Oh, the Gall of It All

Today while I was cooling my heels waiting to get my hair cut and highlighted at the salon, I picked up a copy of Oprah’s magazine. Sometimes, I come prepared with a stack of medical papers or a good book and invariably my stylist is running ahead of schedule and gets me right in. Today, I took nothing and had the usual choice of salon mags: recent issues of People, US, Oprah, Vogue and an ancient and dog-earred Travel and Leisure (which issue I’ve now read thrice). Although I do not subscribe to any of these periodicals, except T&L, I must confess that I do on occasion riffle through them at the salon…just to keep up on the latest breaking news, of course. Granted, the news in them is all about Brangelina or what my beloved Johnny Depp wore on the red carpet, but it’s something to pass the time while sniffing the hair spray.

Today, I happened to notice a short piece in O: The Oprah Magazine entitled “Cream Puffs, Anyone?” about the recently and widely reported results of the Women’s Health Initiative that showed that eating less fat doesn’t reduce the risk of breast cancer, colon cancer, or heart disease. The gist of the piece was a caution that despite the lack of connection of eating fat to any of these problems, we should all still eat a diet low in fat, particularly in saturated fat, and high in healthy whole grains.

The usual drivel.

What was interesting here, however, was the comment of Elizabeth Nabel, MD, director of the National Heart, Lung, and Blood Institute and of the WHI study, who was reported as having said:

…the investigators have yet to report on many other things–like the effect of a low-fat diet on gallbladder disease. And eating fatty foods may saturate the bile (stored in the gallbladder) with cholesterol, which could increase the risk of stones.

Cling onto that feeble hope, Lizzie, but don’t come whining to me when you get the results all analyzed and find that the people who ate the least fat had the most gallstones.

Mike and I saw exactly that result, albeit in a smaller group of patients, during the lead-in to a large weight maintenance drug trial we monitored in the late 1990s. During the trial, participants were asked to first lose weight on a low fat diet for 6 months, then were to be placed on one of three strenghths of the study drug or a placebo for a year to determine if the drug helped them maintain their meager low-fat weight loss. As a part of the study, before they began the weight loss phase, the participants underwent extensive testing, including having ultra-sound examinations of their gall bladders to look for stones. They then followed a low-fat, high-carb reduced calorie diet for 6 months with lots of nutritionist contact and regular visits and behavior mod.

At the end of the weight loss period those who had lost at least 4% of their starting weight in 6 months could go on to enter the drug trial. This cut off meant, of course, that a 200 pound woman would work for 6 months to lose 8 pounds and then be permitted to enter the maintenance trial to receive drug or placebo in a double-blinded set up, where neither the subjects nor the staff knew who got what. All this effort to see if taking a prescription drug, with not especially pleasant side effects, three times a day could help a 200 pound person maintain at 192 pounds, while continuing on a low-fat high carb maintenance number of calories.

Sheesh!

Before the subjects could enter the drug phase of the trial, however, each one had to again undergo the extensive battery of tests, including another gall bladder ultrasound. Although I don’t have the numbers at my fingertips, I can attest that an unusually large number of these moderately overweight to modestly obese people had developed gallstones during the 6 months of monitored low-fat dieting. We know they hadn’t had them before because we had pretty ultrasound pictures to prove it!

In all our many years (decades, actually) of helping patients lose weight on a low carb diet, which by its very nature is higher in fat, I cannot recall a single one (from among many thousands that we treated ourselves hands on) who developed symptomatic gall bladder disease.

This…there’s no other word for it…ignorant notion that eating fat will cause gallbladder disease is laughable.

What makes the gall bladder empty? As any basic human physiology text will you, it’s fat entering the first portion of the small intestine. When saturated, monounsaturated, or even polyunsaturated fat reaches this area, its entry triggers the release of cholecystokinin (CCK) which is the hormone that causes the gall bladder to squeeze and squirt bile into the intestine to emulsify the fat.

This is what the gall bladder is supposed to do, for crying out loud; it’s its raison d’etre.

Translated loosely from its medical Latin roots, it’s very name says it all: chole (gall) cysto (bladder) kinin (mover).

When little or no fat comes through, the bile in the gall bladder sits around turning to sludge. Absence of fat is the recipe for supersaturation of bile and gall stone formation, not eating fat!

You buy them their books and you send them to school and still they don’t get it.

When (and if) they finally do release the further results of the WHI trial pertaining to the effect of the low fat diet on gall stone formation get ready for Round 2 of head scratching, back peddling, and scrambling from the low fat camp.

If ever there were a hypothesis doomed to failure the theory that a low fat diet prevents gallbladder disease is it.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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15 thoughts on “Oh, the Gall of It All

  1. But isn’t there a concern that those of us who, like many Americans, followed a low-fat diet for most of our lives will develop gallbladder problems when we make the change to a low-carb diet?

    One we begin to take in adequate amounts of fat, does this not tend to cause gallbladder attacks, due to the change in diet?

    I am eating lower-carb, and this is one of my concerns.
    COMMENT from MD EADES:

    You’re absolutely correct that making a switch from a low fat diet to a higher fat diet can cause a gall bladder attack, but if and only if the gall bladder is already filled with sludge or stones. On a very low fat diet (say Dean Ornish or an ultra low fat protein sparing shake fast such as Optifast or Medifast which has only shakes and no food) the gall bladder doesn’t do much; it and the bile within it just sit there and turn to Elmer’s glue. If after doing that, you chow down on a fatty meal and ask the lazy gall bladder to do something, you could be asking it to squeeze down around a bag of stones or sludge, which will cause pain.

    If a person following a low carb diet for a few weeks hasn’t suffered any gall bladder symptoms, the chances that there are stones present is pretty small. And, at least in our experience, they’re not likely to form.

    PS Because you didn’t type in the password on the comment page, your comment got shunted to the junk comments file (from which I rescued it from among the spam junk that is supposed to go there.) To be sure that future comments get through, type the password, given at the bottom of the comment form, in as shown.

  2. This is a very interesting article because I now have symptoms of gallbladder disease. It is the 6th time I have had it and also the worst. Usually it would come on around 2am and would last about 2 hours. Now it has lasted 2 weeks and I had to have strong pain killers. My doctor sent me for ultrasounds and endoscopy. The point I am making is that each time the symptoms came I was on a low fat diet for health reasons (I’m not over weight but I have had a lifetime of fairly fatty diet. So maybe my gallbladder was so used to digesting my high fat intake that a low fat diet sent it into a spin. People that have spent a lifetime on low fat wouldn’t have that problem would they?

    COMMENT from MD EADES: Indeed they might, since gall bladder disease is a component of the metabolic insulin-resistance syndrome.

    Once the stones have developed, however, there isn’t to my knowledge any good way to get rid of them except surgical.

  3. Hello Dr Eades,
    I don’t mean to quibble, and this is a most-interesting article, but I have a question.

    In the initial paragraphs, you mention that the people you monitored for the drug study had two sets of tests done, the second of which (for the low-fat people) showed the formation of stones. You compare this with your own low-carb clients who in years of practice did not develop SYMPTOMATIC gall bladder disease.

    How many of the low-fat people developed symptomatic gall bladder disease? Or, the other way, did you have ultrasund tests done on the low-carb people to see if they had silent stones?

    I am not tryng to be disrespectful, but I was wondering if perhaps this is a bit like comparing not apples and oranges but Spartans and Granny Smiths? It would increase the objectivity of the statement, but would it make any difference in terms of the results?

    Thank you, by the way, for this article. I have been trying to find definative information and most of what I can read on-line seems to be very general so it was interesting to read something a bit more scientific.

    COMMENT from MD EADES; You’re quite correct in pointing out that we don’t have the hard data to discover who among our low carb patient population had asymptomatic gall stones. What I would assume, however, is that most of the people who entered the drug study asymptomatic and proven on ultrasound to be without gallstones had been on pretty much the high everything diet and had no stones, yet developed them on a low fat diet. Would those people have done so on a low carb higher fat diet? We don’t have those scans, but common biochemical sense would dictate otherwise, since the gall bladder has to empty regularly on a higher carb diet. Would that we had had the money to undertake such a study on our low carb population, but sadly, we didn’t.

  4. I have no gallbladder! But want to diet to lose about 25lbs I have gained since having it removed. I was considering Optifast. I have high triglycerides 800-1600 without medication and take gemfibrozil, 600 mg, twice a day. I am worried about more gallstones in my bile duct. What diet would be best for me. All my lab values are normal with the gemfibrozil.

    COMMENT from MD EADES: While we can’t really diagnose or prescribe treatments via the internet, one general comment I would make is to remember that gall bladder disease (as the post discusses) and elevated triglycerides are both disorders of the insulin resistance syndrome. Any diet that would benefit that syndrome–ie a healthy, varied diet, rich in protein, rich in good fats (especially the omega 3s) and full of fresh low-starch veggies, greens, and low-sugar fruits, a diet, say, much like Protein Power, would be in order. Of course, you should discuss any dietary therapy with your physician who can see and evaluate you and help to reduce your medications as your health improves.

  5. I am living proof that a low fat does cause problems with gall bladder. I have alternately been on low fat diets for years. (As my doctor suggested) I had learned about antibiotics in our meat,milk,eggs,and now fruits and vegetables, and so went organic as I am allergic to antibiotics. Only problem is I was on a low fat diet so long that I dont know how to get more fatty foods in a healthy way. Since being on a low fat diet I have a harder time keeping my weight down. I also 9 years ago had a very severe gall bladder attack. I tried to change my diet and I gained even more weight, with the same amount of exercise and food intake. I just recently had another attack again so severe I had to go the hospital. As I had pain and vomiting. And what did they find both times? I had a lazy gall bladder no stones. Both incidents were after eating out. Which hey I am willing to risk a rash to eat out once in a while. I have been taking fish oil supplements for about 2 months to get extra healthy fat as I had tried Olive oil and gained 10 lbs. With the fish oil I didnt gain any more and actually started to loose with a diet of meat and vegetables for dinner. Anything for lunch. I am not a breakfast eater. So I am left with OK so now what? I have tried to get more healthy fat I dont even eat fried foods, except on the rare occasions, I eat vegetables and fruit, and yet had the worst attack ever! And even though I have an attack from a lazy gall bladder what did the doctor say to do? Eat a low fat diet until we can do a radiation scan. Well forget it I will be my own lab rat thank you. Any suggestions are appreciated. Thank You
    Lisa

    COMMENT from MD EADES: While we can’t diagnose or make treatment recommendations via the internet, I can make a few general comments:

    As a source of good fat, fish oil (pure and of good quality) is great, but you don’t get enought in a few capsules to spur the gall bladder to do much. For quantity, try avocados, coconut, olives, nuts, organic dairy products, and pasture-raised, natural meats. Olive oil would probably be okay, too, under the right circumstances. Remember that added fat can only cause weight gain in the presence of elevated insulin and excess carbohydrate–ie, “anything at lunch”. To lose weight, our experience with thousands upon thousands of patients suggests that the surest course is to keep carbs low, protein and good fat up, and create a calorie deficit by controlling how many come in or increasing how many get spent…or both.

    If you haven’t done so, you might enjoy joining the Discussion Board (accessed from the homepage of the website) where you will find the answers to many questions, lively discussion on a wide range of topics relative to diet, and a welcoming atmosphere of like-minded people on the same journey you’re taking.

  6. In the late 90’s I had very good success with the Atkins diet or high protein and fat low carb diet.
    Since then I have had some health issues which led to my gall bladder being removed. I hve also gained a lot of weight. My question is a high protein, fat diet ok for me. Do you have any recommendations?

    COMMENT from MD EADES; Unfortunately we can’t really respond with medical advice for a particular individual. In general, I can say that the low carb, adequate protein and fat diet that we describe in our books is a healthy diet to control the entire constellation of insulin resistance disorders, one of which is obesity and another of which is gall bladder disease.

  7. During the fall of 1997, I had my first bout with gallbladder disease This started after about 6 very successful weeks on a nationally-known weight-loss plan that is almost universally endorsed within the medical profession as being healthy and safe. The first attack hit after I had a slice of cheese pizza for the first time in many weeks — I figured it was killer heartburn and went on.

    After a handful of debilitating attacks in a span of 3 weeks, I had gallstones identified via ultrasound. Of course, I was referred to a surgeon. For personal reasons, I couldn’t do the surgery at that time. So the surgeon gave me some bentyl and I took that the next couple attacks and then seemed to quit having them. They went away when I stopped following that particular diet. (Downside is that I’ve gained a ton of weight since then. )

    After 9 years of no discernible problems, I think I had another attack a couple nights ago. This time, I had not been on a diet; but I did have surgery 3 weeks ago. I was in a cast and on crutches for over 2 weeks and honestly just didn’t eat much during the day because it was too much hassle to fix myself something. But I had “normal ” dinners – nothing I would call a low-fat diet. But I lost 3 lbs the past 3 weeks doing almost nothing besides sitting on the couch and hobbling to the bathroom.

    COMMENT from MD EADES: There you have it; the gall bladder exists as a reservoir to hold bile which the digestive system uses to emulsify fat as it enters the small intestine. The signal for it to squeeze is, naturally enough, fat entering the small intestine. No fat entering, no signal, no squeeze, no emptying and voila…sludge and/or stones form. A very low fat/no fat diet is a recipe for gallstone formation.
    Could the overall inactivity along with the general lower food intake contribute to the buildup of “sludge” leading to this attack? The night I got sick was the first time I ate REALLY bad stuff (onion rings, egg rolls) since my surgery.

  8. Doctor Eades,

    I am a 38yo male who had my GB removed aproximately 6 years ago. I have always been physically active and would consider myself to be average in physical fitness.

    About 2-3 years before my surgery I had been getting abdominal pains in the middle of the night for 2 or more hours at a time. At this same time I noticed weight gain of about 25 lbs that I could not control and in the military the cuases problems.

    My GB was dead and I had to be cut open the old fashion way. Since then my weight gain has been the same and after 18 years I am in danger of being disharged for not being within weight limits. No matter what diet I choose or how much exercise i do, my weight stays steady around 220lbs at height of 6ft.

    I have seen nutritionist and keep getting told that I need to eat more. Unless I can keep my food intake to 1500 cal or less I gain and hold 220lbs(1800-2000cal). For me to make my standards for the military I end up going on a 900cal diet for one month to reduce my weight to the 200lbs requirement. Do you know of any correlation to the GB and weight gain that I should know about? And what can you suggest for me that may not have already tried to keep this weight off?

    COMMENT from MD EADES: The fact that you had Gall Bladder disease is prima facia evidence that you have metabolic syndrome (insulin resistance) and therein most likely lies the cause of your weight gain, since it, too, is most often a consequence of insulin resistance. In our experience, the single most effective diet for the components of the metabolic syndrome is a low carb one. While we cannot diagnose specific conditions or recommend specific treatments, I would suggest that you might go to Mike’s blog (from the homepage) and search the term ‘intermittent fasting’ and discuss this concept with your health care practitioner.

  9. i had my gall bladder removed 10 months ago..always ate lowfat, was always thin, and had sludge in my GB..i gained 40lbs in 4 months!!! i eat healthy and keep my cal. at 1000- 1200 a day and work out..i can’t lose the weight!! i am going on beta plus which has bile salts..will this help along w/ my high protein diet?

    COMMENT from MD EADES:  As it mentions on the email contact form, we cannot respond to personal medical issues via email, phone, or mail.  I can make a few general comments on the topic of gall bladder disease, however:

    1) The gall bladder functions to store bile (or gall as it was called in days gone by) that is produced in the liver.

    2)  The function of bile acids (or bile salts) is to emulsify dietary fat as it enters the intestine from the stomach.

    3)  Fat entering the intestine triggers the release of a hormone called CCK (CholeCystoKinin, which means ‘gall sack mover’) that tells the gall bladder to squeeze a shot of its stored bile into the intestine to work on the incoming fat.

    4) In conditions when the gall bladder functions poorly or is absent, there is no ability to squirt a good shot of bile at once into the intestine.  The bile simply enters the intestine as it is produced.  While there is usually enough to handle the fat in a typical meal, there may not be enough to emulsify the fat in an extremely fatty meal, which in the absence of added bile salts could result in incomplete fat absorption from the meal.

    5)  Gall bladder disease is now known as a component of the insulin resistance syndrome.  Like all components of this syndrome, it is improved by a low carb diet.

  10. My sister had her gall bladder removed 2 years ago as a result of sludge. She has since gained a few pounds but exercises more than ever (burns an avg. calorie count of 400/day). She’s 26, 5’6, and 140 lbs and has been a vegetarian for almost 10 years. She eats very healthy but cannot seem to lose any weight. I try to tell her that she’s not getting enough protein, but the more research I do seems to say that one of the side effects of having no gall bladder is weight gain. I’m just looking to find out if this is a true statement? I really would like to help her. She exercises so hard but doesn’t see results and it frustrates her. Does she need more protein? Also, she is on birth control, could this be the reason for holding on to the extra 10 lbs?

    COMMENT from MD EADES: Well, as you’re probably aware, state-by-state medical licensing regulations preclude our being able to specifically address any individual’s particular health issue. That job is rightly the purview of his/her medical practitioner. However, in a general sense, an adequate amount of protein, particularly of the amino acid leucine, is critical to weight loss. The body keys off its protein intake as an indication of how well fed it is. Cranking up the protein, up the good fats, and down the carbs (even if the protein comes from milk, eggs, cheese, and whey protein powder on a vegetarian diet) and making sure the carbs all come from low-starch veggies and low sugar fruits and not from pasta, potatoes, rice, and other grains will help to spur weight loss in virtually anybody.

  11. My situation is a bit like the person above, except i have not had gallbladder surgery yet.
    My triglycerides are 800, which is confusing to me as I have been vegetarian for 14 years and have always watched my fat intake. Even more so now that I am on Weight Watchers. I cna’t seem to lose a pound. I fear that when I have surgery I will suffer even greater. I have been prescribed lopid, but will this help? I am 145lbs (5’4″). Normally I’d be 115 (have two kids, one a baby). Are my triglycerides to blame for not being able to lose weight? will this surgery make it even harder?

    COMMENT from MD EADES: Your diet is to blame, for both your not being able to lose weight or to get your triglycerides down. Triglyceride levels have zero correlation with fat in the diet. The two food stuffs that drive triglycerides up are carbohydrates (sugars and starches) and alcohol. That’s not just us saying so; that’s textbook human biochemistry. If you have not done so, I’d recommend that you read our books Protein Power and The Protein Power LifePlan. (The LifePlan in hardcover is available on our website product pages and both are available in all formats through Amazon; any bookstore can order them as well. Many public libraries even have them available to check out.) After you’ve read them, I think that you will understand what’s going on and why both your standard veggie diet and WW have not been able to correct your problems. Good luck!

  12. May I ask: if one has, as a result of bad diet, built up an “Elmer’s Glue” like quantity of bile in one’s gallbladder, is there a way of clearing it out or thinning it away?

    COMMENT from MD EADES: Tincture of time on a good diet, perhaps.

  13. You not going to believe it but I have wasted all day researching for some information about this. You’re a lifesaver, it was a thought provoking read and really helped me out. Have a good one.

  14. Greetings Doctor Eades. I had some lower abdominal pain for about a year now, over the last month or so the pain had intensified quite a bit so much so that I went to my physician who had me get my abdomen checked via ultrasound as well as the HIDA test.

    The ultrasound showed no stones, no sludge. The HIDA however showed that my gallbladder squeezed less than 10%.

    I am having a diet fairly high in carbs and fats but sadly little veggies, fruits, fiber. I am also taking a medication to reduce my stomach acids (Omeprazole 40mg) along with a multivitamin, vitamin b,c,d supplements as well as flaxseed oils.

    Based upon my results my general physician immediately recommended the removal of my gallbladder.

    Couple of things which I would be curious to know:

    Firstly, I took vicodin due to pain approx. 36 hours prior to the tests, I know that it slows down the digestive track, could it also result in less squeezing action of the galbladder?

    Secondly, could the acid reducer have an adverse

    Thirdly, it would seem that virtually everywhere I look I see the “yank it out” recommendation. However I would hope with a change in diet one could “reset” the gallbladder is this true? (I’m pretty much willing to change my diet in whichever way necessary) or once it goes lazy it never comes back?

    Thank you so much in advance for your response.

    COMMENT: Unfortunately I can’t make diagnoses or treatment recommendations regarding specific medical problems for specific individuals over the internet, via phone, or mail. It simply an unwise medical practice to attempt to do so, with incomplete medical information, on a person one has not ever seen or examined (and cannot see or examine.) One general comment regarding the possibility that narcotic medication could have slowed gall bladder function: that’s possible and is something that ought to be discussed with a person’s physician at length prior to contemplating surgery to remove a sluggishly functioning gall bladder that has no stones or sludge.

  15. Lemme rephrase.

    A) Can opioid containing medicines impair gallbladder function?
    B) Can PPI’s such as Omeprazole impair gallbladder function?
    C) Are there dietary changes one can make which could “reset” a lazy gallbladder?

    Thanks again.

    Yes; probably; yes.