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This week's topic: HDL Cholesterol
Mainstream medicine often simplifies cholesterol as "good" (HDL) and "bad" (LDL); but HDL isn't always beneficial.
Overview of today's email:
- Overview of HDL cholesterol
- Considerations for increasing levels
- Practical clinical tips on addressing high HDL
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1. HDL cholesterol
Some basic physiology:
- HDL half life is around 5 days
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Main functions of HDL (when functioning properly) include:
- Reverse cholesterol transport (RCT) (aka remove peripheral cholesterol to be metabolized by the liver)
- Anti-thrombotic
- Pro-fibrinolytic
- Stimulate production of nitric oxide
- Antioxidant
- Anti-inflammatory
- Improve endothelial integrity
- Possible role in immunomodulation (e.g. really high levels may increase the risk of infectious disease; autoimmune diseases may modify HDL particles to be more pro-inflammatory) (source)
A few important points:
- Optimal HDL levels: 50-70 mg/dL
- HDL is not always "good" cholesterol; levels over 80 mg/dL are associated with a higher risk of all-cause and cardiovascular mortality (source)
For a more detailed review of HDL, check out this podcast with Dr. Dan Radar and Peter Attia.
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2. Considerations for increasing levels
When HDL levels are under 60 mg/dL, the following are some ways to increase levels (source):
- Increase olive oil intake (can raise levels by 2.3 mg/dL over 3 months)
- Increase omega 3 foods (can increase levels by 1-3%, and improve HDL function)
- Decrease carbohydrates (no specifics on this in studies, but can increase HDL by 20%)
- Alcohol intake can actually increase HDL by 9mg/dL (but we must think critically about this: source/type of alcohol, predisposing factors, is this increase in HDL pro- or anti-inflammatory, etc)
- Increase in aerobic exercise (can raise levels by up to 3%)
- Niacin at 1-2 grams per day (can raise levels by 15-35%; but watch blood sugar levels if using this, since niacin can increase blood glucose levels)
- Estrogen therapy (if indicated for other reasons) can increase levels by 15%
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3. Practical Clinical Tips on Addressing High HDL
In mainstream medicine, we are more likely to see low or suboptimal levels of HDL. Over the years, I've had over a dozen patients with HDL levels over 100 mg/dL (which sent me into research mode!).
If you see high levels of HDL, consider the following:
- Look at other acute phase reactants such as ferritin, ESR, and hsCRP (HDL can become pro-inflammatory during the acute phase response) (source)
- An NMR panel can be helpful, but note that there aren't necessarily a lot of well-tested interventions for addressing a poor HDL profile...yet.
- I believe genetic SNP testing should be considered in anyone with a high risk of CVD, who show symptoms that are cardiovascular in nature, who do not respond to interventions, or who continue to have high levels upon re-evaluation.
However, don't go down a rabbit hole of trying to get HDL levels to under 60 mg/dL (since there aren't a lot of studies on the negative effects of high HDL), as long as you have been thorough on autoimmune and cardiovascular evaluation!
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ANNOUNCEMENT
The Functional Medicine Collective Mentorship (FMC) is open! As a bonus for being a founding member, those that join before the end of June will get two 1:1 mentor calls with me to chat about anything or going over a case! Here are some of the things we've touched on in the last few weeks:
- Improving efficiency (e.g. faster documentation)
- Documentation to CYA (e.g. suppressed TSH)
- Burning mouth syndrome
- Case reviews (challenging patients, where to start with lab results…)
- Resources (e.g. systemic analysis on effects of food on LDL cholesterol, Peter Attia podcast episode on menopause, podcast on the history of testosterone therapy…)
And the first Focused Mastery Workshop is coming next week in the FMC (topic = the Glucose Quintet)!
Click the button below to learn more and apply!
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I hope this was clinically useful!
Next newsletter topic: Triglycerides and VLDL.
Meg
Additional resources that may be helpful
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