The Peter Attia Drive - #282 - AMA #54： Magnesium： risks of deficiency, how to correct it, supplement options, potential cognitive and sleep benefits, and more

00:00:00.000 hey everyone welcome to a sneak peek ask me anything or ama episode of the drive podcast

00:00:16.400 i'm your host peter atia at the end of this short episode i'll explain how you can access

00:00:20.840 the ama episodes in full along with a ton of other membership benefits we've created

00:00:25.460 or you can learn more now by going to peter atia md.com forward slash subscribe so without

00:00:31.820 further delay here's today's sneak peek of the ask me anything episode

00:00:35.880 welcome to ask me anything ama number 54 i'm once again joined by my co-host nick stenson in today's

00:00:47.580 episode we focus mainly on one thing which is magnesium and magnesium supplementation this

00:00:54.480 is a supplement we get asked about a lot in fact it's certainly among the most asked about

00:01:00.440 supplements and i think that's because it exists in so many forms there seems to be no limit to

00:01:06.820 the amount of confusion surrounding this and for that reason we decided we probably need to do a

00:01:11.260 dedicated podcast on this it's also one of the most common supplements that my patients take in fact i

00:01:17.000 take three or four different forms of magnesium every day and i get asked about it a lot so i

00:01:23.160 finally decided let's have a deep discussion about it so people can understand it because obviously if

00:01:27.460 i'm taking that much of it i must think it's pretty important in today's ama we speak about

00:01:31.880 the role of magnesium in the body it plays a very important role in so many processes we talk about

00:01:38.620 the three or four most important and then of course that leads to a very clear extension of well what

00:01:44.200 are the negative aspects or the harms of magnesium deficiency how do you know if somebody's

00:01:49.500 magnesium deficient we then talk about the various ways you can increase your magnesium levels including

00:01:55.180 through diet but also through supplementation from there we dive deeper into the different types of

00:02:00.840 magnesium supplements and again this might be the most important part of the discussion for people

00:02:05.300 who don't really want to understand the physiology they just want to know what to do we end the

00:02:09.680 discussion looking at the potential cognitive and sleep benefits of magnesium as well we then end the

00:02:15.800 ama with a quick discussion on a few new benchmarks i've been thinking about as it relates to exercise

00:02:21.960 and age in particular i've become really interested in understanding now that i'm 50 what i think i should

00:02:31.440 be able to do relative to what i did when i was 40 or 30 and perhaps more importantly how much longer

00:02:38.280 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

00:02:44.920 thinking a lot about has nothing to do with magnesium as always if you're a subscriber and want to watch

00:02:49.780 the full video of the podcast you can find it on the show notes page if you're not a subscriber

00:02:54.340 you can watch the sneak peek of the video on our youtube page so without further delay i hope you

00:03:00.180 enjoy ama number 54. peter welcome to another ama how you doing good how are you doing good i think we have a

00:03:14.920 we get asked a lot about supplements and i know it's not always your favorite subject to talk about

00:03:22.000 but we are actually dedicating this ama to one type of supplement in particular magnesium which we get a

00:03:29.820 lot of questions about i think there's a lot of confusion around there's all these different types

00:03:34.440 there's all the different benefits when do you use it how much do you use it how much is through food

00:03:40.200 how much is through an actual supplement and so we decided to compile all of those together and

00:03:45.820 really hit them today and i think the reason if you're wondering why we're spending an entire ama on

00:03:52.240 it is it's one of the most common supplements for patients in your practice you place a lot of emphasis

00:03:58.040 on it for yourself and for your patients and because of that we decided to talk about it in detail today

00:04:04.520 and i think what might be helpful as we start this process for people is at the simplest level

00:04:11.160 what is the role of magnesium in the body and why does low magnesium matter why should people really

00:04:19.460 care about this and listen to this full thing yeah everybody's heard of magnesium as we'll talk about

00:04:25.400 there's no shortage of magnesium supplements out there but in order to i think talk about this subject

00:04:31.980 intelligently it does help to set the stage and get into all the things magnesium does now the

00:04:36.360 reality of it is magnesium is a cofactor in at least 300 enzymatic systems in the body it is very

00:04:45.840 important as a co-transporter for the movement of potassium and calcium across membranes i guess maybe

00:04:53.160 i'll say a little bit about that in a moment but first let me just give the high level the three big

00:04:57.720 systems where i think magnesium matters the most is with respect to bone health with respect to nerve

00:05:04.160 transmission and with respect to glucose control and insulin metabolism so again there are lots of

00:05:10.840 things we could spend easily two or three hours just talking about what magnesium does we're not going

00:05:16.820 to do that we're going to spend three minutes talking about that but those would be the big three so

00:05:21.560 again what is magnesium right so magnesium is a cation that means it's a positively charged ion so it

00:05:27.640 has two positive charges and just like potassium is a cation with one positive charge and calcium is a

00:05:33.480 cation with two positive charges these things often have to move in opposition to each other we'll talk

00:05:39.480 about that in a moment with respect to nerve transmission let's start with bone health the bones

00:05:45.000 basically reflect the largest total body pool of magnesium so 60 of the magnesium in your body resides

00:05:52.100 within your bones not surprisingly therefore magnesium deficiency is a significant problem when it comes

00:05:59.620 to bone health so i want to keep this a little bit simple so that we don't get lost in the weeds but

00:06:05.540 bones are basically in a constant state of building and breaking the building cells are called osteoblasts

00:06:14.660 in med school we remembered that b for building and the breaking cells are osteoclasts and i don't know why i

00:06:20.980 remembered that but it seemed somehow easier so there's a balance between the osteoblasts and the osteoclasts

00:06:26.900 obviously if that balance moves too far in the direction of bone breakdown you get osteopenia

00:06:32.740 and ultimately osteoporosis it turns out that magnesium plays a very important role into that both directly

00:06:41.380 and indirectly it plays a role in that directly through the up regulation and down regulation of

00:06:48.820 osteoblasts and osteoclasts it also plays a role in that indirectly through the metabolism of calcium

00:06:55.460 pth parathyroid hormone and vitamin d i'm not going to say much more about that at the moment because

00:07:01.060 that's not really the purpose of what we want to do i just want to point out that magnesium deficiency

00:07:07.140 is very bad for bones peter real quick before you continue on beyond bone health for anyone who hasn't

00:07:12.820 listened yet ama 37 was a ama dedicated fully to bone health it's importance all the different

00:07:20.420 factors so if you want to learn more about that that's another great resource for people to have

00:07:25.540 yeah so let's go on to the second point which is magnesium helps with glucose control and insulin

00:07:30.180 metabolism so magnesium is involved in the regulation of insulin secretion in the pancreatic beta cells

00:07:36.340 in addition to the phosphorylation of the insulin receptor in the target cells so if you recall and

00:07:41.300 we discussed this in great detail in the podcast with jerry shulman when insulin hits the insulin

00:07:45.540 receptor that leads to an intracellular kinase that phosphorylates and ultimately leads to the movement

00:07:52.740 of the glute transporters that move across the cell membrane and allow glucose to flow in and so

00:07:59.940 metabolism obviously therefore heavily impacted by that and so in addition to increasing glucose movement

00:08:06.180 into the cell and facilitating the effects of insulin i.e. driving insulin sensitivity

00:08:10.020 it's also a cofactor in carbohydrate oxidation there are a number of clinical studies though not

00:08:15.540 all of them that suggest that supplementing with magnesium and a magnesium rich diet can improve

00:08:20.260 insulin sensitivity and fasting glucose this is going to be a common theme in this podcast which is

00:08:25.780 that the extent to which magnesium can help in a given area whether it be bone health or as we're

00:08:33.140 talking about here with respect to metabolism is largely a function of magnesium deficiency in other

00:08:38.660 words the more deficient you are in magnesium the more you will be helped by supplementing

00:08:44.180 magnesium we're going to talk a lot about how to supplement magnesium and all of the different ways

00:08:49.220 and i will tell you it's way more complicated than i think most of us would realize we'll also

00:08:54.420 obviously talk about how do you know if you're magnesium deficient and there's good news on the first

00:08:58.420 question not so great news on the second question but just to round out why should we care about

00:09:01.940 magnesium i would say the third big bucket here is the effect that magnesium plays in nerve transmission

00:09:08.740 and muscle function so magnesium is an antagonist of the nmda receptor and a gaba agonist so if you

00:09:16.340 think about how nerve transduction works imagine a couple of big proteins that sit spanning across the

00:09:25.460 membrane of a cell and they create a pore and the pore is what allows the ions that participate in the

00:09:33.780 action potential to move so again these things are like kind of taking stored energy in the form of the

00:09:40.020 charges of the ion and as they move one way across the channel that creates a polarization of the cell

00:09:47.060 and it's the serial or sequential firing of those action potentials that leads to signal transduction down

00:09:53.860 a cell well it turns out that magnesium sits right smack in the middle of that receptor and it must be

00:10:00.820 removed for the excitatory signal to occur so when magnesium is deficient this is a contributing factor

00:10:09.140 to things like mood and other neurologic conditions even potentially a contributor to migraines again we'll

00:10:14.580 talk more about some of these applications later but the point here again is that magnesium sits

00:10:20.340 very much in the center both literally and figuratively for a lot of the action as we think about

00:10:27.140 signal transduction across nerves across muscles and various other cells again it all kind of factors into

00:10:32.980 the movement of these other cations i spoke about earlier sodium potassium calcium etc

00:10:38.900 you hinted at it a second ago but i think now is a really good time to get to this question which is

00:10:44.020 for people who have listened to that and are now worried they have low magnesium are there certain

00:10:49.860 symptoms or things that they can do to kind of know where they're at i'll just tell you a funny

00:10:54.100 story when i was in residency there are certain things that you're measuring on hospitalized patients

00:10:59.780 relentlessly one of them is potassium potassium you measure that in the plasma we cared greatly about

00:11:06.740 what our patients potassium level was if it was too low or too high it was problematic if it was too

00:11:11.540 high it could be fatal and just to give you a sense of the narrow range in which we're looking at here

00:11:16.660 we're talking about a normal physiologic potassium level might be between three and a half and five

00:11:21.940 milliequivalents per liter don't worry about what the units mean but the point is somewhere between

00:11:25.700 three point five and five units per liter and it's not uncommon in hospitalized patients that you have

00:11:31.140 to replace potassium if god forbid you ever replaced too much potassium you got somebody up to five and

00:11:36.820 a half or six milliequivalents per liter the risk that you could throw them into a fatal

00:11:41.300 heart rhythm was so significant that if you ever saw that value even if you thought the lab made a

00:11:46.740 mistake you were immediately rechecking it and taking corrective actions similarly if the levels are

00:11:52.660 too low you're going to see all sorts of typically not as problematic and not necessarily fatal but

00:11:58.820 other sorts of changes in heart rhythm won't get into the whys of that because we're not really

00:12:02.740 here to talk about potassium but suffice it to say you would not be replacing potassium in a

00:12:08.340 patient without having measured the level first let's talk about magnesium most chief residents

00:12:13.860 when i was a junior resident would scream at you if you ever measured a magnesium level in a patient

00:12:20.100 with normal kidneys before giving them magnesium the reason for it is twofold one it costs more

00:12:26.740 it's not altering management but more importantly because we now understand and probably understood then

00:12:31.940 if we were paying attention that the measurement of serum magnesium is not really indicative of total

00:12:37.860 body magnesium and you have an enormous buffer for overshooting so it's also true by the way that

00:12:44.740 most of the potassium in a person is not in the extracellular space in the plasma most of it is in the cells

00:12:52.020 but because potassium and the difference between what's in the cell and out of the cell is a very important

00:12:59.700 electrical gradient if you overshoot what's out of the cell a little too much it can be fatal

00:13:05.060 that's not the case with magnesium because magnesium is not used to set the charge across the cell

00:13:10.660 okay if you're sitting here listening to this saying peter what the hell are you talking about

00:13:14.020 my only point here is one we don't have great ways to measure magnesium i will talk about how it's done

00:13:20.500 but two we don't tend to care about it very much clinically because unless a person's kidneys are

00:13:27.380 really compromised and the kidneys become the acute place in where magnesium regulation happens

00:13:34.020 we don't care about overdoing it so with that said there are basically a few ways to do this you

00:13:38.580 can measure plasma levels and by the way that's a test that's commercially available i can honestly

00:13:42.580 say i don't know the last time i've ordered it on myself or any of my patients but you can go to

00:13:47.140 lab core quest or wherever and request that i think if you're really concerned about magnesium

00:13:51.860 deficiency though you have to do these other types of tests so one of them is a urinary test so this is

00:13:57.460 a test where you collect the urine that is made over a period of time say 24 hours and you look at the

00:14:03.060 amount of magnesium in the urine and that gives you a sense of magnesium deficiency in other words

00:14:08.500 the less magnesium in the urine the more likely the person is to be deficient why because it tells

00:14:14.340 you boy those kidneys are really holding on to magnesium we have a sense of how much magnesium

00:14:19.300 should come out of a person in a day state of quote-unquote equilibrium and if the amount of

00:14:24.660 magnesium that's coming out is really low you would surmise that that person truly has total

00:14:29.300 body deficiency the other way you do it is a more elaborate version of this test where you load the

00:14:33.940 patient with magnesium so you give them a huge iv bolus of magnesium and then you also measure the

00:14:39.780 urinary excretion that's just a more involved test to do that and to be honest with you i've never

00:14:44.100 done either of those it's possible that an endocrinologist might look to something like that but again

00:14:49.060 it begs the point which is in a person with normal renal function you tend to err on the side of

00:14:54.340 assuming people are magnesium deficient and if you have any reason to believe it based on symptoms

00:15:00.100 or signs so low bone density pre-ventricular contractions so relatively benign skipped heartbeats

00:15:07.300 things of that nature cramps that would be a very common thing that would give you reason to believe a

00:15:12.100 person is magnesium deficient we just go ahead and replace the magnesium anyway just to double click you

00:15:17.060 mention migraines a bit ago can you talk a little bit more about migraines and low magnesium because

00:15:22.580 i think anyone who has had migraines is willing to look at anything to help alleviate those yeah

00:15:28.420 earlier i stated i hope i stated it correctly that magnesium plays an important role in inhibiting the

00:15:34.340 glutamate excitatory pathway of the nmda receptor in the brain and not surprisingly migraines are associated

00:15:41.700 with more excitation so the thinking would be that if you are deficient in magnesium you have less

00:15:48.980 inhibition of an incitatory neurotransmission pathway and therefore you might see more migraines in

00:15:55.140 people who are susceptible so looking back we were able to find a 2016 meta-analysis of all the rcts

00:16:01.860 that were done for acute migraines that found that intravenous magnesium provided significant

00:16:08.100 short-term relief i.e within 15 to 45 minutes and up to 24 hours post administration now again

00:16:15.700 that's intravenous magnesium we're going to talk in a minute about oral magnesium which is the way

00:16:19.860 most people are going to get magnesium it's unlikely that oral magnesium is going to be able to provide

00:16:24.820 relief acutely for this but intravenously and we're talking somewhere in the neighborhood of two

00:16:29.140 to four grams intravenously again i want you to keep that number in the back of your mind two to four

00:16:34.340 grams of intravenous magnesium when we start talking about how much oral magnesium you need

00:16:39.620 to take to get that oral magnesium treatments may reduce the frequency and the severity of attacks

00:16:46.980 but really provides very little relief in the acute setting what do we know about how common magnesium

00:16:54.740 deficiency is because i think anyone who's listening is kind of curious what are the odds this is going on

00:17:00.340 with them thank you for listening to today's sneak peek ama episode of the drive if you're interested

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00:20:36.100 Yeah.

00:20:36.800 Yeah.

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The Peter Attia Drive - December 11, 2023

#282 - AMA #54： Magnesium： risks of deficiency, how to correct it, supplement options, potential cognitive and sleep benefits, and more

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