RBC/Hemoglobin/Hematocrit Discussion for the EXPERT PANEL 9/27/2020

[Ken "Skip" Hill]

There is a lot of debate right now about whether phlebotomy is the best course of action to relieve higher blood viscosity due to elevated RBC/hemoglobin/hematocrit numbers. Some believe that phlebotomy actually increases the risk of stroke/heart attack and I have wondered the same thing for a couple of years, now, based on something I came across while living at an elevation of 9k feet in Colorado until moving to South Florida.

For those who don't know, in a nut shell, I have issues with my blood numbers that started when I moved to the higher elevation. Of course, higher elevation causes blood viscosity to rise and that is why my upper range for RBC/Hematocrit/Hemoglobin were substantially higher than someone who might have lived at sea level or even in Denver at roughly 5200 feet in elevation. What struck me while doing research was this: people who lived at higher elevations (roughly 12k feet) were found to have low morbidity rates for heart attack and stroke. This struck me as counterintuitive because at those elevations, blood viscosity would be significantly higher (higher RBC/hematocrit/hemoglobin) and yet their morbidity was low. If the numbers are higher, how could that possibly mean that their risk was lower?

I want to discuss this topic amongst the expert panel and get their (your) feedback and opinions. Even if you do not know much about this or aren't aware of some of this information, please join in on the discussion to debate your thoughts and ask questions, etc. If you have access to anyone who you feel would be better qualified from a medical standpoint, please invite them to chime in here and discuss this topic. I have a client who is a doctor in Canada and she specializes in blood pathology. I will try to get her to chime in as I have had some good conversations/discussions with her about this topic in the past.

Here is a link to get a better idea of what I am talking about and I would like everyone's thoughts on this link:

https://www.haematologica.org/article/view/8839


Skip

Jeff Black
homonunculus
troponin
Allen Cress
Datas4
Jeffrey Su
Wolfpack
JamiePinder14
Doggcrapp
dusty hanshaw
ScoobyPrep
sweetjane57
pastorpump
BSmitley
MattKouba

[homonunculus]

Ken,

Do you have a link for the study you refer to here?... "What struck me while doing research was this: people who lived at higher elevations (roughly 12k feet) were found to have low morbidity rates for heart attack and stroke. This struck me as counterintuitive because at those elevations, blood viscosity would be significantly higher (higher RBC/hematocrit/hemoglobin) and yet their morbidity was low. If the numbers are higher, how could that possibly mean that their risk was lower?"

-S

[Doggcrapp]

https://ashpublications.org/blood/ar...f-Testosterone

[Doggcrapp]

https://pubmed.ncbi.nlm.nih.gov/28150363/

[Doggcrapp]

https://youtu.be/mH-J5kXU-jQ

[Datas4]

I generally do not use phlebotomy as a means to control hemoglobin/hematocrit/RBCs.

I definitely notice that in some it makes things worse. This idea was originally brought to me by an MD friend of mine at the time and I started seeing it more and more in lab work.

This is not the case across the board, it does seem to help some folks.

If its a chronic issue (especially in PED users), I tend to lean toward a low dose ARB med. These meds are Renin-angiotensin-aldosterone system inhibitors and they will lower both hemoglobin and hematocrit. They are cardioprotective and renal protective as well. Generally they are used for hypertension but they dont require a high dose to help with RBC values some someone with pretty normal BP could still benefit. Effects will increase as dose goes up as well.

There are several protective benefits of these ARB drugs, even in lower doses. A lot of bodybuilders could benefit from them in the right context.

This is obviously assuming that values arent skewed because the person is overly dehydrated on the labs or using a lot of AAS.

Plugging a podcast link in here too as long as Ken is cool with it. This is a recent chat with an MD thats a PED harm reduction specialist and overall very bright guy. We do chat about the topic in here and I know hes not a fan of using phlebotomy for this reason.

https://player.fm/series/optimal-phy...r-scott-howell

[pastorpump]

I didn't start using gear until my 30s and it was for TRT. Doctor told me right off the bat to do the procedure on a regular. Not sure if it was month or 3 months. I hate doing it so I would just go before doing blood work. Numbers would come back a bit better after doing it but then I had another doctor tell me if it's not way over why wouldn't I want "rich" blood. So I stopped. The numbers stayed at 15 or so and never went higher so it wasn't a situation where if I didn't do it I would keep going off the charts. It has stayed just a tad over "normal" levels so I don't even bother doing it anymore

[nelson.howard]

There is a lot of debate right now about whether phlebotomy is the best course of action to relieve higher blood viscosity due to elevated RBC/hemoglobin/hematocrit numbers. Some believe that phlebotomy actually increases the risk of stroke/heart attack and I have wondered the same thing for a couple of years, now, based on something I came across while living at an elevation of 9k feet in Colorado until moving to South Florida.

For those who don't know, in a nut shell, I have issues with my blood numbers that started when I moved to the higher elevation. Of course, higher elevation causes blood viscosity to rise and that is why my upper range for RBC/Hematocrit/Hemoglobin were substantially higher than someone who might have lived at sea level or even in Denver at roughly 5200 feet in elevation. What struck me while doing research was this: people who lived at higher elevations (roughly 12k feet) were found to have low morbidity rates for heart attack and stroke. This struck me as counterintuitive because at those elevations, blood viscosity would be significantly higher (higher RBC/hematocrit/hemoglobin) and yet their morbidity was low. If the numbers are higher, how could that possibly mean that their risk was lower?

I want to discuss this topic amongst the expert panel and get their (your) feedback and opinions. Even if you do not know much about this or aren't aware of some of this information, please join in on the discussion to debate your thoughts and ask questions, etc. If you have access to anyone who you feel would be better qualified from a medical standpoint, please invite them to chime in here and discuss this topic. I have a client who is a doctor in Canada and she specializes in blood pathology. I will try to get her to chime in as I have had some good conversations/discussions with her about this topic in the past.

Here is a link to get a better idea of what I am talking about and I would like everyone's thoughts on this link:

https://www.haematologica.org/article/view/8839


Skip

Jeff Black
homonunculus
troponin
Allen Cress
Datas4
Jeffrey Su
Wolfpack
JamiePinder14
Doggcrapp
dusty hanshaw
ScoobyPrep
sweetjane57
pastorpump
BSmitley
MattKouba

Very interesting! thanks

[moco]

https://youtu.be/mH-J5kXU-jQ

This is interesting. Thank you!

[Jeffrey Su]

I've seen the research as well, and it points to the overall improvement and "training of" the body's systems which lowers the risk of Metabolic Syndrome and improves insulin sensitivity as well. All of this would lower inflammation and boom - lower risk of a cardiac event, despite the fact that blood viscosity would be increased versus someone who didn't live in a high-altitude environment. My guess is that how long you live there would factor in (a baby born into the environment for example vs. an adult relocating) to whether it's a benefit or risk, since there are studies which point to the obvious risks of visiting or relocating to a high-altitude environment with an existing condition.

In terms of managing hematocrit, I'm someone who can easily run high if I don't watch things. I do go and donate blood every 8 weeks in addition to other things to keep my overall heart health and circulatory health in check - cardio year round (3 mile fasted walk every morning), cardio/circulatory-protective supplements, and staying off gear for long enough that levels eventually normalize.

[Ken "Skip" Hill]

Ken,

Do you have a link for the study you refer to here?... "What struck me while doing research was this: people who lived at higher elevations (roughly 12k feet) were found to have low morbidity rates for heart attack and stroke. This struck me as counterintuitive because at those elevations, blood viscosity would be significantly higher (higher RBC/hematocrit/hemoglobin) and yet their morbidity was low. If the numbers are higher, how could that possibly mean that their risk was lower?"

-S

I do not, no. I am referring to studies that I came across when I was having blood issues around 2013 and was doing as much research as I could. However, I am sure that a quick search would provide numerous studies because I was surprised at how much information was available at that time. I would be surprised if there wasn't significantly more now, considering that was 7 or 8 years ago.

What are your thoughts on the information in the link I provided in the original post?


Skip

[Jeff Black]

I have never struggled with my hematocrit due to my bone disease. We tend to be more anemic than anything.

Labs back in July showed my hematocrit at 53.9 which is higher, but not bad. I chatted with Austin about it and his MD friend said anything I believe under 55 was acceptable.

I dug in a little bit as my hematocrit is always 44-47 and found some of the foods I was using (cereals) because I was burned out on COR and Oats were heavily fortified in iron. I removed them and followed up in 6 weeks and it was at 48.

I use 200-300mg of test a year depending on what phase I am in.

I do have a question though.

Vitamin K1...it increases blood clotting. I have been digging in on Vitamin K2 heavily as it relates to bone remodeling and cardiovascular benefits which are key issues with my bone disease. WIth K1 and some of the foods bodybuilders tend to eat, high leafy greens, could this be a hand in hand thing with the clotting? I guess to further expound my question would be if hematocrit is higher would you want to watch Vitamin K1 as well? Has anyone found any research on this as a correlation between the two? If so, please share

[homonunculus]

I do not, no. I am referring to studies that I came across when I was having blood issues around 2013 and was doing as much research as I could. However, I am sure that a quick search would provide numerous studies because I was surprised at how much information was available at that time. I would be surprised if there wasn't significantly more now, considering that was 7 or 8 years ago.

What are your thoughts on the information in the link I provided in the original post?


Skip

Well, I first wanted to contextualize what you were referring to, as there are indigenous peoples who live at altitude, those who have moved there, etc. There will be some selection pressure at play when you're talking about highlanders (Andes, Tibet, Ethiopia) which confounds extrapolation to gear users. As you know, people who live at altitude, after moving there, tends to select only certain folks, too. Colorado is full of very healthy folks and you don't get couch potatoes moving to places where you lived, really.

The review you posted looked mainly at pathological conditions which are categorically different than a situation whereby someone has adapted to altitude.

So, as far as TRT and polycythemia (erythrocytosis) goes, the data are all over the place as far as CVD risk goes: https://sci-hub.scihubtw.tw/10.1038/s41569-019-0211-4

I suspect that what Austin noted wrt phlebotomy not being terribly effective could be the what's going on in different situation the produce increases RBC's

Living at altitude: Perhaps for some (those who adapt well) this is a well regulated physiological acclimatization and you've got selection bias as far as risk for stroke, etc. b/c they folks simply would have a reduced risk at any altitude or we're talking about folks who are otherwise very healthy (and deal with the hypobaria well).

GEAR: Those who get the higher HCT / Hb and who see it climb more so with age also have greater underlying pathology (e.g., endothelial disfunction, oxidative stress, etc.) such that even if the HCT is brought down and viscosity issues (partially) remedied, the fact that there was such an uncontrolled elevation in HCT points to other underlying issues that create a greater risk for a cerebro-/cardiovascular event, thrombosis, etc.

------

So, the phenomenology is perhaps not so simple as erythrocytosis --> increased CVD risk, etc, but rather:

Underlying issues (or lack thereof), including diet, exercise, genetic proclivities --- Determine ---> erythropoietic response (Drugs and altitude) --1) indicates and 2) mediates --> clotting risk (and whether you find certain peoples or individuals living at altitude in the first place


-S

[Ken "Skip" Hill]

After reading your post, I did a quick google search and was surprised to find so much conflicting information. It is quite confusing. However, I agree with you that there are likely for more variables at play, as well.

I am waiting for the massive study to be done on steroid users over 20-plus years in relation to rbc/hematoctrit/hemoglobin, heart attack and stroke. I'm sure it's just around the corner.

Skip

[homonunculus]

After reading your post, I did a quick google search and was surprised to find so much conflicting information. It is quite confusing. However, I agree with you that there are likely for more variables at play, as well.

I am waiting for the massive study to be done on steroid users over 20-plus years in relation to rbc/hematoctrit/hemoglobin, heart attack and stroke. I'm sure it's just around the corner.

Skip

For sure! There are probably dozens of research groups furiously working away to get the scoop on that one... LOL

One thing that might help wrap our heads around this is to consider that we can frame a physiological phenomenon in various and multiple ways:

Symptom
Cause
Adaptive response / Adaptation
Pathophysiological Change / Pathology

An above normal / average HCT might be an adaptation that lessens stress at high altitude but could also be stimulated by androgen use in a person where the HCT is run-away b/c of some underlying deterioration / pathology (e.g., age, failure of regulatory systems over time more acutely that is a sign of underlying poor health).

The higher HCT and BP might not necessarily in a health person increase clotting risk b/c that healthy person's has more tightly controlled systems of hemostasis.

In the drug-related / pathological system, the increased HCT might be something that does indeed tip the balance towards more clotting, atherogenesis, etc. and greater risk of stroke, embolism, etc.

So what is for one person represents (the symptom of) a positive adaptive response could be a symptom of a pathological change that could be considered the cause of an adverse cerebro-/cardiovascular event.

-S