High serum triglyceride levels are reported often from South Asian countries. We also have been specifically looking at it in our project very diligently and will ultimately compare them among different districts of Jammu and Kashmir and suggest preventive measures specifically tailored for our people.
In our Budgam district Healthy heart project analysis where a post meal lipid profile was done in 36 consecutive random patients comprising high BP and diabetes, we got a disturbing finding of 84% with triglyceride levels of more than 200 mgs and 20% with levels more than 500 mgs, the highest reading was 638mgs/dl. One third of these patients were known diabetic. Forty two percent were overweight (BMI > 25) and 14% were obese (BMI>30). None of them had history of hypothyroidism and none of them were aware of this dyslipidemia. Low HDLc (< 40 mgs/dl) was present in 17% of these patients but was seen in one third of the population screened for lipids. An important observation was that 20 % of these individuals were on variable doses of statins.
These findings have important bearing because the population screened was not an urban population coming from the areas close to Khan Sahib and the surrounding villages, mostly small level farmers with limited resources. A high carbohydrate intake in the form of bowlful of boiled rice as the main meal with low consumption of fresh vegetables and fruits except a few leaves of Haakh (Collard Green), seems to be an important cause. Potatoes, a small serving of meat or poultry with onions, tomato and chilies, a few times a week is an add on. Hypothyroidism, which is reported in up to 18% people in rural Kashmir, may have been under estimated by us as an additional reason. This typical diet with only a modest level of physical activity is the perfect recipe for high triglycerides in the population under study.
Significance of Triglycerides and High Triglyceride Levels:
Triglycerides in our body is an important constituent, a form of fat needed as a major source of energy. Most of them are stored in fatty (adipose) tissue. However, a part circulates in blood to provide fuel to muscles for their work. After having a meal there is always an increase in the blood levels of triglycerides released from the gut which goes and gets deposited for being utilized by the body. Most triglycerides are carried in the blood by lipo-proteins called very low-density lipoproteins (VLDL).
Triglycerides and cholesterol are different types of lipids found in the blood. While cholesterol builds cells and supports certain hormones, triglycerides give the body energy by storing excess calories.
The total content of the fat in the blood often lumped under the heading Cholesterol, is measured by the overall level of triglycerides, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) in the blood. HDL, known as “good cholesterol,” works to remove “bad” LDL cholesterol from the blood and protects the heart. LDL cholesterol is sometimes called “bad” cholesterol because it can build up in the arteries and cause blockage in blood vessels. LDL levels can get too high if you eat a diet that’s high in trans or saturated fats. The major dietary sources of trans fats are bakery products like breads, biscuits, fried potatoes, potato chips, nadir churma, popcorn and rolls of bread wrapped with meat. All these have become very popular food items in our life even in small towns and villages.
High triglyceride levels, a striking finding as seen by us, increases the risk of stroke or heart attack by thickening and hardening of the arteries. Very high levels can even cause pancreatitis, which can be a life-threatening disease. Many times, high triglycerides go hand in hand with other medical conditions such as obesity, diabetes, hypothyroidism, and metabolic syndrome, a group of problems caused by high blood pressure, obesity and high blood sugar seen in up to 15% of our population even in the remoter areas of the valley.
Normal Range of Triglycerides:
These levels are influenced significantly by the timing of the blood sampling. A sample after an overnight fasting is often done and the cut off is less than 150 mgs/dl. Levels of 150 to 199 are taken as borderline and 200 to 499 as high, levels more than 500 are taken as very high.
For the last several years however, researchers have been looking at the benefits of non-fasting triglyceride tests. The theory is that for most of the day, levels are what they would be after meals, so a sample taken without fasting could be as useful. In Europe it is no longer recommended to fast before routine testing. The American College of Cardiology (ACC) has divided their guidelines for when to use a fasting or a non-fasting test based on the individual. As per their recommendations non-fasting levels are acceptable to evaluate the risk of heart disease and for screening for metabolic syndrome (A triad of high BP, obesity and diabetes). Lipid Association of India takes a fasting level more than 150 as high. In general for confirming hypertriglyceridemia before starting on drugs fasting levels are generally recommended.
High Density Lipoprotein (HDL) Cholesterol:
It is also known as “good” cholesterol because it helps remove other forms of cholesterol from the bloodstream. Higher levels of HDL cholesterol are associated with a lower risk of heart disease. An average level of 40 mgs/dl is the cut off in men and 50 mgs /dl in women. Lower levels are often associated with high triglyceride levels and increase the bad effects of high level. These levels are usually genetically driven and increasing them is not easy. Good life style especially exercise increases it very modestly. Drugs to increase it substantially have so far never succeeded or even harmed, in improving the survival or reducing vascular events. Agents like Niacin which held some promise failed in large academic studies. The goal therefore even in patients with low HDLc is to reduce the LDL cholesterol aggressively by using the statin group of drugs.
In our study population one third of those tested had levels lower than 40mg/dl and half of them had high triglycerides. Our recommendation in all these patients was to add or increase the dose of Statins.
What about LDL cholesterol?
Since high triglycerides are often associated with high LDL cholesterol levels (more than 130 mgs/dl). Measuring it is also essential. The levels between 100-129 mgs are termed borderline. Lowering LDL cholesterol using drugs is very effective in preventing these events especially in high risk patients like patients with history of a heart attack, angina, and in those in whom an angioplasty or a bypass surgery has been done. Diabetic patients with or without heart involvement are also in need of an aggressive lipid lowering. In our GHHP camp in Khan Sahib area levels more than 100 mgs were present in 48% patients evaluated, 20% of whom were on statin group of drugs.
Statin group of drugs (Atorvastatin and Rosuvastatin) are equally effective in reducing the levels with appropriate doses. If the target of < 70 is not being met addition of ezetimibe is recommended. In the highest risk group of patients (those with heart attack or a stroke at a younger age, recurrent attacks, those with a very strong family history of premature death) the targets are less than 55 mgs/dl. Such low levels need newer agents called PCSK9 inhibitors like alirocumab and evolocumab, given as an injection once in 2 weeks. These injectable agents are very expensive and beyond the affordability of most of the patients who would need them in our setting .
What about drugs specifically to reduce Triglycerides?
The use of triglyceride lowering medications is always to be considered after high dose of statins and achieving the LDL cholesterol targets. In patients where the triglyceride levels are still very high and adequate dietary and exercise treatment has been attempted. Use of omega 3 fatty acids (fish oils and eicosanoids) in high doses should be the first choice. Agents like Fenofibrate which is the safest fibrate should be considered for prevention of pancreatitis or in diabetics on high dose of statins. This agent is easily available commercially and not very expensive.
Healthy Life Style is always a very important accompaniment. it means regular exercise, eating more of fresh vegetables and fruits, reducing the quantity of carbohydrates like polished rice, maida, cakes, breads, samosas, pakoras, potatoes and an absolute no to smoking and tobacco, used in any form.
Lessons Learnt:
Although traditionally high cholesterol levels receive the most attention but it is important to remember high triglyceride levels are seen in our population even more frequently. This needs aggressive preventive measures by dietary modifications in the form of reducing rice and refined carbohydrate intake and increasing the consumption of fruits and vegetables. A targeted control of diabetes and a low threshold to use appropriate dose of statin group of drugs in high risk groups is important. Drugs specifically meant to reduce triglycerides are required only sparingly if other measures are taken. The real efficacy of these drugs (Fibrates) other than fish oils is questionable except when levels are so high which can produce pancreatitis.
*Founder Director GHHP, Cardiologist, recipient of Dr B C Roy Award and Padma Shiri
Acknowledgements:
The Team:
CEO, GHHP Ajaz Rashid and the Project Director, Nasir Lone.
Team doctors, Yasir Wani, Riaz Ahmad, Zubair Saleem, Jan Mohammed and the doctors of the District along with the team of the Academics and Research Batra Hospital and Medical Research Centre lead by Ms Priyadarshini Arambam.
The staff of the Kremshore CHC, deserves a special thanks
Pharmaceutical industry for facilitating the investigations and giving starter kit of drugs.