C H A P T E R
2
Effect of Age, Gender, Diet, Exercise,
and Ethnicity on Laboratory Test Results
Octavia M. Peck Palmer
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
INTRODUCTION
Annually, the United States performs approximately
7 billion clinical laboratory tests [1]. Clinical laboratory
test results are an indispensable part of the clinicians
decision-making process. Accurate laboratory results
aid in timely and effective diagnosis, prognosis, treat-
ment, and management of diseases. It is imperative
that the in vitro diagnostic testing results accurately
reflect the in vivo physiological processes of the patient.
Inaccurate results may lead to unwarranted, invasive
testing, postponement of critical therapies, increased
patient anxiety, and expensive health care costs. The
quality assurance program of each laboratory focuses
on providing the highest quality in analytical testing.
Pre-analytical (steps prior to analysis), analytical
(sample analysis), and post-analytical (steps after
analysis) factors can affect the accuracy of serum/
plasma analytes measured in the laboratory. The
pre-analytical phase refers to the processes that occur
prior to blood/body fluid testing. These processes
include the phlebotomy collection techniques (sample
labeling, tourniquet, and posture), blood/body fluid
tube/container types (anticoagulants, gel separators,
clot activators, and preservatives), and sample han-
dling (mixing/clotting protocol, temperature, storage,
and transport). Nonmodifiable factors such as age,
gender, and ethnicity/race (biological factors) must
be accounted for in the pre-analysis stage. Patient-
related factors such as diet and exercise regimens
can be controlled. Standardized patient preparation
prior to blood collection can minimize the effects
of pre-analytical factors. In some cases, age- and
gender-specific reference limits can account for the
influence of pre-analytical factors.
Accurate Results in the Clinical Laboratory.
DOI: http://dx.doi.org/10.1016/B978-0-12-415783-5.00002-5
This chapter reviews the pre-analytical variables of
age, gender, diet, exercise, and ethnicity/race (a surrogate
marker for environmental, socioeconomic/demographic,
and genetic factors) and their influence on analytes
measured in the clinical laboratory. In addition, the
chapter discusses other less known effects of fasting,
special diets, and nutraceuticals on laboratory tests,
with an abbreviated discussion of the influence of
genetic factors in response to food and nutraceuticals.
EFFECTS OF AGE-RELATED CHANGES
ON CLINICAL LABORATORY
TEST RESULTS
Aging is a complex metabolic process that is not
fully understood [2]. Complex physiological changes
occur during transitions from the newborn to adult
to geriatric stages of life [3]. Understanding the effects
of age on laboratory findings can increase diagnostic
accuracy. Clinicians must distinguish nonpathologic,
age-related changes from pathologic changes. Adult
reference ranges for a majority of serum/plasma/urine
analytes measured in the laboratory are available [4].
However, complete, standardized, age-specific reference
ranges are not available.
In 2000, following the passage of the National
Childrens Act, the U.S. Congress authorized the
National Childrens Health Study (NCS). NCS, led by
the Eunice Kennedy Shriver National Institute of Child
Health and Human Development, is a longitudinal study
of 100,000 healthy individuals aged 0 21 years. The
American Association of Clinical Chemistry, a collabora-
tor of NCS, funded pilot studies focused on establishing
age-specific reference ranges [5].
9 2013 Elsevier Inc. All rights reserved.
10 2. EFFECT OF AGE, GENDER, DIET, EXERCISE, AND ETHNICITY ON LABORATORY TEST RESULTS
Newborn Population
Following birth, arterial blood pO2 rises to
approximately 80 90 mmHg. Oxygen consumption
is significantly higher in neonates compared to
adults. A significant reduction in uric acid concentra-
tions occurs between birth and 6 days of age. Healthy
newborns rapidly metabolize glucose as a result of
their high red blood cell count, which is not evident in
healthy adults [6]. Newborns have increased circu-
lating bilirubin concentrations due to their immature
liver. The developing liver is unable to convert bili-
rubin to bilirubin diglucuronide. Hyperbilirubinemia
due to physiologic jaundice is a common condition
in newborns and usually resolves within 5 7 days
following birth. However, after birth it may be difficult
to distinguish this normal physiological phenomenon
from hemolytic disease of the newborn [7,8]. Immature
kidneys demonstrate vascular resistance, reduced
outgoing blood flow from the outer cortex, and
reduced glomerular filtration rate (GFR). The kidneys
do not efficiently concentrate and dilute urine; regu-
late acid base pathways; reabsorb, excrete, or retain
sodium; or secrete hydrogen ions [9]. Newborns
experience an expanded extracellular fluid volume
state. Hypocalcemia usually resolves within the first
2 days of life [10].
Childhood to Puberty Population
Growth impacts laboratory test results. Two weeks
following birth, luteinizing hormone (LH) concentra-
tions increase in both boys and girls, but they
decline to prepubertal concentrations by the infants
first birthday. Similarly, follicle-stimulating hormone
(FSH) concentrations follow the same trend as LH
concentrations after birth but decline to prepubertal
concentrations in boys by the first year of life and in
girls by the second year of life. Reduced LH and FSH
concentrations in the teenage period are not sensitive
enough to distinguish between pubertal delay and
hypogonadotropic hypogonadism. Gonadal failure
indicated by an upward trajectory of LH and FSH
concentrations cannot be expected until 10 years of
age. Elevated estradiol concentrations are present at
birth but rapidly decline during the first week of life
to prepubertal concentrations (0.5 5.0 ng/dL for girls
and 1.0 3.2 ng/dL for boys). Additional decline to
prepubertal concentrations is present by the sixth
month in boys and the first year of life in girls
[11,12]. Skeletal growth and muscle mass develop-
ment account, in part, for the increased alkaline
phosphatase (ALP), -glutamyl transferase (-GGT),
creatinine, and human growth hormone concentra-
tions seen in the childhood to puberty developmental
ACCURATE RESULTS IN THE CLINICAL LABORATORY
period. The decline in ALP concentrations varies
among genders. After the age of 12 years, girls exhibit
a decline in ALP, and this decline is apparent in boys
after the age of 14 years [13]. Increased circulating
ALP concentrations are present during normal growth
spurts but also in the setting of bone malignancies
(osteoblastic bone cancers, osteomalacia, Pagets dis-
ease, and rickets). ALP concentrations are threefold
higher in adolescents compared to adults [14].
Increases in creatinine occur between ages 12 and 19
years. Cystatin C concentrations in females decrease
during the same age range. Uric acid concentrations
continue to decline during the first decade of life [15].
Adult Population
In both sexes, total cholesterol increases with
advancing age (men age 60 years and women age 55
years). In the second decade of life, men have peak
uric acid concentrations, which are not detected in
women until the fifth decade of life [7].
Menopausal (Pre and Post) Period
Postmenopausal women have increased total
cholesterol concentrations, attributed to decreased
circulating estrogen. High-density lipoprotein choles-
terol (HDL-C) also declines up to 30% [7]. Transition
from the peri- to the postmenopausal stage presents
dramatic endocrine changes. A strong correlation
between age and human chorionic gonadotropin
(hCG) is observed [16]. Accurate interpretation of
elevated hCG concentrations is critical because appre-
ciable concentrations are present during healthy
pregnancy, cancer, or trophoblastic disease [17]. In
females, serum hCG concentrations (reference limit
hCG , 0.5 mIU/mL) are used to either identify or
rule out pregnancy. Knowing the pregnancy status of
a patient is essential because invasive medical proce-
dures and medications can have potentially harmful
effects on a developing fetus [18]. Slight increases
in serum hCG concentrations ($0.5 mIU/mL) occur
in women between the ages of 41 and 55 years. Thus,
it is critical to distinguish the origin of the hCG (pla-
cental origin vs. pituitary origin). Misinterpretation
of elevated hCG concentrations in peri- and postmen-
opausal women may postpone clinical treatments. In
peri- and postmenopausal women (41 55 years old),
studies demonstrate that FSH concentrations can help
determine the origin of hCG. In peri- and postmeno-
pausal women (41 55 years old) with serum hCG
concentrations ranging between 5.0 and 14.0 IU/L,
a FSH cutoff of 45.0 IU/L identifies hCG of placental
origin with 100% sensitivity and 75% specificity.
Importantly, FSH concentrations greater than 45 IU/L
are not present in females with hCG of placental
 EFFECTS OF AGE-RELATED CHANGES ON CLINICAL LABORATORY TEST RESULTS
origin. FSH reflex testing should only be utilized
in pregnancy evaluation of peri- and postmenopausal
women (serum hCG concentrations between 5.0
and 14.0 IU/L) [19]. hCG concentrations greater than
14.0 IU/L in this age group indicate pregnancy unless
the clinical setting dictates otherwise [16].
Geriatric Population
The aging population is rapidly increasing in the
United States. Between the year 2000 (35 million
persons) and the year 2010 (40 million persons), the
United States experienced a 15% increase in the geriatric
population (. 65 years or older) [20]. Interpretation of
laboratory findings in the geriatric population is chal-
lenging due to multiple confounding factors that
include (1) physiologic changes that naturally occur
with healthy aging, (2) acute and chronic conditions
(kidney disease, diabetes, and cardiovascular disease),
(3) diets, (4) lifestyles, and (5) medication regimens [21].
After the age of 60 years, albumin concentrations
decline each decade, with significant decreases noted in
individuals older than 90 years [22]. Low serum
calcium concentration in the geriatric population is
most commonly caused by low serum albumin con-
centrations [23]. Protein concentration changes may be
entirely due to compromised liver function or poor die-
tary regimens. Individuals older than 90 years may
have decreased total cholesterol concentrations.
Iron perturbations such as decreases in iron storage,
serum iron concentrations, and total iron-binding
capacity occur during aging. Depletion of iron stores
may be followed by increases in serum ferritin and
decreases in serum transferrin. Dysregulated liver
synthesis during aging may account for the reduced
transferrin concentrations [4]. Lack of sufficient dietary
iron intake may account for the high prevalence of
anemia in the geriatric population. However, iron loss,
due to bleeding in the intestinal tract, may also be the
culprit for the anemia. Anemia in the geriatric popula-
tion may, in part, be explained by the age-related
decreases in stomach hydrochloric acid (HCl), a key
acid responsible for iron absorption in the intestines.
Vitamin B12 deficiency is also prevalent in geriatrics
due to age-related decreases in serum vitamin B12 con-
centrations. The underlying cause of vitamin B12 defi-
ciency may be decreased HCI concentrations or chronic
atrophic gastritis, which subsequently accounts for lim-
ited intrinsic factor and vitamin B12 absorption [21].
Age-associated organ function decline correlates
with changes in laboratory findings (i.e., reduced
creatinine clearance, glucose tolerance, and hypotha-
lamic pituitary adrenal axis regulation) that may
represent disease or non-disease processes. At least 10%
of the healthy geriatric population exhibits physiologic
changes that may not be associated with disease. These
ACCURATE RESULTS IN THE CLINICAL LABORATORY
11
changes include decreased partial pressure of oxygen
in arterial blood (decreases by 25% between the third
and eighth decades of life) and magnesium (decreases
by 15%) concentrations. Geriatrics may also exhibit
elevated serum alkaline phosphatase (increases by 20%
between the third and eighth decades of life) and 2-hr
postprandial glucose concentrations (after age 40 years,
increases 30 40 mg/dL per decade). Increases in cho-
lesterol concentrations (increases by 30 40 mg/dL by
age 60 years) and erythrocyte sedimentation rate as
high as 40 can be nonpathogenic [7,21].
A 30 40% decline in functioning kidney and the
GFR is responsible for reduced creatinine clearance.
Creatinine and blood urea nitrogen (BUN) concentra-
tions can overestimate the kidney functioning capacity,
as measured by GFR or creatinine clearance, due to
reduced muscle mass [24]. Muscle mass degeneration
accounts for reduced creatinine production. Serum
creatinine concentrations can remain within normal
limits despite the underlying diminished renal clear-
ance capacity [21]. Mean creatinine clearance concen-
trations decrease by 10 mL/min/1.73 m2 per decade
and are significantly different between the adult and
geriatric populations. The mean creatinine clearance for
a 30-year-old individual is approximately 140 mL/min
(2.33 mL/sec) per 1.73 m2 of body surface area. In con-
trast, the mean creatinine clearance for an 80-year-old
individual is 97 mL/min (1.62 mL/sec) per 1.73 m2
of body surface area [25]. Small increases in serum
aspartate aminotransferase (AST) (18 to 30 U/L) occur
between 60 and 90 years of age, whereas peaks in
serum alanine aminotransferase (ALT) occur in the fifth
decade of life and by the sixth decade gradually decline
to concentrations well below those noted in young
adults [21]. GGT concentrations rise during aging.
A steady increase in serum glucose concentrations and
a decrease in glucose tolerance are prevalent in geria-
trics. Lower glucose concentrations in geriatrics may be
due to poor diet and reduced body mass. Higher serum
insulin concentrations are prevalent in elderly adults
and may be associated with insulin resistance [21].
In persons older than 75 years, insulin resistance is
reportedly responsible for impaired glucose tolerance.
The capacity of insulin receptors may be lower in elderly
adults. Regarding serum immunoglobulin concentrations,
IgA concentration increases slightly in geriatric men, but
overall IgG and IgM concentrations gradually decline.
Aging compromises the hypothalamic pituitary adrenal
axis. Aging-related changes include decreases in free
thyroxine (T4), triiodothyronine (T3), corticotrophin, and
corticosteroid [26]. Specific to men, free testosterone
decreases without significant changes in total testosterone
concentrations [27,28]. Prostate-specific antigen concen-
trations increase up to 6.5 ng/mL in men 70 years or
older without clinical evidence of prostate cancer [21].
12 2. EFFECT OF AGE, GENDER, DIET, EXERCISE, AND ETHNICITY ON LABORATORY TEST RESULTS
Serum electrolytes, such as potassium and calcium,
rise as one ages. Calcium concentration increases in
individuals aged 60 90 years in the presence of normal
albumin concentrations. However, after the age of
90 years, calcium concentrations gradually decline.
Hypocalcemia may be due to a simultaneous drop in
serum pH and an increase in parathyroid hormone
concentrations. Age significantly impacts lung elastic
architecture, alveoli function, and diaphragm strength
and significantly alters respiratory function. Thus, the
individual has decreased partial pressure of arterial
oxygen and increased carbon dioxide pressure and
bicarbonate ion concentration [21].
Although age can significantly account for altered
clinical laboratory test results, one must consider the
overlapping effects caused by disease, such as obesity
and hypertension, and/or inadequate dietary intake
when interpreting laboratory results that are outside
of the reference limits [29]. The abnormal results may
highlight age-associated disease processes that require
clinical intervention. It is clinically necessary to con-
duct laboratory studies focused on the systematic
effects of aging on serum/plasma/urine analytes. The
resulting data will be useful for the development of
effective age-specific diagnostic cutoffs.
EFFECTS OF GENDER-RELATED
CHANGES ON CLINICAL
LABORATORY TEST RESULTS
Gender encompasses a myriad of complex endo-
crine and metabolic responses. Gender differences in
laboratory analytes can be explained by differential
endocrine organ-related functions and skeletal muscle
mass [30]. On average, albumin, calcium, magnesium,
hemoglobin, ferritin, and iron concentrations are lower
in females [7]. A reduction in circulating iron concen-
trations is, in part, due to blood loss during monthly
menses. Mean serum creatinine and cystatin C concen-
trations are commonly lower in adolescent females
compared to adolescent males [15]. Aldolase con-
centrations are higher in males following the start of
puberty. ALP concentrations are higher in girls ages
10 11 years. Boys ages 12 13, 14 15, and 16 17 years
have higher ALP concentrations compared to girls in
the corresponding age categories. A decline in ALP
concentrations begins after age 12 years for girls
and 14 years for boys [13]. Menopausal women have
higher ALP concentrations compared to males. Serum
bilirubin concentrations are lower in women due to
decreased hemoglobin concentrations. Females have
higher albumin concentrations compared to males of
the same age [31]. Lipid profiles are heavily influenced
by gender. Total cholesterol concentrations vary not
ACCURATE RESULTS IN THE CLINICAL LABORATORY
only with age but also with gender. Females younger
than age 20 years have higher total cholesterol concen-
trations compared to males in the corresponding age
span. However, between the ages of 20 and 45 years,
males commonly have higher total cholesterol concen-
trations than females. Male peak lipid concentrations
occur between the ages of 40 and 60 years, whereas
female peak lipid concentrations occur between the
ages of 60 and 80 years [32]. Between the ages of 30 and
80 years, mean HDL-C decreases by approximately
30% in females but increases by 30% in males [21,33]
These lipid increases may be due to the stimulatory
effect of estrogen in women. In contrast, low-density
lipoprotein cholesterol (LDL-C) is higher in men. Men
also have higher 24-hr urinary excretions of epineph-
rine, norepinephrine, cortisol, and creatinine compared
to women [34]. Women have higher serum GGT and
copper and reticulocyte count (due to increased eryth-
rocyte turnover) compared to their male counterparts.
EFFECTS OF DIET ON CLINICAL
LABORATORY TEST RESULTS
Diet may affect test results, whereas starvation also
has a profound impact on clinical laboratory test results.
Food Ingestion-Related Changes on
Clinical Laboratory Values
Food ingestion activates in vivo metabolic signaling
pathways that significantly affect laboratory test
results [35]. First, the stomach secretes HCl in response
to food consumption, which causes a decrease in plasma
chloride concentrations. This mild metabolic alkalotic
state (alkaline tide phenomenon) results from exagger-
ated circulating bicarbonate concentrations in the sto-
machs venous blood with an accompanying decreased
ionized calcium (by 0.05 mmol/L, 0.2 mg/dL) [36].
Second, postprandial-associated impairment in the liver
leads to increased bilirubin and enzyme activities.
Depending on the content of the meal ingested, the
effects on commonly measured analytes may be short-
or long-lasting. Thus, an overnight fasting for at least
12 hr is necessary to obtain an accurate representation of
in vivo glucose, lipids, iron, phosphorus, urate, urea, and
ALP concentrations. Interestingly, Lewis a secretors
(blood groups B and O) experience spikes in ALP con-
centrations following ingestion of high-fat meals.
Lipemia can also interfere with a variety of analytical
methods, such as indirect potentiometry. Prior to analy-
sis, lipids can be removed from lipemic samples via
ultracentrifugation or by the use of lipid-clearing
reagents [37]. Carbohydrate (increases glucose and insu-
lin and decreases phosphorus concentrations) and
 EFFECTS OF DIET ON CLINICAL LABORATORY TEST RESULTS
protein meals (increases cholesterol and growth hor-
mone concentrations within 1 hr of food consumption
and also increases glucagon and insulin concentrations)
have differential effects on serum analytes. High-protein
diets significantly affect various analytes measured in
24-hr urine test. A standard 700-calorie meal markedly
increases triglycerides (B50%), AST (B20%), bilirubin
and glucose (B15%), and AST concentrations (B10%) [3].
Rapid changes in lipid concentrations are consistent
with dietary changes, medications, or disease.
Caffeine intake has significant effects on the human
body. Varying concentrations of this stimulant are
present in a variety of foods (coffee, tea, chocolate,
soft drinks, and energy drinks). The short half-life
of caffeine (3 7 hr) also varies among individuals.
Caffeine induces catecholamine excretion from the
adrenal medulla. In addition, increased gluconeo-
genesis, which subsequently increases glucose con-
centrations and impairs glucose tolerance, is evident
following caffeine intake. The adrenal cortex is also
vulnerable to caffeines stimulatory effects, as evidenced
by increased cortisol, free cortisol, 11-hydroxycorticoids,
and 5-hydroxindoleaceatic acid concentrations. Caffeine
is responsible for a threefold increase in nonesterified
fatty acids, which interfere with the accurate quantifica-
tion of albumin-bound drugs and hormones. Spuriously
high ionized calcium concentrations are present follow-
ing caffeine ingestion. Caffeine induces elevations in
free fatty acids causing a rapid decrease in pH that frees
calcium from protein.
Noni juice contains significant amounts of potassium
(B56 mEq/L). Ingestion of noni juice leads to hyperkale-
mia. Specifically, hyperkalemia is apparent in vulnerable
populations such as individuals with renal dysfunction
and/or populations receiving potassium-increasing regi-
mens such as spironolactone or angiotensin-converting
enzyme inhibitors. Bran stimulates bile acid synthesis
within 8 hr of ingestion [38]. However, bran inhibits
gastrointestinal absorption of vital nutrients, including
calcium (decreased by 0.3 mg/dL, 0.08 mmol/L), choles-
terol, and triglycerides (decreased by 20 mg/dL,
0.23 mmol/L) [3]. Serotonin (5-hydroxytryptamine) is
an ingredient present in a myriad of fruits and vegeta-
bles, such as bananas, black walnuts, kiwis, pineapples,
and plantains. Bananas markedly increase 24-hr urinary
excretion of 5-hydroxyindoleacetic acid in the absence
of disease. Avocados suppress insulin secretion, caus-
ing impaired glucose tolerance.
Special Diet-Related Changes on Clinical
Laboratory Values
The ketogenic diet is a low-carbohydrate (,40 g/day),
moderate-protein, high-fat diet. In the absence of
ACCURATE RESULTS IN THE CLINICAL LABORATORY
13
sufficient carbohydrates, the liver converts fat into fatty
acids and ketones. Adherence to a ketogenic diet results
in elevated blood and urine ketones within several days
and diuresis within 2 weeks. Reportedly, a decline in
serum triglycerides and an increase in HDL-C occur over
several weeks [39]. The nonvegetarian diet has higher
plasma ammonia, uric acid, and urea concentrations com-
pared to the vegetarian diet. This diet commonly includes
saturated fatty acids. Palmitic acid, a saturated fatty
acid, causes a significant rise in plasma cholesterol con-
centrations. The substitution of saturated fatty acids
with polyunsaturated fats and complex carbohydrates
can lower LDL-C concentrations. Intake of omega-3 oils
may lower triglycerides and very low-density lipoprotein
(VLDL) concentrations. Vegetarians have lower LDL-C
(approximately 37% lower) and HDL-C (approximately
12%) concentrations compared to nonvegetarians. In
contrast, lactovegetarians (vegetarians who consume
dairy products) have higher LDL-C (approximately 24%
higher) and HDL-C (approximately 7% higher) concen-
trations compared to vegetarians. Within 20 weeks, a
lactovegetarian diet regimen accompanied by low protein
and high dietary fiber intake can reduce adrenocortical
activity. Lactovegetarians have higher plasma concen-
trations of dehydroepiandrosterone sulfate (DHEAS)
compared to nonvegetarians (individuals who adhere
to a moderately protein-rich diet). Moreover, lactovege-
tarians have reduced urinary 24-hr excretion rates for
C-peptide, free cortisol, DHEAS, and total 17-
ketosteroid [40]. In middle-aged North American black
individuals, reduced urinary 24-hr excretion rates of
adrenal and gonadal androgen metabolites occurred
following a conversion from the meat-containing
Western diet to the vegetarian diet. The fecal fat test,
which measures the amount of fat content in stool to
diagnose absorption or digestion abnormalities, is sus-
ceptible to dietary influences. It is critical that indivi-
duals refrain from significant dietary changes before
and during sample collection.
The hCG diet consists of hCG sublingual drops
or injections paired with a low 500-calorie diet. As pre-
viously discussed, hCG can be of placental or nonpla-
cental origin. hCG is evident in placental trophoblastic
(hydatidiform mole and choriocarcinoma), gonadal
(ovarian, testicular, or extragonadal teratoma), ectopic,
or nontrophoblastic tumors. Exogenous hCG may be
detectable in the body 10 days post injection/ingestion.
Individuals on the hCG diet who received injections of
hCG had markedly elevated serum hCG concentra-
tions in the absence of pregnancy or malignancy [41].
It is obvious that individuals on the hCG diet may
have unreliable test results. However, the effects of
hCG sublingual drops on laboratory tests are
unknown. In healthy males, hCG injections (purified
urinary and recombinant hCG) stimulate Leydig cells
14 2. EFFECT OF AGE, GENDER, DIET, EXERCISE, AND ETHNICITY ON LABORATORY TEST RESULTS
and cause a dose-dependent increase in serum testos-
terone concentrations [42].
Fasting/Starvation-Related Changes on
Clinical Laboratory Values
Fasting (decreased caloric intake) and starvation
(no caloric intake) initiate complex metabolic derange-
ments. Many individuals fast in accordance with
culture and religious traditions, so understanding the
effects of fasting on laboratory results is paramount.
Within 3 days of fasting, glucose concentrations rise
by as much as 18 mg/dL despite the bodys coordi-
nated efforts to conserve proteins. Subsequently, insu-
lin rapidly declines while glucagon secretion increases
in an effort to restore blood glucose to pre-fasting
concentrations. The fasting individual undergoes both
lipolysis and hepatic ketogenesis. The metabolic aci-
dosis state includes elevated serum acetoacetic acid,
-hydroxybutyrate, and fatty acids and reduced pH,
pCO2, and bicarbonate. Focal necrosis of the liver is
responsible for reduced hepatic blood flow and
impaired glomerular filtration and creatinine clearance;
elevated serum ALT, AST, bilirubin, creatinine, and
lactate concentrations [3].
The bodys reduced energy stores mainly account
for significant declines up to 50% in both total and free
triiodothyronine concentrations. Fasting differentially
affects lipid concentrations. Within 6 days, cholesterol
and triglycerides increase while HDL concentrations
decrease. Sharp increases up to 15 times the pre-fast
plasma in growth hormone concentrations occur early
in fasting. Within 3 days of completing a fast, the
plasma growth hormone concentration returns to
pre-fast levels. Albumin, prealbumin, and complement
3 concentrations decline during an extended fast.
However, protein intake following fasting rapidly
returns albumin, prealbumin, and complement 3 to
pre-fasting concentrations.
Starvation triggers the release of aldosterone and
excessive urinary ammonia, calcium, magnesium, and
potassium excretion. In contrast, the bodys urinary
excretion of phosphorus declines. Following a short-
term, 14-hr fast, acetoacetate, -hydroxybutyrate,
lactate, and pyruvate blood concentrations begin to
rise. Long-term starvation lasting for 40 48 hr causes
up to a 30-fold increase in -hydroxybutyrate.
Reportedly, starvation for 4 weeks significantly
increased AST, creatinine, and uric acid (20 40%) and
decreased GGT, triglycerides, and urea (20 50%).
Upon adequate caloric intake, the body begins to
restore blood constituents to pre-fasting concentra-
tions and retains sodium as a result of decreased
urinary excretion of both sodium and chloride.
ACCURATE RESULTS IN THE CLINICAL LABORATORY
Subsequently, aldosterone exceeds fasting concentra-
tions, and urinary excretion potassium slowly returns
to normal.
EFFECTS OF NUTRACEUTICALS
ON CLINICAL LABORATORY
TEST RESULTS
In 1989, Dr. Stephen DeFelice coined the term nutra-
ceutical from the two words nutrition and pharma-
ceutical. Nutraceuticals, according to the American
Nutraceutical Association, include functional foods
with health-promoting and disease-preventing bene-
fits. Rigorous safety and efficacy studies are lacking in
the field. The pharmacokinetic properties of the
commercially available nutraceuticals still need to be
elucidated. An estimated 100 million Americans use
dietary supplements regularly. Although nutraceuti-
cals exhibit pharmacological effects, patients do not
consider them drugs and often do not disclose usage
to their physicians [43]. How nutraceuticals and con-
ventional drugs interact within the body requires more
investigation. Few studies have documented the
pharmacokinetics of nutraceuticals and their effects
on laboratory results [44]. High-protein supplements
cause intermittent abdominal pain. Laboratory studies
have reported that high-protein diets can lead to
hyperalbuminemia and increased concentrations of
AST and ALT. Albumin and liver enzyme activities
returned to normal after patients discontinued using
the high-protein supplements [45]. Widely used as an
antidepressant, St. Johns wort (Hypericum perforatum)
markedly interferes with the metabolism of pre-
scribed drugs. St. Johns wort is a potent inducer of
P-glycoprotein and cytochrome P450 3A4 (CYP3A4)
and, to a lesser extent, CYP1A2 and CYP2C9 [43].
Co-administration of St. Johns wort significantly
alters concentrations of cyclosporine (transplant rejec-
tion) [46], indinavir (HIV inhibitor) [47], and digoxin
(P-glycoprotein transporter) [48]. Royal jelly, pro-
duced by special glands in the heads of nurse honey-
bees, is a nutrient-rich food for queen bees. An
elderly man undergoing warfarin therapy developed
hematuria and an elevated international normalized
ratio (7.29) after taking royal jelly supplements for 1
week. The mechanisms by which royal jelly increases
the effects of warfarin are not clear. Valerian, pre-
scribed for its antidepressant properties, causes acute
hepatotoxicity (elevated ALT, AST, and GGT).
Valerians long-term effects on liver function are
unknown. See Chapter 7 for more in-depth discus-
sion on the effects of herbal supplements on clinical
laboratory test results.
 EFFECTS OF ETHNICITY/RACE ON CLINICAL LABORATORY TEST RESULTS 15

EFFECTS OF EXERCISE ON CLINICAL These findings highlight the importance of refraining

LABORATORY TEST RESULTS
The effect of exercise on laboratory findings varies
and highly correlates with the health status of the
person [49], temperature, and dietary intake (food or
liquid) that occurs during or following exercise [50].
Figure 2.1 shows the frequency distribution of serum
creatinine concentrations in athletes and controls
(sedentary people) [49]. Alterations in thyroid function
occur during high-intensity exercise. Anaerobic exercise
elicits increases in T4, free T4, and thyroid-stimulating
hormone and decreases in T3 and free T3 [51]. Physical
exercise significantly alters plasma volume as a result
of fluid volume loss due to sweating and fluid shifts
between both intravascular and interstitial bodily com-
partments [52]. Exercise reduces urinary erythrocyte and
leukocyte content and the volume of urine while increas-
ing the urinary protein excretion. Elevated urinary pro-
tein will resolve within 24 48 hr. Following exercise,
a transient increase in white blood cells, hematocrit, and
platelets occurs in parallel with electrolyte abnormalities
(serum potassium decreases by 8%), which are present
due to the altered hydration state and usually normalize
with rehydration. Dehydration causes elevated creati-
nine and BUN concentrations. In the setting of severe
dehydration, a sharp rise in BUN occurs, but creatinine
is only mildly elevated. Again, rehydration will gradu-
ally decrease these concentrations to normal.
Regular vigorous exercise raises HDL-C and low-
ers triglycerides, VLDL-C, and LDL-C. AST, ALT,
LD, creatinine kinase (CK), and myoglobin signifi-
cantly increase following weight lifting and can
remain elevated for up to 7 days post exercise [53].
from weight lifting prior to clinical laboratory testing.
Healthy males who cycled for 30 min (maximal heart
rate of 70 75%) and recovered for 30 min had signifi-
cant increases in hematocrit, red blood cell count,
plasma albumin and fibrinogen concentrations,
plasma viscosity, and whole blood viscosity [54].
However, the changes were temporary, and concen-
trations returned to baseline after the 30-min recovery
period. In endurance runners, exercise-associated iron
deficiency is common. Moderately trained female
long-distance runners who underwent long-term
endurance exercise (8 weeks) did not have changes in
high-sensitivity C-reactive protein, suggesting that
inflammation is not a normal process of endurance
training. Changes in both serum hepcidin and soluble
transferrin receptor may explain the higher preva-
lence of iron deficiency in this population. Analytes
affected by exercise are summarized in Table 2.1.
EFFECTS OF ETHNICITY/RACE
ON CLINICAL LABORATORY
TEST RESULTS
Several analytes exhibit race-related changes, and it
is important for laboratory professionals to recognize
such changes [55]. Total serum protein concentration
is usually higher in African Americans than in white
individuals, mostly attributable to -globulin concentra-
tions. Serum albumin concentrations, on average, are
lower in the African American population compared
TABLE 2.1 Analytes That Are Affected by Exercise
Analyte Effect of exercise

Urea Value may increase after exercise

75%
Athletes Creatinine Value may increase after exercise
Frequency distribution, %

Control
60% Aspartate aminotransferase Value may increase after exercise
Lactate dehydrogenase Value may increase after exercise
45%
Total creatinine kinase (CK) Value may increase after exercise
30%
CK-MB Value may increase after exercise
15% Myoglobin Value may increase after exercise
WBC count Value may increase after exercise
0%
<88 mol/L >88 mol/L Platelet count Value may increase after exercise
Serum ceratinine
Prothrombin time Value may increase after exercise
FIGURE 2.1 Frequency distribution of serum creatinine concen-
D-dimer Value may increase after exercise
trations in the two groups, athletes and controls. Data are divided
considering as threshold the median value of the control group Packed cell volume Value may decrease after exercise
[88 mol/L (1.0 mg/dL)]. Source: Reprinted with permission from the
American Association for Clinical Chemistry, publisher of Clinical Activated partial Value may decrease after exercise
Chemistry. From Banfi, G., Del Fabbro, M. Serum creatinine values in thromboplastin time
elite athletes competing in 8 different sports: Comparison with sedentary Fibrinogen Value may decrease after exercise
people. Clinic Chemistry 2006; 52(2), 330 331.

ACCURATE RESULTS IN THE CLINICAL LABORATORY

16 2. EFFECT OF AGE, GENDER, DIET, EXERCISE, AND ETHNICITY ON LABORATORY TEST RESULTS
to the white population. The activity of CK is usually
lower in white individuals compared to African
Americans. African American children usually have
higher ALP than white children. Serum cystatin C sig-
nificantly correlated with race/ethnicity in adolescents
(ages 12 19 years) [15]. Cystatin C concentrations
were higher in non-Hispanic white compared to non-
Hispanic black and Mexican Americans. In contrast,
creatinine was lower in non-Hispanic white and
Mexican Americans compared with non-Hispanic black
Americans. In an adult population-based sample (ages
50 67 years), black men had higher 24-hr urinary excre-
tion of creatinine, epinephrine, and norepinephrine
compared to white men in the study [34]. In the U.S.
Modified Diet of Renal Disease (MDRD) calculation,
an ethnicity factor of 1.2 aids in the estimation of GFR
in African Americans. However, two large studies con-
ducted in sub-Saharan Africa (Ghana (N 5 944) and
South Africa (N 5 100)) showed that the MDRD equa-
tion performed better in the absence of the ethnicity
actor of 1.2 [56]. In a Saudi population (N 5 32), GFR
estimated by MDRD strongly correlated with the mea-
sured inulin clearance [57]. However, in a Japanese pop-
ulation (N 5 248), GFR estimated by the 0.881 3 MDRD
equation correlated better with measured inulin clear-
ance than with the 1.0 3 MDRD equation [58]. Clearly,
estimation of GFR by MDRD varies by global region.
The variability of GFR may correlate with genetic/
environmental factors associated with body muscle
mass. Carbohydrate and lipid metabolism also differ
between black and white individuals. On average,
African Americans exhibit less glucose tolerance than
white individuals. However, in a cohort of individuals
with normal glucose tolerance, African Americans
had higher hemoglobin A1c concentrations compared
to white individuals [59]. Significant hematologic
differences exist between healthy African Americans
and white individuals who are iron sufficient. African
Americans have lower hemoglobin concentrations
and are more likely to be diagnosed with anemia
compared to white individuals [60]. Interpretation of
laboratory findings based solely on the presumed
effect of ethnicity/race is not appropriate.
CONCLUSIONS
It is necessary for laboratory professionals to
implement age- and gender-specific reference ranges
for certain analytes, and such reference range
information should be a part of routine reporting of
laboratory test results. Nevertheless, diet, exercise,
and other factors may alter laboratory test results,
and proper investigation must be made to interpret
such laboratory test results for proper patient
ACCURATE RESULTS IN THE CLINICAL LABORATORY
management. Especially for pharmacogenetics testing,
ethnic differences are obvious for certain isoenzymes
of the cytochrome P450 mixed function oxidase
family of enzymes. This important topic is discussed
in-depth in Chapter 22.
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