Dear Mark: High-Fat Diet, Gall Stones, and NAFLD

Gallbladder and Gallstones in lineFor today’s edition of Dear Mark, I’m answering two questions. Both concern the gallbladder. First, how does a high-fat ketogenic diet relate to the presence of gall stones? Can the former cause the latter? Or is the story a bit more complicated than that? Then, I discuss which fats are most amenable to the gall bladder-less. Also, where does non-alcoholic fatty liver disease, or NAFLD, come in?

Let’s go:

So I’m currently in school for diagnostic medical sonography, and interestingly enough, while learning to scan gall bladders I found that I have a stone! It’s mobile, but currently looks like it is too big to migrate into the cystic duct (whew). I have been doing a ketogenic diet for a few years, and am curious if you have any knowledge of data on people on the diet and gallbladder pathologies?

Also I have a report do in a month or so, and am choosing to focus on the ‘leaky gut syndrome’ that I’ve heard you speak of, and was wondering if you have access to any data about that?

Ok, well thanks for everything man! love your work!

-Ben Yarbrough

Gallstones are a tricky one. We all know that gall stones and gall bladders have something to do with how much fat we eat.

Here’s how I currently understand diet’s relation to gall stones:

The primary role of the gall bladder is to collect bile from the liver, concentrate it into potent super-bile (my term), and release the concentrated bile to break up incoming dietary fat into smaller molecules that lipase can attack and digest. Dietary fat is the biggest driver of gallbladder emptying.

If the gall bladder isn’t regularly emptied, gall stones can form. Usually made of hardened cholesterol, gall stones are quite common and often produce no symptoms. Problems arise when normal gall bladder emptying flushes out a stone small enough to make it into but too large to pass through the bile duct and a blockage occurs. Gall stones can also directly damage the walls of the gall bladder, leading to cholecystis, or gallbladder inflammation.

A high-fat diet can exacerbate or even uncover gall stone issues by increasing gall bladder emptying. Remember: the more fat you eat, the more often you empty your gall bladder—and everything in it.

But the original cause of the gall stones isn’t the high-fat diet.

It’s not eating enough fat, believe it or not. That’s right: assuming there aren’t any gall stones present, eating more fat will keep your gall bladder clear of stones.

Risk factors for gallstone formation are as follows:

  • A high intake of high-glycemic carbohydrates.
  • High estrogen levels, which concentrate cholesterol deposition in the gall bladder. This is why women, especially pregnant women and/or those taking hormonal birth control, are more likely to have gall stones.
  • Obesity, which also increases cholesterol levels in the gall bladder.

One of the bigger risk factors for gallstone formation is weight loss, with a caveat: high-fat diets reduce and even prevent gallstone formation. In fact, when you compare people who lose weight on a low-fat diet to those who lose it on a high-fat diet, research shows that 45% of the low-fatters develop gallstones while none of the high-fatters develop them.

That’s right. Zero.

When you don’t eat enough fat, and the gall bladder isn’t emptied regularly, the bile gets more concentrated. Anything that’s in the bile, like cholesterol, also becomes more concentrated. If it hardens, you’ve got yourself a stone.

Although the common treatment for gall stones is to just remove the bladder, there are other ways that don’t involve removing an organ. You can use ultrasound to break the stones up into tiny, easy-to-pass pieces. That same study found that a drug called ursodeoxycholic acid, or UDCA, can dissolve gallstones already present in the gall bladder.

What I think is happening in your case? I’m not a doctor, but I’d say your ketogenic diet hasn’t caused the gallstones, but the increased fat intake may flush them out. Ask your doctor about UDCA. Once you’ve got the gallstones cleared out or dissolved, sticking with a high-fat intake should decrease your risk of developing any more.

As for leaky gut, I wrote a decent post that contains many references on leaky gut. You should find it a good place to start.

Where do coconut and mct oil fall in this category? Especially for someone without a gallbladder and NAFLD? Thanks!

For folks without gall bladders, coconut and MCT oil are probably better options than longer-chain fats. The shorter-chain fatty acids found in coconut oil and MCT oil don’t require as much bile to break apart, so the concentrated bile produced by the gall bladder isn’t necessary.

Remember, your liver still makes bile without a gall bladder. It’s just not the super-concentrated potent stuff a gall bladder spews out.

Honestly, it’s unclear how having a non-alcoholic fatty liver changes things. There’s some evidence that missing your gall bladder increases the risk of fatty liver, but that’s neither here nor there. You’ve already got NAFLD. What to do?

Well, short chain fats seem to be better for fatty liver than others. One study compared soybean oil (high PUFA omega-6) to coconut oil in rodents, finding that coconut oil was better for fatty liver than soybean oil. That’s good news.

You can also take some extra steps to improve liver health and bile activity.

Support your liver with choline from liver and egg yolks. Higher fat intakes require greater amounts of choline to allow the liver to process the fat.

Support glutathione production and recycling with whey isolate, NAC, fibrous green veggies, alpha lipoic acid, raw dairy, and any polyphenol-rich foods you can imagine (turmeric, chocolate, blueberries, etc).

Consider some taurine (or beef heart), which increases bile production.

Consider some ox bile products, which may replace some of the effects the gall bladder typically provides.

Consider bitters (or foods with bitter flavors), which have been used for centuries to improve digestion.

You may have to moderate your fat intake until you get everything sorted out. Use your symptoms as a guideline: if you feel nauseated, get loose stools, and have stomach issues after eating a high-fat meal, dial it back.

That’s it for today, everyone. Thanks for reading!

I’d love to hear about your experiences with gall stones or without a gall bladder. Extra points if you’ve dealt with NAFLD, too.


About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending more than three decades educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates flavorful and delicious kitchen staples crafted with premium ingredients like avocado oil. With over 70 condiments, sauces, oils, and dressings in their lineup, Primal Kitchen makes it easy to prep mouthwatering meals that fit into your lifestyle.

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