[twinkletoes77]

Hope this is the correct forum for this quesiton:

Background: I began weight training and cardio training last December. I work out with free weights 2 days a week and then on 3 other days I do an intense cardio/interval session. All of these workouts leave me feeling exhausted when I am done (because I always push myself to the point that I cannot go anymore), but they have worked so well for me thus far. My strength is so much better than it was when I began, and my cardio endurance is also much better. Since December I have gone down about 60 pounds in net weight and about 10-12% in %BF.

My Question: I recently had blood work done and while most all my blood indicators say this program is going gang-busters for me (compared to my results from one year ago- my total cholesterol is down, my LDL and triglycerides are down, my HDL is up, my blood pressure is down, etc..), my liver enzymes tested at a high level. And that has never happened to me before. My ALT was 190 (approximately 4-5X the upper limit on the reference) and my AST was 87 (approximately 2X the upper limit on the reference).

My doctor asked me if I had before the test 1) been drinking, 2) taken tylenol, or 3) been taking drugs to lose weight and bulk up. I assured her that I hadn't done any of those things. The only 'drugs' I have been taking since I began are 2 multivitatmins/day, 4-6 capsules of fish oil/day and 2 capsules of flax seed oil/day. And, occasionally I take an ibuprofen, but not on a regular basis. Other than that, I eat alot of fruit and vegetables and meats and supplement with protein shakes.

I have been feverishly googling the web, and have found that there is a recommendation not to do strenuous exercise right before having these enzymes tested, since damaged muscles can contribute these enzymes to the bloodstream, although they are primarily put out by a damaged liver. Since I had no idea of this, I did do very intense workouts up until the night before the morning of my test. As a matter of fact, I have been working out intensely for almost 8 months now! Could this cause the results I obtained? Do athletes that train hard sometimes have this issue with their liver indicating enzymes? No other liver function parameters (nor any other parameters) were out of line in my most current blood testing, just the enzymes I mentioned above. And, other than getting tired after my workouts, I feel great! Thanks!

[Kris Aiken]

I do hope one of the doctors posts a more scientific answer for you. But in the meantime, I will say that I do believe that strenuous exercise can affect your test results, especially if done in close proximity to the blood being drawn.

I would not worry, if the rest of your markers are improved and you have made such a dramatic physical transformation.

Cheers,

Kris

[Daniel Freedman]

My experience duplicates almost precisely what twinkeltoes77 mentioned.

I began doing intense Crossfit workouts in June and started PN shortly thereafter. Results have been remarkable: quickly dropped 11 pounds and kept it off; bodyfat down from 22% to 14%, performance in various benchmark workouts up 23% to 38% (measured at one month intervals).

Along the way, I've been having regular blood work done. I'm on lifelong warfarin (coumadin) due to deep vein thrombosis and pulmonary embolism. We've had to tweak dosage levels as I adjusted diet and exercise. I should add that my doctor has been very supportive, and has consulted a clinical pharmacist, a nutritionist, and a haematolgist. They have decided that slightly elevated CK levels are not a cause for concern, given my intense level of exercise.

Cholestorol and other markers have improved, but my doctor is puzzled by elevated ALT and AST levels. I don't have the numbers in front of me, but she said the moderately elevated levels (and the relationship between them, if I understood correctly) were often found in heavy drinkers. Except I'm not a heavy drinker. I average about 8 drinks a week, but am not consistent. I might have a couple of beers one day, then nothing for three days. If I buy a bottle of wine, I might drink a third of it for three consecutive nights, then consume nothing alcoholic for the next few days, etc...

My doctor asked if I'd had anything to drink the night before the test. I frankly couldn't remember. I don't use tylenol, but do take vitamins B6, B12, folic acid, calcium and one fish oil cap (along with 14 mg. of coumadin) every day. So she's asked me to abstain from all alcohol for three weeks and then be re-tested for ALT and AST. At the same time, I'll also have other tests -- to rule out other liver-related possibilities. In the meantime, she is going to talk again to the pharmacist to review everything.

(The doctor also sent me for an EKG and wrote on top of the requisition "Extreme Athlete". I was thrilled!)

So: back to the original question -- can intense exercise affect AST and ALT levels?

[Dr Lopez]

twinkletoes,

my apololgies for not seeing this thread sooner!

Daniel hit the nail on the head...Exercise (even if not incredibly intense) can and will transiently and mildly elevate both AST and ALT. Although, it tends to show a prediliction for proportionately greater increase in AST. There are very limited well-controlled studies on this phenomenon, but there are plenty of descriptive studies in the medical literature.

This is a topic that a few of us docs from PPP have edified other primary care physicians on, since so many of our patients are very active (some pro/elite level athletes), and we typically "prescribe" exercise (therapeutic/corrective for sports/spine/musculoskeletal injuries) and (metabolic protocols for patients with obesity/cardio-metabolic risk factors).

We've done some "in-house" experimental work and found that AST/ALT elevations typically BEGIN within 8 hours after the exercise event, PEAK at 30-36 hours, and MAY REMAIN elevated for as long as 6-7 days.

---elevations tend to be greater in novice exercisers, or those returning after a layoff/deconditioned state (makes sense, since they have yet to experience the repeated bout effect, and skeletal muscle membranes/ myo-tendionus junctions are still apt to micro-injury)

---elevations greater with eccentric-emphasis training (also no surprise)

---" " " " " higher total work (load x volume) performed (ditto with no surprise)

Some interesting points to help other docs (and patients) feel easier about the mild elevations. If a GGT (gamma-glutamyltransferase) is checked concurrently, it will often be stone-cold normal...an this enzyme is even more specific for the hepatic (liver) injury. Also, we've found (and there is evidence in the sci lit) that patients on a STATIN medication tend to have exaggerated AST/ALT responses.

a few other pearls.....AST tends to be found primarily in the mitochondrial/microsomal fraction of cells, while ALT is primarily in the cytosolic/cytoplasmic fraction. The AST is found in liver, striated muscle (heart and skeletal muscle), and RBCs. ALT is found in liver and kidney, with smaller quantities in heart and skeletal muscle. This helps to explain why Daniel's doctor commented on the pattern of elevation being similar to what we find with acute alcoholic hepatitis, since the AST is the more prominent enzyme in skeletal muscle, it will be result in higher "AST/ALT" ratio ( an AST/ALT ratio of more than 2.0 is more consistent with alcoholic hepatitis).

Other enzymes that may be transiently elevated by exercise include CK and LDH.

hope this helps to shed some light on the matter.

Best in health and performance to all,

[Daniel Freedman]

I got back my re-test results today and discussed them with my doctor. The findings are completely in line with what Dr. Lopez said above.

* ALT, AZT and CK levels were down from moderately elevated to high normal or near normal.

* GGT was normal

* small changes in my moderate alcohol consumption pattern seem to be a red herring

The conclusion is that the first set of results was related to the timing of the test vis a vis exercise -- and was not indicative of any underlying cause for concern.

[lafern]

Dr. Lopez,

I was wondering what should individuals with this type of body characteristics do? Is it bad to have those high elevations of ALT and AST? Is there any way to lower them? Or is it just that some bodies are wired differently?

I know that these tests are done to check on the liver and its functions. I had the same problems as stated above in the thread. Then I was retested after resting for a month with no strenuous exercise and everything was normal. My liver was in great shape and it was definitely linked to my training. Therefore, is there anything I can do to avoid these problems in the future? What would you recommend?

Thanks

[Dr Lopez]

Hi lafern,

as i mentioned in the last post, there are very good reasons for individuals to respond to certain exercise stressors with elevations in the enzymes we've discussed.

I probably should have mentioned, but took it for granted that with all these enzyme assayed on diagnostic tests....they are strictly "MARKERS". Because they are only markers, in this case there is nothing inherently dangerous, toxic or harmful about the enzymes found in blood plasma. So, we really do NOT have to worry about finding ways to lower them per say. Also, i am sure that as people start experiencing the "repeated bout effect" and begin adapting to their exercise/training, the magnitude of enzyme elevations should DECREASE. We have plenty of evidence in the scientific literature, although mostly with endurance athletes of nutritional strategies geared toward improving performance, which have also resulted in decreased muscle enzyme elevations (post-exercise). Most of you are already incorporating these strategies: peri-workout nutrition (pre, intra, post), timing of essential amino acids (including BCAAs), creatine, antioxidant status, long-chain PUFAs (DHA/EPA), etc.

Taken in a different clinical context, if there are other symptoms of liver damage, or kidney disease combined with extreme muscle soreness....then, we need to worry about other conditions which need to be addressed.

[Dr Lopez]

A different spin on the above scenario, is that for some athletes or exercise enthusiasts, there are enzymes which are more reliably an indication of the overall training LOAD or STRESS placed on skeletal muscles. Hence, some may argue that over time, the goal would be to have these short-term muscle enzyme elevations followed by an attenuation (or decrease) in the elevations post-training as an indication of positive ADAPTATION to the trainng/exercise stress.

So, why not do this routinely for athletes or weekend warriors looking to enhance their performance? Well, these enzyme measurements from blood plasma have not been standardized for this purpose (i.e., tracking training progress or periodizing exercise/training modes, load and volume). Therefore, they are not reliable for this purpose. Also, there is tremendous variability and way too many factors to discuss here, which would also make this less reliable.
However, something that the doctors of PPP have been interested for some time now (due to backgrounds in MOLECULAR BIO), include exercise and nutritional genomics and metabolomics. As the science of biomics related to applied nutrition, exercise, & strength and conditioning continues to evolve and develop IT will be a very nice, reliable tool for many of us to utilize to augment not only human performance, but also to manage disease, injury, and rehabilitation!

best regards,

[lafern]

Dr. Lopez,

Thanks you very much for all your help. You have helped me understand this so much more.

In regards to having my blood work done again, what do you recommend I should do the weeks before to be able to lower my levels.

Should I take a break from my weight lifting activities?
Should I drop cardio as well?
Should I cut out supplements like multivitamin, glutamine, creatine, whey protein?

Any other tips you would recommend me to do and how long before taking the tests.

Thank you very much.

[Daniel Freedman]

I'm NOT a doctor, but I can't resist chiming in.

My advice: make no changes in your routine prior to testing. The goal of testing is to get a realistic snapshot. It is not to somehow "beat the test" through unusual and temporary behavior, before resuming normal activities.

Once you have the results, you may want to discuss with your doctor the possibility of modifications. Or you might decide on a re-test with no modifications. But the time for any modification is AFTER the tests, not before.

A few years ago, a nurse told me of a patient who proudly announced he had taken a long walk just prior an annual physical to "get a good score" on blood pressure. The nurse said she gently pointed out that taking a long walk was a good idea -- but he might want to consider doing it EVERY day, and not just on days he was being tested.

I think the same principle applies in your case. Testing is a tool, not an end in itself.