Non-HDL cholesterol is all the cholesterol in the body that isn’t carried by HDL, the “good” cholesterol. Essentially, it is all the cholesterol that can cause hardening of the arteries and formation of plaques. Research shows that it is one of the best lipid markers in assessing the risk of heart disease, heart attack, and stroke. Read more to discover what increases non-HDL cholesterol and what you can do to reduce it and your risk of heart disease.
What is Non-HDL Cholesterol?
Lipoproteins are a group of proteins and fat-like molecules called phospholipids that carry cholesterol and triglycerides (fats) around the body. Since cholesterol and triglycerides do not easily dissolve in the blood, lipoproteins help transport it around .
You can think of lipoproteins as cars on a highway (blood vessels) and cholesterol and triglycerides as the passengers.
The five main types of lipoproteins are:
- High-density lipoprotein (HDL): carries so-called “good cholesterol”
- Low-density lipoprotein (LDL): carries so-called “bad cholesterol”
- Very low-density lipoprotein (VLDL): carries some cholesterol and mostly triglycerides and which eventually becomes LDL
- Intermediate-density lipoprotein (IDL): the transition form between VLDL and LDL
- Chylomicrons: transport fats from the gut to the rest of the body
A standard lipid panel measures the total amount of cholesterol carried by these lipoproteins. Non-HDL cholesterol (non-HDL-C) is a measure of all of the cholesterol being carried by VLDL, IDL, and LDL .
VLDL is made in the liver after the body absorbs fat from the diet. VLDL transports triglycerides to the heart, muscles, and fat tissues. As VLDL loses more and more triglycerides, it becomes LDL – particles rich in cholesterol and low in triglycerides [1, 1].
HDL carries cholesterol away from the cells and the walls of blood vessels to the liver to be removed. The other three lipoproteins carry cholesterol away from the liver and can become stuck in the blood vessel walls. This process causes plaques and hardening of the arteries (atherosclerosis). HDL reverses this process and is the only lipoprotein that is not associated with an increased risk of heart disease .
Non-HDL Cholesterol Testing
Your non-HDL-C value is calculated by subtracting your HDL-C value from your total cholesterol value. Your total cholesterol is calculated by adding your HDL-C, LDL-C, and 20% of your triglycerides (an estimate for VLDL). It is tested as part of a standard lipid panel .
Non-HDL-C is used to assess your risk of heart disease or serve as a treatment target for cholesterol-lowering drug therapy.
The benefits of using non-HDL-C include:
- It measures all of the cholesterol that can cause hardening of the arteries (atherosclerosis), including LDL-C
- It is easy to calculate and does not require additional costs and tests besides a lipid profile
- Does not require a fasted sample, unlike LDL-C
Normal Non-HDL Cholesterol Levels
The normal range for non-HDL-C is 0- 120 mg/dL for people under 20 years old and 0- 130 mg/dL for people 20 years and older.
Non-HDL-C levels, along with all lipids, are elevated during the second and third trimesters of pregnancy. However, there is no reference range for lipid levels during pregnancy .
Causes of Increased Non-HDL Cholesterol
1) High-carbohydrate Diets
Longer term trials (> 3 weeks) show that while VLDL-C (triglycerides) are increased, total cholesterol and LDL-C tend to decrease (131 total people). This means long-term high-carbohydrate diets have little effects on non-HDL-C [11, 12, 13, 14].
LDL receptors are needed for cells to take in LDL. In obesity, there’s a reduced number of LDL receptors in the body, which means that more LDL stays around in the bloodstream. Obesity also increases the production of VLDL-C and decreases how fast it’s removed from circulation [15, 16].
In a study of 75 people, those who smoked had 25% higher non-HDL-C levels compared to non-smokers. Two other studies have also found non-HDL-C levels to be higher in smokers (281 total people) [21, 22, 23].
Another study of 1,500 people found that more cigarettes smoked per day were linked to higher non-HDL-C levels .
4) Type 2 Diabetes
In 339 people with type 2 diabetes, higher non-HDL-C levels were associated with worse diabetes control and higher BMI .
There are fewer LDL receptors in people with an underactive thyroid (hypothyroidism). This means that IDL-C and LDL-C increase in the blood. As a result, hypothyroidism causes elevated non-HDL-C levels [34, 35, 36].
Non-HDL-C was also increased in 1443 people with undiagnosed mild (subclinical) hypothyroidism .
Taking thyroid hormones reduced high non-HDL-C levels in 39 people with hypothyroidism. Another study of 26 people found that one year of thyroid hormone replacement decreased non-HDL-C in hypothyroidism [38, 36].
6) H. Pylori Infection
H. pylori infection is consistently associated with increased levels of non-HDL-C. Multiple studies of 5,200 people found that getting rid of H. pylori decreases non-HDL-C levels [39, 40, 40, 41, 42, 43, 44, 45, 46].
7) Gum Inflammation
Inflammation of the gums (periodontitis) is often caused by bacteria. This bacteria and the inflammatory molecules created to fight them enter the circulation and may cause hardening of the arteries (atherosclerosis) .
A meta-analysis of 15 studies with 105k people found that gum inflammation increased the risk of heart disease .
In a meta-analysis of 18 studies and 1940 people, gum inflammation was linked to increased levels of non-HDL-C .
8) Kidney Disease
Kidney disease increases the amount of VLDL the body makes and reduces how fast it’s broken down. As a result, elevated non-HDL-C levels are commonly found in patients with chronic kidney disease [53, 54, 55].
Diseases and Conditions Associated with Increased Non-HDL Cholesterol
1) Heart Disease (likely causal)
Non-HDL-C is strongly associated with an increased risk of developing as well as dying from heart disease. Non-HDL-C is even better at predicting your risk of heart disease than the traditional risk factor LDL-C [56, 57, 58, 59, 60, 61, 62, 63].
Non-HDL-C is also more closely linked to the underlying mechanisms of heart disease, including inflammation and hardening of the arteries (atherosclerosis), than LDL-C alone [64, 65, 66, 67, 67, 68, 69, 70, 71, 72].
2) Metabolic Syndrome
Metabolic syndrome is a condition characterized by at least three of the following: high blood pressure, high blood sugar, excess stomach fat, high triglycerides, and low HDL cholesterol.
Like the name implies, non-alcoholic fatty liver disease (NAFLD) is an accumulation of fat in the liver due to causes other than drinking too much (viruses, diet, and drugs).
4) Vitamin D Deficiency
Psoriasis is an autoimmune disease that causes red, dry, and itchy patches on the skin.
Multiple studies of 597 total people found that non-HDL-C levels were higher in people with psoriasis. One study in 70 people with psoriasis found that nearly 63% had non-HDL-C levels above the normal range [81, 82, 83, 84, 85].
6) Aspirin Resistance
High non-HDL-C levels were linked to an increased risk of aspirin resistance in 1,045 people .
Ways to Decrease Non-HDL Cholesterol
1) Weight Loss
A meta-analysis of 70 studies found that weight loss substantially decreases non-HDL-C. Losing weight reduces how much cholesterol the body makes .
In a population study of over 80k people, more days per week of aerobic or strength exercise were associated with lower non-HDL-C levels .
Simply walking reduced non-HDL-C by 4%, according to a meta-analysis of 22 studies and 948 people .
However, a meta-analysis of 13 studies and 404 people found that aerobic exercise does not decrease non-HDL-C levels .
In a population study of over 43,000 people, non-HDL-C levels were lower in those who drank alcohol. This effect was seen even in those who drank less than one beer or one small glass of wine a day (10 g). Please keep this in mind and limit your alcohol intake .
Red yeast rice reduced non-HDL-C concentrations in a meta-analysis of 13 studies and 804 total people .
5) Green Tea
In a meta-analysis of 14 studies and 1,136 total people, green tea beverage or extract reduced non-HDL levels without affecting HDL levels .
Green tea reduces non-HDL by decreasing the production of cholesterol and increasing the number of LDL receptors .
6) Vitamin C
Supplementing with at least 500 mg a day for four weeks of vitamin C reduced non-HDL levels in a meta-analysis of 13 studies and 405 people .
A meta-analysis of 33 studies and 1273 people found that garlic reduced non-HDL-C levels .
8) Soluble Fiber
Soluble fiber is fiber that dissolves in water and is easily fermentable by bacteria in the gut. It is also referred to as prebiotic fiber.
Konjac glucomannan, a type of soluble fiber, reduced non-HDL-C in a meta-analysis of 12 studies and 370 total people .
Another soluble fiber called psyllium husk reduced non-HDL in a meta-analysis of 28 studies and 1,924 total people .
Beta-glucans are long-chain sugars (polysaccharides) that improve the function of the immune system.
A meta-analysis of 58 studies and 3974 total people showed that beta-glucans reduced non-HDL-C levels .
Beta-glucans reduce non-HDL-C by increasing the conversion of cholesterol into bile .
As little as 1 g of cinnamon a day for 40 days reduced non-HDL levels in 60 people .
In a study of 95 people, ginger reduced non-HDL levels .
In a study of 33 people, 2 g of curcumin daily for 2 months reduced non-HDL levels .
A trial of 94 people found that 2 g/day of black cumin seed oil (Nigella sativa) reduced non-HDL-C levels .
15) Fish Oil and Fish
In a study of 95 people, non-HDL levels decreased in people who ate 250 g (8.8 oz) of trout twice a week or took 2 g of fish oil daily .
A study of 36 people found that 2.2 g of fish oil daily decreased non-HDL levels .
Eating one avocado a day reduced non-HDL-C levels in a study of 45 people .
Amla fruit (Emblica officinalis) powder reduced non-HDL-C levels by a similar amount as statins in a study of 60 people .
Eating 1.5 oz/day of walnuts reduced non-HDL-C levels in 40 people .
In a study of 48 people, 1.5 oz/day of almonds decreased non-HDL-C levels .
Eating 2 oz/day of pistachios decreased non-HDL-C concentrations in a study of 54 people .
Rice bran oil decreased non-HDL-C levels by in hamsters by 70% .
Conjugated linoleic acid (CLA) is a fat found in meat and dairy that may have health benefits. CLA reduced non-HDL-C levels in hamsters .
Genetics of LDL-C
Some people have reduced activity of genes that break down cholesterol (ABC transporters). This can increase LDL levels and lower response to cholesterol medication .
These mutations cause problems in removing LDL from the blood, resulting in elevated LDL .
Genetics of VLDL-C
Apolipoprotein E (ApoE)
ApoE is a protein found in VLDL molecules. As a result of mutations in the gene that encodes the protein, different versions of this it exists. Having a defective copy of ApoE contributes to high VLDL levels .
Effect of Drugs on Non-HDL Cholesterol
Drugs that increase VLDL and/or LDL-C levels include:
- Anabolic steroids 
- Antipsychotics 
- Amiodarone (Cordarone, Nexterone), a drug used to treat irregular heartbeats 
- Corticosteroids [128, 130, 131]
- Danazol (Danocrine) 
- Estrogen replacement and selective estrogen receptor modulators (SERMS) 
- Growth hormone 
- Immunosuppressive drugs (cyclosporine (Neoral, Sandimmune) and tacrolimus (Prograf, Advagraf, Protopic), used to treat autoimmune disease 
- Loop and thiazide diuretics [128, 132, 133]
- Protease inhibitors, antiviral drugs used to treat HIV 
- Retinoids, vitamin A derivatives used to treat skin problems [128, 134]
- Second-generation antipsychotics such as clozapine (Clozaril, FazaClo, Versacloz) and risperidone (Risperdal, Risperdal Consta) 
- Sotalol (Betapace), a beta-blocker 
Drugs that decrease VLDL and/or LDL-C levels include:
- Statins (Lipitor and Zocor), a drug used to decrease the production of cholesterol 
- Bile acid sequestrants (e.g. cholestyramine) 
- Estrogen replacement and selective estrogen receptor modulators (SERMS) 
- Ezetimibe (Zetia), a drug that lowers cholesterol levels by decreasing cholesterol absorption in the gut 
- Fibrates [140, 141]
- Mipomersen and lomitapide, drugs used to decrease the production of VLDL [142, 142]
- PCSK9 inhibitors 
Irregular Non-HDL Levels?
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