Very high AST / ALT / Cholesterol (LDL) after 6 weeks on a ketogenic diet

cholesterol
keto
newbies
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(Txdr) #1

Hi everyone:

I considered adapting a ketogenic diet and read about it for several months now and have successfully (?) implemented some of these dietary manipulations into my lifestyle.

I’m a male / 33 yrs / 5′10″. / CW: 152lbs.

My overall goals are to have (1) a healthy weight, (2) good physical shape (say 15% of less BF; currently at 10-11%), (3) optimal brain power (no fogginess or lack of focus, as I’m a scientist), (4) steady energy levels throughout the day (no constant ups and downs), and (5) control over hunger, among other things. This led me to find a combination of keto and OMAD very attractive.

My macros have been roughly 161g protein (45%) / 18g net carbs (5%) / 80g fat (50%) but most days I end up closer to 20% protein (99g) / 5% carbs (18g) / 75% fat (157g). I keep track of most of my macros using MFP and aim for a total of ~ 1,400 - 1,500 cals per day (but often end up consuming close to 2,000 cals some days). I get close to zero carbs some days and never over 20-25g net carbs. Right now my macros are undergoing some modifications as I would now like to maintain or increase a bit my weight by getting back some muscle, so leaning towards 2,000-2,200 cals per day.

A typical day for me is:

Breakfast (~7:30AM or so) (~ 50 cals give or take):

  1. A cup (~ 12 oz) of black pour over coffee.

  2. Two Pure Alaska Omega-3 Wild Alaskan Salmon Oil 1000mg Softgels.

  3. Three Perfect Keto MCT Oil Softgels.

  4. One One A Day Multivitamin for Men capsule.

  5. One Hi-Lyte Advanced Electrolyte Salt capsule.

Dinner (7:30PM or so) (OMAD; ~ 1,500 cals give or take):

  1. Some vegetables (like broccoli / french green beans / avocado / spinach / mixed greens / others).

  2. Some cheese (like cheddar / parmigiano / gouda / mozzarella / manchego / others).

  3. Some protein (like chicken breast / wild salmon / mahi mahi / pork chops / burgers / others [including very fatty cuts, such as pork belly every now and then but currently leaning towards “healthier” cuts and more fatty fish instead]).

  4. Some fat (most comes with the protein unless eating lean protein; otherwise olive oil / avocado oil / butter / macadamia nuts / others).

  5. Some snacks/dessert (like macadamia nuts / 1 cup of FAGE Total 5% Plain Greek Yogurt w/ 3 Tbsp chia seeds / sometimes a square or two of 85% dark chocolate).

  6. Sometimes my OMAD will include a protein shake (2 cups of No Sugar Almond Milk + 2 Tbsp of Nutzo Butter + 4 scoops of Naked Whey + 1 Tbsp of Barleans Flax Oil [rarely]) but this is not that common anymore. This used to be my breakfast shake pre-keto.

So here’s my situation. I just got some test results and am a bit concerned.

  1. AST = 85 u/L (standard values are <=34 u/L)

  2. ALT = 163 u/L (standard values are 10 - 49 u/L)

  3. Total Cholesterol = 249 mg/dL (standard values are - Desirable: < 200mg/dL / Borderline High: 200-239 mg/dL / High: >=240 mg/dL)

  4. Triglycerides = 41 mg/dL (standard values are <=149 mg/dL)

  5. HDL = 46 mg/dL (standard values are >=40 mg/dL)

  6. LDL = 195 mg/dL (standard values are <=99 mg/dL)

  7. Cholesterol/HDL Ratio = 5.4

Obviously these numbers (particularly the cholesterol numbers) can be a bit concerning to the general population and most doctors but I am not worried about them. What worries me are the levels of the liver enzymes and whether it is possible that this is related to how I am eating.

I’ve kept very good track of my dietary manipulations for the last 5 months. I weighted 207 lbs in Aug 28th 2018 (which is when I decided that it was about time I made some changes) and currently weight around 155 lbs give or take. I dropped all of this weight via a combination of dieting and exercise.

From Aug 28th (207 lbs) until Dec 28th (168 lbs), I was basically doing relatively high protein / moderate carb / relatively low fat (~1,500 cals total) and cardio/strength workouts. On Dec 28th (6 weeks ago; 168 lbs), I switched to what could be considered a ketogenic diet (moderate to high protein / low carb (20g per day) / high fat) (1,500 cals total, sometimes up to 2,500) and cardio/strength workouts and am now at ~ 152 lbs and still on ketosis.

I’ve read and listened to quite a bit of informative material (here, elsewhere, and the primary literature, as well as what I consider good podcasts, such as Peter Attia’s The Drive and Rhonda Patrick’s Found My Fitness podcasts, among others) and have seen and heard that early during keto adaptation, AST, ALT, and LDL levels can skyrocket while the liver gets used to burning mostly fat (and I must be somewhat fat adapted because I can very easily fast for 24hrs (and perhaps even longer, although have capped it at 36hrs for now) without having any energy fluctuations or hunger whatsoever, even after working out pretty hard. In fact, I’ve never, ever felt better in my life. What should I do? Unfortunately I don’t have proper pre-keto lab tests before Dec 28th 2018, so I can’t compare pre- and post-keto.

The only prior labs I have are from about a year ago (12/12/2017):

  1. ⁠AST = 22 u/L (now 85 U/L (standard values are <=34 U/L))
  2. ⁠ALA = 27 u/L (now 163 U/L (standard values are 10 - 49 U/L))
  3. ⁠Total Cholesterol = 210.0 mg/dL (now 249 mg/dL (standard values are - Desirable: <200 mg/dL / Borderline High: 200-239 mg/dL / High: >=240 mg/dL))
  4. ⁠Triglycerides = 118 mg/dL (now 41 mg/dL (standard values are <=149 mg/dL))
  5. ⁠HDL = 46 mg/dL (still 46 mg/dL (standard values are >=40 mg/dL))
  6. ⁠LDL = 140 mg/dL (now 195 mg/dL (standard values are <=99 mg/dL))
  7. ⁠Cholesterol/HDL Ratio = 4.6 (now 5.4)

I just got my doctor’s recommendation of modifying my diet by introducing complex carbs, brown rice, and whole grains, as well as lean sources of protein followed by repeating tests in 4 weeks, which really sucks because I would ideally like to keep burning fat for energy (not for losing weight; I’m all set in that regard) but I also don’t want to develop liver disease down the road. That said, I am leaning towards not thinking that reintroducing carbs will fix anything whatsoever and think that it might be some temporary adaptive process or perhaps something about the macros or sources of fats that might be triggering this?

It really makes me wonder what all of this means. If we only look at the lipids, it suggests decent HDL levels, “bad” LDL levels, and “optimal” triglyceride levels… Isn’t that consistent w/ some of the paradoxical changes that other people in LCHF/keto report somewhat frequently? It immediately reminded me of some of the stuff that Peter Attia has discussed in the past (e.g. https://peterattiamd.com/davefeldman/).

The liver enzymes though… completely different story… no idea how to explain any of this…

I’ve come across information that suggests that intense workouts the day of the blood test (or even a few days before the blood test) can lead to a transient spike in the levels of liver enzymes - any thoughts about this? That morning I had a relatively intense workout (5x5 w/ squats being pretty intense) followed by no breakfast or lunch whatsoever before the blood tests and I was overall pretty sore. Just wondering if this might explain this.

In terms of workouts, I recently started 5x5 alternated w/ my cardio of choice Peloton (which I’ve been doing for 6 months or so now).

I’m planning on not changing my diet or workouts whatsoever for now and then get re-tested in 4 weeks to see if the liver enzymes have stabilized, increased, or decreased, and then decide what to do. Would this make sense?

I also came across posts like these:

… which haven’t really helped me reach any conclusions…

Thoughts?

(You've tried everything else; why not try bacon?) #2

Okay. Your ratio of triglycerides to HDL is fantastic, which you can use against anyone who comes at you about the other numbers. If you had an NMR done on your LDL, the pattern would almost certainly be A.

I am not a fan of the cholesterol theory in any case; there is just too much evidence that works against it. Ravnskov & Diamond hypothesize that the real cause of CVD is clotting abnormalities, in particular, polymorphisms of fibrinogen and factor VIII.

The liver enzymes are a bit concerning, but you haven’t been on a ketogenic diet for that long. Wait till the six-month mark at the end of June and retest. See what the numbers are then. There are studies showing that a low-carb/ketogenic diet reverses fatty liver disease, so you should be fine. Can you fend off your doctor for that long?

(Bob M) #3

I agree with Paul, I’d wait a bit. Here’s a study of Type 2 diabetics on a keto diet versus Type 2 diabetics on a normally proscribed diet (not randomized, though):

ALT-AST
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See here:

It may just be the liver itself is clearing itself of fat perhaps.

You could also try this:

I have been using the Alpha lipoic acid and Milk thistle to see if it helps my liver, and drinking green tea (recommended by Dr. Fung). Can’t tell whether the green tea does anything other than give me more caffeine, and won’t know about the other two until I get liver tests done.

(Full Metal KETO AF) #4

It looks like your LDL went up quite a bit but you’re HDL stayed the same. I had a similar issue and my doctor suggested upping my fish oil dose. I just had my triglycerides tested this week and my ratio was totally fixed. Triglycerides were down. I hand my LDL go from 140 to 152 but HDL was way up.

I take 1600 EPA and 1200 DHA daily and it fixed me up in three months.

(Bob M) #5

I meant, prescribed. One tiny letter’s difference.

Personally, I think markers like LDL and TC are not important. You can potentially modify them, say via the fish oil, but does that help or hurt? If it helps, it’s because of lower inflammation and coagulation, not because the marker itself went down. But, there’s always the danger of too much of a good thing. Maybe you now have not enough coagulation, leading bleed through strokes or the like. There’s so much we don’t know, and medicine has done us a disservice by “knowing” that LDL is “bad” and spending billions to get that one marker down, instead of looking at other possibilities.

(Carl Keller) #6

I’m in Bob’s boat. I’ve read a lot or research and watched quite a few videos that give good proof that the cholesterol hypothesis is dead wrong. LDL is a ferry that moves cholesterol to our cells while TC’s main job is to store excess calories into cells as well as ferry that stored energy out when needed. TC is obviously going to be greater in someone overweight and simply losing weight lowers that number because there is less work to do. LDL is extremely necessary since every cell in our body needs cholesterol to survive. No cholesterol = no life.

IIRC, 80% of cholesterol is produced in our own bodies and 20% comes from diet and from what I understand, if you reduce dietary cholesterol, your body will ramp up production. That’s why it seems totally counterintuitive to take drugs that lower an important component we need to survive.

I’ve heard and read about numerous cardiologists stating that it’s not uncommon for people with “normal” LDL levels to have heart attacks. Normal LDL is harmless but it’s oxidized LDL that is bad.

Heart attacks and strokes are predominately inflammatory diseases, rather than simply diseases of high cholesterol levels.
Jason Fung

https://www.docsopinion.com/health-and-nutrition/lipids/ldl-c/

This is a rather long video but it’s fascinating and eye opening.

(Txdr) #7

Thank you very much for your response Paul. I think I can push for having my tests re-done 6 months from now instead (or in addition to 1 month from now). In my view the more data the better! I wish I could have a detailed panel similar to the ones that people like Peter Attia tend to discuss in their podcasts but of course my doctor likely won’t approve these “fancier” tests. Or is there a way to get around that? As metabolism is so plastic I would love to have more data on hormones, more detailed lipid panels, etc, particularly over time to see how these dietary manipulations affect my body. I find it super intriguing.

(Txdr) #8

Thanks. I’ll look into these additional supplements. I really hope the liver issues are transient as my life hasn’t changed that much over the last year other than losing almost 60 pounds, eating way healthier, exercising quite a bit, and not drinking much anymore (if at all these days). Its all confusing to me.

(Cancer Fighting Ketovore :)) #9

You could check: https://www.healthlabs.com/
Depending on what you need, maybe pay yourself?

Also, I’d at least get the liver tests done in a month. You don’t want a potential problem to skip through the cracks.

(You've tried everything else; why not try bacon?) #10

One thing you can try is to manipulate your results. Go to www.cholesterolcode.com and learn Dave Feldman’s protocol for this. If you eat a certain way for five or six days in advance and then fast just the right number of hours before the blood draw, you can change your test results and make the doc leave you alone. Dave has done a lot of excellent work on cholesterol. Another citizen scientist worth checking out is Ivor Cummins, at www.fatemperor.com.

ETA: You might also find it worthwhile to go on PubMed and check out the papers that Uffe Ravnskov and David Diamond have published over the past few years on the topic of cholesterol, heart disease, and statins. Prof. Diamond also has a number of excellent videos on YouTube, of presentations in which he gives even more references that you might enjoy checking out. Lastly, check out the Hyperlipid blog, at http://high-fat-nutrition.blogspot.com/. It is well worth reading for Peter’s sense of humour alone.

(Central Florida Bob ) #11

I’m going to take a completely different path. First off, I had elevated AST/ALT for a decade. Maybe more. It was caused by the statins I was on. The first doctor that I talked with about it said that having a single beer or glass of wine can make them go out of range but I hadn’t had anything alcoholic within weeks of the test. Basically, they weren’t concerned with me having both of them near to 3x normal. I recall hearing they’re easily affected by many things.

You didn’t mention being on a statin, but it makes me wonder if one of the supplements you’re taking is elevating the liver enzymes. Have you tried to search on any of the supplements and elevated AST/ALT levels?

I eventually switched the particular statin I was taking to get the lowest impact on the enzymes, but they were OK with those enzymes being high. I found an old lab from when I was on Crestor. AST was 98 with 35 as top of normal, and ALT was 164 with 60 at the top of normal.

I asked my current GP if I could quit statins as an experiment and they recovered. AST 11, ALT 16.

(Txdr) #12

Thanks for your message Bob. Interesting. I honestly didn’t think about the supplements negatively impinging on the liver.

These are the supplements I take per day:

  • Two Pure Alaska Omega-3 Wild Alaskan Salmon Oil 1000mg Softgels (thinking of increasing the dose).
  • Six Perfect Keto MCT Oil Softgels (3 during AM and 3 during PM; sometimes 3 extra ones around lunch, but this is rare).
  • One One A Day Multivitamin for Men capsule.
  • Two Hi-Lyte Advanced Electrolyte Salt capsule (1 during AM and 1 during PM).

These are the medicines I take per day (to treat anxiety):

  • 10.5mg Citalopram
  • 10mg Adderall

And that’s it. Nothing else. I wonder if the combination of these might have a negative effect on the liver… Any thoughts?

Thanks!

(You've tried everything else; why not try bacon?) #13

Not likely to be the citalopram. I take that, and my liver numbers are fine.

Don’t know anything about the effects of Adderall, however.

(Dawn O Miller) #14

It is rare, but apparently a possibility that medications such as Adderall can cause hepatoxicity. Maybe talk to your doctor about adjusting your medicines to see if this will impact your LFT tests?

(You've tried everything else; why not try bacon?) #15

Oh! So Adderall is speed, huh? No wonder it has effects on the liver.

(Txdr) #16

I actually do not take this for fun… thought I should clarify this before any of the usual criticisms pop up… In fact I hate having to take 2 different medicines per day to deal w/ anxiety - which was almost crippling to me ~ 3yrs ago or so…

(You've tried everything else; why not try bacon?) #17

No, no, that was a serious comment, not a criticism. All I meant to say was, I expect amphetamine to have deleterious effects on the liver, and if that’s what Adderall is, then no wonder it affects the liver. No criticism intended, I assure you. I apologize for even the appearance of criticizing.

(Eric - The patient needs to be patient!) #18

Wow, awesome labs.

(Bob M) #19

Mine is similar, ALT of 18 and AST of 15 U/L. I’ve had other readings of 23 ALT, 20 AST; 20 ALT and 19 AST (latter after fasting 4.5 days).

It’ll be interesting to see what they are now, as I’ve been doing a liver treatment protocol for a while.

(Central Florida Bob ) #20

The amazing part is how much they dropped: AST from 98 to 11, ALT from 164 to 16. They’re both about 1/10 of the bad values.