Seth Martin, MD, is a professor of medicine at Johns Hopkins University School of Medicine and director of the Advanced Lipid Disorders Program and Digital Health Lab at the Ciccarone Center for the Prevention of Cardiovascular Disease at Johns Hopkins Medicine.
Martin treats people with complex lipid disorders, including very high triglycerides. He shares what he tells people with severe hypertriglyceridemia and how treatment can help lower levels quickly and protect your health.
Q: What’s the first thing you want people to know about very high triglycerides?
It's not just about making the number look better.
When your triglycerides are in the severe range, the most urgent concern is pancreatitis. That's sudden inflammation of the pancreas. It can be a serious, life-threatening event, and we want to do everything we can to avoid it.
The short-term goal is to get triglycerides out of the severe range and lower your risk of pancreatitis.
Longer term, we're also thinking about your broader cardiometabolic health. That means your heart and blood vessel health, your blood sugar, your weight if that's part of the picture, and the habits that support your health over time.
Q: Why is 500 mg/dL the cutoff for severe hypertriglyceridemia?
It's important to know that 500 isn't a magical number where everything suddenly changes.
In clinical medicine, we need clear cutoff points so we know when to act. And a triglyceride level of 500 ng/dL or higher is where we draw the line.
That doesn't mean someone with a level below 500 has no chance of pancreatitis or that everyone over 500 will get it. But we know that very high triglycerides are part of what leads to pancreatic inflammation.
We're still learning the exact mechanism. But the basic idea is the pancreas can't handle that much fat in the blood. It may clog up or overwhelm the system in a way that makes the pancreas "angry" and inflamed.
Q: What are the most common causes of very high triglycerides?
I usually think about this in two broad buckets: genetic reasons and other factors that push triglycerides higher.
If your triglycerides are in the thousands, we start wondering whether you have familial chylomicronemia syndrome, or FCS, or another hidden genetic cause. These are really extreme levels of triglycerides.
Lipoprotein lipase is a key enzyme here. It helps break down triglycerides. If that system doesn't work well, triglycerides can build up.
But genetics can be complicated. Usually, very high triglycerides involve the genes you're born with, plus lifestyle and other exposures.
Common contributors include:
Diabetes. The higher your blood sugar is, the more it can drive triglyceride production. So if diabetes is poorly controlled, that's very important to address.
Diet. Fat content matters. So does what you drink. Alcohol is a classic trigger for high triglycerides.
Sugary drinks. This one can surprise people. For example, sports drinks can have a lot of added sugar.
Physical inactivity. Exercise matters more than you may realize. That's because physical activity triggers lipoprotein lipase, which helps break down triglycerides. So if you're very sedentary, that can boost triglycerides.
Other health issues. Thyroid disease, obesity, kidney disease, and liver disease can all play a role.
Certain medications. Some medicines can affect your triglycerides, including birth control pills, corticosteroids, and HIV medications. That doesn't mean you should stop using them. But it helps your doctor understand what may be affecting your numbers.
Q: Is severe hypertriglyceridemia my fault?
No. And I think it helps to talk through why this is happening in the first place.
When triglycerides get to such severe levels, there's generally a genetic component. We may not always have a test that can find the genetic cause in every person. But when levels are extremely high, it usually means your body has a built-in problem clearing triglycerides.
One way I try to lessen self-blame is to say this: There are lots of people out there who don't have very healthy lifestyles, but their triglycerides don't get to very high levels. So when your numbers are in the severe range, that suggests your underlying genes are playing a part.
That said, lifestyle changes can still make a big difference.
Q: How much does exercise really matter?
It can matter a lot. The good news is that you don't have to go from sitting on the couch to running a marathon. The biggest benefits tend to happen when you go from doing nothing to doing something.
If you're very inactive, you can start small. Walk around your house or your neighborhood, and make movement a regular part of your day. Resistance exercise is another good tool that often gets forgotten. But you don't have to join a gym or start lifting heavy weights.
Resistance bands are inexpensive, don't take up much space, and can travel with you. They're also commonly used in cardiac rehab programs. Or you can use things you already have at home, like cans from your kitchen, and do simple arm exercises.
The exact fitness goal will vary from person to person. But I'd rather see you start with small doable goals than set something so big it feels impossible to stick with.
Q: Can lifestyle changes alone lower very high triglycerides ?
How much you move your body and what you eat or drink can make a big difference.
But if you're in the severe range, you often need both lifestyle changes and medication. And if you have FCS, even a very strict lifestyle may not be enough. That's where medications, especially newer treatments with APOC-III inhibitors, can be game changers.
Lifestyle counseling is still a key part of care. We talk about it in the clinic, but it often helps to have more support over time.
That may mean working with a dietitian who has experience helping people with very high triglycerides. It may also mean joining a broader lifestyle program that includes healthy eating, physical activity, and weight management support.
For many people, care works best when it's not just one doctor saying, "Eat differently and exercise." It's a team helping you build a plan you can actually follow.
Q: How do you decide which medication to start with?
We talk through where you are now, what lifestyle changes might help, what your triglyceride levels look like, and which medications make sense for your situation.
Statins are a tried-and-true option. They can help with triglyceride lowering and pancreatitis risk. And many people with severe hypertriglyceridemia also benefit from the long-term cardiovascular risk reduction statins can provide.
Some people need more than one medicine. In those cases, we may talk about high-dose omega-3 fatty acid therapy or fibrates.
I work in a specialty lipid clinic, so I see hard-to-treat cases. That includes people with familial chylomicronemia syndrome (FCS). If someone's triglycerides are still very high despite standard therapies and they meet clinical criteria for FCS, then we may be able to use APOC-III inhibitors.
The point is to match the treatment to the person and the pattern of the disease.
Q: If my triglycerides are very high, do I need to see a specialist?
Not always. Start by following the advice of your regular doctor. They may be able to handle your care if your levels aren't extremely high.
But if your triglycerides are above 1,000, they may refer you to a lipid specialist. Levels that high are uncommon enough that many primary care doctors would want you seen in a specialized clinic.
That doesn't mean you have to wait until you get into that clinic to start treatment. You can make healthy lifestyle changes right away. And your regular doctor may also start a statin and order follow-up testing.
But if your triglycerides stay very high despite basic lifestyle changes and standard medication, then you should see a lipid specialist.
Q: How do you find out if you have very high triglycerides?
A lipid panel is the usual way.
Many times, this is done as part of a wellness visit with your primary care provider. But if you notice you haven't had your cholesterol or triglycerides checked in many years, it's very reasonable to ask. Your doctor will likely support that idea.
Sometimes people get cholesterol screening through insurance programs or community health fairs. But those may not always include the full lipid profile. Some screenings may only check total cholesterol.
If you want to know your triglyceride level, make sure you're getting a lipid panel that includes triglycerides.
One other thing to know: Triglycerides can be higher if they're measured after you've eaten recently. It can make a difference whether your test was done in a fasting or non-fasting state.
Q: How quickly can triglycerides improve?
They can go down quickly.
We generally suggest repeating a lipid panel in four to 12 weeks. Four weeks is usually the earliest we'd check again. But triglycerides may start moving in the right direction even sooner than that, especially if you've started medication and made meaningful lifestyle changes.
Q: What gives you hope for people with severe hypertriglyceridemia?
We have medications that work well, and treatments keep getting better.
We're lucky to live in a time when we know a lot about managing high triglycerides from both a lifestyle and medication angle. And for people who qualify for newer medicines, those treatments can be highly effective at lowering very high triglycerides and lessening the chances of pancreatitis.
This is also an active area of research. We're going to keep learning more every year.
Another hopeful point is that healthy lifestyle changes don't only lower triglycerides. They can also support your long-term heart health and overall well-being.
If you've just been diagnosed with severe hypertriglyceridemia, or you've been living with it a long time, there's a lot to feel good about. And it's important to know you're not alone. With the right plan and care team, your triglycerides can get better.
