Choline Deficiency, Its Consequences and How You Fix It | Part 2 of the "Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them" Series

Don't you tell me there was no fancy cooking with the choline source #1, i.e. egg yolk! What about egg yolk on ricotta cauliflower ravioli filling, for example, | get the recipe @ tastespotting.com

If you've read the last installment of this series, you can hardly be surprised that today, we are about to talk or rather I am about to write about choline. Choline is, as Wikipedia informs us, a water-soluble essential nutrient. Why choline is not officially called a "vitamin" is beyond me. "Experts" will still group it within the B-complex vitamins, anyway.

In my analyses in the series on nutrients other than carbohydrates that influence glucose control, you've read that the former, the "other", "real" B-vitamins are - in my humble opinion - totally overrated. Choline, which can come in various forms of quaternary ammonium salts all of which contain the characteristic N,N,N-trimethylethanolammonium cation, on the other hand, it probably the most underrated micronutrient - not only for glucose control, by the way.

You can learn more about choline at the SuppVersity

Huge GH Spikes from GPC!?

Choline & Classic Bodybuilding

Improved Lipid Profile W/ Eggs

Caffeine, Choline, L-Car = Fat Loss

Choline Maximizes Carnitine Storage

Choline as a Nootropic?

One of the reasons choline has been depreciated is probably that it occurs in all the good foods of which scientists have been (falsely) telling you that you must not eat them for decades.

Figure 1: Eggs, or rather their fatty yolks, are a very good source of choline. One too few people appreciate for its nutritional density and too many people fear for its allegedly bad cholesterol content | learn why this is bullocks

Voilà, exhibit A (see Figure 1), an egg. The "bad" yolk of a single egg contains enough choline to "get you through the day" - whether that's also enough choline for optimal health is a question we are about to tackle later in today's installment of the Common Nutrient Deficiencies, Their Health Consequences and How You Can Fix Them" Series (you can browse through past and previous issues, here, if you have an RSS compatible web-browser).

The fact that generations of bodybuilders have been throwing away the yolks only to supplement with even more choline than they'd have gotten from their eggs does yet certainly tell you something about the importance of this nutrient.

But I am digressing, here. What we actually wanted to talk about is after all "normal" people, not bodybuilders. Normal people like the participants of the 2005 National Health and Nutrition Examination Survey (NHANES) among which only 2% of postmenopausal women consumed the recommended amount of for choline, and in general "mean choline intakes for older children, men, women and pregnant women are far below the Adequate Intake established by the IOM" (Zeisel. 1991).

When people don't get enough choline in their diets, and the amount of choline in their system declines, will eventually lose their ability to methylate homocysteine to methionine. The result, their plasma levels of homocysteine increase and heart disease, dementia, and even cancer are lurking right around the corner.

Why is high plasma homocysteine bad? In spite of the fact that it is still questionable, whether homocysteine is causally involved in the etiology of heart disease (Brattström. 2000), the present evidence leaves little doubt that high homocysteine levels are a marker of increased risks for several chronic diseases and conditions including cardiovascular disease, cancer, cognitive decline and bone fractures (HSC. 2002; Wu. 2002; Seshadri. 2002; van Meurs. 2004).

Even in the absence of vitamin B6, and B12, of which everybody is talking these days, choline and its cousin betaine have the ability to lower homocysteine levels (Chiuve. 2007). In this context you should also keep in mind that (a) homocysteine levels and the development of the triage we call "metabolic syndrome" (obesity, diabetes, high cholesterol) and that (b) choline is "lost" (oxidized) during the methylation process -- the choline requirements of the average, meanwhile at least chubby US citizen are thus naturally higher than the RDA scientists have determined in a day and age, when a BMI of >30 was still the exception.

Figure 2: The maintenance of healthy homocysteine levels is only one of choline's many important effects.

Aside from being involved in the clearance of homocysteine, choline is also, and maybe even more importantly, used in the synthesis of the constructional components of your body's cell membranes and much more (see Figure 2, as well):

• Choline figures in cell signaling, where the choline-containing phospholipids, phosphatidylcholine, and sphingomyelin, are precursors for the intracellular messenger molecules, diacylglycerol and ceramide. And with the platelet activating factor (PAF, an activator, and mediator of many leukocyte functions, including platelet aggregation and degranulation, inflammation, and anaphylaxis) and sphingophosphorylcholine (regulate traffic around / across the cell membrane; Ramstedt. 2002), there are two additional choline metabolites with important systemic functions.
• The transmission of never impulses is another, certainly one of the most important functions of choline or rather acetylcholine, an important neurotransmitter involved in muscle control, memory, and many other functions. No wonder that low choline levels have been associated with the progression of Alzheimer's and non-Alzheimer's dementia (Babic. 1999; Seshadri. 2002)

Apropos beyond methylation - choline can make up for a lack of folate! The often decried lack of folate intake (just as a reminder the folate fortification program in the US made no one healthier - with one exception, maybe: The recommendations to increase folate intake for pregnant women/women of childbearing age has been relatively successful in preventing neural tube defects in infants) would be much less of an issue in the diabesity problem, if the average American consumed 2,200mg of choline per day. The same amount of choline that is which preserved the markers of cellular methylation and attenuated folate deficiency related DNA damage in a genetic subgroup of folate-compromised men in a 2010 study by Shin et al.

• The effects on lipid (fat) transport and metabolism are probably still totally underrated by both the public and certain parts of the medical establishment. The fat and cholesterol that's consumed in the diet are after all transported to the liver by lipoproteins (chylomicrons) which are built from phosphatidylcholine. If there is not enough choline to build these 'cholesterol shuttles' the fat and cholesterol will begin to accumulate in your liver. No wonder scientists have long discovered an intricate relationship between choline intakes, on the one hand, and the development of non-alcoholic fatty liver disease, on the other hand - in fact, more recent evidence suggests that millions of US citizens have been able to escape a non-alcoholic fatty liver only due to "good genes" that allow them to budget their insufficient choline intake better than others (Spencer. 2011).

In spite of the fact that a full-blown choline deficiency will impair your exercise performance, the provision of supplemental choline has not been shown to consistently produce meaningful increases in exercise performance (Penry. 2008). As a physical culturist, you should still keep in mind that intense exercise will increase your basal choline requirements of which the wise USDA says based on data of which the researchers say that its quality "varies widely across studies", with the most significant sources of potential sources being over- or underreporting of portion sizes and frequency of intake, omission of foods, and inaccuracies related to the use of food composition tables. Accordingly Yates et al. add for consideration:

Table 1: High choline foods for omnivores and vegetarians; choline content in milligrams / 100g | data adapted from nutritiondata.com

"Therefore, the values reported by nationwide surveys or studies that rely on self-report may be somewhat inaccurate and possibly biased. Food composition databases that are used to calculate nutrient intake from self-reported and observed intake data introduce errors due to random variability, genetic variation in the nutrient content, analytical errors, and missing or imputed data.

In general, when nutrient intakes for groups are estimated, the effect of errors in the composition data is probably considerably smaller than the effect of errors in the self-reported intake data (NRC, 1986). However, it is not known to what extent this is true for folate, biotin, pantothenic acid, or choline." (Yates. 1998)

That's bad because the first signs of liver damage in humans (beginning NAFLD if you will) occur after only 3 weeks on a choline deficient diet (Zeisel. 1991). In view of the fact that doses of safe therapeutic doses go into the 8-10 gram range and considering the fact that the total amount of choline in foods is not exactly exorbitantly high, it would appear prudent to follow the "more is better principle", when it comes to choline-rich foods (see Table 1 and bottom line for suggestions | Didn't find the food you were looking for? Try the official USDA Overview).

Don't go overboard on supplements! When it comes to supplementation, on the other hand, you better be careful not do overdo it. While choline is generally relatively benign, it can produce side effects that range from increased potassium and magnesium requirements over depressive-like symptoms (a general sluggishness) to vomiting and, in some people, acne-like skin rashes. Dosages in the below 3g per day range do yet generally appear to be tolerated very well. In the long term, the phospholipid-bound forms of choline can yet produce quite nasty depressive-like side-effects - another reason to prefer the cheap and effective citrates and tartrates if you are just "supplementing" your diet or looking for the metabolic effects, primarily.

Unless you are following a no fat diet, the use of dietary supplements to cover your baseline requirements of 500-600mg (I am deliberately not using the ostensibly "accurate" RDA, here) shouldn't  be necessary - at least if you eat your healthy eggs every day ;-)

Choline as a "metabolic activator" and diet aid!?

If you mimic the old-school body- builders and have your choline supps with meat, this will increase the retention & effects of carnitine.

If you remember my previous article on the relatively unknown "CCC-Stack" which consists of caffeine, carnitine, and... you guessed it, choline you will yet remember that doubling your intake with 500mg of choline tartrate or citrate had quite remarkable effects on the metabolism (learn more | for metabolic purposes I would prefer the citrate and tartrate forms over the expensive phospholipid bound version of choline, which may have its advantages, though, when it comes to brain-related effects).

Moreover, a recent study from the Zagazig and the Mansura University in Egypt suggests that choline alone, will produce quite impressive weight loss effects - even in the absence of the "fat liberator" caffeine and the "fat transporter" carnitine, i.e. the other "C"s in the CCC stack.

The study, Elsawy, Abdelrahman and Hamza conducted investigated the effects of choline supplementation on body mass reduction and leptin levels among female taekwondo and judo athletes in the pre-competition phase (Elsawy. 2014).

Figure 3: Relative changes in lipid oxidation, body fat (%), body mass and strength parameters in female athletes during contest prep with (choline) and without (control) 2x2g of supplemental choline in their meals (Elsawy. 2014)

Twenty-two female athletes (15 taekwondo and 7 judo athletes) were selected from different weight
categories and divided into two groups, according to weight. The players in the experimental group consumed their choline supplements (2x2.0g of choline bitartrate) daily with meals for one week.

I guess the results actually speak for themselves. As expected, the experiment revealed significant differences between pre- and post-competition measurements of free plasma choline, and urine choline levels. The significantly higher fat loss, on the other hand, is something even the researchers did not necessary expect to see. In view of the reduction in malondialdehyde (MDA = lipid oxidation) and the increase in carnitine retention and effects you've read about in a previous SuppVersity article ("Choline Maximizes Carnitine Retention + Effects" | read more) it is yet eventually not surprising that the choline group lost more body fat without suffering significant reductions in strength and lean mass.

Eat three of these or combine two of them: One whole eggs, 4oz of shrimp, or 5oz scallop, 5oz chicken, 5oz turkey

Eat four of these or combine four of them: 4oz cod, 1.5 cups of collard greens, 1.75 cups of Brussel sprouts, 1.75cups of broccoli, 5oz tuna, 5oz salmon, 6oz beef, 6 oz sardines

Eat five of these or combine one of each 2cups of swiss chard, 2cups of cauliflower, 2cups of asparagus, 2.25cups of spinach, 2cups green peas, 2.5 cups cabbage, 2 cups of Shiitake mushrooms

Other foods with choline, of which you'd yet probably have to eat too much to get to your SRI (SuppVersity recommended intake for adults) of 500-600mg are green beans and bok choy (5% of SRI per cup), summer squash, miso and tomatoes (1-2% of SRI per cup)

Bottom line: I am well aware that the fat loss effects, I deliberately mentioned last are probably the "sexiest" benefits choline has to offer. Compared to the conservation of liver, brain and heart hearth for which you "just" have to make sure that you consume enough of the foods in the list to the right, the ability of supplemental choline to promote fat loss and conserve lean mass and strength in "average Janes" (read more) and competitive athletes (Figure 3) is actually quite pathetic.

Speaking of "pathetic" the notion that eggs would be bad for you because they contain cholesterol is probably even more pathetic than the notion that being ripped was more attractive than being healthy. In view of the fact that the amount of highly bioavailable choline in a single egg can cover 20%-35% (depending on its size) of your daily choline demands, having an egg for breakfast is nothing you should consider, but rather something you should simply do! The increase in choline intake, the beneficial effects on your cholesterol particle and phospholipid profile and the increase in HDL-driven lipid reverse-transport are after all something you don't want to sacrifice on the altar or unwarranted prejudices and in blind obedience to dietary guidelines of which more and more researchers say that they "are not benefiting the public as a whole and may actually have negative nutritional implications." (Herron. 2004)

References:

• Babic, T. "The cholinergic hypothesis of Alzheimer’s disease: a review of progress." Journal of Neurology, Neurosurgery & Psychiatry 67.4 (1999): 558-558.
• Brattström, Lars, and David EL Wilcken. "Homocysteine and cardiovascular disease: cause or effect?." The American journal of clinical nutrition 72.2 (2000): 315-323.
• Elsawy, Gehan, Osama Abdelrahman, and Amr Hamza. "Effect of Choline Supplementation on Rapid Weight Loss and Biochemical Variables Among Female Taekwondo and Judo Athletes." Journal of Human Kinetics 40.1 (2014): 77-82.
• Herron, Kristin L., and Maria Luz Fernandez. "Are the current dietary guidelines regarding egg consumption appropriate?." The Journal of nutrition 134.1 (2004): 187-190.
• HSC: Homocysteine Studies Collaboration. "Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis." Jama 288.16 (2002): 2015-2022. 
• Penry, Jason T., and Melinda M. Manore. "Choline: an important micronutrient for maximal endurance-exercise performance?." International journal of sport nutrition and exercise metabolism 18.2 (2008): 191.
• Ramstedt, Bodil, and J. Peter Slotte. "Membrane properties of sphingomyelins." FEBS letters 531.1 (2002): 33-37.
• Seshadri, Sudha, et al. "Plasma homocysteine as a risk factor for dementia and Alzheimer's disease." New England Journal of Medicine 346.7 (2002): 476-483. 
• Shin, William, et al. "Choline intake exceeding current dietary recommendations preserves markers of cellular methylation in a genetic subgroup of folate-compromised men." The Journal of nutrition 140.5 (2010): 975-980.
• Spencer, Melanie D., et al. "Association between composition of the human gastrointestinal microbiome and development of fatty liver with choline deficiency." Gastroenterology 140.3 (2011): 976-986.
• van Meurs, Joyce BJ, et al. "Homocysteine levels and the risk of osteoporotic fracture." New England Journal of Medicine 350.20 (2004): 2033-2041.
• Wu, Lily L., and James T. Wu. "Hyperhomocysteinemia is a risk factor for cancer and a new potential tumor marker." Clinica Chimica Acta 322.1 (2002): 21-28.
• Yates, Allison A., Sandra A. Schlicker, and Carol W. Suitor. "Dietary reference intakes: the new basis for recommendations for calcium and related nutrients, B vitamins, and choline." Journal of the American Dietetic Association 98.6 (1998): 699-706. 
• Zeisel, STEVEN H., et al. "Choline, an essential nutrient for humans." The FASEB journal 5.7 (1991): 2093-2098.