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🎙Truth About Triglycerides Ep 219

• Dr. Michael Koren • Episode 219

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What if understanding cholesterol and triglycerides could dramatically improve your health? This episode is a thorough and in-depth discussion where Dr. Michael Koren sheds light on the intricate relationship between genetics, diet, and lipid levels across different ethnic groups. We'll explore why non-Hispanic whites and Mexican Americans are more prone to high triglycerides than non-Hispanic blacks and dive into the liver's pivotal role in lipid metabolism. Learn the significance of managing LDL cholesterol for high-risk patients and get insights into the ongoing challenges of raising HDL levels and the latest advancements in medications.

From practical strategies to lower cholesterol and triglycerides to understanding the impact of fasting for accurate measurements, this episode covers it all. Discover how lifestyle choices, diet, and even the timing of your blood tests can affect your lipid profile. We also delve into the benefits of fish oil and new pharmacological treatments like statins and PCSK9 inhibitors. Equip yourself with the knowledge to make informed health decisions and improve your cardiovascular well-being.

Talking Topics:

  • Understanding Cholesterol and Triglycerides
  • Lipids, Genetics, and Health Insights
  • Lowering Cholesterol and Triglycerides Accessibly
  • Understanding Triglycerides and Diet Impact
  • Triglycerides, HDL, and Heart Health
  • Omega-3s Impact on Triglycerides


This episode is a rebroadcast of a live event hosted at ENCORE Research Group on July 15, 2024.

Be a part of advancing science by participating in clinical research.

Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Music: Storyblocks - Corporate Inspired

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Announcer:

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts. Hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren:

We're going to talk today about the truth about triglycerides. So the first thing I want to get a sense for from the audience is what you feel you know about the concept of lipids. Who's heard the word lipids before? Okay, who feels like they understand what cholesterol is? Who feels they understand what triglycerides are? One, okay, two, okay, so that's it. Maybe three. I want to talk to you a little bit about understanding things, and this gets into exactly the question you've addressed or that you've brought up. That I will address, and let's use an example of traffic rules, rules of traffic.

Dr. Michael Koren:

Everybody here probably drives or has experience with driving. So does the red light make sense all the time? Is it relevant all the time? So if you're in a dark street and there's a red light and there's no traffic for miles and miles and miles it's two o'clock in the morning you get to stop at the red light, usually because you understand why it's there, what the concept is and why it's there and you're respecting the concept. Does it mean that that red light is saving your life?

Dr. Michael Koren:

at that point? No, but in general it does. Red lights or traffic lights help us and provide public health benefits. Of course, now, people don't have that same intrinsic understanding for a lot of things in medicine, and one of the things that I'm trying to help people understand is that the rules of medicine and the information about medicine is similar to other parts of our lives, that the more you understand it, the more it makes sense, and the more you understand it, the more you make good decisions for yourself and your family, because at the end of the day, what matters is making good decisions, right? Okay, so with that in mind, we're going to get into what is cholesterol, what is triglycerides and what are these rules and ultimately, how we transmit this information and make decisions. And again, it's up to you if you want to bring up individual cases, but I'll address the issue that this gentleman brought up and also get into more individual cases.

Dr. Michael Koren:

So we do have a nice presentation here. So first, my staff Sharon Smith, who came up and introduced me, is the head of our efforts to get people involved in clinical research. Just so you know, we have been very involved in developing a lot of new medications for cholesterol and triglycerides to some degree, and Sharon is part of bringing you folks in so you can understand whether or not these type of programs would be something you might want to get interested in. So that's one of the reasons we have this educational event. At the end of the day, we're happy if everybody learns more about the area and just talks about the scientific elements of what we do and, ultimately, why we're making progress in medicine because of these scientific methods. So she showed a nice picture of our typical American diet, which, of course, is the type of thing that leads to both elevation in cholesterol and triglycerides, and I'll explain both the genetics and the dietary elements of this. But that's a good place to start. So what we like to do here is to, one, assess your knowledge base, but also get you familiar with the terminology that we're using. A lot of things in medicine and science is about terminology and how to understand that.

Dr. Michael Koren:

So here's our first audience trivia question. The other thing I'd like to tell everybody is there's no such thing as a free lunch. You are enjoying eating this food. You're gonna have to work for it and we're gonna give you some quiz questions, and this is part of working for your food for your meal. The first audience question is where do you find the largest store of triglycerides in the body? Here's your choices the liver, the brain, the blood, the fat cells or all of the above? All of the above? Well, that's always a safe answer, but it happens to not be the correct answer. The correct answer is actually the blood. So that's something that's actually fundamentally different between triglycerides and cholesterol. We'll be talking more about that. This is the second trivia question.

Dr. Michael Koren:

Which of the following statements is true about triglycerides? Elevated triglycerides are associated with cardiovascular disease. One in five US adults has elevated triglycerides. Elevated triglycerides are associated with cardiovascular disease. One in five US adults has elevated triglycerides. Our bodies use triglycerides for energy. Diet has a major impact on triglycerides, or all of the above? Now, it's all of the above, all right. So there we go. So those are good starting points.

Dr. Michael Koren:

So now let's really break down what triglycerides are. So triglycerides and cholesterol are both forms of fat, and they're both forms of fat that our body needs. And this is the confusing part for people is that cholesterol is bad and triglycerides are bad. They're bad if you have too much of them. You actually need these things for the body to function. But the way your body uses these things is fundamentally different between triglycerides and cholesterol, and therein lies the details that are so important. So triglycerides are a type of fat in your blood that serves as an energy source. So triglycerides is an energy source, whereas cholesterol is a structural component of your body.

Dr. Michael Koren:

Cholesterol is very important to every cell in your body. Every cell in your body has cholesterol in it, and every cell in your body, except for your eyelashes, can make cholesterol. Think about that. Every cell, your skin cells, your gut cells, every cell in your body can make cholesterol. And what's confusing for people is the cholesterol in your bloodstream is the extra stuff that your body's trying to get rid of, because your body is constantly making it.

Dr. Michael Koren:

So that gets to your question, sir. You were saying is it genetic? Well, your body is always making cholesterol. So, from a cholesterol standpoint, dietary cholesterol is not necessarily what's the biggest impact when we measure our cholesterol levels. Now, of course, some people overdo it, but in fact, every cell in the body makes cholesterol and every cell in the body pumps cholesterol into the circulation. So what you eat doesn't necessarily have to be a huge amount of that. So that's the partial answer to your question. We'll get to more of that. The structural elements of triglycerides are shown here. There's different ways. I don't know who took a chemistry course in high school or college but if you remember these are structural diagrams and I was a chemistry major so happen to like these kind of things. But triglyceride is a molecule that has a backbone of three carbons called glycerol, and then glycerol has what's called fatty acid chains and in the fatty acid chain is actually the energy.

Dr. Michael Koren:

So the way your body stores this, in the bloodstream in the short run is having this glycerol molecule with these fatty acids, and fatty acids have a big impact in terms of inflammation of the body and hardening of the arteries, which we'll get to in a second. But that's the basic structure of triglycerides. The other part of this is that there's about a third of the people who said they kind of understood cholesterol, whereas very few understand triglycerides. But they're actually both part of the standard lipid test that your doctors do. So when you get your lipid test, they tell you your total cholesterol, they tell you your HDL very good cholesterol and the triglycerides, and usually they calculate the LDL based on an equation called the Friedewald equation that looks at LDL based on these other components. So, even though triglycerides aren't necessarily the focus in most of your interactions with physicians, it's actually measured very routinely.

Dr. Michael Koren:

I can guarantee you, everybody in this room has had their triglycerides measured in their life and we'll get more into that in a second. So, as I mentioned, our bodies convert calories from a meal that we don't use immediately into triglycerides because it's an energy store. So again to your question triglycerides are much more determined by your diet than cholesterol, because triglycerides by their very nature is food substances that come into our body that get turned into a fat. So we have a ready access to that energy source.

Dr. Michael Koren:

Now there are genetic elements to the way you metabolize triglycerides. But triglycerides, much more than cholesterol, is determined by diet. And that's a common confusion because people say, oh, genetically, I have high cholesterol. Well, that is true for a lot of people, but triglycerides are less likely to be genetic and much more likely to be related to lifestyle and diet. So that's a distinction. And the other thing is that hormones regulate the release of triglycerides from fat tissues so they can be used from energy between meals. So this gets into a lot of really interesting science. People have heard of Ozempic and Mounjaro and all these sorts of things. Well, we now learn that there's a very complex pattern of hormones that tell our body when we need energy, when we need glucose, when we need other things, and this communication is now something that we can change using pharmaceuticals. And a lot of the research that's going on that's helping literally millions of people is based on this understanding of how these different hormones interact in our body and regulate our energy sources and regulate how we store fat and regulate our appetite. All these things are a complex series of chemical reactions that we now understand better and we can help people.

Dr. Michael Koren:

So we always like to talk about genetics, and one of the easy ways to talk about genetics is looking at different patient profiles and seeing if you're more or less likely to develop problems. So, interestingly, when you look at triglycerides, there tends to be more problem in non-Hispanic whites and non-Hispanic blacks. Actually, non-hispanic whites and Mexican Americans, non-hispanic blacks, actually have a lower risk of having high triglycerides. That's interesting. South Asian populations also have higher levels of triglycerides. So again, this gets into some of the genetics that you mentioned. But it's also the way diet interacts with genetics. So people are more or less prone to having problems with their diet when it comes to triglycerides. But in this case, black patients did have lower risk of triglycerides doesn't mean that black patients don't have triglyceride issues, it's just overall, statistically, there's a lower likelihood.

Dr. Michael Koren:

How are triglycerides different than cholesterol? So here's our picture of the two. So you can see here that it shows the similarities and differences of this and cholesterol. You might have seen it looks like a steroid molecule with four benzene ring type things. That is a structural component. So those are differences.

Dr. Michael Koren:

If you're interested in chemistry, I know that's beyond the scope of most people, but I find that interesting and these are the key things for the audience here is that both molecules are fatty substances called lipids. Both can't mix in the bloodstream because fats and liquids don't mix. We know that fats and waters don't mix, so because of that, they have to be in these molecules called lipoproteins, which are a combination of fat and protein that allows a fat to circulate in the bloodstream without coagulating. Right, that makes sense. Everybody. You can't put fat and water together and it won't mix. Well, lipoproteins allow fats and liquids water particularly to mix, and these lipoproteins help move these particles in and out of different places.

Dr. Michael Koren:

So somebody mentioned the liver, which is very important for lipid metabolism. So in our liver we have something called the LDL receptor, which is the low-density lipoprotein receptor, which is the main way your body gets rid of cholesterol. So what your body does is all this extra cholesterol that's in your circulation that you need to get rid of goes through the liver, it's attracted by the LDL receptor and then it goes into your stool. And that's the way we use a lot of medicines to help people. They actually help that liver pull LDL cholesterol out of the body. We don't have a similar drug for triglycerides. We don't have a similar drug that helps the liver get rid of triglycerides, so we have to use other mechanisms to do that, and that's the interesting part. As I mentioned before, cholesterol is a structural molecule for cell-numbed brains and hormones, whereas triglycerides are an energy source.

Dr. Michael Koren:

So if there's one take-home lesson for today about the difference between triglycerides and cholesterol. Triglycerides are an energy source. Cholesterol is a structural molecule that every cell in your body makes and the excess stuff that your doctor talks to you is the stuff you have to get rid of. All right, so this is an interesting chart and Sharon and I were just talking about this before the lecture today which gives quote the normal levels of these different lipid molecules which, quite frankly, as a cardiologist, we don't consider normal. So we consider much lower levels normal. But for somebody who, let's just say, is a 24-year-old, healthy person and their total cholesterol is below 200, a primary care doctor would say that's fine If you're that same 20-year-old person and your LDL cholesterol is less than 100, people would say, okay, that's fine.

Dr. Michael Koren:

If you have HDL above 60, which is hard for some people because HDL is genetically mediated to a very large degree that would be considered quite good. Triglycerides less than 150 are considered normal, being again in that normal healthy population. The non-HL cholesterol, which is basically total cholesterol minus HDL, should be less than 130, again in the populations of relatively healthy people. And then this is the triglyceride to HDL ratio. It's really three. Anyway, the thing is that this is actually not accurate for the patients that come see me. So the patients that come see me have had bypass surgery, they've had heart attacks, they've had strokes, they have had angiograms that show blockages in the arteries and for that patient population we're looking at much lower levels of these numbers. So when I have a patient that comes in to see me as a cardiologist that's had a heart attack, I would never say you need to get below 100. I would say you need to get below 70. In fact, if you're really close to me, I would say you should get below 50. The current recommendation is for the highest risk patients. You should get below 55 for LDL cholesterol. But when my friends call me up, they say, well, where should it be? And I tell them, hey, if I were you, I'd get that LDL cholesterol below 50. Because the lower the better. All the studies have shown, the lower the better. And we have excellent drugs. A lot of drugs were developed here that enable people to get their LDLs that low. Hdl is hard to move, but ideally you want to get that as high as possible, and the way you do that is with lifestyle. There's no magic drugs that raise HDL, and the magic drugs that we have used in the past to raise HDL tend to not make a big difference in terms of your outcomes. That may change and we actually are doing studies on drugs that raise HDL, but there's no data to support the concept that just raising HDL will result in people having fewer heart attacks or strokes or a better life.

Dr. Michael Koren:

And then we get to the triglycerides. So the triglycerides is an area of focus right now for a number of reasons. The most important reason is that we now understand these chemical interactions in our bodies to a much better degree and we know how to use medications to enhance the body's mechanism for lowering effects, and some people who have high triglycerides are particularly at risk for inflammation in our bloodstream and they're also at higher risk for having other complications as the triglyceride level gets up. So at super high levels, triglycerides can cause a problem in your pancreas. Have you heard the term pancreatitis? Pancreatitis is an inflammation of your pancreas and it can be lethal, and that's something that happens when you have extremely high triglyceride levels. The other thing is that high triglyceride levels are also a reflection of poor diabetic control, or a problem called metabolic syndrome, which is a precursor to diabetes. So if you have high triglycerides, that could be an indication that you're not metabolizing glucose and sugars the way you should. So that's another little important element of treating people. So now that we have the ability to start to look at medications and mechanisms that lower triglycerides, we're actually bringing that to the attention of people like you and we're trying to make sure that people in the community know their triglyceride levels, know the simple ways of dealing with that and if the simple ways don't work, know that there are other methods out there that can help.

Dr. Michael Koren:

And I think the non-HDL cholesterol is only important from the standpoint of that. Hdl is protected. So when you get that total cholesterol number, some of that is LDL and some of that is HDL, and knowing the amount that's from LDL or other of these lipoproteins other than HDL is quite important Because, for example, if this total cholesterol number is, say, 250 and your HDL is 100, well, that's pretty darn good. That means you're genetically in a situation where you're less likely to have heart attacks and strokes, even though the total cholesterol is high, because your total cholesterol is circulating in these very favorable HDL packages rather than the less favorable LDL packages. That all make sense. Question.

Audience:

Okay, so LDL. You said that cholesterol is pretty genetic, but you want that number to be so low. What can you do if it's genetic and it's not near that?

Dr. Michael Koren:

Well, I said, cholesterol is more genetic than triglycerides and we have lots of ways of treating that. So, again, statin drugs are on the market and they can lower your LDL cholesterol by 50% easily. That can help. There are other drugs out there that help your gut get rid of cholesterol. There's a lot of things out there.

Dr. Michael Koren:

In fact, quite frankly, with the drugs that are on the market right now, we can take anybody in this room and get the LDL cholesterol down 80% from baseline. So we have lots of technology, lots of ability to do this, and in many cases these are inexpensive drugs like the statins or all generic drugs. So that's the number one way that we load cholesterol is using statins. Now, for some people, getting down to an ideal body weight will help. For some people, increasing exercise will help, but the truth is that for a lot, some people, increasing exercise will help, but the truth is that for a lot of people it doesn't move the cholesterol number that much and in that case, particularly if you have heart disease or you have very high risk for heart disease, you should get some medication.

Audience:

What about the particle size?

Dr. Michael Koren:

Now that gets into a more complicated concept. But particle size is very related to triglycerides. So if you start to study things about particle size and this gets into what's called advanced profiles you you find that small dense LDL is more likely to cause inflammation and other problems compared to large buoyant molecules, and the number one thing that drives that is high triglyceride levels. So I used to play a game with my cardiology colleagues let's get an advanced lipid profile and I said I can predict if this is type A or type B particles, type A being more favorable than type B based on triglyceride level 9 out of 10 times. And they challenged me on that and I was absolutely right. So all that means is that when the triglycerides are high, the packages, which is the size that we're talking about, will be less favorable.

Dr. Michael Koren:

The other point that brings up, if you want to get into particle stuff, is actually the number of particles is probably more important than the qualitative elements of the particles. So again, small particles are less favorable than large particles. And when you think about it, when you look at your total cholesterol, it's milligrams. Milligrams is a weight. So if you have a lot of smaller particles that make up the same weight as fewer bigger particles. You're in worse shape. Does that make sense?

Audience:

And one quick question. Did you mean to say less than three for the ratio? Is that right?

Dr. Michael Koren:

Again. Basically, you don't want your triglycerides to be more than three times your HDL, okay, so I'm going to try to get to a cholesterol ratio. Yeah, yeah, yeah, okay, that's right. Again, it should not be milligrams, it's a ratio, it just should be a number. So basically, if your HDL was 50, your triglyceride should be less than 150. If your HDL is 30, then your triglyceride should be less than 150. If your HDL is 30, then your triglyceride should be less than 90. That make sense.

Audience:

Yes.

Audience:

Does fish oil help with triglycerides?

Dr. Michael Koren:

It does and we're going to get into that, but it's a really good question.

Dr. Michael Koren:

All right, so what leads to high triglycerides.

Dr. Michael Koren:

And number one excessive alcohol use. Remember, alcohol is a sugar that has to be put into an energy source. When it gets in the bloodstream and what your body does is, it creates triglycerides. So this can have a big impact. So if somebody comes in and has their triglycerides checked and they just had six drinks the night before, your triglycerides can be very, very high.

Dr. Michael Koren:

The other thing is that cholesterol levels can be taken any time of the day or night and they're usually pretty accurate within 10%. Triglycerides have to be done in a fasting state. So when you go to your doctor's office and you get a cholesterol profile, a lipid profile, they tell you to fast. That's not because of the total cholesterol. You don't need to fast for the total cholesterol. You need to fast because of the triglycerides. Triglycerides are very highly variable depending on your diet and because the LDL cholesterol is calculated based on that triglyceride number. That's why you need to fast. Now, if you do something called a direct lipid profile, you don't need to fast because you're not measuring it based on the triglycerides. You're actually measuring the number of LDL particles.

Dr. Michael Koren:

But yeah, alcohol use is number one reason for high triglycerides. Poorly controlled diabetes is number two. People who are overweight are much more likely to have high triglycerides. A diet that has a lot of sugar, saturated fats and simple carbohydrates, which are much more likely to cause high triglyceride levels. Smoking cigarettes causes high triglyceride levels and inflammation in the bloodstream, and then certain medications do it. So a very common medication that we use in cardiology is a diuretic for your blood pressure, or swelling. Diuretics help people with high blood pressure that they can have an offsetting effect of causing high triglycerides. Other things like hormones or steroids or beta blockers or some HIV meds can also cause high triglycerides. So your physicians should always look at your med list. When you come into a research program, you look at your med list very carefully. You come into a research program, you look at your med list very carefully to determine if there's some other medication or something that you're taking that you may or may not know about that's causing high triglycerides. And then, finally, there's certain inflammatory diseases that are associated with high triglycerides. It's a little bit of a rare point, but we just like people to know that sometimes that goes along with other conditions.

Dr. Michael Koren:

Alright, so next trivia question, now that you guys are getting educated, which local foods cause elevated triglycerides. So this was to talk about local places that you may eat and what gets into, trouble. What doesn't get you into trouble? Okay,Julington Creek Fish Camp Fried Shrimp. Okay, The Bearded Pig, BBQ sauce, drenched ribs, Intuition Ale works Beer , Donut Shoppe donuts, you guys. So let's break it down. Let's see if you know the answer within the answer. So for A, what's the problem in A Fried? Fried exactly? Is the shrimp bad? No, shrimp's not bad. Shrimp, by the way, has a lot of cholesterol in it. That's very low in saturated fat and your body actually can produce more cholesterol from saturated fat than the actual ingested cholesterol. But if you eat raw shrimp, that's a good food for somebody with heart disease. When you put all that oil and breading and crap on it, then it's not so good.

Dr. Michael Koren:

It may taste good, but it's not so good.

Dr. Michael Koren:

Same thing with the Bearded Pig BBQ Sauce. It's not so much the ribs, but it's not so good. Same thing with the beer and pig barbecue sauce and the ribs. It's not so much the ribs, it's all the sauce. There's sugar in it, there's fat in it. There's all kinds of stuff in it.

Dr. Michael Koren:

Lean meats tend to not be horrible. Lean cuts of beef, lean cuts of chicken, lean cuts of pork they're not that horrible, but it's all the stuff you put in. And processed meats are the worst. So a lot of pork is processed and because of that it drives me crazy. People aren't healthy and they're putting bacon bits in everything. Well, that is, it's just processed fat, basically. So again, the real food isn't usually the problem, it's the stuff with it. So one of the take-home lessons and if you want to practice what I preach, always have your dressing on the side, put your sauce on the side. They add to the taste, but just dip it in. You don't need to drench everything with this, and that simple rule of thumb will help lower your triglycerides and lead to better health outcomes. We talked about alcohol, alcohol being a big source of triglycerides. Obviously, alcohol being a big source of triglycerides. Obviously, donut shop donuts, fried dough with sugar, is going to cause your triglycerides to go through the roof. All right, which combination most increases risk for heart attacks? Low LDL and low.

Dr. Michael Koren:

HDL.

Dr. Michael Koren:

No High triglycerides and low HDL.

Dr. Michael Koren:

Low triglycerides and low HDL

Dr. Michael Koren:

Low triglycerides and high HDL.

Dr. Michael Koren:

Yes, High HDL and high LDL, or nagging spouses. So who says A, who says B, yeah, okay. Who says C, who says D and who says E?

Dr. Michael Koren:

The answer is B.

Dr. Michael Koren:

So, again, this is what we call the metabolic dyslipidemia, which is this high triglyceride and low HDL state. Remember, hdl is high-density lipoprotein. That's the good cholesterol. It's a good lipoprotein that very favorably carries these lipid molecules through your bloodstream. Remember, all these lipoproteins are a combination of cholesterol and triglycerides and proteins. They all have them in it, but the proportionality and the way they package is different. So the number one molecule that moves cholesterol in our circulation is LDL cholesterol. The number one molecule that moves triglycerides in our circulation is called VLDL cholesterol, or something called chylomicrons. And HDL is the most favorable package of getting cholesterol back to the liver by a process called reverse cholesterol transport. So by doing that, it helps the liver clear cholesterol out of circulation. All right, and here's some science that we just like to let people know, about because, again, we have less favorable ways of lowering triglycerides compared to cholesterol.

Dr. Michael Koren:

I told you about all the different ways of lowering LDL cholesterol by triglycerides. We'll go into a little bit more. Doesn't have as many ways of doing this effectively and this is a really important study that shows that when you have high triglycerides, the residual risk of having a heart attack or a stroke or other atherosclerosis goes up significantly and a lot of it is probably related to a vascular inflammation. All right, so how to lower high triglycerides? We talked about eating more healthy, and, again, lower sugars, lower amounts of alcohol are really important. Lower amounts of simple carbohydrates, more vegetables, more lean proteins. Be physically active. So I mentioned HDL is a hard thing. HDL is one of those things that is a genetic element of our lipid profile, but the one thing that can influence HDL is being physically active. So if you walk 30 minutes a day or do whatever you like to do, chances are you're going to have lower triglycerides and a bit higher HDL.

Dr. Michael Koren:

Losing weight. Obviously, getting to your ideal body weight is not always the easiest thing for a lot of people, but it makes a big difference. A lot of people that need their triglycerides treated when they're overweight don't need it anymore when they get down to a normal weight. Managed blood sugar we've talked about that. This can be challenging for certain people, but it makes a big difference in terms of these triglycerides. Quit smoking and alcohol Again, alcohol is a dose response. I don't like to tell people they have to quit alcohol completely, because if you actually drink one or two alcohol beverages a day, you live longer now, but it's all about the dose. So people that drink wine with dinner tend to have a very healthy lifestyle. People that knock down 12 beers on a Saturday have a less healthy lifestyle. So these are important distinctions.

Dr. Michael Koren:

As mentioned, we have these statin drugs and other drugs called PCSK9 inhibitors and many other drugs that lower LDL cholesterol. They all reduce triglycerides some. They have some effect and the reason they reduce triglycerides some is because they remove LDL cholesterol and LDL has some triglycerides in it, but they're not primary triglyceride drugs. The things and this gets your question in is that we have drugs that are really focused on triglycerides. We have niacin, which is a B vitamin. Niacin will lower your triglycerides maybe 30-40%, but it's usually not well tolerated. So in order for you to get enough niacin to lower your triglycerides, you'll typically have flushing sensations or can have adverse effects on the liver. Adverse effects on the liver. Fibrates is another class of drugs that is primarily focused on triglyceride lowering. Phenofibrate is the most commonly used one and that also will lower your triglycerides probably about 30%. And then you ask about fish oils. These are called omega-3 fatty acids, and omega-3 fatty acids will definitely lower your triglycerides.

Dr. Michael Koren:

Now getting a little nerdy here for a second.

Dr. Michael Koren:

As I mentioned, there are different packages for triglycerides. One's called chylomicrons, and that comes directly from dietary sources. The other one's called VLDL, which is these packages of lipoproteins, and, depending on your particular problem, your particular breakdown, one of these products may work better than others, but the truth is that none of these lowers your triglycerides as much as statins and PCSK9 inhibitors lower your cholesterol. Yes, sir,

Audience:

What about? Flush-free niacin, which is I've been taking for years,

Dr. Michael Koren:

Doesn't work. Flush-free niacin is not the form of niacin that lowers triglycerides. That's why it's flush-free.

Audience:

Does milligram of the omega make a difference? For example, like a 600mg we have 500, where, say, a 2000 we have 1500. Does that make a difference?

Dr. Michael Koren:

Well, it does.

Dr. Michael Koren:

And so if you have a primary triglyceride problem, you may need massive doses of omega-3 fatty acids. So it wasn't uncommon for me when I was treating high triglycerides in the academic setting, to use 10 grams of omega-3 fatty acids. For most people nowadays, especially people that I treat with cardiovascular disease, we usually use a total of about two grams a day of omega-3s, but that may not be enough. And again, there's two different elements to the triglyceride treatment concept. One is to reduce your risk for pancreatitis. Treatment concept One is to reduce your risk for pancreatitis. So if you have a familial genetic condition, we have super high triglycerides. We have some people that can have triglycerides in the thousands and those people are at very risk more of developing pancreatitis. And then you use very high doses of fatty acid. You have to be super compulsive about any kind of dietary fat and other things of that nature other than the omega-3s.

Dr. Michael Koren:

That's different than the cardiac patients that I deal with, that we get the. Ldl down with the statins and possibly the PCSK9 inhibitors, and they still have this residual risk based on elevated triglycerides. And then we're typically using a dose of omega-3s of about two grams, sometimes three, sometimes the only tolerate one.

Audience:

How high does niacin need to be?

Dr. Michael Koren:

The studies that have shown niacin making a difference. Used up to three grams a day of niacin, but when you get much higher than that, virtually everybody's going to have some liver issues and most people will have flushing. So niacin's a drug that in order for it to work, you have to start slow and low and then build up. What's the difference between PCSK9 and the other one? P, are drugs that are on the market Repatha probably went. Have you seen those advertised? They're injectable drugs that hit a enzyme called PCSK9 that's responsible for reducing the effect of the LDL receptor. I mentioned that LDL receptor before, which is the way your liver gets rid of LDL cholesterol, and there's a protein that your body makes called PCSK9, that prevents that receptor from recycling and being used over and over again by your liver. Again, this is a little technical, but PCSK9 inhibitors block that protein from interfering with the LDL receptor. So again they've been on the market. Now block that protein from interfering with the LDL receptor, so again they've been on the market now.

Dr. Michael Koren:

We had a major impact in developing those drugs here in Jacksonville. By the way, there are three of them on the market. Repatha, Praluent and Leqvio are the three on the market. Two of them are monoclonal antibodies and Leqvio is the newest one in the block which is called a small interfering RNA, and I personally made a major presentation about Leqvio at the National American College of Cardiology meeting a few months ago.

Audience:

Yeah, now does this new class statin because I'm a layperson does it cause muscle?

Dr. Michael Koren:

It's less likely.

Dr. Michael Koren:

One of the biggest complaints about statins is muscle aches and pains, and it's a tricky issue, quite frankly, because muscle aches and pains are very common and it's sometimes hard to know if it's from the statin or something else. So there are some strategies, but it is believed that statins cause muscle aches by affecting something called ubiquinone, lay people call it coenzyme Q and what happens with statins is that the effect of these drugs is to reduce the levels of ubiquinone in muscle cells, and people who exercise in particular are more prone to feel those muscle aches. Now there are strategies to deal with that. So the simplest strategy to deal with that is to not dose statins every day. It's to give your muscles a chance to recover, because the statins will have an effect on the LDL receptor two, three, four days out, but their effects on muscles is usually 24 hours. So the simplest solution if you're having a problem with statins and muscle aches is not take it every day.

Audience:

That's why everyone says take CoQ10 when you're on statins?

Dr. Michael Koren:

Correct. Now it's a little tricky because the CoQ10 doesn't always know where to go. It has to get into your muscle cells. But it's a common recommendation that physicians make, but probably the most important thing, if you have statin muscle aches is not take it every day. You don't have to statins every every day for them to work.

Dr. Michael Koren:

And the PCSK9 inhibitors tend to not have that problem because statins are small molecules that get into all the parts of your body. The PCSK9 drugs are called monoclonal antibodies. These are big molecules that just circulate in your bloodstream and don't get into the tissues. So they work by blocking the effects of PCSK9, so PCSK9 cannot affect your liver. So because the PCSK9 inhibitors don't get, into your muscles.

Dr. Michael Koren:

They shouldn't cause muscle aches. Yes,

Audience:

Do you think that plant-based sources for omega-3s are as effective as fish oil?

Dr. Michael Koren:

That's a good question. I haven't seen head-to-head studies on it. It has to do with the amount of saturation. Are you familiar with the concept of saturation of fats? You've heard unsaturated fats, saturated fats, trans versus cis fats. This all gets into the chemistry. So an unsaturated fat means that you have double bonds between the carbon atoms and if it's saturated they're all single bonds. Single bonds tend to be stronger and harder to break than double bonds. Double bonds can be oxidized more easily. Harder to break than double bonds, double bonds can be oxidized more easily. So, to answer your question, the science around fatty acids and omega-3s has a lot to do with if they're unsaturated. Where they're unsaturated You've heard of monounsaturated versus polyunsaturated Monounsaturated means there's just one double bond. Polyunsaturated means that there's multiple double bonds and there's all kinds of debate about which of these molecules is really good or which is bad. So the chances are that we'll learn a lot more about that in the future.

Dr. Michael Koren:

But plant-based molecules have not been studied as extensively as fish oil-based molecules. But there are synthetic molecules that have been extremely well studied. Icosapent ethyl is the one that's been most widely studied and that's been shown to reduce triglycerides and reduce coronary events. So the simple answer to your question is we don't know Other questions. There it is. This is a reduced study which is using a drug called Vecepa, which is a Icosapent ethyl, and this is basically a synthetic omega-3 fatty acid that has been shown to lower triglyceride levels and improve cardiovascular outcomes, in addition to statins in patients with coronary disease. But not all of the studies that have looked at omega-3s have had similar results, so that's why it's complicated. We don't really understand all the elements of it, but the best theory is that there are certain omega-3s that probably are more anti-inflammatory than others, based on where the double bonds are.

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