The Best Choline Supplements for Pregnancy, According to a Prenatal Dietitian

Are Choline Supplements Beneficial for Pregnant People?

It has largely been agreed upon by the American Medical Association and American Academy of Pediatrics that maternal choline intake is important and supplementation should be routinely recommended for all pregnant people.

Obtaining nutrients from whole foods has many benefits, but for many reasons it can be more challenging to meet one’s needs solely through diet during pregnancy. Pregnant people are encouraged to take a prenatal vitamin to fill in the gaps when nutrition from food is lacking. However, choline is often not included in these supplements.

Who May Not Benefit from Choline

According to Manaker, “supplementing [with choline] comes with little risk (if any).” However, one thing to highlight about supplemental choline is its connection with trimethylamine-N-oxide (TMAO). 

TMAO is a byproduct of nutrient metabolism in the gut. More specifically, when gut microbes digest certain nutrients, they produce a substance called TMA, which can then be absorbed and converted into TMAO. In humans, high levels of circulating TMAO have been linked with an increased risk for cardiovascular disease.

Some supplement forms of choline are linked to increased levels of TMAO while others are not. Interestingly, food sources of choline do not impact TMAO to the same level as supplements.

Choline is not known to have any interactions with medications, but always speak with a healthcare provider to ensure supplementation is safe for you.

How We Select Supplements

Our team works hard to be transparent about why we recommend certain supplements; you can read more about our dietary supplement methodology here.

We support supplements that are evidence-based and rooted in science. We value certain product attributes that we find to be associated with the highest quality products. We prioritize products that are third-party tested and certified by one of three independent, third party certifiers: USP, NSF, or ConsumerLab.com. We also spoke to registered dietitian and certified lactation educator Lauren Manaker, MS, RD, LD, about what to look for in a choline supplement.

It's important to note that the FDA does not review dietary supplements for safety and effectiveness before they go to market. Our team of experts has created a detailed, science-backed methodology to choose the supplements we recommend.

Why Pregnant People May Benefit from Choline Supplementation

Pregnant people may benefit from a choline supplement for a variety of reasons:

Potential Cognitive Function Improvement: Manaker says, “Choline appears to play a role in self-regulation, processing speed, and attention as the baby gets older.”

• Not only is choline an important structural component for the rapidly developing baby, but it may also have an impact on the neurodevelopment of the baby farther into their future.
• Data from observational studies are somewhat mixed. However, there is evidence that higher maternal intake of choline—at levels as high as 930 mg—is linked to faster processing speed and reaction time in infants 4 to 13 months of age and even up through age seven. 

Possible Neural Tube Defect Prevention: Research is now looking at the link between other nutrients, such as choline, and the possible reduction in NTDs.

• Folate gets most of the press when it comes to preventing neural tube defects (NTDs) for babies, and while folic acid supplementation does help reduce the risk of NTDs, these birth defects do still occur.
• It seems that studies are mixed, and while some show a strong link between higher choline intakes and fewer NTDs, other studies are less conclusive.

Possible Placental Health Improvement: All of the nutrients that the baby needs and receives are passed through the placenta, so the health and functioning of this unique organ is vital.

• While the research has mostly been conducted in animals, there appears to be a link between high level choline supplementation and enhanced nutrient transport, specifically improved transport of DHA, a fatty acid crucial for baby’s brain and nervous system development.
• A small study in pregnant women, which provided 930 mg of choline per day for 12 weeks, showed improved placental vascular function and a likely benefit to modifying preeclampsia risk.

What to Look for in a Choline Supplement for Pregnancy

Third-Party Testing

Supplements that are third-party tested are sent to a lab where they are tested to ensure they contain what they say they contain and are not contaminated with specific high-risk, common contaminants. However, it’s important to note:

• Third party testing does not test to see if a product is effective or safe for everyone, and it does not ensure the supplement will not interact with other supplements or medications.
• Not all third-party testing is created equal. It is not uncommon for supplement companies to pay labs for certificates after conducting minimal to no testing. 
• The third party certifications we can trust are: ConsumerLab.com, NSF, and USP. However, these certifications are difficult to obtain and/or expensive for manufacturers, so many companies choose not to get their products tested by one of these three organizations. 
• Sometimes products tested by these three companies are more expensive to try to offset the cost they pay for certification.
• Just because a supplement is not tested by one of these three companies, it does not mean it’s a bad product. We recommend doing some research on the reputability of the manufacturer, and calling up the manufacturer and their testing lab to determine their protocols and decide if you feel comfortable consuming the supplement.

Form

Choline supplements can be found in a variety of forms.One important consideration is that each supplement form actually provides a different amount of the active choline compound. Supplement labels commonly only list the amount of the ingredient, but not the amount of active choline, which can be confusing.

More specifically, the CDP-choline, choline citrate, alpha-GPC, bitartrate, and chloride forms have much greater concentrations of choline per gram. This means you can take less of the supplement to obtain the same amount of the active choline. However, as we will discuss below, some of these forms are not necessarily “better.” 

Forms of Choline We Recommend

• Phosphatidylcholine is the form predominantly found in food, the most abundant form of phospholipid in the body, and is commonly found in supplement form. Research has shown that phosphatidylcholine may be better absorbed than other sources, which leaves less choline in the gut to be potentially turned into potentially harmful TMAO.
• Choline citrate is less commonly found as a supplement, and it is worth noting that it’s often found to have a very sour taste. This form is not shown to significantly raise TMAO levels, and one study showed that high dose supplementation with this form decreased asthma symptoms and need for medication.
• Citicoline (CDP-choline) is a more expensive form, but it is highly sought after due to the two-in-one benefit of choline and cytidine, which is a precursor for uridine—a compound studied for neuroprotection and cognition. In a small study of pregnant animals, supplementation of citicoline showed decreased brain inflammation and improved memory function in offspring.
• Alpha-GPC choline contains about 40% choline and has been shown to modestly improve cognition in elderly people with Alzheimer’s.
• Lecithin is another form you will find as a choline supplement. This is usually derived from soybean, sunflower, and rapeseed and so could be found as a food-based supplement, or as a pill. Lecithin is actually a purified form of phosphatidylcholine, but the true amount of choline is only 2-3%. 

Forms of Choline We Recommend with Caution

Choline bitartrate contains quite a high percentage of active choline, but it has been demonstrated that this type possibly raises TMAO levels in the body more so than other forms. However, this risk may only be for high doses of the supplement as it was documented in findings from a 2021 study that provided subjects with 1000 mg of choline bitartrate daily, which is well above the recommended amount for pregnancy.

Interestingly, many prenatal vitamin companies use choline bitartrate in their products, but often well below 500 mg. These supplements commonly provide VitaCholine, which is manufactured from a supplement chemical company, Balchem (the same brand that is used in many research studies as well).

It is very likely that in low doses, choline bitartrate is safe, but more research needs to be done on the benefit and/or harm of this source of choline for pregnancy and the general population.

Ingredients & Potential Interactions

It is essential to carefully read the ingredient list and nutrition facts panel of a supplement to know which ingredients and how much of each ingredient is included, relative to the recommended daily value of that ingredient. Please bring the supplement label to a healthcare provider to review the different ingredients contained in the supplement and any potential interactions between these ingredients and other supplements and medications you are taking.

Choline supplements are, in general, fairly straightforward, but some products will contain additional nutrients. You may find B vitamins paired with choline because these nutrients work together in the body.

Choline Dosage

Always speak with a healthcare professional before adding a supplement to your routine to ensure that the supplement is appropriate for your individual needs and to understand which dosage to take.

According to the Institute of Medicine (IOM), there was not enough evidence to establish an Estimated Average Requirement (EAR) for choline, and so an Adequate Intake (AI) level was determined and for pregnancy is as follows:

• 4-18 years- 450 mg for pregnancy
• 19+ years- 450 mg for pregnancy

It is also important to note that the amount of choline that you need is influenced by the amount of methionine, betaine, and folate in your diet, your body’s ability to produce choline, and possible genetic mutations.

How Much is Too Much?

The IOM established the Tolerable Upper Intake Level (UL), meaning the maximum amount that can be safely taken on a daily basis, for choline as 3500 mg for adults, including during pregnancy and lactation.

Consuming excessive choline can cause a fishy body odor in some people, excessive sweating and salivation, vomiting and gastrointestinal upset, hypotension (low blood pressure), and liver toxicity.

Again, one concern that is being discussed more is the connection between choline and the production of TMAO, a compound that has been linked to a higher risk of cardiovascular disease in adults, depending on the dose. It does not appear that food sources of choline significantly impact TMAO, but choline supplements, particularly choline bitartrate, have been shown to raise TMAO levels. The choline-TMAO connection is not well-established, however, and many other factors such as genetics and gut microbiota may also influence TMAO production.

Why Trust Verywell Family

Casey Seiden, MS, RDN, CDN, CDCES is a registered dietitian nutritionist and certified diabetes care and education specialist based out of New York City. Casey works at Maternal Fetal Medicine Associates, the premier maternal fetal medicine practice in Manhattan, where she provides nutrition therapy and counseling to women with high risk pregnancies. She is also the founder of Casey Seiden Nutrition, a virtual private practice specializing in a non-diet approach to diabetes care and women’s health.