What Are High Triglycerides?

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Triglycerides are a type of fat that play a key role in metabolism: Calories from food that aren't used are stored in fat cells as triglycerides where they can be called upon when energy is needed and released into the bloodstream. High triglycerides, (hypertriglyceridemia) is a medical condition in which more triglycerides than can be burned off or stored accumulate in the bloodstream. Persistently high levels are linked to serious illnesses, including pancreatitis (inflammation of the pancreas), atherosclerosis ("hardening of the arteries"), cardiovascular disease, and stroke. Obesity, overeating, metabolic syndromes, and type 2 diabetes are all associated with hypertriglyceridemia, but other genetic and health factors may be involved as well. An improved diet, exercise, and prescription medications are among the steps you can take to lower high triglycerides.

Older couple running in a park to lower high triglycerides
Betsie Van Der Meer / Getty Images

Symptoms

Hypertriglyceridemia usually doesn't cause symptoms until triglycerides levels become excessively high—typically between 1,000 milligrams per deciliter (mg/dL) and 2,000 mg/dL. At this level, symptoms of pancreatitis, including upper abdominal pain and nausea, may occur.

At these same levels, symptoms of atherosclerotic cardiovascular disease (ASCVD) can develop, including angina (chest pain), dyspnea (shortness of breath), and arrhythmia (irregular heartbeat). However, even levels at or above 443 mg/dL can increase the risk of a heart attack by more than three-fold.

According to a 2013 study in Clinical Lipidology, the median age of onset of cardiovascular disease in adults with hypertriglyceridemia was 57 for women and 50 for men. The age of onset of pancreatitis was similar.

As levels near or exceed 5,000 mg/dL, which typically only occurs in people with genetic disorders such as familial dysbetalipoproteinemia and familial chylomicronemia, both of which cause extreme elevations in triglyceride and cholesterol levels. other organ systems may be affected, leading to:

  • Hepatosplenomegaly (enlarged liver and spleen)
  • Eruptive xanthomas (small, painless nodules on the trunk, buttocks, and thighs)
  • Tuburoeruptive xanthomas (nodules on the elbows and knees)
  • Xanthoma striata palmaris (yellowish discoloration of the palms)
  • Xanthelasmas (yellowish, raised lesions around the eyelids)
  • Corneal arcus (a grayish-white opacity of the cornea)
  • Acute pancreatitis (manifesting fever, vomiting, rapid heart rate, loss of appetite, and radiating pain from the stomach to the back)
  • Neurological symptoms (including memory loss, depression, and dementia)

Causes

Hypertriglyceridemia can be caused by many different things, broadly described as lifestyle causes, genetic causes, medical conditions, and medications:

  • Lifestyle: Obesity, a high-fat diet, a lack of physical activity, and excessive alcohol consumption.
  • Genetic: Familial hyperlipidemia, familial chylomicronemia, mixed hyperlipidemia, lipoprotein lipase deficiency, lysosomal acid lipase deficiency, glycogen storage disease, and cholesteryl ester storage disease.
  • Medical conditions: Acute kidney failure, diabetes, hypothyroidism, pancreatitis, and lupus.
  • Medications: Beta-blockers, estrogen replacement therapy, estrogen-based oral contraceptives, thiazide diuretics, HIV protease inhibitors, isotretinoin, steroids, and tamoxifen.

It is possible to have overlapping causes of hyperlipidemia. For example, lifestyle choices (like diet) paired with medications (such as beta-blockers) can complicate a person's genetic predisposition for high triglycerides.

Diagnosis

For most people, hypertriglyceridemia is diagnosed with a series of blood tests known as a lipid panel. In addition to triglycerides, the lipid panel will measure the major forms of cholesterol—total cholesterol, high-density lipoprotein cholesterol (HDL), and low-density lipoprotein cholesterol (LDL). Prior to having a lipid panel, you may be asked to fast for 12 to 14 hours.

Lab results are usually returned in one to two days. The triglyceride test results are described within a reference range of values established by the Endocrine Society Task Force:

  • Normal: Less than 150 mg/dL
  • Borderline-high: Between 150 and 199 mg/dL
  • High: Between 200 and 499 mg/dL
  • Very high: 500 mg/dL or more
  • Severe hyperglyceridemia: Between 1,000 to 1,999 mg/dL
  • Very severe hypertriglyceridemia: Over 2,000 mg/dL

If triglyceride levels are higher than 500 mg/dL, additional tests may be performed to determine if there are genetic causes. A physical exam may be conducted to check for skin and eye symptoms as well as swelling of the liver or spleen.

In cases like these, a doctor will want to differentiate between the primary causes of hypertriglyceridemia and the secondary causes (in which the elevation is a consequence of another condition).

The conditions explored in a differential diagnosis may include:

  • Alcohol abuse
  • Hormone replacement therapy
  • Hypothyroidism
  • Kidney failure
  • Pancreatitis
  • Type 1 diabetes
  • Type 2 diabetes

Treatment

Hypertriglyceridemia typically is treated with a combination of lifestyle and pharmaceutical interventions. For borderline high triglyceride levels, medication may not be needed immediately but a diet and exercise program to improve overall health will be essential.

Lifestyle

Treating hypertriglyceridemia usually starts with an adjustment of lifestyle factors:

Low-fat diet: Dietary interventions can vary based on triglyceride levels but usually involve restricting dietary fats, replacing saturated and trans fats with polyunsaturated and monounsaturated fats, and eating fewer carbohydrates.

Exercise: This should involve a combination of moderate aerobic exercise and resistance training. A personal trainer can design a program specific to your fitness level and help you safely and gradually increase the intensity and duration of workouts over the course of weeks and months.

The American Heart Association (AHA) recommends between 30 and 60 of aerobic exercise most days of the week and resistance training for at least 20 to 30 minutes twice weekly.

Smoking cessation: If you smoke any amount, kicking the habit will lower your risk of atherosclerosis and cardiovascular disease.

Decreased alcohol consumption: For some people drinking can cause triglyceride levels to rise. Your doctor can tell you if alcohol might be a factor for you and advise you to cut back (and by how much) or stop drinking altogether.

Medications

Because it's rare for a person's triglyceride levels to increase while all other lipids remain normal, the decision to start medication usually is based on a review of their entire lipid profile.

To this end, the AHA in association with the American College of Cardiology (ACC) established guidelines to direct the appropriate treatment of hyperlipidemia (high blood lipids) as a whole. Among the medications used to reduce triglycerides and improve cholesterol levels are:

  • Statin drugs, such as Crestor (rosuvastatin), Lipitor (atorvastatin), Pravachol (pravastatin), and Zocor (simvastatin)
  • Zetia (ezetimibe), the first in a class of selective cholesterol-absorption inhibitors 
  • PCSK9 inhibitors, a class of injectable biologic drugs consisting of Praluent (alirocumab) and Repatha (evolocumab).
  • Fibrate acid derivatives, such as Atromid-S (clofibrate) and Lopid (gemfibrozil)
  • Bile acid sequestrants, such as Questran (cholestyramine) and Welchol (colesevelam)
  • Nicotinic acid, also known as niacin

Drug treatment should be considered when "bad" LDL levels reach a certain threshold. Though triglyceride levels will contribute to the decision (especially in people with diabetes and familial hypertriglyceridemia), the LDL values paired with the risk of ASCVD are the two factors that will ultimately decide whether treatment is needed or not.

According to the AHA/ACC guidelines, the treatment protocols are as follows:

  • For adults with clinically diagnosed ASCVD, start a statin drug at the maximally tolerated dose.
  • For adults with an LDL over 70 mg/dL and a moderate risk of ASCVD, start with a moderate-intensity statin.
  • For adults with an LDL over 70 mg/dL and diabetes, start with a moderate-intensity statin.
  • For adults with an LDL over 70 mg/dL and a very high risk of ASCVD, start with a high-dose statin with or without Zetia. A PCSK9 inhibitor can be added, as needed
  • For adults with an LDL greater than 190 mg/dL (but no ASCVD risk assessment), a high-dose statin with Zetia may be appropriate. A PCSK9 inhibitor can be added, as needed.

Hypertriglyceridemia is never treated with drugs alone. If medications are needed, it is all the more important that you reduce your intake of fat and sugar, exercise regularly, reduce alcohol consumption, and stop smoking.

Coping

Hypertriglyceridemia is not a condition that can be "cured" but rather one that must be managed for a lifetime to reduce the risk of heart disease and improve overall health and well-being.

To that end it can help to:

  • Set realistic goals: Do not start an aggressive weight-loss program if you are sedentary and 20 to 30 pounds overweight. Work with your doctor to establish incremental goals and a program you can sustain over the long term.
  • Learn good nutrition: Whatever your dietary restrictions may be, you need to maintain optimal nutrition to remain healthy and have enough energy to fuel your day. Steer clear of fad diets, and work with a dietitian to formulate a sensible, balanced approach.
  • Control all dietary sugar: Excess calories from sugar are converted by the body into triglycerides. This includes the sugar in fruit known as fructose. Although it is important to obtain dietary fiber from fruit and other food sources, don't go overboard: Use fresh whole fruit to replace candy and other sweets, including fruit drinks made with high-fructose corn syrup.
  • Seek support: It is difficult to adhere to dietary and fitness programs without the support of family and friends. Educate them on why you need to make lifestyle changes and explain how they can help. Don't try to go it alone. If needed, ask your doctor to speak with your loved ones.
  • Seek treatment: If you have a drinking problem or are unable to stop smoking, ask your doctor about treatment options. The Affordable Care Act mandates that certain alcohol addiction and smoking cessation aids be made available free of charge as an Essential Health Benefit (EHB) of your insurance plan.
  • Seek financial assistance: PCSK9 inhibitors are expensive. Don't assume that you can't afford them if you're uninsured or have high copay or deductible costs. There are copay assistance programs available for both Praluent and Repatha that may reduce your out-of-pocket costs to $0.

A Word From Verywell

It can be frustrating to learn your triglyceride and other lipid levels are higher than is healthy, particularly since it likely means you'll have to make some permanent changes in your lifestyle whether you also need medication or not. But it's vital to never treat hypertriglyceridemia in isolation. By managing your blood sugar, blood pressure, weight, bone health, lung health, and chronic medical conditions, you will almost invariably improve your blood lipid profile.

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