Choline Deficiency: Fatty Liver, Muscle Damage and Who Is at Risk
What happens when diets lack choline in controlled studies: fatty liver, liver and muscle damage, who may be more susceptible, why there is no routine test, and why a clinician should assess symptoms.
Content last updated . This page has not been medically reviewed.
If you have liver disease, unexplained muscle pain or weakness, or any health symptom you are worried about, see a clinician. Do not diagnose or treat choline deficiency yourself. Fatty liver, muscle damage and many other conditions have causes that need medical assessment, and there is no routine test that confirms choline deficiency.
What choline deficiency is
EFSA, the European Food Safety Authority, states that choline deficiency can have adverse effects, including fatty liver, and liver and muscle damage. [1] Its consultation draft added that dietary deficiency can cause fatty liver that can result in non-alcoholic fatty liver disease, which indicates that the body's own production can be insufficient. [2] Choline deficiency in the controlled-study sense is rare in people eating ordinary diets; the evidence comes mainly from experiments that deliberately restricted choline and from patients fed by vein with solutions lacking it.Evidence labels used here: established nutritional role / deficiency, promising but limited, insufficient evidence, Proper evidence not found.
What depletion studies found
Established in controlled studies.| Setting | What the source found |
|---|---|
| Healthy men on a choline-restricted diet | Liver damage (raised serum ALT) after only three weeks in 7 men versus no rise in 8 controls, with a 30 percent fall in plasma free choline. [3] |
| Dietary restriction and muscle | Muscle damage (raised creatine phosphokinase) was reported after three weeks of restriction. [3] |
| Long-term parenteral nutrition without choline | Similar fatty liver changes were reported in patients receiving long-term total parenteral nutrition devoid of choline. [3] |
| Lower choline in a recent feeding study | Participants ate about 100, 50 and 25 percent of the US choline AI for 15 days each; a scan identified a subset with increased liver fat on the 25 percent diet, and responses varied between individuals. [4] |
The reviewer's explanation is that without enough choline to make phosphatidylcholine, fat accumulates in the liver, and cell membranes become more leaky. [3] These were short, controlled experiments, so they do not show what happens in ordinary life with moderately low intake.
Who may be more susceptible
- Men and postmenopausal women were more susceptible than premenopausal women to organ dysfunction on choline-deficient diets, possibly because oestrogen supports the body's own production of phosphatidylcholine. [3]
- Genetic differences in the body's production pathway (PEMT and other enzymes) influence susceptibility. [3]
- People on long-term parenteral nutrition without choline, as above. [3]
- Pregnancy and lactation: official levels are higher (pregnancy).
- Vegetarian or vegan diets, alcohol use, bariatric surgery, malabsorption and kidney or liver conditions: Proper evidence not found in the sources read for choline-specific risk. See vitamins after bariatric surgery and vegetarian and vegan supplements for broader nutrient guidance.
Is common fatty liver caused by low choline?
Not shown. The studies above show that withholding choline can cause fatty liver in experiments. Whether choline supplements treat or prevent the common fatty liver diseases seen in clinics: Proper evidence not found in the sources read (a PubMed search for human trials of choline in non-alcoholic fatty liver disease returned no usable result). A clinician decides on tests and treatment. See liver safety.Testing and what results can and cannot show
There is no routine clinical test for choline status. EFSA's consultation draft concluded that none of the biomarkers of choline intake or status is suitable to derive reference values. [2] In the 2026 feeding study, plasma choline and betaine concentrations separated low from adequate intake under controlled conditions in research participants; that does not make them diagnostic tests for individuals. [4] A clinician interprets any liver or muscle test in context; see deficiency testing and its limits.How intake compares with the published levels
US surveys show average intake of 396 mg a day in men and 260 mg a day in women in 2007 to 2008, against AIs of 550 and 425 mg. [3] [5] Reviewers caution that intake below an AI does not itself indicate inadequacy. [3] Food sources are on foods high in choline.Treatment is clinician-led
If a clinician suspects low choline as one factor, they decide on diet, supplements or other treatment, taking medicines and other conditions into account. Do not start high amounts alone: upper levels exist (for example 3,500 mg a day for US and Canadian adults) (intake levels). [5] Do not stop or change prescribed medicines without asking your prescriber. Tell the care team before surgery. For supplement quality see quality testing.Related
Choline overview · Vitamins and kidney or liver diseaseFrequently asked questions
What are the signs of choline deficiency?
In controlled studies the findings were liver damage, fatty liver and muscle damage. [1] These signs have many other causes, so symptoms alone cannot identify choline deficiency. See a clinician.
Is there a blood test for choline?
Not a routine one. EFSA's draft judged that no biomarker is suitable for setting reference values. [2]
Who is more likely to be affected?
In studies, men and postmenopausal women were more susceptible than premenopausal women. [3]
Can choline fix fatty liver?
Proper evidence not found in the sources read for treating common fatty liver disease with choline. Ask a clinician.
Does a low intake mean I am deficient?
No. Intake below an AI does not by itself show inadequacy. [3]
References
- European Food Safety Authority (EFSA). Dietary reference values: EFSA publishes advice on choline. Published 17 August 2016. Read 2026-10-23.
- European Food Safety Authority (EFSA), NDA Panel. Draft scientific opinion on Dietary Reference Values for choline (public consultation draft, February 2016). A consultation draft, not the final opinion; the final opinion page could not be read. Read 2026-10-23.
- Dietary Choline Intake: Current State of Knowledge Across the Life Cycle. Nutrients 2018 (review). Read 2026-10-23.
- Choline and betaine concentrations in plasma discriminate levels of dietary choline intake in healthy adults. Am J Clin Nutr 2026 (controlled feeding study). Read 2026-10-23.
- Health Canada. Dietary reference intakes tables: Reference values for vitamins. Page dated 2025-11-19; the choline values are the US and Canada Dietary Reference Intakes. Read 2026-10-23 through a web-fetch tool.