What is the best way to lower triglycerides?

Best Approaches to Lower Triglycerides

Weight loss through lifestyle modifications is the most effective intervention for lowering triglycerides, with a 5-10% reduction in body weight associated with a 20% decrease in triglycerides, and potential reductions of up to 70% in some patients. 1

Lifestyle Interventions: First-Line Approach

Diet Modifications

• Carbohydrate restriction: Very low-carbohydrate diets (<10% of calories from carbohydrates) provide the greatest triglyceride reduction (24 mg/dL) 1
• Reduce added sugars and fructose: Can contribute an additional 10-20% reduction in triglyceride levels 1
• Increase consumption of:
  • Vegetables (especially non-starchy)
  • Legumes (beans, lentils, chickpeas)
  • Fatty fish (at least 2 servings/week)
  • Fiber-rich whole grains (6 servings/day)
  • Nuts and peanuts 2
• Limit or avoid:
  • Sugar-sweetened beverages
  • Full-fat dairy products
  • Sugar-sweetened dairy products 2

Alcohol Management

• For mild-moderate hypertriglyceridemia: Restrict alcohol (maximum 2 drinks/day for men, 1 drink/day for women) 2
• For severe hypertriglyceridemia (>500 mg/dL): Complete abstinence from alcohol 1, 2

Physical Activity

• Recommendation: At least 150 minutes per week of moderate-intensity or 75 minutes of vigorous aerobic activity 2
• Expected benefit: Up to 30% reduction in triglycerides 2

Pharmacological Interventions

For Severe Hypertriglyceridemia (≥500 mg/dL)

1. Fibrates (First-line):

   • Reduce triglycerides by 46-54% 3
   • Fenofibrate 160 mg daily has shown significant reductions in triglycerides in clinical trials 3
   • Also increase HDL-C by 19-23% 3

2. Omega-3 Fatty Acids (Second-line):

   • Recommended dose: 4 g/day 2, 4
   • Indicated as an adjunct to diet for severe hypertriglyceridemia 4
   • Common side effects include eructation, infection, flu syndrome, and dyspepsia 4

For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL)

• Focus primarily on lifestyle modifications
• If concurrent elevated LDL-C exists, statins should be considered 2
• Combination therapy may be necessary for optimal management 5

Treatment Algorithm Based on Triglyceride Levels

Normal (<150 mg/dL)

• Maintain healthy lifestyle

Mild to Moderate (150-499 mg/dL)

1. Implement intensive lifestyle modifications
2. Target 5-10% weight loss
3. Consider statin therapy if elevated LDL-C or high cardiovascular risk
4. Monitor every 3-6 months

Severe (500-999 mg/dL)

1. Intensive lifestyle modifications with stricter dietary control
2. Fibrate therapy (e.g., fenofibrate 160 mg daily)
3. Consider omega-3 fatty acids 4 g/day if inadequate response
4. Monitor every 4-8 weeks until stabilized

Very Severe (≥1000 mg/dL)

1. Immediate pharmacological intervention with fibrates
2. Complete alcohol abstinence
3. Very low-fat diet (10-15% of calories)
4. Consider combination therapy
5. Monitor closely for risk of pancreatitis

Common Pitfalls and Caveats

1. Underestimating diet impact: Many patients focus only on medications while continuing poor dietary habits

   • Solution: Emphasize that dietary changes can reduce triglycerides by >70% 2

2. Overlooking alcohol consumption: Even moderate alcohol intake can significantly elevate triglycerides

   • Solution: Detailed alcohol history and clear recommendations for reduction/abstinence

3. Focusing only on LDL-C: Traditional focus on LDL-C may lead to neglect of triglyceride management

   • Solution: Assess and address both lipid abnormalities concurrently 1

4. Medication interactions: Fibrates combined with statins may increase risk of myopathy

   • Solution: Monitor for muscle symptoms and consider fenofibrate over gemfibrozil when combining with statins

5. Inadequate monitoring: Triglyceride levels can fluctuate significantly

   • Solution: Regular monitoring every 4-8 weeks until stabilized, then every 3 months 2

The management of hypertriglyceridemia requires a structured approach based on severity, with lifestyle modifications forming the cornerstone of treatment across all levels. For those with severe hypertriglyceridemia, pharmacological interventions become necessary to reduce the risk of pancreatitis and cardiovascular events.