Are you getting enough choline?
A little-known micronutrient that might become increasingly important with perimenopause
Good nutrition is vital at each life stage to thrive, and the menopause transition is no different. If anything, we need to be more mindful of nourishing ourselves properly as our bodies don’t let us get away with the same old shite anymore. This is the time where we need to invest in our future self. (You know the one that is ready to kick arse again once she has made it through this menopause malarkey!) I did already speak about this in my previous post when I said that I see menopause as a window of opportunity. There are plenty of macro- and micronutrients to be aware of and I will address many of these in future posts. For today, let’s step away from the more obvious nutrients.
I bet though that if I throw a micronutrient called choline into the mix, you are scratching your head, wondering what I am on about. Well, choline does actually have an important role to play throughout our lifetime, but very rarely will you hear someone banging on about choline in your diet. Many dietary guidelines don’t mention it (yet), so by just considering these, you are none the wiser. Let’s change that!
Drumroll… Meet choline
Although choline is strictly-speaking not a Vitamin, it has a similar role in our body as the group known as the B-Vitamins. Very often when looking at the label of a B-Vitamin complex supplement, you might also spot choline lurking somewhere at the bottom.
This one is an interesting one, because although we have started to get a good idea regarding the functions of choline in our bodies, there is still some disagreement amongst official bodies whether there should be official recommendations for its dietary intake. This is because whilst we have data on how much choline (in its different forms) is contained in foods, we don’t have a biomarker itself yet that tells us whether someone is deficient in it. Take iron for example – we can measure how much we are consuming, and we also have research on blood markers that give us thresholds of whether we are at risk of deficiencies. Dietary guidelines acknowledge this and therefore tell us how much iron we should consume to prevent such deficiencies. We don’t have the same with choline. The research so far has given us an idea of intake thresholds – below which point people started showing signs of something going wrong in their bodies and at also which point they improved again. (I will talk about this a bit later on.)
This is the bone of contention, some official organisations in charge of making recommendations have taken what we know so far and deemed this to be enough evidence for setting specific amounts for dietary choline requirements to at least prevent signs of deficiency from occurring. The European Food Safety Advisory Panel (EFSA) and The Institute of Medicine (IoM) in the US are amongst them. Our liver can actually make some choline itself – but not necessarily enough to cover the body’s demands. We therefore need to get choline from other, ideally dietary sources, which makes choline a so-called ‘essential nutrient’ – at least in the eyes of EFSA and the IoM and some individual countries, such as for example Australia, China, and the Scandinavian countries. These have set adequate intake values for choline. Others, such as Austria, Germany and the UK have not included choline into their recommendations as they think that the evidence to do so is not strong enough yet.
What does choline actually do and how is this important for wellbeing?
The choline contained in our foods comes in different forms, which reaches our bloodstream through digestion with the help of gut bacteria. It can be metabolised in our bodies to a number of other compounds that are involved in various physiological functions, one of them being the neurotransmitter acetylcholine, another one being phosphatidylcholine, abundant in cell membranes. Maybe somewhat confusingly, phosphatidylcholine is both present in foods itself, but it can also be converted in our bodies from free choline. Whereas acetylcholine, the neurotransmitter, is not present in food, but is the product of choline transformation within our bodies. A lack of choline can mean that these further compounds can only be produced to a limited extent. Choline therefore plays an important role in a number of functions in the body – ensuring stable cell membranes, keeping our livers healthy, keeping our brains in good nick and ensuring that brain and nerve cells can communicate with each other through neurotransmitters. Links have also been made between choline intake and muscle health and function.
The reason why some official organisations are hesitant with regards to choline recommendations is yet again a lack of high-quality research conducted in humans. Mostly, we have some studies in younger and older populations, but research in women at our stage is distinctively lacking – also, yet again! (I am starting to feel like a broken record!) What do we know about choline and how and why could this be relevant to the likes of us?
Due to its role in creating stable cell membranes, a lack of choline has been shown to affect muscle function. A diet low in choline could therefore lead to muscle damage. This would be an important consideration as during the menopause transition and beyond we tend to lose lean mass and strength.
A couple of studies that looked specifically at the impact of choline intake on strength, lean mass gains and muscle quality, were conducted in 37 and 46 adults aged between 50 or 60 and 69 years respectively. All participants followed a 12-week resistance exercise training programme three times per week. Women in both studies had been in postmenopause for at least two years. In the first study participants were instructed to follow the US dietary guidelines with slightly increased protein intake (20% of energy intake) and were given a protein supplement. Following analysis of the dietary records over the 12-week period, participants were then separated into three groups, based on their dietary choline intake – deemed to be low, medium-low and adequate. Participants in all three groups gained in strength following the exercise programme, but less so if they were in the low-choline group. All groups increased their lean mass, but this was most pronounced in the group with adequate choline intakes.
In the second study all participants were given the same dietary instructions as previously plus a protein supplement. They were then randomised into three groups either eating one, two or three extra egg yolks per day. The statistical analysis showed that (as in the previous study independent of the higher protein intake, which could have also been a factor in increased strength and muscle gain), those in the group with the lower choline intake (<50% of official recommendations) gained less strength. There were no differences in how much lean mass participants gained. The authors of this study highlighted that consuming choline above the recommended intakes did not provide any extra training benefits. They therefore recommended to focus on adequate intakes of choline, rather than excess.
Findings from observational studies have suggested that adequate intake of choline could have positive effects on cognitive function in older people, although it is important to say that findings have been mixed, even when the data came from the same cohort. This might have been related to the type of analysis conducted. Some studies also indicate that the type of choline might play a role. In a Finnish study in nearly 2500 men (aged 42 – 60 years) not total choline intake in general but higher intakes of a phosphatidylcholine was associated with better cognitive performance. Phosphatidylcholine is important for brain health and is able to bind with the omega-3 fatty acids DHA and EPA, both also linked to cognition. In addition, phosphatidylcholine seems to have better absorbability and more health-benefits than for example free choline.
A recent analysis of a Chinese longitudinal study where participants were followed for between 6 and 21 years included 931 women of postmenopausal age. It found that those in the highest quartile of choline intake (on average 299 mg per day) scored significantly higher in cognitive tests and also showed slower rates of cognitive decline over the years than those in the lowest quartile of intake (on average 59 mg per day).
We also have evidence from other longitudinal, observational studies, such as the US Framingham cohorts, that higher choline intake might be linked to better memory and less cognitive decline. At least these were the findings from a 10-year study in 1,391 participants with a mean age of 61 years.
Last but not least, a 2024 publication on findings from the US Study of Women's Health Across the Nation (SWAN) did actually report the impact of dietary choline on cognitive performance and its change over a nine-year period in just over 1000 women who were aged 42 to 52 at study beginning and either pre- or early perimenopausal. (Hurray!) The researchers reported that over the course of data collection the majority of women had entered postmenopause. Dietary intake was recorded at three different timepoints and from this total dietary choline was calculated. The study team found that higher dietary intakes of choline were associated with a lower decline in cognitive performance, specifically being able to recall information ten minutes after it had first been read to participants. The findings for other subdomains were not significant and inconsistent. Only links between total dietary choline intake and not individual types were investigated. It’s therefore not possible to determine whether – similar to other studies – specific types of choline might have differential effects on cognition.
What changes with choline once we hit perimenopause?
This is where it is important to remind ourselves (as if we could forget! I know!) that our friend oestrogen is starting to make a disappearance as levels of oestradiol begin first to fluctuate and then continue or even accelerate their decline, with oestrone trying to take over (less successfully so) some of the functions of the former CEO. Why does this matter? Oestrogen plays a role in enabling the liver to synthesise phosphatidylcholine, which is involved in the number of important functions that I mentioned above. Less oestrogen = less phosphatidylcholine. (In addition to this, as mentioned before, it also plays a role in producing the omega-3 fatty acid DHA, an important player in brain health.)
In premenopausal women lack of choline in the diet is unlikely to cause issues, such as fatty liver (as choline is involved in removing fats from the liver), as our body is capable of ratcheting up choline production thanks to oestrogen - unless they have a genetic variation that leads to these processes not working. In this case even premenopausal women with higher oestrogen concentrations could do with an extra helping of choline from food. Small, but intense, studies have indeed shown that in postmenopausal women being put on a low-choline diet (less than 50 mg per day) led to liver and muscle dysfunction, which was reversed once participants went back to dietary choline levels of 550 mg per day.
How much choline do I actually need and where can I get it from?
For healthy populations, EFSA has determined that an adequate intake for women in general would be 400 mg per day, whereas the IoM is recommending 425 mg per day (or 7 mg per kg of body weight per day). This is thought to be an adequate intake to prevent choline deficiencies. And this is where the waters get a bit murky though. As already mentioned, the dietary guidelines in some countries, including the UK, Austria and Germany do not actually have reference values for choline intake because they argue that the research is still too unclear on this topic and they therefore don’t even class choline as an essential nutrient. To the contrary, the latest Nordic Nutrition Recommendations from 2023 have decided to indeed declare choline an essential nutrient and to go with EFSA’s advice.
I think yet again we have the problem that our particular stage of life, where so much is changing in our bodies, gets lumped in with the rest of the population! No recognition that for us things might look different and that we therefore need to make adaptations to the recommendations that might have worked before our hormones started to get into a turmoil!
The dietary sources richest in choline come from animals, including beef liver, eggs, specifically egg yolk (and fried eggs contain more than hard-boiled eggs), beef steak, other meats and salmon, ranging from 430 mg to 62 mg of choline per 100 g. They are also very good sources of phosphatidylcholine in particular. You can also get your choline from plant-based sources, but the amounts in these foods are lower. Edamame beans (56 mg/100g) almonds (52 mg/100g) and broccoli (40 mg/100g) are still a good source of choline and also rich in phosphatidylcholine. Different types of beans can also be a good source. If you are looking for fruits to add to your choline intake, clementines and tangerines contain 14 mg and 10 mg per 100 g respectively.
Interestingly, herbs and spices also contain choline and whilst you won’t be eating 100 g of dried parsley, basil or garlic powder in one go (At least I hope so!), adding these flavour-bombs to your dishes can make at least a small contribution to your daily dietary intake.
If you are interested in finding out the choline content of many foods eaten at least in Western cultures on a regular basis you can download the 2008 edition of the USDA Database for the choline content of common foods for free.
Depending on the form of choline contained in foods, cooking can potentially lead to a decrease in many of them. It would therefore be good to use gentle cooking methods, such as steaming rather than prolonged boiling, especially for vegetables. Consuming a mix of raw (where they are safe to eat) and cooked foods is a good strategy. If you fancy cooking something in a way that might lead to a reduction in choline content, just be aware of this and try to compensate with your additional food choices that day.
All things considered should I be mindful of my choline intake?
I think it is best to have a bit of a recap here. Choline (in its different forms) is either a component in itself, or a precursor involved in important processes in our bodies. Low intakes have been found to have a negative impact on wellbeing. Premenopausal women in general can produce phosphatidylcholine by themselves through the involvement of oestrogen. When oestrogen levels decline over the course of the menopause transition, as a consequence our bodies are less able to do so. It therefore becomes more important to get choline from our diet to cover our body’s demand for this. Therefore - spoiler alert - yes, my question was really more rhetorical. I do think that this is a time where we will need to take a look at the types of the foods that we consume to see whether our choline supply would be sufficient. It looks like choline is definitely becoming an essential nutrient as we are going through the menopause transition. Whilst we don’t have many studies that separate individual types of choline contained in foods, due to its important role in many bodily processes and the findings from cognition studies, phosphatidylcholine could potentially be of particular interest – at least in this domain. Fortunately, this particular form of choline is contained in a lot of foods.
Important aspects to think about in my opinion are that whilst we have evidence that low choline intake (around 10% of the amounts that some officials currently recommend) can be extremely detrimental to our health, studies have not been so clear cut at the other end of the spectrum with the most not necessarily meaning the best results. Therefore, even increasing your choline intake to around 70-80% of those recommendations can be a good start. If you are an omnivore chances are that you are at least close to reaching the required daily amounts and might only slightly need to tweak what you eat. But this is not an invitation to chomp down on meat at the expense of fibre and polyphenol rich foods delivered from plants. Diversity is the key here! Whilst in this post I have highlighted the importance of one nutrient in particular, we need to remember that this is only one amongst many and we should therefore try and consume a wide variety of foods every single day. If you don’t eat meat or animal products in general, this becomes even more important! You will probably need to be start being more mindful of how you can cover your back there with regards to choline. I repeat - both for human carnivores and herbivores variety is the key!
Before you break the seal on that bottle of supplements, because you want to be on the safe side, be aware that the upper daily limit for choline is 3500 mg to prevent us from getting too much of the good stuff. As there are differences in quality of different supplements on the market, definitely check with a trusted source of information before you buy. Ideally, you should try and get your choline from your diet, unless you have other underlying health conditions that require further medical advice anyway. It’s extremely hard to overdose on choline coming from dietary sources. A literature review conducted for the Nordic Nutrition Recommendations concluded that to get more than 3500 mg of choline from the diet, you would need to eat nearly 3 kg of salmon each day! And that is a LOT! of salmon!!
Your call to action this week
Take a look at the USDA database for choline content in foods and think about which ones you are currently consuming. Granted, you might not live in the US, but the composition of many raw foods will be very similar. (Plus researchers from around the world are using this one in the absence of choline tables for their native country.) Do you think that you are getting enough choline, or do you need to up your game a little? What about the diversity of your dietary intake? Does every meal look more or less the same and does beige reign supreme? Are there vegetables, fruits, nuts that you could easily introduce to up your choline intake (and as a bonus get a host of other beneficial compounds thrown into the mix)?
I would love to hear from you in the comments section how you get on!
See you next week!
Tanja x