April 2026 correspondence

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Response to ‘Hypertriglyceridaemia: A practical approach for primary care’

My colleagues and I read with interest the recent article by Lan et al, ‘Hypertriglyceridaemia: A practical approach for primary care’.1 While comprehensive, we were concerned that carbohydrate restriction – the intervention with the strongest mechanistic rationale and clinical evidence for triglyceride reduction – received insufficient emphasis in the dietary recommendations.

Table 2’s dietary guidance appropriately mentions restricting refined sugars and sugar‑sweetened beverages, yet frames carbohydrate intake generically as ‘4–6 servings/day unless a lower‑carbohydrate diet is indicated’. This understates the primary role of dietary carbohydrate in driving hepatic triglyceride synthesis. Parks demonstrated that carbohydrate intake, particularly fructose, directly stimulates hepatic de novo lipogenesis and very low‑density lipoprotein production – the metabolic foundation of hypertriglyceridaemia.2 Importantly, Forsythe et al showed triglyceride reduction occurs with carbohydrate restriction independent of weight loss, confirming this is a direct metabolic effect rather than merely a consequence of caloric reduction.3

The clinical trial evidence strongly supports prioritising carbohydrate restriction. Multiple systematic reviews demonstrate consistently superior triglyceride reduction with low‑carbohydrate versus low‑fat diets. The meta‑analysis by Mansoor et al found an additional 0.26 mmol/L reduction favouring low‑carbohydrate approaches,4 while Volek et al demonstrated 51% triglyceride reduction with very low‑carbohydrate diets, in comparison to 19% with conventional low‑fat diets.5 These represent clinically meaningful differences for our patients.

For patients with insulin resistance and metabolic syndrome – the very populations most likely to present with hypertriglyceridaemia – carbohydrate restriction addresses the underlying metabolic dysfunction.6 Rather than treating triglycerides as an isolated lipid abnormality, therapeutic carbohydrate reduction improves the entire metabolic cluster: triglycerides, high‑density lipoprotein cholesterol, glycaemic control, blood pressure and hepatic steatosis.

My colleagues and I suggest that clinical reviews and educational materials for general practitioners (GPs) should position carbohydrate restriction more prominently in hypertriglyceridaemia management. For mild‑to‑moderate elevation, eliminating refined carbohydrates and sugary beverages should be explicit first‑line advice. For patients whose triglycerides remain elevated or who have concurrent metabolic syndrome, more comprehensive carbohydrate restriction (targeting <130 g or even <50 g daily for therapeutic ketosis) warrants consideration as primary dietary therapy, not merely as an optional approach.

Australian general practitioners need clear, evidence‑based dietary guidance. The mechanistic rationale, trial evidence and clinical experience all support carbohydrate restriction as foundational therapy for hypertriglyceridaemia.

Author

Penelope Figtree MBBS, FRACGP, Chair, Scientific Committee, Australasian Metabolic Health Society, Sydney, NSW; Conjoint Lecturer, School of Clinical Medicine, Rural Clinical Campus Port Macquarie, UNSW Medicine & Health, NSW; General Practitioner, Lowcarbpmq, Port Macquarie, NSW
Competing interests: PF is Chair of the Scientific Committee for the Australasian Society of Metabolic Health and operates a general practice with a special interest in metabolic health and low‑carbohydrate dietary interventions. PF declares no financial conflicts of interest relevant to this correspondence.

AI declaration: The author advises that there was use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and accepts full responsibility for all content. Details on how AI was used have been declared to the editors.

References

  1. Lan NSR, Nelson AJ, Brett T, Hespe CM, Watts GF, Nicholls SJ. Hypertriglyceridaemia: A practical approach for primary care. Aust J Gen Pract 2025;54(11):800–806. doi: 10.31128/AJGP‑01‑25‑7535.
  2. Parks EJ. Dietary carbohydrate’s effects on lipogenesis and the relationship of lipogenesis to blood insulin and glucose concentrations. Br J Nutr 2002;87(Suppl 2):S247–53. doi: 10.1079/BJN/2002544.
  3. Forsythe CE, Phinney SD, Fernandez ML, et al. Comparison of low fat and low carbohydrate diets on circulating fatty acid composition and markers of inflammation. Lipids 2008;43(1):65–77. doi: 10.1007/s11745‑007‑3132‑7.
  4. Mansoor N, Vinknes KJ, Veierød MB, Retterstøl K. Effects of low‑carbohydrate diets v. low‑fat diets on body weight and cardiovascular risk factors: A meta‑analysis of randomised controlled trials. Br J Nutr 2016;115(3):466–79. doi: 10.1017/S0007114515004699.
  5. Volek JS, Phinney SD, Forsythe CE, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids 2009;44(4):297–309. doi: 10.1007/s11745‑008‑3274‑2.
  6. Volek JS, Feinman RD. Carbohydrate restriction improves the features of metabolic syndrome. Metabolic syndrome may be defined by the response to carbohydrate restriction. Nutr Metab (Lond) 2005;2(1):31. doi: 10.1186/1743‑7075‑2‑31.

Reply

Thank you for your letter regarding our clinical article, ‘Hypertriglyceridaemia: A practical approach for primary care’.1 We agree that reducing carbohydrate intake is foundational in the management of hypertriglyceridaemia and that this aspect could have been emphasised further. Within the limits of the word count, the article aimed to provide an overview of the overall management of hypertriglyceridaemia. This includes the identification of secondary causes such as diets high in carbohydrates and the importance of dietary modifications focusing on healthy eating patterns, which encompasses a reduction in simple carbohydrates. The importance of regulation of dietary carbohydrates was collectively emphasised in Tables 1 and 2, in Figure 1 and in the section on non‑pharmacological treatment. As noted, prior studies have shown that carbohydrate‑restricted diets lower triglyceride levels, with greatest reductions seen in very low‑carbohydrate diets.2

Table 2 was reproduced from the American College of Cardiology guidelines for the management of persistent hypertriglyceridaemia3 and was also featured in a recent National Lipid Association (US) clinical perspective article.4 The quoted recommendation for ‘4–6 servings/day’ refers to grains (principally fibre‑rich whole grains) rather than carbohydrates as a whole; we apologise if this was unclear. Nonetheless, we recognise that grains are a source of carbohydrates and that this should be considered in any dietary recommendations. Understanding and adhering to dietary modifications can be challenging for many patients, particularly diets that are low in both carbohydrates and fats.5 This highlights the need for personalised nutritional recommendations by a registered dietitian, which may enhance adherence and cardiometabolic care.

Overall, we agree that evidence‑based dietary guidance for Australian general practitioners is essential and that carbohydrate restriction should be emphasised as foundational therapy for hypertriglyceridaemia. Comprehensive practical guidance on food consumption for the prevention of cardiovascular disease is provided in an earlier expert position statement.6

Author

Nick S R Lan MBBS (Hons), MClinUS, MClinRes (Dist), MSc, FRACP, Cardiologist, Department of Cardiology, Fiona Stanley Hospital, Perth, WA; Clinical Senior Lecturer, Medical School, The University of Western Australia, Perth, WA

Adam J Nelson MBBS, MBA/MPH, PhD, FRACP, Cardiologist, Victorian Heart Institute, Monash University, Melbourne, Vic; Associate Professor, Adelaide Medical School, The University of Adelaide, Adelaide, SA

Gerald F Watts MD, DSc, PhD, FRCP, FRACP, Professor, Medical School, The University of Western Australia, Perth, WA; Consultant Physician, Departments of Internal Medicine and Cardiology, Royal Perth Hospital, Perth, WA

Stephen J Nicholls MBBS, PhD, FRACP, Professor, Cardiologist, Victorian Heart Institute, Monash University, Melbourne, Vic
Competing interests: NSRL has received research funding from Sanofi as part of a Clinical Fellowship in Endocrinology and Diabetes; education support from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, CSL Seqirus, Eli Lilly, Novartis, Novo Nordisk and Pfizer; speaker honoraria from Amgen, AstraZeneca, Boehringer Ingelheim, CSL Seqirus, Eli Lilly, Menarini, Novartis, Novo Nordisk and Sanofi; and has participated in advisory boards for Eli Lilly. AJN has received research support from AstraZeneca, Amgen, Eli Lilly, Novartis and is a consultant for Amgen, AstraZeneca, Boehringer Ingelheim, CSL Sequiris, Eli Lilly, GSK, Sanofi Pasteur and Novo Nordisk. GFW has received honoraria for advisory boards and research grants from Amgen, Arrowhead, Esperion, Gemphire, Kowa, Novartis, Pfizer, Sanofi, Novo Nordisk and Regeneron. SJN has received grant/research support from AstraZeneca, NewAmsterdam Pharma, Amgen, Anthera, Cyclarity, Eli Lilly, Esperion, Novartis, Cerenis, The Medicines Company, Resverlogix, InfraReDx, Roche, Sanofi‑Regeneron, and LipoScience; and was a consultant for Abcentra, AstraZeneca, Amarin, Akcea, Eli Lilly, Anthera, Omthera, Merck, Takeda, Resverlogix, Sanofi‑Regeneron, CSL Behring, Esperion, Boehringer Ingelheim, Daiichi Sankyo, Scribe Therapeutics, Silence Therapeutics, CSL Seqirus and Vaxxinity and holds stock options for NewAmsterdam Pharma.

AI declaration: The authors confirm that there was no use of artificial intelligence (AI)‑assisted technology for assisting in the writing or editing of the manuscript.

References

  1. Lan NSR, Nelson AJ, Brett T, Hespe CM, Watts GF, Nicholls SJ. Hypertriglyceridaemia: A practical approach for primary care. Aust J Gen Pract 2025;54(11):800–06. doi: 10.31128/AJGP‑01‑25‑7535.
  2. Fechner E, Smeets ETHC, Schrauwen P, Mensink RP. The effects of different degrees of carbohydrate restriction and carbohydrate replacement on cardiometabolic risk markers in humans – A systematic review and meta‑analysis. Nutrients 2020;12(4):991. doi: 10.3390/nu12040991.
  3. Virani SS, Morris PB, Agarwala A, et al. 2021 ACC expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia: A report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol 2021;78(9):960–93. doi: 10.1016/j.jacc.2021.06.011.
  4. Kirkpatrick CF, Sikand G, Petersen KS, et al. Nutrition interventions for adults with dyslipidemia: A clinical perspective from the National Lipid Association. J Clin Lipidol 2023;17(4):428–51. doi: 10.1016/j.jacl.2023.05.099.
  5. Kowalski C, Dustin D, Ilayan A, Johnson LK, Belury MA, Conrad Z. Are people consuming the diets they say they are? Self‑reported vs estimated adherence to low‑carbohydrate and low‑fat diets: National health and nutrition examination survey, 2007–2018. J Acad Nutr Diet 2025;125(2):239–46.e1. doi: 10.1016/j.jand.2024.07.006.
  6. Nestel PJ, Beilin LJ, Clifton PM, Watts GF, Mori TA. Practical guidance for food consumption to prevent cardiovascular disease. Heart Lung Circ 2021;30(2):163–79. doi: 10.1016/j.hlc.2020.08.022.

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