How to decrease triglycerides?

How to Decrease Triglycerides

The most effective approach to lowering triglycerides combines lifestyle modifications as first-line therapy—specifically weight loss, carbohydrate restriction, increased physical activity, and alcohol elimination—followed by pharmacotherapy with statins for cardiovascular risk reduction or fibrates/omega-3 fatty acids for severe hypertriglyceridemia. 1

Initial Assessment and Risk Stratification

Before initiating treatment, identify and address secondary causes of hypertriglyceridemia 1, 2:

• Uncontrolled diabetes (optimize glycemic control first) 1
• Medications (thiazides, beta-blockers, estrogens, corticosteroids)
• Hypothyroidism
• Kidney disease
• Excessive alcohol consumption (even 1 oz/day increases triglycerides 5-10%) 1

Classify severity to guide treatment intensity 1:

• High triglycerides: 150-499 mg/dL (focus on cardiovascular risk reduction)
• Very high triglycerides: 500-999 mg/dL (pancreatitis risk emerges)
• Severe hypertriglyceridemia: ≥1,000 mg/dL (high pancreatitis risk, requires aggressive intervention)

Lifestyle Modifications (First-Line for All Patients)

Weight Loss

Modest weight loss of 5-10% body weight combined with moderate physical activity reduces triglycerides by up to 20%. 1 Weight loss is particularly effective in patients with abdominal obesity and metabolic syndrome 1.

Dietary Modifications

Carbohydrate Restriction:

• Limit refined carbohydrates and added sugars (the most potent dietary trigger for triglycerides) 1
• Eliminate sugar-sweetened beverages completely 1
• Very-low-carbohydrate diets produce the greatest triglyceride reductions (30-40% with significant weight loss) 1
• For every 1% energy from carbohydrates replaced by monounsaturated fats, triglycerides decrease 1.7 mg/dL 1

Fat Modification:

• Reduce saturated fat to <7% of total energy intake 1
• Limit dietary cholesterol to <200 mg/day 1
• Replace saturated fats with monounsaturated fats or polyunsaturated fats (not refined carbohydrates) 1
• For triglycerides ≥1,000 mg/dL: restrict ALL dietary fat to <5% of calories until levels drop below 1,000 mg/dL 1

Fiber and Plant Sterols:

• Increase viscous (soluble) fiber to 10-25 g/day 1
• Add plant stanols/sterols 2 g/day 1

Alcohol:

• Complete abstinence for patients with triglycerides ≥500 mg/dL (alcohol synergistically increases triglycerides when combined with high-fat meals and can precipitate pancreatitis) 1
• Limit to minimal amounts for those with lower levels 1

Physical Activity

Engage in at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic activity. 1

• Regular aerobic training decreases triglycerides by ~11% 1
• Resistance training decreases triglycerides by ~6% 1
• Daily aerobic exercise attenuates postprandial triglyceride elevation 1

Pharmacotherapy

For Triglycerides 150-499 mg/dL (High)

Calculate 10-year ASCVD risk to guide statin therapy: 1, 2

• Initiate or maximize statin therapy for patients with diabetes, established ASCVD, or elevated LDL-C 1
• Statins are the preferred first-line medication as they reduce cardiovascular events 1

If triglycerides remain elevated (≥200 mg/dL) despite maximized statin therapy and lifestyle changes:

• Consider high-dose icosapent ethyl (purified EPA) 4 grams/day for high-risk patients (NNT=111 to prevent one cardiovascular death over 5 years) 2
• Alternative: omega-3 fatty acids (EPA+DHA) 3-4 grams/day reduces triglycerides 25-35% 3

For Triglycerides 500-999 mg/dL (Very High)

Implement very-low-fat diet (10-15% of calories from fat) immediately to reduce pancreatitis risk 1

Pharmacotherapy options: 1

• Fibrates (fenofibrate preferred) to prevent pancreatitis
• Omega-3 fatty acids 4 grams/day (EPA+DHA or purified EPA) 1
• Continue or initiate statin therapy for cardiovascular risk reduction 1

Important caveat: Fish oils may increase LDL-C, requiring monitoring 1

For Triglycerides ≥1,000 mg/dL (Severe)

This is a medical emergency due to high pancreatitis risk. 1

Immediate interventions:

• Restrict ALL dietary fat to <5% of total calories (except omega-3 fatty acids) until triglycerides <1,000 mg/dL 1
• Eliminate added sugars and alcohol completely 1
• Initiate fibrate therapy immediately 1, 4
• Consider adding omega-3 fatty acids once triglycerides begin to decrease 1

For acute pancreatitis with triglycerides ≥1,000 mg/dL:

• Consider insulin infusion and plasmapheresis if conservative management fails 2

Special Populations

Patients with Diabetes

Optimize glycemic control first—effective insulin therapy in type 1 diabetes usually normalizes triglycerides 1. For type 2 diabetes with persistent dyslipidemia despite glycemic control, follow the general algorithm above emphasizing weight loss and saturated fat restriction 1.

Monitoring Strategy

• Reassess triglycerides after 6 weeks of lifestyle modifications or medication changes 1
• Monitor LDL-C when using omega-3 fatty acids (may increase LDL-C) 1
• Continue monitoring every 4-6 months once therapeutic goals achieved 1

Common Pitfalls to Avoid

• Don't replace saturated fat with refined carbohydrates—this can worsen triglycerides 1
• Don't use low-dose omega-3 supplements (<2 grams/day)—insufficient for meaningful triglyceride reduction 3
• Don't delay aggressive fat restriction in patients with triglycerides ≥1,000 mg/dL—pancreatitis risk is immediate 1
• Don't ignore secondary causes—treating underlying conditions (especially diabetes and hypothyroidism) is essential 1, 2