Monday, January 28, 2019

What should be my HDL cholesterol?

HDL cholesterol levels are a rough measure of HDL particle quantity in the blood. They actually tell us next to nothing about HDL particle type, although HDL cholesterol increases are usually associated with increases in LDL particle size. This a good thing, since small-dense LDL particles are associated with increased cardiovascular disease.

Most blood lipid panels reviewed by family doctors with patients give information about HDL status through measures of HDL cholesterol, provided in one of the standard units (e.g., mg/dl).

Study after study shows that HDL cholesterol levels, although imprecise, are a much better predictor of cardiovascular disease than LDL or total cholesterol levels. How high should be one’s HDL cholesterol? The answer to this question is somewhat dependent on each individual’s health profile, but most data suggest that a level greater than 60 mg/dl (1.55 mmol/l) is close to optimal for most people.

The figure below (from Eckardstein, 2008; full reference at the end of this post) plots incidence of coronary events in men (on the vertical axis), over a period of 10 years, against HDL cholesterol levels (on the horizontal axis). Note: IFG = impaired fasting glucose. This relationship is similar for women, particularly post-menopausal women. Pre-menopausal women usually have higher HDL cholesterol levels than men, and a low incidence of coronary events.

From the figure above, one can say that a diabetic man with about 55 mg/dl of HDL cholesterol will have approximately the same chance, on average, of having a coronary event (a heart attack) as a man with no risk factors and about 20 mg/dl of HDL cholesterol. That chance will be about 7 percent. With 20 mg/dl of HDL cholesterol, the chance of a diabetic man having a coronary event would approach 50 percent.

We can also conclude from the figure above that a man with no risk factors will have a 5 percent chance of having a coronary event if his HDL cholesterol is about 25 mg/dl; and about 2 percent if his HDL cholesterol is greater than 60 mg/dl. This a 60 percent reduction in risk, a risk that was low to start with because of the absence of risk factors.

HDL cholesterol levels greater than 60 are associated with significantly reduced risks of coronary events, particularly for those with diabetes (the graph does not take diabetes type into consideration). Much higher levels of HDL cholesterol (beyond 60) do not seem to be associated with much lower risk of coronary events.

Conversely, a very low HDL cholesterol level (below 25) is a major risk factor when other risk factors are also present, particularly: diabetes, hypertension (high blood pressure), and familial hypercholesteromia (gene-induced very elevated LDL cholesterol).

It is not yet clear whether HDL cholesterol is a cause of reduced cardiovascular disease, or just a marker of other health factors that lead to reduced risk for cardiovascular disease. Much of the empirical evidence suggests a causal relationship, and if this is the case then it may be a good idea to try to increase HDL levels. Even if HDL cholesterol is just a marker, the same strategy that increases it may also have a positive impact on the real causative factor of which HDL cholesterol is a marker.

What can one do to increase his or her HDL cholesterol? One way is to replace refined carbs and sugars with saturated fat and cholesterol in one’s diet. (I know that this sounds counterintuitive, but seems to work.) Another is to increase one’s vitamin D status, through sun exposure or supplementation.

Other therapeutic interventions can also be used to increase HDL; some more natural than others. The figure below (also from Eckardstein, 2008) shows the maximum effects of several therapeutic interventions to increase HDL cholesterol.

Among the therapeutic interventions shown in the figure above, taking nicotinic acid (niacin) in pharmacological doses, of 1 to 3 g per day (higher dosages may be toxic), is by far the most effective way of increasing one’s HDL cholesterol. Only the niacin that causes flush is effective in this respect. No-flush niacin preparations may have some anti-inflammatory effects, but do not cause increases in HDL cholesterol.

Rimonabant, which is second to niacin in its effect on HDL cholesterol, is an appetite suppressor that has been associated with serious side effects and, to be best of my knowledge, has been largely banned from use in pharmaceutical drugs.

Third in terms of effectiveness, among the factors shown in the figure, is moderate alcohol consumption. Running about 19 miles per week (2.7 miles per day) and taking fibrates are tied in forth place.

Many people think that they are having a major allergic reaction, and have a panic attack, when they experience the niacin flush. This usually happens several minutes after taking niacin, and depends on the dose and whether niacin was consumed with food or not. It is not uncommon for one’s entire torso to turn hot red, as though the person had had major sunburn. This reaction is harmless, and usually disappears after several minutes.

One could say that, with niacin: no “pain” (i.e., flush), no gain.


von Eckardstein, A. (2008). HDL – a difficult friend. Drug Discovery Today: Disease Mechanisms, 5(3), 315-324.


Dr. B G said...

Great post and wonderful review of the best HDL strategies, Ned! Love ur evo posts too.

I've done them all:
--cessation of cigarettes and cigars
--jogging 15-20 miles/wk
--niacin 500mg every 1-2wks
--I'm a grrl (estrogen)
--omega-3 ALA DHA EPA 5-8 g/day (which hit PPAR like glitazones and niacin -- flushing produces prostaglandin analogues which hit PPAR)
--vitamin D! (statins mimic)
--intermittent fasting
--low carb
--low carb
--high sat fat
--high sat fat
--red red wine and tequila :)

The HDLs increased from basement bottom of 60s to 105 mg/dl (and probably higher now). I suspect probiotics would help too so will try next...

Ned Kock said...

Thank you, and congrats on getting your HDL that high!

Not many people have an HDL higher than 100, and the ones I know consume plenty of sat fat and little or no refined carbs and sugars.

I felt compelled to give a warning regarding rimonabant, because this anorectic has a very bad rep.

By the way, NephroPal and Animal Pharm are great resources!

And this is one of my favorite books ever ...

Dr. B G said...

Yes -- Orwell rocks. I appreciate your kinds words!

I must add indeed rimonabant is problematic. Causes suicidal ideation and depression (despite being 5lbs lighter). Mechanism of action: it blocks the cannabinoid receptor... must we say more?

Rudy said...

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Nigel Kinbrum said...

Years ago, I was on Nia-span (I'm not anymore). I would be driving along in my automobile when suddenly I'd have a hot flash. This could be a hour after taking the stuff! I now keep TGs as low as possible & HDL as high as possible by controlling my intake of sugary/starchy carbs and by taking an effective (5,000iu/100kg BW/day) dose of Vitamin D3.

PaleoDoc said...

Hi Ned, thanks for your intersting insights. Have you come across any reliable studies of lipids in H-Gs? I remember reading that they typically had low total cholesterol at variuos carb intakes. I wonder if anybody looked at their HDL.

I managed to get my HDL cholesterol to 79, but LDL of 271 (direct) has been worrying me. Double cream was most likely the culprit, so I gave it up. It might be easier to approxiamte paleo diet than split hairs over good bad and bad good cholesterol..

Ned Kock said...

I am trying to get a handle on lipids first. Lipid metabolism, as you know, is a very complicated business, with endless cycles of particles going in and out of the liver. I always find very good information at Hyperlipid:

With such a high HDL, I would bet that a good percentage of your LDL cholesterol comes from large particles, which are harmless. Have you done a lipoprotein particle test?

Ed Terry said...

12 years ago, my HDL was 25. I didn't exercise, and ate a lot of carbs (pasta, potatoes, sweet fruits, etc.) Two years later, I started wokring out (lots of cardio and strength training) and got it up to 32, still eating a lot of carbs and avoiding sat fat like the plague. Three years later , my doc asked me to try IR niacin. A year later, taking 2 grams twice a day, my HDL shot up to 42. I figured this was as good as it was every going to get.

The I read "Good Calories, Bad Calories" by Taubes. Over the next six months, I gradually moved to a high-fat, moderate protein, and low-carb way of eating.

During that time, my cardiologist also put me on Zocor because that's what cardiologists do. My HDL went up to 48 but so did my liver enzymes, so I had to discontinue both niacin and zocor. At the same time, I started adding coconut oil to my diet. A month later, I had another blood test and I expected that my HDL would plummet. Much to my surprise, it actually increased to 52 without the niacin. I then started niaicin again (no more statin ever) and after two months my HDL was 71. I saw my cardiologist again and he stated that he wished I had gone back on a statin instead of niacin. He was still concerned about my elevated LDL (81) because it wasn't under 70. I basically told him that he didn't know what he was talking about.

In all fairness to my cardiologist, I later realized that the concept of raising HDL that much goes over his head. He simply doesn't have a framework to process that kind of information. He's so fixated on reducing LDL as the cure even though ezitimibe should have put the last nail on the coffin of the "LDL cholesterol causes heart disease" theory.

As far as particle size goes, I paid out of pocket to have an NMR lipoprotein analysis performed after being off niacin and zocor. My LDL particle number was over 2,000 and my s,d-LDL over 1,600.

A year later with niacin and 50% of my calories coming from saturated fat, my LDL particle number is under 1,000 and my s,d-LDL particle number is 120. My LDL pattern type has changed from small to large.

Ned Kock said...

Thanks for sharing you experience ET. The improvements are not surprising, but they are dramatic. Congratulations on doing the right thing for you, in spite of professional advice to the contrary!

Anonymous said...

It has been my experience that it is not necessary to be on a low carb or very low carb diet to increase HDL-cholesterol. My HDL has averaged over 100 and triglycerides have been about 50 for many years on a diet that probably has about 50% fat and 35% carbs. We eat rice and potatoes, usually covered with lots of butter. My wife's HDL is about 90. We eat a lot of butter and scrupulously avoid foods containing refined vegetable oils that are high in LA.

We do not take niacin, and I see no need to do so as long as our HDL and TG levels are good.

I think there is no doubt that HDL is the cause of reduced cardiovascular disease, not simply a marker. In fact, my file on the subject includes data on about a dozen mechanisms by which HDL reduces risk of atherosclerosis and improves endothelial function.

Do you have any data supporting your supposition that HDL levels above 60 do not further reduce CHD risk? I am inclined to believe that there are significant benefits to getting HDL well above 60.

Ned Kock said...
This comment has been removed by the author.
Ned Kock said...

Hi Jack.

Take a look at the top figure on the post. There are several curves, which refer to different health conditions. The "all" curve, which is a composite, seems to converge to a stable point after HDL hits 60.

If one is diabetic, then it seems that and HDL >> 60 maybe helpful. But for a "no risk factor" person, the gains are minimal after 60.

For most people, bringing HDL from 25 to 50 has a much stronger positive health impact than from 50 to 75.

It seems that HDL is particularly protective when some kind of health condition (e.g., diabetes) is present. This, indeed, suggests that HDL is a causative factor, not a marker.

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In cases of postmenopausal women, should follow a regimen of tests to take care of your cholesterol?

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Anonymous said...

My HDL stayed around 30 for the last several years, despite eating low carb. Supplementing with fish oil, vitamin D, and vitamin K for the last year didn't help.

Only niacin has helped bump my reading up to a (still less than ideal) 36. At least, for the first time in years my TC:HDL Ratio is in a satisfactory range, at 4.4.

I envy those who have had great results from some of the things I've tried. Maybe after I lose 80 pounds or so my numbers will improve?

Ned Kock said...

First of all, I wouldn't be too concerned about lipids, if you are doing the right things, which seems to be your case. In the end, what look like "bad lipids" are really bad only if you have a glucose metabolism problem, or a rare genetic disease. Outside those contexts, things get a little more complicated, and a low HDL may not mean much in isolation.

Having said that, what dose of niacin have you been taking? Typically niacin will have significant effects on HDL at doses of 1.5 g and above, which should be taken under doctor's supervision.

Body fat loss, combined with exercise, will also have an effect on most people. High levels of body fat predispose people to many diseases, and often having a high HDL does not keep disease away for too long.

Now, based on the decay curves on the graph in this post, an HDL of 36 looks pretty good if you don't have any of the risk factors listed. If you have diabetes, then the graph tells us that an HDL > 60 would be quite protective.

Sometimes people have more of the most protective HDL particles, and less of the least protective (when we break them into two groups), and still get a low overall HDL cholesterol number.

Also, some people may have too little undesirable (e.g., endothelial, contributing to the formation of atheromas) cholesterol to be picked up by HDL particles; a good thing. The end result is a low HDL cholesterol because the HDL particles in the blood do not have as much cholesterol as they would have in someone with a lot of undesirable cholesterol in the wrong places.

You may want to do a VAP test (see post below) to get a better picture of your lipids.

I wrote a little bit more on niacin's mechanisms of action here:

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Men Health Issues said...

I am neither a doctor nor a medical student but I am a general student and interested to read such informative things. I read this article found very useful to know how much HDL cholesterol levels and LDL cholesterol levels are required for a normal person.

Carol W. said...

Hi, I just returned from the doctor where he went over the results of my recent blood work. My total cholesterol is 193. My HDL cholesterol level is 130 and my LDL is 59. I am concerned about my high HDL and wondering if this this something I should worry about.

Anonymous said...

Sustained release niacin such as Enduracin avoids the flush while still preserving the beneficial effects of niacin. This is different from the no-flush inositol version which as you say precludes the beneficial effects.

Anonymous said...

I am 63 My total Cholesterol was 269 LDL 172 HDL 97 and triglycerides were doctor suggested I cange my diet. I find the ratio is excellent and my triglycerides are this accurate?

Anonymous said...

Hi Ned,
Some times while taking niacin with food[protein shake]I get the flush only after about 45 minutes,is this normal?does this mean we have to time the exercise session to 5 hrs after the flush.
Also does 500mg niacin have the same effects as 1g niacin as a GH secretagogue?is it age dependent- as in older folks need 1g while younger need less?

Ned Kock said...

This post is a revised version of a previous post. The original comments are preserved here. More comments welcome, but no spam please!