Who is Deficient in Choline? Understanding the At-Risk Populations

November 1, 2025 •

4 min read

According to the National Institutes of Health, a significant portion of the population, particularly pregnant and lactating women, consumes less than the adequate intake of choline. Understanding who is deficient in choline is the first step toward preventing serious health consequences like fatty liver disease and cognitive decline.

Quick Summary

Choline deficiency is a risk for pregnant and postmenopausal women, vegans, athletes, and individuals with specific genetic variants that affect choline metabolism.

Key Points

At-Risk Groups: Pregnant and lactating women, postmenopausal women, vegans, athletes, and those with specific genetic variations are at a higher risk of choline deficiency.
Genetic Factors: Genetic polymorphisms, particularly in the PEMT gene, can reduce the body's ability to synthesize choline, increasing dietary requirements.
Key Symptoms: Signs of deficiency can include liver damage (NAFLD), memory impairment, muscle aches, and mood changes like anxiety.
Estrogen's Role: Higher estrogen levels protect premenopausal women by inducing choline synthesis, a protective effect lost after menopause.
Dietary Sources: The most concentrated sources are eggs, liver, meat, and fish, though plant-based foods like legumes and cruciferous vegetables also contain choline.
Diet vs. Synthesis: While the liver produces some choline, it is not enough to meet the body's needs, making adequate dietary intake essential for preventing deficiency.

The Prevalence of Inadequate Choline Intake

Although frank choline deficiency causing severe symptoms is rare, suboptimal intake is surprisingly common in the United States and other Western populations. A 2013–2014 National Health and Nutrition Examination Survey (NHANES) showed that the average daily choline intake from foods was often below the Adequate Intake (AI) recommendations for many groups. This widespread inadequate intake means that many individuals are not meeting the levels required for optimal health, potentially leading to long-term health issues.

Several factors contribute to this shortfall, including dietary choices, life stage, genetic predisposition, and certain medical conditions. The body can synthesize a small amount of choline, but this is insufficient to meet physiological needs, making dietary intake essential. The following sections detail the populations most at risk for inadequate choline status.

High-Risk Groups for Choline Deficiency

Pregnant and Lactating Women

Pregnancy and lactation significantly increase the body's need for choline to support fetal and infant brain development. During these critical periods, the mother's choline stores are depleted to supply the developing baby. Studies show that approximately 90–95% of pregnant women consume less than the recommended adequate intake of 450 mg per day. A deficiency during this time is associated with an increased risk of neural tube defects, cognitive deficits in the offspring, and maternal health complications like fatty liver disease. This risk is compounded by the fact that many prenatal supplements contain little to no choline.

Postmenopausal Women

Estrogen plays a protective role in choline metabolism by inducing the PEMT gene, which helps the body synthesize its own choline. Once estrogen levels decline after menopause, this protective mechanism is lost, and women become more dependent on dietary sources. Studies have shown that postmenopausal women are significantly more susceptible to developing signs of choline deficiency, such as liver or muscle damage, when placed on a low-choline diet compared to premenopausal women. Genetic variations in the PEMT gene can further increase this risk.

Vegans and Vegetarians

Choline is most abundant in animal products such as eggs, meat, fish, and dairy. As a result, individuals following a strict plant-based diet are at a much higher risk of inadequate intake. While some plant-based foods like nuts, beans, and cruciferous vegetables contain choline, it can be challenging to meet the AI without careful dietary planning or supplementation. This shift toward plant-based eating is often cited as a contributing factor to the low choline intake seen in many populations.

Individuals with Specific Genetic Variations

Genetic makeup can significantly influence an individual's choline needs. Common single nucleotide polymorphisms (SNPs) in genes like PEMT and MTHFD1 can impair the body's ability to synthesize or metabolize choline efficiently. For example, studies have identified PEMT gene variants that reduce the body's ability to produce choline by up to 40%. These individuals may require a significantly higher dietary intake to avoid deficiency symptoms, even if they appear healthy.

Patients on Total Parenteral Nutrition and with Liver Disease

Patients who receive total parenteral nutrition (TPN), or intravenous feeding, without supplemental choline can develop liver abnormalities, including nonalcoholic fatty liver disease (NAFLD). Additionally, individuals with pre-existing liver disease or conditions like cystic fibrosis that affect pancreatic function may have increased choline requirements. Choline is essential for transporting fats away from the liver, so any impairment in this process can lead to fat accumulation and liver damage.

Key Symptoms of Choline Deficiency

Symptoms of choline deficiency can be subtle or significant, and often affect the liver, brain, and muscles.

Liver Problems: Fatty liver disease (NAFLD), elevated liver enzymes, and overall liver dysfunction are common due to impaired fat transport from the liver.
Cognitive Decline: Memory impairment, difficulties with concentration, mental fatigue, and 'brain fog' are associated with low choline levels, which impact the production of the neurotransmitter acetylcholine.
Muscle Damage: Unexplained muscle aches, weakness, and elevated creatine kinase levels can occur.
Mood Changes: Anxiety, restlessness, and mood fluctuations have been linked to inadequate choline intake.

Comparison of Choline Sources

To help meet adequate intake levels, here is a comparison of choline content in various food types. The Adequate Intake (AI) for adult men is 550 mg per day, and 425 mg per day for adult women.


Food Source	Serving Size	Approximate Choline Content	Recommended For	Considerations
Eggs (with yolk)	1 large egg	~147 mg	Most people	A major source in the Western diet.
Beef Liver	3 oz, cooked	>350 mg	Optimal for rapid repletion	Very high concentration, may not be a dietary staple.
Salmon	3 oz, cooked	~187 mg	Those seeking brain benefits	Also rich in omega-3 fatty acids.
Chicken Breast	3 oz, cooked	~56 mg	Those seeking a leaner source	A good contributor to daily intake.
Soybeans/Tofu	½ cup, firm tofu	~35 mg	Vegans/Vegetarians	Reliable plant-based source.
Cruciferous Veggies	½ cup, Brussels sprouts	~32 mg	Vegans/Vegetarians, general health	Moderate source, adds to overall intake.

Conclusion

Despite its crucial role in human health, choline remains an underappreciated and underconsumed nutrient. The risk of inadequate intake and potential deficiency is not limited to one group but spans various populations, including pregnant and lactating women, postmenopausal women, vegans, and individuals with specific genetic predispositions. Recognizing the risk factors and potential symptoms is vital for preventing the cascade of health issues associated with low choline status, such as liver and cognitive problems. While the body can synthesize some choline, relying on a diet rich in sources like eggs, meat, fish, and certain plant-based options is the most effective way to maintain optimal levels. For those with higher needs or dietary restrictions, discussing supplementation with a healthcare provider may be appropriate.

For more detailed information on choline and its health effects, refer to the National Institutes of Health's Office of Dietary Supplements website.

Frequently Asked Questions

The most common cause of choline inadequacy is insufficient dietary intake, especially with the reduced consumption of choline-rich foods like eggs and liver. Genetic variations can also increase an individual's need for choline.

Yes, vegans and vegetarians are at an increased risk because the richest sources of choline are animal products. They must be proactive in consuming plant-based sources like soy products, legumes, nuts, and cruciferous vegetables, and may require supplementation.

During pregnancy and lactation, there is a significantly increased demand for choline to support the development of the fetal and infant brain. Maternal choline stores are prioritized for the baby, increasing the mother's risk of deficiency.

After menopause, a woman's estrogen levels decrease, which also reduces the body's ability to synthesize choline internally via the PEMT gene. This increases the dependence on dietary sources, making postmenopausal women more susceptible to deficiency.

Yes, choline is a precursor to acetylcholine, a crucial neurotransmitter for memory and muscle control. Low choline levels can lead to cognitive decline, memory issues, and mental fatigue.

Inadequate choline can impair the liver's ability to transport fats, leading to the accumulation of fat and potentially causing nonalcoholic fatty liver disease (NAFLD) and elevated liver enzymes.

Yes, genetic variations in genes like PEMT can affect how efficiently your body produces and uses choline. Individuals with certain variants may need a higher dietary intake of choline to prevent deficiency.