25 Oct Diet in chronic diseases – Gallstone Disease
Need for planning diet in Gall Stone Disease:
- To prevent gallstone formation and
- To reduce the likelihood of painful attacks if the patient is already suffering from stones, it is important to reduce the intake of foods high in cholesterol and fats.
Although diet doesn’t directly cause gallbladder problems, and it won’t cure them, watching what one eats and keeping a healthy weight might help them prevent gallstones from forming and avoid some discomfort if they do develop gallstones.
Risk factors for getting gallstone disease are:
- Genetics: If somebody in the family has had gallstones, one is at increased risk of developing gallstones.
- Obesity: The biggest risk factor that can cause a rise in cholesterol and can also keep the gallbladder from emptying completely.
- Estrogen: Can increase cholesterol and reduce gallbladder motility. Women who are pregnant or who take birth control pills or hormone replacement therapy have higher levels of estrogen and may be more likely to develop gallstones.
- Gender and age: Are more common among women and older people.
- Cholesterol drugs: Some cholesterol-lowering drugs increase the amount of cholesterol in bile, which may increase the chances of developing cholesterol stones.
- Diabetes: People with diabetes tend to have higher levels of triglycerides which is a risk factor for gallstones.
- Rapid weight: If a person loses weight too quickly, his or her liver secretes extra cholesterol, which may lead to gallstones. Also, fasting may cause the gallbladder to contract less.
Important points to be taken into consideration while planning a diet for patients with Gall Stone Disease is:
A diet must be:
- Low in saturated fat and refined sugar
- Higher in polyunsaturated and monounsaturated fats, and
- High in fibre
|HYPO – CHOLESTEROLEMIC SPICES
Garlic, Onion, Fenugreek, Red Pepper, Turmeric, and Ginger
|ü Reduce blood and liver cholesterol by enhancing cholesterol conversion to bile acids through activation of hepatic cholesterol-7α-hydroxylase. (Srinivasan K)
ü Enhances secretion of bile acids into bile. (Reddy RR, et al)
Health implications of the hypocholesterolemic effect of spices include:
v Protection of the structural integrity of erythrocytes by restoration of membrane cholesterol/phospholipid profile.
v Prevention of cholesterol gallstones by modulation of the cholesterol saturation index in bile. (Srinivasan K)
|CAPSAICIN AND CURCUMIN
Bioactive compounds of Red Pepper and Turmeric
|ü Have been shown to be hypotriglyceridemic, thus preventing accumulation of fat in the liver under adverse situations by enhancing triglyceride transport out of the liver.
ü Enhances secretion of bile acids into bile. (Srinivasan K)
The anti-lithogenic influence of spice compounds was attributable to the cholesterol-lowering effect of these dietary spices in blood and liver, as well as a moderate increase in phospholipids.
Effects caused by lithogenic diet that were effectively countered by Capsaicin and Curcumin, individually or in combination, were:
v Decreased activities of hepatic glutathione reductase and glutathione-S-transferase
v The increased lipid peroxidation and
v The decreased concentration of ascorbic acid in the liver
Their combination was more beneficial in enhancing the activity of hepatic antioxidant enzyme ─ glutathione reductase in the lithogenic situation. (Shubha MC, et al)
|FENUGREEK, ONION AND THEIR COMBINATION||Significantly reduces:
v Incidence of cholesterol gallstones by 75%, 27% and 76%, respectively.
v Total cholesterol content by 38-42%, 50-72% and 61-80% in serum, liver and bile respectively.
v Cholesterol/phospholipid ratio in serum, liver and bile.
v The increase in accumulation of fat in the liver and inflammation of the gallbladder membrane produced by HCD was markedly reduced.
v Phospholipid and bile acid contents of the bile upon consuming fenugreek and onion combination.
Changes in the hepatic enzyme activities (3-hydroxy-3-methylglutaryl Coenzyme A reductase, cholesterol-7α-hydroxylase and cholesterol-27-hydroxylase) induced by high (0.5%) cholesterol diet were well countered by fenugreek, onion and their combination. (Reddy RR, et al)
|Fenugreek seed significantly lowered:
v Incidence of cholesterol gallstones
v Serum cholesterol level
v Hepatic cholesterol level, and
v Biliary cholesterol levels
The antilithogenic influence of fenugreek is attributable to its hypocholesterolemic effect. (Reddy RL, et al)
|GARLIC AND ONION
Either raw or heat processed
|Feeding garlic and onion effectively accelerates the regression of preformed cholesterol gallstone by promoting cholesterol desaturation in bile. (Vidyashankar S, et al) Dietary garlic and onion possess anti-lithogenic potential. (Sambaiah K, et al)
Dietary garlic and onion significantly reduced:
v Cholesterol gallstone upto 53% to 59% (Vidyashankar S, et al), the effect being maximum in the heat-processed onion group (Srinivasan K, et al)
v Biliary cholesterol
v Biliary cholesterol saturation index and hydrophobicity index
v Serum and liver cholesterol levels
Increase in levels were seen in:
v Hepatic hydroxymethylglutaryl-coenzyme A reductase activity.
v Activities of the cholesterol-degrading enzymes cholesterol-7α-hydroxylase and sterol-27-hydroxylase. (Vidyashankar S, et al)
Dietary allium spices exerted anti-lithogenic influence by decreasing the cholesterol hyper-secretion into bile and increasing the bile acid output thus decreasing the formation of lithogenic bile (Srinivasan K, et al) and thereby reduced the incidence of gallstones. (Alan R. Gaby)
Point to be considered
Ø Anti-lithogenic potency of garlic was decreased by its heat processing. (Vidyashankar S, et al)
|COFFEE AND CAFFEINE||ü A possible protective effect of coffee or caffeine intake in the formation of gallstones has been suggested (Ruhl CE, et al) (Ishizuk H, et al) in men (Leitzmann MF, et al) and women. (Stampfer MJ, et al) (Ruhl CE, et al)
ü The protective effect of caffeine appeared to be due in part to stimulation of bile flow.
ü Consumption of decaffeinated coffee was not associated with lower gallbladder disease risk, suggesting the beneficial effect of coffee is due to caffeine. (Alan R. Gaby)
|IRON – CONTAINING FOODS||ü An iron-deficient diet had a higher incidence of cholesterol crystals in their bile. There is a possibility that iron deficiency plays a role in the pathogenesis of gallstone formation in humans. (Alan R. Gaby)
ü The frequency of gallstones plus cholecystectomy was significantly higher in iron deficiency anemia patients.
ü The increased prevalence of gallstones in iron deficiency anemia might be explained with impaired gall bladder motility. (Pamuk GE, et al)
|VITAMIN C SUPPLEMENTATION||ü Regular vitamin C supplementation and, to a lesser extent, increased physical activity and total cholesterol levels are associated with a reduced prevalence of gallstones. Regular vitamin C supplementation might exert a protective effect on the development of gallstones. (Walcher T, et al) (Shaffer EA)
ü Vitamin C is a cofactor for the enzyme 7α-hydroxylase, the rate-limiting step in the conversion of cholesterol to bile acids. Thus, vitamin C appeared to prevent gallstone formation by promoting the conversion of cholesterol to bile salts, thereby decreasing the lithogenicity of bile.
ü Vitamin C supplementation also inhibited cholelithiasis and accelerated the conversion of cholesterol to bile salts. (Alan R. Gaby)
Most popular edible tree nuts are almonds, hazelnuts, walnuts and pistachios
Other common edible nuts are pine nuts, cashews , pecans, macadamias and Brazil nuts
|ü Nuts (tree nuts and peanuts) are nutrient dense foods with complex matrices rich in unsaturated fatty and other bioactive compounds: high-quality vegetable protein, fiber, minerals, tocopherols, phytosterols, and phenolic compounds. Because of the richness of nuts in bioactive components, particularly unsaturated fatty acids, fiber, and minerals, a protective effect of nut intake on gallstone disease is biologically plausible.
v Frequent nut consumers (≥ 5/week) had a 25% reduced risk of cholecystectomy compared to non-consumers.
v Those who consumed 5 or more servings of nuts per week showed a risk of developing clinical gallstone disease that was 30% lower compared to those who rarely or never ate nuts. (Ros E)
Frequent nut consumption is equally protective of gallstone disease in men and women. (Ros E) (Tsai CJ, et al)
In women, frequent nut consumption is associated with a reduced risk of cholecystectomy (Leitzmann MF, et al)
|POLYUNSATURATED (PUFA) AND MONO UNSATURATED (MUFA) FATTY ACIDS||ü A high intake of polyunsaturated and monounsaturated fats in the context of an energy-balanced diet is associated with a reduced risk for gallstone disease in men. (Willett WC, et al)
ü MUFA has a protective role in gallbladder diseases and may decrease the risk of gallstone formation. (Ada Cuevas, et al)
ü PUFA consumption induces biliary lipid secretion (Ada Cuevas, et al) which in turn significantly reduces gallstone formation. (Kim JK, et al) It also decreases cholesterol concentration in bile. (Zák A, et al) (Méndez-Sánchez N, et al)
ü When PUFA is consumed in combination with ursodeoxycholic acid (UDCA) (the only established medical agent used to dissolve gallstones), there was:
v Further reduction in stone formation
v Significant elevation in level of bile phospholipids
ü PUFA attenuated gallstone formation through increasing the levels of bile phospholipids and suppressing bile mucin formation. (Kim JK, et al)
ü PUFA maintain the cholesterol saturation index (CSI) and nucleation time (NT) in obese women during rapid weight loss, which probably results in the prevention of cholesterol gallstone formation. (Méndez-Sánchez N, et al)
Rich in polyunsaturated fatty acids
|ü Fish oil exerts a potent anti-lithogenic effect on cholesterol gallstone disease. (Magnuson TH, et al)
ü Fish oil supplementation induced a significant reduction in cholesterol monohydrate crystal nucleation and gallstone formation. (Ada Cuevas, et al) (Janowitz P, et al) (Magnuson TH, et al)
ü Fish oil has shown to have triglyceride-lowering capacities and also increases synthesis of bile acid.
v Completely inhibits solid cholesterol crystal precipitation and gallstone formation (Magnuson TH, et al)
v Reduced serum triglyceridemia (TG) concentration
v Increased bile acid synthesis
v Altered bile acid distribution, reflected by an increased ratio of the cholic acid (CA) synthesis rate to the chenodeoxycholic acid (CDCA) synthesis rate (Jonkers IJ, et al)
v Improves gall bladder motility (Smelt AH)
ü Fish oil decreases biliary cholesterol saturation. (Smelt AH) (Janowitz P, et al) Supplementation with 11.3 gm per day of fish oil has shown to decrease cholesterol saturation of bile by nearly 25%. (Alan R. Gaby)
ü Fish-oil may increase bile acid synthesis by activation of 7-α-hydroxylase and may inhibit very low-density lipoprotein (VLDL) production and secretion through activation of nuclear factors and increased apoB degradation. (Smelt AH)
ü Fish oil induced the expression of cholesterol and bile acid transporters not only in liver but in intestine. (Kamisako T, et al)
|OMEGA – 3 FATTY ACIDS
Eicosapentaenoic Acid (EPA)
|ü Dietary supplementation with omega-3 fatty acids significantly influences biliary phospholipids, and decreases the incidence of cholesterol monohydrate crystal formation. (Booker ML, et al)
|RAPESEED OIL AND SUNFLOWER SEED OIL||ü Rapeseed and sunflower seed oils significantly reduced plasma cholesterol and triacyglycerol concentrations.
ü Chances of developing gallstones are highly negligible while consuming diets containing these oils. (Trautwein EA, et al)
|ü Raw wheat bran intake increases levels of chenodeoxycholate. (Pomare EW, et al) Chenodeoxycholate (3 alpha, 7 alpha-dihydroxy-5 beta-cholanic acid) is a primary bile acid directly synthesized from cholesterol. (Broughton G 2nd)
ü Bran probably operates primarily on the colon, reducing the formation or absorption of the bacterial metabolite deoxycholate, a substance which impairs chenodeoxycholate synthesis. (Pomare EW, et al) (Wicks AC, et al) Decrease in the levels of deoxycholate, thereby increases levels of chenodeoxycholate (Wicks AC, et al)
Other effects of intake of bran supplementation:
v Gallbladder bile aspirates from the duodenum became less saturated with cholesterol
v Molar percentage of cholesterol fell
v Saturation index of bile fell
v Reduced the lithogenic potential of bile (Wechsler JG, et al) (Wenzel H, et al) (Watts JM, et al)
A high bran diet
v Produced a substantial decrease in biliary cholesterol values (Wechsler JG, et al) (Wenzel H, et al) in patients with gallstones after 4 weeks. (McDougall RM, et al) (Wicks AC, et al)
v A significant increase in the concentration of HDL cholesterol in the serum of patients who course was followed for 6 months or longer. (McDougall RM, et al)
An increased intake of dietary fibres of the wheat bran type should be the first dietary measure in both prevention and treatment of cholesterol gallstone disease. (Wechsler JG, et al) (Wenzel H, et al)