Editor,—In showing for the first time that raised serum insulin is a risk factor for incident gall stones, independent of body mass index, Misciagna et al((2000) Gut 47:144–7; OpenUrlAbstract/FREE Full Text) have made an important contribution. However, they do not seem to realise that we had similar findings in the East Bristol Gallstone Study (population based like theirs)—namely, that raised plasma insulin is a risk factor for prevalent gall stones, at least in men.1 In our study, another significant factor was abdominal fatness or central obesity, but not body mass index (as is usually the case in men), and abdominal fatness probably explained the hyperinsulinaemia as the association of insulin with gall stones disappeared when we controlled for waist-hip ratio. Abdominal fatness is a well known determinant of fasting plasma insulin and it is a pity that Misciagna et al did not include any measure of it in their study.

Should Misciagna et al continue this line of enquiry, they will be well advised to measure the insulin response to eating because in our experience, postprandial as well as fasting levels of insulin are raised in men with gall stones.1 I fully agree with Misciagna et al's conclusion that “hyperinsulinaemia may play an important role in the aetiology of gall stones”. I also suggest that future studies of gall stone aetiology should include measures of insulin sensitivity and of its determinants. One such determinant is physical fitness2 and this may be relevant because, in our study, there was a hint that loss of muscle bulk may be associated with gall stones in men. Men with gall stones had not gained weight during adult life more than controls, despite having more abdominal fat, suggesting they had lost more lean body mass.1