Hypertriglyceridemia

We’re used to seeing hypercholesterolemia as a known risk factor, but high triglycerides are also associated with an increased risk of cardiovascular disease. High triglyceride levels are additive to risk factors such as diabetes, hypertension, obesity and smoking. Hypertriglyceridemia is also contributory to metabolic syndrome, and it may cause pancreatitis through toxic effects from free fatty acids released by the enzyme pancreatic lipase. So there are significant effects that have to be accounted for in underwriting when elevated levels are encountered.

Hypertriglyceridemia is defined as a fasting serum triglyceride level of 150 mg/dl or more. Levels to 200 mg/dl may be considered normal, but it is important to recognize that triglyceride levels are distinctly affected by fasting. High levels are generally reported as up to 500 mg/dl, and severe is classified as levels over 500 mg/dl. It is important to counsel clients to take their blood draw under fasting conditions. It is also helpful to remove alcohol from the diet prior to blood sampling as well, as it has a deleterious effect on triglyceride levels.

There are five recognized hyperlipoproteinemias recognized by the Fredrickson WHO classification and the American College of Cardiology. The ones that affect triglycerides most are type 2b and type 4. 2b is the commonest one seen in clinical practice and is often associated with a high serum cholesterol as well. Hypertriglyceridemia may result from a genetic or familial predisposition, but is of course affected strongly by diet and lifestyle management.

Lifestyle management is key in managing hypertriglyceridemia. Weight loss, nutritional changes and structured physical activity are the key triad. Reducing carbohydrate intake, and increasing fat or protein intake both lower fasting triglyceride levels. Intake of any fat (saturated or unsaturated) lowers serum triglycerides—an increased intake of unsaturated fats actually increases HDL, the “good” cholesterol fraction. Mediterranean diets have been studied and found to effectively lower triglyceride levels, as do diets designed to lower blood pressure. Exercise on a regular basis has also been found to favorably affect triglyceride levels.

When these measures fail, medications may be prescribed to lower both cholesterol and triglycerides to more favorable levels. Statins are still the mainstay of therapy, and are used in those over age 40 with triglyceride levels of 500 or less and a borderline to intermediate risk of heart disease. Fibrates were more commonly used in years past, but are generally reserved for combination therapy with statins currently. Newer medications including omega free fatty acids (Icosapent, or Vascepa is the newest approved one) may also be added. These of course have to be combined with dietary measures and exercise.

Generally, in considering cases of hypertriglyceridemia, overall cardiovascular risk and the presence or absence of demonstrated cardiovascular disease and/or diabetes is taken into account. Hypercholesterolemia and hypertension are also additive risk factors. While not causing a rating in and of themselves, they can be a multiplier of risk in the presence of other contributing conditions. Cardiovascular disease is the more important of the two.

Hypertriglyceridemia can sometimes be an unpleasant source for a rating when discovered on bloodwork because an insured is generally unaware of it. It can also be a cause of eliminating preferred consideration for an applicant who has already been shown this likely outcome on an illustration. Preferred consideration is generally reserved for levels of triglycerides under 200mg/dl (fasting) or under 400 mg/dl (non-fasting), the absence of cardiovascular risk factors (build, blood pressure, smoking, diabetes) and no diagnosis of metabolic syndrome. This still bears repeating: If there is any question of cholesterol, lipid or triglyceride problems, be sure that the potential insured has his or her blood sample drawn fasting. Preferred categories are tight enough so that even a small difference or elevation in triglyceride levels can have an unfavorable outcome in policy pricing.

MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life.

Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1991.

Goldstone can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.