How to increase high-density lipoprotein (HDL) levels?

How to Increase HDL Cholesterol

Regular aerobic exercise for at least 30 minutes, 5 times weekly, combined with resistance training, represents the most effective lifestyle intervention for raising HDL cholesterol levels, and should be the first-line approach before considering pharmacological options. 1, 2

Exercise Interventions (Most Effective)

Aerobic Exercise:

• Perform at least 30 minutes of moderate-intensity aerobic exercise 5 times weekly, targeting 1200-1600 kcal per week of exercise expenditure 1, 2
• For healthy individuals, exercise at 70-80% heart rate reserve with prolonged moderate-intensity sessions 1, 2
• For those with dyslipidemia, progress to higher intensity at 85% maximum heart rate for greater HDL improvements 1, 2
• Exercise demonstrates a dose-response relationship—more activity yields greater HDL increases, with meta-analysis showing an average 4.6% HDL increase after 12+ weeks 2
• Individual studies report HDL increases ranging from 13% to 29% depending on intensity and duration 2

Resistance Training:

• Combine aerobic exercise with resistance training for optimal results 1, 2
• Start with low-intensity resistance training at 50% of 1 repetition maximum (1RM) 1, 2
• Progress to moderate-to-high intensity at 75-85% of 1RM for those with dyslipidemia 1, 2
• For limited mobility populations, implement resistance training progressing from 50% to 75% of 1RM in major muscle groups 1

Dietary Modifications

Fat Composition:

• Replace saturated fats with monounsaturated fats (olive oil, canola oil) and polyunsaturated fats (corn oil, peanuts) rather than increasing carbohydrates 3, 1, 4
• Limit saturated fat to <7% of total daily calories 1, 4
• Completely avoid trans-unsaturated fatty acids (<1% of energy), which actively lower HDL 3, 1, 2

Carbohydrate Management:

• Minimize refined carbohydrates and added sugars, as high-carbohydrate diets reduce HDL levels 3, 1, 4
• When consuming carbohydrates, choose low glycemic index foods with high fiber content to minimize HDL reduction 3
• Limit beverages and foods with added sugars 1, 4

Additional Dietary Components:

• Include plant stanols/sterols (2g/day) for overall lipid profile improvement 1, 4
• Increase soluble fiber intake (10-25g/day) 1, 4
• Consume fish, especially oily fish, at least twice weekly for omega-3 fatty acids 4
• Limit dietary cholesterol to <200 mg/day 4

Weight Management and Smoking Cessation

Weight Loss:

• Achieve and maintain a healthy body weight (BMI 18.5-24.9 kg/m²), as excess weight adversely affects HDL levels 1, 4
• Weight reduction produces a 0.01 mmol/L (0.4 mg/dL) HDL increase for every kg decrease in body weight once stabilized 3

Smoking Cessation:

• Quit smoking immediately—this single intervention can increase HDL cholesterol by up to 30% 3, 1, 2, 4

Alcohol Consumption

• Moderate ethanol consumption (up to 20-30 g/day in men and 10-20 g/day in women) is associated with increased HDL-C levels compared to abstainers 3
• However, excessive alcohol can aggravate hypertriglyceridemia and should be avoided 4

Pharmacological Options (When Lifestyle Changes Are Insufficient)

Niacin (Nicotinic Acid):

• Niacin is the most effective drug for raising HDL cholesterol 3, 1, 2, 4
• Important caveat: Niacin can adversely affect blood glucose levels, particularly relevant in diabetic patients 1, 2, 4
• Dosing ranges from 1.5-3 g for immediate-release to 1-2 g for extended-release formulations 3

Fibrates:

• Fibrates (gemfibrozil, fenofibrate) effectively increase HDL and reduce triglycerides 3, 1, 2, 4
• Fenofibrate is FDA-approved to increase HDL-C in adult patients with primary hypercholesterolemia or mixed dyslipidemia 5
• Gemfibrozil demonstrated a 34% relative reduction in serious coronary events in the VA-HIT trial among patients with low HDL and prior cardiovascular disease 1
• Fenofibrate should be given with meals to optimize bioavailability 5
• Initial dose of fenofibrate is 160 mg once daily for primary hypercholesterolemia or mixed dyslipidemia 5

Target HDL Levels and Monitoring

Target Levels:

• Target HDL levels are >40 mg/dL for men and >50 mg/dL for women, due to physiological differences 1

Monitoring Strategy:

• Measure lipid levels annually in adults with diabetes or cardiovascular risk factors 1, 4
• Measure every 2 years for low-risk individuals 1
• Evaluate lifestyle interventions at regular intervals 1, 4
• Consider pharmacological therapy at 3-6 months if targets are not achieved with lifestyle modifications alone 1, 4

Common Pitfalls to Avoid

• Very low-fat diets (<15% energy as fat) can paradoxically lower HDL cholesterol 4
• Replacing saturated fats with high-carbohydrate foods (rather than unsaturated fats) reduces HDL while lowering LDL 3
• High fructose/sucrose intake is associated with more pronounced HDL decrease 3
• Relying on medication without addressing underlying lifestyle factors will limit long-term success 4
• ATP III reduced the trial period of lifestyle modifications from six months to 12 weeks before considering medications, recognizing the limitations of nonpharmacologic treatment 3