What about a low-fat diet?While Americans traditionally have ingested too much fat in the diet, and while limiting total fat in the diet is useful not only for cholesterol control but also for weight reduction, evidence is emerging that too little fat in the diet can be dangerous. A diet in which fat has all but been eliminated can result in a deficit in the essential fatty acids - certain fatty acids that are essential to life, but which the body cannot manufacture itself. Furthermore, ultra-low-fat diets have been reported to result in a significant reduction in HDL cholesterol in some individuals.
The best advice regarding fat in the diet appears to be this: 1) reduce the fat intake to 30 - 35% of the total calories in the diet - but probably no lower than 25% of total calories; 2) try to eliminate saturated fats and trans fats from the diet, and substitute monounsaturated and polyunsaturated fats instead. (That is, eliminate animal and dairy fat, and substitute unprocessed vegetable fats.) Such a diet will avoid the problems seen with an ultra-low-fat diet, and should help raise HDL cholesterol levels.
What about drugs for raising HDL cholesterol?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 has been 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. Furthermore, "niacin" takes several forms, including nicotinic acid, nicotinamide, and inositol hexaniacinate - and all of these are labelled as "niacin." Unfortunately, only nicotinic acid raises HDL cholesterol, and this drug can be difficult to take because of its propensity to cause flushing, itching and hot flashes. In general, taking niacin to treat cholesterol levels should be supervised by a doctor. ( Read more about niacin here.)
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.
A three-drug regimen of niacin, cholestyramine, and gemfibrozil has been shown to increase HDL cholesterol substantially, but this drug combination can be particularly difficult to tolerate, is rarely used, and has never been demonstrated to improve clinical outcomes.
And 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, now is stacking up as 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, initial 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.
Tell us how you raised your HDL. Raising your HDL levels can be a challenge, because it usually requires lifestyle changes rather than simply taking a pill. So every bit of encouragement we can give each other will help. Share with other readers what you did to raise your HDL levels.
Click on the link (under "Readers Respond," below) to participate.
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.
Moffatt RJ. Effects of cessation of smoking on serum lipids and high density lipoprotein-cholesterol. Atherosclerosis 1988; 74:85.
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.
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
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.