HDL – the Good Cholesterol Isn’t Good

For years medical students have been trying to remember the good cholesterol is HDL and the bad cholesterol is LDL and they remember H is for “happy” and L is for “lousy.” This was based on studies that showed people who had naturally occurring higher levels of HDL had lower risk of heart disease.

Because of those early studies the next goal for drug therapy was to raise the HDL, with the consequence of reducing heart disease. Two major efforts – one from using niacin, the other from using fish oils- both shown to raise HDL in subjects were universally prescribed in order to diminish heart disease. Any patient with risk factors was put on one or both of those over-the-counter medications.

But as large studies looked at both niacin and fish oil a surprising result came: while they raised HDL they did not appear to protect from heart disease. For those patients who had known heart disease niacin and fish oil appeared to have no effect on the progression of the disease.

Eat fish, don't take the capsules

This last week the medical journal Lancet examined genetics and discovered that the holy grain of HDL was not protective. In contrast LDL (Low Density Lipoprotein) is still highly predictive of heart disease.

While this appears to be news to the “medical journalists” for those who have been following the story of HDL, and lipo-proteins in general – for those in the field, it has been felt that it was the lipoproteins themselves that caused the damage to the endothelial lining of the arteries of the body. For a simple way of looking at it see our earlier video above. Essentially the lipoproteins, no matter what type, cause the damage to the arteries. Some cause more damage (LDL) – but if you increase the lipoproteins you will have increased damage.

Triglycerides are the focus of much work these days- as processed flours, sugars, rapidly raise triglycerides – increasing the carriers (lipoproteins) which increase risk of heart disease. Simplistic, but thus far it is the hypothesis of choice.

Until then, drugs that lower LDL, statins, clearly decrease incidence of both heart disease, and even cause regression of plaque.


AIM-HIGH Investigators, Boden WE, Probstfield JL, Anderson T, Chaitman BR, Desvignes-Nickens P,Koprowicz K, McBride R, Teo K, Weintraub W
The New England Journal of Medicine [2011, 365(24):2255-67]. – Study of Niacin raising HDL but not having an effect on heart disease – or to quote: “CONCLUSIONS: Among patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of less than 70 mg per deciliter (1.81 mmol per liter), there was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period, despite significant improvements in HDL cholesterol and triglyceride levels.”

Omega-3 Fatty Acids and Secondary Prevention of Cardiovascular Disease—Is It Just a Fish Tale?
Comment on “Efficacy of Omega-3 Fatty Acid Supplements (Eicosapentaenoic Acid and Docosahexaenoic Acid) in the Secondary Prevention of Cardiovascular Disease” Frank B. Hu, MD, PhD; JoAnn E. Manson, MD, DrPH <- they concluded “To date, there is no conclusive evidence to recommend fish oil supplementation for primary or secondary prevention of CVD. However, a diet high in fatty fish (≥2 servings of marine fish per week) should continue to be recommended for the general population and for patients with existing CVD because fish not only provides omega-3 fatty acids but also may replace less healthy protein sources, such as red meat. Individuals who are unable or unwilling to eat fish or related products should consider increasing their consumption of plant-derived omega-3 fatty acid (α-linolenic acid). For primary or secondary prevention, omega-3 supplementation cannot supersede an overall healthy diet, but a cardioprotective diet needs to be rich in omega-3 fatty acids.”

The Lancet, Early Online Publication, 17 May 2012
doi:10.1016/S0140-6736(12)60312-2Cite or Link Using DOI
Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study.

Dr. Terry Simpson About Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and went to medical school. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine. The first surgeon to become certified in Culinary Medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.

Share this article on social media!

Latest Comments

  1. Lynn says:

    Everything that we regarded as true in medicine is now being diss-proven. PSA testing is now being considered to cause needless treatment. Re-excision after lumpectomy for missed margins is now being questioned as well as mammography every year. Flexible sigmoid is now being done rather than routine colonoscopy.

  2. thedoc says:

    its because we now think we need to prove things – as opposed to “educated guess.” Much better this way.

  3. Lynn says:

    I would say that our neighbor Canada has a lousy system of socialized medicine but other countries such as Israel, have decent medical care that is covered by the government. We are critical of socialized medicine because people are getting less medical intervention but now much of what we have long regarded as necessary for improving longevity is being regarded as dangerous intervention with little proof that it does any good. Routine EKGs and cardiac stress tests are now being viewed as leading to dangerous tests that carry a significant mortality rate.
    I am most familiar with the system of medicine in Israel because one of our sons is raising his family there. Along with the government medicine though, is a government that does not subsidize junk food. In addition, the IDF (military service) shapes up the kids in that the military training given to every non-ultra-Orthodox young adult, male or female, builds their bodies. The ultra-Orthodox are often poor and while much of their diet is bread and plain yogurt, there is not much obesity. There are unfortunately cancers that are genetically based among Jews as well as many Israelis smoke or spend lots of time on sunny beaches. Driving on Israeli highways brings one closer to G-d and repentance.
    The average Israeli breakfast is fish, tomatoes, and cucumbers and lunch is the main meal of the day. It is too hot to eat much during the summer. There are some fast food shwarma restaurants and felafel stands but much of Israel is mountainous and people are always walking uphill. People who live near beaches tend to want to look good.

  4. The Doc says:

    I am familiar with Israel and Canada. I like Canada’s system, and do not know what you base your opinion on. Their ER wait times are less, they cover all their population, cost less than half of what our coverage has- and by all metrics (infant mortality, cancer mortality, heart disease) they do better than most. Israel is like a Phoenix – about the same size, about the same population, and about the same geography.

  5. Lynn says:

    My son went to rabbinical school in Toronto for 2 years and kept hearing about people who waited for months for treatments that would only take weeks in the US. I recently saw a magazine article headline that stated, “Don’t get sick in Canada.” We kept hearing stories about Canadians who left Canada for surgeries that they could not get in Canada without a long wait. It could be that people were impatient to have those surgeries and that waiting would not really change the outcome but this is what I have heard. From my understanding of socialized medicine, most routine care is on a first come , first served basis, rather than by private appointment like we do in the US. In places like Israel and Australia (another haunt of one of my kids), pharmacies can treat minor illnesses like upper respiratory infections, sprained ankles, etc. I think that that has been tried on a limited basis in the US but has not really caught on. I read that some beta-blockers and oral meds for diabetes are soon going to be able to be dispensed by pharmacists without a doctors prescription and that will get medicare and private insurers off the hook and it will have to come out of the pockets of the patients themselves. For those who already pay for private insurance, that is a raw deal.
    I remember that years ago, there were hospitals that catered to the poor with large open wards, staffed by medical and nursing students, and lacking in amenities such as menu choices. I don’t think that these hospitals were run by various religious groups or universities but I could be wrong. I always thought that they were government run and that was why the prison population was treated there. I figured that they were similar to veterans hospitals or other military hospitals. From what I can see, those kind of hospitals don’t exist anymore and hospitals are apparently eating the cost of treating the uninsured. Then again, every headache does not need an MRI or a CT scan and I don’t think that socialized medicine is in favor of unwarranted expensive intervention. Americans are spoiled and paying the price and I would not mind seeing socialized medicine available here at least on some level.

  6. thedoc says:

    I’ve experienced Canada first hand. Americans also go to Canada for treatment. My in-laws are all Canadian, and as a physician, I would not mind being treated there. Yes, small towns in Canada do not have the same access to care as larger towns- just like the U.S. small towns.
    I want universal health care – Canada plus, or something. Americans pay too much and get too little

  7. Jacob V says:

    Here in Bellingham WA 25 miles from Canada and an hour drive from Vancouver, we have a cardiac center that would be the envy of many major cities. What floats its boat is Canadian patients who don’t want to wait six months for bypass surgery so they come down here and pay cash for time and higher quality care. I have lots of friends and some relatives in Canada and while routine and emergent care is good other tests and procedures means lots and lots of waiting.

  8. The Doc says:

    There are also those from Washington who go to Canada for care. Every system has its failings and faults.

  9. Nicole says:

    I am from Canada and yeah maybe there are longer wait times but it’s because the majority of people can’t afford to pay for what it would probably cost in the United States. For the most part medical astablishments aren’t privatized here. Harper (our prime minister) is working to change that but then there is the problem of doctors choosing to start a private business where they may make more money and government owned facilities suffering from even less doctors which makes for longer waits for patients who can’t afford the prices of going to a privatized clinic. There are other upsides to our system however we have for the most part cheaper drugs and our insurance companies cover birth control. I think another issue is that some of our doctors are leaving Canada for the United States so they can make more money I could be wrong about that though.

  10. The Doc says:

    I like Canadian Health Care – but the average income of US physicians has been declining for four decades, so it is a less attractive brain-drain for Canada. Then again, Canada has always suffered from the drain of people to the US – and hockey teams.

Leave a Reply