What is the best exercise to improve high-density lipoprotein (HDL) levels in a general adult population?

Best Exercise to Improve HDL Cholesterol

Despite widespread belief, neither aerobic exercise nor resistance training consistently increases HDL cholesterol levels according to the highest-quality guideline evidence, though aerobic exercise at sufficient volume (≥120 minutes weekly, 900-1200 kcal expenditure) may produce modest improvements in select populations. 1

The Evidence Paradox

The 2013 AHA/ACC guidelines—the most authoritative source on this topic—present a sobering reality that contradicts common assumptions:

• Aerobic exercise alone has no consistent effect on HDL-C (moderate strength of evidence) 1
• Resistance training has no effect on HDL-C (low strength of evidence) 1

This represents the most rigorous systematic review of meta-analyses from 2001 onward, rated fair to good quality. 1

When Exercise Does Work: The Threshold Effect

Despite the guideline's conservative stance, more recent evidence synthesis suggests aerobic exercise can modestly increase HDL when specific thresholds are exceeded:

Minimum Effective Dose

• At least 120-150 minutes of total weekly exercise is necessary for meaningful HDL elevation 2
• Minimum 900-1200 kcal energy expenditure per week to produce statistically significant increases 2, 3
• Exercise duration per session is the most critical factor—every 10-minute prolongation associates with approximately 1.4 mg/dL HDL-C increase 3

Optimal Exercise Prescription

For patients seeking HDL improvement, prescribe moderate-to-high intensity aerobic exercise at 70-85% maximal heart rate, 3-4 sessions weekly, 40 minutes per session, for at least 12 weeks. 1, 2, 4

This translates to:

• Jogging 7-14 miles per week (equivalent to 1200-1600 kcal expenditure) 5
• Brisk walking 150 minutes weekly at minimum 1, 4
• High-intensity training at 80% VO2max produces greater effects than lower intensities 2, 4

Expected Magnitude of Benefit

When the exercise threshold is met:

• Average HDL increase of 4.6% (approximately 2.5 mg/dL) across meta-analyses 4, 3
• Individual studies report 13-29% increases depending on intensity and duration 2
• Effects appear at 12 weeks and are sustained with continued activity 1, 2

Critical Caveats

The Dose-Response Relationship

More exercise yields greater HDL increases—there is a linear relationship between activity volume and HDL elevation. 2, 4, 5 Patients below the 900 kcal/week threshold will likely see no HDL benefit. 3

Gender Differences

Women require substantially more exercise volume than men to achieve similar HDL increases, likely due to higher baseline HDL-C levels. 5 However, women should still exercise for the numerous other cardiovascular benefits. 5

Baseline Characteristics Matter

Exercise is more effective in patients with:

• Body mass index <28 3
• Total cholesterol ≥220 mg/dL 3

These patients experience approximately 2.1 mg/dL larger HDL-C increases compared to those with BMI ≥28 and lower cholesterol. 3

Combined Aerobic and Resistance Training

The combination of aerobic exercise with resistance training may provide enhanced benefits for overall lipid profile compared to either alone, though specific effects on HDL remain inconsistent. 2, 4

For patients with limited mobility:

• Resistance training at 50-75% 1RM in major muscle groups can be incorporated 2
• Low-intensity resistance (50% 1RM) combined with moderate aerobic exercise (70-80% heart rate reserve) is suggested for healthy individuals 2

Practical Clinical Approach

Start with moderate-intensity aerobic exercise (70-80% predicted maximal heart rate), 3-5 times weekly, totaling 7-14 miles per week of jogging-equivalent activity. 5 This minimizes cardiac complication risk while maximizing patient adherence. 5

Alternative activities (cycling, swimming, rowing) are acceptable if they meet or exceed 1200-1600 kcal weekly expenditure. 5

The Bottom Line on HDL Quality vs. Quantity

Recent research suggests exercise may improve HDL function (antioxidant capacity, cholesterol efflux) even when HDL-C levels don't increase substantially. 6, 7 This functional improvement may explain cardiovascular benefits independent of HDL-C quantity. 6

For patients with persistently low HDL despite adequate exercise, focus on achieving the lowest possible LDL-C levels rather than pursuing aggressive HDL elevation, as pharmacologic HDL-raising strategies have failed to show clinical benefit. 8