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The Effect of Diet On Gallstones Formation in Turkish Patients: A Case-Control Study

Türk Populasyonunda Safra Taşı Oluşumunda Diyetin Etkisi: Vaka-Kontrol Çalışması

Cemile Idiz, Coskun Cakir

Euras J Fam Med 2020;9(3):147-53. https://doi.org/10.33880/ejfm.2020090305

 

Original Research / Orijinal Araştırma


ABSTRACT

Aim: There are many defined risk factors for the formation of gallstones and nutrition is one of them. We have investigated if there is a relationship between diet and gallstone formation in Turkish gallstone patients. 

Methods:  This prospective case-control study were performed between July 2018- March 2019. A food consumption survey was performed to the gallstone patients and control group. The results of demographic and food consumption data of gallstone patients were compared. 

Results: There were 110 patients with gallbladder stones and 115 controls with no gallbladder stones. There was no significant difference between the two groups in terms of demographic data; but body mass index was higher and regular physical activity was lower in case group.  Although case group eat more eggs than the controls, there were no statistically significant difference. In case group, the consumption of snack and cheese, energy intake, more daily fat consumption, more saturated fatty acids, and cholesterol uptake was higher, whereas red meat consumption was lower.

Conclusion: A significant association between the gallstone and the nutrition especially in particular nutritional elements supports the fact that, diet is an important risk factor for gallbladder stone formation. 

Keywords: gallstones, nutrition, cholesterol, diet

ÖZ

Amaç: Safra kesesi taşı oluşumu için tanımlanmış birçok risk faktörü bulunmakta olup beslenme de bunlardan biridir. Bu çalışmamızda safra kesesi taşı olan Türk hastalarda diyet ile safra taşı oluşumu arasında ilişkiyi değerlendirdik.

Yöntem: Bu prospektif vaka-kontrol çalışması Temmuz 2018-Mart 2019 tarihleri ​​arasında gerçekleştirilmiştir. Safra taşı hastalarına ve safra kesesi taşı olmayan kontrol grubuna bir besin tüketimi anketi uygulandı. Çalışmada safra kesesi taşı hastalarının demografik ve besin tüketim verileri kontrol grubu ile karşılaştırıldı. 

Bulgular: Safra kesesi taşı olan 110 hasta, safra kesesi taşı olmayan 115 kontrol gönüllü çalışmaya dahil edildi. İki grup arasında demografik verilerde anlamlı bir fark bulunmadığı, ancak safra kesesi taşı olanlarda vücut kitle indeksinin daha yüksek olduğu ve düzenli fiziksel aktivitesinin düşük olduğu gözlendi. Yine safra kesesi taşı olanlarda atıştırmalık ve peynir tüketiminin daha yüksek, kırmızı et tüketiminin ise daha düşük olduğu saptandı. Vaka grubu, kontrollerden daha fazla yumurta tüketiyorsa da, istatistiksel olarak anlamlı bir fark saptanmadı. Safra kesesi taşı olanlarda daha fazla enerji alımı, daha fazla günlük yağ tüketimi, daha fazla doymuş yağ asidi ve daha fazla kolesterol tüketimi gösterilmiştir.

Sonuç: Bu çalışma, safra kesesi taşı ile beslenme arasında önemli bir ilişki olduğu ortaya konmakta olup, özellikle de belirli besin ögelerinin, safra kesesi taşı oluşumunda rolü olduğu gerçeğini desteklemektedir.

Anahtar kelimeler: safra taşları, beslenme, kolesterol, diyet


Introduction

Gallbladder diseases are the most common pathologies of the biliary system and most of them are usually asymptomatic (1). Complications such as cholecystitis, cholangitis, and pancreatitis develop up to 4% of asymptomatic patients. In addition, 1/4 of patients with gallbladder stones will experience these complications in a period of their lives (2,3). There are many defined risk factors for the formation of the gallstones. 

Gallstone formation increases with age and it is reported that gallstone formation increases between four and ten times from age 40 (4). The type and prevalence of the gallstones change according to geographic settlement and ethnicity. Cholesterol stones are more frequently observed in the west, while brown pigment stones are more common in the east (5). It is reported that gallstone content changes with age. As the age progresses, the stone type turns from the cholesterol stone to the pigment stone. Also, the genetic predisposition for gallstone formation is around 30% (6).

Gallbladder stones are more common in women due to the effect of the estrogen hormone. Cholesterol stones are observed more frequently especially in pregnancy and use of oral contraceptives (5). It is thought that physical activity increases the movement of the gallbladder and thus prevents the collapse of cholesterol and protects against the formation of gallstones (7).

There is a positive correlation between obesity and gallbladder stone. Obese women (BMI >30) have at least two-fold the risk of gallbladder stone formation compared to normal weight women (BMI 20-25) (8). In addition, many comprehensive epidemiological studies have shown that increased dietary refined car-bohydrates and triglycerides and reduced fiber intake are associated with gallbladder stone formation (9).

In this case-control study, we have investigated if there is a relationship between diet and gallstone formation in Turkish gallstone patients.

Methods

This prospective case-control study was performed between July 2018 - March 2019 after approval of the Local Human Ethical Committee. The patients who admitted for operation with gallstone were the case group of the study. Also, the patients who were admitted to the same hospital with such as eye, ear/nose/throat, dermatologic diseases or elective surgeries and did not have a history of chronic liver or gallbladder diseases selected as control group. The patients who had cancer, pregnancy, chronic liver diseases, and previous abdominal surgery history and the patients who had weight loss above the 20% of the body weight in the last 6 months were excluded from the study. Written informed consent was obtained from each participant. The numbers of cases and controls were matched based on age and gender so that, in each age group, and gender-group the number of controls was twice as that of the cases.

Weight was measured with a weighing machine while participants were standing without shoes and height was measured without shoes, using a meter fixed to a wall and was recorded. Weight was then divided by the square root of height for calculation of body mass index (BMI).

The food consumption frequency survey was performed for all of the participants. Three days food consumption records were evaluated in the BeBis 8 full version program.  Also, the age, gender, tobacco, alcohol, daily activity, meal habits of the participants were noted. The results of demographic and food consumption data of gallstone patients were compared to the control group. 

The data of the study were processed on SPSS version 21 and the continuous data obtained from the study were given as mean ± standard derivation. The analysis of categorical data was performed with the Chi-square test and Fisher exact test. Normally distributed continuous data were analyzed by Student T-test and non-normally distributed continuous data were analyzed by Mann Whitney U test. The level of significance was set as p<0.05.

Results

A total of 225 volunteers were included in the study, of which 110 have gallstones in the gallbladder and named as group 1, 115 of them don’t have gallstones and named as group 2.  The mean age of the volunteers in the first group was 52.03 years, the female / male ratio was 76/34, the mean age of the volunteers in the second group was 51.76 years and the female/male ratio was 80/35. When the demographic data of the patients were evaluated, there was no significant difference between the two groups; but the gallbladder stones were found to be more with higher body mass index, less regular physical activity, and less alcohol consuming (Table 1).

Table 1. Demographic data of the groups 

 

Group 1 (gallstone) (n=110)

Group 2 (control) (n=115)

p value

Mean

SD

Mean

SD

Age (year)

52.03

10.83

51.76

14.06

0.717

BMI (kg/m2)

28.14

3.11

27.31

3.99

0.087

Gender (n-%)

Female

76 (69%)

80 (69.5%)

0.939

Male

34 (31%)

35 (30.5%)

Tobacco (n-%)

Never

59 (53.6%)

52 (45.2%)

0.331

Quit

24 (21.8%)

25 (21.7%)

Yes

27 (24.6%)

38 (33.1%)

Alcohol (n-%)

Yes

10 (9.1%)

20 (17.4%)

0.067

No

100 (90.9%)

95 (82.6%)

Routine physical activity (n-%) (≥150min/week)

Yes

15 (13.6%)

26 (22.6%)

0.081

No

95 (86.4%)

89 (77.4%)

(SD: standard derivation)

 

When the eating habits of the participants were evaluated, it was determined that the snack consumption was significantly higher in the patients with gallbladder stone (p=0.026) (Table 2); and when we look at the dietary habits of the patients the gallbladder stone had significantly more cheese and less red meat (respectively p=0.003, p=0.001). In addition, patients with gallbladder stones, although not meaningful, eat more eggs than the control group (Table 3).

Table 2. Evaluation of the meal habits of individuals

 

Group 1 (gallstone) (n=110)

Group 2 (control) (n=115)

p value

Regular breakfast (n-%)

Yes

106 (96.3%)

110 (95.6%)

1.000

No

4 (3.7%)

5 (4.4%)

Skipping meal (n-%)

Yes

53 (48.2%)

65 (59%)

0.211

No

57 (51.8%)

50 (41%)

Snacks (n-%)

Yes

44 (40%)

63 (54.7%)

0.026

No

66 (60%)

52 (45.3%)

Bread Preference (n-%)

White

82 (74.5%)

83 (72.1%)

0.688

Brown

28 (25.5%)

32 (27.9%)

 

 

Table 3. Assessment of nutritional habits of participants 

 

Group 1 (gallstone) (n=110)

Group 2 (control) (n=115)

p value

 

Mean

SD

Mean

SD

 

Daily bread consumption (g)

158.60

63.61

160.69

65.09

0.767

Daily milk / yoghurt consumption (g)

132.09

82.02

133.58

85.58

0.940

Daily cheese consumption (g)

56.15

24.34

45.95

22.92

0.003

Daily red meat consumption (g)

16.21

11.79

22.76

15.45

0.001

Daily chicken / turkey consumption (g)

29.18

13.73

32.66

29.88

0.173

Daily fish consumption (g)

17.69

20.52

17.04

14.84

0.370

Daily delicatessen products (salami, sausage, sausage, etc.) (g)

6.67

8.50

6.52

8.56

0.905

Daily offal consumption (g)

3.63

7.10

2.98

6.33

0.535

Daily egg consumption (g)

30.31

22.47

24.64

17.18

0.088

Daily nut food consumption (g)

7.31

7.54

6.79

6.98

0.684

Daily legume consumption (g)

12.77

8.86

12.56

8.92

0.672

Daily rice/pasta consumption (g)

62.20

35.44

63.90

34.19

0.366

Daily pastry / cakes / cookies consumption (g)

30.00

29.33

38.60

39.14

0.185

Daily vegetable consumption (g)

137.29

64.99

138.82

72.09

0.998

Daily fruit consumption (g)

120.42

89.21

106.33

98.93

0.113

Daily fastfood consumption (g)

19.46

20.66

16.18

15.72

0.314

(SD: standard derivation)

 

Comparing the daily consumption of the dietary nutrients of the volunteers, the patients who had gallstones had more energy intake, more daily fat consumption, more saturated fatty acids and more cholesterol uptake compared to control (respectively p=0.042, p=0.012, p<0.001, p=0.023) (Table 4).

Table 4. Comparison of nutrients

 

Group 1 (gallstone) (n=110)

Group 2 (control) (n=115)

p value

Mean

SD

Mean

SD

Energy (kcal/day)

1893.65

349.18

1807.04

345.98

0.042

Carbohydrate (g/day)

230.16

50.03

218.32

46.74

0.085

Carbohydrate (%)

49.49

3.98

49.60

5.37

0.751

Protein (g/day)

66.85

13.43

64.87

14.03

0.281

Protein (%)

14.39

1.44

14.65

1.82

0.217

Fat (g/day)

76.74

14.76

72.22

15.66

0.012

Fat (%)

36.09

3.63

35.71

4.56

0.239

Saturated fatty acid (g/day)

27.54

6.29

24.04

6.28

0.000

Multiple saturated fatty acids (g/day)

22.34

6.68

22.55

6.34

0.803

Cholesterol (mg/day)

279.48

100.15

250.21

91.01

0.023

Fiber (g/day)

18.29

5.37

18.23

4.80

0.693

 

Discussion

Gallbladder stone is one of the biliary system pathologies that can be seen with many complications and has a high incidence in the community. Genetic predisposition, geographic location, female gender, obesity, and nutrition are among the risk factors identified so far (2,3,5). 

Studies have reported that obesity is an important risk factor for gallbladder stone formation (7,10). Gallbladder stones are present in 1/4 of obese people (6). Obesity causes an increase in bile secretion and increased cholesterol synthesis in the liver. Also, the increase of the insulin levels in obesity could cause the formation of the gallbladder stones (6,11). BMI rates of people with gallbladder stones were found to be higher than those without gallbladder stones but there were no significant differences. It was also observed that those who had gallstone stones were more sedentary and had less physical activity.

Slow weight loss of obese patients reduces the risk of gallbladder stones, and weight loss over 1.5 kilos per week is a risk for gallbladder stone development. Rapid weight loss after obesity surgery or low-calorie diets increases the risk of gallbladder stone formation (4,6). Because of the exclusion the patients who had obesity or gastrointestinal system surgery and who had a history of excessive weight from the study, the effect of rapid weight loss on gallbladder stone formation could not be evaluated in our study.

Western culture diets, high refined carbohydrates and high triglyceride content of high fat consumption, low-fiber diet are risk factors in the formation of gallbladder stones and cholecystitis. It has been reported that a healthy diet pattern including high fruit, vegetables, whole grain, and vegetable oil reduces the risk of gallbladder stone formation. Also, unhealthy nutrition pattern including sugar consumption, refined grains, and sugary drinks increase the risk of gallbladder stone formation (12). 

There are publications reporting that a vegetarian diet reduces the risk of gallbladder stone formation (13,14). In some studies, it was reported that vegetables and fruits prevent the formation of gallbladder stones due to ingredients of antioxidants, vitamin C, magnesium, fiber (15-18). In our study, there was no significant difference in terms of vegetable, fruit, brown bread, legumes and fiber intake in patients without gallbladder stone patients.

Previous studies have shown that refined sugar, pastry and cake, and sucrose-containing drinks increase the risk of gallbladder stones (19,20). Even in a study, it was argued that more than 40 g of daily sugar changes the contents of the bile by altering the lipoprotein metabolism and doubling the risk of symptomatic gallbladder stone formation (21). In addition, the relationship between refined sugar intake and gallbladder stones is attributed to the increase in bile synthesis due to increased insulin secretion (20). In our study, there was no significant difference between the groups in terms of the amount of cakes, pastry, and cookies found in the diet. But, daily carbohydrate consumption was higher in patients with gallstones. 

In many studies, it has been reported that egg, red meat, animal fat, animal protein, and dietary cholesterol increase the cholesterol content in bile and increase cholesterol gallstones (12,15,22-24). In some studies, it is reported that high protein diets prevent gallbladder stone formation (25). Again in a few studies, it was reported that there was no relation between the amount of cholesterol taken with diet and gallstone (20,26,27). In many studies, it is stated that total and saturated fat amount is consumed more in individuals with gallbladder stones and this is an etiologic factor (28). In our study, it was observed that animal origin cheese consumed more in patients with gallbladder stones; but on the contrary, it was observed that red meat of animal origin was significantly less consumed in patients with gallbladder stones. Besides, it is observed that patients with gallstones had more eggs consume in accordance with other studies. It was determined that patients with gallbladder stones were also consumed more total and saturated fat, and received more cholesterol.

There are publications reporting that fish oil and n-3 fatty acid intake decrease gallbladder stone formation (12). Moreover, it is thought that a moderate level of alcohol consumption has a protective effect on the formation of gallbladder stones by increasing the conversion of cholesterol to bile acids or by altering the enterohepatic circulation of bile acids (29,30). In our study, there was no difference between the groups in terms of fish consumption. However, alcohol consumption of patients with gallbladder stones were less than control group but the difference is not significant.

Conclusion

Fat, cholesterol, eggs and carbohydrates were determined in accordance with the literature in our study. But we found some of the animal protein consumption is high, some of them low in the gallstone patients and this is controversial in the literature. We believe that this is probably due to cultural and ethnic differences. However, as our study supports that, the relationship between diet and gallbladder stones is an undeniable fact.

 

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How to cite / Atıf için: Idiz C, Cakir C. The effect of diet on gallstones formation in Turkish patients: a case-control study. Euras J Fam Med 2020;9(3):147-53. doi:10.33880/ejfm.2020090305.

 


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