Dietary Management of Hypertriglyceridemia
Patients with hypertriglyceridemia should restrict added sugars to <10% of calories (or <5% if triglycerides ≥500 mg/dL), limit total fat to 30-35% of calories (or 20-25% if triglycerides ≥500 mg/dL), eliminate alcohol completely if triglycerides ≥500 mg/dL, and consume at least 2 servings per week of fatty fish rich in omega-3 fatty acids. 1
Carbohydrate and Sugar Management
The severity of your triglyceride elevation determines how aggressively you must restrict carbohydrates and sugars:
- For triglycerides <500 mg/dL: Limit added sugars to <10% of total daily calories 1
- For triglycerides 500-999 mg/dL: Restrict added sugars to <5% of total daily calories 1
- For triglycerides ≥1,000 mg/dL: Eliminate all added sugars completely 1, 2
Simple sugars (monosaccharides and disaccharides) increase triglycerides more than complex carbohydrates, with fructose being particularly problematic as it stimulates hepatic triglyceride synthesis through de novo lipogenesis 1. Higher dietary sugar intake increases triglycerides by approximately 9.7 mg/dL independent of body weight effects 1.
Replace refined grains (white bread, white rice, pasta) with fiber-rich whole grain cereals, brown rice, and whole grain bread to maintain adequate fiber intake while reducing triglyceride-raising effects 1. Dietary fiber attenuates the triglyceride-raising effect of carbohydrates 1.
Fruit Consumption
Consume whole fresh fruits without added sugar, but avoid fruit juices 1. Despite containing fructose, whole fruit consumption is associated with a 21% decrease in triglycerides (OR: 0.79; 95% CI: 0.72-0.87) for highest versus lowest intake 1. For severe hypertriglyceridemia (500-999 mg/dL), limit to 3-4 servings daily and avoid high glycemic index fruits like pineapples, mangoes, watermelon, and ripe bananas 1.
Fat Intake: Type and Quantity
The amount and type of fat you should consume depends on your triglyceride level:
- Triglycerides <500 mg/dL: Moderate fat intake at 30-35% of total calories 1, 2
- Triglycerides 500-999 mg/dL: Low fat intake at 20-25% of total calories 1, 2
- Triglycerides ≥1,000 mg/dL: Very low fat intake at 10-15% of total calories 1, 2
Fat Type Matters Significantly
Prioritize polyunsaturated fatty acids (PUFAs) and monounsaturated fatty acids (MUFAs) over saturated fats 1. When 1% of energy from saturated fatty acids is replaced by PUFAs, triglycerides decrease by 0.4 mg/dL; when replaced by MUFAs, triglycerides increase only 0.2 mg/dL (compared to 1.9 mg/dL increase when replaced by carbohydrates) 1.
Limit saturated fats to <7% of total energy intake 1, 2. Eliminate trans fats completely 1.
Omega-3 Fatty Acids from Fish
Consume at least 2 servings (8+ ounces) per week of fatty fish such as salmon, rainbow trout, tuna, herring, mackerel, sardines, and anchovies 1, 3. This provides approximately 250 mg per day of EPA+DHA, which reduces coronary heart disease death 1, 3.
For patients with triglycerides 500-999 mg/dL who must severely restrict fat, choose lean fish or seafood rather than fatty fish, but maintain at least 2 servings per week 2. Prioritize fish varieties higher in EPA and DHA but lower in methylmercury: salmon, anchovies, sardines, Pacific oysters, and trout 1, 3.
Dietary fish intake alone is insufficient for therapeutic triglyceride lowering in established hypertriglyceridemia—prescription omega-3 fatty acids at 4 grams per day are required for maximal triglyceride reduction of 25-30% 1, 4, 3.
Alcohol Restriction
Alcohol consumption is directly proportional to triglyceride elevation:
- For triglycerides <500 mg/dL: Restrict alcohol (do not exceed 2 drinks/day for men, 1 drink/day for women) 1
- For triglycerides 500-999 mg/dL: Abstain completely 1
- For triglycerides ≥1,000 mg/dL: Abstain completely 1
Even 1 ounce of alcohol per day increases triglycerides by 5-10%, and alcohol can precipitate hypertriglyceridemic pancreatitis at severe levels 2. The effects of alcohol are synergistically exaggerated when coupled with meals high in saturated fat 2.
Protein and Fiber
Increase protein intake from lean sources (poultry, lean meats, legumes) 1. Replacing 10% of calories from carbohydrates with protein lowers triglycerides by 16 mg/dL 2.
Increase soluble fiber to >10 g/day from sources like oats, beans, lentils, chickpeas, and vegetables 1, 2. In individuals with type 2 diabetes, high fiber intake (20 g/1000 kcal) decreased triglycerides by 8-13% compared to low fiber intake 1.
Mediterranean-Style Dietary Pattern
A Mediterranean-style diet providing 28% of calories from total fat (8% saturated, 12% monounsaturated, 8% polyunsaturated) decreased triglycerides by 12% over 2 years 1. This pattern emphasizes fruits, vegetables, nuts, whole grains, olive oil, and fatty fish while limiting red meat and processed meats 1.
Weight Loss
Target a 5-10% body weight reduction, which produces a 20% decrease in triglycerides—the single most effective lifestyle intervention 2. In some patients, weight loss can reduce triglyceride levels by up to 50-70% 2.
Common Pitfalls to Avoid
- Do not replace saturated fats with refined carbohydrates—this increases triglycerides by ~1.9 mg/dL per 1% energy substitution 1
- Do not use over-the-counter fish oil supplements as a substitute for prescription omega-3 formulations when therapeutic triglyceride lowering is needed 2
- Do not consume sugar-sweetened beverages or fruit juices—eliminate these completely 1
- Do not ignore secondary causes like uncontrolled diabetes, hypothyroidism, or medications that raise triglycerides 2, 5
Expected Outcomes
An individualized lifestyle intervention combining these dietary modifications can reduce triglycerides by 48% (interquartile range: 73% to 23%) regardless of lipid-lowering medications 1. The combined effects of multiple dietary interventions provide the most potent means of maximally lowering plasma triglyceride levels 6.