Abstract-More than 90% of patients with type III hyperlipoproteinemia are homozygous carriers of the apolipoprotein (apo) E*2 allele. The great majority of these apoE2(Arg1583 Cys) homozygotes in the general population, however, are normolipidemic. Apparently, expression of the hyperlipidemic state requires additional genetic and/or environmental factors, suggesting a multifactorial etiology. To elucidate these additional risk factors, we analyzed normolipidemic and hyperlipidemic apoE2 homozygotes. Hyperinsulinemia was observed in 27 of 49 apoE2 homozygotes and associated with elevated lipid levels: hyperinsulinemic apoE2 homozygotes had type III hyperlipoproteinemia 6 times more often than apoE2 homozygotes with normal insulin levels (odds ratio 6.2, Pϭ0.02). We screened the normolipidemic and hyperlipidemic apoE2 homozygotes for common variants in candidate genes involved in lipolysis-the APOA1-C3-A4 gene cluster, lipoprotein lipase, and hepatic lipase-and analyzed for associations with the expression of hyperlipidemia.In the hyperinsulinemic group, the 7 carriers of the SstI polymorphism (S2) in the APOC3 gene displayed severely elevated VLDL cholesterol (P insulin by SstI Ͻ0.001) and VLDL triglyceride (P insulin by SstI Ͻ0.01) and low levels of HDL (P insulin by SstI Ͻ0.02). In the normoinsulinemic group, no such relation of the SstI polymorphism with hyperlipidemia was observed. These data provide the first evidence for a combined effect of hyperinsulinemia and the SstI polymorphism on the expression of hyperlipidemia in apoE2 homozygotes. (HLP), is characterized by dysfunctional apolipoprotein (apo) E and by increased serum concentrations of both cholesterol and triglyceride. 3 Biochemically, the disorder is characterized by the presence of -VLDL particles, which are cholesterol-enriched chylomicron and VLDL remnants. More than 90% of the patients with type III HLP are homozygous for a specific isoform of apoE: apoE2(Arg1583 Cys). 4 Compared with the other common isoforms, apoE3 and E4, apoE2 has Ͻ2% binding activity for hepatic lipoprotein receptors, 5,6 which renders apoE2 homozygotes susceptible to accumulation of circulating remnant lipoprotein particles. However, the majority of apoE2 homozygotes in the general population are normolipidemic or even hypolipidemic. 7,8 The latter is due to low plasma LDL levels as a result of (1) compensatory upregulated expression of LDL receptors on the surface of hepatocytes to maintain a normal intrahepatocellular cholesterol concentration and (2) a delayed conversion of IDL into LDL in plasma. 9 The expression of overt hyperlipidemia in apoE2 homozygotes occurs despite compensatory mechanisms, when additional genetic and/or environmental factors result in large amounts of circulating remnants. 4 For the majority of the apoE2 homozygotes with type III HLP, the additional factors causing hyperlipidemia are not known. It has been reported that uncontrolled diabetes mellitus 10,11 and hypothyroidism 12 occasionally contribute to the expression of type III HLP in apo...