The Best Way to Lower Triglycerides? Research on Key Strategies

Inside: What’s the best way to lower triglycerides? And is there a best diet to lower triglycerides? Dietitians play a vital role when a triglyceride test shows blood triglycerides are too high, since research shows that lifestyle changes are the top priority.

 

Every dietitian has worked with people who made a change in eating habits… and overlooked the unintended consequences. Maybe someone switched to a plant-based alternative to milk, but didn’t notice that the kind they chose was a poor source of protein and calcium. Someone else didn’t notice how some switches they made sent the sodium content of their diet soaring. And someone else was trying to cut fat consumption for heart health or weight loss, but didn’t notice the extra calories from more added sugars and starches.

Keeping LDL (“bad”) cholesterol in a healthy range is among the ways you hear about most that diet can influence cardiovascular health. But be wary about advice with a single-minded focus on reducing saturated fat without regard for what replaces it. Current research shows the benefits of a dietary pattern that combines dietary strategies to reduce LDL-cholesterol while supporting overall cardiovascular health.

And one of those markers of cardiovascular health? A healthy level of blood triglycerides.

 

If you’re unclear about the best way to lower triglycerides – or whether triglyceride levels even matter that much – it’s no wonder. A lot of the information that’s most easily accessible doesn’t clarify how it fits in the context of overall research. Even scientific journals seem to sometimes overlook fundamental points about what sends blood triglycerides high. Dietitians can be proud of their role in helping people find clarity amidst today’s information overload.

 

 

3 Kinds of Studies Show High Triglyceride Levels Really Do Matter for Health

High blood triglycerides, a condition called hypertriglyceridemia, is becoming increasingly common.

 

Progress in research has re-shaped perspectives on blood triglyceride levels.

• Observational studies show risk of heart attack in the next 10 years was 2 to more than 3 times greater in people with triglyceride levels of 200 to 500 mg/dl compared to people with levels well within the healthy range.
  • Even in studies of people with LDL-cholesterol reduced by statin medications, those with elevated blood triglycerides have increased risk of atherosclerotic cardiovascular events (like heart attacks and strokes).
• In randomized controlled trials, each 40 mg/dl drop in triglyceride levels was associated with a decrease in risk of major cardiovascular events in an analysis of 48 trials.
• Genetic studies provide another piece of the puzzle about links between triglyceride levels and CVD risk. People with specific inherited traits that increase blood levels of triglycerides show increased risk of atherosclerotic CVD events.

 

Together, these types of studies confirm that high triglyceride levels indicate increased CVD risk.

• Getting LDL-cholesterol levels to a healthy range is the first and most important goal when it comes to blood lipids.
• High blood triglyceride levels are especially common in people known to be at increased CVD risk – like people with type 2 diabetes and visceral adiposity (excess fat in and around major organs in the abdomen). But research now shows high blood triglyceride levels don’t simply occur more often in people at increased cardiovascular disease risk, they indicate conditions that contribute to that risk.

 

 

Triglyceride Tests: What Do They Show About Risk?

Hypertriglyceridemia is defined as fasting triglycerides of 150 mg/dl or more, according to a report from the American College of Cardiology (ACC) and a statement from the National Lipid Association (NLA). For non-fasting blood tests, levels of 175 mg/dl or more define elevated levels.

Blood triglyceride levels may be considered optimal when they are less than 106 mg/dl, since each increase above that is associated with some increase in CVD risk, even at levels not categorized as hypertriglyceridemia.

Beyond that, risks of high blood triglycerides depend on how much they are elevated. Fasting levels are categorized as:

• Moderately elevated: 150 mg/dl or higher but less than 500 mg/dl
  → Usually caused by insulin resistance leading to overproduction of VLDLs (triglyceride carrying lipoproteins) by the liver. May also reflect decreased clearance of VLDLs.
• Severe: 500 mg/dl or higher but less than 1,000 mg/dl
  → Usually caused by dramatically reduced clearance of both kinds of triglyceride-rich lipoproteins (VLDLs and chylomicrons).
• Critical: 1,000 mg/dl or higher
  → These levels almost always signal very high levels of chylomicrons that increase risk of acute pancreatitis.

Several aspects of lifestyle can strongly affect blood triglycerides levels – as summarized below. But it’s important to remember that healthcare providers need to check for influences other than diet and lifestyle that may cause elevated levels.

• Health conditions like insulin resistance and diabetes that’s not well-controlled, certain autoimmune diseases (like rheumatoid arthritis, psoriasis, and systemic lupus erythematosus), hypothyroidism, and certain forms of kidney disease.
• Some medications can raise blood triglycerides in some people. Examples include beta-blockers (used for several heart conditions), thiazides (diuretics often used to treat high blood pressure), corticosteroids, tamoxifen (a hormone therapy used for breast cancer), and raloxifene (hormone therapy to treat and prevent osteoporosis in postmenopausal women). Several others can also increase triglyceride levels.

 

What’s the Best Way to Lower Triglycerides?

Once your healthcare provider has ruled out other health conditions and medications as causes for high blood triglycerides, all major health recommendations call for attention to lifestyle choices as the next step before prescribing medications specifically targeted at triglyceride levels.

In part, that’s because lifestyle habits that raise blood triglycerides often pose other health risks, too. For example, when insulin resistance and uncontrolled high blood sugars are causing rising triglyceride levels, once blood sugars are controlled, triglyceride levels often drop.

Does Alcohol Affect Triglycerides?

Yes! Even one standard alcoholic drink per day (12 ounces of beer, 5 ounces of wine, a 1½ ounce shot of distilled spirits) can raise triglycerides 5 to 10 percent. If triglyceride levels are more than moderately elevated, alcohol should be completely avoided, at least until levels are normalized.
For mild to moderate elevations, limiting alcohol to no more than one (for women) or two (for men) in a day may be low enough…. But check portions to make sure “one drink” isn’t providing more alcohol than you think.

 

Does Exercise Lower Triglycerides?

Physical activity, especially aerobic exercise like moderate walking at least 5 days/week, can reduce elevated triglycerides levels about 10 percent, or even up to 30 percent. Resistance exercise produces somewhat smaller drops but can also be effective.

Triglyceride clearance from the blood increases with physical activity, and the insulin resistance that promotes increased levels of triglycerides is reduced.

 

What Can You Expect from a Diet to Lower Triglycerides?

Medical nutrition therapy – a dietary pattern created with the help of a registered dietitian nutritionist targeting triglyceride reduction and cardiovascular health – reduced triglyceride levels in several controlled intervention trials. Average reduction in these trials ranged from about 16 mg/dl to 33 mg/dl.

Dietary changes combined with avoiding or limiting alcohol consumption can reduce triglyceride levels 10 to 40 percent, though sometimes 70 percent or more, according to the National Lipid Association and an American College of Cardiology consensus panel report.

 

 

What’s the Best Diet to Lower Triglycerides?

Triglycerides in the blood can include fat from the diet (transported in chylomicrons), but for most people, blood levels largely reflect triglycerides formed in the liver and then transported in the blood in VLDL lipoproteins.

Although triglycerides are fats, a diet with moderate amounts of fat – like a Mediterranean-style pattern or the DASH diet variations that are a little higher in healthy fat or plant protein – can be excellent choices for most people, as long as blood triglycerides are below 500 mg/dl. (When blood triglycerides are higher, fat consumption needs to be kept low to avoid overwhelming the body’s capacity to clear triglycerides and increasing risk of pancreatitis.)

 

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What About Dietary Carbohydrate? 

You may see some sources that recommend a low-carbohydrate diet to reduce triglyceride levels. But carbohydrate-containing foods don’t all have the same effects. Instead, start first by looking separately at different sources of carbohydrate.

• Sugars and refined grains particularly increase triglyceride production in the liver, especially in people with insulin resistance (like people with type 2 diabetes, prediabetes, or metabolic syndrome).
• Dietary fiber (especially viscous kinds) slows the absorption of carbohydrate so that it’s less likely to prompt a rise in production of triglycerides in the liver.

Start Here: Limit Added Sugars 

Nix the sugar-sweetened sodas, energy drinks, and “sweet tea”.

• For most people with elevated triglycerides — with levels remaining below 500 mg/dl — recommended limits on added sugars are the same as for overall health (no more than 6% to 10% of calories).
• If triglycerides are 500 mg/dl or higher, added sugars need to be kept very low (less than 5% of calories). In these cases, sugar-sweetened beverages should be completely avoided.

 

Is Low-Carb Really the Best Diet to Lower Triglycerides? 

When it comes to questions about carbohydrate content of diets for reducing blood triglycerides, here are the conclusions of a National Lipid Association (NLA) task force scientific statement:

• Triglyceride levels can be reduced with a diet that’s low (less than 130 grams/day) or moderate (130 to 225 grams/day) in carbohydrate compared to levels on a high-carbohydrate, low-fat diet.
• Ketogenic diets don’t show additional effectiveness for triglyceride-lowering beyond what’s achieved with low- or moderate-carbohydrate diets.
• What replaces carbohydrate matters for overall cardiovascular health. Increasing saturated fat consumption raises LDL-cholesterol, including on a low-carbohydrate diet. Even if a smaller proportion of LDL particles are the small dense LDL that is the most harmful, the big picture of research shows that keeping total LDL-cholesterol low remains important for health.

Carbohydrate Quality: For High Quality Carbs, Look Beyond Glycemic Index

Insulin resistance and the high insulin levels that go with it drive the increase in triglycerides and VLDL levels for most people. That means the learnings from research on prediabetes can be applied to questions about specific carbohydrate-containing foods.

Find Ways to Make Non-Starchy Vegetables a Delicious Focus

Including lots of green – and other – vegetables throughout the day was an essential strategy in studies that tried to maximize dietary fiber when using diets that limited carbohydrates. Ask: what will it take to get comfortable with this as a long-term eating habit?

Don’t Fear the Fruit

You might see headlines about studies in which the sugar fructose stimulates liver production of triglycerides and VLDL secretion. Those studies involve large amounts of fructose that you’d get from many servings of fruit juice or sugar-sweetened beverages. And regardless of whether the sweetener in drinks comes from high fructose corn syrup (HFCS), table sugar, or something “natural” like agave, large amounts mean large amounts of fructose.

Eating solid fruit would be unlikely to provide the levels of fructose in those headline-making stories. In fact, fruit consumption is associated with lower triglyceride levels. Unless triglyceride levels are at extremely high levels (1000 mg/dl or more), two or three servings of fruit per day contribute valuable nutrients. What’s more, many provide viscous dietary fiber that helps reduce blood sugar and insulin surges after meals.

Embrace Pulses (like dry beans, chickpeas, and lentils) 

These plant-based sources of protein are so rich in viscous fiber that they do not raise triglycerides and should be encouraged. The version of the DASH diet that includes more plant proteins, like pulses, is one of the dietary patterns that’s recommended as a choice to lower triglyceride levels while promoting overall cardiovascular health.

Choose Whole Grains Over Refined Grains

Don’t think of “grains” as all being the same for health. Whether or not whole grains help reduce blood triglycerides or have no effect differs among studies. And considering all their other health benefits, whole grains can contribute to a healthy diet unless triglycerides reach critically high levels.

Watch the “health halo” effect, of course. If the image of all those anti-inflammatory plant compounds in whole grains has led you to giant plates of whole grain pasta or triple-servings of whole-grain cereal, reducing high triglyceride levels may mean cutting back to moderate portions.

Focus on Carbohydrate Quality Over Glycemic Index

The concept of being especially cautious about portions of foods that are most likely to trigger a surge in blood sugars and insulin (and thus triglyceride production) – and how many of those foods you eat at one time – makes sense. But although you may hear advice online and in the media to pick the foods you eat based on their Glycemic Index (GI) or Glycemic Load (GL), the values found in GI tables really don’t show how food choices will affect you individually.

Instead, count on choosing whole food sources for most of your carbohydrate and choosing amounts that are appropriate for you – both of individual foods and of how many carbohydrate-rich foods you’re eating at one time.

 

 

What About Omega-3 Fats to Lower Triglycerides? 

Certain omega-3 fatty acids can reduce high blood triglycerides. Studies suggest that they do this by decreasing triglyceride synthesis, decreasing liver production and secretion of VLDL (the triglyceride lipoprotein carrier), and possibly by increasing triglyceride clearance from the blood. Omega-3s also protect against cardiovascular disease (CVD) through their anti-inflammatory effects. (See the Resources section for links to background information about omega-3s.)

EPA and DHA, omega-3s that come mainly from seafood and other marine sources, are the omega-3s that research consistently shows offer the most heart-health protection.

How much decrease in triglycerides can you expect from EPA+DHA?

The answer largely depends on the amount of EPA+DHA.

• In people with triglycerides of over 200 to 499 mg/dl or with severe increases in triglycerides (500 mg/dl and higher), 4,000 mg/day of EPA+DHA lower blood levels by about 30%.
• Smaller amounts of EPA+DHA, possibly starting at about 500 mg/day, may lower blood triglycerides to a lesser degree, according to one major review.

Boosting Dietary Omega-3s – What are the Options?

You can increase dietary omega-3s by eating more fish – depending on the fish you choose.

The dietary pattern recommended by the American Heart Association (AHA) to promote cardiovascular health encourages eating fish at least twice a week (or about 8 ounces/week). The Mediterranean-style dietary pattern in the Dietary Guidelines for Americans may even include about 15 ounces of seafood/week.

>> The benefits to heart health are reported to likely come from both the boost to omega-3 consumption and the improvement in overall dietary quality when eating fish reduces consumption of choices like red and processed meat.

With a goal of increasing omega-3 consumption, all seafood is not the same. A dietary pattern that provides an average of at least 250 mg/day of EPA+DHA has been identified as a level that promotes cardiovascular health, though it’s likely not enough to lower blood triglycerides that are already high.

An average of 250 mg/day means consuming 1750 mg total during a week. If you eat two or three moderate portions a week, include seafood with at least 500 mg EPA+DHA per serving to reach that total.

>> Choice of seafood matters to reach this level of omega-3s. For many people, this means stretching beyond their habits of just a few typical choices that are very lean and thus relatively low in omega-3s. For example, cod, shrimp, and tilapia are nutrient-rich and provide a great alternative for people who want to reduce their red meat consumption. You can find lists of fish and other seafood that provide at least 500 mg EPA+DHA in a three-ounce portion here from the Seafood Nutrition Partnership.

>> If you’re feeding young children, and for women who are pregnant or breastfeeding, or who may become pregnant, choice of seafood is also important to avoid excess amounts of methyl mercury, which poses special risk to babies and young children.

>> Many kinds of farm-raised fish are as high in omega-3s as their wild-caught counterparts. (See the Resources section below for tips on including seafood on a budget.)

Another option to boost EPA+DHA in the diet is with foods fortified with these fatty acids. In most cases, though, these help people reach levels similar to what’s possible with frequent consumption of fish high in omega-3s, not the high levels that research has shown effective for large reductions in blood triglycerides.

What about plant food sources of omega-3s?

ALA (α-linolenic acid) is an omega-3 fatty acid that’s found in the oil of certain seeds and nuts. For example, flaxseeds, chia seeds, and walnuts are top sources. However, only a small amount of ALA is converted in the body to EPA and DHA. It’s a heart-healthy, unsaturated type of fat, but studies show that ALA has little to no effect on blood triglycerides.

 

Omega-3 Supplements: Over-the-Counter and Prescription

Dose matters: According to a scientific statement from the American Heart Association based on review of multiple clinical trials, at least 4 grams/day of fish oil that provides at least 3 grams/day (that’s 3,000 mg) of omega-3s is needed to effectively lower blood triglycerides. This report concluded that trials providing less than 2 grams/day were much less effective, although a Cochrane review concluded that while triglyceride-lowering is dose-dependent, smaller doses can provide some effects.

Fish oil supplements and isolated omega-3 fatty acids are options to reach the levels recommended to reduce triglyceride levels.

Prescription products have traditionally been combinations of EPA+DHA, but studies with a highly purified EPA have also shown strong benefit. Although many studies have already been done, more work is in progress to better understand who might benefit most from the different options available. Since these are used to treat medical conditions, they are regulated by the FDA as medications, with strict watch for quality and for content delivering the level of omega-3s as labeled.

Over-the-counter supplements of fish oil, krill oil (from a tiny marine animal), and algal oil (from algae) can also deliver high doses of EPA+DHA for triglyceride-lowering. Because these supplements are not regulated by the FDA, you need to check labels carefully.

• Check grams of EPA+DHA (either the total listed or add amounts of the two yourself). Depending on the product, less than half of the fish oil may be EPA and DHA. So grams of fish oil – and even grams of omega-3s (since there are other types of omega-3s) – is not the same as grams of EPA+DHA.
• Check the serving size on the Supplement Facts panel. In some cases, for example, it may take 2 softgels to get the amount of EPA+DHA listed.
• Check for quality control review by an independent, nonprofit organization. You might see USP-Verified, NSF-certified, or ConsumerLab.com-approved. These certifications don’t guarantee that a supplement is safe or effective, but do show that testing indicates the product contains the ingredients listed on the label and doesn’t contain harmful levels of contaminants.

And talk with your healthcare provider if you’re considering a supplement to boost omega-3s. Even over-the-counter fish oil supplements can interfere with certain medical conditions and their treatments, so that’s one more safety check that’s not worth skipping.

 

Will Losing Weight – and Waist Size – Benefit Triglycerides? 

People with insulin resistance – those with type 2 diabetes, prediabetes, waistline obesity, or metabolic syndrome – are especially prone to over-produce triglycerides.

For people with overweight or obesity, especially with excess fat around the waist, weight loss is considered the most effective step to reduce triglyceride levels. Avoiding excess calories and reducing high levels of insulin reduce triglyceride production in the liver.

In an analysis of 30 controlled intervention trials, for each kilogram (about 2 ¼ pounds) of weight loss from lifestyle change, triglycerides dropped 3 mg/dl at 6 months, and a bit more at one year. (Another analysis frames results as a 5% to 10% weight loss reducing blood triglycerides by an average of 20%.)

• Studies show large variation in people’s triglyceride response to weight loss. And it’s not really clear whether that reflects individual genetic and metabolic differences among people (for example, whether they have insulin resistance or type 2 diabetes), differences in how much change people made, or specific diet and lifestyle strategies people chose to lose weight. For some people, weight loss can lower triglycerides by 50% to 70%, but that can’t be the expectation for everyone.
• People often think of weight loss as an all-or-nothing goal. It’s important to clarify that small amounts of weight loss can make a meaningful difference in health, especially when excess weight involves visceral fat deep in the abdomen. So rather than aiming for large weight loss that may require unrealistic changes in eating or exercise habits, the goal can focus on finding ways to create modest changes that become sustainable.

Step 1 is Lifestyle: The Best Way to Lower Triglycerides

For most people, a rise in blood triglycerides that promotes atherosclerosis, heightens inflammation, and increases CVD risk involves moderate elevations to levels under 500 mg/dl. Research is consistent in showing that diet, alcohol, physical activity and body fat all influence blood triglyceride levels.

In some cases, medications are a necessary step to reduce elevated triglycerides. Healthcare providers can consider whether prescription omega-3 fatty acids, statins, niacin, or fibrates are best for each individual patient.

For many people, confusion from the conflicting nutrition information they encounter every day plus the challenges of finding doable tweaks to food choices combine to make creating a healthy dietary pattern harder than it needs to be.

 

Here’s what an American College of Cardiology expert consensus panel recommends:

“Referral to a registered dietitian nutritionist is strongly recommended to improve understanding of heart-healthy dietary principles and individualize nutrition recommendations for patients with hypertriglyceridemia. Given that metabolic risk factors such as hypertriglyceridemia cluster with other metabolic risk factors (abdominal obesity, hypertension, hyperglycemia), adherence to a recommended dietary intervention can markedly benefit the entire metabolic risk profile over the life course.”