Tangier disease (TD), caused by mutations in the ATP-binding cassette 1 (ABC-1) gene, is a rare genetic disorder characterized by severe deficiency of high density lipoproteins (HDL) in the plasma, hypercatabolism of HDL, and defective apolipoprotein (apo)-mediated cellular cholesterol efflux. In the present study, we assessed plasma lipid concentrations, HDL particle size and subspecies, and cellular cholesterol efflux in 9 TD heterozygotes from a kindred in which the proband was homozygous for an A ¨ C missense mutation at nucleotide 5338 of the ABC-1 transcript. Relative to age-and gender-matched controls from the Framingham Offspring Study (FOS), TD heterozygotes had significant reductions ( P Ͻ 0.000) in HDL-C ( ؊ 54% female; ؊ 40% male) and apoA-I ( ؊ 33% female; ؊ 37% male) concentrations, as well as significantly less cholesterol ( ؊ 68% female; ؊ 58% male) distributed in the largest HDL subclasses, H5 and H4. Consequently, HDL particle size (nm) was significantly smaller ( P Ͻ 0.000) in TD heterozygotes (8.6 ؎ 0.6 female; 8.7 ؎ 0.1 male) relative to FOS controls (9.4 ؎ 0.4 female; 9.0 ؎ 0.3 male). Further studies demonstrated that apoA-I-mediated cellular cholesterol efflux in TD heterozygotes was essentially half that of controls (11 ؎ 2 vs. 20 ؎ 3% of total [ 3 H]cholesterol, P Ͻ 0.001), with strong correlations observed between cholesterol efflux and both HDL-C level (r ؍ 0.600) and particle size (r ؍ 0.680). In summary, our data demonstrate that apolipoprotein-mediated cholesterol efflux is aberrant in TD heterozygotes, as it is in homozygotes. This finding, along with the associations observed between HDL-C concentration, HDL particle size, and cholesterol efflux, supports the concept that plasma HDL-C levels are regulated, in part, by cholesterol efflux, which in turn influences HDL particle size and, ultimately, HDL apoA-I catabolism.