Case Study: Management of Hypertriglyceridemia in a Patient Considered an Undocumented Immigrant

Introduction
The management of elevated triglycerides is a means by which the burden of Atherosclerotic Cardiovascular Disease
(ASCVD) may be reduced and the complication of pancreatitis may be prevented. Simultaneous reduction of significantly elevated triglycerides and non-HDL-C is often needed to mitigate the risk of pancreatitis and decrease
long term ASCVD risk. Secondary causes of elevated triglycerides include diet, medications, metabolic disorders, liver, or  renal disease. Treatment may involve both pharmaceuticals and lifestyle modification. For individuals experiencing the impact of social determinants of health (SDOH), there may be unique barriers to achieving normal triglyceride levels. Lack of access to medical care, healthy food options, or the ability to engage in exercise in a safe environment are areas of potential disruption to achieving normalized lipids. These challenges are even more daunting if one is an undocumented immigrant.

The Department of Homeland Security estimates there are currently 11.4 million undocumented immigrants (UI) in the United States (U.S.). These individuals are classified as persons not born in the U.S., not a citizen, nor a legal resident. (1) Limited health care options, increased vulnerability to food insecurity, and avoidance of medical care due to fear of deportation are SDOH unique to this population.(2) There is also an increased vulnerability associated with interruption of continuous care or regular treatment for chronic conditions common in middle and low-income countries, such as diabetes or hypertension.(3)

According to recent estimates, individuals of Hispanic origin make up more than half of undocumented immigrants, with the majority identified as Mexican-born.(1) Contributors to health disparities experienced disproportionately among Hispanic and Latino Americans include obesity and diabetes.(4) Additional metabolic risk factors frequently associated with obesity include low levels of high density lipoprotein cholesterol (HDL-C) and elevated triglycerides which are most common among Hispanics and South Asians.(5,6) While low HDL-C and elevated low density lipoprotein cholesterol (LDL-C) are the types of dyslipidemias seen most often, Hispanic men specifically tend to experience elevation in triglycerides, LDL-C, and non-HDL-C.(5,7)  

Case Presentation
The patient is a 46-year-old Hispanic male with a past medical history of hyperlipidemia, hypertension, diabetes, and obesity. He presented to an after-hours clinic that provides free primary and specialty care medical services, concerned about results for recent blood work ordered during a previous visit with a volunteer Cardiologist. He was asymptomatic and denied any recent abdominal pain, nausea/vomiting, stool changes, or changes in weight or appetite. His recent fasting lab results included a triglyceride (TG) level of 836 mg/dL, HDL-C level of 36 mg/dL and a hemoglobin A1c level of 8.6 %. Blood pressure was 132/84 and his Body Mass Index (BMI) was 38.8 kg/m2. His current medications included metformin 500mg BID, lisinopril 20mg, and atorvastatin 40mg.

Through a volunteer Spanish translator, the patient shared that he did not think he had ever experienced pancreatitis. He denied any previous surgery, hospitalizations, or additional chronic conditions. He stated for religious reasons he has never tried alcohol. He has not received routine medical care since he was a child, and this was his third visit to the evening clinic.

Currently, his living situation is predominantly reliant on donations from the church he attends. He resides in the spare bed of a fellow church member, and his meals are supplied from a food pantry located in the church. Although unemployed at this time, his previous employment included construction labor. His method of transportation comes from rides provided by friends or his bicycle.

Much time was spent during this visit on patient education. The ability to return for any follow-up appointments, given the instability of his current living situation, was noted as a relevant factor in his clinical care. Thus, medications and lifestyle modifications for ASCVD risk reduction and to avoid pancreatitis were discussed. Handouts on  nutrition recommendations to reduce elevated triglycerides and heart healthy eating patterns were given in both English and Spanish. A new prescription for fenofibric acid 160mg was given, in addition to an increase in metformin to 1000mg BID, as well as refills on his lisinopril and atorvastatin.

Discussion
Triglyceride levels < 150 mg/dL are considered normal (150-199 mg/dL borderline high, 200-499 mg/dL high, and > 500 mg/dL are considered very high). Elevated triglycerides are considered an independent risk factor for cardiovascular disease, and individuals with abnormal levels are considered at an increased risk independent of obesity and diabetes (8). For triglycerides greater than 500 mg/dl, fibrates and omega-3 fatty acids should be considered to reduce the risk of pancreatitis.(9) Diet and lifestyle modifications to reduce high triglycerides include alcohol avoidance, weight loss
if indicated, diet optimization, and an increase in physical activity.(10)

Lipid Abnormalities in Hispanic and Latinos
Data from the National Health and Nutrition Examination Survey (NHANES) 2001- 2012, shows the trend of elevated triglycerides in the U.S. is declining. Currently there is a 25% prevalence among adults, compared to previous 33%.(11) Mexican men and women were more likely to have elevated triglyceride levels compared to non-Hispanic Whites and African Americans.(12) Prevalence has been associated with genes, diet, and/or weight.(13) Lifestyle factors found frequently in the Hispanic population such as diets high in carbohydrates, limited physical activity, and obesity are likely contributors.(14) 

Therapeutic Lifestyle Change and Social Determinants of Health
Lifestyle modifications are important in addressing elevated triglycerides, therefore include limiting excess calories, reducing excess body weight, increasing physical activity, and restricting highly processed carbohydrates. These necessary modifications may present challenges for individuals experiencing SDOH. Barriers such as low health literacy can be further exacerbated if there is a language barrier. Reduced social support and limited access to safe and nutritious foods can also contribute to an elevated risk for cardiovascular disease.(15)

Among immigrant populations, food insecurity is a reality.(16) This may translate into limited access to nutritious foods considered part of a heart healthy eating pattern. Relying on food that has been donated to a food pantry may mean meals that are higher in processed carbohydrates and saturated fat, which can not only worsen dyslipidemia but also contribute to associated conditions such as obesity and diabetes.

In conclusion, when treating patients with elevated triglycerides, success comes with, “meeting the patient where they are”. This may mean assessment of the living situations impacting care such as housing, job status, transportation, and detailed understanding of their access to healthy foods. Spending extra time with patients to understand the current risk factors that could influence their health outcomes such as these socioeconomic factors, allows development of a tailored care plan. Other options include choosing medications that are low cost or prescribing a higher dose so the individual may cut the medicine in half for longer lasting prescriptions.

Availability of  resource lists to hand to the patient with shelter information, local food pantries, bus stop locations, etc., are other helpful tools. Ultimately, it is important to recognize the impact an individual’s social risk factors can have on health status and incorporate that into their care.

Disclosure statement: Ms. Kindig has no financial disclosures to report.
Dr. Elkins has no financial disclosures to report.
References are listed in the LipidSpin .pdf on www.lipid.org