Fish Oil for Triglyceride Reduction - With the Low Down on Lovaza

We have all heard about the perils of high cholesterol, and many of us have heard about the dangers of high homocysteine. But what are high triglycerides and why is it important to know about Lovaza and fish oil for high triglycerides?

High triglyceride levels are very easy to treat, but they can cause very serious symptoms if they are left untreated. Let's start with an explanation of what a triglyceride is, and what makes high triglyceride levels a health concern.

Triglycerides Are the Body's Storage Molecule

You can get high triglycerides if you eat too much fat. You can get high triglycerides if you eat too much carbohydrate. You can even get high triglycerides if you eat too much protein, although the body's processes for converting excess protein into sugar and then converting sugar into triglycerides are relatively slow and inefficient. Triglycerides are the way the body stores excess calories until it decides what t do with them.

A triglyceride is a fat that can travel through the bloodstream. The blood is mostly water. Fats don't dissolve in water unless they are chemically combined with a substance that does. A triglyceride is a chemical combination of three molecules of fatty acids with a molecule of glycerol, enabling the fat to circulate in the bloodstream.

Depiction of a Triglyceride

Depiction of a Triglyceride, Courtesy of Dr. Ruth Lawson, Otago Polytechnic, New Zealand

Sometimes we get triglycerides directly from our food. The fat in food is first broken down into individual fatty acids. These fatty acids "catch a ride" with cholesterol. They are reassembled into triglycerides which then enter the body inside a covering of protein known as VLDL cholesterol, or very low-density lipoprotein cholesterol.

You have probably heard about the "bad" form of cholesterol known as LDL cholesterol. VLDL cholesterol is "too big to be bad." It is such a large molecule that it does not get stuck in the linings of blood vessels. It fills up with fatty acids from food about 10 minutes after they are digested, and then for the next 10 hours it delivers them to cells throughout the body to be burned as fuel.

Depiction of VLDL Cholesterol

Depiction of VLDL Cholesterol Surrounding Triglycerides, Courtesy of Red Andr

The problem with triglycerides comes when there are so many triglycerides that VLDL is "bursting at the seams" to get rid of them. If the VLDL cholesterol containing the triglycerides does not circulate back to the liver, it fragments into pieces of LDL cholesterol that are just the right size to get "stuck" in artery walls. If the VLDL cholesterol survives the trip to the liver, then the liver can convert it into a safer form of LDL and also into HDL.

There is also a problem when we eat too much sugar. Free sugar in the bloodstream tends to "burn" all on its own. This creates glycosylates, a kind of sticky caramel that can coat cells and interfere with their function.

To prevent this problem, the liver turns sugar into triglycerides, but these triglycerides also hitch a ride with VLDL to the fat cells where they are stored. If there are too many triglycerides, the VLDL bursts on the way to belly fat and turns into the fragments that can cause cardiovascular disease.

It is the job of HDL cholesterol to gather up these fragments and take them back to the liver for further processing. Snce HDL is made from LDL cholesterol, there won't be enough HDL to do the job.

But that's only part of the problem.

High Triglycerides Can Cause Their Own Symptoms

Part of the reason to be concerned about high triglycerides is that they interfere with the normal processing of cholesterol. However, very high levels of triglycerides can cause their own problems.

When people have triglycerides higher than about 1000 mg/dl, the first thing they may notice are small lumps called xanthomas (pronounced ZAN-tho-mas) on the skin. These skin growths are non-cancerous. They are actually accumulations of white blood cells called macrophages, which feed on cholesterol. Macrophages are drawn to the skin by VLDL cholesterol that cannot empty all the triglycerides inside it. They attempt to remove the cholesterol and the triglycerides by surrounding them in a way a little like Pac Man eating a dot, only this "Pac Man" gets its jaws stuck in the open position.

The result is a soft, yellowish growth, usually at the inside corner of the eyes. A colored growth on the skin of this type is sometimes termed a xanthelasma. They usually appear in pairs, first at the eyes, and then over the chest and back. There may also be yellow creases in the palms. The xanthoma or xanthelasma is primarily a cosmetic problem, but it can be a signal of a much more serious problem inside the body.


This is an image of a xanthelasma, courtesy of Klaus D. Peter.

That more serious problem may be pancreatitis. When triglyceride levels reach about 5,000 mg/dl, there may be nausea, vomiting, and abdominal pain. The pain that originates in the abdomen may be referred by the central nervous system so that it seems to originate in the neck and back.

Acute Pancreatitis

Visual Presentation of Acute Pancreatitis, Courtesy of Dr. Herman Fred.

Triglycerides levels can get so high that they accumulate in the retinas at the back of the eyes. There can be depression, confusion, and memory loss. Fortunately, almost all of these symptoms are almost always preventable and reversible, although pancreatitis is a medical emergency that has to be treated by a medical doctor.

The diagnosis of high triglycerides, however, is defined by a blood test. Here are the new numbers that define healthy levels of triglycerides and the levels of triglycerides requiring treatment.

ClassificationTG level, mg/dL
Normal TG levelLess than 150
Borderline-high TG level150-199
High TG level200-499
Very high TG levelMore than 500

How to Get and Keep Triglyceride Levels Under Control

You may be expecting that this is place where I'll be telling you that if you just take fish oil, your high triglyceride levels will go down and everything will be fine again. Actually, I am going to recommend fish oil, but it is even more important to control the underlying causes of high triglycerides than it is to take fish oil to lower high triglycerides.

  • Excessive alcohol consumption. If you get a large part of your calories from alcohol, for example, you consume more than 3 drinks a day, the enzyme that releases triglyceride from the VLDL cholesterol that carries it through the bloodstream may not work. In alcoholics, high triglyercide levels are especially likely to be associated with pancreatitis. The most visible sign of pancreatitis is foul-smelling stools that float and stick to the sides of the toilet bowl. It's as important to reduce alcohol consumption and to avoid consumption of bitter foods (which can cause overproduction of stomach acid) as it is to take fish oil.
  • High-carbohydrate diets, diets which provide more than 60% of calories in the form of carbohydrates. A high-carb diet, however, is only a problem if you overeat. It is the excess carbohydrates that become triglycerides.
  • Uncontrolled type 1 diabetes. The enzyme that releases triglycerides will not work when insulin levels are low. The solution is to take more insulin.
  • Uncontrolled type 2 diabetes. In non-insulin dependent diabetes, the problem is usually both excessive consumption of carbohydrates and overweight. When type 2 diabetics bring their blood sugar levels back into control by eating less, their triglyceride levels usually improve. However, type 2 diabetics who do not get their triglycerides under control more often have to have amputations.
  • Obesity. Even without diabetes, overconsumption of fat and carbohydrates can lead to overproduction of triglycerides. The solution is to eat less.
  • Hypothyroidism. In persons who have low thyroid function, the enzyme that releases triglycerides into the tissues that feed on them does not work. The intervention is to increase thyroid hormone levels.
  • Chronic kidney disease. Kidney failure resulting in protein spillover is usually accompanied by high cholesterol and high triglyceride levels. This is a condition that you have to manage with the help of a specialist.

There are also medications that cause high triglycerides. Birth control pills that contain relatively more estrogen are more likely to cause high triglyceride levels (as well as nausea, breast tenderness, and vomiting). Birth control pills that are mostly progesterone will not cause high triglyceride levels.

Estrogen replacement therapy may raise triglycerides, but so can tamoxifen (Nolvadex) for binding estrogen levels after treatment for breast cancer. High cholesterol levels can be caused by diuretics for high blood pressure, beta-blockers for high blood pressure, Accutane or Retin-A, steroids, and some drugs for schizophrenia and HIV. If you have seriously elevated levels of triglycerides, you should discuss any prescription drugs you use with both your doctor and your pharmacist.

Using Natural Methods to Get Triglycerides Under Control

If you are taking care of the conditions that cause your high triglyceride levels, then it makes sense to lower them with supplements. Your doctor may suggest niacin. Here's what you need to know about niacin for high triglycerides:

  • Niacinamide, also known as vitamin B3, will not lower triglyceride levels. Neither will inositol hexanicotinate.
  • High-dose niacin usually lowers triglyceride levels about 40%, and raises HDL cholesterol levels about 40%.
  • If you take more than 1500 to 2000 mg of niacin a day, you are likely to experience facial flushing, bumpy skin that looks like rosacea across your cheeks, and rashes.
  • If you switch from a fast-acting form of niacin to a slow-acting form of niacin, you are less likely to suffer these annoying side effects BUT
  • If you don't reduce the dosage of niacin when you switch from fast-acting niacin to slow-acting niacin, you run the risk of liver failure.

Personally, I prefer to avoid any risk of liver failure. It's fine to use niacin if you get your liver enzyme levels checked about once a month to catch this problem before it starts.

Another natural approach to lowering triglycerides is an extremely low-salt diet. I have interacted with a woman who had triglycerides of 4610 mg/dl (so high her doctor repeated the test) who got them down to 810 mg/dl (so low her doctor repeated that test, too) in just two weeks by following an absolutely no-salt diet. She also eliminated any sea foods or sea vegetables and even foods like beets and carrots. This approach works, but the reality is, it is very hard to get sodium levels low enough to use it.

And the method that most people use is fish oil. What is it about fish oil that soaks up triglycerides?

The omega-3 essential fatty acids in fish oil won't lower the levels of triglycerides you absorb from food. You still have to reduce your consumption of fatty foods to do that.

What the docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) and fish oil will do is to reduce the liver's production of triglycerides from surplus sugars. If you can consume about 4 grams of fish oil a day, your liver will make enough fewer triglycerides to lower your triglyceride levels about 30%. That's not as much niacin, but it's usually enough to make a big difference in symptoms and also in LDL cholesterol levels.

What About Lovaza?

You may have heard about the prescription "fish oil" that used to be marketed as Omacor and more recently has been renamed Lovaza. It is a very highly concentrated combination of DHA and EPA in an especially stable chemical form. Each capsule of Lovaza delivers about 800 mg of essential fatty acids and costs about $9, usually not covered by insurance. High-quality brands of fish oil like Xtend Life are not covered by insurance, either, and they deliver about 400 mg of essential fatty acids for about $0.25.

The makers of Lovaza claim, truthfully, that their product is more stable during storage than "triglyceride" forms of fish oil that you get online. The problem is that they make Lovaza by boiling fish oil in alcohol to form fish oil esters that won't spoil. Your gut has to break them down into DHA and EPA before they can travel into the bloodstream, and you may not absorb about 30% of the essential fatty acids because they are flushed away. You actually pay about 25 times as much for Lovaza as for the equivalent amount of high-quality, non-esterified fish oil.

Fish Oil Side Effects?

If you stick to fish oil that has at least 400 mg of essential fatty acids per capsule, you won't experience any side effects. There is one group of people who should avoid fish oil, however, and that is type 2 diabetics who suffer congestive heart failure.

In type 2 diabetics, congestive heart failure is a frequent complication of treatment with Actos (pioglitazone) or Avandia (rosiglitazone). The damage to the heart muscle keeps some cells in the heart muscle from contracting without an inflammatory reaction to stimulate them.

Diabetics with congestive heart failure who take fish oil have lower levels of inflammation and fewer heart cells firing with each beat. In this particular circumstance, fish oil or Lovaza can actually weaken the heart further.

But if you don't have congestive heart failure, fish oil is reliably helpful. You will see lower triglyceride levels in a couple of months, and you will probably notice changes in your skin in about a year.

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