ORIGINAL ARTICLE

Triglyceride Profile in Dyslipidaemia of Type 2 Diabetes Mellitus

Sohail Rafi Khan1, Nishat Ayub1, Sohail Nawab 2 and Tahir S. Shamsi3

ABSTRACT
Objective: To evaluate ratios of serum triglycerides and cholesterol levels which may indicate postprandial lipid handling
and to assess their role as prospective markers of dyslipidaemia in type 2 diabetes mellitus.
Study Design: Comparative, observational study.
Place and Duration of Study: Bismillah Taqee Hospital, Karachi from July 2002 till December 2003.
Patients and Methods: The study comprised 160 subjects, including 83 known type 2 diabetics (45 males, 38 females)
and 77 age-matched controls (45 males, 32 females). Fasting blood samples were analysed for serum triglycerides and
total cholesterol, using automated chemistry analyzer. HDL-C was determined by precipitation method and LDL-C and
VLDL-C were estimated by Friedewalds formula. LDL/HDL ratio and TG/HDL ratios were also calculated. The mean
values for male and female diabetics were compared with that for the male and female non-diabetics respectively and
tested for significance by paired t-test.
Results: Serum triglycerides and VLDL were raised in both male and female diabetics. No significant differences were
observed in levels of serum total cholesterol, LDL, HDL and the LDL/HDL ratio. The mean value of the TG/HDL ratio for
male diabetics was higher than that for the male non-diabetics (p=0.39). A statistically significant difference was found in
the TG/HDL ratios for the female diabetics and non-diabetics (p<0.05).
Conclusion: In this study, type 2 diabetics showed marked hypertriglyceridaemia and raised TG/HDL ratio. The
dyslipidaemia of diabetes predisposes to development of coronary heart disease and, therefore, evaluation of the
TG:HDL ratio may provide a good tool to monitor and manage the lipid abnormalities in diabetics.

Key words: Type 2 diabetes. Serum triglycerides. High density lipoprotein cholesterol (HDL-C).
Low density lipoprotein cholesterol (LDL). Atherogenic index. Triglyceride high density lipoprotein ratio (TG:HDL ratio).

INTRODUCTION type 2 diabetics, high TG levels and low HDL-C levels

Diabetics are at an increased risk of developing
Coronary Heart Disease (CHD).1 Both the Bedford
study2 and the Whitehall study3 showed a strong
relationship between glucose intolerance and arterial
disease.
A major reason for this increased risk of atherosclerosis
lies in the changes that take place in the lipid/lipoprotein
metabolism in the diabetic.1,4 Studies have shown that
the impact of diabetes on the relative risk for developing
CHD is greater for women than men, as diabetes
eliminates the “female advantage”. This increased risk
in diabetic women is due to lower HDL-cholesterol levels
(<50 mg/dL) and raised triglycerides (TG) levels.1,4
Many studies have also indicated an important
predictive role of increased serum TG levels contributing
to the risk for CHD, especially in type 2 diabetics.5,6 In
1 Department of Biochemistry, Karachi Medical and Dental
College, Karachi.
2 Department of Medicine/Haematology3, Bismillah Taqee
Hospital, Karachi.
Correspondence: Prof. Sohail Rafi Khan, B-350, Block-6,
Gulshan-e-Iqbal, Karachi.
E-mail: sohailrafi425@hotmail.com
Received October 20, 2005; accepted March 19, 2008.
frequently co-exist, which are important factors for CHD.
In this regard, TG/HDL-C ratio is one of the important
predictors of heart disease. It is generally considered
that number below 2.5 represents a lower risk of heart
disease. This ratio is also an indicator of LDL particle
size7 and a good predictor of LDL, phenotype B, that
is associated with an increased atherogenic risk.8,9
Whereas, HDL has been assigned a protective role
against the development of atherosclerosis because
of its role in reverse cholesterol transport. HDL is also
associated with the metabolism of the TG rich
lipoproteins, since it is the reservoir of apoprotein
C-2,10 which is the activator of lipoprotein lipase, the
enzyme responsible for the metabolism of chylomicrons
and VLDL in the peripheral tissues. During the
postprandial metabolism of these lipoproteins, there is
an active exchange of lipids and apolipoproteins with
HDL.
Hence the TG:HDL ratio highlights the integrated role
of these two parameters in the removal of a lipid load
from the circulation in the postprandial state.
Many investigators have reported that while fasting
levels of lipids are important in evaluating the risk of
CHD, it may be more relevant to consider the post-
prandial metabolism of lipids,11 particularly in patients
with hypertriglyceridemia.12 It has also been shown that

270 Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (5): 270-273
Triglyceride profile in dyslipidaemia of type 2 diabetes mellitus

chylomicron remnants may be the most atherogenic of RESULTS

lipoprotein particles and highlighted the role of lipolysis
There were a total of 160 subjects. The diabetics (n=83)
and the removal of chylomicrons and chylomicron
were further divided into males (n=45) and females
remnant particles as being important in the development
(n=38).
of coronary heart disease.13,14
The clinically verified non-diabetics (n=77), were also
Particularly in type 2 diabetes mellitus, postprandial
further divided into male (n=45) and female (n=32).
hypertriglyceridaemia has been shown to cause
endothelial dysfunction and predisposing to The mean values for serum total cholesterol, HDL-C,
atherogenesis.15 It has also been suggested that post- LDL-C, VLDL-C and triglycerides in the male diabetics
prandial metabolism of lipids may be affected by even and non-diabetics are given in Table I. The mean value
relatively small changes in the fasting levels.16 Thus of serum triglycerides level was considerably higher in
there is a need to evaluate lipid profiles in our population the diabetics as opposed to that estimated for the
and determine the level of the major lipid risk factors non-diabetics (p=0.28).
for CHD.17 Subsequently, the physician is in a better Table I: Lipids and lipoproteins in male type 2 diabetics.
position to advise our diabetic population about Non-diabetics Type 2 diabetics p-value
therapeutic and dietary measures. Serum triglycerides
mg% (mean + SD) 170 + 84 187 + 69 0.28
The objective of this study was to assess the level of
the major lipid risk factors for CHD in type 2 diabetics by Serum cholesterol
mg% (mean + SD) 194 + 33 196 + 37 0.8
estimation of serum values of cholesterol, TG, HDL-C,
HDL cholesterol
LDL-C, and VLDL, assessing the cumulative stress
mg% (mean + SD) 36 + 5.6 35 + 7.1 0.6
imposed by LDL and HDL by evaluating the LDL:HDL
LDL cholesterol
ratio (The Atherogenic Index) and evaluating the mg% (mean + SD) 126 + 28 123 + 37 0.7
efficiency with which a lipid load is removed from the
VLDL cholesterol
circulation by estimation of the TG:HDL ratio. mg% (mean + SD) 34 + 17 37 + 14 0.286
TG: HDL 5.0 + 3.0 5.5 + 2.2 0.39
PATIENTS AND METHODS LDL: HDL 3.6 + 1.2 3.7 + 1.4 0.96
The study was carried out as a comparative, The mean values for serum levels of total cholesterol,
observational study on a total of 160 subjects, who were HDL-C, LDL-C in the female diabetics were found to be
all outpatients at Bismillah Taqee Hospital, Karachi. The non-significant when compared to those of the female
subject population was divided into two groups of non-diabetics. However, the mean value for serum
clinically diagnosed cases of type 2 diabetes and triglycerides was again found to be considerably higher
clinically verified non-diabetics who were further in female diabetics compared to that of non-diabetics
subdivided gender-wise. (p=0.06) Table II.
The inclusion criteria for the former group was clinically Table II: Lipids and lipoproteins in female type 2 diabetics.
diagnosed type 2 non-obese diabetics above 40 years Non-diabetics Type 2 diabetics p-value
of age with no history of any other pre-existing disease Serum triglycerides
e.g. known coronary heart disease, renal disease or mg% (mean + SD) 184 + 64 177 + 65 0.06
hormonal abnormalities that could effect the lipid profile. Serum cholesterol
Fasting venous blood samples were taken from all mg% (mean + SD) 210 + 50 201 + 34 0.3
individuals and analyzed on the same day. Serum HDL cholesterol
triglyceride and cholesterol were estimated by mg% (mean + SD) 39 + 6.7 38 + 6.6 0.4
enzymatic methods18 by auto-analyzer. The co-efficient LDL cholesterol
of variation was cholesterol (3.5%) and triglycerides mg% (mean + SD) 142 + 46 129 + 26 0.18
(3.2%). The automated chemistry was subjected to VLDL cholesterol
rigorous internal and external quality control measures. mg% (mean + SD) 30 + 13 35 + 13 0.06
HDL-C was estimated by precipitation method and LDL- TG:HDL 3.9 + 1.8 4.9 + 2.0 0.04
C and VLDL-C were calculated by the Friedewald LDL:HDL 3.7 + 1.1 3.5 + 0.8 0.4
formula.19 The ratios of TG:HDL and LDL:HDL were
calculated from their respective mean values. The lipid ratios i.e. LDL:HDL ratio and TG:HDL ratio
were not significantly different between male diabetics
Data was entered and analysis was done on Microsoft
and non-diabetics. The difference in the LDL:HDL ratio
Excel. The mean values for each parameter in the male
in the females was found to be non-significant but a
and female diabetics were compared with that of the comparison of TG:HDL ratios estimated for the female
male and female non-diabetics respectively and the diabetics and non-diabetics showed a significant
differences were tested for significance by paired t-test. difference (p<0.05).

Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (5): 270-273 271
Sohail Rafi Khan, Nishat Ayub, Sohail Nawab and Tahir S. Shamsi
DISCUSSION
The study was carried out on normoglycemic type 2
diabetics and non-diabetics controls to assess the role
of individual parameters of lipid profile in the
dyslipidaemia of type 2 diabetes mellitus, with particular
emphasis on the lipid ratios.
The lipid ratios LDL:HDL and TG:HDL may be better
indicators of how the individual parameters correlate
with each other, while in circulation during the
postparandial state.
Diabetes mellitus type 2 is typically associated with a
dyslipidaemia20 characterized by hypertriglyceridaemia
and low HDL-C levels, while the levels of total
cholesterol and LDL-cholesterol may not differ
significantly from those in the non-diabetics. However,
patients with diabetes often have an abnormally high
number of small dense LDL particles, which has been
found to be related to the TG:HDL ratio.21
These have been reported to be more atherogenic than
larger LDL particles.9 Thus, the LDL-C level in a diabetic
is not the only parameter that should be observed to
evaluate markedly increased cardiovascular risk in
patients with type 2 diabetes.
The results show that regarding the individual values
lipid profile, the main impact of type 2 diabetes appeared
to be on the serum triglyceride and VLDL levels in both
men and women. The mean values of both these
parameters were raised in comparison to their controls,
with the difference being greater and more significant in
the female diabetics. No significant differences were
found between the levels of serum total cholesterol,
HDL-C and LDL-C in diabetic men when compared to
their controls. The diabetic women, however, had lower
mean values for these parameters compared to their
controls. These findings coincide with that of other
studies carried out in the region.6,22 There is a reported
hypertriglyceridaemia as a significant finding in
dyslipidaemia of type 2 diabetes. Other local studies
have reported hypertriglyceridaemia as the predominant
type of dyslipidaemia23,24 ( 60%) followed by low levels
of HDL-C (52%). The findings were more common in
females.
This study supports the above findings by showing
that hypertriglyceridaemia predominates and is more
significant in female type 2 diabetics.
However, another study done in Pakistan reported
raised levels of total cholesterol and LDL as the main
finding.25
Hence, majority of studies reported the finding of
hypertriglyceridaemia as the major indicator of
dyslipidaemia predisposing to coronary risk in the type 2
diabetics of the population.
The LDL:HDL ratio did not differ significantly between
the diabetic groups and their controls.
272
The values of the TG:HDL ratio was higher in the
diabetic groups when compared to their controls, being
significant in the female diabetics.
The value of TG:HDL ratio takes into account both
factors, i.e. the lipid load and the ability to remove the
lipid laden particle from the circulation. The association
of hypertriglyceridaemia with low levels of HDL and its
subfraction HDL2 is established. HDL has been shown
to be protective with regard to CHD because of its role
in reverse transport of cholesterol and by its capacity to
remove triglyceride rich lipoproteins.10 Many studies
have shown that poor efficiency in removing the lipid
stress from the circulation would increase the risk of
atherogenesis.13 The results of this study have shown
that diabetics had a higher value of the TG:HDL ratio,
suggesting a more sluggish removal of lipids from the
circulation and increased concentrations of small dense
LDL particles8,9 than in the non-diabetics. The risk
appeared to be higher in females than males.
However, it should be noted that the desirable value for
TG:HDL ratio has been suggested to be less than 2.5.
The TG:HDL ratio gives an assessment of the total
integrated lipid exposure to the tissues. A combined
parameter of TG:HDL ratio is also beneficial for
assessing the presence of small LDL, therefore, by
considering the ratio of TG:HDL, it may be possible to
differentiate those subjects who are at greater risk of
CHD.
It is, therefore, suggested that evaluation of both these
ratios LDL:HDL and TG:HDL may serve as sensitive
tools to monitor and manage the lipid abnormalities in
type 2 diabetics and in individuals at increased risk of
CHD.
CONCLUSION
Triglyceride levels and TG:HDL ratio should be given as
much importance as the serum cholesterol level and
LDL:HDL ratio, when assessing the risk of CHD.
Triglyceride levels and TG:HDL ratio may be improved
in the diabetic by good blood glucose control for which
aerobic exercise (e.g. walking), a high fibre diet,
decreased dietary refined carbohydrates in the diet and
use of fibrates to lower serum TG level, if necessary. In
addition to diabetics, it may be useful to evaluate the
higher risk subjects i.e. obese and the elderly by
evaluating them in terms of TG:HDL ratio.
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