Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr Warrick Bishop and I'd like to welcome you to my podcast and videocast station. And today I've got the opportunity to speak with Dr Karam Kostner about triglycerides. Welcome, Karam. Thank you, Warrick. Glad to be part of your program. Well, you know, I'm really excited to be talking about triglycerides today. It's a word that... comes up all the time when i first heard it as a medical student i had no idea what a triglyceride was i thought it was something we used as well actually to keep the bowels regular but it's far more complicated than that and i'm sure people are hearing the word triglyceride all the time so without further ado could you just tell us in simple terms what a triglyceride is Very happy to work. Triglycerides like cholesterol and phospholipids are fats or lipids as we call them in the scientific language. And they basically sit on membranes, but they also sit on proteins that transport other fats in the body, in the bloodstream. but they also sit in adipose tissue. If you look at tummy fat, for example, or other storage fats in the body, they mainly consist of triglycerides. And even though everybody talks about cholesterol nowadays, and this is really where most of our treatments aim to make a difference, triglycerides are also important, as we will discuss in this podcast. So what is a triglyceride? Is it the fatty ball or is that a component of the fatty ball? Glyceride is basically a fat, as we said, a lipid, and it looks slightly different biochemically to cholesterol, but it is a much more volatile and mobilizable lipid. So for example, when we ingest fat, saturated fat, in our diet, the body takes this fat up in chylomicrons, which are proteins that transport fat in the bloodstream, and that mainly consists of triglycerides. But also if you look at adipose tissue, fat tissue like tummy fat, for example, then you can see that most of that fat is again triglycerides. And it is an important fat for storage, but also for other functions in our body. But unfortunately, it also makes the blood more viscous. So people with very high triglycerides. have a much more viscous blood. And as you and I often see in clinical practice, people with very high triglycerides, if you look at their blood and spin down the red blood cells, have this milky appearance of their plasma or serum. That's how we often see it without even looking into a microscope. So that sort of appearance is the extreme and they're fairly uncommon. The average patient who would be going to a clinical or listening to this, is probably going to be having triglycerides which fluctuate between, is it a range that's pretty similar to cholesterol ranges or how does the range of cholesterol? It's a slightly different range because triglycerides as opposed to cholesterol, even in normal individuals, individuals fluctuate with food intake. So triglycerides rapidly rise after a fatty meal or any meal that contains a significant amount of calories, also sugars, for example, and then they come back to baseline levels when we are fasting. A normal range of triglycerides is anything below 2.5 millimole per liter. As you indicated, especially people with diabetes, with obesity, and some genetic conditions that increase triglycerides, can have much higher triglyceride levels, up to 5, 10, 20, and 100. And once our triglycerides are above 10, especially in the fasting state, the risk of pancreatitis, which is an inflammation and painful condition of our pancreas, is significantly increased. That sounds like a very serious condition. But back to the fluctuation of triglycerides, if they vary so much with food, When should we be measuring them and what's the best way to do that? And how long should you have fasted for? It's a good question. Generally, we recommend a 12-hour fast to get a fasting triglyceride level. And that's basically as a baseline and to see what the optimal level of an individual with regards to triglycerides is. Sometimes we are also interested in non-fasting triglyceride levels. So I would like to see both in my patients. because the non-fasting triglycerides tell us what a patient's triglycerides are during the day, after a meal, in between meals, and are more reflective of the extreme levels that a particular individual might have. So you mentioned some of the extreme levels might be seen in people who are diabetic or pre-diabetic. Why is diabetes tied in with triglyceride levels? How does that interact? What basically happens is that sugars can easily be transformed into triglycerides. And people who have diabetes or who have metabolic syndrome have much more fatty acids, glucose, and that's why triglyceride levels are generally much higher, especially if these conditions are not controlled, than in non-diabetic patients. So it's all linked to fatty acids, which are acids in our body that also contain a fat particle. And in diabetics, particularly fatty acid levels can easily be transformed into triglycerides. So we've talked about why we worry about triglycerides, particularly in a very, very small population. Very rarely, these triglycerides can be very high and lead to things like pancreatitis. But for the more average clinic setting where we're worried about cardiovascular health of our patient. Why are we worried about triglycerides? What do they do that's a problem? Well, apart from the things that we've discussed, mainly for pancreatitis and viscosity of the blood, if you have high triglycerides, triglycerides tend to go into the dangerous lipid particles, the small dense LDL. or LDL particles that are taken up by the artery wall much easier. So not only do triglycerides end up in our pancreas and cause a problem for the microcirculation of the pancreas, not only do they make blood more viscous and sticky, but they also end up in LDL particles. And in fact, LDL that are rich in triglycerides are sometimes more dangerous than normal LDL. So it's... potentially that these particles, these triglycerides can contribute to the deposition of fat within arteries or atherosclerosis. Correct. Exactly. Okay. So we've talked about diabetes, maybe pushing these triglycerides up. Well, in general terms, what are the things that push triglycerides up and what are the things, well, I'll ask you presently what we can do to pull them down, but what are the main things you're worried about that push? triglycerides up? Obesity we've already mentioned and diabetes. Smoking is another condition where triglycerides go up and it's related directly to smoking effects on the vasculature and other functions in our body. Hormones have also got an influence on triglycerides, for example, estrogen after menopause, but also the contraceptive pill in younger women, testosterone in bodybuilders and people who take testosterone. And they are the main things that increase triglyceride levels apart from genetic conditions where people are born with an inability to metabolize triglycerides. And they're often problems with apolipoprotein E or problems with lipoprotein lipase, which is an enzyme that helps to degrade triglycerides or problems with other enzymes in our body that increase triglycerides. without making it too complicated. So you're sort of saying that the genetic causes are either along the line of producing too much triglyceride or not being able to clear it and utilise it as normal. Exactly, exactly. So I'll just bring you back to a couple of the clinical pictures in my own practice. I'm sure you look at them too when we see raised triglycerides. The hormones I agree with, but I also think, I always used to think that thyroid, low thyroid hormone levels or hypothyroid levels, hypothyroid conditions could lead to raised triglycerides. And alcohol is the other one that I'm concerned about when I see raised triglycerides. Do you see alcohol? Is there an issue for triglycerides or is it a risk? Absolutely. You're absolutely correct. So especially large amounts of alcohol, you know, heavy alcohol intake increases triglycerides significantly. And again, especially in people who have these genetic conditions. So for example, you have got somebody with hypertriglyceridemia or you have somebody with familial combined hyperlipidemia, they drink a lot of alcohol and their triglycerides will go up a lot. Whereas in the normal population, even with heavy alcohol intake, they wouldn't go up that much. So I'm just going to pin you down on a lot of alcohol. When I was an intern, I worked in Darwin. Yeah. When I used to take a history from them, having grown up in Tasmania in a fairly conservative household, I was staggered by what they thought was a modest or average amount of alcohol. And I think we all have a different perception. I enjoy a couple of glasses of wine with a meal most nights, one with a meal and maybe one afterwards. What level of alcohol would you perceive is likely to be a problem? Apart from the people who have a predisposition or a genetic, but maybe for someone who's pre-diabetic or carrying a bit of extra weight, would two glasses be too many or four? Probably not. No, probably not. So we are talking about four to five standard drinks a night or more in the people that you mentioned. The exception is, again, people who have a genetic condition that increases triglycerides dramatically. They would probably also... with less alcohol run into increases in triglycerides that are above normal. So four to five standard drinks in most people, you would need to have a significant effect on triglycerides. Yeah. Okay. So if we've identified someone with high triglycerides, we know what some of the problems are. Let's talk about how we're going to lower those triglycerides. Obviously, we've just talked about alcohol and reducing alcohol is the first thing. What are the non-pharmacological, non-drug ways that we could reduce triglycerides in the first instance, Carol? Yeah, very good points, Warrick, and very good questions. So the first thing to say, if somebody's got coronary disease or a high risk of coronary disease and their cholesterol is also slightly elevated, we would still use statins and ezetrol as a first line to get these bad cholesterol particles and to get the cholesterol down in the first step. But to specifically lower triglycerides, statins are not very effective. You know, they will lower triglycerides up to 20, 30, sometimes 40%. But for severe hypertriglyceridemia or elevated triglycerides, natural things are very effective and dietary changes. So the first thing that I always recommend is a diet that is very low in saturated fat. And for some people nowadays, that's a difficult recommendation because you have all these high saturated fat diets for weight loss. You have these caveman diets. You have the low carbohydrate, high meat diets that Pete Evans recommends. Now, for somebody with high triglycerides, they are the worst diets that you can have. Because for elevated triglyceride, it's really all about saturated fat and sugar reduction to a certain degree. That's the first thing. The second thing is weight loss and smoking cessation, which will have an effect on triglycerides. And to a certain degree, also exercise. The third thing is that this is a condition where fish oil in the form of long-chain omega-3 fatty acids is very effective. So fish oil, for example, to somebody with high cholesterol alone does very little. But if you have hypertriglyceridemia or if both your cholesterol and triglycerides are elevated and you have a significant intake in omega-3 fatty acids, fish oil, you can see bigger drops in triglycerides than with many of the medications. that we use for high cholesterol. So the best way to get that fish oil is probably with eating deep sea fish fresh from the fish shop I would imagine because the oil weight of salmon is quite substantial I understand. So it's correct 150 gram piece of salmon you've actually got at least 15 to 20 grams of oil in that, haven't you? No, unfortunately not. So you'd have to eat salmon three times a day to get to four grams of EPA or DHA a day, which you really need for the very high triglyceride levels. So what we usually recommend is supplements in the form of liquid fish oil, melrose, ethical nutrients, or highly concentrated fish oil capsules, because the EPA and DHA, which are these long-chain fatty acids, are not the same in all supplements. So some of the cheaper supplements only contain 300 milligrams per capsule. If you use the liquid fish oil or the high-strength capsules, you get about a gram per capsule or per milliliter. So while eating fish is obviously tasty and good, you'd have to eat a lot of fish to get the triglyceride reduction. Okay, well, so we've got reducing alcohol, we've got changing diet, particularly reducing saturated fats, we've got smoking cessation, of course, we've got weight loss and we've got some exercise, plus we've got a supplement in there. I want to come back to the dietary thing and ask you if you think what the most important component of these triglycerides are in terms of a driver, because in my own observation... I often advocate reduced carbohydrate eating. And these are not people with terribly high triglycerides, but nonetheless, I see very positive results in triglyceride reduction for many of these people, making me wonder if the carbohydrate is a greater driver. Maybe this is in people who are pre-insulin resistant. Would you like to speak on that apparent? almost disconnect or that reflective sort of situation where reducing saturated fats may be beneficial, but maybe reducing carbohydrate can be as well in certain people? Look, it's a complicated question because it really depends on your overall sort of clinical picture. It depends whether you have diabetes, whether you have cholesterol and triglycerides that are elevated. But to come back to your question, if your main problem are elevated triglycerides, The most important thing is to reduce saturated fats, butter, cream, fatty cuts of meat, and fast and processed foods. The second thing that's important, as you mentioned, is to reduce sugar as well and carbohydrates to a certain degree because they can be transformed into triglycerides as well. But you're absolutely right. If you only have mildly elevated triglycerides and cholesterol is your main problem, other things are more important or equally important. So it depends a little bit on the constellation. Okay. So if we've exhausted our lifestyle modification and supplements, and a patient still has concerningly elevated triglycerides, and I'm guessing you would be talking about a number of greater than 2.5 to 3 millimoles per litre for an individual, maybe at increased risk, what sort of medications would you then be looking to think about using for that patient? And how would you pass those medications with that patient? The most effective medication for elevated triglycerides are fibrates and nicotinic acid. So especially phenofibrate, which we use especially in diabetics and people with metabolic syndrome who have high triglycerides, is very effective. You take it as a tablet once a day. It's been around for 30 years. It's a very safe medication. You only need to reduce it if you have significant renal problems or gallstones. And the other medication that we use is nicotinic acid or niacin if available, but that can have some side effects, as you know. So they're the two main medications that we use for high triglyceride levels, apart from statins in people who have coronary disease or high risk for coronary disease. So the phenofibrate group of drugs, how do they work? Is there an easy way to explain how they work, Karam? They basically prevent triglycerides from being formed and they interfere with triglyceride metabolism. So, vibrates are very effective. They also have a small effect on HDL and cholesterol in addition to the triglyceride effect. They work on receptors called PIPA, but again, I don't want to make it too complicated for your audience. Yeah, I have to admit, I can barely understand people are receptors myself. So stopping metabolism is a good start. But while we are talking about pharmacological or drug treatments, is that a good time to mention the reducer trial, which looked at really pharmacological doses of fish oil therapy? Would you like to expand on that a little bit, Karam? Very happy to do that. With triglyceride trials in the past, we have seen some positive results, you know, in people with heart failure, in people post-MI. But until the reduced trial that you mentioned, nobody has done a very large trial in people with high triglycerides and increased cardiovascular risk and shown that supplementing with highly concentrated omega-3 fatty acids, in this case, Epanova, which is EPA mainly, reduces cardiovascular events such as heart attacks and stroke. And as you mentioned, the REDUCED trial was the first big trial in this particular indication with high triglycerides that has shown exactly that. So very interesting space. And I think not available in Australia, but available in the United States at the moment. Is that correct? That's correct. And reimbursed by health authorities and private funds as well. Okay, so we can get it in Australia? We will be able to get it in Australia, but this is where experts are divided in their opinion. In my opinion, for example, getting EPA from other sources like highly concentrated available fish oils. well omacoa will in my opinion have a very similar effect even though it hasn't been studied in exactly this this particular way other specialists seem to think that you really have to use the epanova that was used in this particular clinical trial what's your view on this i think if we're looking at epa as the active agent which it appears to be i would probably be open to it being a class effect rather than the specific proprietary patented extraction method. And we see benefit with fish oil in combination with DHA anyway. So I think it's probably greater than just a single pharmacological agent, but that's where the data is. So you can understand people arguing about it. I agree, I agree. Look, is there anything else that you wanted to add, Karim? Because I think we'll come to a close. No, not really. Look, I'd like to summarize that triglycerides are a different lipid, another independent risk factor for cardiovascular disease, especially in people with metabolic syndrome and diabetes. In very high concentrations, they can cause pancreatitis, which is a painful condition that can ultimately also lead to diabetes. And I'd like to reiterate what we've both said, that lifestyle factors, diet and fish oil, have a good effect on triglycerides. And if necessary, there's also some pharmacological therapies available. Well, look, it's been really fantastic to speak with you. I always enjoy chewing the fat with you. I'm going to go and have some dinner fairly soon and enjoy a glass of wine and keep my triglycerides down as low as possible. I'm going to thank you for joining me tonight. I'm going to thank those who are listening. I hope you've learned something from this journey about triglycerides. If you have any queries or questions, please drop me a note at info at drwaribishop.com. If you have any suggestions for further podcasts, please let us know. Thank you so much again for joining us. And until next time, I wish you good health and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
