What to do if high-density lipoprotein (HDL) cholesterol is low but other lipids are normal?

From the Guidelines

To address low HDL cholesterol when other lipids are normal, focus on lifestyle modifications before considering medications, as these interventions can improve HDL levels and overall cardiovascular health. Increasing physical activity with at least 30 minutes of moderate exercise most days of the week can raise HDL levels by 5-10% 1. Adopting a Mediterranean-style diet rich in olive oil, nuts, fatty fish, fruits, and vegetables while limiting processed foods and refined carbohydrates can also help improve HDL levels. If you smoke, quitting can increase HDL by up to 10%. Maintaining a healthy weight, as losing excess weight can improve HDL levels, is also crucial. Moderate alcohol consumption (one drink daily for women, up to two for men) may slightly increase HDL, though this isn't recommended as a treatment strategy.

Some key lifestyle modifications include:

• Increasing physical activity to enhance HDL production and function
• Adopting a healthy diet to improve cholesterol transport from tissues back to the liver for elimination
• Quitting smoking to reduce cardiovascular risk
• Maintaining a healthy weight to improve HDL levels

For medications, statins like atorvastatin or rosuvastatin may modestly increase HDL while primarily lowering LDL 1. Fibrates such as fenofibrate (145mg daily) can raise HDL by 10-15% and are sometimes prescribed when triglycerides are also elevated 1. Niacin (vitamin B3) can increase HDL by 15-35%, starting at 500mg daily and gradually increasing to 1-2g daily, but side effects like flushing limit its use 1. These interventions work by enhancing HDL production and function, improving cholesterol transport from tissues back to the liver for elimination.

It's essential to prioritize lifestyle modifications and consider medications only when necessary, as the goal is to improve HDL levels and overall cardiovascular health while minimizing potential side effects and risks. Regular monitoring and consultation with a healthcare provider are necessary to determine the best course of treatment for individual cases of low HDL cholesterol.

From the FDA Drug Label

GEMFIBROZIL IS ALSO NOT INDICATED FOR THE TREATMENT OF PATIENTS WITH LOW HDL-CHOLESTEROL AS THEIR ONLY LIPID ABNORMALITY. The FDA drug label does not answer the question.

From the Research

Low HDL Cholesterol with Normal Other Lipids

If high-density lipoprotein (HDL) cholesterol is low but other lipids are normal, there are several steps that can be taken to improve HDL levels.

• Lifestyle interventions can be effective in increasing HDL cholesterol levels, including:
  • A healthful diet that is low in saturated fat and sufficient in unsaturated fat 2
  • Regular physical activity 2, 3
  • Attaining a healthy weight 2, 4
  • Moderate alcohol consumption 2, 3
  • Cessation of cigarette smoking 2, 3
• Combining a healthy diet with weight loss and physical activity can increase HDL cholesterol by 10% to 13% 2
• Pharmacological agents such as fibrates and niacin can also modify HDL cholesterol levels, although their use should be considered on a case-by-case basis 5, 6

Pharmacological Interventions

While lifestyle interventions are the first line of treatment, pharmacological interventions may be necessary in some cases.

• Fibrates have been shown to increase HDL cholesterol and reduce cardiovascular mortality in secondary prevention 5, 6
• Niacin can also raise HDL cholesterol, but its use is limited due to side effects and lack of evidence for cardiovascular benefit 6

Importance of Lifestyle Changes

Lifestyle changes are crucial in managing low HDL cholesterol, even if other lipids are normal.

• A healthy diet and regular physical activity can help improve HDL cholesterol levels and reduce the risk of cardiovascular disease 2, 4, 3
• Further studies are needed to document the effect of lifestyle changes on HDL structure-function and health 3