Letters to the Editor

Managing Hypertriglyceridemia with Diet Modifications



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Am Fam Physician. 2008 Feb 15;77(4):417-418.

to the editor: In the article, “Management of Hypertriglyceridemia,” the authors cover the various medical treatment options for hypertriglyceridemia.1 They briefly mention the importance of weight control as an initial consideration and recommend a very low-fat diet for patients with very high triglyceride levels. However, they did not consider results of the latest studies validating carbohydrate-controlled dieting in the treatment of hypertriglyceridemia and low levels of high-density lipoprotein (HDL) cholesterol.

Since the publication of the National Cholesterol Education Program (NCEP) final report in 2002, there have been six quality randomized controlled trials published showing the superiority of carbohydrate-controlled dieting over low-fat dieting in the management of triglyceride levels.26 In head-to-head comparisons with low-fat diet groups, carbohydrate-controlled groups consistently resulted in equal or superior weight loss. The carbohydrate-controlled dieters consistently showed an improvement in triglyceride and HDL cholesterol levels above the improvement seen in low-fat dieters, independent of achieved weight loss. The positive impact of carbohydrate-controlled dieting on lowering triglyceride levels in high-risk patients is often underestimated and not emphasized in practice.

Author disclosure: Nothing to disclose.

REFERENCES

1. Oh RC, Lanier JB. Management of hypertriglyceridemia. Am Fam Physician. 2007;75(9):1365–1371.

2. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003;348(210):2074–2081.

3. Aude YW, Agatston AS, Lopez-Jimenez F, et al. The National Cholesterol Education Program Diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat: a randomized trial. Arch Intern Med. 2004;164(19):2141–2146.

4. Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007;297(9):969–977.

5. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med. 2004;140(10):778–785.

6. Pereira MA, Swain J, Goldfine AB, Rifai N, Ludwig DS. Effects of a low-glycemic load diet on resting energy expenditure and heart disease risk factors during weight loss. JAMA. 2004;292(20):2482–2490.

in reply: We appreciate the comments regarding our article.1 With regards to our recommendations for the treatment of hypertriglyceridemia using statins, Dr. Raghavan suggests that fibrates, niacin, or fish oil should play a more prominent role. We agree with his comments about the pharmacotherapy of patients with very high levels of serum triglycerides (at least 500 mg per dL [5.65 mmol per L]), which is supported in our article. However, for patients with lower degrees of triglyceride elevation (between 200 and 499 mg per dL [2.26 to 5.64 mmol per L]) the current treatment guidelines emphasize low-density lipoprotein (LDL)-cholesterol as the main target of therapy, followed by non-high-density lipoprotein cholesterol.1 The overwhelming literature on the benefit of statins recommends it as a first-line option in patients with no contraindications who are at moderate to high cardiovascular risk and have elevated LDL cholesterol levels.

Dr. Raghavan also purports that our algorithm is misleading. We agree that most patients with severe hypertriglyceridemia (at least 1,000 mg per dL [11.30 mmol per L]) will require medication with lifestyle modifications to reduce the risk of pancreatitis. However, the National Cholesterol Education Program (NCEP) guidelines recommend that all patients immediately start on a very low-fat diet and that the patients' medical history be reviewed by the physician for any evidence of acquired or secondary causes of hypertriglyceridemia.2 Many medications may elevate triglyceride levels, and insulin or oral hypoglycemics may adequately control hypertriglyceridemia. Although these interventions may not completely normalize triglyceride levels, even those with severe hypertriglyceridemia can significantly reduce levels to less than 500 mg per dL with dietary interventions alone.3 Close follow-up is required, and pharmacotherapy should be initiated if dietary and lifestyle measures do not adequately lower triglycerides. However, we agree that the algorithm in our article may inadvertently de-emphasize the importance of drug therapy and we have made modifications accordingly (see accompanying revised Figure 1).

Management of Hypertriglyceridemia

Figure 1.

Algorithm for the management of hypertriglyceridemia. (LDL-C= low-density lipoprotein cholesterol; HDL-C= high-density lipoprotein cholesterol.)

Information from reference 2.

View Large

Management of Hypertriglyceridemia


Figure 1.

Algorithm for the management of hypertriglyceridemia. (LDL-C= low-density lipoprotein cholesterol; HDL-C= high-density lipoprotein cholesterol.)

Information from reference 2.

Management of Hypertriglyceridemia


Figure 1.

Algorithm for the management of hypertriglyceridemia. (LDL-C= low-density lipoprotein cholesterol; HDL-C= high-density lipoprotein cholesterol.)

Information from reference 2.

Dr. Virji suggests that patients with hypertriglyceridemia may benefit from a carbohydrate-controlled diet. Two of the articles he cites involve severely obese patients randomized to carbohydrate-controlled diets or more traditionally recommended low-fat diets.45 Patients randomized to the low-fat diet, on average, failed to significantly alter their diets to reach the NCEP recommended goal of less than 30 percent of daily calories from fat.45 Another article compared patients in various dietary programs, but did not directly compare carbohydrate-controlled diets with a low-fat diet.6 Only one of these trials had a randomized group with hypertriglyceridemia at baseline (defined as greater than 200 mg per dL).4 Research suggests that the response to low-fat versus carbohydrate-controlled diets varies with the degree of hypertriglyceridemia, such that patients with lower degrees of triglyceride elevation respond more to a carbohydrate-controlled diet, whereas patients with more pronounced triglyceride elevations respond more to a low-fat diet.2 A low-carbohydrate approach in the management of hypertriglyceridemia in certain patient populations is promising and should be studied further. Dietary counseling should always be individualized, and consultation with a certified nutritionist may improve adherence to lifelong dietary changes.

Author disclosure: Dr. Lanier has nothing to disclose. Dr. Oh purchased stocks with Pfizer Pharmaceuticals, Inc., the manufacturer of Lipitor; Merck and Co., the manufacturer of Zocor; and Teva Neuroscience, Inc., after submitting his article “Management of Hypertriglyceridemia,” to AFP but prior to the publication of this letter.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army or the U.S. Army Service at large.

REFERENCES

1. Oh RC, Lanier JB. Management of hypertriglyceridemia. Am Fam Physician. 2007;75(9):1365–1371.

2. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. NIH publication no.: 02-5215. Bethesda, Md.: National Heart, Lung, and Blood Institute, 2002.

3. Jacobs B, De Angelis-Schierbaum G, Egert S, Assmann G, Kratz M. Individual serum triglyceride responses to high-fat and low-fat diets differ in men with modest and severe hypertriglyceridemia. J Nutr. 2004;134(6):1400–1405.

4. Samaha FF, Iqbal N, Seshadri P, et al. A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med. 2003;348(21):2074–2081.

5. Stern L, Iqbal N, Seshadri P, et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med. 2004;140(10):778–785.

6. Gardner CD, Kiazand A, Alhassan S, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007;297(9):969–977.

editor's note: The editors of American Family Physician (AFP) would like to use the opportunity presented by Dr. Oh's financial disclosure to clarify our policy regarding author conflicts of interest. AFP does not consider papers that are sponsored directly or indirectly by a pharmaceutical company, public relations firm, or other commercial entity. We also strongly prefer that authors do not have a financial interest in or arrangement with any organization with a direct interest in the subject of the submitted article. Authors who develop new financial interests in or arrangements with a relevant organization after completing our Author Disclosure form and submitting their manuscripts, but prior to the publication of that article, are asked to update their disclosure form and send it to our editorial office in Washington, D.C. The editors of American Family Physician carefully review changes in such affiliations to determine what actions are appropriate to resolve new conflicts of interest.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

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