How Doctors Treat High Triglycerides
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Cholesterol gets all the attention, but doctors are concerned with another number that makes up your blood lipid levels: triglycerides.
“Triglycerides are a subgroup, or type, of our total cholesterol,” says Douglas Jacoby, MD, a cardiologist with Penn Medicine in Philadelphia. Basically, there are various lipoproteins in the body that make up your cholesterol, and triglycerides are one. Similar to low-density lipoprotein (LDL) cholesterol, triglycerides fall under the “bad” cholesterol category, he says.
To put it another way, your total cholesterol is calculated by adding your high-density lipoprotein (HDL, or “good”) cholesterol, LDL cholesterol, and 20 percent of your triglycerides, according to the American Heart Association (AHA). Doctors look at these numbers as well as other risk factors — your family history, your age, whether you smoke or have other health conditions, such as diabetes or high blood pressure — to determine your risk of heart attack or stroke.
When and Why Triglyceride Levels Should Be Treated
Triglyceride levels are only part of the picture of cardiovascular disease risk, and what’s “normal” can depend on your individual health factors. That said, according to MedlinePlus, triglyceride guidelines are defined as:
- Normal: Less than 150 mg/dL (milligrams per deciliter)
- Borderline high: 150 mg/dL to 199 mg/dL
- High: 200 to 499 mg/dL
- Very high: 500 mg/dL and above
If you are in a category above normal, your doctor will likely recommend lifestyle changes and possibly discuss medications to normalize your levels and reduce your risk of cardiovascular disease. “High triglycerides seem to create some increased levels of cardiovascular risk similar to LDL cholesterol,” says Andrew Freeman, MD, a cardiologist and the director of cardiovascular prevention and wellness at National Jewish Health in Denver. Triglycerides can play a role in the development of atherosclerosis, or the buildup of plaque in arteries that restricts blood flow and is associated with coronary heart disease, angina, and peripheral artery disease, says the AHA.
According to Mayo Clinic, high triglycerides can often be a sign of other conditions that raise your cardiovascular disease risk, such as obesity and metabolic syndrome, which is defined as having at least three out of a group of conditions: excess abdominal fat, high blood pressure, elevated blood sugar, reduced HDL cholesterol, and, of course, high triglycerides. Extremely high triglycerides can lead to pancreatitis, or inflammation of the pancreas.
The good news is that, as with cholesterol, you can improve and manage high triglycerides with treatment. “For the vast majority of people, we can make their triglyceride levels perfect by intervening through lifestyle changes and medications, which will lower their risk of heart attack and stroke,” says Dr. Jacoby. “Don’t accept leaving your triglycerides high, and seek additional help through a specialist if needed.”
Factors That Contribute to High Triglycerides
To assess what kind of treatment might be best for you — or if you’ll need treatment at all — your doctor will first look at your blood lipid levels, paying attention to the ratio of triglycerides to total cholesterol, as well as your personal and family history and existing risk factors, says Jacoby.
Joint guidelines from the AHA and the American College of Cardiology (ACC) recommend that anyone age 20 or older who has triglyceride levels of 175 to 499 mg/dL first be treated for the underlying medical causes that can contribute to poor blood lipid levels. These include:
If you’ve been diagnosed with one of these conditions, your doctor may recommend specific management techniques, which could include many of the lifestyle changes mentioned below, as well as medications.
Some medications, such as oral estrogen medications, beta-blockers, and certain corticosteroids and osteoporosis drugs, may also raise triglyceride levels. If one or more of your medications contributes to your high triglyceride levels, it’s important to talk to your doctor about how your medications may be affecting you and what that means for your health. According to Dr. Freeman, your doctor might add medication, switch medications, or recommend changes to your diet to lower your levels. Those changes often include reducing your intake of added sugar, simple carbs, and high-fat foods and moving to a low-fat, whole-foods–based diet.
Lifestyle Management for High Triglycerides
If your triglyceride levels fall into the “borderline high” category, says Jacoby, “It’s extremely likely that making lifestyle improvements alone will control your levels.” Most often, people with moderate levels have metabolic problems, including prediabetes and diabetes, which also respond well to healthy lifestyle changes.
The AHA/ACC guidelines recommend the following lifestyle changes to lower levels:
- Reduce your body weight
- Reduce or avoid alcohol intake
- Increase your physical activity
- Reduce your carbohydrate consumption
- Eat omega-3 fatty acids
Combining a low-carb diet with exercise and fish oil is often enough to get control of your triglycerides, says Jacoby, and can have the additional benefit of addressing metabolic problems and reducing body weight. “For the majority of people with moderate to severe elevations, triglyceride levels are very responsive to a heart-healthy lifestyle. It’s worth trying to normalize through those changes and then moving on to medications if lifestyle isn’t sufficient,” he says.
Medications for High Triglycerides
If diet, exercise, and other lifestyle changes are not sufficiently reducing your triglycerides, or your doctor feels your numbers are too high to address the problem with lifestyle interventions alone, they may recommend medication. Some common drugs prescribed to lower triglycerides include:
Statins Statins are appropriate as a cornerstone treatment for moderate to severely high triglyceride levels, according to the AHA/ACC guideline. These prescription drugs help prevent cholesterol from forming in the liver, lower LDL cholesterol and triglycerides, and raise HDL cholesterol, notes the AHA.
Omega-3 Fatty Acids These essential nutrients are found in fish, flaxseed, and other foods and in fish oil supplements, according to the National Institutes of Health Office of Dietary Supplements (ODS). The three main omega-3 fatty acids are alpha-linolenic acid (ALA), which is mainly found in plant oils, such as flaxseed and canola, and eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which are found in fish and other seafood.
According to the ODS, many studies have shown that eating fish (salmon, mackerel, and tuna) and seafood rich in omega-3s may help you keep your heart healthy and reduce your risk of heart disease. And boosting your EPA and DHA intake through foods and supplements can help lower your triglycerides.
While fish oil is available as over-the-counter supplements, prescription fish oil medications are tested and regulated in a way that supplements are not. A review of research examined the differences between dietary supplements, such as fish oils, and prescription omega-3 fatty acids and noted that there are “well-documented issues with consistency of product content and purity” when it comes to supplements. The review concluded that supplements contain inconsistent levels of omega-3 fatty acids and lower amounts of omega-3s than prescriptions. “I prefer prescription for safety reasons, since you do not know how carefully screened and purified supplements are,” says Jacoby.
According to the AHA, prescription omega-3s come in two forms: those with both DHA and EPA and a newer one that contains icosapent ethyl, which is a purified form of EPA. According to research, patients with triglyceride levels of 150 to 499 mg/dL who were on statin therapy and took 2 grams of icosapent ethyl omega-3 medication twice per day experienced a 25 percent reduced risk of heart attack, stroke, and cardiovascular death compared with those who took a placebo. These patients also saw their triglyceride levels decline by 18 percent, on average, after one year.
Fenofibrate If you have severely high levels of triglycerides, your doctor may recommend taking both fenofibrate (Tricor) and omega-3 fatty acids, notes the AHA/ACC guideline. Fenofibrate reduces both cholesterol and triglycerides and increases HDL cholesterol by speeding up cholesterol removal from the body, according to MedlinePlus. Unlike icosapent ethyl, though, fenofibrate has not been shown to decrease heart attack or stroke risk.
Niacin Niacin (nicotinic acid) has been shown to be effective in lowering LDL and increasing HDL cholesterol, and there’s evidence that it may help lower triglycerides, but it may also lead to uncomfortable — or even dangerous — side effects, ranging from upset stomach, high blood sugar, flushing, and irregular heartbeat, according to MedlinePlus. Moreover, there is evidence that niacin is not effective for preventing heart attack or stroke in people who take it to prevent cardiovascular disease.
“Niacin does lower triglycerides, but it is less potent than fish oil or fibrates, and it has a worse side effect profile,” says Jacoby. He prescribes it in rare cases but cautions that only healthcare providers who specialize in cholesterol management should consider it for certain patients.
The bottom line: Elevated triglycerides, like high cholesterol, are a potentially serious health problem. But with lifestyle changes and, if necessary, medications, most people will be able to successfully manage their condition and reduce their cardiovascular disease risk.
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