How can I increase my high‑density lipoprotein (HDL) cholesterol?

How to Increase HDL Cholesterol

Start with lifestyle modifications—specifically regular aerobic exercise combined with dietary fat optimization—which can raise HDL-C by 10-13% when combined, and add pharmacological therapy with niacin or fibrates only if lifestyle changes fail to achieve target HDL-C levels (>40 mg/dL in men, >50 mg/dL in women) after 3-6 months. 1, 2

Lifestyle Interventions: First-Line Approach

Exercise (Most Effective Single Intervention)

Engage in at least 150 minutes per week of moderate-intensity aerobic exercise, which increases HDL-C by 3.1-6 mg/dL. 1 For optimal results:

• Perform aerobic exercise at 70-80% heart rate reserve for at least 30 minutes, 5 times weekly, targeting 1,200-1,600 kcal per week of energy expenditure. 2
• Add resistance training at 50% of 1 repetition maximum (1RM) for healthy individuals, progressing to 75-85% of 1RM for those with dyslipidemia. 2
• Exercise demonstrates a dose-response relationship—more activity yields greater HDL-C increases. 2

Dietary Modifications

Replace saturated fats with monounsaturated and polyunsaturated fats rather than increasing carbohydrates, keeping saturated fat <7% of total daily calories. 2, 3

• Completely avoid trans-unsaturated fatty acids (<1% of energy), which actively lower HDL-C. 2
• Minimize refined carbohydrates and added sugars—high-carbohydrate diets reduce HDL-C by 0.1 mmol/L for every 10% energy substitution from fat. 1, 3
• Consume more than 10 grams of soluble fiber per day for modest HDL-C improvements. 1
• Eat fish, especially oily fish, at least twice weekly for omega-3 fatty acids. 2, 3

Weight Loss and Smoking Cessation

Each kilogram of sustained weight loss increases HDL-C by 0.4 mg/dL, so achieve and maintain a healthy BMI of 18.5-24.9 kg/m². 1, 2

Quit smoking immediately—this single intervention can increase HDL-C by up to 30%. 1, 2, 3

Alcohol Consumption

Moderate alcohol consumption (up to 20-30 g/day in men, 10-20 g/day in women) is associated with increased HDL-C levels compared to abstainers. 1 However, excessive alcohol can aggravate hypertriglyceridemia. 3

Pharmacological Therapy: When Lifestyle Is Insufficient

Consider pharmacological therapy at 3-6 months if lifestyle modifications fail to achieve target HDL-C levels. 1, 3

Niacin (Nicotinic Acid): First-Line Pharmacological Option

Niacin is the most effective drug for raising HDL-C and has demonstrated CHD risk reduction in clinical trials both alone and in combination with statins. 4, 1, 2

• Low doses (≤2 g/day) have minimal effect on glycemic control in diabetic patients, though niacin can adversely affect blood glucose levels. 1, 2
• A sizable minority of patients are intolerant due to side effects, primarily flushing. 4

Fibrates: Second-Line Option

Fibrates (gemfibrozil, fenofibrate) effectively increase HDL-C and reduce triglycerides, with gemfibrozil demonstrating a 24-34% decrease in cardiovascular events in patients with low HDL-C and prior cardiovascular disease in the VA-HIT trial. 1, 2

• Fenofibrate is FDA-approved as adjunctive therapy to diet to increase HDL-C in patients with primary hypercholesterolemia or mixed dyslipidemia, with initial dosing of 160 mg once daily with meals. 5
• For diabetic patients, fibrates are preferred over niacin because they do not adversely affect glycemic control. 1
• Fenofibrate does not interfere with statin catabolism and likely does not substantially increase myopathy risk when combined with moderate-dose statins, unlike gemfibrozil. 4

Important Caveat About Combination Therapy

The combination of statins with nicotinic acid, fenofibrate, and especially gemfibrozil has been associated with increased risk of myositis. 1 Fenofibrate is safer than gemfibrozil for statin combinations. 4

Target HDL-C Goals

Aim for HDL-C >40 mg/dL (1.02 mmol/L) in men and >50 mg/dL (1.28 mmol/L) in women. 1, 2, 3

Monitoring Strategy

Measure lipid levels annually in adults with diabetes or cardiovascular risk factors, and every 2 years for low-risk individuals. 2, 3

Evaluate lifestyle interventions at regular intervals and consider pharmacological therapy at 3-6 months if targets are not achieved. 2, 3

Withdraw therapy in patients who do not have an adequate response after two months of treatment with the maximum recommended dose. 5

Common Pitfalls to Avoid

Very low-fat diets (<15% energy as fat) can paradoxically lower HDL-C. 3

High-carbohydrate diets, especially those high in sugars, reduce HDL-C levels—avoid this common mistake. 3

Relying on medication without addressing underlying lifestyle factors will limit long-term success. 3

The magnitude of HDL-C increase from lifestyle changes alone is typically only 3-6 mg/dL, so realistic expectations are important. 1

Special Considerations for Diabetic Patients

Optimizing glycemic control should be the first therapeutic priority in diabetic patients, as better diabetes management improves the overall lipid profile, including HDL-C. 1

Fibrates are the preferred pharmacological agents for diabetic patients needing HDL-C elevation, as niacin is relatively contraindicated due to glycemic effects. 1

Important Limitation

Although HDL-C is a powerful predictor of cardiovascular disease, current documentation of risk reduction through controlled clinical trials is not sufficient to warrant setting a specific goal value for raising HDL-C beyond the thresholds mentioned. 4 The primary target of lipid-lowering therapy remains LDL-C. 4