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

How to Increase HDL Cholesterol

The most effective strategy to raise HDL cholesterol combines regular aerobic exercise (at least 150 minutes weekly of moderate-intensity activity), weight loss if overweight, smoking cessation, and dietary modifications that replace saturated fats with monounsaturated fats—this combination can increase HDL-C by 10-13%. 1, 2, 3

Lifestyle Interventions (First-Line Approach)

Exercise (Most Effective Single Intervention)

• Engage in aerobic exercise totaling 1,500-2,200 kcal/week of energy expenditure (approximately 25-30 km of brisk walking weekly), which increases HDL-C by 3.1-6 mg/dL (0.08-0.15 mmol/L). 4, 1, 5
• Aim for at least 30 minutes of moderate-intensity aerobic activity, 5 times weekly, combined with resistance training for optimal results. 1, 2
• For patients with dyslipidemia, progress to higher intensity aerobic exercise at 85% maximum heart rate and moderate-to-high intensity resistance training at 75-85% of 1RM for greater improvements. 1

Weight Management

• Each kilogram of sustained weight loss increases HDL-C by 0.4 mg/dL (0.01 mmol/L) once weight stabilizes. 4, 5
• Target a BMI of 18.5-24.9 kg/m². 1, 2

Smoking Cessation

• Quit smoking immediately—this single intervention can increase HDL-C by up to 30%. 4, 1, 2, 5

Dietary Modifications

• Replace saturated fats (limit to <7% of total calories) with monounsaturated fats (olive oil, avocados, nuts) or polyunsaturated fats rather than increasing carbohydrates, which can lower HDL-C. 4, 1, 2
• Completely avoid trans-unsaturated fatty acids (<1% of energy), as they actively lower HDL-C. 4, 1
• Minimize refined carbohydrates and added sugars—high-carbohydrate diets decrease HDL-C by 0.1 mmol/L (4 mg/dL) for every 10% energy substitution from fat. 4, 5
• Choose carbohydrate-rich foods with low glycemic index and high fiber content to minimize HDL-C reduction. 4
• Consume more than 10 g of soluble fiber daily from legumes, fruits, vegetables, and whole grains. 4, 2, 5
• Eat fish, especially oily fish, at least twice weekly for omega-3 fatty acids. 1, 2

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, though this must be balanced against other health risks. 4, 5

Pharmacological Interventions (When Lifestyle Is Insufficient After 3-6 Months)

Primary Target: LDL-C First

• The primary target of therapy remains LDL cholesterol—HDL-C raising becomes a secondary priority only after achieving LDL-C goals. 4
• ATP III does not specify a specific HDL-C raising goal, as evidence for targeted HDL-C therapy remains insufficient. 4

Niacin (Nicotinic Acid) - First-Line Pharmacological Option

• Niacin is the most effective drug for raising HDL-C (increases by 25-35% at highest doses) and has demonstrated coronary heart disease risk reduction in randomized trials both as monotherapy and combined with statins. 1, 6
• Low doses (≤2 g/day) have minimal effect on glycemic control in diabetic patients. 5
• A sizable minority of patients experience flushing, which limits tolerability. 1
• Niacin is relatively contraindicated in diabetic patients due to potential adverse effects on blood glucose. 1, 5

Fibrates - Second-Line Option (Preferred in Diabetics)

• Fibrates (gemfibrozil, fenofibrate) effectively increase HDL-C and reduce triglycerides without adversely affecting glycemic control, making them the preferred agents for diabetic patients. 1, 5
• Gemfibrozil demonstrated a 34% relative reduction in serious coronary events in the VA-HIT trial among patients with low HDL-C and prior cardiovascular disease. 1
• Fenofibrate does not interfere with statin metabolism and is safer than gemfibrozil when combined with statins—gemfibrozil substantially increases myopathy risk. 1, 7
• Initial fenofibrate dosing: 54-160 mg daily with meals, individualized based on response; use 54 mg daily in patients with mild-to-moderate renal impairment. 7

Statins

• Statins modestly raise HDL-C while primarily lowering LDL-C, and have the greatest evidence for reducing CAD events in patients with low HDL-C. 8

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, 5

Monitoring Strategy

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

Critical Pitfalls to Avoid

• Very low-fat diets (<15% energy as fat) paradoxically lower HDL-C—maintain adequate unsaturated fat intake (15-20% of calories). 2, 3
• High-carbohydrate diets, especially those high in fructose/sucrose, significantly reduce HDL-C. 4, 2
• Combination therapy with statins plus gemfibrozil carries substantial myositis risk; fenofibrate is safer for combination therapy. 1, 5
• In diabetic patients, optimize glycemic control first, as better diabetes management improves the overall lipid profile including HDL-C. 5