Dietary advice for management of high triglycerides

This leaflet is for people with elevated triglycerides who have been advised to make dietary changes to try and reduce these. The aim of this diet sheet is to provide information about what triglycerides are and the dietary and lifestyle changes that can be made to help reduce these.

What are triglycerides?

Triglycerides are a type of fat. They are the major storage form of fats and a key source of energy in the diet. They are found in foods that we eat, for example in meat, dairy products and cooking oils. During digestion, triglycerides are absorbed in the intestines andtransported in the bloodstream to the tissues where they are either taken up by cells and used to provide energy, or stored as fat. As well as absorbing triglycerides from the diet, many tissues also have the ability to synthesise triglycerides, including the liver, gut, muscle and adipose tissues.

Any excess calories in our diet are converted to triglycerides by the liver, and stored in our fat (adipose) cells until required. Hormones regulate the release of triglycerides from fat cells to be used as energy when needed.

If you have lipodystrophy, your ability to store fat is different to the general population and you may have very little or no fat storage. This means that any excess energy from foods which gets converted to triglycerides will not have a place to be stored. These triglycerides will therefore stay in your bloodstream or be stored inappropriately within your organs (such as your liver / pancreas) and muscles.

Very high levels of triglycerides in the blood can cause problems such as inflammation of the pancreas (pancreatitis). This can be a very serious condition, causing a lot of pain and admission to hospital. High levels of triglycerides can also increase the risk of coronary heart disease. Having high levels of triglycerides can be accompanied by changes in blood clotting mechanisms, including abnormalities in clotting factors and in the mechanisms involved in breaking down blood clots.

What are the guidelines for triglyceride levels?

The current guidance for triglyceride levels in adults is to aim for a blood triglyceride level of less than 1.7mmol/l. A fasting level above 10mmol/l is classed as severe hypertriglyceridemia (severe high triglycerides).

Your triglyceride level is . . . . . . . . . . . . . . . . . .

When do raised triglycerides occur?

The level of triglycerides in the bloodstream rises following a meal. The amount of fat consumed will determine the rise in triglyceride levels. In order to avoid rises in circulating triglyceride levels, it is advisable to spread intake of dietary fat throughout the day. Triglycerides can be raised as a secondary effect of conditions such as poorly controlled diabetes or obesity. Controlling these can often result in lowering of triglyceride levels. Obesity exacerbates all forms of high triglycerides.

How can triglycerides be lowered?

If you have high triglycerides, making changes to your diet and lifestyle can help to reduce these.

Diet and lifestyle recommendations

1. Follow a diet low in fat, with less than 30% of daily calories from total fat. Choose polyunsaturated fats over saturated fats
2. Include oily fish two to three times per week within your fat allowance as these contain omega 3 fatty acids which can have a beneficial effect on triglyceride levels
3. Reduce consumption of high-sugar food and drinks, and choose unrefined carbohydrate sources such as higher fibre breads and cereals
4. Limit or abstain from alcohol
5. Lose weight if overweight
6. Participate in regular physical activity
7. If you have diabetes, aim for good blood glucose control

People who have high triglycerides may also require medications as well as diet and lifestyle modifications. You can discuss this further with your medical team.

If you have severely high triglycerides (above 10mmol/l) then you will be advised to reduce all types of fat, aiming for less than 25g fat per day. Further information on this is at the end of this diet sheet (section 8).

Dietary and lifestyle recommendations

1) Follow a diet low in fat, with less than 30% of daily calories from total fat. Choose polyunsaturated fats over saturated fat:

An example of someone eating a 1500Kcal diet and aiming for less than 30% fat would be less than 50 grams of fat per day. If your triglycerides do not reduce with this, then you may need to aim for less. You will see a dietitian who will discuss this with you.

Grams of fat to aim for: . . . . . . . . . . . . .grams per day.

Fat should be spread out throughout the day, rather than all eaten at one mealtime. Just one large, fatty meal can increase your risk of developing pancreatitis (inflamed pancreas). A meal should not contain more than 15g of fat at one time.

If your triglycerides are severely raised then it will be suggested that you follow a very strict low fat diet (less than 25g of fat per day) to bring the levels down as quickly as possible (further information on this can be found at the bottom of this leaflet).

How do you know how much fat is in foods?

Fat is found in many different foods and drinks for example dairy products, meats, oils, nuts and cakes.

If you have a packaged food then reading the food label is the best way to identify how much fat it contains. When you look at the back of a food label, the nutritional information is often given on a table similar to below. Food labels provide information about many different nutrients found in foods including the amount of fat.

The information is generally given both per 100g of the food and per portion / serving size. If comparing two products it is better to look per 100g of a food as this allows you to compare between products that may give different portion sizes. Be aware that the portion size listed on the package may be different to the portion size that you will eat and so you will have to scale the nutritional information up or down accordingly.

Food labels may be colour coded with a traffic light system to give you an idea of whether a food is high or low in a nutrient. Green would indicate a food is low in a nutrient, amber: medium in a nutrient or red: high in a nutrient.

When looking at food labels per 100g you should aim for:

• Less than 3g of fat per 100g of the food – this is a low fat product
• A medium fat product would contain 3.1-17.4g fat per 100g
• A high fat product would contain over 17.5g fat per 100g

Try and choose low fat options the majority of the time. Choose medium fat products only occasionally and aim to avoid high fat products where possible.

Tips to reduce fat in the diet

• Try steaming, poaching, boiling or grilling instead of roasting and frying. If you do fry, use a non-stick pan and you may not need to use any fat or oil at all. Spray oils are a good way of reducing the amount of fat needed.
• Buy lean meats and avoid processed meats (e.g. sausages and bacon). Take the skin off poultry and remove visible fat from the meat before you start cooking.
• Use low-fat / fat-free products where available e.g. skimmed rather than semi-skimmed or whole milk; 0% fat yoghurts, low-fat spreads rather than margarine or butter (however be careful not be tempted to put on more because it’s lower in fat).
• Avoid all cheese with the exception of extra low fat cream cheese and cottage cheese. There is also a 3% fat hard cheese (EatLean) available in supermarkets which can be used.
• Avoid or choose much smaller portion sizes of fatty foods such as crisps, nuts, pastry, cakes, biscuits, cream, tinned meats, Yorkshire puddings, dumplings and gravy made with meat juices.
• When having potatoes choose boiled, mashed (without butter) or jacket rather than roast or chipped.

For low fat recipe ideas please see the Heart UK website (opens in a new tab).

Choose those recipes with less than 15g fat per portion – you can reduce the fat content of recipes further by omitting oil or fats during cooking.

If you do not have internet access please ask your dietitian for more information.

2) Omega-3 fatty acids

Omega-3 fatty acids, which are found in fish oils, can have a beneficial effect on reducing triglyceride levels.

Despite reducing the fat content of your diet significantly, it is important that you do get some essential fats in your diet so including oily fish two to three times a week can help with this. It is suggested to incorporate oily fish that are lower in fat than others, for example trout and pilchards compared to herring or mackerel. Please see the table below for more information on the fat content of different oily fish. As previously mentioned, your daily fat content should be spread throughout the day with less than 15g at a time, therefore you may not be able to consume this all in one go - having half portions and incorporating it into dishes low in fat like pasta/salads/sandwiches is best.

What about Omega-3 supplements?

If your triglycerides are very high you may be may be asked to take an Omega 3 supplement. For more information speak with your medical team regarding whether this is appropriate for you. Do not start taking supplements without discussing this with your medical team / GP first.

3) Reduce consumption of high-sugar food and drinks and choose unrefined carbohydrate sources

Carbohydrate containing foods are broken down by the body to glucose (a simple form of sugar). Glucose is then used for energy by the body. Excess glucose can also be converted to triglycerides for storage in fat cells.

Different carbohydrate containing foods are broken down at different rates. Those carbohydrates which are broken down very rapidly by the body (refined carbohydrates), and those foods high in sugar, can contribute to higher levels of triglycerides and therefore it is advised to reduce consumption of these foods. The table below gives information on those refined carbohydrate sources to avoid, and the unrefined carbohydrate choices to choose instead.

Top Tips for cutting down on sugar

• Choose ‘diet’, no added sugar or unsweetened versions of fizzy drinks, squashes and fruit juices.
• Try swapping a high sugar cereal for one that is lower in sugar such as porridge, whole-wheat cereal biscuits or wholegrain cereals.
• Watch out for dishes that are high in sugar: sweet and sour dishes, sweet chilli dishes and some curry sauces and salad dressings.
• Reduce consumption of biscuits, cakes, chocolate and sweets.
• Instead of adding sugar/honey to hot drinks, use artificial sweeteners or allow your taste buds to adapt to the taste of drinks without sugar.
• Choose sugar-free gum or mints instead of the regular versions.
• Snack on whole fruit instead fruit juices
• Try sugar-free jellies and reduced sugar puddings instead of their regular versions.
• Look at food labels to choose foods low in sugar: a low sugar product will contain less than 5g sugar per 100g.

4) Alcohol

Alcohol is a common cause of elevated triglycerides and can exacerbate existing high triglyceride levels. The type of alcohol doesn’t seem to matter: beers, wines and spirits all have the same effect on raising triglyceride levels. Complete alcohol avoidance for a month can result in a significant reduction in triglyceride levels.

For people who are sensitive, even a small amount of alcohol can trigger elevated triglycerides. It is therefore strongly recommended to reduce consumption to less than 1-2 units of alcohol per day (1 unit = ½ pint beer, 100ml wine, 25ml of spirit), or ideally eliminate alcohol completely. If you have severe hypertriglyceridaemia (levels above 10mmol/l) you will be advised to avoid all alcohol.

5) Weight loss

Weight loss has a beneficial effect on many metabolic risk factors including reducing triglyceride levels. If you are overweight then aiming initially for losing 5-10% of your body weight can lead to a significant reduction in triglyceride levels. If you have lipodystrophy, then even though you may not appear overweight, it is very important not to overeat, as any extra energy consumed will be converted to triglycerides and stored within the organs and muscles.

Tips for achieving weight loss

• Aim to reduce portion sizes e.g. you could try initially reducing by a third. This reduces energy intake to help achieve weight loss.
• Eat regularly – skipping meals is a false economy. When you eat three meals a day you are less likely to feel hungry and less tempted to eat unsuitable snacks between meals.
• Plan ahead – have healthy snacks ready in the fridge and place them at the front so you see them first. Try and avoid having unhealthy options in the house.
• Shop ahead so you have the ingredients to make your healthy meals.
• Eat slowly and give the food your full attention – do not eat in front of the TV. Sit down to eat and focus on what you are doing – food should be enjoyed, not rushed.
• Do not feel guilty after eating. It will make you feel worse and set you back on reaching your goals.
• Stop eating when you’re full.
• Wait for 30-60 minutes after a meal to eat your dessert. You may find that you no longer want this.
• Shop on a full stomach only and take a shopping list with you that you stick to.
• Remember the calories you take from drinks. Try to always have low fat or sugar free drinks.
• Treat yourself with no food related treats!

For more support with losing weight please speak further to your dietitian. If you are struggling with motivation, some people also find group support such as weight loss groups e.g. Weight watchers / Slimming world / Rosemary Conley useful. You can also speak with your GP about NHS weight loss support services within your local area.

6) Increase physical activity

Having a low level of physical activity is associated with high triglycerides levels; therefore increasing physical activity is key to help reduce these.

What are the recommendations?

It is recommended that we all do a minimum of 150 minutes every week (30 minutes on five days a week) of moderate intensity physical activity. Moderate-intensity physical activity means you should be exercising hard enough to feel your heart rate increase and break into a sweat, but you should still feel comfortable enough to maintain a conversation while doing the activity. Examples of good aerobic activities include brisk walking, swimming and cycling.

Exercise does not need to take up hours of your time or mean that you have to buy lots of expensive equipment or clothing. If you don’t attend a gym already or play a sport then think about increasing your walking. Walking should not be underestimated as a way to improve fitness. It is a great all round exercise and can be completed at any time of the day.

Although 30 minutes a day may be too much when starting out, this can be broken down into three 10 minute sessions during the day. If you are already managing the 150 minutes per week already, then increasing the duration will give added benefits.

It is also recommended that adults should do physical activities that strengthen muscles at least twice a week. This should involve using all the major muscle groups, for example, carrying and lifting, using weights or resistance bands.

Ways to increase your activity levels

• Walk while on the phone (most phones are mobile now). If you know the call will last more than 10 or 15 minutes, walk while you talk!
• Aim to walk locally, for example, to the shops or get off the bus a stop early or park a little further away from where you need to be.
• Build a walk into your lunch break.
• If you are watching television, get up and walk around, or up and down the stairs during the advert breaks.
• If you’re bored at home or feel fed up, a walk will give you fresh air and help keep you busy.
• Go for a walk with friends – walk and talk rather than meeting in a pub or café.
• Walk or cycle to work if possible.
• Join a gym, or find an exercise buddy to help motivate you.
• If you find the weather a barrier to exercise, consider indoor activities such as exercise DVDs, online exercise classes or home exercises. Ask your Dietitian for a sheet on home-based activities for more ideas.
• Set yourself activity goals / targets as these can help ensure you stay motivated.
• Enjoy it! If you enjoy an activity you are much more likely to stick to it in the long run.

Orlistat (Xenical)

Orlistat (Xenical) is a drug used to induce and maintain weight loss. Orlistat blocks the enzymes (chemicals) secreted by your stomach and intestines that break down fat in your food allowing it to be absorbed into the body. This means that about one third of the fat in your food will not be absorbed. As Orlistat causes a reduction in fat absorption, it may also help reduce triglyceride levels.

Discuss with your dietitian or medical team whether or not Orlistat may be a beneficial option for you to try.

7) Diabetes

In poorly controlled diabetes, high triglycerides are likely. If you have diabetes then aiming for good glycaemic control may improve your triglyceride levels. If you would like support with managing your diabetes then speak with your dietitian or diabetes specialist nurse.

8) Severe hypertriglyceridaemia

If your triglycerides are very high it may be suggested that you follow a triglyceride rescue diet for a short period of 2 weeks. This involves reducing total fat in the diet to less than 25g per day. You will be asked to get your triglycerides re-checked after one week on this diet to see whether these are improving as required.

25g fat / day TRIGLYCERIDE CONTROL DIET

Indications

Severe hypertriglyceridaemia.

You can adapt your own diet to provide less than 25g per day of fat if you are confident with this. The fat should be spread throughout the day. Otherwise please see below for some ideas or speak with your dietitian. If you are hungry, try increasing the lean protein content of the diet.

Daily allowances

Dairy, fat-free: 3 servings
Carbohydrate: 9-10 servings
Fruit: 3-4 servings
Proteins (lean): 5-6 servings
Fat: 0 servings

Contacts and further information

For more information please contact the Severe Insulin Resistance Team:
Dietitian: 01223 216655
Office: 01223 768625

References and sources of evidence

American Heart Association: 2011. AHA Scientific Statement: Triglycerides and Cardiovascular Disease. Circulation; 123: pp. 2292-2333
Durrington, P. 2007. Hyperlipidaemia: Diagnosis and management. Third Edition.
Published by Hodder Arnold.
European Society of Cardiology/European Atherosclerosis Society. 2011. Guidelines for the management of dyslipidaemias. Atherosclerosis. 217:1, pp. 3–46
Heart UK: Triglycerides (opens in a new tab)
NHS website (opens in a new tab)