Season 1 Episode 2: Triglycerides

When you see elevated triglycerides on a lab report, what’s your first move? Diet talk? Lifestyle handout?

It’s time to pause — because triglycerides aren’t just about carbs and alcohol. They can be a clue to deeper issues: insulin resistance, hepatic strain, even pancreatitis risk.

In this episode of LipidCurious, we take a deep dive into:

• What triglycerides actually are?
• Why triglycerides go up — and when you should worry?
• Whether they really cause atherosclerosis, or are just guilty by association

We’ll also walk through a 5-question framework you can use in clinic to make sense of elevated TGs, and what to prioritize when the number is >150 mg/dL.

Don’t forget: The free LipidCurious Starter Kit is available now at www.lipidcurious.com — packed with quick, practical tools for lipid management.

Disclaimer: This podcast is for educational purposes only. It is NOT medical advice.

Transcript

SEASON 1, EPISODE 2: TRIGLYCERIDES

When you see an elevated triglyceride on a lab report, what’s your first instinct?

I’ll admit — I used to go straight to counseling. 

“Let’s clean up the diet, cut back on carbs, ease off the alcohol...”

And yes, those things matter — but over time, I’ve learned to pause.

Because high triglycerides aren’t always just about lifestyle.
Sometimes, they’re a whisper — pointing toward insulin resistance, metabolic strain, or an overworked liver.
And sometimes, they’re a siren — warning us about acute pancreatitis.

This one number can hold big clues. So today, we’re slowing down to really listen.
 It’s time triglycerides got the spotlight they deserve.

Welcome to LipidCurious — the podcast dedicated to demystifying lipids for medical boards and real-world clinical practice.
I’m your host, Dr. Vishnu Priya Pulipati — a board-certified Endocrinologist and Lipidologist.

This is Season 1, Episode 2: Triglycerides

Here’s what we’re unpacking today:

1. What is a triglyceride? 
2. Why do triglycerides go up — and when should we worry?
3. Do they actually cause atherosclerosis — or are they just guilty by association?

If you’re just joining us — welcome!
 This season builds step by step, so if you want the full picture, I recommend starting at Episode 1. We’re laying the foundation so that everything that follows makes more clinical sense.

Quick reminder: This podcast is for educational purposes only. It is not medical advice. 

And if you haven’t grabbed it yet — the LipidCurious Starter Kit is a free download designed for busy clinicians like you. It’s got quick-hit guides on lipid panels, treatment targets, and common clinical pitfalls.
Check it out at www.lipidcurious.com.

Alright — let’s get started.

What is a triglyceride? 

Let’s go molecular for a moment. A triglyceride is exactly what it sounds like — “tri” for three fatty acids, and “glyceride” for the glycerol backbone they attach to. It’s the classic “simple lipid” — a fatty acid plus an alcohol — just like we discussed in Episode 1.

In food, triglycerides are the main form of fat — whether it’s butter, olive oil, or marbled steak. If it is solid at room temperature, we call it a fat. If it is liquid at room temperature, we call it oil. Its only the difference in physical form.

Now here’s the clincher: they’re energy powerhouses. One gram of fat provides 9 calories — more than double what you get from carbs or protein.

Your body stores extra energy as triglycerides — mostly in adipose tissue. And when you need fuel, say during fasting or stress, triglycerides get broken down and shipped off to muscle, heart, or liver for energy.

Triglycerides don’t float around freely — they need transport. That’s where lipoproteins come in. There are two triglyceride-rich lipoproteins

• Chylomicrons carry triglycerides from the gut after meals.
• VLDL particles carry triglycerides from the liver to organs

So when you see triglycerides on a lab report, you're really measuring the triglyceride cargo inside these lipoprotein particles.

Here’s the takeaway: Triglycerides are not inherently harmful. we need them for energy and metabolic needs.

What matters is context — how high they are, how long they stay elevated, and what else is going on metabolically.

Why Do Triglycerides Go Up — and When Does It Matter?

Mechanistically, triglycerides increase due to 3 main reasons:

1. Overproduction: Too much VLDL production from the liver
2. Poor clearance of triglyceride-rich particles: often due to low lipoprotein lipase activity
3. Or both — which is the most common scenario

But in clinic, I like to simplify this with 5 questions:

1. Is it lifestyle-related? High saturated fat intake, refined carbs, alcohol excess — all common triggers.
2. Could it be medication-related?  Watch for thiazides, beta-blockers, estrogens, corticosteroids, antipsychotics, antiretrovirals, and more.
3. Is there a metabolic driver?  Insulin resistance, metabolic syndrome, uncontrolled diabetes — red flags everywhere.
4. Is there a secondary medical cause?  Hypothyroidism, CKD, liver disease, autoimmune conditions, HIV, pregnancy — all can elevate TGs
5. Is it genetic? Family history, very high TGs, early-onset or recurrent pancreatitis — think familial chylomicronemia

These five questions will cover about 90% of real-world cases. For a more comprehensive list of causes, major society guidelines — like AHA 2011, NLA 2015, AACE 2017, and ACC 2021 — all provide detailed tables you can reference.

When does it matter?

• TG <150 mg/dL is normal
• TGs 150–499 = cardiovascular risk, often tied to insulin resistance
• TGs ≥500 = pancreatitis risk, especially above 1000

Key point:
 High triglycerides are usually a symptom, not a diagnosis. They point to an underlying issue — hepatic overload, metabolic dysfunction, or inefficient clearance. Don’t just treat the number. Treat the why.

Do Triglycerides Cause Atherosclerosis?

Here’s the nuance: Triglycerides themselves don’t cause plaque. But the particles carrying them can.

Chylomicrons — big post-meal TG-rich particles — are too large to enter the vessel wall. That’s why even in familial chylomicronemia syndrome, where TGs can exceed 1000, we see pancreatitis, not heart attacks.

But remnant particles — the leftovers from VLDL or chylomicrons — are small enough to sneak into the endothelium. And they’re cholesterol-rich. That’s where the plaque risk comes in.

When TGs are high, we often see:

• High non-HDL-C
• High apoB
• Small dense LDL
• Low HDL
• Insulin resistance

And that’s a constellation that is atherogenic.

We’ll unpack how these markers connect — and what to do about them — in future episodes.

What does the data say?

• Mendelian randomization studies support a causal role for TG-rich lipoproteins in ASCVD
• Several statin trials have demonstrated that even after significant LDL-C (low-density lipoprotein cholesterol) lowering, a residual risk of atherosclerotic cardiovascular disease (ASCVD) remains, particularly in patients with elevated triglycerides (TGs).
• REDUCE-IT trial, which involved over 8,000 participants with high cardiovascular risk and elevated triglyceride levels (despite statin therapy), found that icosapent ethyl significantly reduced the risk of cardiovascular events. While remnant cholesterol wasn't directly measured in REDUCE-IT, calculations based on the observed triglyceride lowering suggest a beneficial effect on remnant cholesterol levels

So yes — triglycerides matter. They aren’t atherogenic directly. But they often ride with the wrong crowd which are atherogenic. 

So next time you see an elevated triglyceride, pause. Don’t just hand out a diet sheet. Ask: What’s driving this? Not just how do I lower it?

So here’s what I want you to walk away with:

• Triglycerides are normal, essential molecules — but when elevated, they’re often reflecting a deeper problem in energy balance, metabolic health, and sometimes impending pancreatitis.
• When TG is elevated, think lifestyle, medications, metabolism, secondary conditions and genetics.
• TG 150–499 = ASCVD risk, but not because of TG alone — because of the company they keep. TG ≥500 = treatment priorities shift, focus on pancreatitis prevention 

I have a challenge for you.
For the next 10 lipid panels you see, if the triglycerides are >150 mg/dL, Pause — and run through this 5-point check: think lifestyle, medications, metabolism, secondary conditions and genetics.

Next episode in 2 weeks Fatty Acids: The Good, the Bad, and the Essential 

Alright folks, thanks for joining me on LipidCurious.
 If you found today helpful, check out the free LipidCurious Starter Kit at lipidcurious.com — it’s packed with quick tools and checklists you can actually use in clinic.

I’d love to hear your feedback, suggestions — or even if you just want to connect.
You can reach me at hello@lipidcurious.com, and you’ll find my LinkedIn details on the website. Be sure to subscribe or follow, so you don’t miss what’s next.

Until next time — stay curious, and stay confident.
Signing off, Dr. Pulipati.