September 10, 2025 • 24 mins
Join Cardiologist Dr. Michael Koren as he speaks in front of a live audience to break down the truth about triglycerides. Triglycerides are a type of fat in our blood that acts as an energy source for the body, but high levels can have serious impacts on your heart and health.
Dr. Koren explains what triglycerides are, what they do in the body, how the numbers you get from a cholesterol test are calculated, and how to know when the numbers are too high. The cardiologist also moves through risks; how genetic factors, other conditions, diet, and exercise can affect triglycerides. He finishes up with audience questions and actionable advice for what you can do today to help lower your triglycerides - and your risk of heart disease!
Be a part of advancing science by participating in clinical research.
Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com
Listen on Spotify
Listen on Apple Podcasts
Watch on YouTube
Share with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.
Follow us on Social Media:
Facebook
Instagram
X (Formerly Twitter)
LinkedIn
Want to learn more? Checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com
Music: Storyblocks - Corporate Inspired
Thank you for listening!
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcer (00:00):
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts.
Hosted by cardiologist and topmedical researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence, and a
cardiologist, and from time totime I get questions that I've
heard enough times where I saidyou know what, let's sit down
and go over this with a coregroup of people to make sure
everybody understands it.
And here I am at JacksonvilleCenter for Clinical Research.
We run clinical trials here andI have several people in the
(00:33):
room who are employees ofJacksonville Center for Clinical
Research and they've beenasking me, Dr.
Koren, what the heck is atriglyceride?
We talk about it all the timebut I'm not really sure exactly
what it is.
So, with the help of SharonSmith, who is our editor I'm the
executive editor, but sheactually does the work, Sharon
Smith we are going to break downwhat is a triglyceride and get
(00:57):
to the truth about triglycerides.
So here we go.
So those of you that have seenour programs before know that we
like to ask questions.
We use the Socratic method oflearning, meaning that the
audience gets involved and weask them questions.
So the first question is wheredo you find the largest store of
triglycerides in the body?
Is it the liver?
(01:19):
Liver is involved in a lot ofthings, including the metabolism
of fats.
Is it the brain, is it theblood, is it the fat cells or
all of the above?
So I'm going to pick on anaudience member.
What would you say?
What would you guess, giventhose choices?
Audience (01:41):
I'm going to guess the blood.
Did you see these slides before?
I did not, but that's where we test for triglycerides.
Dr. Michael Koren (01:49):
All right.
Well, that was a great insightbecause most people would not
think in those terms.
But yes, the actual biggeststore of triglycerides are the
blood, and that tells you thatthese things are circulating and
our body needs a way toaccommodate that circulation,
because fat and water don't mixthe blood is mostly aqueous or
(02:11):
water and triglycerides are fat.
So in order for them to becompatible with each other,
there has to be some mechanismby which this happens, and we'll
talk more about that in asecond, 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 followingstatements is true about
(02:32):
triglycerides?
Is it elevated?
Triglycerides are associatedwith cardiovascular disease.
One in five US adults haveelevated triglycerides.
Our bodies use triglyceridesfor energy.
Diet has a major impact ontriglycerides, or all the above?
The floor is yours.
Audience (02:52):
Okay, I'm going to go with all the above.
Dr. Michael Koren (02:54):
All the above and you guys are good.
You guys are really really welltrained.
I'm very proud of you.
Audience (02:59):
I was questioning one in five US adults, but Okay.
Dr. Michael Koren (03:04):
All right, but you nailed it Very
impressive.
So let's jump in a little bitmore.
So triglycerides are a type offat in your blood that serves as
an energy source for the body.
Again, it's an energy source.
Triglycerides are composed ofthree fatty acid chains attached
to a glycerin molecule.
(03:30):
And so if you see, here in thismodel the glycerol is in the
red and the chains are thosegray parts of the molecule that
extend as tails.
There's different ways ofrepresenting that.
That is one of the ways they'reusually measured.
As part of a standard lipidprofile, our bodies convert
calories consumed in a meal thatwe don't use immediately into
triglycerides, and then they getstored ultimately in fat cells.
(03:51):
So actually, if you eat a lotof sugar, it eventually becomes
triglycerides and then, if youdon't use it as an energy source
, eventually it'll end up in thefat cells.
The liver is also part of that,by the way, so your liver also
stores of these things in theshort term, but for long-term
storage we use the fat cells.
Hormones regulate the releaseof triglycerides from fat tissue
(04:13):
so they can be used for energybetween meals.
So let's talk about thelikelihood of elevated
triglycerides, and this showsyou that if you are ages from
childhood to being older, and ifyou look at in the blue
non-Hispanic whites, in the redare non-Hispanic blacks and
(04:35):
green is Mexican-Americans, youcan see the likelihood of
developing triglycerides above150 milligrams per deciliter in
men and in women.
So you can see that people ofMexican-American heritage have
the highest risk of having hightriglycerides.
But actually people from alldifferent backgrounds have this
risk and even in the lowestcohort you're still looking at
(04:59):
rates of above 20% overall, withpeople in sort of their middle
years most likely to haveelevated triglycerides, probably
because they're still eatingrobustly and maybe their
activity is not quite as good asit was when they were younger.
So that's the epidemiology ofhigh triglycerides.
Hopefully that's clear.
(05:21):
So a question I get all the timeis how are triglycerides
different than cholesterol?
Well, they're both fats,they're both types of fats, but
they are very, very differentstructurally and in terms of how
our body metabolizes them.
They're both fatty substancesand we call them lipids.
So when you use the term lipids, it's not just LDL, cholesterol
or triglyceride, it's acombination of all these
(05:43):
different types of lipoproteins,combination of lipid and
protein, because that's howthese molecules circulate in our
bloodstream, as I mentioned fatand water don't mix.
So in order for these fats toget to different parts of our
body, they are associated withlipoproteins.
Hopefully that's clear.
Because these molecules cannotdissolve in blood, the body
(06:07):
packages them with proteins intolipoproteins, which transport
them throughout the body towhere they are needed.
So, reiterating that point.
Cholesterol serves as astructural component of cell
membranes and a precursor forhormone production.
That's very, very important.
So you can see here that in amore complex molecule, that this
(06:28):
would be something that'sstructural and that would be
something that we'd use forhormonal basis, whereas
something like triglycerides aresimpler molecules that are
there for quick energy.
I think we have a betterpicture of that in a different
slide.
This is a basic concept of thetriglyceride molecule.
(06:51):
Here you can see the glycerinbackbone and these are the fatty
acid chains.
Another way of looking at it.
We've looked at it in differentways.
We like to represent chemistryusing different types of models.
The models that you saw beforeare more realistic.
These are more cartoon-like butsometimes easier to understand.
(07:11):
So one of the things that comesup is what is a normal level of
triglycerides and other types ofblood fat.
So here you see the entire list.
So total cholesterol we'd liketo see it less than 200
milligrams per deciliter, but ifyou have had a heart attack we
may want it even lower than that.
Remember, all these things aresituational, depending on who
(07:31):
you are and what yourcircumstances are.
LDL most times LDL is notmeasured directly, but actually
calculated based on thecholesterol level, the HDL and
the triglycerides.
But that should ideally be lessthan 100.
But again, in people that areat very high risk for
complications, we get that downbelow 50.
With our new drugs we can getLDL cholesterol down to the 20s.
(07:53):
It's pretty remarkable, butagain, for the person that
doesn't have any heart disease,we want to see below 100.
Typically, HDL is the goodcholesterol, so that's the
lipoprotein molecule thatcirculates more favorably and
helps remove cholesterol fromthe circulation using a
favorable lipoprotein format.
And again, ideally we like tosee that above 60 milligrams per
(08:16):
deciliter.
But there's a lot of geneticvariation in that and that's
something that's very difficultto change with standard
medications or with physicalactivity.
Even so.
For example, people that aregenetically predisposed to heart
disease sometimes have a verylow level of HDL, and people who
are lucky enough to havegenetically high levels of HDL
(08:39):
seem to be somewhat protectedagainst cardiovascular
complications.
Triglycerides, as we mentioned,is the focus for today and
typically we considertriglycerides above 150
milligrams per deciliter to beelevated, to be increased.
But triglycerides are alsosomething that tends to vary
more with your dietary intake.
So it's important that when youhave your triglyceride level
(09:00):
measured, it should be a fastingmeasurement.
Cholesterol doesn't change thatmuch fasting or not, but
triglycerides do quite a bit,and LDL, especially the
calculated LDL, changes withfasting because part of the
calculation for LDL is to knowthe triglyceride level.
And then we have somethingcalled the non-HDL cholesterol,
which is a simple formula totalcholesterol minus HDL, and, if
(09:23):
you want to think about it, thisis all the different forms of
bad cholesterol.
And then, finally, somethingthat we talk about is what's
called the triglyceride to HDLratio.
So if that's particularly high,say more than three, that's
usually associated with theworst prognosis and ideally,
when we treat people,cardiologists love it when the
(09:44):
HDL and the LDL are the same.
So if you've had a heart attackand you needed a statin but you
still need additional help andwe put you on a PCSK9 inhibitor,
then we're happy to see thatthese two things work together
and got your LDL down to 30,because your HDL unfortunately
is only 30 genetically.
But we've accomplishedsomething by making those two
(10:05):
numbers the same and typicallywe want to see those
triglycerides below 100 inpeople who are actively treating
.
So what leads to hightriglycerides?
Here's your list.
One, excessive alcohol use.
Two, poorly controlled type 2diabetes.
Three, being overweight with aBMI of greater than 25.
(10:27):
Four, a diet high in sugar,saturated fat and simple
carbohydrates the standardAmerican diet probably is
something that leads to hightriglycerides.
Unfortunately, cigarettesmoking raises your
triglycerides.
Please don't do that.
Certain medications likediuretics, hormones,
corticosteroids, beta blockersand some HIV meds are known to
(10:48):
increase triglyceride levels.
So if you're on drugs or you'reconcerned about your
triglycerides, talk to yourphysician about the medicines
you're on to make sure thatthey're not contributing to your
problem.
Certain inflammatory diseasesare associated with high
triglycerides, such asrheumatoid arthritis.
And finally, thyroid, liver orkidney disease can be associated
with higher levels oftriglycerides.
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 alittle bit different, but in men
we like to see two drinks orless and women one drink or less
per day.
On average it's usually more ofa weekly tally because not
everybody drinks the exact sameamount each day.
But 14 drinks per week for aman is considered more than
enough, and seven drinks perweek for a woman is considered
(11:42):
more than enough.
And that's one ounce of alcohol.
So again, one shot of liquor orfour ounces of wine or eight
ounces of beer.
A little bit more preciseanswer than my first one.
Okay, which restaurant foodscause elevated triglycerides?
A (11:59):
red lobster fried shrimp.
B (12:02):
Pappy's Smokehouse barbecued drenched ribs?
We have no endorsement from anyof these companies, by the way,
you don't have to worry aboutthat.
C (12:10):
Miller's Alehouse beer.
D (12:13):
Dunkin' Donuts or E
Does anybody want to look atthat 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 welike to get into is what
combination of these numbers orthese lipid parameters are worse
than increase the risk forheart attacks?
So we have A (12:39):
a low LDL and a low HDL.
B (12:43):
high triglycerides and low HDL.
C (12:47):
low triglycerides and high HDL.
D (12:50):
high HDL and high LDL.
And E (12:54):
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.
Does anybody have anotheropinion?
We have an E.
Okay, so it looks like we havea split decision.
I'm going to go with B Okay, soit looks like we have a split
decision, but I'm going to gowith the Bs, I agree.
All right, good work.
So just to break this down LDLis the bad cholesterol we want
(13:29):
that low.
Hdl is the good cholesterol wewant that.
High Triglycerides accentuatethe problem.
So, whatever your situation is,high triglycerides make it
worse.
So think about it like that.
So having a high triglycerideand a low HDL is not a good
combination, and we call thatactually a metabolic
(13:51):
dyslipidemia.
And sometimes even people thatdon't have particularly high LDL
cholesterols have thiscombination of high
triglycerides and low HDL, andthat can be a very difficult
problem for cardiologists totreat.
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 isIn research and in clinical
(14:49):
practice, people come in who'vehad a history of a heart attack
and we focus on getting theirLDL cholesterol down, and we
often use the number 55, whichcomes from our guidelines.
And that number is based onclinical trials, including many
of the studies we've done righthere, to show that when we get
people below that level theyhave fewer heart attacks
compared to being above thatlevel.
So, the lower is better, and 55is generally considered a level
we can achieve in most patientsthat has been shown in study
after study to result in betteroutcomes.
And just going through the rest, low triglycerides and high HDL
is a good combination.
High HDL and high LDL is sortof opposite of each other, and
then I won't get into thenagging spouses issue, but
that's up to you guys to figureout.
Yes?
Announcer (15:08):
Would it be preferable if you had high LDL
or high triglycerides?
Obviously, the answer would beneither, but is one worse than
the other?
Dr. Michael Koren (15:20):
For coronary artery disease, high LDL would
be worse.
For pancreatitis, hightriglycerides would be worse.
Okay, so I think we're gettingtowards the end of this little
discussion and here's a nicepaper that came out recently
that talked about the residualrisk of high triglycerides and
(15:42):
that gets someone to thequestion that you just mentioned
.
So usually LDL is the firsttarget of treatment when
somebody's had a heart attackand we really focus on getting
that number down.
Nowadays we try to get ourpatients below that 55 level in
many cases.
So sometimes when we get thatLDL down where it belongs, we'll
add additional treatments tolower the triglycerides as our
(16:04):
secondary target.
So we can use something likefish oils or icosapent ethyl or
Fenofibrate to help get thatbelow that 150 or 100 mark, as
the case may be for thetriglycerides, And the
conclusion of this paper isresearch has identified a
significant association betweenhypertriglyceridemia again
(16:25):
defined as triglycerides above150, and non-coronary
arthrosclerosis and vascularinflammation in apparently
healthy persons with low tomoderate cardiovascular risk,
even in those people with normalLDL levels.
These data reinforce the roleof targeting triglycerides in
primary cardiovascular treatment.
So you mentioned the fact abouttreating a heart attack patient
(16:46):
.
That's secondary treatment, butwe happen to know that even
before you have a heart attack,there are people that we can
identify that have super highrisk.
They could have diabetes, theycould have a very strong family
history and those people we findit's important to look at the
triglycerides.
So how do you lower yourtriglycerides?
I got into some of this, butlet's reiterate these points
(17:07):
because they're so important.
One eat heart-healthy foods.
We were having a discussionbefore we got on camera that
processed foods are not whereyou want to go.
Simple sugars are not where youwant to go.
Too much alcohol is not whereyou want to go, but a
Mediterranean style diet withlean cuts of meat, a lot of
salads and minimize the oils,and the oils that you use, like
(17:29):
olive oil, are going to be morefavorable.
Oils that have omega-3 fattyacids in them are going to be
better.
So I personally eat fish as myprimary protein.
I probably eat some fishvirtually every day.
There's some controversy aboutwhether or not eating fish alone
should be a therapeutic optionfor people, but I happen to
follow that advice.
(17:49):
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.
If somebody didn't say you'regoing to increase your mercury
level
Dr. Michael Koren (18:09):
Yeah, I think your chances of dying of a
heart attack are way more thandying 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 didthis, our heart disease rates
in this country would drop by50%.
Simple advice, but hard to do,and please get into your
(18:34):
schedules.
Lose weight is a great thing.
We have more and more ways thatpeople are helped, either
through structured programs ofvery careful eating.
We know that if you reduce yourcalorie intake, you will lose
weight.
But of course, we have theGLP-1 phenomenon now, so there's
a lot of choices out there interms of how to get that weight
down.
Manage your blood sugar that'simportant.
So people that have these bigspikes in blood sugar are more
(18:54):
likely to binge eat or eatthings 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 bloodsugars you will also tend to run
high triglycerides.
Quit smoking and reduce youralcohol risk.
Some doctors think that youshould cut out alcohol
completely.
(19:15):
I don't subscribe to thatparticular philosophy.
I think that low doses ofalcohol or moderate alcohol use
is okay.
Audience (19:23):
What about nicotine, because
obviously now everything's goingto move from smoking to
nicotine.
Same thing Knock off thenicotine?
Dr. Michael Koren (19:31):
Nicotine is not as bad as smoking.
So when you burn tobacco, yourelease 3,000 different
chemicals, none of which aregood for you.
Nicotine is the thing thatmakes people feel good.
So if you're using a purenicotine product, I believe that
that's a much better choicethan smoking cigarettes.
Now, some people in the publichealth world may disagree with
(19:54):
that.
They think anything that'saddictive in that way is not
necessarily good for you.
But the data really support theidea that it's the 2,999 other
chemicals other than thenicotine that really do the
damage, and the nicotine is whatmakes you feel good.
So, again, if you could get offnicotine completely, that'd be
great, but if you're addicted tonicotine, I would strongly
(20:15):
advise you to use a nicotineproduct and not smoke.
LDL lowering drugs have modesteffects on triglycerides and
that's important to know.
So even if you're on a statindrug that has some effects on
triglycerides or PCSK9 agentthat has some effects on
triglycerides, they're not goingto touch it the way they work
against LDL cholesterol.
So very modest effects of thoseparticular products on the
(20:37):
triglycerides.
It's a separate category thatrequires a separate approach and
, as I mentioned, niacin,fibrates, omega-3 fatty acids
and ethyl esters have variableeffects, but these are all the
things that we tend to use whenwe say variable effects.
We can get your triglyceridelevel down anywhere between 20
and 50% with these things, butit's really hard to use
(20:59):
medicines to get it super low,whereas for LDL cholesterol, we
can now have the drugs to get itsuper low and I mentioned this
before icosapent ethyl orVascepa.
And there's a very, very nicestudy by Deepak Bhat, who's a
tremendous researcher that I'veworked with on a number of
occasions in the REDUCE-IT studyand I was a REDUCE-IT
(21:22):
investigator as part of thisstudy and we showed that this
product resulted in reducedcardiovascular events in
patients with known coronarydisease.
So shout out for that reallynice work.
All right,Question number four
alternatives to foods that raiseyour triglycerides.
A red lobster, fried shrimpwhat do you do as an alternative
(21:44):
?
Well, we like red lobster, wehave nothing against it, but
when you go there, order thetuna poke or a peel and eat
boiled shrimp, okay, so thereyou go.
So all these.
You know, nowadays in mostrestaurants there are choices
and so you can order the healthychoice.
It's available to you, and Ienjoy going out to eat and I
(22:06):
enjoy also looking at the menu,sometimes giving the waitstaff a
little bit of grief over theunhealthy options, but typically
you can find a healthy option.
Just focus on that and enjoythe meal.
So we're not trying to takethis experience away from
anybody and it's really not thathard once you get into that
mindset.
(22:26):
Ah the bearded pig.
Barbecued sauce, drenched ribsOkay, well, maybe order a filet
mignon without butter or asirloin 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 butteron your steak, more often than
not you will get it, and theperception is that people think
(22:47):
it makes it taste better, but Iactually think it takes
something away from the puretaste of the meat.
So I do indulge in fillets onoccasion and I always order for
my steak with no butter, andthat's easy to accommodate.
The chefs don't mind doing thatand you'll actually enjoy the
meat better, I would argue.
So try that and see, and let meknow if you like it.
(23:12):
Intuition Ale works.
Beer, order red wine or beer inmoderation.
Again, there's nothing wrongwith going to these
establishments.
It's fun.
Enjoy the company of yourfriends and family, but be
mindful of what you're drinkingand, instead of just taking one
shot after another, after afteranother, enjoy a nice IPA.
Look at the wine list and enjoysomething that may be a little
(23:35):
bit different than what youusually have.
Become knowledgeable about theworld of wine.
It's fascinating.
Wine is such a fascinating areaand there's so much to think
about in terms of the differentvarieties 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 aroundthese products, as long as you
(23:59):
don't overindulge.
And donut shop donuts, okay.
Well, that may be a little bitof a challenge, but I think if
you work on it, you can probablyorder a thin bagel with low-fat
cream cheese, and so even inplaces that don't necessarily
cater to healthy eaters, youusually can find something that
(24:19):
will be acceptable from acardiologist's viewpoint.
So I'm going to stop there, butyou guys were very impressive
on the questions and thank youvery much for your attention and
your interest in triglycerides.
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts.
Hosted by cardiologist and topmedical researcher, Dr.
Michael Koren.
Dr. Michael Koren (00:11):
Hello, I'm Dr .
Michael Koren, the executiveeditor of MedEvidence, and a
cardiologist, and from time totime I get questions that I've
heard enough times where I saidyou know what, let's sit down
and go over this with a coregroup of people to make sure
everybody understands it.
And here I am at JacksonvilleCenter for Clinical Research.
We run clinical trials here andI have several people in the
(00:33):
room who are employees ofJacksonville Center for Clinical
Research and they've beenasking me, Dr.
Koren, what the heck is atriglyceride?
We talk about it all the timebut I'm not really sure exactly
what it is.
So, with the help of SharonSmith, who is our editor I'm the
executive editor, but sheactually does the work, Sharon
Smith we are going to break downwhat is a triglyceride and get
(00:57):
to the truth about triglycerides.
So here we go.
So those of you that have seenour programs before know that we
like to ask questions.
We use the Socratic method oflearning, meaning that the
audience gets involved and weask them questions.
So the first question is wheredo you find the largest store of
triglycerides in the body?
Is it the liver?
(01:19):
Liver is involved in a lot ofthings, including the metabolism
of fats.
Is it the brain, is it theblood, is it the fat cells or
all of the above?
So I'm going to pick on anaudience member.
What would you say?
What would you guess, giventhose choices?
Audience (01:41):
I'm going to guess the blood.
Did you see these slides before?
I did not, but that's where we test for triglycerides.
Dr. Michael Koren (01:49):
All right.
Well, that was a great insightbecause most people would not
think in those terms.
But yes, the actual biggeststore of triglycerides are the
blood, and that tells you thatthese things are circulating and
our body needs a way toaccommodate that circulation,
because fat and water don't mixthe blood is mostly aqueous or
(02:11):
water and triglycerides are fat.
So in order for them to becompatible with each other,
there has to be some mechanismby which this happens, and we'll
talk more about that in asecond, 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 followingstatements is true about
(02:32):
triglycerides?
Is it elevated?
Triglycerides are associatedwith cardiovascular disease.
One in five US adults haveelevated triglycerides.
Our bodies use triglyceridesfor energy.
Diet has a major impact ontriglycerides, or all the above?
The floor is yours.
Audience (02:52):
Okay, I'm going to go with all the above.
Dr. Michael Koren (02:54):
All the above and you guys are good.
You guys are really really welltrained.
I'm very proud of you.
Audience (02:59):
I was questioning one in five US adults, but Okay.
Dr. Michael Koren (03:04):
All right, but you nailed it Very
impressive.
So let's jump in a little bitmore.
So triglycerides are a type offat in your blood that serves as
an energy source for the body.
Again, it's an energy source.
Triglycerides are composed ofthree fatty acid chains attached
to a glycerin molecule.
(03:30):
And so if you see, here in thismodel the glycerol is in the
red and the chains are thosegray parts of the molecule that
extend as tails.
There's different ways ofrepresenting that.
That is one of the ways they'reusually measured.
As part of a standard lipidprofile, our bodies convert
calories consumed in a meal thatwe don't use immediately into
triglycerides, and then they getstored ultimately in fat cells.
(03:51):
So actually, if you eat a lotof sugar, it eventually becomes
triglycerides and then, if youdon't use it as an energy source
, eventually it'll end up in thefat cells.
The liver is also part of that,by the way, so your liver also
stores of these things in theshort term, but for long-term
storage we use the fat cells.
Hormones regulate the releaseof triglycerides from fat tissue
(04:13):
so they can be used for energybetween meals.
So let's talk about thelikelihood of elevated
triglycerides, and this showsyou that if you are ages from
childhood to being older, and ifyou look at in the blue
non-Hispanic whites, in the redare non-Hispanic blacks and
(04:35):
green is Mexican-Americans, youcan see the likelihood of
developing triglycerides above150 milligrams per deciliter in
men and in women.
So you can see that people ofMexican-American heritage have
the highest risk of having hightriglycerides.
But actually people from alldifferent backgrounds have this
risk and even in the lowestcohort you're still looking at
(04:59):
rates of above 20% overall, withpeople in sort of their middle
years most likely to haveelevated triglycerides, probably
because they're still eatingrobustly and maybe their
activity is not quite as good asit was when they were younger.
So that's the epidemiology ofhigh triglycerides.
Hopefully that's clear.
(05:21):
So a question I get all the timeis how are triglycerides
different than cholesterol?
Well, they're both fats,they're both types of fats, but
they are very, very differentstructurally and in terms of how
our body metabolizes them.
They're both fatty substancesand we call them lipids.
So when you use the term lipids, it's not just LDL, cholesterol
or triglyceride, it's acombination of all these
(05:43):
different types of lipoproteins,combination of lipid and
protein, because that's howthese molecules circulate in our
bloodstream, as I mentioned fatand water don't mix.
So in order for these fats toget to different parts of our
body, they are associated withlipoproteins.
Hopefully that's clear.
Because these molecules cannotdissolve in blood, the body
(06:07):
packages them with proteins intolipoproteins, which transport
them throughout the body towhere they are needed.
So, reiterating that point.
Cholesterol serves as astructural component of cell
membranes and a precursor forhormone production.
That's very, very important.
So you can see here that in amore complex molecule, that this
(06:28):
would be something that'sstructural and that would be
something that we'd use forhormonal basis, whereas
something like triglycerides aresimpler molecules that are
there for quick energy.
I think we have a betterpicture of that in a different
slide.
This is a basic concept of thetriglyceride molecule.
(06:51):
Here you can see the glycerinbackbone and these are the fatty
acid chains.
Another way of looking at it.
We've looked at it in differentways.
We like to represent chemistryusing different types of models.
The models that you saw beforeare more realistic.
These are more cartoon-like butsometimes easier to understand.
(07:11):
So one of the things that comesup is what is a normal level of
triglycerides and other types ofblood fat.
So here you see the entire list.
So total cholesterol we'd liketo see it less than 200
milligrams per deciliter, but ifyou have had a heart attack we
may want it even lower than that.
Remember, all these things aresituational, depending on who
(07:31):
you are and what yourcircumstances are.
LDL most times LDL is notmeasured directly, but actually
calculated based on thecholesterol level, the HDL and
the triglycerides.
But that should ideally be lessthan 100.
But again, in people that areat very high risk for
complications, we get that downbelow 50.
With our new drugs we can getLDL cholesterol down to the 20s.
(07:53):
It's pretty remarkable, butagain, for the person that
doesn't have any heart disease,we want to see below 100.
Typically, HDL is the goodcholesterol, so that's the
lipoprotein molecule thatcirculates more favorably and
helps remove cholesterol fromthe circulation using a
favorable lipoprotein format.
And again, ideally we like tosee that above 60 milligrams per
(08:16):
deciliter.
But there's a lot of geneticvariation in that and that's
something that's very difficultto change with standard
medications or with physicalactivity.
Even so.
For example, people that aregenetically predisposed to heart
disease sometimes have a verylow level of HDL, and people who
are lucky enough to havegenetically high levels of HDL
(08:39):
seem to be somewhat protectedagainst cardiovascular
complications.
Triglycerides, as we mentioned,is the focus for today and
typically we considertriglycerides above 150
milligrams per deciliter to beelevated, to be increased.
But triglycerides are alsosomething that tends to vary
more with your dietary intake.
So it's important that when youhave your triglyceride level
(09:00):
measured, it should be a fastingmeasurement.
Cholesterol doesn't change thatmuch fasting or not, but
triglycerides do quite a bit,and LDL, especially the
calculated LDL, changes withfasting because part of the
calculation for LDL is to knowthe triglyceride level.
And then we have somethingcalled the non-HDL cholesterol,
which is a simple formula totalcholesterol minus HDL, and, if
(09:23):
you want to think about it, thisis all the different forms of
bad cholesterol.
And then, finally, somethingthat we talk about is what's
called the triglyceride to HDLratio.
So if that's particularly high,say more than three, that's
usually associated with theworst prognosis and ideally,
when we treat people,cardiologists love it when the
(09:44):
HDL and the LDL are the same.
So if you've had a heart attackand you needed a statin but you
still need additional help andwe put you on a PCSK9 inhibitor,
then we're happy to see thatthese two things work together
and got your LDL down to 30,because your HDL unfortunately
is only 30 genetically.
But we've accomplishedsomething by making those two
(10:05):
numbers the same and typicallywe want to see those
triglycerides below 100 inpeople who are actively treating
.
So what leads to hightriglycerides?
Here's your list.
One, excessive alcohol use.
Two, poorly controlled type 2diabetes.
Three, being overweight with aBMI of greater than 25.
(10:27):
Four, a diet high in sugar,saturated fat and simple
carbohydrates the standardAmerican diet probably is
something that leads to hightriglycerides.
Unfortunately, cigarettesmoking raises your
triglycerides.
Please don't do that.
Certain medications likediuretics, hormones,
corticosteroids, beta blockersand some HIV meds are known to
(10:48):
increase triglyceride levels.
So if you're on drugs or you'reconcerned about your
triglycerides, talk to yourphysician about the medicines
you're on to make sure thatthey're not contributing to your
problem.
Certain inflammatory diseasesare associated with high
triglycerides, such asrheumatoid arthritis.
And finally, thyroid, liver orkidney disease can be associated
with higher levels oftriglycerides.
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 alittle bit different, but in men
we like to see two drinks orless and women one drink or less
per day.
On average it's usually more ofa weekly tally because not
everybody drinks the exact sameamount each day.
But 14 drinks per week for aman is considered more than
enough, and seven drinks perweek for a woman is considered
(11:42):
more than enough.
And that's one ounce of alcohol.
So again, one shot of liquor orfour ounces of wine or eight
ounces of beer.
A little bit more preciseanswer than my first one.
Okay, which restaurant foodscause elevated triglycerides?
A (11:59):
red lobster fried shrimp.
B (12:02):
Pappy's Smokehouse barbecued drenched ribs?
We have no endorsement from anyof these companies, by the way,
you don't have to worry aboutthat.
C (12:10):
Miller's Alehouse beer.
D (12:13):
Dunkin' Donuts or E
Does anybody want to look atthat 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 welike to get into is what
combination of these numbers orthese lipid parameters are worse
than increase the risk forheart attacks?
So we have A (12:39):
a low LDL and a low HDL.
B (12:43):
high triglycerides and low HDL.
C (12:47):
low triglycerides and high HDL.
D (12:50):
high HDL and high LDL.
And E (12:54):
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.
Does anybody have anotheropinion?
We have an E.
Okay, so it looks like we havea split decision.
I'm going to go with B Okay, soit looks like we have a split
decision, but I'm going to gowith the Bs, I agree.
All right, good work.
So just to break this down LDLis the bad cholesterol we want
(13:29):
that low.
Hdl is the good cholesterol wewant that.
High Triglycerides accentuatethe problem.
So, whatever your situation is,high triglycerides make it
worse.
So think about it like that.
So having a high triglycerideand a low HDL is not a good
combination, and we call thatactually a metabolic
(13:51):
dyslipidemia.
And sometimes even people thatdon't have particularly high LDL
cholesterols have thiscombination of high
triglycerides and low HDL, andthat can be a very difficult
problem for cardiologists totreat.
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 isIn research and in clinical
(14:49):
practice, people come in who'vehad a history of a heart attack
and we focus on getting theirLDL cholesterol down, and we
often use the number 55, whichcomes from our guidelines.
And that number is based onclinical trials, including many
of the studies we've done righthere, to show that when we get
people below that level theyhave fewer heart attacks
compared to being above thatlevel.
So, the lower is better, and 55is generally considered a level
we can achieve in most patientsthat has been shown in study
after study to result in betteroutcomes.
And just going through the rest, low triglycerides and high HDL
is a good combination.
High HDL and high LDL is sortof opposite of each other, and
then I won't get into thenagging spouses issue, but
that's up to you guys to figureout.
Yes?
Announcer (15:08):
Would it be preferable if you had high LDL
or high triglycerides?
Obviously, the answer would beneither, but is one worse than
the other?
Dr. Michael Koren (15:20):
For coronary artery disease, high LDL would
be worse.
For pancreatitis, hightriglycerides would be worse.
Okay, so I think we're gettingtowards the end of this little
discussion and here's a nicepaper that came out recently
that talked about the residualrisk of high triglycerides and
(15:42):
that gets someone to thequestion that you just mentioned
.
So usually LDL is the firsttarget of treatment when
somebody's had a heart attackand we really focus on getting
that number down.
Nowadays we try to get ourpatients below that 55 level in
many cases.
So sometimes when we get thatLDL down where it belongs, we'll
add additional treatments tolower the triglycerides as our
(16:04):
secondary target.
So we can use something likefish oils or icosapent ethyl or
Fenofibrate to help get thatbelow that 150 or 100 mark, as
the case may be for thetriglycerides, And the
conclusion of this paper isresearch has identified a
significant association betweenhypertriglyceridemia again
(16:25):
defined as triglycerides above150, and non-coronary
arthrosclerosis and vascularinflammation in apparently
healthy persons with low tomoderate cardiovascular risk,
even in those people with normalLDL levels.
These data reinforce the roleof targeting triglycerides in
primary cardiovascular treatment.
So you mentioned the fact abouttreating a heart attack patient
(16:46):
.
That's secondary treatment, butwe happen to know that even
before you have a heart attack,there are people that we can
identify that have super highrisk.
They could have diabetes, theycould have a very strong family
history and those people we findit's important to look at the
triglycerides.
So how do you lower yourtriglycerides?
I got into some of this, butlet's reiterate these points
(17:07):
because they're so important.
One eat heart-healthy foods.
We were having a discussionbefore we got on camera that
processed foods are not whereyou want to go.
Simple sugars are not where youwant to go.
Too much alcohol is not whereyou want to go, but a
Mediterranean style diet withlean cuts of meat, a lot of
salads and minimize the oils,and the oils that you use, like
(17:29):
olive oil, are going to be morefavorable.
Oils that have omega-3 fattyacids in them are going to be
better.
So I personally eat fish as myprimary protein.
I probably eat some fishvirtually every day.
There's some controversy aboutwhether or not eating fish alone
should be a therapeutic optionfor people, but I happen to
follow that advice.
(17:49):
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.
If somebody didn't say you'regoing to increase your mercury
level
Dr. Michael Koren (18:09):
Yeah, I think your chances of dying of a
heart attack are way more thandying 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 didthis, our heart disease rates
in this country would drop by50%.
Simple advice, but hard to do,and please get into your
(18:34):
schedules.
Lose weight is a great thing.
We have more and more ways thatpeople are helped, either
through structured programs ofvery careful eating.
We know that if you reduce yourcalorie intake, you will lose
weight.
But of course, we have theGLP-1 phenomenon now, so there's
a lot of choices out there interms of how to get that weight
down.
Manage your blood sugar that'simportant.
So people that have these bigspikes in blood sugar are more
(18:54):
likely to binge eat or eatthings 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 bloodsugars you will also tend to run
high triglycerides.
Quit smoking and reduce youralcohol risk.
Some doctors think that youshould cut out alcohol
completely.
(19:15):
I don't subscribe to thatparticular philosophy.
I think that low doses ofalcohol or moderate alcohol use
is okay.
Audience (19:23):
What about nicotine, because
obviously now everything's goingto move from smoking to
nicotine.
Same thing Knock off thenicotine?
Dr. Michael Koren (19:31):
Nicotine is not as bad as smoking.
So when you burn tobacco, yourelease 3,000 different
chemicals, none of which aregood for you.
Nicotine is the thing thatmakes people feel good.
So if you're using a purenicotine product, I believe that
that's a much better choicethan smoking cigarettes.
Now, some people in the publichealth world may disagree with
(19:54):
that.
They think anything that'saddictive in that way is not
necessarily good for you.
But the data really support theidea that it's the 2,999 other
chemicals other than thenicotine that really do the
damage, and the nicotine is whatmakes you feel good.
So, again, if you could get offnicotine completely, that'd be
great, but if you're addicted tonicotine, I would strongly
(20:15):
advise you to use a nicotineproduct and not smoke.
LDL lowering drugs have modesteffects on triglycerides and
that's important to know.
So even if you're on a statindrug that has some effects on
triglycerides or PCSK9 agentthat has some effects on
triglycerides, they're not goingto touch it the way they work
against LDL cholesterol.
So very modest effects of thoseparticular products on the
(20:37):
triglycerides.
It's a separate category thatrequires a separate approach and
, as I mentioned, niacin,fibrates, omega-3 fatty acids
and ethyl esters have variableeffects, but these are all the
things that we tend to use whenwe say variable effects.
We can get your triglyceridelevel down anywhere between 20
and 50% with these things, butit's really hard to use
(20:59):
medicines to get it super low,whereas for LDL cholesterol, we
can now have the drugs to get itsuper low and I mentioned this
before icosapent ethyl orVascepa.
And there's a very, very nicestudy by Deepak Bhat, who's a
tremendous researcher that I'veworked with on a number of
occasions in the REDUCE-IT studyand I was a REDUCE-IT
(21:22):
investigator as part of thisstudy and we showed that this
product resulted in reducedcardiovascular events in
patients with known coronarydisease.
So shout out for that reallynice work.
All right,Question number four
alternatives to foods that raiseyour triglycerides.
A red lobster, fried shrimpwhat do you do as an alternative
(21:44):
?
Well, we like red lobster, wehave nothing against it, but
when you go there, order thetuna poke or a peel and eat
boiled shrimp, okay, so thereyou go.
So all these.
You know, nowadays in mostrestaurants there are choices
and so you can order the healthychoice.
It's available to you, and Ienjoy going out to eat and I
(22:06):
enjoy also looking at the menu,sometimes giving the waitstaff a
little bit of grief over theunhealthy options, but typically
you can find a healthy option.
Just focus on that and enjoythe meal.
So we're not trying to takethis experience away from
anybody and it's really not thathard once you get into that
mindset.
(22:26):
Ah the bearded pig.
Barbecued sauce, drenched ribsOkay, well, maybe order a filet
mignon without butter or asirloin 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 butteron your steak, more often than
not you will get it, and theperception is that people think
(22:47):
it makes it taste better, but Iactually think it takes
something away from the puretaste of the meat.
So I do indulge in fillets onoccasion and I always order for
my steak with no butter, andthat's easy to accommodate.
The chefs don't mind doing thatand you'll actually enjoy the
meat better, I would argue.
So try that and see, and let meknow if you like it.
(23:12):
Intuition Ale works.
Beer, order red wine or beer inmoderation.
Again, there's nothing wrongwith going to these
establishments.
It's fun.
Enjoy the company of yourfriends and family, but be
mindful of what you're drinkingand, instead of just taking one
shot after another, after afteranother, enjoy a nice IPA.
Look at the wine list and enjoysomething that may be a little
(23:35):
bit different than what youusually have.
Become knowledgeable about theworld of wine.
It's fascinating.
Wine is such a fascinating areaand there's so much to think
about in terms of the differentvarieties 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 aroundthese products, as long as you
(23:59):
don't overindulge.
And donut shop donuts, okay.
Well, that may be a little bitof a challenge, but I think if
you work on it, you can probablyorder a thin bagel with low-fat
cream cheese, and so even inplaces that don't necessarily
cater to healthy eaters, youusually can find something that
(24:19):
will be acceptable from acardiologist's viewpoint.
So I'm going to stop there, butyou guys were very impressive
on the questions and thank youvery much for your attention and
your interest in triglycerides.
Popular Podcasts
My Favorite Murder with Karen Kilgariff and Georgia Hardstark
My Favorite Murder is a true crime comedy podcast hosted by Karen Kilgariff and Georgia Hardstark. Each week, Karen and Georgia share compelling true crimes and hometown stories from friends and listeners. Since MFM launched in January of 2016, Karen and Georgia have shared their lifelong interest in true crime and have covered stories of infamous serial killers like the Night Stalker, mysterious cold cases, captivating cults, incredible survivor stories and important events from history like the Tulsa race massacre of 1921. My Favorite Murder is part of the Exactly Right podcast network that provides a platform for bold, creative voices to bring to life provocative, entertaining and relatable stories for audiences everywhere. The Exactly Right roster of podcasts covers a variety of topics including historic true crime, comedic interviews and news, science, pop culture and more. Podcasts on the network include Buried Bones with Kate Winkler Dawson and Paul Holes, That's Messed Up: An SVU Podcast, This Podcast Will Kill You, Bananas and more.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com