Last reviewed by Faculty of Harvard Medical School on February 25, 2010
By Harvey B. Simon, M.D.
Harvard Medical School
Men have a higher risk of coronary artery disease than women, and they develop angina and heart attacks about 10 years earlier than their female counterparts. One reason for the gender gap is HDL ("good") cholesterol: Women have higher levels of this protective form of cholesterol.
For decades, scientists have known that high levels of HDL cholesterol protect you from cardiovascular disease. Despite this knowledge, doctors have paid much more attention to lowering the LDL ("bad") cholesterol than to raising the "good" HDL.
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What is HDL?
Doctors call it high density lipoprotein cholesterol, but most people know it as the "good" cholesterol. By any name, HDL cholesterol protects the heart and circulation. It removes harmful cholesterol deposits from the walls of vulnerable arteries, and then brings the cholesterol to the liver, so the body can get rid of it. But new research shows that HDL is even better than we thought. It also has antioxidant, anti-inflammatory and anti-clotting properties. And it improves the workings of the endothelium, the thin layer of cells that lines the arteries, allowing arteries to widen when tissues need more oxygen-rich blood.
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How Much HDL Do You Need?
When it comes to HDL cholesterol, more is better. A level of 40 mg/dL is desirable, but levels above 60 mg/dL are best. Unfortunately, over 35% of American men have HDLs that fall below 40 and many more have HDLs that are below the ideal 60. Since each 1 mg/dL rise in HDL will lower cardiac risk by 2% to 3%, you should get your levels as high as possible.
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Seven Ways To Raise Your HDL
It's easier to take a pill or two than to change the way you live. But in the case of HDL cholesterol, lifestyle therapy is the best way to make changes. Here are seven ways to raise your HDL before you try medication.
- Exercise. Sedentary people who become regular exercisers can raise their HDL by up to 20%. The benefits can kick in with as little as one mile of walking or jogging a day, but the more you do, the better your results. Work up to brisk walking for 40 minutes a day. For added benefit, aim higher. Be patient and persistent in some men, the HDL can start to rise after just two months of exercise, but in others, it may take two years for maximum benefit to occur.
- Dietary fat. Just a few years ago, many doctors believed that a drastic cut in dietary fat was the best way to improve blood cholesterol levels. But scientists noticed that cutting dietary fat below 16% to 22% of total calories actually reduces HDL cholesterol levels (although it also lowers LDL cholesterol levels for the better). So, most nutrition guidelines call for a total fat intake of 25% to 35% of daily calories. But that doesn't mean fat is good for your good cholesterol. Far from it. In fact, the key is the type of fat you eat.
You want to avoid trans fatty acids, which have been widely used in stick margarine, snack foods, fried foods, and commercially-baked goods. A 2% increase in trans fat consumption has been linked to a 23% increase in the risk of coronary heart disease. Even a low intake of trans fat (3 to 7 grams a day) increases risk because trans fat lowers HDL cholesterol and raises LDL cholesterol a double whammy for your health.
The new American Heart Association guidelines recommend limiting trans fatty acids to less than 1% of total daily calories. (If you eat 2,000 calories a day, fewer than 20 should come from trans fats.) Federal regulations now require manufacturers to list the trans fat content of foods on their labels, and many are scrambling to reduce or eliminate these very bad fats. Beware, though. A label is allowed to boast "No Trans Fat" as long as an individual serving contains less than 0.5 grams of trans fat. But serving sizes on labels are typically unreasonably small, and you can exceed your daily maximum of 2 to 3 grams of trans fatty acids with a few "trans fat free" snacks during a single ball game.
- Dietary carbohydrates. Just as there are good fats and bad fats when it comes to heart health, there are good carbohydrates and bad carbohydrates. Eating large amounts of highly refined carbohydrates that are rapidly absorbed into the bloodstream is clearly linked to low levels of HDL cholesterol. But eating slowly absorbed or complex carbohydrates does not depress HDL levels. Here are some examples:
Whole grain bread
Cream of Wheat
Beans, whole wheat pasta
Tropical fruit (bananas)
Temperate climate fruits (apples)
- Alcohol. Alcohol abuse is a major cause of death, disability, and psychosocial difficulties in the United States and around the globe. But moderate amounts of alcohol may provide substantial protection against heart attacks and cardiac death. Much of that protection is due to alcohols effect on HDL cholesterol. In general, moderate drinking will raise HDL levels by about 4 mg/dL, which should cut cardiac risk by about 10%. For men who can drink responsibly and safely, a "prescription" of 1 to 2 drinks a day 5 ounces of wine, 1½ ounces of liquor, or 12 ounces of beer may give a nice boost to lagging HDL levels.
- Weight control. People who are obese have lower HDL levels. But losing excess pounds through the dynamic duo of exercise and diet, will boost HDL levels over and above the effects of regular exercise and a healthful diet. Aim to bring your Body Mass Index (BMI) into the normal range, but even if a BMI of 25 eludes you, be assured that any weight loss will help.
- Tobacco. Smoking has many deleterious effects including substantially reducing good cholesterol. Even passive smoking is harmful. Fortunately, smokers who quit will see their HDL rise by 15% to 20%.
- Chromium. Tiny amounts of this trace mineral are required for good health; 35 mcg (micrograms) a day is the target for men, 25 mcg for women. Chromium works with insulin to help cells use glucose. Supplements are heavily promoted for weight loss, but they are not effective. However, a 1991 study of 63 men found that a chromium supplement could boost HDL levels by 16%, a highly significant increase. The study used 200 mcg of glucose tolerance factor (GTF), an organic form of chromium, 3 times a day. Other studies of chromium and HDL have had mixed results, and much more research is needed before doctors know if chromium really works. Meanwhile, men should get at least the recommended amount from their diets from foods such as brewer's yeast, peanuts, whole grains, and legumes (beans).
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When You Need Medication
Most people with serious cholesterol problems require medication in addition to lifestyle therapy. Medication has been enormously beneficial for both lowering LDL cholesterol and reducing the risk of heart attack and cardiac death. People at the highest risk enjoy the greatest benefit. (See Man to Man, November 2006.)
The statins are the best-studied and most effective cholesterol-lowering drugs. Their major effect is to lower LDL cholesterol, which helps lower overall cardiac risk. (They have only a minor effect on HDL.) Still, boosting HDL is an important goal in its own right.
Niacin is the champion at raising HDL but it's also the most overlooked medication, largely because it's tricky to use. Niacin is a natural substance vitamin B3. Like other vitamins, it's needed to keep the metabolism working right. But the RDA for B3 is only 18 mg a day far, far less than the amount needed to improve HDL cholesterol levels. Still, any dose of niacin can be sold as a "dietary supplement" without a doctor's prescription and without FDA oversight. Many people turn to niacin because they want to treat themselves. Even though you can get all the niacin you want without a prescription, you should always coordinate treatment with a doctor who can tell you if niacin is right for you and can monitor for efficacy and side effects as you slowly increase the dose. Prescription drugs called fibrates will also boost HDL levels.
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On the Horizon
Just how much can raising HDL cholesterol help? In a startling 2003 experiment, doctors gave 47 heart patients five weekly infusions of synthetic Apo A-1 Milano, an unusually potent variant of HDL produced naturally by a small number of villagers in the Italian Alps. After just 5 weeks of treatment, the American patients demonstrated a 4.2% decrease in the volume of their coronary artery blockages.
Apo A-1 Milano may never emerge as a practical treatment for coronary artery disease. And torcetrapib, a drug that looked hopeful as a new way to raise HDL, has been withdrawn from development because of side effects.
Medications are much more effective at lowering LDL cholesterol than raising HDL cholesterol. New drugs may someday change that, but even now, doctors and patients should give HDL the respect it deserves. Raising the HDL may be difficult, but it is possible.
Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.