Choline supports various bodily functions, including fat transport and metabolism, cell maintenance, DNA synthesis, and nervous system functioning. [2]
Humans are able to produce small amounts of choline in the liver, but not enough to meet daily needs. Therefore, a regular dietary intake of choline is necessary to maintain adequate health. [1]
Animal sources generally contain the highest concentration of choline. Cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and kale are also good sources of choline. [1]
Studies show that choline plays a significant role in brain and memory development in the fetus. [3]
Children with autism are at risk of inadequate intake of dietary choline even after supplementation. [4]
Food Sources of Choline
Recommended Intake
Choline does not have a Recommended Dietary Allowance (RDA). Instead, experts have established Adequate Intakes (AIs) - the amount assumed to ensure nutritional adequacy - for all ages based on the prevention of liver damage. [1]
Males
0-6 months: 125 mg/d
7-12 months: 150 mg/d
1-3 years: 200 mg/d
4-8 years: 250 mg/d
9-13 years: 375 mg/d
14-18 years: 550 mg/d
19+ years: 550 mg/d
Females
0-6 months: 125 mg/d
7-12 months: 150 mg/d
1-3 years: 200 mg/d
4-8 years: 250 mg/d
9-13 years: 375 mg/d
14-18 years: 400 mg/d
19+ years: 425 mg/d
Pregnancy
14-18 years: 450 mg/d
19+ years: 450 mg/d
Lactation
14-18 years: 550 mg/d
19+ years: 550 mg/d
Deficiency
Although most Americans consume less than the AI for choline, deficiency is rare in healthy individuals. The amount of choline an individual needs can vary. Because of their lower estrogen levels, postmenopausal women require a higher dietary intake of choline than premenopausal women. Furthermore, a higher choline requirement may be needed for those who do not consume sufficient amounts of choline-rich foods or who have difficulty digesting the nutrient. [1]
Symptoms of deficiency may include [1]:
Hypotension (low blood pressure)
Vomiting
Muscle and liver damage
Nonalcoholic fatty liver disease (NAFLD)
Individuals at increased risk for choline inadequacy include [1]:
Those with restrictive diets and poor intake of choline food sources
Pregnant women
Individuals with certain genetic alterations that interfere with the normal metabolism of choline
Patients dependent on intravenous nutrition
Toxicity
High doses of choline intake have been associated with increased sweating and salivation, nausea/vomiting, hypotension (low blood pressure), fishy body odor, and liver toxicity. Other studies show that it may also lead to increased production of trimethylamine N-oxide (TMAO), which is linked to a greater risk of cardiovascular disease. An overdose of choline is likely to be caused by supplementation rather than from the diet alone. [2]
Upper limits for choline have been established due to the concern of associated side effects, especially hypotension and fishy body odor, that can occur. The Tolerable Upper Intake Level (UL) is the maximum daily intake unlikely to cause adverse health effects. [1]
Males & Females
1-3 years: 1000 mg/d
4-8 years: 1000 mg/d
9-13 years: 2000 mg/d
14-18 years: 3000 mg/d
19+ years: 3500 mg/d
Pregnancy
14-18 years: 3000 mg/d
19+ years: 3500 mg/d
Lactation
14-18 years: 3000 mg/d
19+ years: 3500 mg/d
Supplements
Choline in supplemental form is available within B-complex vitamins, in some multivitamin/multimineral products, or just as isolated choline. Forms of choline commonly found within supplements include choline bitartrate, phosphatidylcholine, and lecithin.
You can find them in the form of a tablet, capsule, powder or gummy. [1] The supplements will tell you the amount and the percentage of each on the supplement facts label.
Examples
Note: All supplements are linked to Amazon for convenience, however, buying supplements on Amazon does not guarantee quality, as there are many “unverified resellers” selling nutrition supplements. To buy supplements that are verified to be sent directly to the consumer, you can create an account on the Autism Dietitian FullScript and search for the respective supplement under “Catalog”.
DISCLAIMER: Before starting any supplement or medication, always consult with your healthcare provider to ensure it is a good fit for your child. Dosage can vary based on age, weight, gender, and current diet.
Choline & Autism in the Research
Deficiency
Children with autism are likely to consume less than the recommended intake for choline. [4]
Research shows that some children with autism taking supplements are still at risk of not meeting recommended intake needs for choline. [5]
Choline deficiency is associated with high levels of homocysteine in the blood (hyperhomocysteinemia), which is a risk factor for neurodegenerative disorders, including autism spectrum disorders (ASDs). [6]
Maternal Choline
Studies found that preconception and prenatal choline supplementation improved autistic-associated behaviors, specifically, social and repetitive behaviors and anxiety in offspring. [7]
Supplementation
Supplementation of choline in addition to donepezil hydrochloride has been shown to influence receptive language skills in children with autism. [8]
Brain Development
Children with autism show differences in choline levels in the brain, revealing that they may have different neural maturation than typically developing children. [9]
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[1] National Institutes of Health Office of Dietary Supplements. Choline. National Institutes of Health; 2020. Available from: https://ods.od.nih.gov/pdf/factsheets/Choline-Consumer.pdf
[2] Micronutrient Information Center. Choline. Oregon State University Linus Pauling Institute; 2001. Available from: https://lpi.oregonstate.edu/mic/other-nutrients/choline#deficiency
[3] Zeisel SH. Choline: critical role during fetal development and dietary requirements in adults. Annu Rev Nutr. 2006;26:229-250.
[4] Hamlin JC, Pauly M, Melnyk S, et al. Dietary intake and plasma levels of choline and betaine in children with autism spectrum disorders. Autism Research and Treatment. 2013;2013:1-7.
[5] Tas AA. Dietary strategies in autism spectrum disorder(Asd). Progress in Nutrition. 2018;20(4):554-562.
[6] Waligóra A, Waligóra S, Damasiewicz-Bodzek A, Gorczyca P, Tyrpień-Golder K. Autism spectrum disorder (Asd) - biomarkers of oxidative stress and methylation and transsulfuration cycle. Psychiatr Pol. 2019;53(4):771-788.
[7] Agam G, Taylor Z, Vainer E, Golan HM. The influence of choline treatment on behavioral and neurochemical autistic-like phenotype in Mthfr-deficient mice. Translational Psychiatry. 2020;10(1):1-14.
[8] Gabis LV, Ben-Hur R, Shefer S, Jokel A, Shalom DB. Improvement of language in children with autism with combined donepezil and choline treatment. J Mol Neurosci. 2019;69(2):224-234.
[9] Li D, Karnath H-O, Xu X. Candidate biomarkers in children with autism spectrum disorder: a review of mri studies. Neurosci Bull. 2017;33(2):219-237.
Authors
Contributed by Brittyn Coleman, MS, RDN/LD, CLT
April Allen, Dietetic Intern
Laura Flournoy, Dietetic Intern
