By Louise D. Metz, MD
In medical school, we were taught a multitude of mnemonics to help us memorize lists related to basic science and clinical care. One of those mnemonics was the 5 F’s, a list of risk factors for the development of gallstone disease: “Female, Fertile, Fat, Fair, and Forty”. If a patient came in to the hospital or clinic with upper abdominal pain, we were taught to use this mnemonic to determine if the patient’s symptoms may be caused by gallstones. The gallbladder is a small organ adjacent to the liver that holds bile, a liquid that helps the body digest food. Gallstones are small, hard masses that form in the gallbladder and are made up of cholesterol, calcium salts, and bile pigments. About 10-15 % of the population has gallstones, and this incidence varies among ethnic groups. However, only 15-25% of those with gallstones will have symptoms related to gallstones. In some individuals, gallstones can push against the opening of the gallbladder, leading to increased pressure in the gallbladder and associated abdominal pain, known as biliary colic.
There was an explanation behind the 5 F’s mnemonic of gallstone disease: The incidence of gallstones had been thought to be more common in Females over Forty as they were reaching perimenopause. Women who were Fertile, meaning that they had one or more children, were thought to be at higher risk due to higher estrogen levels and the association of gallstones with pregnancy. Fair was part of the 5 F’s because it was believed that gallstones were more common in Caucasian women, and Fat was included because being “overweight” or “obese” was linked to increased levels of cholesterol that could cause gallstones. Despite this reasoning, this mnemonic was different than the usual mnemonic lists such as MUDPILES for the list of causes of a metabolic acidosis or the 4 T’s for mediastinal masses. This mnemonic was not just an objective list of risk factors for a condition, as it implied a biased image of a certain type of patient who has gallstones. It carried with it a focus of blame on the individual for their lifestyle or behaviors causing their health condition.
Instead of actually helping with diagnostic dilemmas, this mnemonic narrows the critical thinking of the diagnostician and labels a large group of people who fall into these demographics as having this particular health condition. What other conditions might be missed in a woman over 40 in a larger body with abdominal pain if we are only thinking of gallstones? How about heart disease, which can present with abdominal pain or nausea in women rather than the typical chest pain syndrome that was defined in a male population? What about a stomach ulcer, which can lead to serious complications if missed? Given that gallstones are often present but asymptomatic, gallstone disease could often be an erroneous diagnosis once gallstones are identified on an imaging test. And how about individuals who do not fit into this profile, such as women of color? Might the presence of gallbladder disease in this group be missed? And what about the actual validity of this mnemonic? Does it accurately represent the risk factors and physiology of gallstone disease?
The 5 F’s mnemonic has been taught to medical students since well before the 1950s, when a study in the British Medical Journal assessed the validity of the mnemonic. They found that gallstones were more common in women in general, but that men were more likely to have gallstones at older ages. They found that while women under 50 with children were more likely to have gallstones than those without children, the opposite was true after age 50. Similarly, they found that women under 50 with gallstones had higher weights than those without gallstones, but this was not the case after age 50. In addition, we know that Native American women and Mexican American women have a higher prevalence of gallstones (50% and 27% respectively) than Caucasian women (17%), so the “Fair” in the mnemonic also does not hold up. A more recent study in 2013 looking at the validity of this mnemonic found that family history, which is not included in this mnemonic, is actually one of the strongest risk factors for gallstones. Despite the inaccuracies of this mnemonic in these studies done over 60 years ago and in the recent past, medical students have continued to learn this biased list.
What about Fat in the 5 F’s? Though the term fat has been reclaimed as an objective descriptor of body size, the term fat in this gallstone mnemonic was used in a stigmatizing way. It was posited that women who are fat are predisposed to gallstones due to their eating behaviors and cholesterol levels, which could cause gallstones to form. However, this idea is rooted in weight bias, as we know that one’s body size does not provide us with any information about eating behaviors or cholesterol levels. In addition, what we didn’t learn in medical school is that the association between body size and gallstones may be a correlation rather than a causal connection, and there may be other mediating factors that are causal. For instance, weight cycling (yo-yo dieting) increases the risk of gallstones. Studies in both women and men have found that weight cycling (as little as 5-9 lbs) has been found to be independently associated with gallstone disease after controlling for BMI, age, fat intake, and alcohol intake. Rapid weight loss due to very low calorie diets or gastric bypass surgery has also been shown to lead to formation of gallstones. Therefore, it is likely not the body size that is causing the gallstones, but it may instead be the restrictive and repeated dieting that is causing gallstone disease. Prescribing diets is harmful and may be a causal factor in not just gallstone disease, but many other health conditions including heart disease, hypertension, and diabetes, which are also typically blamed on individuals’ body sizes.
Weight bias is pervasive among healthcare providers. Despite our sense of pride in having objectivity in medicine, we as providers carry significant implicit bias and are not neutral in the care that we provide. Weight stigma that is internalized by individuals can lead to avoidance of care, non-adherence to treatment, and an increase in the risk of a multitude of health conditions. The 5 F’s of gallstone disease illustrates the weight bias that is entrenched in our medical culture. It labels individuals as being to blame for a condition when, in fact, the treatments that we are prescribing to those in larger bodies, including diets and weight loss surgery, may actually be causes of these conditions. We must acknowledge the weight bias and stigma that exists in our western medical model, and recognize the harm that is done in the name of health. The health and wellness of each individual is much more complex than a simple and biased mnemonic.
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