Marie Caudill, PhD, RD

Scientific Dietary Guidelines Suggest Americans Consume Too Little Choline Interview with:

Marie Caudill, PhD, RD

Dr. Caudill

Marie Caudill, PhD, RD

Professor Caudill is a registered dietitian and professor in the Division of Nutritional Sciences at Cornell University. She is internationally recognized for her research on folate and choline, and has published more than 150 papers, reviews, or chapters in these areas. Her current research focuses primarily on the level of choline intake required to meet metabolic requirements and improve health outcomes during pregnancy. Professor Caudill is a co-editor of the graduate level textbook “Biochemical, Physiological, & Molecular Aspects of Human Nutrition,” and is frequently invited to speak on topics related to prenatal nutrition, one-carbon metabolism and nutritional genomics. What is the background for this study?

Response: The U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) (collectively ‘Departments’) work together to update and release the Dietary Guidelines for Americans every five years. The Departments use an external Federal Advisory Committee (Dietary Guidelines Advisory Committee, DGAC or Committee) to review the current body of nutrition science. The 2020-2025 DGAC includes 20 nationally recognized scientific experts in nutrition and medicine.

On July 15, the Committee’s report—Scientific Report of the 2020 Dietary Guidelines Advisory Committee—was released to the general public for review and feedback (via a 30-day open comments period). Contents of the report include the DGAC’s scientific conclusions and advice to the Departments when developing the next Dietary Guidelines for Americans, as well as recommendations for future scientific directions.

Through scientific review, the DGAC concluded several food components, including choline, are under-consumed by all Americans ages 1 year and older, and therefore pose a special public health challenge.

What is choline and why is it important, especially during pregnancy?

Choline is an essential nutrient for a variety of physiological functions across all ages and stages of life. It is needed by every single cell in the body and supports many functions, including:

  • Cellular integrity: Functions as a major component of cell walls
  • Liver health: Exports fat from the liver
  • Brain health: Builds and enhances the brain’s information ‘superhighways;’ improves memory potential; and enhances focus
  • Genetic balance: Supports DNA methylation to influence gene expression

Choline is especially important during pregnancy and lactation, and health experts recommend pregnant and lactating women consume 450 mg per day and 550 mg per day, respectively. It offers five key benefits for fetal and infant development:

  • Synergizes with other nutrients: As a major methyl donor, choline synergistically interacts with several other nutrients, including folate and DHA (omega-3 fatty acid) to ensure normal physiological processes.
  • Supports brain development: Emerging data from human studies report that a higher prenatal choline intake improves processing speed and attention among infants, and associates with fewer social withdrawal problems and better visual memory among children. Prenatal choline may also provide protection against some of the neural insults arising from fetal alcohol exposure.
  • Reduces risk of neural tube defects (NTDs): Cell division is critical for the normal closure of the neural tube. While more emphasis is typically placed on folate’s essential role in this process, choline has an equally important role as a main constituent of all cell membranes. Importantly, not all NTDs are folic acid responsive.
  • Eases baby’s response to stress: Choline helps to reduce baby’s cortisol levels.
  • Supports placental health: Choline lowers placental production and maternal circulating levels of sFLT1, an anti-angiogenic protein that contributes to the development of placental dysfunction and pre-eclampsia.

Despite the essentiality, data suggests 8 percent of pregnant women meet recommendations. What are the main recommendations?

 Response: In recent years, authoritative bodies’ recognition of choline’s importance for women of childbearing age has grown, as has the recommendation to consume choline during these life stages. The American Medical Association (AMA) vocally supports higher amounts of choline in prenatal vitamins, and the American Academy of Pediatrics (AAP) highlights choline as a key nutrient for neurodevelopment within the first 1,000 days.

The DGAC findings concur with the AMA and AAP recommendations to increase choline intake among vulnerable populations, such as pregnant and lactating women and infants and children. While more research is needed for choline to reach the level of a ‘nutrient of public health concern,’ the Committee recognized current choline intake levels are too low for most Americans. Data suggest less than 10 percent of the general American population meets adequate intake recommendations.

Adequate Intake (AI)
Infants (Birth-6 months) 125 mg/d, 18 mg/kg
Infants (7-12 months) 150 mg/d
Male (1-3 years) 200 mg/d
Male (4-8 years) 250 mg/d
Male (9-13 years) 375 mg/d
Male (14-18 years) 550 mg/d
Male (>19 years) 550 mg/d
Female (1-3 years) 200 mg/d
Female (4-8 years) 250 mg/d
Female (9-13 years) 375 mg/d
Female (14-18 years)* 400 mg/d
Female (>19 years)* 425 mg/d
Pregnant 450 mg/d
Lactating 550 mg/d

*Excluding pregnant and lactating women

How can readers get more choline into their diet?

Choline is found mainly in animal foods—eggs, beef, chicken, salmon—and in smaller amounts in plant-based foods—brussels sprouts, wheat germ, broccoli; it is also fortified in some foods and available through choline supplements. Few prenatal vitamins currently on the market contain enough—if any—choline.

Typical eating patterns make it difficult to meet daily choline needs. In fact, the DGAC presented three food pattern styles—the Healthy U.S.-Style Eating Style, the Healthy Vegetarian Pattern and the Healthy Mediterranean-Style Pattern—which generally meet all nutrient needs across the lifespan, except for a few, including choline.

Given these findings, all Americans, especially vulnerable populations such as pregnant and lactating women, can benefit from a more aggressive approach to choline consumption. Choline-containing foods can be added to healthy diets, and choline supplements can be used to fill consumption gaps. Pregnant and lactating women should couple their prenatal vitamin with a choline supplement.

What recommendations do you have for future research as a result of this work?

Response: Choline’s increased recognition in the DGAC report is an important scientific milestone for the public health community. We are quickly approaching an inflection point in time for choline awareness – and it is critical we build on this momentum to help close the consumption gap.

As outlined in the DGAC report, future Committees will benefit from several recommendations.

  • Update and strengthen choline DRIs for all age-sex groups and life stages, especially infants and children younger than age 24 months and women during pregnancy and lactation, to better characterize potential risk of dietary inadequacy and excess.
  • Evaluate the relative contribution of choline from all sources of foods and beverages, including fortified foods and supplements among women who are pregnant and lactating, and identify strategies to help women attain sufficiency and avoid excess to balance intake from foods, including fortified foods and supplements.
  • Build upon the existing research to identify how maternal dietary patterns, including beverages and foods, as well as specific components, including choline, are related to child development.
  • Examine questions on the relationship between maternal dietary supplement and/or fortified food intake of choline and maternal and child outcomes.
  • Develop research in women who are lactating that focuses on an examination of maternal dietary intake patterns and child development (child language development, autism spectrum disorder, cognitive development, social emotional development, academic performance, ADD/ADHD, anxiety, and depression) emphasizing foods rich in key nutrients for which a relationship between maternal intake and human milk composition has been established (e.g., choline in relation to brain development).
  • Identify deficiency and excess of choline through the development of choline biomarkers, for infants and children younger than age 2 years. Is there anything else you would like to add?

Response: The Committee’s scientific report shines a light on the growing body of evidence that shows choline plays a critical role in health during specific life stages and is under consumed among all Americans at every life stage. The Committee’s conclusions and perspectives shared in their report set the stage for inclusion of choline in future DGAs. In the meantime, work should be done to address the recommendations and research priorities outlined in the DGAC report. Education and product innovation should continue to evolve to ensure that all Americans can meet choline needs, as part of healthy diets, throughout the lifespan. 


Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC.


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Last Updated on July 28, 2020 by Marie Benz MD FAAD