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R / subscribe so without further delay. Here's today's sneak peek of the ask me anything episode. Welcome to ask me anything AMA number 54. I'm once again joined by my co-host next Ensign in today's episode. We focus mainly on one thing which is magnesium and magnesium supplementation. This is a supplement we get asked about a lot. In fact, it's certainly among the most
About supplements and I think that's because it exists in so many forms there seems to be no limit to the amount of confusion surrounding this and for that reason we decided we probably need to do a dedicated podcast on this. It's also one of the most common supplements that my patients take in fact, I take three or four different forms of magnesium every day and I get asked about a lot. So I finally decided let's have a deep discussion about it. So people can understand it because obviously if I'm taking that much of it, I must think it's pretty important.
Aunt in today's I am a we speak about the role of magnesium in the body. It plays a very important role in so many processes we talked about the three or four most important and then of course that leads to a very clear extension of well, what are the negative aspects or the harms of magnesium deficiency? How do you know if somebody's magnesium deficient we then talked about the various ways. You can increase your magnesium levels including through diet, but also through supplementation from there. We dive deeper into the
Types of magnesium supplements and again, this might be the most important part of the discussion for people who don't really want to understand the physiology. They just want to know what to do. We end the discussion looking at the potential cognitive and sleep benefits of magnesium as well. We then end the AMA with a quick discussion on a few new benchmarks. I've been thinking about as it relates to exercise and age in particular. I've become really interested in understanding now that I'm 50
what I think I should be able to do relative to what I did when I was 40 or 30 and perhaps more importantly how much longer I'll be able to do those things as I turn 55 60 Etc. This is just me musing on some things that I've been thinking a lot about has nothing to do with magnesium as always if you're a subscriber and want to watch the full video of the podcast you can find it on the show notes page. If you're not a subscriber you can watch the sneak peek of the video on our YouTube page. So without further delay
Hope you enjoy am a number 54.
Welcome to another am a how you doing?
Good? How are you
doing? Good. I think we have a good one. Today. We get asked a lot about supplements. And I know it's not always your favorite subject to talk about but we are actually dedicating this am a to one type of supplement in particular magnesium, which we get a lot.
Lot of questions about I think there's a lot of confusion around there's all these different types. There's all the different benefits when you use it. How much do you use it? How much is through food? How much is through an actual supplement? And so we decided to compile all of those together and really hit them today? And I think the reason if you're wondering why we're spending an entire AMA on it is it's one of the most common supplements for patients in your practice. You place a lot of emphasis on it for yourself and for your
Patience and because of that we decided to talk about it in detail today and I think what might be helpful as we start this process for people is at the simplest level. What is the role of magnesium in the body? And why does low magnesium matter? Why should people really care about this and listen to this full thing?
Yeah, everybody's heard of magnesium as we'll talk about there's no shortage of magnesium supplements out there, but in order to
22 I think talk about this subject intelligently, it does help to set the stage and get into all the things magnesium does now the reality of it is magnesium is a cofactor in at least 300 enzymatic systems in the body. It is very important as a co-transporter for the movement of potassium and calcium across membranes. I guess. Maybe I'll say a little bit about that in a moment. But first, let me just give the high-level the three big systems where I think magnesium matter
Most is with respect to bone health with respect to nerve transmission and with respect to glucose control and Insulin metabolism. So again, there are lots of things we could spend easily two or three hours just talking about what magnesium does we're not going to do that. We're going to spend three minutes talking about that but those would be the big three. So again, what is magnesium right? So magnesium is a cation that means it's a positively charged ion. So it has two positive charges and
Just like potassium is a cation with one positive charge and calcium is a cation with two positive charges these things often have to move in opposition to each other. We'll talk about that in a moment with respect to nerve transmission. Let's start with bone health the bones basically reflect the largest total body pool of magnesium. So 60% of the magnesium in your body resides within your bones not surprisingly there for magnesium deficiency. He is a significant problem when it comes
To bone health, so I want to keep this a little bit simple so that we don't get lost in the weeds but bones are basically in a constant state of building and breaking the building cells are called osteoblasts in med school. We remembered that be for Building and the breaking cells are osteoclasts and I don't know why I remembered that but it seems somehow easier. So there's a balance between the osteoblast and the osteoclasts. Obviously if that balance moves too far in the direction.
Action of bone breakdown you get osteopenia and ultimately osteoporosis. It turns out that magnesium plays a very important role in that both directly and indirectly, it plays a role in that directly through the app regulation and down-regulation of osteoblasts and osteoclasts. It also plays a role in that indirectly through the metabolism of calcium pth parathyroid hormone and vitamin D not gonna say,
More about that at the moment because it's really the purpose of what we want to do. I just want to point out that magnesium deficiency is very bad for
bones Peter real quick. Before you continue on Beyond bone health for anyone who hasn't listened yet. Am a 37 was a am a dedicated fully to bone health its importance all the different factors. So if you want to learn more about that, that's another great resource for people to have.
Yeah. So let's go on to the second point which is magnesium helps with glucose control.
And Insulin metabolism. So magnesium is involved in the regulation of insulin secretion in the pancreatic beta cells in addition to the phosphorylation of the insulin receptor in the target cells. So if you recall when we discussed this in great detail on the podcast with Jerry Schulman when insulin hits the insulin receptor that leads to an intracellular kinase that phosphorylates and ultimately leads to the movement of the glute Transporters that move across the cell membrane and allow glucose to flow in and
Metabolism obviously therefore heavily impacted by that and so in addition to increasing glucose movement into the cell and facilitating the effects of insulin IE driving insulin sensitivity. It's also a cofactor in carbohydrate oxidation. There are a number of clinical studies though not all of them that suggests that supplementing with magnesium and magnesium Rich diet can improve insulin sensitivity and fasting glucose. This is going to be a common theme in this podcast, which is that the extent to which magnesium can
An help in a given area, whether it be bone health or as we're talking about here with respect to metabolism is largely a function of magnesium deficiency. In other words, the more deficient you are in magnesium the more you will be helped by supplementing magnesium. We're going to talk a lot about how to supplement magnesium and all of the different ways and I will tell you it's way more complicated than I think most of us would realize will also obviously talk about how do you know if your magnesium deficient and there's good news on the first question not-so-great news on
Question, but just to round out why should we care about magnesium? I would say the third big bucket here is the effect that magnesium plays in nerve transmission and muscle function. So magnesium is an antagonist of the nmda receptor and a Gaba Agonist. So if you think about how nerve transduction Works, imagine a couple of big proteins that sit spanning across the membrane of a cell and they create a poor
in the poor is what allows the ions that participate in the action potential to move. So again, these things are like kind of taking stored energy in the form of the charges of the ion and as they move one way across the channel that creates a polarization of this cell and it's the serial or sequential firing of those Action potentials that leads to Signal transduction down a cell. Well, it turns out that magnesium sits right smack in the middle of that.
And it must be removed for the excitatory signal to occur. So when magnesium is deficient, this is a contributing factor to things like mood and other neurologic conditions even potentially a contributor to migraines and we'll talk more about some of these applications later. But the point here again is that magnesium sits very much in the center both literally and figuratively for a lot of the action as we think about signal transduction across nerves across
Cil's and various other cells again it all kind of factors into the movement of these other cations. I spoke about earlier sodium potassium calcium cetera.
You hinted a second ago, but I think now's a really good time to get to this question, which is for people who have listened to that and are now worried. They have low magnesium are there certain symptoms or things that they can do to kind of know where they're at.
I'll tell you a funny story when I was in residency. There are certain things that you're measuring on hospitalized.
Relentlessly, one of them is potassium potassium. You measure that in the plasma we cared greatly about what our patients potassium level was. If it was too low or too high. It was problematic if it was too high, it could be fatal and just to give you a sense of the narrow range in which we're looking at here. We're talking about a normal physiologic potassium level might be between three and a half and five milliequivalents per liter. Don't worry about what the units mean, but the point is somewhere between three point five and five units per liter and it's not
Common in hospitalized patients that you have to replace potassium. If God forbid you ever replaced too much potassium. You got somebody up to five and a half or six million equivalents per liter the risk that you could throw them into a fatal heart rhythm was so significant that if you ever saw that value, even if you thought the lab made a mistake you were immediately rechecking it and taking corrective actions. Similarly. If the levels are too low, you're going to see all sorts of typically not as problematic and not necessarily fatal, but other sorts of changes.
Is in heart rhythm won't get into the why's that because we're not really here to talk about potassium. But suffice it to say you would not be replacing potassium in a patient without having measured the level first. Let's talk about magnesium. Most Chief residents when I was a junior resident would scream at you. If you ever measured a magnesium level in a patient with normal kidneys before giving the Magnesium. The reason for it is twofold one. It costs more. It's not altering management, but more importantly because
Because we Now understand and probably understood then if we were paying attention that the measurement of serum magnesium is not really indicative of total body magnesium and you have an enormous buffer for overshooting. So it's also True by the way that most of the potassium in a person is not in the extracellular space in the plasma. Most of it is in the cells, but because potassium and the difference between what's in the cell and out of the cell is a very important.
Electrical gradient if you overshoot what's out of the cell a little too much. It can be fatal. That's not the case with magnesium because magnesium is not used to set the charge across the cell. Okay, if you're sitting here listening to this saying Peter, what the hell are you talking about? My only Point here is one we don't have great ways to measure magnesium. I will talk about how it's done. But to we don't tend to care about it very much clinically Because unless a person's kidneys are really compromised and the kidneys.
Become the acute place in where magnesium regulation happens. We don't care about overdoing it. So with that said there are basically a few ways to do this. You can measure plasma levels. And by the way, that's a test that's commercially available. I can honestly say, I don't know the last time I've ordered it on myself or any of my patients, but you can go to LabCorp request or wherever and request that I think if you're really concerned about magnesium deficiency. Do you have to do these other types of tests? So one of them is a urinary test, so this is a test where you collect the urine
And that is made over a period of time say 24 hours and you look at the amount of magnesium in the urine and that gives you a sense of magnesium deficiency. In other words the less magnesium in the urine the more likely the person is to be deficient. Why because it tells you boy those kidneys are really holding onto magnesium. We have a sense of how much magnesium should come out of a person in a day state of quote-unquote equilibrium. And if the amount of magnesium that's coming out is really low you would surmise that that person truly has total body.
Deficiency the other way you do. It is a more elaborate version of this test where you load the patient with magnesium, so you give them a huge IV bolus of magnesium. And then you also measure the urinary excretion. That's just a more involved has to do that. And to be honest with you. I've never done either of those it's possible that an endocrinologist might look to something like that. But again, it begs the point which is in a person with normal renal function you tend to err on the side of assuming people are magnesium deficient and if you have any reason to believe it based on
Tim's or signs so low bone density prevent regular contractions. So relatively benign skipped heartbeats things of that nature cramps. That would be a very common thing that would give you reason to believe a person is magnesium deficient. We just go ahead and replace the Magnesium. Anyway,
just a double click you mentioned migraines have been ago. Can you talk a little bit more about my grains and low magnesium because I think anyone who is had migraines is willing to look at anything to help alleviate those.
Yeah earlier I say
Did I hope I stated it correctly that magnesium plays an important role in inhibiting the glutamate excitatory pathway of the nmda receptor in the brain and not surprisingly migraines are associated with more excitation. So the thinking would be that if you are deficient in magnesium, you have less inhibition of an excitatory neurotransmission pathway. And therefore you might see more migraines in people who are susceptible. So looking back we were able to find a 2016
Analysis of all the rcts that were done for acute migraines that found that intravenous magnesium provided significant short-term relief IE within 15 to 45 minutes and up to 24 hours post Administration. Now again, that's intravenous magnesium. We're going to talk about in a minute about oral magnesium, which is the way most people are going to get magnesium. It's unlikely that oral magnesium is going to be able to provide relief acutely for this but intravenously and we're talking somewhere in the neighborhood of 2 to 4.
Or G intravenously again. I want to keep that number in the back of your mind to 24 grams of intravenous magnesium. When we start talking about how much oral magnesium you need to take to get that oral magnesium treatments May reduce the frequency and the severity of attacks, but really provides very little relief in the acute setting.
What do we know about how common magnesium deficiency is because I think anyone who's listening is kind of curious. What are the hot?
This is going on with them.
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