Know Your Triglyceride Level: Lessons from the Frontline
Primary Care Providers routinely screen for lipids. Included in this panel is the triglyceride level. Studies support that triglycerides has important health implications and can be a marker of disease states. Elevations in triglycerides have been associated with an increased risk of coronary artery disease and all-cause mortality. This article will explain the importance of triglycerides on health and ways in which an optimal diet can address the condition.
The Link of Glucose and Triglycerides
“You are what you eat.” When I heard that adage as a child, I thought that I was going to turn into a chocolate bar from the inside. I did not realize at that time the important implications of this advice in addressing my own health issues and how I viewed health in general. For every meal that we eat, the beautiful system that is our bodies slowly absorbs the foods, activating our genes to produce molecules for digestion and metabolism. In this way, there is a cellular encounter between the environment and our bodies. I would like to explain about the harms of elevated triglyceride levels and how a wholesome diet awards one with the greatest gift: optimal health and optimal life. Although some of the terms used in this article are medical, I will provide definitions and links as you read on. The amazing part of this story is that the take-home is very simple: a healthy diet ensures a healthy body. You are what you eat!
Let’s start with a patient visit to illustrate the harms of hypertriglyceridemia. I recently saw a 30 year old man who had diabetes mellitus since he was a child (Type I Diabetes). Unlike Type II diabetes, most commonly encountered in adulthood, Type I diabetes is associated with disruptions in insulin production to the point that the blood becomes acidic (ketoacidosis) if insulin is not given. The acid level can make someone very sick and is a life threatening condition. Usually this is given through a mixture of long-acting and short-acting premeal insulin that attempt to mimic what happens in the body with a functioning pancreas. Within the last few decades, technologies of insulin delivery and glucose sensors have improved the delivery of insulin using insulin pumps, which reduce both the harms of high blood glucose and ketoacidosis.
A year before the visit with me in the infectious disease clinic, he met with an endocrine specialist and was started on an insulin pump. His glucoses improved substantially over the last year. He reported an improvement in his Hemoglobin A1c (a test used to check these levels over 3 months, or the lifespan of a red cell) from 8.8% to 7.8%. This was a significant improvement for him. Normal blood glucose levels stay in a narrow window from 70 to 85 mg/dl (up to 99 is still considered “normal”), because of the work of the hormones insulin and glucagon. The stress and regulatory hormones norepinephrine, cortisol, and epinephrine play an important role of glucose utilization as well. The glucose levels equate to an A1c between 4.1 to 4.6 for super-optimal and up to 5.7 as “normal.” Here is an A1c conversion table.
The A1c that the patient now had was still not optimal. A prospective study of 10,232 men and women aged 45 to 79 showed that higher A1c’s are associated with steady increases in risk of cardiovascular disease and total mortality. The risk begins even at levels above 5, which would otherwise be considered normal. In the setting of impaired glucose management, the system is harmed by elevated levels (even above 100 mg/dl), leading to a stress on the system that results in microvascular and microvascular damage and other dysfunction, including in lipid metabolism.
The patient complained of intermittent abdominal pains, fevers, sweats, nausea, diarrhea, and severe fatigue. The symptoms seemed to occur in waves. One of the reasons why he sought care with his primary doctor was that he woke up with profound back pain that gradually worsened over weeks. The doctor referred him to physical therapy without much benefit. He was then sent for a lumbar MRI which did not show any obvious nerve impingement. He presented to the emergency department a few months before with abdominal pain. The bloodwork was normal and nothing was found on his ultrasound other than fatty liver. The other concerns seemed to be eclipsed by his sensation of back pain.
How did he end up in an infectious disease clinic? The primary doctor asked me to see him because the patient was having fevers. Could this be an infectious cause? We scheduled the appointment and he was seen. However, it did not quite sound like an infection. It was an episodic process, associated with thoracic back pain radiating forward.
The patient mentioned that the pain level would settle down after a week-long course of prednisone was administered. It is true that prednisone, with its anti-inflammatory properties, has been used for back pain flares, though I do not recommend it. After he developed more severe pain a few months later, another course did not help. Doubling the dose seemed to help for a week, only to lead to an evolution of the pain from localized to generalized after it stopped.
After listening, I examined him and noted some skin findings are red-yellow bumps (papules) which looked like a finding of high triglycerides. He also had some abdominal discomfort in the upper left and central part. I ordered tests that could be useful to explaining his symptoms. I wondered about his diabetes, impaired lipid metabolism, and how insulin causes carbohydrate craving, as it shifts glucose out of the blood stream. Maybe this can all be explained by the triglyceride state. I cast a net of bloodwork toward some of the other possibilities as well.
The next morning, he obtained fasting bloodwork. His triglyceride level, was not a level, it was a cut-off >10,000. His lipase level was normal, not suggesting acute pancreatitis. I notified his primary doctor who will ensure that repeat testing is ordered to confirm chylomicronemia syndrome as the cause of all of his symptoms. I relayed to the patient that, if the triglycerides are severely elevated, they factor into his symptoms.
The Cause of High Triglycerides
“Let food be thy medicine and medicine be thy food.” -anon.
It all starts and ends with food. Genes are activated by what we eat, leading to health or harm. The effect of food is particularly important in obesity and metabolic syndrome, conditions associated with gout, high blood pressure, type II diabetes, and high triglycerides.
A high sugar diet results in seemingly paradoxical elevated lipid and triglyceride levels. Parks (2001) explains that this may occur because of a relative reduction of fat during the meal. This has been referred to as carbohydrate-induced hypertriglyceridemia. Higher body mass index was associated with increases in the peak triglyceride level. A high sugar diet also triggers fat stores through a process known as lipogenesis.
Sugar has a narrow safety window and can cause harm above this. Aside from familial hypertriglyceridemia syndromes, an important cause of high triglycerides is a high sugar diet. This type of diet causes a continuum of short-term effects, like high triglycerides and uric acids, and long-term effects, like diabetes, cancer, heart disease, likely the former contributing to the latter.
Triglycerides (triacylglycerols) are synthesized in the body. From sugar in the diet, the liver forms and complexes glycerol (an alcohol-carbon compound) with three fatty acids to make triglycerides. These are carried in the bloodstream in chylomicrons and very-low density lipoprotein (VLDL) particles. The liver also stores glucose in the from of glycogen, which is used during the fasting state between meals. With excess glucose intake comes the spilling of higher levels of chylomicrons (i.e. high triglycerides) in the bloodstream. The degree of harm increase directly with the triglyceride level.
Signs of High Triglyceride levels:
Most patients with mildly elevated triglyceride levels do not have any obvious signs and symptoms. However, when levels rise to high and very high, patients may present with several systemic issues.
Signs/Effects of Very High Triglyceride levels:
- Acute pancreatitis: The pancreas is the center of hormone and enzyme production in the body. Hormones are released in the bloodstream, while enzymes are released in a tube that connects to the duodenum known as the pancreatic duct. Very high triglyceride levels (>1000 mg/dl) can trigger pancreatitis, acute or smoldering. It is the third-most common cause of pancreatitis behind alcohol and gallstones.
- Nonalcoholic fatty-liver disorder (NAFLD): High triglycerides levels are associated with fatty liver in patients with obesity and high levels of insulin seen in insulin resistance. One-third of those with NAFLD have nonalcoholic steatohepatitis (NASH). In the setting of smoldering inflammation, these changes in the liver can lead to scarring (fibrosis) with progression to cirrhosis. They are also a risk factor for liver cancer.
- Cardiovascular Disease: High triglyceride levels can cause inflammation in the vascular system and are an independent risk factor for heart disease. In a metanalysis of 17 studies and thousands of patients followed over 10 years, higher triglycerides increased the risk of heart disease. They are associated with small dense LDL particles and atherosclerosis (hardening of the arteries). It is thought that free fatty acid release with high triglycerides cause the production of inflammatory markers (cytokines).
- Stroke: If triglycerides can cause atherosclerosis and lead to inflammation, it stands to reason that other vascular areas could be impacted, including the brain. Triglyceride levels were found to correlate with one type of ischemic stroke lacunar infarcts in type 2 diabetics. Here is a link of an article on the types of stroke titled How to Prevent Your First (and Next) Stroke.
- Skin conditions: The skin is the largest organ of the body. Multiple skin findings have been associated with high triglyceride states including cutaneous xanthomas (yellow eruptions on the body), tuberous xanthomas usually on the extensor surfaces.
- Chylomicronemia syndrome: This condition can either be associated with familial chylomicronemia syndrome (FCS) or multifactorial, as was likely in this case. All of the features are related to the severely high levels of triglycerides, including skin eruptions (xanthomas), retinal injury (lipemia retinalis), pancreatitis, an enlarged spleen and liver, recurrent abdominal pain, “brain fog,” and fatigue.
Test and Address Your Triglycerides
The fundamental lesson of health is that directives to improve one condition will improve the whole body. Here are a few ways that you can find out if this is a problem:
Awareness: Know Your Triglyceride Level
Screening bloodwork is an important part of a physical examination visit. The purpose of screening is to find a condition early on, even if it is developing without symptoms. Triglyceride screening in the setting of a complete lipid panel is useful to determine the metabolic health of the body. The Triglyceride/HDL ratio is more predictive of heart disease than the LDL cholesterol.
- Normal: Less than 150 mg/dl
- Borderline High: 150 to 199 mg/dl
- High: 200 to 499 mg/dl
- Very High: >500 mg/dl
Hypertriglyceridemia can be associated with certain medications (antipsychotics, some HIV therapies, steroids, and blood pressure medications), endocrine conditions like hypothyroidism (a low functioning thyroid), organ dysfunction (kidneys and nephrotic syndrome) and underlying familial conditions.
Optimize the diet and reduce substances
Food is the integral fuel of the cellular mechanisms and function of the body. Low sugar intake can reduce insulin production leading to less lipogenesis. Intermittent fasting may provide the mechanism for lipolysis and a reduction of adipose tissues. Since a high sugar and processed food diet fuel high triglycerides, a reduction of these foods can improve the condition. Very low-fat diets are also recommended. The ideal way of having a low-fat and low-sugar diet is to eat mostly a plant-based diet. Curbing use of alcohol, sugary drinks, and smoking can improve triglyceride levels.
With very high levels of triglycerides, most beneficial is the combination of dietary recommendations with medications.
Hitting the gym, cycling, and jogging can acutely lead to improvements in triglyceride levels. This is another good reason to exercise.
There are multiple medications that are routinely used to reduce triglyceride levels. For borderline and high (<499 mg/dl) levels, a focus on LDL control (if needed) is generally recommended. With the exception of the “fish burp” in fish oils, each medication can cause side effects that need to be monitored by your primary doctor.
- Fish oils are replete in omega-3 fatty acids. Studies have supported the use of fish oils in patients with very high triglyceride levels. A range of 2 to 4 grams of fish oil lower triglyceride levels by 30 to 50 percent.
- Fibrates (fenofibrate and gemfibrozil) can lower triglycerides by 40 to 60 percent and raise HDL levels. There is a decrease risk of cardiovascular events shown in the use of fibrates.
- Niacin can also be effective in lower triglycerides and raising HDL levels, 20-30% and 5-25%, respectively.
Triglycerides are an important marker of health and illness. Elevated levels are associated with increased vascular risk factors. Very high levels can be associated with inflammatory presentations, such as skin lesions and pancreatitis. Screening for this level can help provide input on setting health goals.
References are included as links in the article.