High Triglycerides - A Major Health Issue | No Magic Drugs in Sight

Patients with high triglycerides are at risk of vascular events when they have associated issues
High Triglycerides - A Major Health Issue | No Magic Drugs in Sight

Triglycerides are a type of fat (Lipid) found in our blood. When we eat, the body converts the calories right away into triglycerides. These are stored in the fat cells as ready form of energy as in camel’s hump.  When required these triglycerides are released for energy. They are important to life and are the main form of fat.

A common cause of high triglycerides in blood is eating more calories than are needed to provide energy. This is also called Hypertriglyceridemia. It is a common finding with its prevalence being at least 25% of our population of India. The data from the study from Gauri Kaul Foundation showed it to be present in more than 33% subjects evaluated in our camps across the valley. 

Common causes of High triglycerides: Overeating foods high in fat and carbohydrates, increased body weight and obesity, lack of exercise, some genetic disorders affecting breakdown of lipids, tobacco use, Alcohol in excess, uncontrolled diabetes, Hypo- thyroidism, liver and kidney diseases, Certain drugs needed to treat HIV, breast cancer, steroids and some non-selective beta blockers (propranolol, carvedilol, sotalol etc.).

Normal and Abnormal Ranges of Triglycerides:

Normal < 150 mgs/dl, Borderline high 150 to 199 mgs/dl, High 200 to 499 mgs/dl and Very High > 500mgs/ dl.

The levels must be checked after an overnight fast. Fat from a recent meal can vitiate the reading.

High Triglycerides and health issues:

Very high triglycerides (> 500mgs/dl) can cause a serious and potentially fatal condition called acute pancreatitis. It needs prompt attention and drug therapy along with general measures to prevent this serious complication.

Patients with high triglycerides are at risk of vascular events when they have associated issues. This is also called “Triglycerides become hazardous when they are in a bad company”. The components of this wrong associations are; 1.  low HDL cholesterol (levels < 40mgs/dl in men and > 50mgs/dl in women), 2. obesity especially truncal or abdominal (waist measurement more than 90 cm’s in males and more than 80 cm’s in women. 3. presence of diabetes mellitus, presence of high LDL cholesterol (more than 100 mgs/dl) and blood pressure more than 140/90 mms Hg.

Methods to Reduce Triglycerides:

Healthy life styles:

1. Regular Exercise, aim for at least 30 minutes on most days, in terms of steps 8000 or more steps/day. It lowers triglycerides and increases HDL cholesterol. Climb stairs, take longer route to go for work or shopping. cycling uphill is also a good way.

2. Avoid sugars and refined carbohydrates. Sugars, cakes, products made of refined flour, bakery products, Chot, girda the staple Kashmiri bread served with breakfast noon chay. These all are rich sources to increase triglycerides in blood.

3. Lose weight by cutting on calories.

4. Choose Healthier Fats. Fats are essential but those obtained from plant sources like olive, mustard, canola, sesame, sunflower, peanut oils. Oils however should not be burnt to carbon while cooking

5. Fish and poultry instead of red meat.

6. Avoid trans fats. Like cooking in vanaspati ghee (hydrogenated oils ), using pre-cooked foods, coffee creamers etc.

7. Desi Ghee or clarified butter provides some health benefits but it is important to realize that it contains saturated fats, an excess of which increases the cholesterol levels and increase the risk of heart disease. To consume more than 2 to 3 tea spoons can lead to long term problems especially in subset of people who have other risk factors like obesity, high BP and diabetes.

8. Alcohol in any form is unsafe for health as per the 2023 guidelines from WHO

9. Don’t Skip meals. It is no solution to cut on calories because it leads to over eating at the next meal invariably making the triglyceride levels jump. A meal with plenty of fruits, salads, nuts, carrots should be kept around not biscuits and bakery products to extinguish the hunger pangs. 

Do we have a magic drug to reduce triglycerides?

This is an area of intense research for the last several decades. A number of drugs have undergone very credible scientific trials to see if the levels reduced towards normal i.e., < 150 mgs/dl led to improvement in outcomes like heart attacks and other related illnesses. Several drugs which include, Niacin, Fibrates (Gemfibrozil, Bezafibrate and Fenofibrate etc), fish oils and synthetic high dose omega 3 fatty acids and vitamin E etc have been used extensively without any proof of benefit. Likewise, agents like Saroglitazar (Lipaglyn and Bilypsa) have no outcomes data indicating their usefulness and no trial to this effect is going on. The reduction in levels is therefore of only cosmetic value.

End of fibrates?

In a recent large trial “PROMINENT” a very potent fibrate (Pemafibrate) vs placebo was used in a population with high Triglycerides and low HDL with a high percentage of diabetics. They were all on high doses of statins. In this typical population which we also see in our valley Pemafibrate despite a 26 % reduction in triglycerides and 5% increase in HDLc, did not improve the outcomes (heart attack, stroke, death) at all.

What about omega 3 fatty acids?

These agents traditionally have been considered to be safe modality to reduce triglycerides. This concept was suddenly hyped by a recent placebo-controlled trial of 2019 (REDUCE IT) showing a significant benefit in the patients consuming a very high dose of 4 gm of icosapent ethyl twice per day. The study showed a significant benefit in the patients on very high dose of omega 3 fatty acids. This led to a short-lasting boom in its use. It was however soon realised that the benefit was because of higher events in the placebo group which had a mineral oil which was producing a hazardous effect of increasing the LDL cholesterol. This finding was not duplicated in a study following it where omega 3 fatty acid with statins “STRENGTH” where the placebo had corn oil and statins. Thus, the study has punctured the enthusiasm shown by REDUCE IT. Omega 3 acids also have failed to improve the desired outcomes and only do a cosmetic reduction in levels.

Take home message

High triglyceride levels are common in Asians. they are often accompanied with other adverse factors. There is no specific triglyceride reducing agent which has shown benefit in reducing heart attacks and associated problems. It is LDL cholesterol lowering which finally matters. Atorvastatin and Rosuvastatin use to improve the bad company of high triglycerides is the solution. Besides this the use of the non-drug general measures of diet and exercise is always desirable. Use of triglyceride lowering drugs is only meant for population with > 500 mgs/dl triglycerides to prevent acute pancreatic problems.

Prof Upendra Kaul, awarded Padmashiri and Dr B C Roy award is Chairman Cardiology and Dean Academics and Research Batra Hospital and Medical Research Center, New Delhi. He is founder Director, Gauri Kaul Foundation.

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