The Arrow #264 Gall Bladder & Fat, New Food Pyramid

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Greetings and salutations all! The rain has finally stopped, thanks be to the meteorologic gurus, and the sun is out full force!

Lots of comments on last week’s Arrow in the mail bag, most of them just that…comments. A bunch from readers who themselves have been prescribed antihypertensive therapies (which some accepted and others didn’t) for high in-office blood pressure readings that resolved out of sight of a white coat and a stethoscope. As I say, it’s not an uncommon scenario.

But one missive came in on a different topic entirely, one that posed a question that may have broader interest. It was a situation where a low-carb, high-fat diet that would be just the ticket for addressing one health issue complicated some other. The ‘other’ being a gall bladder with stones and a history of gall bladder colic.

So let’s take a look at what’s in play here.

High Fat Diet and a Diseased Gall Bladder

The gall bladder is a smooth muscular storage reservoir designed to hold the bile produced steadily by the liver so there will be a bolus of it at the ready when called for. Bile’s job is to emulsify incoming dietary fat, to make it more readily absorbed from the small intestine. The body—an amazing piece of work to be sure—has the process automated, such that when we eat fat and it exits the stomach and makes its appearance in the first portion of the small intestine, its entry triggers the release of a hormone called cholecystokinin (or CCK for short) that gets the ball rolling.

Its name says it all: the chole part refers to bile, the cysto to the bladder/reservoir, and the kinin to movement/action. So CCK is a hormone that stimulates the smooth muscle of the wall of the gall bladder to contract and squeeze bile into the small intestine. Which it dutifully does each and every time we eat fat.

In the absence of much incoming dietary fat entering the small intestine, say in someone following a very low fat diet, there is no regular signal to contract and the bile simply accumulates and sits in the reservoir, where over time it concentrates and turns to sludge. Or worse yet, coalesces into stones. Incoming dietary fat is a prerequisite for the gall bladder’s normal function.

I’ve mentioned in the past that years ago our clinic was tapped by a large pharmaceutical company to be one of the centers studying the maintenance arm for a new fat-blocking drug. We ended up being the largest center (i.e., most patients enrolled and completing the study) in the world. The drug was designed to put patients on what amounted to a ‘forced’ low fat diet by blocking the absorption of about a third of incoming dietary fat. Our charge was to see if doing this helped people who had lost some weight maintain the loss over the coming year.

The patients were screened with copious labs, EKG, x-rays, and other tests including an ultrasound of the gall bladder before they were cleared to participate in the study. And then they were all put on 6-months of a reduced-calorie, low-fat diet for weight loss, closely monitored with weekly education, supervision, and encouragement and lots of hand holding on the part of our RN and dietitian and sometimes, when needed, one of us.

After the 6 months of dieting, those who had lost at least 4% of their starting weight could be randomized into the actual getting-the-drug-or-placebo part of the study which would last a year.

(As an aside, most of these patients were in the range of 200 pounds and some much heavier, and the 4% cut-off to qualify for entering the maintenance arm meant they had to lose only 8 pounds in 6 months, which to our surprise a great many of them couldn’t do on a closely-monitored, standard low-calorie, low-fat diet. (Take that CICO-ists!)

By contrast our own clinic patients on low-carb, high-fat diets routinely lost around 4 pounds or more a month on average. So in the same 6-month span, they’d have lost on the order of 24 pounds, not 8. This disparity, as you might imagine, didn’t go unnoticed by the study participants and caused a lot of lively conversation in the waiting room; it took a whole lot of coaxing to keep the study patients from jumping ship and bolting to the low-carb approach. Some did. Some waiting to complete the study and then jumped.)

But before the cohort of ‘4%+ losers’ could go on to participate in the final leg of the study, we had to repeat all their screening tests, including a repeat of the gall bladder ultrasound. A surprising number of the subjects who had clean ultrasounds at the start had developed gall stones in the intervening low-fat dietary lead-in period and had to be dropped from the final leg of the study. In just 6 months of low fat eating.

The ancestral human diet at the time when our physiology was evolving was one of (mainly) meat and fat. So fat entering the small intestine is a normal and desirable thing and has been for millennia. Little to no fat entering the system mucks up the works. As the old Chiffon margarine ad reminded us years ago: ‘It’s not nice to fool Mother Nature!’ Or I guess we could use the ‘apple’ corollary: some fat a day keeps the doctor away.

PSA: If you’re interested in that paleolithic aspect, here’s a blast from the past you might enjoy. A long time ago MD and I were featured (along with some other people you probably recognize) in a movie that explored what the Perfect Human Diet was. We just learned yesterday from its producer/developer (our friend CJ Hunt) that right now the movie is available on Amazon for free (though I don’t know for how long and sadly you’ll have to endure ads.) Give it a watch. And now, back to our regularly scheduled programming on the gall bladder story.

What happens when the bile has become sludge or stones are sitting in the gall bladder and a big load of dietary fat comes down the pipe? The body does what millennia of evolution and fatty meat eating has prepared it to do. The CCK fires off and the gall bladder contracts and, in this case, at the very least there’s crampy/colicky pain in the right upper abdomen and often referred pain up under the tip of the right scapula. At worst the squeeze sends a stone down the bile duct to obstruct the flow of bile and cause a whole lot of colicky pain and probably a trip to the OR via the ER.

But what about someone with known gall stones who really needs to go low carb (which means eating higher fat) for other metabolic or mental health reasons? How can that work?

Get rid of the stones.

I wrote a blog a number of years back on non-surgical therapy for gall stones, which you can find here.

It’s not necessarily the answer for everybody, but if you’ve got time, it’s worth a trial to see if it will work. Most clinicians agree that it will get rid of cholesterol stones, far and away the most common sort, but they still don’t use it because they say ‘Well, yes the stones will dissolve but that doesn’t address the underlying cause, so they’ll just reform! So what’s the point?’

So, DUH. Address the underlying cause, which is often metabolic syndrome and a sugar and starch and crappy seed oil rich diet. Once the risk of triggering a gall bladder attack is alleviated, replacing that high-carb, low-fat regimen with a low-carb diet (replete with good fats to keep the gallbladder emptied regularly) will generally address that concern.

But if the resolution of the other health issue(s) (not the gall bladder one) is more urgent, there’s always the option of laparoscopic removal of the stones, or even of the gall bladder itself, depending on the situation. Laparoscopic stone removal would make way for instituting the high-fat, ketogenic nutrition more quickly.

In a case requiring removal of the entire gall bladder, although the liver will continue producing bile steadily and dribbling it down the common bile duct, the holding tank is now gone. And for a time at least a meal with a huge amount of fat taken in all at once can overwhelm the intestinal ability to emulsify and absorb the fat, which if not fully absorbed will travel on down the way in the stool – a condition called steatorrhea.

Thus smaller doses of dietary fat eaten more frequently may help an individual missing a gall bladder consume an overall higher fat diet without much problem. Eating a few macadamia nuts regularly throughout the day; eating half an avocado with salt and pepper; adding a bit of heavy cream to coffee or tea; having a small chunk of full fat cheese… you get the idea, sort of little fat snacks. And over time there is often a compensatory dilation of the common bile duct sufficient to make a sort of ‘faux’ reservoir that will allow for greater amounts of fat at a meal.

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Start One Simple Habit

 And speaking of dietary fat…

Congress, as I wrote a couple of weeks ago, passed legislation to require US schools to provide full fat milk and dairy products for students, a praise-worthy action that over time will surely improve kids’ health and cognitive function.

And now this week, we get more praise-worthy news with the unveiling of the NEW food pyramid, one that literally turns past nutritional ‘wisdom’ (lunacy more like) on its ear.

The new recommendations encourage consumption of nutrient dense whole ‘real’ foods that better align with what it will take to make our citizens, young and old, healthier and, again in time, rid us of the crushing burden of chronic disease that’s staggering our people and our economy.

At the broad top of the new pyramid are (praise be) meat, fish, poultry, full fat milk, yogurt, and cheese, fresh low-starch vegetables and low sugar fruits. Hmmmm…sounds remarkably like the Protein Power diet the Bride and I have advocated for now over 40 years. Glad they finally caught up!

I scratched my head at the placement of butter on the new pyramid image. It’s down by bananas. And I couldn’t fathom why it (and while we’re at it heavy cream) were not right up top with the full fat dairy and other animal food sources. But I won’t quibble too loudly and maybe it’s not significant; there’s still much to be thankful for here.

For instance, they doubled the daily recommended protein intake from the barely adequate 0.8 g/kg body weight to 1.2 to 1.6g/kg body weight. Lean body masses around the nation cheered! I can promise you that MD and I both jumped up and shouted ‘Hallelujah!’ (And I suspect Jesus likely did as well!)

The narrow tip of the new pyramid (once a space reserved for fats) is now the lonely province of whole cereal grains. And added sugar, refined carbs, sugar-sweetened beverages, and ultra-processed foods have been pointedly consigned to the junk heap, where they belong.

The one sour note in this otherwise cracking good news is that the guideline formulators bowed to – well, honestly I’m not sure to whom exactly -- anyway, whoever it was, they wound up keeping the ill-advised, knee-jerk limit of no more than 10% of daily calories as saturated fat on alleged cardiovascular health grounds. Utter idiocy, since even the American College of Cardiology released a statement long hence exonerating saturated fat from guilt on that score. So why the dogged adherence to this artificial (and wrong-headed) limit? Cherchez l’argent, I suppose.

Not to mention that the new guidelines’ unequivocal push for eating more meat, fish, poultry, eggs, and full fat dairy – and even a statement from HHS that beef tallow and lard aren’t the dietary devils incarnate once thought -- is going to make for a strange bedfellow next to that 10% limit.

Fortunately the legislature’s mandate for return of full fat milk (a recommended three servings a day) to schools specifically exempts the saturated fat content of dairy products from being counted in the 10% daily sat fat total. A bit of a work around, but maybe it will all be to the advantage of the health of the 30 million kids fed in the nation’s school lunch program at least.

Before you say who cares about that 10% because nobody looks at or abides by those silly recommended intake percentages, remember that it is a law that any public institution offering meals and receiving federal funds must abide by the current Nutritional Guidelines for Americans. (That’s part of what got us into this metabolic mess to begin with, abiding by the looney 6 to 11 servings of bread and cereal grains and low-fat or skim dairy.) And further remember that it isn’t only school lunch menus that are under the government pyramid’s purview. There are about another 50 million people or more fed daily by the government in our military, in prisons, and in college and university dining halls. Granted in the latter group, college students can pick and choose from the offerings in the dining hall and maybe cobble together something approaching decent, should they wish. Most of them, truth be told, probably subsist mainly on pizza delivery in any case, where at least they’ll get some full fat meat and cheese and a few veggies with their tomato sauce and crust. And beer.

The Arrow is a reader-supported guide to nutrition, medicine, books, critical thinking & culture. Both free and paid subscriptions are available. If you would like to support my work, the best way is by taking out a paid subscription. At just $6 per month, it’s cheaper than one Starbucks Vente double pump caramel latte or whatever. And a lot better for you. It will run your IQ up instead of your insulin.

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