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

How to Improve HDL Cholesterol Levels

Regular aerobic exercise at moderate-to-high intensity (70-85% maximum heart rate) for at least 120-150 minutes per week, combined with resistance training, represents the single most effective intervention for raising HDL cholesterol, with dietary modifications and smoking cessation providing additional benefit. 1, 2

Exercise: The Primary Intervention

Exercise is the cornerstone of HDL elevation and should be prescribed first. The evidence consistently demonstrates that physical activity produces the most reliable HDL increases among all lifestyle interventions. 1, 2

Aerobic Exercise Prescription

• Intensity: Train at 70-85% of maximum heart rate (moderate-to-high intensity) for optimal HDL elevation 1, 2
• Duration: Aim for at least 120-150 minutes total per week, as exercise duration per session is critical for HDL elevation 1
• Volume threshold: A minimum of 900-1200 kcal of energy expenditure per week is required to produce statistically significant HDL increases 1
• Expected benefit: Meta-analysis shows an average HDL increase of 4.6% with 12+ weeks of aerobic exercise, with individual studies reporting increases ranging from 13% (3.9 mg/dL) to 29% depending on intensity and duration 1

Resistance Training Component

• For healthy individuals: Start with low-intensity resistance training at 50% of 1 repetition maximum (1RM) 1, 2
• For those with dyslipidemia: Progress to moderate-to-high intensity resistance training at 75-85% of 1RM 1, 2
• For limited mobility: Implement resistance training progressing from 50% to 75% of 1RM in major muscle groups using circuit training 1, 2

The combination of aerobic and resistance training provides enhanced benefits for the overall lipid profile compared to either modality alone. 1

Dose-Response Relationship

There is a linear dose-response relationship between activity levels and HDL cholesterol—more activity yields greater HDL increases. 1, 2 High-intensity training (65-80% of peak VO2) at high volumes (approximately 20 miles per week) demonstrates the most robust improvements in HDL. 3 One practical target is 7-14 miles per week of jogging or equivalent caloric expenditure of 1200-1600 kcal per week. 4

Dietary Modifications: Secondary but Essential

Fats

• Eliminate trans fats completely (<1% of energy), as they actively lower HDL 2, 5
• Limit saturated fat to <7% of total daily calories 2, 5
• Replace saturated fats with monounsaturated fats (olive oil, canola oil) or polyunsaturated fats (corn oil, peanuts) rather than increasing carbohydrates 1, 2

Carbohydrates and Sugars

• Limit refined carbohydrates and added sugars, as high-carbohydrate diets can reduce HDL cholesterol levels 1, 2, 5
• Avoid very low-fat diets (<15% energy as fat), which paradoxically lower HDL cholesterol 5

Additional Dietary Components

• Include plant stanols/sterols (2g/day) and increase soluble fiber intake (10-25g/day) for overall lipid profile improvement 2
• Consume fish, especially oily fish, at least twice weekly for omega-3 fatty acids 2, 5
• Limit dietary cholesterol to <200 mg/day 2

Weight Management

Achieve and maintain a healthy body weight (BMI 18.5-24.9 kg/m²), as excess weight adversely affects HDL levels. 2, 5 Combining a healthy diet with weight loss and physical activity can increase HDL-C by 10-13%. 6, 7

Smoking Cessation: Immediate Priority

Quit smoking immediately—this single intervention can increase HDL cholesterol by up to 30%. 2, 5 This represents one of the most powerful single interventions available and should be addressed urgently in all smokers.

Pharmacological Options: When Lifestyle Is Insufficient

Niacin (Nicotinic Acid)

Niacin is the most effective drug for raising HDL cholesterol but requires careful monitoring, particularly in diabetic patients. 3, 2, 8

• Dosing: Start at 500 mg at bedtime with a low-fat snack; titrate by no more than 500 mg every 4 weeks to a maintenance dose of 1000-2000 mg daily 8
• Expected benefit: Significant improvements in HDL, LDL, and triglyceride levels 3
• Critical caveat: Can significantly increase blood glucose, particularly at high doses, though modest doses (750-2000 mg/day) produce modest glucose changes generally amenable to adjustment of diabetes therapy 3
• Important limitation: Addition of niacin did not reduce cardiovascular morbidity or mortality among patients treated with simvastatin in the AIM-HIGH trial 8

Fibrates

Fibrates (gemfibrozil, fenofibrate) effectively increase HDL and reduce triglycerides. 3, 2

• Indication: Consider fibrates when HDL is <40 mg/dL and LDL is between 100-129 mg/dL 3
• Evidence: Therapy with fibrates in patients with low HDL has been shown to reduce cardiovascular disease rates and progression of carotid intimal medial progression 3
• Caution: When prescribing fibrates or niacin in combination therapy with a statin, care is needed to minimize the risk of adverse effects 3

Target HDL Levels

• Men: >40 mg/dL 2
• Women: >50 mg/dL (10 mg/dL higher than men due to physiological differences) 3, 2

Monitoring Strategy

• Annual lipid testing in adults with diabetes or cardiovascular risk factors 2, 5
• Every 2 years for low-risk individuals (LDL <100 mg/dL, HDL >60 mg/dL, triglycerides <150 mg/dL) 3
• Evaluate lifestyle interventions at regular intervals, with consideration of pharmacological therapy at 3-6 months if targets are not achieved 2, 5

Common Pitfalls to Avoid

• Do not replace saturated fats with high-carbohydrate foods, as this can paradoxically lower HDL 5
• Do not prescribe very low-fat diets (<15% of calories from fat), which reduce HDL 5
• Do not rely on medication without addressing underlying lifestyle factors, as this limits long-term success 5
• Do not underestimate the exercise volume required—at least 120-150 minutes per week is necessary for meaningful HDL elevation 1