Expert Interview: How serious is a magnesium deficiency, and what consequences can it have?

Dr. Orfanos-Boeckel, what distinguishes your approach to treating magnesium deficiency from other therapies?

The distinctive feature of my approach is, first of all, that I do not administer magnesium and other nutrients in a one-size-fits-all manner, but rather tailor the dosage to each individual. In other words, I always determine the exact requirements for each person—usually through blood tests.

Second, I don’t measure just a few isolated values, as in a process of elimination, but rather I measure a wide range of laboratory values because I want to understand and examine the metabolism as a whole from a functional perspective. I always “assess” the whole person, so to speak, and use in-depth, functional laboratory diagnostics to determine what is really going on—depending on the symptoms: What conventional medical issues are present? Are there already indications of age-related metabolic disorders, organ insufficiencies, or autoimmune-inflammatory processes? What functional disorders are present? What exactly are the mineral levels? Is the metabolism also well-supplied with other essential nutrients? Especially in magnesium metabolism, nutrients such as calcium and, above all, vitamin D play an important regulatory role, and if these are lacking, it is important to include them in the therapy and adjust them properly.

And thirdly, I measure these various values multiple times during therapy—on the one hand, to repeatedly check the magnesium dosage and adjust it if necessary, and on the other hand, to determine whether the condition I am actually aiming to treat with magnesium and other nutrients is indeed improving. In my practice, I usually do not perform isolated magnesium therapy; I always consider metabolism within the overall internal medical context, and while magnesium plays an important role there, it is usually not sufficient on its own if one truly wants to resolve a specific medical issue.

As a physician, you take a holistic approach. Do you think that a magnesium deficiency could also have an impact on mental health?

That’s a very good question! In fact, my experience shows that the brain—the place where the psyche originates—is highly dependent on an excellent supply of nutrients. Deficiencies in vitamins, minerals, amino acids, and omega-3 fatty acids can certainly have a functional impact on the psyche and the autonomic nervous system—that is, on sleep, digestion, mood, and so on. All of this is regulated in the brain, and it requires a large portion of the energy produced in the cells.

Magnesium plays a very significant role in energy metabolism, in communication between nerve cells, and also in neurotransmitters, making it an important mineral for our brain, as it contributes to normal energy metabolism, normal nervous system function, and normal mental function.

In my blog, I also write about the topic “brain insufficiency.” This term is not used in conventional medicine, but it describes quite well what happens functionally to the brain when it is under constant stress. It loses the ability to respond appropriately to stress.

Cardiology has also recognized the importance of magnesium, for example, for the heart muscle, but in psychosomatic medicine, neurology, and psychiatry, magnesium has unfortunately not yet been utilized as a “pharmacological treatment,” even though magnesium contributes to normal mental function and an effectively dosed nutritional therapy with magnesium can provide excellent support in these areas.

What is the process for determining the correct dosage in cases of magnesium deficiency?

To find the correct dose, one must first determine the patient’s magnesium level via laboratory diagnostics before starting therapy, as requirements vary from person to person. Generally speaking, I would say that 70 to 80% of the people who come to my practice need magnesium. Many do well with 300 mg or even 300 mg twice daily. A few, however, need nothing at all, and some really do need a lot of magnesium daily.

For diagnostic purposes, it is important to know that magnesium is primarily found intracellularly; therefore, measuring serum magnesium levels is not suitable for confirming or ruling out a magnesium deficiency, because even if the serum magnesium level is within the normal range, it is possible that magnesium levels within the cells are already significantly reduced. A much better indication of the state of our cellular magnesium supply is provided by the so-called whole blood mineral analysis, which is now offered by most laboratories.

Here, magnesium is not determined, as is usually the case, “only” from the aqueous portion of the blood, but from the entire blood sample—that is, serum and blood cells. The blood is “shaken,” and the total magnesium level is then determined from the resulting mixture. The best approach would be a direct intracellular measurement of magnesium levels, but this is not yet available in standard laboratories. In my laboratory, the reference range for magnesium in whole blood is 30 to 40 mg per liter. A value of 25 mg per liter would indicate a significant magnesium deficiency, but even values of 30 or 32 mg per liter are not yet optimal. A person is well-supplied if they have around 35 or even 37 mg per liter of magnesium in whole blood. Depending on how far the level—before and during therapy—is from the therapeutic target value of 35 mg per liter, and depending on the medical goal of magnesium supplementation, the therapeutic magnesium dose is then determined.

I believe that nutrient therapy, including magnesium therapy, must always be individually tailored, as needs vary greatly from person to person. Of course, there’s no harm in simply taking a little magnesium; the “worst” that can happen is loose stools or diarrhea. But that—avoiding harm—is not the point. I want to use magnesium to promote health, and for that, the correct dosage is needed, which can only be determined through laboratory diagnostics.

Please briefly explain how nutrients and cells are related, what role magnesium plays, and how a nutrient deficiency would manifest in this context.

Every cell must work 24 hours a day—producing, excreting, eliminating waste, detoxifying, and so on. This process requires about 40 to 50 essential nutrients, which we absorb through food or the environment—I described this in detail in my first book, “Nutrient Therapy, Orthomolecular Medicine & Bioidentical Hormones.” Magnesium is an incredibly important cofactor for the catalytic activity of hundreds of different enzymes. In addition, magnesium is an important structural component, for example in our bones. Within the cell itself, magnesium helps provide ATP from the mitochondria—the energy source that makes the cell’s function possible in the first place. This makes magnesium essential for cellular energy metabolism.

Regarding your question about the effects of a magnesium deficiency: With most nutrients, it unfortunately takes a long time before we notice that a deficiency exists. With magnesium, we notice the deficiency somewhat faster or “more clearly” because magnesium is so important for “comfortable” muscle function, and when muscles aren’t functioning properly, we humans can feel it—because it usually hurts. A severe magnesium deficiency manifests itself, for example, through cramps and tension, but also through heart palpitations, extrasystoles, fluctuations in blood pressure, headaches, and poor sleep.

Conversely, this means: wakefulness and sleep, digestion, normal muscle and heart function—none of this is possible without magnesium. In the long term, magnesium is also very important for bone metabolism. In this context, it works in tandem with vitamin D, vitamin K2, boron, and calcium.

Why is conventional medicine sometimes insufficient for detecting and treating a magnesium deficiency in a timely manner?

In human medicine, nutrients are still not incorporated into the therapeutic approach. Laboratory values and therapy with magnesium, vitamins, amino acids, fatty acids, etc.—none of this is part of medical school or specialist training, nor is it included in clinical guidelines, and thus it is not covered by health insurance. This means that magnesium is rarely measured, and when it is, it is measured only in serum and not in whole blood. Even when magnesium is so severely deficient that serum levels are low, doctors do not prescribe it because they do not recognize the need.

Yes, that’s true, we don’t die from magnesium deficiency, but everything that moves is magnesium-dependent, and it simply doesn’t function well anymore. A person can get away with this for a while in their youth, but not as they get older or if they engage in a lot of sports. A magnesium deficiency is annoying, disruptive, and hinders recovery. Furthermore, many issues that one would prefer to avoid in sports and later in life become more likely. There are only a few exceptions in hospitals where magnesium is actually administered intravenously in fairly high doses, for example, in pregnant women with premature labor or in the intensive care unit for cardiac arrhythmias. But even there, nutrient needs aren’t assessed individually; instead, supplementation is usually administered as a blanket measure and discontinued once symptoms subside. Just how absurd this is is perhaps illustrated by a comparison with blood pressure medications—after all, one would never prescribe, adjust, or discontinue a specific dose without first taking measurements.

In conventional outpatient medicine, nutrient levels aren’t typically tested in the first place, which is why nothing can be found. Tests are only performed in exceptional cases and usually only at the patient’s express request. But that is exactly what I would like to change: I would like to see more research on the topic of nutritional and hormonal medicine, as well as greater attention to these issues in general and specialist medical practice, so that patients can be treated optimally and their metabolism can be optimally regulated both preventively and curatively.

Which vitamins should be taken additionally to help the body absorb magnesium?

Generally, there are no problems with magnesium absorption in the intestines. However, vitamin D and calcium must be present for magnesium absorption—and here in Germany in particular, many people have a vitamin D deficiency, as confirmed by the Robert Koch Institute.

A disrupted vitamin D metabolism is a major issue; I always refer to it as “Vitamin D & Friends.” By “friends,” I mean: vitamin K2, boron *¹, calcium, and magnesium. These vitamins and minerals work as a team in our cells and organ systems, and it is crucial that all “group members” are always present. They are particularly important for bone metabolism and maintenance, as well as for vascular health.

*¹ VitaminExpress points out that boron is not covered by European health claims, but must be mentioned in this interview, as the statement regarding “Vitamin D & Friends” is incomplete without mentioning boron.

One should also keep in mind the interaction between magnesium and potassium: If magnesium is chronically deficient in the cell, this can subsequently lead to a potassium deficiency as well. If potassium is deficient, it is essential to check whether magnesium is also deficient. If you then supplement that, you don’t have to give as much potassium. They know this in the intensive care unit.

As you can see, this is all quite complex; every nutrient is interconnected with many others in its functional processes, much like a sunburst or a web. Every nutrient has a natural place in the body, and if that place is not occupied, the body tries to compensate for it in other ways—until noticeable and measurable problems eventually arise.

How often should an individual’s magnesium needs be checked?

Ideally, a measurement should be taken every 4, 6, or 8 months so that after 2–3 years, you can determine what type of magnesium user you are.

The simpler approach is to simply supplement with magnesium if a deficiency is suspected and then measure how the whole-blood level changes during treatment. You can then use this as a guide, adjust the dose if necessary, and measure again after 3 to 6 months to determine which maintenance dose suits your specific lifestyle—that is, depending on stress levels, exercise, prolonged sitting, medications, frequent travel, or diet.

If key factors change—for example, due to a change in diet, a new exercise regimen, or the use of diuretics—the dose should be adjusted accordingly. Nutritional needs are also increased during pregnancy—supplementation can therefore be particularly beneficial during this phase of life.

It is always important to me to determine individual needs—that is, what dose the body requires to function well at the cellular level. As mentioned, it’s not just about preventing harm, but fundamentally about improving and maintaining quality of life in general and over the long term.

In which cases are magnesium supplements covered by public health insurance?

Unfortunately, oral magnesium supplements are generally not covered by public health insurance in outpatient care. In rare cases, private health insurance may cover the costs, but this is an exception. At most, magnesium infusions may be covered if there is a genetically caused magnesium deficiency.

Is it possible to overdose on magnesium? If so, how would an overdose manifest physically?

In all my years of medical practice, I have never encountered an overdose of oral magnesium. Special caution is only warranted for people with severe kidney disease, dialysis patients, and those with other serious pre-existing conditions—but they shouldn’t undergo nutrient therapy without consulting their treating physician anyway, and certainly not at higher doses without lab monitoring.

In normally healthy people, an oral magnesium overdose is not possible. Even if the intestines were to absorb too much, the kidneys would simply flush it out. If the body is overwhelmed with magnesium, it usually signals this through diarrhea. The standard athlete’s dose of 150 or 300 mg of magnesium per day is in no way harmful, not even for people who don’t actually need additional magnesium. You’d have to take over 2,000 mg to truly overdose, and that—as I mentioned—leads to diarrhea quite quickly.

What can healthy people do as a preventive measure to avoid a magnesium deficiency?

Healthy people definitely benefit from a healthy diet. However, many people come to my practice who already eat a healthy, balanced diet and still have unmet nutritional needs—often linked to metabolic disorders or diseases and hormonal imbalances. This is not only due to the natural aging process, but also to generally elevated stress levels, processed foods, and increasing environmental pollution. In my experience, a healthy diet alone is no longer sufficient to compensate for all of this without symptoms; supplements are simply necessary, ideally before the symptoms become severe.

In cases of persistent fatigue, poor sleep, unexplained nervousness, and muscle tension, I often recommend a therapeutic trial with magnesium, which can be increased in doses of 150, 200, or 300 mg, depending on the specific magnesium compound used.

If you want to know for sure whether you have an increased need for magnesium, you need to undergo laboratory testing—this makes sense as a preventive measure, especially if you lead an active lifestyle and have functional symptoms. These tests also help determine which other nutrients need to be supplemented in addition to magnesium—I have described this in detail in my second book, “Nutrient Therapy—The Practical Guide,” which will be published this October by Trias-Verlag. My primary goal, especially starting in the second half of life, is to use nutrients and hormones—depending on lab results—to address deficiencies early on, so that people can age more healthily based on their individual predispositions.

How can targeted nutrient and hormone therapy help with a magnesium deficiency?

The administration of magnesium is very often a component of preventive or curative nutrient and hormone therapy. Hormones and nutrients work closely together. It is a collaboration between two teams: nutrients enable energy metabolism in the cells. Hormones (and this includes vitamin D, which is actually not a vitamin but a steroid hormone) help regulate the cells healthily. Without the hormone calcidiol (25-OH-vitamin D), magnesium and calcium are not well absorbed from the intestines, and without an adequate supply of vitamin D, estradiol, and progesterone, bone metabolism also does not function properly. Magnesium or calcium alone are not sufficient in older age to maintain healthy bone structure.

Estrogens are also important for healthy intestinal mucosal function. After menopause, not only do the skin and vaginal mucosa become dry, but the stomach and intestinal mucosa also become thinner and atrophic, which in turn can impair the absorption of nutrients, including magnesium.

When taking magnesium following a diagnosed nutrient deficiency, is there a specific dosage form that is optimal for magnesium absorption in our bodies?

Supplementation for all minerals always occurs in the form of a chemical compound with other substances. Whether it’s a powder, drink, or capsule—it’s always a compound and not “pure” magnesium. Especially with magnesium, there are many different compounds available. For simplicity’s sake, I always say: Magnesium is magnesium—the form doesn’t matter at first. What’s more important is the dose and that the form is well-tolerated by the individual.

Generally, a distinction is made between inorganic and organic magnesium compounds. The cheapest and smallest form is inorganic magnesium oxide. Between 300 and 400 mg of this fits into a tablet or capsule that is still easy to swallow. It may not be absorbed as well as, for example, organic magnesium citrate, but it is an affordable option for beginners.

If magnesium oxide doesn’t work well, you can switch to other forms of magnesium, such as citrate, aspartate, or maleate. Organic compounds are bulkier. For example, only about 150 mg of elemental magnesium from magnesium citrate fits into a fairly large capsule. Sometimes, the specific form of magnesium is chosen to provide additional benefits: glycinate is said to have a calming effect, threonate is believed to be good for the brain, and orotate is frequently used in cardiology, for example. However, this shouldn’t confuse anyone, and there’s no need to worry about choosing the wrong form. I always advise reading up on the topic, starting with a small dose, and experimenting. If possible, you should have your whole blood tested during therapy to see if you can achieve a good level with the form you tolerate well.

Why does it sometimes take so long to recognize a magnesium deficiency?

As I mentioned earlier: In conventional medicine, mineral status isn’t tested, and therefore mineral deficiency isn’t considered a relevant problem in the minds of many specialists and primary care physicians. That is precisely why it is so important to me to inform people—through my blog and my books. You really have to educate yourself on what you can achieve by supplementing with vitamins and minerals for specific symptoms.

In doing so, I also repeatedly encourage people not to be afraid and, if necessary, to simply go to a lab and have their levels measured “on their own.” I’ve described key target values for this in both my first and second books, which can also serve as a guide for non-medical professionals.

Please don’t get upset with your family doctors if they don’t know what to do with magnesium or aren’t interested in it, because the topic of nutrients simply isn’t part of their training, and neither the diagnostics nor the treatment are supported or covered by the health insurance system.

What advice can you give to people who want to change their diet due to a magnesium deficiency?

My advice: Please eat unprocessed foods that are rich in magnesium. Good sources of magnesium include whole-grain bread, brown rice, potatoes, broccoli, and basically any green vegetable, since magnesium is a central atom of chlorophyll. But of course, with all these foods, there are also patients who cannot eat this or that due to allergies, intolerances, or metabolic issues. In general, all fresh, green foods contain plenty of magnesium. These should therefore be regularly incorporated into the diet, but whether that is sufficient in practice can only be objectively determined through testing.

As mentioned earlier, there may also be genetic factors in the body that contribute to a magnesium deficiency. Therefore, it’s not surprising if a deficiency persists despite a balanced diet.

What advice do you give to people interested in nutrient therapy with magnesium?

Generally speaking, it makes sense for people who aren’t feeling well to have a laboratory test to check for deficiencies in important nutrients. Magnesium deficiency is very common here. It is not life-threatening, but it “annoys and disrupts” healthy metabolic function. If magnesium is lacking, this can usually be easily remedied by taking magnesium supplements orally, which then quickly leads to a significant improvement in quality of life. It is important to read up on the subject and then simply try it out for yourself. If the symptoms match, you can try taking 150 or 300 mg of magnesium orally daily to see if it helps. If that doesn’t work and you want to know more, you’ll need to get tested and, if necessary, seek advice from someone with experience. This could include practices specializing in orthomolecular medicine, functional medicine, or mitochondrial medicine.