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Prevalence of Gall Stone Disease and its Relation to Hypercholesteraemia, Hypertension and Diabetes in Affluent North Indians: Population Based Study

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To investigate the prevalence of gall stone disease in the affluent north Indian population and to study its …

To investigate the prevalence of gall stone disease in the affluent north Indian population and to study its
association with hypercholesteraemia, hypertension and diabetes, in isolation and together. A survey of 1000 subjects who reported to the hospital for routine health check (including physical examination, routine blood investigations and abdominal ultrasound).

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  • 1. Prevalence of Gall Stone Disease and its Relation to Hypercholesteraemia, Hypertension and Diabetes in Affluent North Indians: Population Based Study
  • 2. Original Article PREVALENCE OF GALL STONE DISEASE AND ITS RELATION TO HYPERCHOLESTERAEMIA, HYPERTENSION AND DIABETES IN AFFLUENT NORTH INDIANS: POPULATION BASED STUDY Arun Prasad+, Tarun Sahni*, Ashima Lyall, Sindhu Chandra+ and Praveen Goenka From the Apollo Surgical Sciences Centre+, Department of Internal Medicine*, Indraprastha Apollo Hospitals, New Delhi - 110044, India. Correspondence to: Dr. Arun Prasad, Apollo Surgical Sciences Centre, Indraprastha Apollo Hospitals, New Delhi 110044, India. E-mail: laparoscopy@hotmail.com Objective: To investigate the prevalence of gall stone disease in the affluent north Indian population and to study its association with hypercholesteraemia, hypertension and diabetes, in isolation and together.Design: A survey of 1000 subjects who reported to the hospital for routine health check (including physical examination, routine blood investigations and abdominal ultrasound).Setting : Apollo Hospital, a private corporate hospital at New Delhi, India. Subjects: 1000 subjects randomly selected, all above 20 yrs. of age; belonging to the higher socio-economic status in urban north India.Results: We observed the prevalence of gall stones in our selected group to be 12% (n = 120). Of the 1000 people we studied, the percentage of gall stones in women (17.63%) was found to be significantly higher than that of men (9.02%) of any age group. Age in itself was found to be statistically significant for the presence of gall bladder stones with a definite increasing trend in the prevalence of stones with increasing age (24.1% in 70-80 yrs.). On differential studies in each gender, this significance was found to be relatively greater in males. Serum cholesterol levels were however not found to be statistically significant in the prevalence of gall bladder stones in our study (p = 0.423). However, when differential analysis was performed in each gender, we found serum cholesterol to be relatively more significant in males (p = 0.458) than females (p = 0.947). There was a positive co-relation (Pearson’s correlate R = 0.115) between the prevalence of diabetes and gall stones that we observed in our data. This co-relation was observed to be even greater in males (p = 0.005) with diabetes in comparison to the corresponding females (p = 0.028). We found a higher percentage of people with co-morbid hypertension and gall bladder stone pathology (17.32%). The differential studies in each sex showed a much higher significance value for males (p = 0.022) over females (p = 0.082) with co-existing hypertension. The multi-variate analysis done for the same study group also revealed that raised serum cholesterol levels, though non-significant statistically on their own, were significant when co-existing with diabetes (p = 0.018). The other co-existing factors found to be statistically significant were diabetes with increasing age (p = 0.015); co-morbid diabetes, hypertension and hypercholesteraemia (p = 0.007); and diabetes with hypertension as well as hypercholesteraemia in the setting of increasing age(p = 0.001).Conclusion: Gall stone disease is one of the important lifestyle related diseases of today as observed by its high prevalence rate in our study, comparable to the rates in the western world[1,2]; with there being strong co-relations between the prevalence of gall stones and the other lifestyle diseases like diabetes, hypertension and hypercholestera Epidemiological implications : • Studies from developing countries are not clear regarding the association between the total serum cholesterol and prevalence of gall stone disease [2,15] . • In urban north India, the prevalence of hypercholeateraemia and hypertension is high. • The prevalence of gall stone disease is higher among the people with hypertension or diabetes or with co-morbid hypercholesteraemia with hypertension. Key words: Gall stone disease, Hypertension, Diabetes. GALL stones are one of the most common disorders of the gastrointestinal tract, affecting about 10% of people in western society[1]. Gall stone disease constitutes a major health problem in the United Kingdom and the United States [2,3]. over 50,000 cholecystectomies are performed each year [3]. The prevalence of gallstones increases with age in all racial groups; increased body weight, rapid weight loss, pregnancy, alcoholic cirrhosis, and a family history of gallstone disease also appear to be risk factors [4,6]. Studies done in India seem to show a lower incidence of gall stones [7]. In a study comprising of a total of 1104 subjects examined, 48 (4.3%) were found to have gallbladder stones8. This prevalence is about half of that in the western world. However India being a Gall stones are the most common abdominal reason for admission to hospital in developed countries and account for an important part of healthcare expenditure [2,3]. Around 5.5 million people have gall stones in the United Kingdom, and 39 Apollo Medicine, Vol.1 September 2004
  • 3. Original Article Results diverse country, taking an overall average may not reflect true prevalence in the population that consists of diverse ethnic groups, variation in dietary habits that vary depending upon socio-economic status [9]. Gall Stone Prevalence Out of a 1000 people studied, gall stones were present in 120 people ( 12% ). These are people with ultrasound findings of gall bladder calculi or as post cholecystectomy status. Methods One thousand people coming for health check up to Apollo Hospital, New Delhi, India from 1st January 2003 onwards were selected for the study. Physical examination included measurements of blood pressure. Supine blood pressure was measured with a standard mercury manometer. Two readings five minutes apart were taken as per WHO guidelines [10]. When a high blood pressure (>= 140/90 mm Hg) was noted a third reading was taken after 30 minutes. The lowest of the three readings was recorded and hypertension diagnosed when systolic blood pressure was >= 140mm Hg or diastolic blood pressure was >= 90 mm Hg [11-13]. The prevalence of gall stones in the population was measured conveniently by ultrasonography [4,6] and the prevalence of gallbladder disease was taken as the sum of people with gall stones and those who had a cholecystectomy in the past. A fasting blood sample was obtained from all the subjects and diabetes was considered in patients with fasting venous plasma glucose over 7 mmol/dL (126 mg/dL) or known diabetics under treatment. The total cholesterol concen-trations were estimated by an enzymatic method and hypercholesterolemia was taken as level above 5 mmol/dL (193 mg/dL or above) [9,10]. The above data were collected and a statistical analysis was done. Age The age wise prevalence is as seen below (Table 1 & Fig. 1). The maximum incidence of gall stones was in the age group 70-80 yrs = 24.1% Sex Distribution There were 346 females and 654 males in the population studied. Of these, 61 and 59 respectively had gall stones (Fig. 2). 17.6% of the females and 9% of males had gall stones. TABLE 1. Age wise prevalence of Gall stone. Age Total Percentage 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 0 4 15 36 43 15 7 0 15 93 224 291 233 113 29 2 0 4.3 6.7 12.4 18.5 13.3 24.1 0 Total Statistical analysis 120 1000 12 350 300 250 200 150 100 50 0 Data were pooled and computerized. Prevalence rates are given as percentages. To determine the significance of trends in the prevalence of gall stone disease and risk factors the χ2 test was used. The Mantel- Haenzel statistic which tests for linear association was determined with the SPSS statistical package (SPSS Inc, Chicago). In addition, Pearson’s coefficient of rank correlation (R) was calculated for gall stone status with various characteristics (age, sex, blood pressure, cholesterol levels and plasma glucose levels). Multivariate analysis to determine the overall relation of gall stone disease with factors such as hypercholesteraemia, diabetes and hypertension present in various combinations was performed by logistic regression. The independent variables were presence or absence of hypertension, diabetes and hypercholesterolaemia. The dependent variable was the gall stone status. A relation was initially determined between the risk factors and the gall stone status in any sex and age group. Gender, which is the major confounding factor, was then accounted for by performing differential studies in males and females and obtaining χ2 values separately for the same characteristics (P values are two tailed, and significance was taken as =< 0.05). Apollo Medicine, Vol. 1, September 2004 Number TOTAL GALL STONES 291 233 224 113 93 15 4 10-20 15 36 43 20-30 30-40 40-50 50-60 15 60-70 AGE GROUPS Fig. 1. Age-wise prevalence. 700 600 500 400 300 200 100 0 654 346 59 Males 61 Females Fig. 2. Sex-wise prevalence. 40 29 2 70-80 80-90 7
  • 4. Original Article 100 TABLE 2. Prevalence of hypertension, diabetes & hypercholesteraemia. Parameter Normal 746 865 135 Serum cholesterol 474 normal values raised values 47.4 60 254 Blood sugar 80 Abnormal Blood pressure 86.5 74.6 526 52.6 25.4 40 13.5 20 0 BP Sugar Cholesterol Fig. 3. Prevalence of hypertension, diabetes and hypercholesteraemia TABLE 3. The Association of Gall stones with various factors. Variable Total N With GS χ2 R Odds Ratio (Confidence Intervals) P value HT 254 44 0.096 8.464 1.847 (1.235 –2.762) 0.003 DM 135 29 0.115 12.25 2.327 (1.462 –3.703) < 0.001 HYPERCHOL. 526 59 –.025 0.497 0.885 (0.584 –1.253) 0.422 HT + DM 56 12 - - 1.238 (0.476 –3.218) 0.661 HT + HYPERCHOL. 147 20 - - 0.889 (0.439 –1.802) 0.744 DM+ HYPERCHOL. 76 16 - - 2.037 (1.129 –3.676) 0.018 HT + DM+ HYPERCHOL. 29 3 - - 0.533 (0.339 –0.839) 0.007 † p values calculated using Mantel-Haenzel’s χ2 test and multivariate logistic regression. ‡ significant when p< 0.05( confidence limits of 95%); highly significant when p< 0.01 (confidence limits of 99%). ∈ R - Coefficient of co-relation using Pearson's co-relation. 60 53.1 50 40 Percentage of hypertensives in those without gall stones = 23.9% 49.2 36.7 Percentage of hypertensives in those with gall stones = 36.7% 24.2 23.9 30 12 Percentage of hypercholesteraemics in those without gall bladder stones = 53.1% 20 10 Percentage of hypercholesteraemics in those with gall bladder stones = 49.2% 0 Hypertension Cholesterol No Stones Diabetes Stones Percentage of diabetics in those without gall stones = 12% Percentage of diabetics amongst those with gall stones = 24.2% Fig. 4. Distribution of hyperension, hypercholestaemia and diabetes Statistical analysis was done with this data in respect to the association of gall stones with the above mentioned factors (Table 3). Further analysis was done for males and females (Table 4). Hypertension, Diabetes & Hypercholesteraemia The prevalence of hypertension ( defined as systolic BP >140 and/or diastolic BP >90 ), diabetes ( defined as plasma venous glucose level >7 m mol/dL or >192.8 mg/dL) and hypercholesterolemia ( defined as total serum cholesterol >5 m mol/dL) was as follows ( Table 2 & Fig. 3). Discussion The prevalence of gall stones in any population is dependent on a number of factors including the ethnicity, demography and various lifestyle factors. The distribution of hypertension, serum cholesterol and blood sugar was compared in those with gall stones versus those without gall stones (Fig. 4). We found the following figures: In India, a gallstones survey limited to railroad workers conducted in 1966 utilizing oral cholecystography had 41 Apollo Medicine, Vol. 1, September 2004
  • 5. Original Article TABLE 4. Differential Studies in Each Gender Variable Male No. Cholesterol Daibetes Hypertension With stones Female χ2 p No. With stones χ2 p 346 28 ( 8.1%) 0.550 0.458 180 31 (17.2%) 0.004 0.947 93 16 ( 17.2%) 7.709 0.005 42 13 (31%) 4.831 0.028 168 23 ( 13.7%) 5.256 0.022 86 21 (24.4%) 3.028 0.082 † χ2 calculated using Mantel Haenzel's test. ‡ p value significant when p <0.05 . observation may be influenced by the fact that the prevalence of hypercholesteraemia was as high as 52.6% reflecting on the higher socio-economic bias of our study group. However, when differential analysis was performed in each gender, we found serum cholesterol to be relatively more significant in males (p = 0.458) than females (p = 0.947). suggested that gallbladder stones occurred 7 times more commonly in North Indian workers than in South Indian workers. This difference was attributed to the different ethnic background of the workers [16]. Another community study was performed to assess the prevalence of gall bladder stones in 1989 in four different colonies of Delhi, each with inhabitants belonging to a specific ethnic group. Of a total of 1104 subjects examined, 48 (4.3%) were found to have gallbladder stones15 with an incidence of 15% in the North Indian Punjabi community, of 24% in the Bengali community and 4% in the South Indian community. The same group was assessed for fasting serum glucose levels with a lower limit of 126 mg/dL of fasting blood sugar taken as the cut off for diabetes or the positive history of medications for diabetes mellitus obtained for the same. There was a positive co-relation between the prevalence of diabetes and gall stones that we observed in our data(r = 0.115). This co-relation was observed to be even greater in males (p = 0.005) with diabetes in comparison to the corresponding females(p = 0.028). We undertook this study at the Apollo Hospital, New Delhi (a private corporate hospital) in a random group of 1000 people reporting to the hospital for their Annual Health Checks. These people were assessed for the presence of stones in the gall bladder or for post cholecystectomy status on the ultrasound. We observed the prevalence of gall stones in our selected group to be 12%. This was significantly larger than what was observed in a previous study. This could be due to the fact that patients reporting to this hospital belonged to the higher socio-economic status. Individuals were also assessed for the presence of hypertension that included those with history of hypertension on anti-hypertensives, those with blood pressure values greater than 140/ 90 as well as those with isolated systolic hypertension of >150 systolic pressure. We found a higher percentage of people with co-morbid hypertension and gall bladder stone pathology (21.5%). The differential studies in each sex showed a much higher significance value for males (p = 0.022) over females (p = 0.082) with co-existing hypertension. Gender was found to be an important influence in the prevalence of gall bladder stones. Of the 1000 people we studied, the percentage of gall stones in women(17.32%) was found to be significantly higher than that of men(9.1%) of any age group. (The Pearson’s coefficient of co-relation for the presence of gall stones in women was of the order of 0.126 that had a significance value by Pearson’s X2 <0.001). Age in itself was found to be statistically significant for the presence of gall bladder stones with a definite increasing trend in the prevalence of stones with increasing age (R = 0.140; p <0.001). On differential studies in each gender, this significance was found to be relatively greater in males (p = 0.014) than in females(p = 0.036). The multi-variate analysis done for the same study group also revealed that raised serum cholesterol levels, though nonsignificant statistically on their own, were significant when coexisting with diabetes (p = 0.018). The other co-existing factors found to be statistically significant were diabetes with increasing age (p = 0.015); hypercholesteraemia with diabetes with hypertension(p = 0.007) on their own and in the setting of increasing age(p = 0.001). Conclusion The study group was analysed for the presence of hypercholesteraemia with normal levels taken up to an upper value of 192.8 mg/dL (5 mmol/dL ) Serum cholesterol levels were however not found to be statistically significant in the prevalence of gall bladder stones in our study(p = 0.423). This Apollo Medicine, Vol. 1, September 2004 Gall stone disease constitute a major portion of digestive tract disorders world over. We in our study have found the incidence amongst the urban affluent of North India to be more than the overall incidence reported in USA and Western Europe. 42
  • 6. Original Article This may be related to the life style and dietary habits amongst this selected population which is quite different from the rest of the country. Emmett PM. Symptomatic and silent gallstones in the community. Gut 1991; 32: 316-320. 7. Tandon RK. Prevalence and type of biliary stones in India. World J Gastroentero 2000; 6(Suppl 3): 4-5. In this study we have found strong co-relations between the prevalence of gall stones and the various lifestyle diseases like diabetes, hypertension and hypercholesteraemia. Hence, in view of our observations, we propose to consider cholelithiasis also as an important part of the lifestyle related diseases of today. 8. Tandon RK. Studies on pathogenesis of gallstones in India. Ann Natl Acad Med Sci (India)1989; 25: 213-222. 9. Tandon RK, Thakur VS, Basak AK, Lal K, Jayanthi V, Nijhawan S. Pigment gallstones predominate in South India. Indian J Gastroenterol1994;13(Suppl 1):81(A-E6). 10. Rose G, Blackburn H. Cardiovascular survey methods. 2nd ed. Geneva: World Health Organisation, 1982. ACKNOWLEDGEMENTS We would like to thank the Departments of Radiology and Clinical Pathology, Apollo Hospital, New Delhi for sharing and contributing data for this study. 11. Thijs L, Staessen JA, Celis H, de Gaudemaris R, Imai Y, Julius S, Fagard R. Reference-values for self-reported blood pressure: a meta-analysis of summary data. Arch Intern Med 1998;158: 481-488. REFERENCES 12. The Database of Abstracts of Reviews of Effectiveness (University of York), Database no. DARE-991548. In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software. 1. Bates T, Harrison M, Lowe D, Lawson C, Padle N. Longitudinal study of gallstone prevalence at necropsy. Gut 1992; 33: 103-107. 13. WHO.ISH. 1999 World Health Organisation - International Society of Hypertension. Guidelines Subcommittee. J Hypertens 1999; 17: 151-183. 2. Traverso L. William. Clinical Manifestation and Impact of Gallstone Disease. Am J of Surg1993; 165:405-408. 3. Beckingham IJ: Gallstone disease. BMJ 2001; 322: 91-94. 14. Halbert JA, Silagy CA, Finucane P, Withers RT, Hamdorf PA. Exercise training and blood lipids in hyperlipidaemic and normolipidemic adults: A meta-analysis of randomized, controlled trials. European Journal of Clinical Nutrition 1999; 53: 514-522. 4. Johnston DE, Kaplan MM: Pathogenesis and treatment of gallstones. N Engl J Med 328:412, 1993 [PMID 8421460]. 5. Ahmed A, Cheung RC, Keeffe EB: Management of gallstones and their complications. Am Fam Physician 61:1673, 2000 [PMID 10750875]. 15. The Database of Abstracts of Reviews of Effectiveness (University of York), Database no. DARE-988462. In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software. 6. Heaton KW, Braddon FEM, Mountford RA, Hughes AO, 43 Apollo Medicine, Vol. 1, September 2004
  • 7. A o oh s i l ht:w wa o o o p a . m/ p l o p a : t / w .p l h s i lc l ts p / l ts o T ie: t s / ie. m/o p a A o o wt rht :t t r o H s i l p l t p /w t c ts l Y uu e ht:w wy uu ec m/p l h s i ln i o tb : t / w . tb . a o o o p a i a p/ o o l ts d F c b o : t :w wfc b o . m/h A o o o p a a e o k ht / w . e o k o T e p l H s i l p/ a c l ts Si s ae ht:w wsd s aen t p l _ o p a l e h r: t / w .i h r.e/ o o H s i l d p/ le A l ts L k d : t :w wl k d . m/ mp n /p l -o p a i e i ht / w . e i c c a y o oh s i l n n p/ i n no o a l ts Bo : t :w wl s l e l . / l ht / w . t a h a hi g p/ e tk t n