High Blood Triglyceride Levels
Triglycerides (TG) are a type of blood fat. They are called triglycerides because their backbone is a form of glucose called glycerol and 3 fatty acids are attached to this backbone. They may be saturated, unsaturated on both. Fatty acids are the building blocks of fat.
Fig 1: Triglyceride structure:
We get triglycerides from food (mainly dairy products, meat, nuts and cooking oil). These are absorbed from our intestines and travel throughout the bloodstream in combination with a protein (lipoprotein). This combination is called chylomicrons which carries the dietary triglycerides to our tissues to be used for energy or is stored for later needs. Our body also makes its own triglycerides in the liver (particularly when we consume too many calories). This triglyceride is packaged differently and is present in the VLDL cholesterol.
What is a high blood TG level & why is it dangerous?
TGs are considered to be high, when the blood TG level is greater than 150 mg/dL after 8-10 hours of fasting. The TG test measures the fat derived from our diet (chylomicrons) and the fat produced by our liver (VLDL-C). If blood TG level is high, there is an increase the risk of diabetes, heart disease and strokes. If TG is >1000 mg/dL, the patient is at high risk of developing a serious condition called acute pancreatitis. In this condition, severe inflammation of the pancreas causes severe upper abdominal pain, nausea and vomiting with dehydration.
What causes high blood TG levels:
Increased blood TG may be due to “primary” or “secondary” causes. Quite commonly, patients may have a combination of both. “Primary” hypertriglyceridemia (high TG level in the blood) refers to inherited conditions (usually related to deficiency of enzymes and cofactors involved in the breakdown of triglycerides).” Secondary” hypertriglyceridemia occurs when diet, lifestyle, other medical conditions or medications affect blood TG levels. See Table 1.
|Diet (unhealthy) ↑Saturated fat ↑ Simple sugars||Kidney disease||Oral Estrogen|
|Alcohol||Underactive thyroid||Some HIV meds|
|Fatty Liver||Diuretics & β-Blockers|
High TG & low HDL-Cholesterol
HDL-Cholesterol (HDL-C) carries cholesterol from our tissues and back to the liver (also called reverse transport). The liver breaks it down and help remove it from our body. If the HDL-C is low, the reverse transport is reduced, it and the cholesterol starts to accumulate and lead to formation of plaques blood vessels and circulation. Generally, if the HDL–C is high, it is associated with reduced cardiovascular risk. There are however some patients with very high HDL-C who are at increased cardiovascular risk as well (perhaps genetic reasons).
High TG levels (hypertriglyceridemia) is often associated with low HDL-C and this unhealthy combination is often associated with the metabolic syndrome and premature heart disease. This combination is commonly noticed those with type 2 diabetes, metabolic syndrome, patients with central obesity & in CKD.
Combination of hypertriglyceridemia and low HDL-C may predispose the patient to coronary artery disease. This may occur even though the blood level of bad cholesterol (LDL-C) is not very high. LDL-C particles are smaller in such patients and therefore may need to atherosclerosis (hardening of the arteries) at lower levels compared to normal sized LDL-C. This is the main reason why so many patients with diabetes or metabolic syndrome have to take statins, in order to reduce the risk of getting heart problems.
How to lower high blood TG levels?
In general, diet and exercise are the most important elements that can help reduce blood triglyceride levels. Results are best achieved when you are working with a registered dietitian and perhaps a personal trainer. The general principles are:
- Reduce or eliminate sweets or simple sugar (including food items that are high in sugar) such as cookies, pies, came week, ice cream, frozen yogurt, soda, sweetened ice he, lemonade, fruit punch. Syrup and honey are also included in this list. If your triglycerides are greater than 500 mg deciliter, you may also help to reduce your total dietary fat to less than 15% of calories. This will require guidance from a registered dietitian.
- Reduce processed or refined carbohydrate intake. This will include white rice, white pasta, white breads bagel, pizza and many cereals. Instead, increase intake of fiber, brown rice, and Quinoa
- Reduce alcohol use and quit smoking
- Choose food items which have high omega-3 fatty acids and monounsaturated fats (good fats). These include fatty fish such as salmon, macro, Tina, Trout etc. (at least 2 servings per week). Also healthy options include flaxseed oil, walnuts, dark leafy greens, nuts and legumes (Chickpeas, lentils, kidney beans etc.)
- Limit saturated fats (such as butter, pork, beef, and, fried food, poultry skin, cream & whole milk).
- Avoid trans-fats in the processed food. You can do so if you avoid fast food and processed or refined food that contains partially hydrogenated oils. Examples include fried foods like donuts and baked goods like cakes, piecrust, biscuits, frozen pizza, cookies, stick margarine and other spreads. Eating trans fats increases your bad cholesterol (LDL-C) and decreasing your good cholesterol (HDL-C). The risk of developing heart disease and stroke is thus increased.
Table2: Good Fats vs. Bad Fats:
|Good FATs Use||Bad FATs Do NOT Use|
|Raw nuts or seeds||Donuts|
|Salmon, Tuna & Fatty fish||French fries|
|Flaxseeds||Ice cream and pastries|
|Organic nuts oils/organic butter||Crackers and cookies|
|Olive oil||Processed meats (pepperoni, sausages, bacon, salami, chorizo)|
|Peanut/ peanut butter||Frozen dinners|
|Walnuts||Hydrogenated oils such as palm oil|
If changes to your lifestyle does not work, you may need medications. The options include:
- Fibrates (e.g. fenofibrate)
- Omega-3 acid ethyl esters (Fish oil) (high dose)
- Combination of these (particularly if initial triglyceride levels are >500-1000mg/dL)
Because oftentimes, a superimposed secondary condition makes the triglyceride levels higher (such as uncontrolled diabetes, oral estrogens including birth control pills, alcoholism), you and your physician will have to address/fix these before triglyceride levels can be successfully reduced. A common example is demonstrated when successful in lowering of blood glucose levels in patients with diabetes automatically improves moderate elevations in blood triglyceride levels.
In general, statins are the preferred lipid medication for lowering blood triglyceride up to 500 mg/dL. stronger statins like rosuvastatin or atorvastatin are more effective in lowering triglycerides. When triglyceride levels are more than 1000 mg/dL, fenofibrate or/and prescription fish oil is often used for most of because they can reduce triglyceride levels are up to 50%.
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