What increases high-density lipoprotein (HDL) levels?

What Increases HDL Cholesterol Levels

The most effective interventions to raise HDL cholesterol are regular aerobic exercise combined with resistance training, weight loss, smoking cessation, moderate alcohol consumption, dietary fat modification, and pharmacologically—niacin (most potent) or fibrates. 1, 2

Lifestyle Interventions

Exercise (Most Effective Non-Pharmacological Approach)

Regular physical activity represents the single most effective lifestyle intervention for raising HDL cholesterol. 1, 2

• For healthy individuals: Perform at least 30 minutes of moderate-intensity aerobic exercise 5 times weekly, targeting 1200-1600 kcal per week of exercise expenditure 1
• Optimal exercise prescription: Prolonged moderate-intensity aerobic exercise at 70-80% heart rate reserve combined with low-intensity resistance training at 50% of 1 repetition maximum (1RM) 1, 2
• For those with dyslipidemia: Progress to higher intensity aerobic exercise at 85% maximum heart rate with moderate-to-high intensity resistance training at 75-85% of 1RM for greater lipid profile improvements 1, 2
• Dose-response relationship exists: More physical activity yields greater HDL increases, with aerobic exercise corresponding to 1500-2200 kcal/week potentially increasing HDL by 0.08-0.15 mmol/L (3.1-6 mg/dL) 3
• Combined modalities superior: Aerobic exercise plus resistance training provides enhanced benefits compared to either alone 1, 2

Dietary Modifications

Replace saturated fats with unsaturated fats rather than increasing carbohydrates, as this is critical for HDL optimization. 1, 2

• Limit saturated fat to <7% of total daily calories and replace with monounsaturated fats (olive oil, canola oil) and polyunsaturated fats (corn oil, peanuts) 1, 4
• Completely eliminate trans-unsaturated fatty acids (<1% of energy), as these actively lower HDL cholesterol 3, 1, 2
• Minimize refined carbohydrates and added sugars: High-carbohydrate diets reduce HDL by approximately 0.1 mmol/L (4 mg/dL) for every 10% energy substitution from fat, though this effect is minimized with low glycemic index, high-fiber carbohydrates 3
• Include soluble fiber (10-25g/day) from legumes, fruits, vegetables, and whole grains 1
• Consume fish at least twice weekly for omega-3 fatty acids, though n-3 PUFAs have limited (<5%) direct effect on HDL 3, 1

Weight Management

Weight reduction beneficially influences HDL levels with approximately 0.01 mmol/L (0.4 mg/dL) increase for every kilogram of weight loss once stabilized. 3

• Achieve and maintain BMI 18.5-24.9 kg/m² 1
• Weight loss of 20-30% reduction in triglycerides typically accompanies HDL improvements 3

Alcohol Consumption

Moderate alcohol consumption (up to 20-30 g/day in men, 10-20 g/day in women) increases HDL cholesterol compared to abstainers. 3

• This corresponds to 1-2 drinks daily 3
• Caution: Alcohol can significantly elevate triglycerides in hypertriglyceridemic patients, even in small amounts 3

Smoking Cessation

Quitting smoking can increase HDL cholesterol by up to 30%, making this one of the most impactful single interventions. 3, 1, 2

Pharmacological Interventions

Niacin (Nicotinic Acid) - Most Potent

Niacin is the most effective pharmacological agent for raising HDL cholesterol, increasing levels up to 30%, but requires careful monitoring especially in diabetic patients. 3, 1, 5, 6

• Dosing: Initiate at low dose and titrate slowly; maximum dose ≤2 g/day in diabetic patients due to hyperglycemia risk 7
• Monitoring requirements: Obtain baseline hepatic transaminases, fasting glucose or HbA1c, and uric acid before initiation, during up-titration, and every 6 months thereafter 7
• Minimize flushing: Pretreat with aspirin 325 mg 30 minutes before dosing, take with food, use slow titration over 4-8 weeks, and consider extended-release preparations 7
• Contraindications: Hepatic transaminase elevations >2-3x upper limit of normal, persistent severe cutaneous symptoms, persistent hyperglycemia, acute gout, unexplained abdominal pain, new-onset atrial fibrillation 7
• Critical caveat: Combination with statins is extremely effective for diabetic dyslipidemia but may significantly worsen hyperglycemia and carries increased myositis risk 3, 7

Fibrates - Effective Alternative

Fibrates (gemfibrozil, fenofibrate) effectively increase HDL by 5-15% and reduce triglycerides without affecting glycemic control, making them particularly useful in diabetic patients. 3, 1, 6

• FDA-approved indication: Fenofibrate is indicated to increase HDL cholesterol in primary hypercholesterolemia or mixed dyslipidemia 8
• Mechanism: Activates PPARα, increasing lipoprotein lipase activity and apolipoprotein A-I and A-II synthesis 8
• Clinical evidence: Gemfibrozil demonstrated 34% relative reduction in serious coronary events in VA-HIT trial among patients with low HDL and prior cardiovascular disease 1
• Dosing: Fenofibrate 54-160 mg daily with meals to optimize bioavailability; start at 54 mg daily in mild-moderate renal impairment 8
• Combination therapy caution: Risk of myositis increases when combined with statins, particularly gemfibrozil with cerivastatin or in renal disease patients 3

Statins - Modest Effect

Statins produce modest and inconsistent HDL increases (2-10%), though pitavastatin and rosuvastatin may elicit more marked sustained increases. 9, 6

• High-dose statins are moderately effective at reducing triglycerides but not necessarily raising HDL 3

Target HDL Levels and Monitoring

Target HDL cholesterol levels are >40 mg/dL (1.02 mmol/L) for men and >50 mg/dL (1.28 mmol/L) for women due to physiological differences. 3, 1

• Measure lipid levels annually in adults with diabetes or cardiovascular risk factors 3, 1
• Every 2 years for low-risk individuals (LDL <100 mg/dL, HDL >50 mg/dL, triglycerides <150 mg/dL) 3
• Evaluate lifestyle interventions at 6-week intervals, with consideration of pharmacological therapy at 3-6 months if targets not achieved 3, 1
• Reassess lipid parameters every 6-12 months once goals achieved 7

Treatment Algorithm Priority

When HDL is low alongside other lipid abnormalities, prioritize LDL lowering first, then address HDL and triglycerides. 3

1. First priority: Behavioral interventions (exercise, diet, weight loss, smoking cessation) 3
2. If inadequate response: Add fibrates for combined HDL raising and triglyceride lowering in diabetic patients 3
3. Alternative: Niacin with extreme caution and frequent glucose monitoring in diabetics 3, 7
4. Combined hyperlipidemia: Improved glycemic control plus high-dose statin, or statin plus fibrate with myositis monitoring 3

Common Pitfalls

• Avoid high-carbohydrate diets as LDL replacement: This lowers HDL; use unsaturated fats instead 3, 1
• Don't use dietary supplement niacin as substitute for prescription niacin: These are not equivalent 7
• Never combine gemfibrozil with statins without careful myositis monitoring: Risk is particularly high 3, 7
• Don't ignore glucose monitoring with niacin in diabetics: Can significantly worsen hyperglycemia 3, 7