Maintaining optimal HDL values is pivotal for heart health, as HDL, or the ‘good cholesterol,’ is renowned for its role in reducing the risk of cardiovascular diseases. However, it’s crucial to understand that elevated HDL levels don’t always equate to lower mortality rates, emphasizing the need for a balanced and nuanced approach to cholesterol management and cardiovascular health.
Understanding Optimal HDL Values for Heart Health: More is Not Better Key Points
- HDL values has long been considered “good” cholesterol due to its ability to remove cholesterol from peripheral tissues and transport it to the liver for excretion, a process known as reverse cholesterol transport.
- Recent studies have challenged the notion that higher HDL values are always better, suggesting that extremely high HDL cholesterol levels may be associated with increased risk of mortality, cardiovascular disease risk and non-cardiovascular events.
- Metrics related to HDL particle concentration rather than cholesterol content and size may offer better insights into the role of HDL metabolism and cardiovascular disease risk.
Introduction to Triglycerides and Lipids
Healthy LDL and HDL cholesterol levels, total cholesterol, triglycerides, and blood sugar are common blood tests for heart health. Regarding cardiovascular disease risk, we often hear about the importance of raising HDL (High-Density Lipoprotein) or “good” cholesterol levels. But did you know that more is not always better regarding HDL values? Many people will often brag how high their HDL’s values are on their lab tests. In this article, we will dive deep into the role of HDL cholesterol levels and heart health and explore the traditional view of HDL as a protective factor.
We will also discuss newer findings that suggest excessively high HDL won’t protect you from a heart attack. Furthermore, we will explore the U-shaped relationship between HDL and atherosclerosis, uncovering the very high HDL levels paradox. We’ve got you covered if you’re wondering who should be concerned about their HDL levels and if lifestyle or medication can alter them. Get ready to understand optimal HDL values for heart health like never before.
Understanding LDL, HDL Lab Values, and Non-HDL Cholesterol
LDL and HDL are lipoproteins that transport cholesterol in the blood. LDL is often called “bad” cholesterol because it can deposit cholesterol in the walls of arteries, leading to atherosclerosis and an increased cardiovascular disease risk. HDL, on the other hand, is often referred to as “good” cholesterol because it can remove cholesterol from the walls of arteries and transport it to the liver for excretion.
LDL delivers cholesterol to peripheral tissues, including the walls of arteries, where it can accumulate and contribute to the development of atherosclerosis. (Quispe et al., 2019)
LDL carries most cholesterol in the blood, while HDL carries a smaller amount. LDL delivers cholesterol to peripheral tissues, including the walls of arteries, where it can accumulate and contribute to the development of atherosclerosis. (Quispe et al., 2019) LDL particles can oxidize, leading to inflammation and plaque formation in the arterial walls. The size and density of LDL particles can also vary, with smaller, denser particles being more atherogenic. Measuring LDL cholesterol levels is a common method for assessing atherosclerosis risk.
Factors that have been shown to increase LDL are certain types of fats (i.e., saturated fats) (Denke, 2006), obesity, metabolic syndrome (Asadi et al., 2020), smoking, and genetic factors.
What is HDL?
HDL removes excess cholesterol from peripheral tissues and transports it to the liver for excretion into bile and feces out of the body. HDL cholesterol has anti-inflammatory and antioxidant properties, and high HDL cholesterol levels are associated with a reduced risk of cardiovascular disease. This process is known as reverse cholesterol transport (RCT), a key anti-atherogenic function of HDL.
The LDL to HDL cholesterol ratio is another important measure providing additional information about cardiovascular risk. Maintaining a balance between LDL and HDL cholesterol levels in the blood lipid panel is important to reduce the risk of cardiovascular disease. (Lemieux et al., 2001)
High LDL and low HDL levels
Elevated LDL and diminished HDL levels correlate with a heightened risk of cardiovascular disease. Conversely, reduced LDL and elevated HDL levels indicate a lower risk. Moreover, both LDL and HDL cholesterol levels can be affected by a range of elements, such as genetic predispositions, lifestyle decisions like saturated fat intake and sedentary behavior, and existing health issues.
Non-high-density lipoprotein cholesterol (non-HDL cholesterol) is a measure of the cholesterol content in all atherogenic lipoproteins, including low-density lipoprotein (LDL) cholesterol, very-low-density lipoprotein (VLDL) cholesterol, and intermediate-density lipoprotein (IDL) cholesterol. It is calculated by subtracting high-density lipoprotein (HDL) cholesterol from the total cholesterol level. (Feeman, 2017) Non-HDL cholesterol represents the cholesterol carried by lipoproteins that may contribute to the development of atherosclerosis and cardiovascular disease (Bittner, 2004)
The Role of HDL in Heart Health
HDL, or high-density lipoprotein, is often considered “good” cholesterol because it helps remove LDL, or low-density lipoprotein (i.e., bad cholesterol), from the bloodstream. (Pirillo et al., 2013)
Low HDL values and high LDL is considered risk factor for atherosclerosis (i.e., hardening of the arteries) by the American Heart Association. It puts people at a greater risk for heart problems. Conversely, increases in high-density lipoprotein cholesterol are generally considered cardioprotective.
Optimal HDL values, typically above 60 mg/dL, have been associated with optimal protection against cardiovascular disease (Han et al., 2017). However, recent studies have challenged the assumption that excessively HDL levels always confer greater benefits. (Razavi et al. 2023)
Optimal HDL values, typically above 60 mg/dL, have been associated with optimal protection against cardiovascular disease (Han et al., 2017). However, recent studies have challenged the assumption that higher HDL levels always confer greater benefits.
The Traditional View of HDL as a Protective Factor
HDL, also known as “good” cholesterol, helps remove excess cholesterol from the bloodstream. For many years, elevated HDL levels have been linked to a reduced risk of heart disease. Numerous studies have supported the idea that for every 1 mg/dL rise in HDL-C, there’s an approximate 2% to 3% decrease in the risk of cardiovascular death, positioning HDL as inversely related to cardiovascular risk.(Gordon et al., 1989; Pekkanen et al., 1990; Wilson et al., 1988)
However, recent research suggests that simply increasing HDL levels above certain thresholds may not reduce the risk of heart disease. For example, niacin supplementation can increase HDL but does not reduce the risk of cardiovascular disease. (Boden et al., 2011) More recently, studies performed in populations free of cardiovascular disease have proposed that very high HDL-C levels may increase the risk of death. (Ko et al., 2016; Madsen et al., 2017)
Genetics and HDL
People that have genetic variations in HDL genes which cause high HDLs do not have lower incidence of cardiovascular events. (Hasse al al. 2012). Large-scale prospective cohort studies also contradict the previous finding of a linear inverse relationship between HDL and cardiovascular disease.(Wilkins et al., 2014)
It is a common finding that low HDL values predict increased cardiovascular risk, data from several cohorts have revealed a plateau in the inverse association above certain HDL levels. There is even a suggestion of increased cardiovascular outcomes in those with extremely high HDLs.
Studies on HDL and Mortality
Two large population-based studies in Denmark (52,268 men and 64,240 women) found that those with extremely elevated HDL-C directly resulted in a U-shaped curve [i.e., In simple terms, a U-shaped curve means that there is an optimal or ideal level of the HDL values where the relationship is strongest, and too low or too high levels can have negative effects.] regarding mortality, cardiovascular, and non-cardiovascular events in a sex-specific manner.
This study showed the lowest mortality rates among European Caucasians at HDL-C levels of 73 mg/dL for men and 93 mg/dL for women. All-cause mortality rates increased significantly for men with HDL-C levels above 97 mg/dL and women above 135 mg/dL.
The quality and functionality of HDL are more important than the quantity. Factors like inflammation, oxidative stress, and other health conditions can impact HDL’s ability to protect against heart disease. Lifestyle factors like exercise, a healthy diet, and avoiding smoking have a greater impact on heart health than solely focusing on increasing HDL levels.
Who Should Be Concerned about HDL Levels?
If you have a family history of heart disease, lead a sedentary lifestyle, have poor diet choices, smoke, have high blood pressure, are overweight, or have existing health conditions like diabetes or high cholesterol, it’s important to monitor your HDL levels. There is an optimal level of HDL, but too low or too high levels can increase risk factors.
Why is there a Different Optimal Range for Men and Women?
Men and women have varying hormonal and physiological profiles that impact their HDL levels. Estrogen in women tends to boost HDL levels, leading to a higher optimal range. Women also tend to have higher HDL cholesterol levels than men, which may be partly due to differences in body fat distribution and physical activity levels. On the other hand, testosterone in men can lower HDL levels, resulting in a lower optimal range. These differences reflect the varying risk factors for heart disease between men and women.
Can Lifestyle or Medication Alter HDL Levels?
Making positive lifestyle changes like exercising regularly and following a healthy diet can boost HDL levels. Certain medications, such as statins, can also help raise HDL levels. Always consult your healthcare provider before making changes or starting medication for personalized advice.
Is it Possible to Have Too Much ‘Good’ Cholesterol?
Having high levels of HDL cholesterol is generally beneficial for heart health. However, extremely high levels may be associated with certain health conditions. Maintaining a balance between HDL and LDL cholesterol is important for optimal heart health.
To sum up, although HDL has earned its reputation as the “good” cholesterol and traditionally indicates a reduced heart disease risk, recent studies suggest that not all HDL offers protective benefits. Surprisingly, excessively high HDL levels might even correlate with a heightened risk of atherosclerosis. It’s important to understand that optimal HDL values for heart health follow a U-shaped relationship, where both low and excessively high levels can be concerning.
High-Density Lipoprotein (HDL)
Cardiologists recommend that the levels of High-Density Lipoprotein (HDL), often referred to as “good” cholesterol, should ideally be above 60 mg/dL. A level below 40 mg/dL could indicate that there is not enough HDL to perform its function effectively. It’s also important to note that the effectiveness of HDL’s protective role depends on the levels of Low-Density Lipoprotein (LDL) and triglycerides. Optimal protection against cardiovascular disease occurs when HDL levels are high (40 mg/dL or higher) and LDL and triglyceride levels are low (100 mg/dL or less).
If you’re wondering whether you should be concerned about your HDL levels, it’s essential to consider factors such as age, gender, and overall cardiovascular health. Due to biological differences, men and women may have different optimal ranges for HDL. Lifestyle modifications and medication can potentially alter HDL levels, but it’s crucial to consult with a healthcare professional before making any changes.
Consult Your Physician
Always consult your doctor before making any decisions about your HDL levels. Your healthcare provider will be able to assess your individual risk factors and guide you towards the most appropriate course of action.
Remember, maintaining a healthy lifestyle is key to optimizing your HDL levels. Regular exercise, a balanced diet, and avoiding smoking are all important steps you can take to support heart health. Aim for at least 150 minutes of moderate-intensity aerobic activity per week, include plenty of fruits and vegetables in your diet, and limit saturated and
Asadi, Z., Moghbeli, M., Khayyatzadeh, S. S., Bajgiran, M. M., Zirak, R. G., Zare-Feyzabadi, R., Eidi, M., bonakdar, M. T., Davari, H., Mahmoudi, A., Andalibi, N. S., Ferns, G. A., Ghazizadeh, H., & Ghayour-Mobarhan, M. (2020). A Positive Association Between a Western Dietary Pattern and High LDL-C Among Iranian Population. Journal of Research in Health Sciences. https://doi.org/10.34172/jrhs.2020.19
Bittner, V. (2004). Non‐High‐Density Lipoprotein Cholesterol: An Alternate Target for Lipid‐Lowering Therapy. Preventive Cardiology. https://doi.org/10.1111/j.1520-037x.2004.3094.x
Boden, W. E., Probstfield, J. L., Anderson, T., Chaitman, B. R., Desvignes-Nickens, P., Koprowicz, K., McBride, R., Teo, K., & Weintraub, W. (2011). Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. N Engl J Med, 365(24), 2255-2267. https://doi.org/10.1056/NEJMoa1107579
Denke, M. A. (2006). Dietary Fats, Fatty Acids, and Their Effects on Lipoproteins. Current Atherosclerosis Reports. https://doi.org/10.1007/s11883-006-0021-0
Feeman, W. E. (2017). Concerns About the Use of Non-High-Density Lipoprotein Cholesterol as a Lipid Predictor. European Medical Journal. https://doi.org/10.33590/emj/10312180
Haase, C. L., Tybjærg-Hansen, A., Ali Qayyum, A., Schou, J., Nordestgaard, B. G., & Frikke-Schmidt, R. (2012). LCAT, HDL Cholesterol and Ischemic Cardiovascular Disease: A Mendelian Randomization Study of HDL Cholesterol in 54,500 Individuals. The Journal of Clinical Endocrinology & Metabolism, 97(2), E248-E256. https://doi.org/10.1210/jc.2011-1846
Gordon, D. J., Probstfield, J. L., Garrison, R. J., Neaton, J. D., Castelli, W. P., Knoke, J. D., Jacobs, D. R., Jr., Bangdiwala, S., & Tyroler, H. A. (1989). High-density lipoprotein cholesterol and cardiovascular disease. Four prospective American studies. Circulation, 79(1), 8-15. https://doi.org/10.1161/01.cir.79.1.8
Ko, D. T., Alter, D. A., Guo, H., Koh, M., Lau, G., Austin, P. C., Booth, G. L., Hogg, W., Jackevicius, C. A., Lee, D. S., Wijeysundera, H. C., Wilkins, J. T., & Tu, J. V. (2016). High-Density Lipoprotein Cholesterol and Cause-Specific Mortality in Individuals Without Previous Cardiovascular Conditions: The CANHEART Study. Journal of the American College of Cardiology, 68(19), 2073-2083. https://doi.org/10.1016/j.jacc.2016.08.038
Lemieux, I., Lamarche, B., Couillard, C., Pascot, A., Cantin, B., Bergeron, J., Dagenais, G. R., & Després, J.-P. (2001). Total Cholesterol/HDL Cholesterol Ratio vs LDL Cholesterol/HDL Cholesterol Ratio as Indices of Ischemic Heart Disease Risk in Men. Archives of Internal Medicine. https://doi.org/10.1001/archinte.161.22.2685
Madsen, C. M., Varbo, A., & Nordestgaard, B. G. (2017). Extreme high high-density lipoprotein cholesterol is paradoxically associated with high mortality in men and women: two prospective cohort studies. Eur Heart J, 38(32), 2478-2486. https://doi.org/10.1093/eurheartj/ehx163
Pekkanen, J., Linn, S., Heiss, G., Suchindran, C. M., Leon, A., Rifkind, B. M., & Tyroler, H. A. (1990). Ten-year mortality from cardiovascular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med, 322(24), 1700-1707. https://doi.org/10.1056/nejm199006143222403
Pirillo, A., Norata, G. D., & Catapano, A. L. (2013). High-Density Lipoprotein Subfractions – What the Clinicians Need to Know. Cardiology. https://doi.org/10.1159/000346463
Alexander C Razavi, MD MPH PhD https://doi.org/10.1210/clinem/dgad406, Does Elevated High-Density Lipoprotein Cholesterol Protect Against Cardiovascular Disease?, The Journal of Clinical Endocrinology & Metabolism, 2023;, dgad406,
Quispe, R., Elshazly, M. B., Zhao, D., Toth, P. P., Puri, R., Virani, S. S., Blumenthal, R. S., Martin, S. S., Jones, S. J. M., & Michos, E. D. (2019). Total Cholesterol/HDL-cholesterol Ratio Discordance With LDL-cholesterol and Non-HDL-Cholesterol and Incidence of Atherosclerotic Cardiovascular Disease in Primary Prevention: The ARIC Study. European Journal of Preventive Cardiology. https://doi.org/10.1177/2047487319862401
Wilkins, J. T., Ning, H., Stone, N. J., Criqui, M. H., Zhao, L., Greenland, P., & Lloyd‐Jones, D. M. (2014). Coronary Heart Disease Risks Associated with High Levels of HDL Cholesterol. Journal of the American Heart Association, 3(2), e000519. https://doi.org/doi:10.1161/JAHA.113.000519
Wilson, P. W., Abbott, R. D., & Castelli, W. P. (1988). High density lipoprotein cholesterol and mortality. The Framingham Heart Study. Arteriosclerosis, 8(6), 737-741. https://doi.org/10.1161/01.atv.8.6.737
More Information on the Intricacies of HDL Cholesterol: Understanding Its Role and Impact on Health
High-Density Lipoprotein (HDL), commonly called the “good cholesterol,” is crucial in maintaining heart health. It is a type of lipoprotein that transports fats, including cholesterol, throughout the body. HDL cholesterol aids in the removal of other forms of cholesterol from the bloodstream, lowering the risk of heart disease. However, the relationship between HDL cholesterol and heart health is more complex.
Cholesterol is a waxy substance found in cells and certain foods. While the body requires cholesterol for various functions, excessive levels can increase the risk of coronary artery disease. HDL cholesterol carries cholesterol back to the liver for removal, while Low-Density Lipoprotein (LDL), known as “bad” cholesterol, contributes to cholesterol buildup in arteries. This buildup can lead to atherosclerosis, a condition characterized by the hardening and narrowing of arteries due to plaque formation.
Optimal HDL Values
Cholesterol levels, including HDL, can be measured through a cholesterol test. This test involves a blood sample taken from a vein in your arm, which may cause a slight sting. The test results provide information about the amount of cholesterol in your blood, measured in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L), depending on the country.
Optimal HDL values level is 60 mg/dL or higher. However, recent research suggests that the protective effect of HDL diminishes beyond approximately 1.4 mmol/L or 54 mg/dL, and extremely high levels can still pose risks, particularly before and after menopause. Certain factors, such as genetic mutations, hormonal changes during menopause, infections, and inflammatory conditions, can naturally elevate HDL levels.
Low and High HDL and LDL
In addition to cholesterol, triglycerides, a type of fat in the blood, also contribute to heart health. High levels of triglycerides, combined with low HDL and high LDL cholesterol, increase the risk of health problems, including heart attacks. Triglycerides are the most common type of fat in the body and are often elevated in overweight, inactive individuals who smoke cigarettes or consume excessive amounts of alcohol.
Benefits of Exercise
Physical activity is one of the most effective ways to increase optimal HDL values and decrease triglyceride levels. Regular exercise, such as brisk walking, running, or cycling, can help raise HDL cholesterol and lower LDL cholesterol and triglycerides. Maintaining a healthy diet low in saturated fats and fiber is also important, which can help regulate cholesterol levels.
Certain medications, such as steroids, can also affect cholesterol levels. Steroids can increase LDL cholesterol and decrease optimal HDL values, potentially leading to a higher risk of heart disease. Therefore, individuals taking steroids should have their cholesterol levels monitored regularly.
While HDL cholesterol is often the “good cholesterol,” it’s important to note that its role in heart health is complex. Ongoing clinical trials and research seek to understand further the role of optimal HDL values and its impact on heart health. Understanding your health history and regular check-ups with your healthcare provider can help manage cholesterol levels and reduce the risk of heart disease.