Did you know that there is a number that gives us five times more accuracy in predicting heart attack and stroke than LDL? It’s called the Triglyceride to HDL Ratio, a powerful yet often overlooked marker for cardiovascular health.
Remember: no single test is 100% accurate. That’s why we ordered several lab panels and imaging tests, so we can have a 30,000-foot view of the situation.
Introduction: The Importance of Triglyceride/HDL Ratio
The Influence of Triglyceride/HDL Ratio
Peter Attia and Thomas Dayspring (a world-renowned lipidologist) once did a podcast together, and they highlighted the significance of the triglyceride-to-HDL ratio as a superior predictor of heart attack risk compared to LDL. This ratio emerged as a crucial factor in assessing cardiovascular health, offering valuable insights into potential risks.
The conclusions that came out of this conversation were:
- The triglyceride/HDL ratio is five times more predictive of heart attack risk than LDL, as demonstrated by the Framingham study.
- Lipoprotein particles are pivotal in transporting cholesterol and fatty acids within the body, shedding light on the intricate mechanisms at play.
Attia and Dayspring’s collaboration and discussions underscored the importance of understanding and analyzing the triglyceride-to-HDL ratio when assessing cardiovascular health while mitigating potential risks.
Understanding Triglycerides: The Basics
Triglycerides (TGs), as the name suggests, consist of three fatty acids linked to a glycerol molecule, forming a type of fat in the body. Elevated TG levels (typically above 100 mg/dL) reveal metabolic disease, especially when the ratio of TGs to HDL is higher than experts in lipidology recommend.
Normal Triglyceride Levels
For most individuals, triglyceride levels ranging from 100 to 200 mg/dL, or 1 to 2 mmol/L, are considered within the “normal” range. However, we recommend lower readings, typically below 100 mg/dL or one mmol/L being more favorable.
Abnormal Triglyceride Levels
- Some disease states can lead to significantly elevated triglyceride levels, with readings exceeding 500 mg/dL or 5.7 mmol/L.
- Patients with triglyceride levels of 300, 5400, 450 mg/dL, and similar high values may be at increased risk for cardiovascular and metabolic disorders, as mentioned above.
- Carbohydrates like fructose (from fruits), processed bread, rice, and especially sweets cause significant increases in TGs.
Ethnicity and the Triglyceride/HDL Ratio
Studies have shown variations in the triglyceride/HDL ratio among different ethnic groups. However, the significance of these differences may be overstated. Ethnicities are often mixed, which makes establishing specific cut points for different ethnicities all the more challenging. The main point is that the triglyceride/HDL ratio indicates insulin and glucose metabolism. Regardless of ethnicity, it should be maintained at a low ratio for a healthy metabolism.
Exploring HDL: The “Good Cholesterol”
High-density lipoprotein (HDL) is often called the “good cholesterol” due to its beneficial impact on cardiovascular health. HDL is essential in protecting our bodies against heart disease and stroke.
The Role of HDL in Lipid Transport
HDL particles are known for “Reverse Cholesterol Transport” (RCT). This process removes excess cholesterol from the arteries and transports it back to the liver for elimination from the body.
The Link Between Triglycerides, HDL, and Prediabetes
Triglycerides and Prediabetes
Elevated triglyceride levels in the blood are commonly associated with prediabetes, serving as an indicator of potential metabolic concern. In prediabetics, higher triglyceride levels often mean there’s a progression to full-blown diabetes, which highlights the importance of monitoring and addressing these levels proactively.
The Role of HDL in Health Assessment
Lower HDL levels indicate potential health risks. Higher HDL levels contribute to improved nitric oxide, reduced oxidase enzyme function, and decreased adhesion molecules, which promotes a healthy metabolism. This is in addition to what we already discussed about HDL’s role in reverse cholesterol transport to maintain cardiovascular health.
Triglycerides, Insulin, and Lipase Activity
There is a clear connection between chronically high insulin levels, often associated with insulin resistance, and the stimulation of hormone-sensitive lipase, partly responsible for the triglyceride elevation in prediabetes.
CETP and the Cholesterol Exchange
The Role of CETP
The body uses LDL and its Apo-B siblings like IDL and VLDL to store fat once the fat cells start producing Resistin, which blocks the further production of fatty tissue. When you eat a lot of glycemic carbs, the metabolism uses the space available inside the large HDL and large LDL to store Triglycerides from VLDL in exchange for Cholesterol Esters. Cholesterol Ester Transfer Protein (CETP) is an enzyme that transfers TGs from VLDL in exchange for cholesterol and vice versa to large HDL and large LDL.
Visualizing HDL and LDL Patterns
High-Density Lipoprotein and Low-Density Lipoprotein were named this way because of spectrometry data.
Interpreting Lipoprotein Mass and Diameter
The vertical axis represents total lipoprotein mass, while the horizontal axis denotes diameter. Large, fluffy HDL and LDL particles in a healthy individual should form smooth bell curves, indicating optimal lipid profiles.
Significance of HDL and LDL Changes in Spectrometry
- In patients with prediabetes, for example, HDL with a lower peak in the bell curve suggests a reduction in large, healthy particles, potentially indicating cholesterol exchange with triglycerides through CETP and subsequent metabolism by liver lipase.
- Shifts in the bell curve of LDL towards the left tend to form smaller, denser particles, known as atherogenic dyslipidemia.
The Case of Familial Hypercholesterolemia (FH)
The Significance of FH
FH, a genetic disorder characterized by high LDL cholesterol levels (frequently above 180), significantly increases the risk for cardiovascular events, especially when combined with other risk factors like prediabetes or elevated triglyceride levels.
Assessing Cardiovascular Risk in FH
Patients with FH often exhibit a substantial area under the curve for LDL, indicating elevated levels that contribute to an increased risk of heart attack and stroke.
Exploring Remnant Cholesterol
Remnant cholesterol, also known as triglyceride-rich lipoproteins (TRLs), is often considered the most dangerous type of cholesterol due to its composition, which primarily consists of very low-density lipoproteins (VLDL) and intermediate-density lipoproteins (IDL).
The Nature of Remnant Cholesterol
Remnant cholesterol (RC) particles, predominantly VLDL and IDL, are short-lived and typically appear transiently in the bloodstream following a meal. These particles undergo rapid metabolism through the breakdown of triglycerides. To calculate RC, you can take the total cholesterol and subtract the LDL and HDL values. If the result is higher than 20, the patient has some grade of metabolic disease.
How to Naturally Lower Triglycerides and Raise HDL
Simple lifestyle modifications and dietary changes can lower triglycerides and raise HDL levels naturally. You want to eat as low carb as possible, less than 100g of glycemic carbs per day. Try obtaining most of your carbs from sources that are rich in fiber, like vegetables and chickpeas, to name a few. Some medications and supplements can aid in this process.
Medications for Improving Triglyceride/HDL Ratio
When lifestyle modifications alone are insufficient to improve the triglyceride-to-HDL ratio, medications can be considered to enhance elevated triglycerides and low HDL levels.
Impact of Statins
Several medications have been found to positively impact the triglyceride over HDL ratio. Statins, commonly prescribed for managing cholesterol levels, have shown a 10 to 20% improvement in the triglyceride over HDL ratio, potentially lowering triglycerides by as much as 50%. Fibrates, prescription strength niacin, niacin supplements, and omega-3 fatty acids have been identified as medications that can decrease triglycerides and increase HDL levels, thereby improving the triglyceride over HDL ratio.
We traditionally use statins in very low doses to help stabilize plaque and prevent it from hindering glucose metabolism more than it already is.
Other Medications and Supplements
- Fibrates: These medications, such as lopid and tricore, have been found to lower triglyceride levels and impact the triglyceride over HDL ratio.
- Niacin: Both prescription-strength niacin and niacin supplements have shown potential in decreasing triglycerides and LDL and increasing HDL, thereby improving the triglyceride over HDL ratio.
- Omega-3 Fatty Acids: Prescription-strength omega-3 supplements, such as icosapent ethyl, and dietary forms of omega-3s have been identified as beneficial in improving the triglyceride over HDL ratio by lowering triglycerides and potentially increasing HDL levels.
The Impact of Lowering Carbs
Effect on Triglyceride Levels
Reducing carbohydrate intake can significantly impact triglyceride levels and the triglyceride-to-HDL ratio while raising HDL levels.
Insights from Clinical Trials and Studies
- Abbasi Study: This human clinical trial revealed that a high-carb diet raises triglyceride levels, increases remnant cholesterol, and lowers HDL.
- Wang Study: A randomized clinical trial in mice demonstrated the beneficial effects of reducing carbohydrate intake on triglycerides and HDL levels.
- Volex Study: A meta-analysis of studies conducted before 2005 indicated that low-carb diets were associated with decreased triglycerides, remnant cholesterol, and increased HDL levels.
- Ebeling Study: This human subjects clinical trial conducted at Harvard found that individuals on a low-carb diet exhibited lower triglyceride levels and higher HDL.
Conclusion: Taking Control of Your Cardiovascular Health
Empowering individuals with the knowledge to understand their cardiovascular health is crucial for making informed decisions and taking control of their well-being. By prioritizing the optimization of the triglyceride/HDL ratio, you can proactively manage your cardiovascular risk and work towards achieving optimal heart health. Whether through natural lifestyle modifications, medication, or dietary changes, various avenues exist to improve your triglyceride/HDL ratio and enhance your cardiovascular well-being. Take charge of your cardiovascular health today and journey towards a healthier and thriving future.
