Low HDL Cholesterol: Treat with Lifestyle Changes, Not Drugs

HDL cholesterol is usually labeled "good", but to help prevent heart attacks, it is far more important to lower the "bad" LDL cholesterol than to try to raise HDL cholesterol. Furthermore, you should try to raise blood levels of the good HDL cholesterol only by changing the harmful lifestyle habits that lower HDL. I do not recommend taking drugs to raise blood levels of HDL cholesterol.

A new study shows that people who have very high levels of HDL cholesterol (>90 mg/dL) are at high risk for premature death (Journal of the American College of Cardiology, October 31, 2016;68(19):2073-2083). Of 631,000 people without heart disease, 40 to 105 years old, those with healthier lifestyles had higher HDL levels. However, very high HDL levels were associated with increased risk of non-heart-attack deaths, particularly cancers. Alcohol could explain this association between cancer and high HDL, since alcohol is a potent carcinogen and it also raises HDL cholesterol. This indicates that HDL should not be used as an independent risk factor for heart attacks.

In this study, low blood levels of HDL cholesterol were associated with:

• not exercising,

• smoking,

• excess weight,

• diabetes, and

• an unhealthful diet. People with low HDL tended to have lower incomes and higher rates of smoking, diabetes and high blood pressure. After the researchers accounted for those factors, low HDL was still linked to higher death rates.

It is very unlikely that a low HDL causes heart attacks; it is more likely to be a marker for an unhealthful lifestyle. When you eat a lot of foods that cause high rises in blood sugar, your liver converts the extra sugar to triglycerides (high triglycerides). Your HDL cholesterol is used up trying to clear the triglycerides from your bloodstream by carrying them to your liver, so your blood level of HDL goes down and your liver gets clogged with fat, which can lead to diabetes. Therefore, efforts to raise HDL levels should concentrate on lifestyle changes.

Lifestyle Changes to Lower LDL and Raise HDL Most people can lower the "bad" LDL cholesterol by:

• losing weight,

• restricting sugar-added foods, sugared drinks including fruit juices, red meat and fried foods,

• eating lots of fruits and vegetables,

• exercising, and

• avoiding smoking and recreational drugs You should try to raise the "good" HDL cholesterol with exactly the same lifestyle changes. You should not try to raise HDL by taking drugs. Niacin is the primary drug used to raise HDL, but it is no more effective than a placebo in preventing heart attacks, death from heart attacks or strokes and at the same time, it raises blood sugar, increases side effects of diabetes and increases risk for bleeding and serious infections (N Engl J Med, July 17, 2014; 371:203-212).

My Recommendations

• More than 40 percent of the deaths in North America are due to heart attacks that are brought on mainly by unhealthful lifestyle habits.

• Have your doctor check your blood levels of LDL and HDL cholesterol. If your LDL is high, try to get it below 100 mg/dL first with lifestyle changes. If that fails, your doctor may recommend statin drugs.

• If your HDL is below 40 mg/dL, you should change your lifestyle immediately. Check with your doctor and follow the changes listed above. 

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