Marie Caudill, PhD, RDElizabeth Ward, MS, RD

CHOLINE: EXPLORING THE GROWING SCIENCE ON ITS BENEFITS FOR MOMS,

DURING FETAL DEVELOPMENT AND BEYOND

Wednesday, September 12, 2018

Internationally recognized expert known for her work on folate andcholine

Research focuses primarily on choline and the level of intake required to meet metabolic requirements and improve physiological outcomes

Published more than 100 papers, reviews or chapters in this area and is an editor on the popular graduate level textbook "Biochemical, Physiological, & Molecular Aspects of Human Nutrition”

Frequently invited to speak on topics related to methyl nutrients, one- carbon metabolism and nutritional genomics

MARIE CAUDILL, PHD, RDPROFESSOR, DIVISION OF NUTRITIONAL SCIENCES AT CORNELL UNIVERSITY

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Award-winning author, nutrition consultant and spokesperson Author/co-author of seven books including her most

recent,“Expect the Best,Your Guide to Healthy Eating Before, During and After Pregnancy, 2nd ed.”

Frequently writes for several top-tier publications and maintains a website, Betteristhenewperfect.com

Previously a spokesperson for the Academy of Nutrition and Dietetics for nine years and was a writer and contributing editor for Environmental Nutrition, and a writer for WebMD

Counseled children, and pregnant women and other adults about healthy eating and disease prevention at Harvard Vanguard Medical Associates

Expert advisor to the HP Hood company 3

ELIZABETH WARD, MS, RDCONSULTANT AND AUTHOR

WEBINAR BROUGHT TO

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1. Recognize the critical role choline plays in supporting positive health outcomes,particularly at important life stages such as during fetal development and beyond.

2. Translate scientific evidence into meaningful dietary recommendations to help boost choline intake.

3. Recommend foods and supplements that can help infants, women and other consumers improve choline intake to achieve research-backed health benefits.

LEARNING OBJECTIVES

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CHOLINE IN THE LIFE CYCLE: THE ESSENTIAL NUTRIENT MORE PEOPLE NEED TO KNOWSTATE OF THE SCIENCE

MARIE A. CAUDILL, PHD, RDDIVISION OF NUTRITIONAL SCIENCESCORNELL UNIVERSITY

Grants/Research Support NIH, USDA, Balchem Corporation, Egg Nutrition Center, National Cattlemen’s Beef

Association/Beef Checkoff Other Financial or Material Support/Honorarium

Balchem Corporation

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DISCLOSURES

Steven H. Zeisel

1932 1990s 1998

Charles H. Best 8

HISTORICAL TIDBITS

Phosphatidylcholine (PC)

PC PC

PC

VLDL Fat ExportMembrane Biosynthesis

WHAT DOES CHOLINE DO?

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WHAT DOES CHOLINE DO?

Acetylcholine

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WHAT DOES CHOLINE DO?

Methyl Donor

+

DNA Methylation

Creatine Phospholipids Hormones Neurotransmitters

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CHOLINE PLAYS A FUNDAMENTAL ROLE IN HUMAN HEALTH ACROSS THE LIFE CYCLE12

CH3

CH3CH3

Learning

Memory

Attention

Fetal Growth Brain Development

Proteins Hormone

s Metabolites

LARGE AMOUNTS OF CHOLINE ARE REQUIRED DURING PREGNANCY

Cellular Function 13

Lasting Effects on Health

N=99OR=0.66 N=98

OR=0.63

N=80 OR=0.49

1

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

Shaw GM, et al. Am J Epidemiol. 2004;160:102-109. Shaw GM, et al. Epidemiology. 2009;20:714-719.

<290 290-371 371-498 >498 14

Choline Intake, mg/d

Odd

s

HIGHER MATERNAL CHOLINE INTAKE REDUCES RISK OF NEURAL TUBE DEFECTS

Categor

Hypothalamus

*

Infant Plasma Cortisol

PituitaryPlacenta

Adrenal Cortex Circulation

4035302520151050

Jiang X, et al. FASEB J. 2012;26:3563-3574.

HIGHER MATERNAL CHOLINE INTAKE EASES BABY’S RESPONSE TO STRESS

g/

Hypertension Obesity Diabetes DepressionCH3 CH3 CH3

“Choline” Baby

Memory Learning Attention

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Jiang X, et al. FASEB J. 2012;26:3563-

LOWER PRODUCTION OF CORTISOL IN “CHOLINE BABIES” MAYREDUCE RISK OF STRESS-RELATED DISEASES

3574.

In PE, placenta produces too much Preeclampsia

Placenta

+FLT1

sFLT1 + VEGFVEGF VEGF

++ VEGF

-

Impaired VEGF binding to mFLT1

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HIGHER MATERNAL CHOLINE INTAKE LOWERS PREECLAMPSIA RISK FACTOR

Endothelial dysfunction

Jiang X, et al. FASEB J. 2013;27:1245-1253.

Maternal hypertension Maternal kidney impairment

Choline Placenta

-FLT1 - VEGF VEGF

sFLT1 VEGF

-- VEGF

VEGF +

Endothelial cells

In PE, placenta produces too much

Normal VEGF binding to mFLT1

Jiang X, et al. FASEB J. 2013;27:1245-1253.

Endothelial health

mFL

T1

In PE, placenta produces too much

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HIGHER MATERNAL CHOLINE INTAKE LOWERS PREECLAMPSIA RISK FACTOR

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CON = control; SUP = supplementation.Meck WH,Williams CL. Neurosci Biobehav Rev. 2003;27:385-399.

HIGHER MATERNAL CHOLINE INTAKE IMPROVES OFFSPRING COGNITIVE FUNCTIONING (ANIMALS)

Administered a visual attention task to measure eye movement reaction time to sequences ofbriefly presented visual stimuli 20

HIGHER MATERNAL CHOLINE INTAKE IMPROVES INFANT INFORMATION PROCESSING SPEED (HUMANS)

• Attention• Memory• Problem Solving

ASN 2018Abstract Submission ID: 424013Abstract Title: “Enduring benefits of prenatal choline supplementation in 7-year olds: enhanced attention task performance”Presenting Author: Charlotte BahnflethOral Session Title:“Nutritional Implications for Brain and Cognition” (Oral 11)Oral Session Date: Sunday, June 10, 2018Oral Session Time: 10:30 AM - 12:30 PM 21

COGNITIVE ASSESSMENT IN THESE CHILDREN AT AGE 7 REVEAL LASTING BENEFITS OF THE HIGHER MATERNAL CHOLINE INTAKE

Oral Session Location: Hynes Convention Center, Room 210

480 mg/d choline930 mg/d choline

Studies are being conducted in pregnant women to address this important question.

Circulating PC- DHA Non-Pregnant Women

Tota

l PC-

Fatty

Acid

s, %

by

CHOLINE-DHA SYNERGY:A WAY TO INCREASE FETAL DHA SUPPLY?

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West AA, et al. Am J Clin Nutr. 2013;97:718-727.

Choline AI is 450 mg/d Average choline intake is

~300- 350 mg/d Common genetic

variants increase choline requirements (further increasing gap between choline needs and intake)

ONLY 10 PERCENT OF US PREGNANT WOMEN ARE MEETING THE CHOLINE AI

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VERY FEW OF THE MOST RECOGNIZED PRENATAL OR MULTIVITAMINS CONTAIN THE RECOMMENDED AMOUNT OF CHOLINE

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THE AMERICAN MEDICAL ASSOCIATION (AMA) RECENTLY ANNOUNCED IT WILL SUPPORT ACTIONS TO BOOST CHOLINE AMOUNTS IN PRENATAL VITAMINS!

THE AMERICAN ACADEMY OF PEDIATRICS RECENTLY RECOGNIZED CHOLINE AS AKEY NUTRIENT TO SUPPORT NEURODEVELOPMENT DURING THE FIRST 1,000 DAYS

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Large amounts of choline are required for normal fetal and neonatal development.

Higher maternal choline intake will likely improve pregnancy outcomes and offspring health.

Most pregnant and lactating women need to increase dietary choline intake orconsume a choline supplement to meet recommendations.

KEY TAKEAWAYS

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HEALTH PROFESSIONALS AND CHOLINE COMMUNICATION: WHERE DO WE STAND?ELIZABETH WARD, MS, RD

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Other Financial or Material Support/Honorarium Balchem Corporation

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DISCLOSURES

600

500

400

300200

550 425

450

550 Recommended (AI)

Actual Intake

200

100

0Kids Men Women Pregnancy Lactation

NHANES 2009-2014 30

Source: http://cholinecouncil.com/health_professional/

mg/

MOST AMERICANS DO NOT ACHIEVE ADEQUATE INTAKE FOR CHOLINE

CHOLINE AND THE DIETARY GUIDELINES FOR

The 2015–2020 Dietary Guidelines for Americans Advisory Committee (DGAC) identified four nutrients with an Adequate Intake (AI) - vitamin K, fiber, potassium, and choline – that are under-consumed by children and adults.

https://health.gov/dietaryguidelines/2015-scientific-report/https://health.gov/dietaryguidelines/2015/guidelines/appendix-3/ 31

CHOLINE AND THE DIETARY GUIDELINES FOR

Of the four, only fiber and potassium were called out in the DGA as nutrients of public health concern.

In addition, almost all of the USDA Healthy U.S.-Style Eating patterns included in the 2015-2020 DGA lack adequate choline. They also lack potassium, and vitamins D and E.

https://health.gov/dietaryguidelines/2015-scientific-report/https://health.gov/dietaryguidelines/2015/guidelines/appendix-3/ 32

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CHOLINE AND THE DIETARY GUIDELINES FOR

Federal food and nutrition health policies and programs are based on the DGA. For example: The Special Supplemental Nutrition Program for

Women, Infants and Children uses DGA to determine the contents of its food packages and nutrition education program.

The USDA's National School Lunch Program and School Breakfast Program, which feeds more than 30 million children each school day, are informed by the DGA.

CHOLINE AND THE DIETARY GUIDELINES FOR https://health.gov/dietaryguidelines/2015/guidelines/introduction/dietary-guidelines-for-americans/

THE CHOLINE

Vegans Vegetarians Mainstream eaters Pregnant and breastfeeding women with

any of these eating styles Pregnant women with aversions to

foods that are rich in choline

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SELECTED CHOLINE

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Egg yolk, large: 147 mg Ground beef, 3 oz. cooked: 85 mg Pork tenderloin, 3 oz. cooked: 83 mg Salmon, Atlantic, farmed, 3 oz. cooked: 77 mg Chicken breast, boneless, skinless, 3 oz. cooked: 65 mg Soybeans, ¼ cup roasted: 53 mg Broccoli, 1 cup cooked: 51 mg Garbanzo beans, ½ cup cooked: 35 mg

https://ndb.nal.usda.gov/ndb/nutrients/report?nutrient1=421&nutrient2=&nutrient3=&fg=&max=25&subset=0&offset=100&sort=c&totCount=4551&measureby=m

CREATING A CHOLINE-CENTRIC MEAL

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CREATING A CHOLINE-CENTRIC MEAL

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FOOD SUPPLEMENTS

“Nutritional needs should be met primarily from foods. … Foods in nutrient-dense forms contain essential vitamins and minerals and also dietary fiber and other naturally occurring substances that may have positive health effects. In some cases, fortified foods and dietary supplements may be useful in providing one or more nutrients that otherwise may be consumed in less-than-recommended amounts.”

Source: 2015-2020 Dietary Guidelines for Americans

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FINDING CHOLINE ON FOOD The FDA has set the Reference Daily

Intake (RDI) for choline at 550 mg. Food labeling of choline content is voluntary. Foods with at least 55 mg of choline per serving are

considered a “good source” of the nutrient. Helpful in educating consumers about choline, and aiding

them in selecting foods that supply it.

https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-11867.pdf

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CHOLINE IS IN SOME MULTIVITAMINS, BUT IN SMALL

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RECOMMENDATION FOR

Multivitamin

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SELECTING A CHOLINE Choline upper level of tolerance = 3,500 mg/d

Only contains 13% choline based on weight

SELECTING A CHOLINE 1 capsule = 300 mg choline 1 tablet = 500 mg choline 1 softgel = 50 mg choline

SPECIAL CONSIDERATIONS FOR CHOLINE:

Mammary cells are capable of uptake of choline from the maternal blood supply for transfer to the child.

Choline levels in breast milk are highest in mature milk. Infant formula contains choline.

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CHOLINE FOR

Encourage choline-abundant foods. Pay particular attention to pregnant/lactating patients and those with vegetarian/vegan diets.

Evaluate each person for their usual intake, and fill in the gap with supplements.

CHOLINE FOR 44

Choline is important for mom and baby, and for everyone else in the family, too, and at every age.

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COMMUNICATING “CHOLINE FOR LIFE”

Visit: VitaCholine.com

Subscribe to VitaCholine’s quarterly46

e-newsletter – The Choline Connectionhttps://confirmsubscription.com/h/d/

FOR MORE INFORMATION ON THE BENEFITS OF CHOLINE AT ALLAGES AND STAGES OF LIFE…

7189DEE61A851D3A

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Visit: https://www.eggnutritioncenter.org/downloads/toolkits/Choline%20facts.pdf

FOR MORE INFORMATION ON THE BENEFITS OF CHOLINE AT ALLAGES AND STAGES OF LIFE…

Marie Caudill, PhD, RD

mac379@cornell.edu

Elizabeth Ward, MS, RD

eward@ix.netcom.com

QUESTIONS?

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THANK YOU!49

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