What do triglycerides measure and how are they lowered?

What Triglycerides Measure and How to Lower Them

What Triglycerides Measure

Triglycerides measure the amount of fat circulating in your blood, transported in both chylomicrons (dietary fat) and VLDL particles (liver-produced fat), serving as a marker of cardiovascular disease risk and metabolic health. 1

• Optimal fasting triglyceride levels are <100 mg/dL, with levels consistently below this threshold associated with the lowest risk of cardiovascular disease 1
• Levels are classified as: Normal (<150 mg/dL), Mild (150-199 mg/dL), Moderate (200-499 mg/dL), Severe (500-999 mg/dL), and Very Severe (≥1,000 mg/dL) 1, 2
• Triglycerides ≥500 mg/dL indicate significant pancreatitis risk, with risk escalating dramatically as levels approach 1,000 mg/dL 2

How to Lower Triglycerides

Weight Loss: The Most Effective Intervention

A 5-10% reduction in body weight produces a 20% decrease in triglycerides, making weight loss the single most powerful lifestyle intervention. 1, 3

• For every kilogram lost, triglycerides decrease by approximately 1.5-1.9 mg/dL 1
• In some patients, weight loss can reduce triglyceride levels by 50-70% 2, 3
• Weight loss of 3-5% provides clinically meaningful triglyceride reduction 3

Dietary Modifications

Sugar and Carbohydrate Management

Eliminate all added sugars and sugar-sweetened beverages completely, as sugar intake directly increases hepatic triglyceride production. 1, 3

• Restrict added sugars to <6% of total daily calories for moderate hypertriglyceridemia (200-499 mg/dL) 1, 2
• Restrict to <5% for severe hypertriglyceridemia (500-999 mg/dL) 1, 2
• Complete elimination is required for very severe hypertriglyceridemia (≥1,000 mg/dL) 1, 2
• Low-carbohydrate diets are more effective at lowering triglycerides than low-fat diets 1, 3
• Replace refined carbohydrates with fiber-rich, complex carbohydrates 1

Fat Quality and Quantity

Replace saturated fats with polyunsaturated fats (PUFAs) and monounsaturated fats (MUFAs), as this substitution lowers triglycerides while low-fat, high-carbohydrate diets increase them. 1

• For moderate hypertriglyceridemia, limit total fat to 30-35% of calories 1, 2
• For severe hypertriglyceridemia (500-999 mg/dL), restrict fat to 20-25% of calories 1, 2
• For very severe hypertriglyceridemia (≥1,000 mg/dL), restrict fat to 10-15% of calories 1, 2
• Eliminate trans fatty acids completely, as each 1% replacement with MUFA or PUFA lowers triglycerides by 1% 1
• Restrict saturated fats to <7% of total energy intake 1, 3

When replacing 1% of energy from carbohydrates with MUFAs, triglycerides decrease by 1.7 mg/dL; with PUFAs, they decrease by 2.3 mg/dL. 1

Omega-3 Fatty Acids from Food

Consume at least 2 servings per week of fatty fish (salmon, trout, sardines, anchovies) rich in EPA and DHA. 1, 2, 3

• Marine-derived omega-3 fatty acids reduce triglycerides by 20-50% at doses of 2-4g/day 3
• For severe hypertriglyceridemia requiring fat restriction, choose lean fish varieties while maintaining at least 2 servings weekly 1, 2

Fiber and Protein

• Increase soluble fiber to >10g/day (ideally 10-25 g/day) 1, 3
• Add plant stanols/sterols 2 g/day 3
• Increase protein intake from lean sources, as replacing 10% of calories from carbohydrates with protein lowers triglycerides by 16 mg/dL 1, 3

Alcohol Restriction

Complete abstinence from alcohol is mandatory for severe hypertriglyceridemia (≥500 mg/dL) to prevent hypertriglyceridemic pancreatitis. 1, 2, 3

• Even 1 ounce of alcohol per day increases triglycerides by 5-10% 2
• Alcohol effects are synergistically exaggerated when combined with high saturated fat meals 2
• For moderate hypertriglyceridemia, restrict alcohol to no more than 2 drinks/day for men, 1 drink/day for women 1

Physical Activity

Engage in at least 150 minutes per week of moderate-intensity aerobic activity (or 75 minutes per week of vigorous activity). 1, 2, 3

• Regular aerobic training decreases triglycerides by approximately 11-30% 2, 3
• Physical activity should be performed at least 5-7 days per week, preferably 30-60 minutes daily 2

Intermittent Fasting

• Alternate-day fasting (0.75 kg/week weight loss) produces 30-40% triglyceride reduction 1
• Periodic fasting (0.25 kg/week weight loss) produces 10-20% triglyceride reduction 1
• Time-restricted eating reduces triglycerides by 6-12 mg/dL 1

Pharmacologic Therapy

For Severe to Very Severe Hypertriglyceridemia (≥500 mg/dL)

Initiate fenofibrate 54-160 mg daily immediately as first-line therapy to prevent acute pancreatitis, before addressing LDL cholesterol. 2, 4

• Fenofibrate reduces triglycerides by 30-50% 2, 4
• Dosage should be individualized and adjusted at 4-8 week intervals 4
• Once triglycerides fall below 500 mg/dL, reassess LDL-C and consider adding statin therapy 2

For Moderate Hypertriglyceridemia (200-499 mg/dL)

If 10-year ASCVD risk is ≥7.5%, initiate moderate-to-high intensity statin therapy (atorvastatin 20-40 mg or rosuvastatin 10-20 mg daily). 2

• Statins provide 10-30% dose-dependent triglyceride reduction 2, 5
• If triglycerides remain >200 mg/dL after 3 months of optimized lifestyle modifications and statin therapy, add prescription omega-3 fatty acids 2

Prescription Omega-3 Fatty Acids

Add icosapent ethyl 2g twice daily (4g/day total) for patients with triglycerides ≥150 mg/dL on maximally tolerated statin with established cardiovascular disease OR diabetes with ≥2 additional risk factors. 2

• Icosapent ethyl provides a 25% reduction in major adverse cardiovascular events (number needed to treat = 21) 2
• Monitor for increased risk of atrial fibrillation 2

Addressing Secondary Causes

Before initiating pharmacotherapy, aggressively evaluate and treat secondary causes: 2, 4

• Optimize glycemic control in diabetic patients, as poor glucose control is often the primary driver of severe hypertriglyceridemia 1, 2
• Screen for and treat hypothyroidism 2
• Discontinue or substitute medications that raise triglycerides (thiazide diuretics, beta-blockers, estrogen therapy, corticosteroids, antiretrovirals, antipsychotics) 2, 4

Critical Pitfalls to Avoid

• Do not start with statin monotherapy when triglycerides are ≥500 mg/dL—statins provide only 10-30% triglyceride reduction and are insufficient for preventing pancreatitis at this level 2
• Do not delay fibrate initiation while attempting lifestyle modifications alone in patients with triglycerides ≥500 mg/dL—pharmacologic therapy is mandatory 2
• Do not use gemfibrozil when combining with statins—fenofibrate has a significantly better safety profile with lower myopathy risk 2
• Do not ignore dietary fat restriction alone without addressing carbohydrate intake—this may worsen triglyceride levels 3
• Do not substitute over-the-counter fish oil supplements for prescription omega-3 formulations—they are not equivalent 2