• Assess non-lifestyle secondary causes   |  
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Categories	Conditions and Medications Contributing to Hypertriglyceridemia
*Caveats: Triglyceride-raising medications require careful monitoring; minimizing other conditions that raise triglycerides; and, when clinically appropriate, using alternatives.
Diseases	Poorly controlled diabetes mellitus Chronic kidney disease, nephrotic syndrome Familial partial lipodystrophy Uncontrolled hypothyroidism Cushing syndrome Glycogen storage disease, acute hepatitis Rheumatoid Psoriasis Systemic lupus erythematosus Multiple myeloma Sepsis (repeat measurement is recommended if lipids were measured during an episode of sepsis)
Diet/Lifestyle	History of alcohol abuse or alcohol excess Diets high in saturated fat, sugar, or high-glycemicindex foods Sedentary lifestyle Total parenteral nutrition with lipid emulsions
Drugs* (Medications)	Anesthesia: Propofol Cardiology: Beta adrenergic blocking agents Thiazide and loop diuretic agents Bile acid sequestrants (cholestyramine, colestipol, colesevelam) Endocrine: Glucocorticosteroids Anabolic steroids Oral estrogens Raloxifene Clomiphene citrate Estradiol Ethinyl estradiol Conjugated estrogens Tamoxifen Dermatology: Isotretinoin Infectious Disease: HIV protease inhibitors Oncology: Tamoxifen L-asparaginase Bexarotene Cyclophosphamide Psychiatry: Atypical antipsychotic agents (eg, olanzapine, mirtazapine, clozapine) Immunosuppressive agents: Tacrolimus Sirolimus Cyclosporine Interferons
Disorders of Metabolism	Overweight and obesity Metabolic syndrome/insulin resistance Weight gain after weight loss Pregnancy (especially third trimester when triglyceride elevation associated with pregnancy is peaking)

• Assess lifestyle practices (body weight; diet, including amount and type of carbohydrates, alcohol, and long-chain omega-3 fatty acids; and physical activity)  |  
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	TG < 500 mg/dL	TG 500-999 mg/dL	TG > 1,000 mg/dL*	Patients Messages
*Nutrition resources for patients are available from the National Lipid Association: https://www.lipid.org/sites/default/files/when_your_tgs_are_over_1000_mgdl.pdf and https://www.learnyourlipids.com/heart-healthy-resources/fcs-cookbook/ † One serving of fruit =1 small piece of fruit (apple, orange, pear) or 1/2 cup chopped. ‡ Recommendations are based on a 2,000-calorie diet § Examples include a patient with diabetes or obesity. For these individuals, fewer servings may be indicated. Clinicians may opt to reduce total fat as percent of calories in some of these patients to 10%-15% (examples include those with a history of pancreatitis or those at the higher end of this range). MCT=medium-chain triglycerides; SFA=saturated fatty acids; TG=triglycerides.
Alcohol	Restrict Do not exceed limits: 2 drinks/d for men, 1 drink/d for women	Abstain completely	Abstain completely	For patients with TG < 500 mg/dL, if alcohol is consumed, wine or beer with lower alcohol content is recommended over beverages with higher alcohol content. Alcohol content is listed on packaging and patients are encouraged to select beverages with lower alcohol content should they choose to consume alcohol
Sugar-sweetened beverages	Restrict	Abstain completely	Abstain completely	Recommend plain or sparkling water, unsweetened tea, or coffee
Fruits †	Okay to include but individualize 3-4 servings/d	Limit to 3 or 4 servings/d and individualize. Avoid fruits with a high glycemic index (ie, pineapple, mangoes, watermelon, ripe bananas)	Limit to 1 serving/d. Recommend individualized medical nutrition therapy with a registered dietitian nutritionist.	Consume whole fruit and avoid fruit juices when possible. Emphasize fresh fruits without added sugar or salt
Vegetables	Emphasize vegetables	Emphasize vegetables, but avoid vegetables with a high glycemic index (ie, carrots, potatoes, sweet potatoes, yams, parsnips)	Abstain completely	Avoid canned vegetables with salt and vegetables frozen with sauces. Avoid vegetable juices. Recommend 2.5 cups/d ‡
Legumes (beans, lentils, chickpeas, tofu, and so on)	Emphasize	Emphasize	Emphasize	Avoid added salt. Emphasize plant-based proteins instead of red meat. Avoid ultraprocessed meat alternatives
Fish/Seafood	Emphasize fatty fish Recommend at least 2 servings/wk	Emphasize either fatty or lean fish Recommend 2 (or more) servings/wk	Emphasize lean fish Recommend 2 (or more) servings/wk	Examples of fatty fish include salmon, farmed rainbow trout, and tuna. Examples of lean fish or seafood include cod, tilapia, haddock, flounder, and shrimp. Prioritize fresh, frozen, or packaged without sodium
Poultry/lean meats	Encourage	Encourage	Limit to the very leanest meats	Substitute poultry and lean meats in place of red meat. Avoid processed meats
Dairy products	Limit full-fat dairy products. Avoid sugar-sweetened dairy products	Limit full-fat dairy products. Avoid sugar-sweetened dairy products	Eliminate full-fat dairy products and sugar-sweetened dairy products/div>	Consume fat-free dairy products. Avoid any dairy products with added sugars
Fiber-rich whole grains	Emphasize 6 servings/d unless a lower-carbohydrate diet is indicated§	Emphasize 4-6 servings/d unless a lower-carbohydrate diet is indicated§	Emphasize individualized medical nutrition therapy with a registered dietician nutritionist	Replace refined grains (white bread, white rice, pasta) with fiber-rich whole-grain cereals, bread, brown rice
Nuts and peanuts	Emphasize	Consume in moderation	Limit	Preferably plain without added sugars or sodium
Total fat Type of fat	Moderate fat (30%-35% of calories) Limit SFA and emphasize unsaturated fat	Low fat (20%-25% of calories) Limit SFA and emphasize unsaturated fat	Very-low fat (10%-15% of calories or less) Limit fats to 20-30 g/d or less Meet essential fatty acid requirements For patients who need extra calories, add MCT oil gradually	Emphasize liquid oils (soybean, canola, corn, olive) instead of solid fats, butter, lard, and tropical oils (coconut, palm, and palm kernel)
Cholesterol	Choosing healthy protein foods, dairy products, and fats will limit cholesterol	Choosing healthy protein foods, dairy products, and fats will limit cholesterol	Choosing healthy protein foods, dairy products, and fats will limit cholesterol
Desserts (sweets, cookies, cakes, pies, other pastries, ice cream, candy)	Occasional indulgence	Occasional indulgence	Abstain completely
Added sugars (table sugar, jams/jellies, honey)	Occasional indulgence (<6% of calories)	Occasional indulgence (<5% of calories)	Abstain completely/eliminate

• Emphasize healthy dietary pattern* and increased physical activity  |  
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Implement shared decision-making intervention	TG < 500 mg/dL	TG 500-999 mg/dL	TG ≥ 1000 mg/dL
RDN = registered dietician nutritionist; TG = triglycerides †RDN referral advised ‡RDN referral necessary §Clinicians may opt to reduce total fat as percent of calories in some of these patients to 10% - 15% (examples include those with a history of pancreatitis or those at the higher end of this range). ‖Although clinicians should aim for their patients to meet the guideline-recommended goals for physical activity, any amount of physical activity is likely beneficial in sedentary individuals and should therefore be encouraged to reduce cardiometabolic risk.
Added sugar (percent calories)	< 6%	< 5%	Eliminate
Total fat (percent calories)	30%-35%	20%-25%	10%-15%
Alcohol	Restrict	Abstain completely	Abstain completely
Aerobic activity	At least 150 min/wk of accumulated moderate-intensity or 75 min/wk of vigorous-intensity aerobic physical activity(or equivalent combination of both)
Weight loss (percent body weight)	Recommended weight loss goal is 5%-10% for all patients with elevated TG

• Monitor response to intervention
• Consider referral to registered dietician nutritionist, exercise trainer, or other supportive services
• Continue intervention or adjust as indicated
• Additional resource: Screening Questions for Assessing Effects of Lifestyle on Triglycerides   |  
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Screening Questions for Assessing Effects of Lifestyle on Triglycerides
• How often do you consume sugar-sweetened beverages (soft drinks, fruit drinks, sweet tea, or sports/energy drinks)?
• Do you consume sweets (pastries, desserts, or candy?) If so, how much and how often?
• Do you drink alcoholic beverages (beer, wine, or spirits)? If so, how much and how often?
• How often do you consume foods that are deep fried or high in saturated fats (ie, butter, coconut, and other tropical oils, full-fat dairy products, or fatty red meat) as well as pizza?
• Have you gained weight in the past year? If so, how much weight have you gained?
• What do you do for physical activity? How often?

• Additional resource: Clinician Messages to Patients to Encourage Healthy Lifestyle   |  
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  Clinician Messages to Patients to Encourage Healthy Lifestyle Behaviors
  • Instead of drinking sugar-sweetened beverages, try a no-calorie sparkling water with a lemon slice.
  • Instead of eating a pastry, dessert, or candy, have fresh fruit or a small piece of dark chocolate.
  • Do you drink alcoholic beverages (beer, wine, or spirits)? If so, how much and how often?
  • If you are ready to lose weight, follow a healthy weight loss diet that achieves a slow, steady (and sustained) weight loss instead of a fad diet.
  • Increase your activity level by incorporating short walks in your daily life instead of being sedentary. Carry small weights on your walks.
  • Take small steps to increase your physical activity by parking the car at the end of a parking lot instead of close to the door, take the stairs rather than the elevator, and stand more during the day.

*Recommendations for a healthy dietary pattern emphasize: vegetables; fruits; legumes; whole grains; nuts; and fish/seafood (other healthy proteins such as low-fat dairy, low-fat poultry); liquid plant-based oils; and replacing saturated fatty acids with monounsaturated fatty acids and polyunsaturated fatty acids. Recommendations also emphasize limiting: red and processed meats; refined carbohydrates; adding sugars (sweets and sugar-sweetened beverages); sodium and dietary cholesterol; and avoiding trans fats.