



































A 24-hour dietary recall for assessing the intake pattern of choline among Bangladeshi pregnant women at their third trimester of pregnancy


 

 

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A 24-hour dietary recall for 

assessing the intake pattern of 

choline among Bangladeshi 

pregnant women at their third 

trimester of pregnancy 

 

 

Shatabdi Goon1, Sima Rani Dey2 

 
1Dept. of Nutrition and Food Engineering, 
Daffodil International University, Dhaka, 
Bangladesh; 2Dept. of Applied Statistics, 
East West University, Dhaka, Bangladesh 

 

 

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Abstract 

Maternal choline intake during the third trimester of human pregnancy can modify systemic and local epigenetic marks in fetal-

derived tissues, promoting better pregnancy outcomes, increased immunity, as well as improved mental and physical work 

capacity with proper memory and cognitive development. 103 pregnant women presenting to the antenatal care of Azimpur 

Maternity Hospital of Dhaka, Bangladesh in their third trimester of pregnancy were randomly selected for this cross sectional 

study exploring dietary intake patterns of choline. A dietary recall form was administered to estimate frequency and amount of 

food consumption of foods for the previous 24 hours. Most women reported diets that delivered less than the recommended 

choline intake (mean ± SD; 189.5 ± 98.2) providing only 42.72% of total RDA value. The results of this study may indicate that 

dietary choline among pregnant, Bangladeshi women may not be adequate to meet the needs of both, the mother and fetus. 

Further studies are warranted to determine clinical implications. 

Keywords: choline, pregnancy, fetal development, cognition, pregnancy outcome 

 

A 24-hour dietary recall for assessing 

the intake pattern of choline among 

Bangladeshi pregnant women at 

their third trimester of pregnancy 

 

Shatabdi Goon1, Sima Rani Dey2 

 
1Dept. of Nutrition and Food Engineering, 
Daffodil International University, Dhaka, 
Bangladesh; 2Dept. of Applied Statistics, 
East West University, Dhaka, Bangladesh 

Research 

Introduction 

Choline, an essential
1-6

 nutrient found in eggs, 

liver, milk, meat, nuts, legumes, and cruciferous 

vegetables,
7
 plays a significant role during the third 

trimester of human pregnancy to reduce the negative 

effect of a mother’s stress
8
 on child health

8
, promoting 

fetal growth,
6,9,10

 proper brain
11-16

 and memory 

function,
17-22

 and learning capabilities,
23-27

 while 

protecting the future health of the child. Previous 

findings suggest that higher maternal choline intake 

may counter some adverse effects
25,28,29

 of prenatal 

stress on behavioral,
29-32

 neuroendocrine, and metabolic 

development
33,34

 in offspring. Higher choline intake 

contributed to a more stable Hypothalamic-Pituitary-

Adrenal (HPA) axis,
8
 which translated to lower cortisol 

levels in the fetus. Changes in fetal genetic expression 

likely continue into adulthood, where they play a role in 

stress-related disease prevention.
35

 Dietary choline 

intake by the pregnant mother and by the infant directly 

affects brain development and results in permanent 

changes in brain function.
36

 Variations in maternal 

choline intake influence memory performance in their 

offspring.
37

  

Several animal model studies have reported on 

the effect of choline intake and fetal development. 

Offspring born to pregnant rats given choline 

supplements were found to be faster learners with better 

memories.
12

 More choline during days 11 to 18 of 

gestation resulted in increased cell proliferation and 

decreased apoptosis in rodent fetal hippocampal 

progenitor cells, promoting better memory and 

cognitive function.
12

 Choline deprivation (CD)-induced 

dysfunction in brain mitochondria may be responsible 

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for impairment in cognition and underlines that the 

brain needs an adequate choline supply for its normal 

functioning. Memory can be permanently enhanced by 

exposure to choline during the latter part of gestation.
16

 

Also, Zeisel et al. showed that when rat pups received 

choline supplements, their brain function changed, 

resulting in lifelong memory enhancement.
27

 Mellot et 

al. showed that increased dietary intake of choline early 

in life improves performance of adult rats on memory 

tasks and prevents their age-related memory decline.
22

 

Choline supplementation during gestation in rats leads 

to augmentation of spatial memory in adulthood.
38

 

Maternal choline appears to decrease the risk of neural 

tube defect (NTD).
39,40

 A retrospective case-control 

study of periconceptional dietary choline intake in 

California, USA women found that women in the lowest 

quartile for daily choline intake had a 4-fold greater risk 

of having a baby with an NTD than women in the 

highest quartile for intake.
40

  

Another study showed that a deficiency of 

choline substantially impaired the body’s ability to 

regulate homocysteine levels.
41

 Excessive homocysteine 

is apparently linked with increased risks for birth 

defects, cardiovascular disease,
42

 cancer, type-2 

diabetes, hypertension, depression, and more. Higher 

intakes of dietary choline are related to lower 

homocysteine concentrations.
43,44

  

Foods rich in choline may help reduce the risk 

of inflammation associated with chronic diseases such 

as cardiovascular disease, bone loss, dementia, and 

Alzheimer's disease.
43

 A study funded by the National 

Institutes of Health concluded that dietary choline 

during pregnancy is associated with a 24% reduced risk 

of breast cancer in female offspring.
45,46

 Tumor growth 

rate was inversely related to choline content in the 

prenatal diet, resulting in 50% longer survival. Choline 

deficiency during pregnancy may lead to increased risk 

of complications during delivery, including prolonged 

labour, preterm delivery, preeclampsia, prematurity, 

very low birth weight,
47

 and maternal and neonatal 

death. It is recommended that pregnant women take 

450mg of choline per day from common food sources or 

supplements.  

In Bangladesh, knowledge of the impact of 

maternal food and micronutrient supplementation on 

infant micronutrient status is limited. Most pregnant 

Bangladeshi women do not meet recommended levels 

of micronutrients, including choline. The main objective 

of this study was to determine the present status of the 

choline intake pattern by Bangladeshi pregnant women 

in their third trimester of pregnancy.  

 

Methods 

This cross sectional study was carried out from 

the 4-May to 6-June, 2013 at Azimpur maternity 

hospital, Dhaka, Bangladesh. A total of two hundred 

pregnant women were randomly selected from all 

pregnant women present the first day of the survey. Of 

the initial 200, 103 women were in their third trimester 

of pregnancy and were included in this investigation. 

Exclusion critieria included: women not in their third 

trimester of pregnancy, history of hypertension, 

gestational diabetes, or history of spontaneous 

abortions. All participants signed an informed consent 

form.  

A semi-structured pre-tested questionnaire (see 

Appendix 1) was developed to gather participant 

characteristics including: age, occupation, stage of 

pregnancy, weight, height, and educational level. A 

dietary recall form was administrated to gather 

information regarding dietary intake for the previous 24 

hours. Choline content of foods was calculated using 

published data from the USDA-Nutrient Database for 

Standard Reference then multiplying the frequency of 

consumption of each food item by its choline content 

and summing the nutrient contributions of all foods. All 

of the collected data were analyzed using SPSS v-15.0. 

Descriptive statistics including mean, standard 

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deviation, and frequency were obtained. All variables 

were normally distributed.  

 

Result 

Subject profile 

In the maternity hospital in Dhaka, 

Bangladesh, 69.9% of participants aged 21-25 years. 

27.2% and 2.9% of were aged 26-30 years and >31 

years, respectively. Approximately 6.8% of participants 

were illiterate; 10.7%, 56.3%, 11.7%, and 14.5% 

completed primary, secondary, undergraduate, and 

graduate levels of study, respectively. 87.4% of 

participants were housewives and 12.6% were service 

holders. In this study, 30.1% of participants were in the 

seventh month of pregnancy, 28.16% in the eighth 

month of pregnancy, and 41.74%, the ninth. Based on 

calculated body mass index (BMI), 3.8% were 

underweight, 42.72% normal weight, 33.98% 

overweight, 13.59% moderately obese, 3.88% severely 

obese, and 1.95% were very severely obese. Table 1 

shows the overall subject profile attending the study. 

 

Table 1: Characteristics of pregnant women 

 

Dietary choline consumption 

Most participants reported low consumption of 

choline-rich foods selected from the Bangladeshi diet. 

Only one participant showed adequate or near adequate 

intake of choline (> 400mg). The mean dietary choline 

consumed was 189.5mg ± 98.2 (mean ± SD). 25.2%, 

31.2%, 23.3%, and 19.4% of pregnant women took 

choline ranges from 0-100, 101-200, 201-300, and 301-

400 mg/day, respectively, through regular diet.  

 

Table 2: Distribution of pregnant women by daily intake 

of choline (mg) 

Parallel improvements were observed in 

average choline intake with educational achievement. 

Average intake level of choline was 147.7 ± 83.3, 157.8 

± 110.5, 185.9 ± 97.4, 208.2 ± 94.2, and 231.4 ± 94.9 

mg/day for illiterate participants, those who completed 

primary, secondary, undergraduate, and graduate levels 

of study, respectively. Table 3 illustrates dietary choline 

consumption.  

 

Table 3: Gradual improvement of average choline 

intake per day with educational status 

 

Among the factors affecting choline level 

intake, education level and age of participant have 

substantial effect. Both factors are positively correlated 

with choline level intake, though the correlation is 

weak.  

 

Table 4: Correlation Analysis 

 

Discussion 

Improving choline intake through regular diet 

benefits all individuals through increasing immunity and 

lower morbidity from infectious diseases, improving 

physical work capacity, memory and cognitive 

development. Pregnant women are less likely to have 

poor pregnancy outcomes (including perinatal 

mortality) and may deliver infants with larger birth 

weights and greater choline stores. 

In this study, an assessment of dietary choline 

intake was made using a dietary recall system to record 

food intake by pregnant women over the previous 24 

hours. Analysis revealed that the choline status of 

Bangladeshi pregnant women is far below clinical 

suggestions, as defined by the Institute of Medicine of 

the National Academy of Sciences (450 mg/day).  

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Data suggest that pregnant Bangladeshi women 

are consuming less than adequate amounts of choline, 

with mean consumption of 189.5 ± 98.2 mg/day. For 

comparision, in a New Zealand study,
49

 daily intake of 

choline was 316 (± 66) mg/day; in another, mean intake 

was 304 mg/day in women;
50

 in a third study, mean 

intake of choline by common food sources among a 

Taiwanese female population
51

 was estimated as 265 ± 

9 mg/day. A study conducted in Jamaica also showed 

poor choline status among pregnant women with 278.5 

mg/day, which was higher than the Bangladeshi 

scenario.
52

 

Bangladeshi pregnant women took only 

42.72% of the RDA value of 450mg/day. Poverty and 

lack of knowledge regarding the importance of choline 

among both pregnant women and health care 

professionals leads to less choline supplementation 

during pregnancy. Therefore, the dietary intake pattern 

of choline during third trimester of pregnancy is 

important to estimate. 
 

Maternal age is an important determinant of 

nutritional status for pregnant women. The ideal age of 

pregnancy is 19-30 years. In this population, the 

majority were 20-25 years of age. Maternal education 

level has a significant effect on choline status during 

pregnancy. The present study showed a direct 

relationship between increase in consumption of choline 

in pregnancy and increase in maternal education level. 

This may due to generally better understanding of the 

mother regarding public health knowledge and 

nutritional status. Weight status also reflects the 

nutritional status of women. About 43% of pregnant 

women were categorized as “healthy weight”. 13.59%, 

3.88%, and 1.95% of participants were moderately, 

severely, and very severely obese, indicating an increase 

level of obesity during pregnancy. The overall survey 

result also shows that most women don’t consume the 

recommended level of choline.  

This is the first documented study evaluating 

dietary choline intake among the Bangladeshi 

population and suggests a need to further assess whether 

the diets of this population ensure an adequate plasma 

choline levels during pregnancy. An extension of this 

study should also examine the implications of low 

plasma choline concentration including the significance 

it may have in ensuring healthy fetal brain development 

in humans. 

Our study has a number of limitations. The 

data was self-reported and the study is cross-sectional 

which does not infer causal relationships. Furthermore, 

we examined only one maternity hospital located in 

Dhaka, Bangladesh. Caution should be taken to 

generalize the data for other maternity hospitals outside 

Dhaka city. A 24-hour dietary recall was taken to 

calculate the daily choline intake. Twenty-four hour 

recall is a retrospective method of diet assessment, 

where an individual is interviewed about their food and 

beverage consumption during the previous day or the 

preceding 24 hours. However, a single 24-hour recall is 

not considered to be representative of habitual diet at an 

individual level. While there may have been a small 

amount of recall bias, this methodology is adequate for 

surveying intake in a large group and estimating group 

mean intakes of diet. 

 

Conclusion 

Choline is a mostly neglected micronutrient by 

both pregnant women and health care professionals. 

These professions have poor knowledge regarding its 

importance and therefore are missing many potential 

causes of health complications due to choline 

deficiency. The results of this study may be an 

indication that the choline included in the diet of 

pregnant Bangladeshi women may not be adequate to 

meet both the needs of the mother and fetus. The results 

presented here may be useful in understanding the 

present choline status among Bangladeshi pregnant 

women aiming to improve using strategic nutritional 

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intervention by both government and public 

stakeholders. 

 

Acknowledgement 

We would like to thank our honorable 

professors, colleagues, and friends for supporting us in 

initiating the study subject. We are also grateful to those 

pregnant women, the doctors, and the staff of the 

selected maternity hospital. 

 

Conflict of interest 

The authors report no conflict of interest. 

 

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49. Mygind VL, Evans SE, Peddie MC, Miller JC, Houghton LA. 

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50. Yonemori KM, Lim U, Koga KR, et al. Dietary choline and 

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52. Gossell-Williams M, Fletcher H, McFarlane-Anderson N, 

Jacob A, Patel J, Zeisel S. Dietary intake of choline and plasma 

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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Central Asian Journal of Global Health 

Volume 3, No. 1 (2014)  |  ISSN 2166-7403 (online) |  DOI 10.5195/cajgh.2014.72 |  http://cajgh.pitt.edu 

  

 

Table 1: Characteristics of pregnant women 

Variable n (%) 

Age (years)  

21-25 72 (69.9%) 

26-30 28(27.2%) 

> 31 3(2.9%) 

Years of Education  

Illiterate 7(6.8%) 

Primary (Level 1-5) 11(10.7%) 

Secondary (Level 6-10) 58(56.3%) 

Undergraduate (Level 11-12) 12(11.7%) 

Graduate (more than 12 years of education) 15(14.5%) 

Status of Pregnant Women  

Housewife 90(87.4%) 

Service holder 13(12.6%) 

Stage of Pregnancy  

7
th

 month of pregnancy 31(30.1%) 

8
th

 month of pregnancy 29(28.16%) 

9
th

 month of pregnancy 43(41.74%) 

BMI Status  

15-16 0 

16-18.5 4(3.9%) 

18.5-25 44(42.72%) 

25-30 35(33.98%) 

30-35 14(14% 

35-40 4(3.9%) 

Over 40 2 

 

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GOON 

 

This work is licensed under a Creative Commons Attribution 3.0 United States License. 

 

This journal is published by the University Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 3, No. 1 (2014)  |  ISSN 2166-7403 (online) |  DOI 10.5195/cajgh.2014.72 |  http://cajgh.pitt.edu 

 

 

Table 2: Distribution of pregnant women by daily intake of choline (mg) 

 

Choline intake level (mg/day) n (%) 

0-100 26 (25.2%) 

101-200 32 (31.2%) 

201-300 24 (23.3%) 

301-400 20 (19.4%) 

≥ 400 1 (0.9%) 

Total 103 

 

  

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

This work is licensed under a Creative Commons Attribution 3.0 United States License. 

 

This journal is published by the University Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 3, No. 1 (2014)  |  ISSN 2166-7403 (online) |  DOI 10.5195/cajgh.2014.72 |  http://cajgh.pitt.edu 

  

 

Table 3: Gradual improvement of average choline intake per day with educational status 

 

Educational level Average choline intake/day (mg) 

Illiterate 147.7 ± 83.3 

Primary 157.8 ± 110.5 

Secondary 185.9 ± 97.4 

Undergraduate 208.2 ± 94.2 

≥ Graduate 231.4 ± 94.9 

 

  

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GOON 

 

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of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 3, No. 1 (2014)  |  ISSN 2166-7403 (online) |  DOI 10.5195/cajgh.2014.72 |  http://cajgh.pitt.edu 

 

 

Table 4: Correlation Analysis 

 

Correlations 

 Choline Level Education Level Age 

Choline Level 1 0.186 0.166 

Education Level 0.186 1 -0.008 

Age 0.166 -0.008 1 

 

  

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CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

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of its D-Scribe Digital Publishing Program, and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 3, No. 1 (2014)  |  ISSN 2166-7403 (online) |  DOI 10.5195/cajgh.2014.72 |  http://cajgh.pitt.edu 

  

 

Appendix 1: Questionnaire 

 

Name: 

Age: 

Level of education: a. Illiterate b. Primary c. Secondary d. Undergraduate e. Graduate 

Height: …………… cm 

Weight: ………………… kg 

BMI: 

Month of pregnancy: 

 

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