Interpreting Lower HDL Cholesterol in Plant-Based Diets: Mechanisms and Clinical Implications

Plant-based dietary patterns are associated with improved cardiometabolic health, including lower concentrations of serum low-density lipoprotein cholesterol, blood pressure, adiposity, inflammation, and lower risk of cardiovascular disease. However, some studies report modestly reduced high-density lipoprotein (HDL) cholesterol concentrations in populations following plant-based diets (e.g., vegan or vegetarian), whereas other studies show null associations. This has created uncertainty about whether these changes in HDL cholesterol reflect clinically meaningful harm or a neutral physiologic response. This review examines the significance of lower HDL cholesterol in the context of plant-based diets and broader cardiometabolic risk. We describe plausible mechanistic pathways, including lower saturated fat and cholesterol intake, reduced apolipoprotein A-I secretion and HDL production, and formation of smaller HDL particles that are cleared more rapidly. We suggest that modest HDL cholesterol reductions observed with healthy and appropriately planned plant-based diets should be interpreted within the broader context of net cardiometabolic benefit rather than as an isolated reason for clinical concern. However, substantial heterogeneity across studies-in both results and methodology, including variation in the definitions of plant-based diets-limits causal directionality and interpretation of reported diet-disease associations. Future analyses should improve diet classification and comparator selection, while controlling for weight change and macronutrient composition to isolate any potential effects of plant-based diets on HDL-related outcomes.