One day old baby

Over the weekend, I put up my first Zombieland post about phospholipids, primarily phosphatidylserine and phosphatidlycholine. These are delectable and important nutrients nature has supplied most richly in the consumption of brains (though bone marrow and eggs are perhaps more palatable sources).  A brilliant psychiatrist friend of mine called it "food for thought."  Someone on twitter called it "sensationalist."  My point was that our consumption of phospholipids has decreased considerably over the past century, and there could theoretically be some mental health effects from it.  

Today I'm going to focus more on a little essential nutrient called choline, which is one component of the phospholipid phosphatidylcholine.  A brain-focused article about choline isn't quite as sexy as brain-eating, so forgive me the zombie pull-in.  But choline is exceedingly important as a preventative against liver disease and fatty liver, and it is one nutrient that is richest in animal offal products and eggs, and not particularly plentiful in modern processed food and processed grain-heavy diets.  There are even some small human trials of induced choline deficiency and fatty liver that was reversed by choline repletion.  

While the liver is on the front lines, the brain is where the nutrition battle really rages oftentimes.  Turns out that choline is exceedingly important in pregnancy and the development of of the little human nervous system, thus the picture of my first born up there, one day old and still adjusting to life in the colder, airier world.

The data in humans concerning choline, mental health, and behavior is… scarce.  We'll examine the rodent studies and then human epidemiology studies and see if we can glean any wisdom from them.

First off, choline is part of the folate cycle. The folate cycle is exceptionally important for liver and brain/nerve health, and includes some key players - iron, vitamin B6, vitamin B12, folate, methionine, choline, oxidized choline (called betaine), SAM, niacin, and riboflavin.  I think of the B vitamins as a team sport (typically I think of football, as a little chemical group called a methyl is passed around between the players, but use rugby or soccer or hockey or whatever sports metaphor floats your boat.)  All the players need to be on the field for the full folate cycle to run efficiently. Most choline absorbed by humans is immediately made into phosphatidylcholine and incorporated into cell membranes. Choline is also made into betaine in the liver, where it serves as a methyl donor for many important chemical reactions (1). One of the products of these many reactions is phosphocreatine, by the way. Phosphocreatine is a super-fast energy source for our muscles and neurons.  Also important to neurons and the brain is sphingomyelin.

Folate cycle

Problems or deficiencies in the folate cycle (including choline deficiency) are implicated in fatty liver disease, neural tube defects (like spina bifida), cardiovascular disease, and cancer. The cycle begins with methionine (an amino acid), which using various B vitamin cofactors is made into SAM. SAM is a methyl donor and is absolutely necessary in nearly sixty important chemical reactions in the liver, from making neurotransmitters to cell membranes to DNA. After being used as a methyl donor, SAM becomes SAH which becomes homocysteine. Having high homocysteine is associated with dementia and cardiovascular disease - in my mind it is associated with poor nutrition in general. Without all the players, homocysteine has a hard time being recycled for use in the folate cycle again. In order to get the majority of the players, you need to eat a lot of whole grains, or vitamins, or organ meats/eggs. Whole grains have their issues, so I'll stick to the latter sources, thank you very much.

So choline is essential and important, but why exactly? Fatty liver develops because you need choline to make VLDL particles. VLDL carries triglycerides from the liver into the bloodstream. If you don't have enough phospholipids like phosphatidylcholine to form the coat of the VLDL particle, you end up with triglycerides stuck in the liver ==> fatty liver. Now if you don't have enough phospholipids to even get your triglycerides out of the liver, how could you possibly have enough for use in your other cell membranes (or in the neurons of the brain, which are especially rich in phospholipids)? And how would they even get there without your cholesterol/fat carrying particles? Fatty liver is just a harbinger of even more serious problems to follow.

Neural tube defects are extremely common birth defects that result from faulty closing of the ends of the neural tube. In very early development, we humans spend some time being sort of flat, like an elongated pancake. Then we roll up in a couple of ways to become more... wormlike, before we grow limb buds and all sorts of other interesting things to become babies. Rolling up properly requires the folate cycle to be running at full efficiency. And, sure enough, epidemiologic studies have linked choline deficiency in human mothers to neural tube defects in their offspring (those in the bottom 25% of choline intake have 4 times the risk of babies with neural tube defects as those in the top 25%), and in mice, choline restriction is shown to cause neural defects.

Pregnancy and lactation are periods in a woman's life when she needs some serious choline to keep the machinery going. Placental/amniotic fluid levels of choline are nearly 10 times mother's serum levels (2).  Moms seem to benefit from an enhanced choline-making machinery during pregnancy, but mom still ends up with depleted levels after childbirth (which will continue during lactation). It's best to have time to replete this vital nutrient between kiddos.

Beyond the neural tube defect issue is the memory issue. Neural tube defects usually begin within the first month of pregnancy, so by the time you realize you are expecting, it's pretty much too late to do anything about it. But studies of rats have shown that choline depleted mothers in the latter half of rat pregnancy results in offspring with lousy memories. The hippocampus is the part of the brain at the epicenter of memory (and depression). Pregnant rats who have plenty of choline seem to be able to make all the membranes, DNA, and stem cells you need to make an awesome hippocampus. Pregnant rats without choline have baby rats who just don't remember as well. In addition, choline supplementation in the second half of pregnancy seems to protect offspring rats from the detrimental brain effects of alcohol given to their mothers. There are no studies in humans showing this link. However, elevated human maternal homocysteine levels are linked with preeclampsia, prematurity, and low birth weight, and most studies have shown that the higher a mother's choline levels, the lower her homocysteine tends to be.

Other studies (including the Nurses Health Study and the Framingham Offspring Study) have shown that higher choline levels are associated with lower inflammatory markers of many kinds, including IL-6, TNF-alpha, and C reactive protein. Keep in mind that in the PROSPECT-EPIC study, even those women in the highest quartile of choline intake fell below the Institutes of Medicine number for Adequate Intake of 425 mg a day for women (to get that amount, you need to eat half a pound of chicken, two eggs, and a quart of 1% milk - and those are relatively rich sources!)  In the Nurses' Health Study, 95% of women fell below an average daily intake of 411 mg. In addition, nearly 50% of us seem to have a genetic polymorphism where we have a hard time making methionine into choline, meaning choline becomes even more of an essential nutrient. This fact may be why some people have bulletproof livers, and others develop fatty liver just by looking at a bottle of wine.

The women with adequate intake in these large studies had a higher than average intake of eggs. I wonder if choline is the reason recent studies have shown that eggs in conjunction with a calorie restricted diet seem to improve diabetes, despite all that fat and cholesterol. (I like these studies and how they seem to annihilate the lipotoxicity hypothesis).

I find the information about choline and total human health to be convincing, and I eat eggs for breakfast about 4X a week (as do my kids), along with bone broth in my stews (from roasted marrow bones), and other bits of offal diced into chili.  The perinatal period where baby rats' brain development benefits from increased choline consumption can be extrapolated to about 4 years old in humans. So to obtain a prudent amount of choline, eat up your eggs and offal, especially if you are a rugrat or plan to have rugrats any time soon!

*Wheat germ and soy lecithin are the richest vegetarian sources of choline.

You are reading

Evolutionary Psychiatry

A Roadmap to the Future of Psychiatry

...and it's not the DSM V.

A Dietary Treatment for Depression

A randomized controlled trial shows the right diet can improve depression.

Practical Tips for Balancing the Omega 6-to-3 Ratio

How to increase the omega 3 and decrease the omega 6 in the diet.