Raising Your HDL Levels

Increasing the GOOD cholesterol

Women exercising together in class
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High levels of HDL cholesterol, often called "good" cholesterol, are associated with a reduced risk of coronary artery disease (CAD). It appears that HDL particles "scour" the walls of blood vessels, cleaning out excess cholesterol that otherwise might have been used to make the plaques that cause CAD. The HDL cholesterol is then carried to the liver, where it is processed into bile, and secreted into the intestines and out of the body.

So, when we measure a person's HDL cholesterol level, we seem to be measuring how vigorously his or her blood vessels are being "scrubbed" free of cholesterol.

HDL levels below 40 mg/dL are associated with an increased risk of CAD, even in people whose total cholesterol and LDL cholesterol levels are normal. HDL levels between 40 and 60 mg/dL are considered "normal," and do not very much affect the risk of CAD one way or the other. However, HDL levels greater than 60 mg/dL are actually associated with a reduced risk of heart disease.

In recent years it has become apparent that it is a gross oversimplification to think of HDL cholesterol as always being "good." Drug companies have spent billions of dollars developing drugs to increase HDL, and to the dismay of all, these drugs have failed to reduce cardiac risk - despite the fact that they make HDL levels go up.

So the HDL story is more complex than scientists originally had hoped.

Fortunately, it is still true that there are several things we can all do to increase our HDL levels in a healthy way, and in a way that does appear to benefit our risk of heart disease.

How Can We Increase Our HDL Levels?

Aerobic Exercise

Many people don't like to hear it, but regular aerobic exercise (any exercise, such as walking, jogging or bike riding, that raises your heart rate for 20 to 30 minutes at a time) may be the most effective way to increase HDL levels. Recent evidence suggests that the duration of exercise, rather than the intensity, is the more important factor in raising HDL cholesterol. But any aerobic exercise helps.

Lose Weight

Obesity results not only in increased LDL cholesterol, but also in reduced HDL cholesterol. If you are overweight, reducing your weight should increase your HDL levels. This is especially important if your excess weight is stored in your abdominal area; your waist-to-hip ratio is particularly important in determining whether you ought to concentrate on weight loss.

Stop Smoking

If you smoke, giving up tobacco will result in an increase in HDL levels. (This is the only advantage I can think of that smokers have over non-smokers—it gives them something else to do that will raise their HDL.)

Cut Out the Trans Fatty Acids

Trans fatty acids are currently present in many of your favorite prepared foods—anything in which the nutrition label reads "partially hydrogenated vegetable oils"—so eliminating them from the diet is not a trivial task. But trans fatty acids not only increase LDL cholesterol levels, they also reduce HDL cholesterol levels. Removing them from your diet will almost certainly result in a measurable increase in HDL levels. 

Alcohol

With apologies to the American Heart Association, which discourages doctors from telling their patients about the advantages of alcohol: one or two drinks per day can significantly increase HDL levels. More than one or two drinks per day, one hastens to add, can lead to substantial health problems including heart failure. And unfortunately there are many people who are simply incapable of limiting their alcohol intake to one or two drinks per day. Here's more on alcohol and the heart.

Increase the Monounsaturated Fats in Your Diet

Monounsaturated fats such as canola oil, avocado oil, or olive oil and in the fats found in peanut butter can increase HDL cholesterol levels without increasing the total cholesterol.

Add Soluble Fiber to Your Diet

Soluble fibers are found in oats, fruits, vegetables, and legumes, and result in both a reduction in LDL cholesterol and an increase HDL cholesterol. For best results, at least two servings a day should be used.

Other Dietary Means to Increasing HDL

Cranberry juice has been shown to increase HDL levels. Fish and other foods containing omega-3 fatty acids can also increase HDL levels. In postmenopausal women (but not, apparently, in men or pre-menopausal women) calcium supplementation can increase HDL levels.

What About a Low-Fat Diet?

Substantial evidence now shows that a low-fat diet often reduces - rather than increases - HDL levels. This result is not specifically caused by “not enough fat,” but rather, is caused by consuming too many carbohydrates. The American Heart Association and the American College of Cardiology have quietly stopped recommending low-fat diets for heart disease prevention.

Indeed, it is low-carb diets—and not low-fat diets—which can substantially increase HDL levels.

What About Drugs?

Drug therapy for raising HDL cholesterol levels has, so far, been a disappointment. While enthusiasm for drugs that would increase HDL levels was high just a few years ago, recent events have significantly dampened that enthusiasm.

Statins, the class of drugs which has proven highly successful in reducing LDL cholesterol ("bad" cholesterol), are generally not very effective at increasing HDL levels.

For years, niacin was the mainstay of drug therapy for raising HDL levels. Niacin is one of the B vitamins. The amount of niacin needed for increasing HDL levels are so high, however, that it is classified as a drug when used for this purpose.

Aside from the inconvenience of taking niacin, two recent, highly-anticipated clinical trials have suggested that raising HDL levels with niacin failed to demonstrate any improvement in cardiovascular outcomes. Furthermore, treatment with niacin was associated with an increased risk of stroke, and increased diabetic complications. At this point, most doctors are very reluctant to prescribe niacin therapy for the purpose of raising HDL levels.

Perhaps most disappointing of all, a new class of drugs (the so-called CETP-inhibitors), which several pharmaceutical companies have been enthusiastically developing for several years to raise HDL levels, has become a great disappointment. While these drugs do indeed increase HDL levels, they have not demonstrated an ability to improve cardiac risk - and on the contrary, studies appear to show a worsening in cardiac risk with some of these drugs. It is unclear today whether any CETP-inhibitors will ever reach the market.

In Summary

Higher levels of HDL cholesterol are generally associated with lower cardiac risk. While pharmacological approaches to increasing HDL levels have so far been a disappointment, there are several lifestyle choices we can all make that will reduce our cardiac risk in general, and our HDL levels in particular.

Sources:

The AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011; 365:2255-2267 DOI: 10.1056/NEJMoa1107579

Gerasimova E, Perova N, Ozerova I, et al. The effect of dietary n-3 polyunsaturated fatty acids on HDL cholesterol in Chukot residents vs muscovites. Lipids 1991; 26:261.

Michos ED, Sibley CT, Baer JT, et al. Niacin and statin combination therapy for atherosclerosis regression and prevention of cardiovascular disease events. J Am Coll Cardiol 2012; DOI:10.1016/j.jacc.2012.01.045.

Moffatt RJ. Effects of cessation of smoking on serum lipids and high density lipoprotein-cholesterol. Atherosclerosis 1988; 74:85.

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106:3143.

Wood PD, Stefanick ML, Williams PT, Haskell WL. The effects on plasma lipoproteins of a prudent weight-reducing diet, with or without exercise, in overweight men and women. N Engl J Med 1991; 325:461.

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