How to increase High-Density Lipoprotein Cholesterol (HDL-C)?

Strategies to Increase HDL-C Levels

Regular aerobic exercise combined with resistance training is the most effective lifestyle intervention to increase HDL cholesterol levels. This should be the cornerstone of any strategy to raise HDL-C 1.

Exercise Interventions

• Aerobic Exercise: At least 30 minutes of moderate-intensity aerobic activity 5 times weekly

  • Walking briskly (15-20 min per mile) is an effective moderate-intensity activity 2
  • Aim for 7-14 miles of walking/jogging per week (equivalent to 1200-1600 kcal) to achieve significant HDL-C increases 3

• Resistance Training:

  • 8-10 different exercises, 1-2 sets per exercise, 10-15 repetitions at moderate intensity, 2 days/week 2
  • For those with elevated cholesterol: aim for moderate to high-intensity resistance training at 75-85% of one-repetition maximum 1

Dietary Modifications

• Reduce saturated fat to <7% of total calories 2, 1
• Increase unsaturated fats to 15-20% of total calories 4
• Limit trans fats, which reduce HDL while increasing LDL 1
• Choose high-fiber, low-glycemic index carbohydrates (whole grains, legumes, fruits, vegetables) 1
• Moderate carbohydrate intake in those with low HDL-C, as high-carbohydrate diets (especially high in sugars) can lower HDL-C 2

Weight Management

• Weight reduction has a beneficial effect on HDL-C levels
  • Each kilogram of weight loss increases HDL-C by approximately 0.4 mg/dL 1
  • A 5-8 kg weight loss can increase HDL-C by 2-3 mg/dL 2
  • Combining healthy diet with weight loss and physical activity can increase HDL-C by 10-13% 4

Alcohol Consumption

• Moderate alcohol consumption (1-2 drinks per day) can increase HDL-C by approximately 12% 2
• Caution: Excessive alcohol should be avoided, particularly in those with hypertriglyceridemia 1
• Wine (especially red wine) contains polyphenols that may provide additional cardiovascular benefits, though non-alcoholic grape beverages may offer similar antioxidant effects 2

Smoking Cessation

• Quitting smoking can increase HDL-C levels by up to 30% 1

Pharmacological Options

When lifestyle interventions are insufficient, medication may be considered:

• Niacin (Nicotinic Acid): Most effective pharmacological agent for raising HDL-C 5

  • Moderate doses (750-2,000 mg/day) can achieve significant HDL benefits 1
  • Side effects include flushing and potential effects on glucose control

• Fibrates (gemfibrozil, fenofibrate):

  • Particularly effective in patients with low HDL and elevated triglycerides 6
  • Fenofibrate is indicated as adjunctive therapy to diet to increase HDL-C in patients with primary hypercholesterolemia or mixed dyslipidemia 7
  • Gemfibrozil can reduce the risk of coronary heart disease in patients with low HDL-C in addition to elevated LDL-C and triglycerides 6

Implementation Strategy

1. Start with lifestyle modifications:

   • Implement regular exercise (both aerobic and resistance)
   • Adopt a heart-healthy diet low in saturated fat and rich in unsaturated fats
   • Achieve and maintain healthy weight
   • Quit smoking
   • Consider moderate alcohol consumption if appropriate

2. Monitor progress with lipid profile checks 4-8 weeks after starting interventions

3. Add pharmacological therapy if lifestyle changes are insufficient:

   • Consider niacin for patients without glucose control issues
   • Consider fibrates, especially for those with concurrent hypertriglyceridemia

Pitfalls and Caveats

• Raising HDL-C alone may not be sufficient to reduce cardiovascular risk; a comprehensive approach addressing all lipid abnormalities is necessary
• High-carbohydrate, low-fat diets may paradoxically lower HDL-C in some individuals 2
• The benefits of raising HDL-C may vary depending on the method used to increase it
• Medication side effects must be carefully monitored, particularly with niacin (flushing, glucose control) and fibrates (gallbladder disease, myopathy risk)