Understanding Triglycerides: Energy, Risk, and Prevention

Announcer: 0:00

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts. Hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren: 0:11

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence, and a cardiologist, and from time to time I get questions that I've heard enough times where I said you know what, let's sit down and go over this with a core group of people to make sure everybody understands it. And here I am at Jacksonville Center for Clinical Research. We run clinical trials here and I have several people in the room who are employees of Jacksonville Center for Clinical Research and they've been asking me, Dr. Koren, what the heck is a triglyceride? We talk about it all the time but I'm not really sure exactly what it is. So, with the help of Sharon Smith, who is our editor I'm the executive editor, but she actually does the work, Sharon Smith we are going to break down what is a triglyceride and get to the truth about triglycerides. So here we go.

Dr. Michael Koren: 1:01

So those of you that have seen our programs before know that we like to ask questions. We use the Socratic method of learning, meaning that the audience gets involved and we ask them questions. So the first question is where do you find the largest store of triglycerides in the body? Is it the liver? Liver is involved in a lot of things, including the metabolism of fats. Is it the brain, is it the blood, is it the fat cells or all of the above? So I'm going to pick on an audience member. What would you say? What would you guess, given those choices?

Audience: 1:41

I'm going to guess the blood.

Dr. Michael Koren: 1:43

Did you see these slides before?

Audience: 1:46

I did not, but that's where we test for triglycerides.

Dr. Michael Koren: 1:49

All right. Well, that was a great insight because most people would not think in those terms. But yes, the actual biggest store of triglycerides are the blood, and that tells you that these things are circulating and our body needs a way to accommodate that circulation, because fat and water don't mix the blood is mostly aqueous or water and triglycerides are fat. So in order for them to be compatible with each other, there has to be some mechanism by which this happens, and we'll talk more about that in a second, second audience question. Let me pick on another audience, the woman in the back in the black dress. You're up next. Which of the following statements is true about triglycerides? Is it elevated? Triglycerides are associated with cardiovascular disease. One in five US adults have elevated triglycerides. Our bodies use triglycerides for energy. Diet has a major impact on triglycerides, or all the above? The floor is yours.

Audience: 2:52

Okay, I'm going to go with all the above.

Dr. Michael Koren: 2:54

All the above and you guys are good. You guys are really really well trained. I'm very proud of you.

Audience: 2:59

I was questioning one in five US adults, but Okay.

Dr. Michael Koren: 3:04

All right, but you nailed it Very impressive. So let's jump in a little bit more. So triglycerides are a type of fat in your blood that serves as an energy source for the body. Again, it's an energy source. Triglycerides are composed of three fatty acid chains attached to a glycerin molecule. And so if you see, here in this model the glycerol is in the red and the chains are those gray parts of the molecule that extend as tails. There's different ways of representing that. That is one of the ways they're usually measured.

Dr. Michael Koren: 3:38

As part of a standard lipid profile, our bodies convert calories consumed in a meal that we don't use immediately into triglycerides, and then they get stored ultimately in fat cells. So actually, if you eat a lot of sugar, it eventually becomes triglycerides and then, if you don't use it as an energy source, eventually it'll end up in the fat cells. The liver is also part of that, by the way, so your liver also stores of these things in the short term, but for long-term storage we use the fat cells. Hormones regulate the release of triglycerides from fat tissue so they can be used for energy between meals. So let's talk about the likelihood of elevated triglycerides, and this shows you that if you are ages from childhood to being older, and if you look at in the blue non-Hispanic whites, in the red are non-Hispanic blacks and green is Mexican-Americans, you can see the likelihood of developing triglycerides above 150 milligrams per deciliter in men and in women. So you can see that people of Mexican-American heritage have the highest risk of having high triglycerides. But actually people from all different backgrounds have this risk and even in the lowest cohort you're still looking at rates of above 20% overall, with people in sort of their middle years most likely to have elevated triglycerides, probably because they're still eating robustly and maybe their activity is not quite as good as it was when they were younger. So that's the epidemiology of high triglycerides. Hopefully that's clear.

Dr. Michael Koren: 5:21

So a question I get all the time is how are triglycerides different than cholesterol? Well, they're both fats, they're both types of fats, but they are very, very different structurally and in terms of how our body metabolizes them. They're both fatty substances and we call them lipids. So when you use the term lipids, it's not just LDL, cholesterol or triglyceride, it's a combination of all these different types of lipoproteins, combination of lipid and protein, because that's how these molecules circulate in our bloodstream, as I mentioned fat and water don't mix. So in order for these fats to get to different parts of our body, they are associated with lipoproteins. Hopefully that's clear. Because these molecules cannot dissolve in blood, the body packages them with proteins into lipoproteins, which transport them throughout the body to where they are needed. So, reiterating that point. Cholesterol serves as a structural component of cell membranes and a precursor for hormone production. That's very, very important. So you can see here that in a more complex molecule, that this would be something that's structural and that would be something that we'd use for hormonal basis, whereas something like triglycerides are simpler molecules that are there for quick energy. I think we have a better picture of that in a different slide.

Dr. Michael Koren: 6:47

This is a basic concept of the triglyceride molecule. Here you can see the glycerin backbone and these are the fatty acid chains. Another way of looking at it. We've looked at it in different ways. We like to represent chemistry using different types of models. The models that you saw before are more realistic. These are more cartoon-like but sometimes easier to understand.

Dr. Michael Koren: 7:11

So one of the things that comes up is what is a normal level of triglycerides and other types of blood fat. So here you see the entire list. So total cholesterol we'd like to see it less than 200 milligrams per deciliter, but if you have had a heart attack we may want it even lower than that. Remember, all these things are situational, depending on who you are and what your circumstances are. LDL most times LDL is not measured directly, but actually calculated based on the cholesterol level, the HDL and the triglycerides. But that should ideally be less than 100. But again, in people that are at very high risk for complications, we get that down below 50. With our new drugs we can get LDL cholesterol down to the 20s. It's pretty remarkable, but again, for the person that doesn't have any heart disease, we want to see below 100. Typically, HDL is the good cholesterol, so that's the lipoprotein molecule that circulates more favorably and helps remove cholesterol from the circulation using a favorable lipoprotein format. And again, ideally we like to see that above 60 milligrams per deciliter. But there's a lot of genetic variation in that and that's something that's very difficult to change with standard medications or with physical activity. Even so. For example, people that are genetically predisposed to heart disease sometimes have a very low level of HDL, and people who are lucky enough to have genetically high levels of HDL seem to be somewhat protected against cardiovascular complications.

Dr. Michael Koren: 8:43

Triglycerides, as we mentioned, is the focus for today and typically we consider triglycerides above 150 milligrams per deciliter to be elevated, to be increased. But triglycerides are also something that tends to vary more with your dietary intake. So it's important that when you have your triglyceride level measured, it should be a fasting measurement. Cholesterol doesn't change that much fasting or not, but triglycerides do quite a bit, and LDL, especially the calculated LDL, changes with fasting because part of the calculation for LDL is to know the triglyceride level. And then we have something called the non-HDL cholesterol, which is a simple formula total cholesterol minus HDL, and, if you want to think about it, this is all the different forms of bad cholesterol. And then, finally, something that we talk about is what's called the triglyceride to HDL ratio. So if that's particularly high, say more than three, that's usually associated with the worst prognosis and ideally, when we treat people, cardiologists love it when the HDL and the LDL are the same. So if you've had a heart attack and you needed a statin but you still need additional help and we put you on a PCSK9 inhibitor, then we're happy to see that these two things work together and got your LDL down to 30, because your HDL unfortunately is only 30 genetically. But we've accomplished something by making those two numbers the same and typically we want to see those triglycerides below 100 in people who are actively treating.

Dr. Michael Koren: 10:14

So what leads to high triglycerides? Here's your list. One, excessive alcohol use. Two, poorly controlled type 2 diabetes. Three, being overweight with a BMI of greater than 25. Four, a diet high in sugar, saturated fat and simple carbohydrates the standard American diet probably is something that leads to high triglycerides. Unfortunately, cigarette smoking raises your triglycerides. Please don't do that. Certain medications like diuretics, hormones, corticosteroids, beta blockers and some HIV meds are known to increase triglyceride levels. So if you're on drugs or you're concerned about your triglycerides, talk to your physician about the medicines you're on to make sure that they're not contributing to your problem. Certain inflammatory diseases are associated with high triglycerides, such as rheumatoid arthritis. And finally, thyroid, liver or kidney disease can be associated with higher levels of triglycerides.

Audience: 11:10

I've got a question what is the definition of excessive drinking?

Dr. Michael Koren: 11:16

Two drinks less per day than you drink.

Audience: 11:18

Okay, all right, dang it.

Dr. Michael Koren: 11:20

The serious answer, that question is obviously, for everybody it's a little bit different, but in men we like to see two drinks or less and women one drink or less per day. On average it's usually more of a weekly tally because not everybody drinks the exact same amount each day. But 14 drinks per week for a man is considered more than enough, and seven drinks per week for a woman is considered more than enough. And that's one ounce of alcohol. So again, one shot of liquor or four ounces of wine or eight ounces of beer. A little bit more precise answer than my first one. Okay, which restaurant foods cause elevated triglycerides? A: red lobster fried shrimp. B: Pappy's Smokehouse barbecued drenched ribs? We have no endorsement from any of these companies, by the way, you don't have to worry about that. C: Miller's Alehouse beer. D: Dunkin' Donuts or E: all the above. Does anybody want to look at that and give us an answer?

Audience: 12:22

I'm going to say all of the above.

Dr. Michael Koren: 12:23

Oh my God, you guys are good. You guys are good. So, again, next question we like to get into is what combination of these numbers or these lipid parameters are worse than increase the risk for heart attacks? So we have A: a low LDL and a low HDL. B: high triglycerides and low HDL. C: low triglycerides and high HDL. D: high HDL and high LDL. And E: nagging spouses

Audience: 12:59

this is a tough one.

Announcer: 13:01

I'm torn between D and E, but I'm going to go with D.

Dr. Michael Koren: 13:07

D okay.

Dr. Michael Koren: 13:10

Does anybody have another opinion? We have an E. Okay, so it looks like we have a split decision. I'm going to go with B Okay, so it looks like we have a split decision, but I'm going to go with the Bs, I agree. All right, good work. So just to break this down LDL is the bad cholesterol we want that low. Hdl is the good cholesterol we want that. High Triglycerides accentuate the problem. So, whatever your situation is, high triglycerides make it worse. So think about it like that. So having a high triglyceride and a low HDL is not a good combination, and we call that actually a metabolic dyslipidemia. And sometimes even people that don't have particularly high LDL cholesterols have this combination of high triglycerides and low HDL, and that can be a very difficult problem for cardiologists to treat. Question from the audience.

Audience: 14:08

Why do we focus on a person that's had a heart attack, having their LDL under 55?

Dr. Michael Koren: 14:15

Great question. So, to repeat; the question is In research and in clinical practice, people come in who've had a history of a heart attack and we focus on getting their LDL cholesterol down, and we often use the number 55, which comes from our guidelines. And that number is based on clinical trials, including many of the studies we've done right here, to show that when we get people below that level they have fewer heart attacks compared to being above that level. So, the lower is better, and 55 is generally considered a level we can achieve in most patients that has been shown in study after study to result in better outcomes. And just going through the rest, low triglycerides and high HDL is a good combination. High HDL and high LDL is sort of opposite of each other, and then I won't get into the nagging spouses issue, but that's up to you guys to figure out.

Dr. Michael Koren: 15:07

Yes?

Announcer: 15:08

Would it be preferable if you had high LDL or high triglycerides? Obviously, the answer would be neither, but is one worse than the other?

Dr. Michael Koren: 15:20

For coronary artery disease, high LDL would be worse. For pancreatitis, high triglycerides would be worse. Okay, so I think we're getting towards the end of this little discussion and here's a nice paper that came out recently that talked about the residual risk of high triglycerides and that gets someone to the question that you just mentioned. So usually LDL is the first target of treatment when somebody's had a heart attack and we really focus on getting that number down. Nowadays we try to get our patients below that 55 level in many cases. So sometimes when we get that LDL down where it belongs, we'll add additional treatments to lower the triglycerides as our secondary target. So we can use something like fish oils or icosapent ethyl or Fenofibrate to help get that below that 150 or 100 mark, as the case may be for the triglycerides, And the conclusion of this paper is research has identified a significant association between hypertriglyceridemia again defined as triglycerides above 150, and non-coronary arthrosclerosis and vascular inflammation in apparently healthy persons with low to moderate cardiovascular risk, even in those people with normal LDL levels. These data reinforce the role of targeting triglycerides in primary cardiovascular treatment. So you mentioned the fact about treating a heart attack patient. That's secondary treatment, but we happen to know that even before you have a heart attack, there are people that we can identify that have super high risk. They could have diabetes, they could have a very strong family history and those people we find it's important to look at the triglycerides. So how do you lower your triglycerides? I got into some of this, but let's reiterate these points because they're so important.

Dr. Michael Koren: 17:08

One eat heart-healthy foods. We were having a discussion before we got on camera that processed foods are not where you want to go. Simple sugars are not where you want to go. Too much alcohol is not where you want to go, but a Mediterranean style diet with lean cuts of meat, a lot of salads and minimize the oils, and the oils that you use, like olive oil, are going to be more favorable. Oils that have omega-3 fatty acids in them are going to be better. So I personally eat fish as my primary protein. I probably eat some fish virtually every day. There's some controversy about whether or not eating fish alone should be a therapeutic option for people, but I happen to follow that advice. Question.

Audience: 17:53

You don't worry about mercury levels?

Dr. Michael Koren: 17:55

I do not no.

Audience: 17:57

Is that a myth?

Dr. Michael Koren: 18:01

No, it's not-

Audience: 18:03

-or is that just a tuna fish thing?

Dr. Michael Koren: 18:04

No, it's not a myth, but-

Audience: 18:07

Because I eat tuna fish every day to lose weight.

Audience: 18:08

If somebody didn't say you're going to increase your mercury level

Dr. Michael Koren: 18:09

Yeah, I think your chances of dying of a heart attack are way more than dying from mercury poison. Let's put it that way, okay, two, be physically active for at least 30 minutes every day. Really, really important. Quite frankly, if everybody did this, our heart disease rates in this country would drop by 50%. Simple advice, but hard to do, and please get into your schedules.

Dr. Michael Koren: 18:35

Lose weight is a great thing. We have more and more ways that people are helped, either through structured programs of very careful eating. We know that if you reduce your calorie intake, you will lose weight. But of course, we have the GLP-1 phenomenon now, so there's a lot of choices out there in terms of how to get that weight down. Manage your blood sugar that's important. So people that have these big spikes in blood sugar are more likely to binge eat or eat things that are maybe not as healthy as they could be. So that's an important concept, and the point here is that if you tend to run high high blood sugars you will also tend to run high triglycerides. Quit smoking and reduce your alcohol risk. Some doctors think that you should cut out alcohol completely. I don't subscribe to that particular philosophy. I think that low doses of alcohol or moderate alcohol use is okay.

Audience: 19:23

What

Audience: 19:23

about nicotine, because obviously now everything's going to move from smoking to nicotine. Same thing Knock off the nicotine?

Dr. Michael Koren: 19:31

Nicotine is not as bad as smoking. So when you burn tobacco, you release 3,000 different chemicals, none of which are good for you. Nicotine is the thing that makes people feel good. So if you're using a pure nicotine product, I believe that that's a much better choice than smoking cigarettes. Now, some people in the public health world may disagree with that. They think anything that's addictive in that way is not necessarily good for you. But the data really support the idea that it's the 2,999 other chemicals other than the nicotine that really do the damage, and the nicotine is what makes you feel good. So, again, if you could get off nicotine completely, that'd be great, but if you're addicted to nicotine, I would strongly advise you to use a nicotine product and not smoke.

Dr. Michael Koren: 20:19

LDL lowering drugs have modest effects on triglycerides and that's important to know. So even if you're on a statin drug that has some effects on triglycerides or PCSK9 agent that has some effects on triglycerides, they're not going to touch it the way they work against LDL cholesterol. So very modest effects of those particular products on the triglycerides. It's a separate category that requires a separate approach and, as I mentioned, niacin, fibrates, omega-3 fatty acids and ethyl esters have variable effects, but these are all the things that we tend to use when we say variable effects. We can get your triglyceride level down anywhere between 20 and 50% with these things, but it's really hard to use medicines to get it super low, whereas for LDL cholesterol, we can now have the drugs to get it super low and I mentioned this before icosapent ethyl or Vascepa. And there's a very, very nice study by Deepak Bhat, who's a tremendous researcher that I've worked with on a number of occasions in the REDUCE-IT study and I was a REDUCE-IT investigator as part of this study and we showed that this product resulted in reduced cardiovascular events in patients with known coronary disease. So shout out for that really nice work. All right,

Dr. Michael Koren: 21:35

Question number four alternatives to foods that raise your triglycerides. A red lobster, fried shrimp what do you do as an alternative? Well, we like red lobster, we have nothing against it, but when you go there, order the tuna poke or a peel and eat boiled shrimp, okay, so there you go. So all these. You know, nowadays in most restaurants there are choices and so you can order the healthy choice. It's available to you, and I enjoy going out to eat and I enjoy also looking at the menu, sometimes giving the waitstaff a little bit of grief over the unhealthy options, but typically you can find a healthy option. Just focus on that and enjoy the meal. So we're not trying to take this experience away from anybody and it's really not that hard once you get into that mindset.

Dr. Michael Koren: 22:26

Ah the bearded pig. Barbecued sauce, drenched ribs Okay, well, maybe order a filet mignon without butter or a sirloin with the fat trimmed. I don't know if you do that, but if you go to a restaurant and you don't ask for no butter on your steak, more often than not you will get it, and the perception is that people think it makes it taste better, but I actually think it takes something away from the pure taste of the meat. So I do indulge in fillets on occasion and I always order for my steak with no butter, and that's easy to accommodate. The chefs don't mind doing that and you'll actually enjoy the meat better, I would argue. So try that and see, and let me know if you like it.

Dr. Michael Koren: 23:12

Intuition Ale works. Beer, order red wine or beer in moderation. Again, there's nothing wrong with going to these establishments. It's fun. Enjoy the company of your friends and family, but be mindful of what you're drinking and, instead of just taking one shot after another, after after another, enjoy a nice IPA. Look at the wine list and enjoy something that may be a little bit different than what you usually have.

Dr. Michael Koren: 23:37

Become knowledgeable about the world of wine. It's fascinating. Wine is such a fascinating area and there's so much to think about in terms of the different varieties that are available to us and the different vintages, and ask questions and then share your experience. What does it taste like to you? What's your sensation? What does it remind you of? So there's a lot of fun around these products, as long as you don't overindulge. And donut shop donuts, okay. Well, that may be a little bit of a challenge, but I think if you work on it, you can probably order a thin bagel with low-fat cream cheese, and so even in places that don't necessarily cater to healthy eaters, you usually can find something that will be acceptable from a cardiologist's viewpoint. So I'm going to stop there, but you guys were very impressive on the questions and thank you very much for your attention and your interest in triglycerides.