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).

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.
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