Hypomagnesemia symptoms and causes list

Hypomagnesemia symptoms and causes – tables from [1, Slatoplosky, et al]

***This is an initial list of magnesium deficiency symptoms and causes. People with these conditions are at risk of chronic magnesium losses from bone stores and the resulting osteoporosis. Magnesium is used as a buffer by the kidneys and gastrointestinal tract when conditions are too acidic – frequently with our modern diet and beverages.

Magnesium supplements given orally during conditions of poor gastrointestinal absorption will be more likely to cause loose stools Magnesium ions can cause relaxation of the smooth muscles lining the intestines and watery bowel movements can occur – the common side effect is not similar to explosive diarrhea unless a very large dose is taken. Magnesium glycinate may be a better absorbed form. Lower more frequent doses are more likely to be absorbed well – 200 mg magnesium glycinate three times a day may result in more retention than 500 mg of a standard form two times a day. The RDA is lower and the UL – Upper Limit is a measly 325 mg but loose stools is really the only oral side effect. Intravenous use can be dangerous due to the rapid changes it can cause in the heart muscle that can trigger a stroke.Dosing Example for someone with a condition or medication that causes chronic wasting of magnesium stores:

“Maintenance therapy may require oral administration of Mg2+ oxide (400 mg twice daily or three times daily) for as long as the risk factors for Mg2+ deficiency exist. Oral Mg2+ gluconate (500 mg twice daily or three times daily) can also be used.” [1, p2293]

***This dosage is in reference to repletion needs for chronic magnesium deficiency typically due to decreased gastrointestinal absorption or increased renal losses.

Ideally our bodies expect a balance of magnesium in everything we eat and drink. Historically it was very rich in the water and soil and nature. An increase in insulin levels is the only main way the body can react to low magnesium levels. Historically an increased appetite would lead to increased magnesium levels because it was so common in the water and food supply. However it isn’t a primary fertilizer – the plants grow with minimal amounts and water softeners and bottling companies take it out along with the calcium and other ‘hard’ minerals. Our food supply and population is low in magnesium and when there is a high calcium intake the body loses more magnesium and preferentially absorbs the calcium. Calcium was never abundant directly in the soil and food supply – bird shells and tiny fish or animal bones would be rich sources and tiny amounts were available throughout the rest of the food and water supplies. Our bodies conserve calcium and waste magnesium because that is what used to work for us.Due to who knows what historical permutations, only sodium and potassium are officially considered electrolytes and have regulation standards for content in water supplies. The soil and everything consumed and drank was rich in magnesium ages ago as our bodies were adapting – before world flooding over the millennia washed nutrients to sea (brine pits are a source of many crucial nutrients and seaweed is a source of iodine because it filters it from the sea water – ocean vegetables for the next season are going to be contaminated from the nuclear accident).  Electrolyte beverages in our current market rarely have magnesium – the Glaceau brand of Smart Water does.

Magnesium can also be absorbed through the skin from Epsom salt baths, foot soaks or skin creams that have had it added (a compounding pharmacist can make it if prescribed). [35 B, 36 B,37 B] Magnesium has been successfully used within emergency inhalers for asthma.
____________________________________________________________________________
Clinical consequences of hypomagnesemia     [tables from 1,Slatoplosky, et al] ***symptom list
Electrolyte abnormalities
                Hypokalemia
                Hypocalcemia
Neuromuscular
                Carpopedal spasm
                Tetany
                Muscle cramps
                Muscle fasciculations
Neurologic
                Vertigo                 / dizziness
                Nystagmus           /  involuntary eye movement
                Aphasia                /  loss of speech abilities, may be temporary [12]
                Hemiparesis
                Depression
                Delirium
                Choreoathetosis    [10]
Cardiovascular
                Ventricular arrhythmias
                Torsade de points
                Supraventricular tachycardia
                Enhanced sensitivity to digoxin
Causes of Magnesium deficiency    [1]
***triggers and conditions that lead to magnesium wasting that may be genetic, pharmaceutical side effect related or possibly preventable –ie quit drinking too much alcohol –also smoking [14] needs to be added to this list [Bruerger’s vasculitis] and proton pump inhibitors for some people.
Gastrointestinal
                Malnutrition
                Malabsorption
                Chronic diarrhea
                Primary infantile hypomagnesemia
                Nasogastric suction
                Intestinal fistula
Renal
                Congenital magnesium wasting
                Bartter syndrome
                Gitelman syndrome
                Postobstructive diuresis
                Diuretic phase of ATN         [11]
                Loop and thiazide diuretics   [3,4, 5,6]
                Cisplatin
                Aminoglycosides   [7-drug names, 9 – kwashiorkor reference]
                Pentamidine
                Foscarnet
                Cyclosporin A
                Tacrolimus
Endocrine
                Hyperparathyroidism
                Hyperthyroidism
SIADH
                Hyperaldosteronism    [8 – edematous malnutrition reference]
Redistribution
                Hungry bone syndrome
                Acute pancreatitis
                Blood transfusions
                Insulin treatment
Miscellaneous
                Diabetes                   [59]
                Chronic alcoholism

“In general, Magnesium deficiency is the result of either gastrointestinal or renal losses. If no cause is readily apparent, then one can distinguish between gastrointestinal and renal losses by measuring the 24-H urinary MG²+ excretion or fractional excretion of Mg2+. The normal response of the kidney to Mg2+ depletion is to reduce Mg2+ excretion to low levels. The measurement of 24-H urinary Mg2+ excretion of  more than 30 mg in a person with normal renal function and hypomagnesemia indicates renal Mg2+ wasting. If Mg2+ deficiency is suspected in the absence of hypomagnesemia, then one might consider evaluating the renal excretion of Mg2+ in response to an intravenous Mg2+ load. [20,21] this, however, is rarely done in clinical practice. In the presence of unexplained hypocalcemia or hypokalemia, a trial of Mg2+ administration is more commonly performed.” (Slatoplosky, et al, p2292 ) [1]

/Disclaimer: Opinions are my own and  the information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes./

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Bibliography
1.   1.   [jasn.asnjournals.org/content/20/11/2291.long]  Kevin J. Martin,  Esther A. González and Eduardo Slatopolsky, Clinical Consequences and Management of Hypomagnesemia,  doi: 10.1681/ASN.2007111194 (JASN November 1, 2009 vol. 20 no. 11 2291-2295)
3.       Michael E. Ernst and Marvin Moser, “Use of Diuretics in Patients with Hypertension,” New England Journal of Medicine 361, no. 22 (2009): 2153-2164.

“However, thiazides are now used in substantially smaller doses, and the term low-dose thiazide has become synonymous with hydrochlorothiazide at a dose of 12.5 to 25 mg per day (or the equivalent dose of another thiazide). Approximately 50% of patients will respond initially to these low doses. In the Systolic Hypertension in the Elderly Program (SHEP),34 chlorthalidone given at a dose of 12.5 mg per day controlled blood pressure, for several years, in more than 50% of patients. Increasing the dose of hydrochlorothiazide from 12.5 to 25 mg per day may result in a response in an additional 20% (approximately) of patients; at 50 mg per day, 80 to 90% of patients should have measurable decreases in blood pressure.35 Increased electrolyte losses at the higher doses of diuretics may preclude their routine use.” [3]                      (***diabetes after a year of use is also a risk)

List of Thiazide and Thazide-like Diuretics (water pills) used in the Treatment of High Blood Pressure     4.   [infobloodpressure.com/drugs/thiazide-list.html ]
  • Bendroflumethiazide (Naturetin)
  • Benzthiazide               (Exna)
  • Chlorothalidone          (Hygroton, Thalitone)
  • Chlorothiazide            (Diurigen, Duril)
  • Hydrochlorothiazide   (Esidrix, Hydrodiuril, Hydro-Par, Microzide, Oretic)
  • Hydroflumethiazide    (Diucardin, Saluron)
  • Indapamide                 (Lozol)
  • Metolazone                 (Mykrox, Zaroxolyn, Diulo)
  • Methychothiazide       (Aquatensen, Enduron)
  • Polythiazide                (Renese)
  • Quinethazone             (Hydromax)
  • Trichlormethiazide      (Diurese, Metahydrin, Naqua)

Examples of loop diuretics include:

  • Bumetanide
  • Ethacrynic acid (Edecrin)
  • Furosemide (Lasix)
  • Torsemide (Demadex)
Aminoglycosides are a group of antibiotics including at least eight drugs: amikacin, gentamicin, kanamycin, neomycin, netilmicin, paromomycin, streptomycin, and tobramycin.
7. Read more on aminoglycoside antibiotics: [healthline.com/galecontent/aminoglycosides#ixzz1HdHbebJf]
Healthline.com – Connect to Better Health

8. [icmr.nic.in/ijmr/2009/November/1128.pdf ] Tahmeed Ahmed, Sabuktagin Rahman & Alejandro Cravioto, Oedematous malnutrition,  Indian J Med Res 130, November 2009, pp 651-654

Hyperaldosteronism may be occurring in edematous malnutrition:

Anti-diuretic factor in the urine of children with nutritional oedema: Nutritional oedema is associated with an increased secretion of an anti-diuretic substance (probably anti-diuretic hormone) which prevents the normal excretory response to water administration. Gopalan and Venkatachalam15 in a study furnished indirect proof of the effect of posture on the urinary response to water load in normal subjects and in cases of nutritional oedema. The normal subjects were found to excrete over 100 per cent of ingested water within 4 h of ingestion in the recumbent posture, while in the erect posture they excreted only 80 per cent. In case of nutritional oedema, the urinary excretion was found to be much lower than in the normal subjects in both recumbent and erect postures. The effect of dietary protein deficiency on the hepatic inactivation of ADH in rats has also been investigated. It was found that the rats maintained on low-protein, low-calorie diets showed a delayed and incomplete response to a water load, and that the livers of these animals showed a reduced capacity for inactivating ADH (Gopalan & Srikantia, unpublished).

Role of ferritin and aldosterone: Srikantia observed presence of ferritin in children with kwashiorkor16. With a view to reveal the precise role of ferritin in the pathogenesis of nutritional oedema, Gopalan and Srikantia17 investigated the sequence of changes occurring in induced protein and calorie under-nutrition with focus on oedema formation in monkeys. O n the basis of the findings, they suggested that calorie-protein undernutrition leads to structural and functional changes in the liver, further leading to defective inactivation of ADH. Active ferritin is released from damaged liver leading to increased secretion of ADH. The net result is water retention. Among other factors, aldosterone, the salt retaining hormone, which is known for influencing water metabolism by altering renal tubular reabsorption of sodium, is also known to be inactivated by the liver. Altered aldosterone metabolism has been reported in diseases of the liver. Associated hyperaldosteronism could account for the sodium retention18. In oedematous children aldosterone secretion becomes higher during loss of oedema19.

“In a clinical trial, the administration of N-acetylcysteine, a glutathione precursor, resulted in more rapid resolution of oedema in kwashiorkor31. These associations between oxidative stress and kwashiorkor indicate that antioxidant depletion may cause kwashiorkor which can therefore be prevented with antioxidant supplementation.”

9. [ajcn.org/content/89/2/592.long]
Reduced production of sulfated glycosaminoglycans occurs in Zambian children with kwashiorkor but not marasmus also good –

10. Excerpt from wikipedia / Choreoathetosis 
10. [en.wikipedia.org/wiki/Chorea_%28disease%29]

Choreia is characterized by brief, quasi-purposeful, irregular contractions that are not repetitive or rhythmic, but appear to flow from one muscle to the next.These ‘dance-like’ movements of choreia (from the same root word as “choreography”) often occur with athetosis, which adds twisting and writhing movements.Choreia can occur in a variety of conditions and disorders.

  • Choreia is a primary feature of Huntington’s disease, a progressive neurological disorder.
  • Twenty percent of children and adolescents with rheumatic fever develop Sydenham’s chorea as a complication.
  • Choreia gravidarum is rare type of choreia which is a complication of pregnancy.
  • Choreia may also be caused by drugs (levodopa, anti-convulsants, anti-psychotics), metabolic disorders, endocrine disorders, and vascular incidents.
  • Ataxia telangiectasia
  • Wilson’s disease, a genetic disorder that leads to toxic levels of copper in the body
  • McLeod syndrome,is a genetic disorder that may affect the blood, brain, peripheral nerves, muscle and heart. Common features include peripheral neuropathy, cardiomyopathy and hemolytic anemia. Other features include limb chorea, facial tics, other oral movements (lip and tongue biting), seizures, a late-onset dementia and behavioral changes.
11. Diseases of the kidney and urinary tract  By Robert W. Schrier  page 2303 hypophosphatemia, diuretic phase of ATN, acute tubule nephropathy

Aphasia is a total or partial loss of the ability to speak correctly or to understand or comprehend what is being said. It may be caused by brain injury or disease. It’s most often caused by a stroke that injures the brain’s language center, located on the left side of the brain in most people. Some people with aphasia recover quickly and completely after a stroke. Others may have permanent speech and language problems.

  • Speech problems can range from trouble finding words to being unable to talk at all. Some stroke patients describe it as “having trouble getting words out.”
  • Some people have problems understanding what others are saying or have trouble with reading, writing or math.
  • In other cases, a person with aphasia may have trouble talking but can understand what others say perfectly.
Each person’s speech and language problem is unique. A language professional (speech therapist) can help set up a treatment plan and help others understand the needs of a person with aphasia.
For stroke information, call the American Stroke Association at 1-888-4-STROKE.
 
13. Garrison M. Tong and Robert K. Rude, “Magnesium Deficiency in Critical Illness,” Journal of Intensive Care Medicine 20, no. 1 (January): 3 -17.

14. Satoru Torii et al., “Magnesium Deficiency Causes Loss of Response to Intermittent Hypoxia in Paraganglion Cells,” Journal of Biological Chemistry 284, no. 28 (July 10, 2009): 19077 -19089. (free article)[jbc.org/content/284/28/19077.full]
*** Magnesium deficiency is found to reduce the normal response to hypoxia (lack of oxygen) of increasing adrenal gland production of erthyopoietin and endothelial vascular growth factor. This could suggest fewer red blood cells and weaker capillary and blood vessel structure in the magnesium deficient individual with breathing issues or other reduced oxygen situations (smokers).

15. “Possible Interactions with: Magnesium,” [umm.edu/altmed/articles/magnesium- 000968.htm.]

16. B Grimaldi, “The central role of magnesium deficiency in Tourette’s syndrome: causal relationships between magnesium deficiency, altered biochemical pathways and symptoms relating to Tourette’s syndrome and several reported comorbid conditions,” Medical Hypotheses 58, no. 1 (1, 2002): 47-60.

17. G Eby, “Rescue treatment and prevention of asthma using magnesium throat lozenges: Hypothesis for a mouth–lung biologically closed electric circuit☆,” Medical Hypotheses 67, no. 5 (2006): 1136-1141.

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22. P Chambers, “Lone atrial fibrillation: Pathologic or not?,” Medical Hypotheses 68, no. 2 (2007): 281-287.

23. “Complementary vascular-protective actions of magnesium and taurine: A rationale for magnesium taurate,” [medical-hypotheses.com/article/S0306-9877(96)90007-9/abstract.]

24. Abe E. Sahmoun and Brij B. Singh, “Does a higher ratio of serum calcium to magnesium increase the risk for postmenopausal breast cancer?,” Medical Hypotheses 75, no. 3 (9, 2010): 315-318.

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29. E Planells et al., “Effect of magnesium deficiency on vitamin B2 and B6 status in the rat,” Journal of the American College of Nutrition 16, no. 4 (August 1997): 352-356.

30. Sivan Ben-Avraham et al., “Dietary strategies for patients with type 2 diabetes in the era of multi-approaches; review and results from the Dietary Intervention Randomized Controlled Trial (DIRECT),” Diabetes Research and Clinical Practice 86 Suppl 1 (December 2009): S41-48.

31. “Utility of magnesium as antiarrhythmic agent reviewed. – Health & Medicine Week | HighBeam Research – FREE trial,” [highbeam.com/doc/1G1-121345520.html.]

32. Barbara Chipperfield and JohnR. Chipperfield, “Relation of Myocardial Metal Concentrations to Water Hardness and Death-Rates from Ishchaemic Heart Disease,” The Lancet 314, no. 8145 (October 6, 1979): 709-712.

33. Barbara Chipperfield et al., “Magnesium and Potassium Content of Normal He3art Muscle in Areas of Hard and Soft Water,” The Lancet 307, no. 7951 (January 17, 1976): 121-122.

34. “Regulation of Contraction in Striated Muscle — Gordon et al. 80 (2): 853 — Physiological Reviews,” [physrev.physiology.org/cgi/content/full/80/2/853.]

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37. “Magnesium Treatment for Sudden Hearing Loss – The Annals of Otology, Rhinology & Laryngology | HighBeam Research – FREE trial,”[highbeam.com/doc/1P3-679636211.html#.]

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41. Daniel G. Chausow et al., “Experimentally-induced magnesium deficiency in growing kittens,” Nutrition Research 6, no. 4 (April 1986): 459-468.

42. Yuhei Kawano et al., “Effects of Magnesium Supplementation in Hypertensive Patients : Assessment by Office, Home, and Ambulatory Blood Pressures,” Hypertension 32, no. 2 (August 1, 1998): 260-265.

43. Robert E. Kleiger et al., “Effects of chronic depletion of potassium and magnesium upon the action of acetylstrophanthidin on the heart,” The American Journal of Cardiology 17, no. 4 (April 1966): 520-527.

44. Andrew D Hershey, “Current approaches to the diagnosis and management of paediatric migraine,” The Lancet Neurology 9, no. 2 (2, 2010): 190-204.

45. A M Gordon and E B Ridgway, “Cross-bridges affect both TnC structure and calcium affinity in muscle fibers,” Advances in Experimental Medicine and Biology 332 (1993): 183-192; discussion 192-194.

46. Karin Ladefoged and Kikki Hagen, “Correlation between concentrations of magnesium, zinc, and potassium in plasma, erythrocytes and muscles,” Clinica Chimica Acta 177, no. 2 (October 14, 1988): 157-166.

47. “Common genetic variants of the ion channel transient receptor potential membrane melastatin 6 and 7 ( TRPM6 and TRPM7 ), magnesium intake, and risk of type 2 diabetes in women.(Research article)(Report) – BMC Medical Genetics | HighBeam Research – FREE trial,”[.highbeam.com/doc/1G1-193482837.html#.]

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51. “Ancient Minerals Launches Comprehensive Online Magnesium Health Resource. – PRWeb Newswire | HighBeam Research – FREE trial,”[.highbeam.com/doc/1G1-241203537.html#.]

52. K Michaelsen, “Inadequate Supplies of Potassium and Magnesium in Relief Food? Implications and Countermeasures,” The Lancet 329, no. 8547 (6, 1987): 1421-1423.

53. “High Dietary Intake of Magnesium May Decrease Risk of Colorectal Cancer in Japanese Men1,2 – The Journal of Nutrition | HighBeam Research – FREE trial,”[highbeam.com/doc/1P3-1998563311.html.]

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55. “Magnesium prevents chemotherapy side effects.(Editorial)(Report) – Townsend Letter | HighBeam Research – FREE trial,”[highbeam.com/doc/1G1-206620332.html#.

56. J Caddell, “Magnesium Deprivation in Sudden Unexpected Infant Death,” The Lancet 300, no. 7771 (8, 1972): 258-262.

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[59.  todaysdietitian.com/newarchives/td_1104p37.shtml]

Victoria Shanta-Retelny, RD, LD, The Magnesium-Diabetes Connection, Today’s Dietitian, Vol. 6, No. 11, p. 37, November 2004

 

Magnesium references From Bibliography for Dietitian Recommends Stop Vitamin D and Calcium ASAP 
8B. http://www.ijkd.org/index.php/ijkd/article/view/140 Assadi, F., Hypomagnesemia, An Evidence-Based Approach to Clinical Cases, (Iranian Journal of Kidney Diseases, Vol 4, No 1 (2010)
18 B. http://www.ncbi.nlm.nih.gov/pubmed/20081245 Magdalena Bujalska, Helena Makulska-Nowak, Stanis³aw W. Gumuka Magnesium ions and opioid agonistsin vincristine-induced neuropathy , Department of Pharmacodynamics, Medical University of Warsaw, Krakowskie Przedmieoecie 26/28, PL 00-927 Warszawa, Poland
19 B. Magnesium: an emerging drug in anaesthesia, , Editorial I, M. F. M. James, British Journal of Anaesthesia, 103 (4): 465-7 (2009) DOI:10.1093/bja/aep242
23 B. http://www.ncbi.nlm.nih.gov/pubmed/17823441 Dai Q, Shrubsole MJ, Ness RM, Schlundt D, Cai Q, Smalley WE, Li M, Shyr Y, Zheng W., The relation of magnesium and calcium intakes and a genetic polymorphism in the magnesium transporter to colorectal neoplasia risk. ( Am J Clin Nutr. 2007 Sep;86(3):743-51)
24 B. Joan L Caddell, Geriatric cachexia: a role for magnesium deficiency as well as for cytokines?, Letter to the Editor, , (Am J Clin Nutr 2000;;71:844-53. pp 851-853)
25 B. Carl J Johnson, M.D., Donald R. Peterson, M.D., Elizabeth K. Smith, PhD, Myocardial tissue concentrations of magnesium and potassium in men dying suddenly from ischemic heart disease, (Am J Clin Nutr 32: MAY 1979, pp 967-970)
29 B. Geeta Sharma and Charles f Stevens, A mutation that alters magnesium block of N-methyl-D-aspartate receptor channels, Pub: Proceedings of the National Academy of Sciences of The United States 93.n17 (August 20, 1996): pp9259+. InfoTrac General Science Collection.
30 B. Beasley R, Aldington S, Magnesium in the treatment of asthma..Medical Research Institute of New Zealand, Wellington, New Zealand., Richard.Beasley@mrinz.ac.nz, Curr Opin Allergy Clin Immunol. 2007 Feb;7(1):107-1
32 B. Maged M. Costantine, MD, Steven J. Weiner, MS, Effects of Antenatal exposure to Magnesium Sulfate on Neuroprotection and Mortality in Preterm Infants: A Meta Analysis, Obstet Gynecol. 2009 August; 114(2 Pt 1): 354-364 DOI:10.1097/AOG0b013e3181ae98c2
33 B. Burton M. Altura, Bella T. Altura and Anthony Carella., Magnesium deficiency-induced spasms of umbilical vessels: relation to preeclampsia, hypertension, growth retardation. Pub:Science, 221 (July 22, 1983): pp376(2)
34 B. Burton M. Altura, Bella T. Altura, Asefa Gebrewold, Harmut Ising and Theo Gunther, Magnesium deficiency and hypertension: correlation between magnesium-deficient diets and microcirculatory changes in situ.,. Pub: Science, 223.(March 23, 1984): pp1315(3).
37 B. [ahavaus.com/site/dead_sea_wonders.html] Line of skin care products containing magnesium.
42 B. Magnesium intake from food and supplements is associated with bone mineral density in healthy older white subjects. (elderly health), Kathryn M. Ryder, Ronald I Shorr, Andrew J. Bush, Tamara Harris, Katie Stone and Frances A Tylavsky. Journal of the American Geriatrics Society, 53.11 (Nove 2005): p1875-1881. Academic One File. Web. 13 Dec. 2010
43 B. DASH Diet May Cut Heart Disease Risk, – source John Hopkins Medicine, Today’s Dietitian, Vol . 12, No. 10, Oct. 2010, p 25
44 B. Christine Feillet-Coudray, Charles Coudray, Zjean-Claude Tressol, Denise Pepin, Andrzej Mazur, Steven A Abrams, Exchangeable magnesium pool masses in healthy women: effects of magnesium supplementation, Yves Rayssiguier, Am J Clin Nutr 2002;75;72-8
45 B. [.highbeam.com/doc/1P3-2180507851.html] “Researchers Identify Protein that Regulates Magnesium and Can Restart Stem Cells.” Targeted News Service. Targeted News Service LLC. 2010. HighBeam Research. 16 Feb. 2011 . “An international team led by researchers at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School has published new findings that demonstrate how a specific protein controls the body’s ability to balance magnesium levels. Magnesium is an essential element for good health and is critical to more than 300 biochemical reactions that occur in the body. “Currently more than half of the US population does not consume an adequate amount of magnesium in their diet,” said Alexey G. Ryazanov, Ph.D., one of the study’s authors and a professor of pharmacology and member of The Cancer Institute of New Jersey at UMDNJ-Robert Wood Johnson Medical School. “Magnesium deficiency may be associated with many medical disorders including hypertension, atherosclerosis, anxiety, asthma and a host of other disorders.” “The team of researchers from the United States, France and Poland demonstrated for the first time that a protein called TRPM7 plays a key role in the maintenance of magnesium homeostasis (balance within the body) and is essential for proliferation of embryonic stem cells.”
77 B. Neuromed Phamaceuticals and Merck and Co., Inc. Announce Agreement for Novel N-type Calcium channel Compounds, from Business Wire, March 20, 2006, High Beam Research – **Neuromed is a pharmaceutical company focusing on calcium channel blockers. “blocking pain signaling through the N-type calcium channel is a novel approach for the treatment of pain” said Christopher Gallen,MD, PhD, President and Chief Executive Officer of Neuromed. **Providing adequate magnesium would be a less novel way to block nerve pain caused by overexcitation by excess calcium. Citation #9 demonstrated that diabetic neuropathy pain could be reduced by magnesium injection alone – why bother with the opioid or the synthetic calcium channel blocker. They are an expensive and dangerous class of pharmaceuticals that would be pretty much not necessary if we weren’t being drained of magnesium reserves by excessive calcium and acidity intakes.
95 B [also 3/PPI article].     [jasn.asnjournals.org/content/20/11/2291.long]  Kevin J. Martin,  Esther A. González and Eduardo Slatopolsky, Clinical Consequences and Management of Hypomagnesemia,  doi: 10.1681/ASN.2007111194 (JASN November 1, 2009 vol. 20 no. 11 2291-2295)
96 B.    [.ncbi.nlm.nih.gov/pmc/articles/PMC2639130/?tool=pubmed] Karl T. Weber, William B. Weglicki, and Robert U. Simpson, Macro- and micronutrient dyshomeostasis in the adverse structural remodelling of myocardium,  (Cardiovasc Res. 2009 February 15; 81(3): 500–508.) Published online 2008 October 3. doi: [10.1093/cvr/cvn261].

Talking about trauma with kids; PTSD, neural mapping, EMDR and reframing

/This article was originally posted on March 21, 2011. It is still important to have open conversations with children about traumatic events or other information they may find confusing, troubling or frightening. EMDR therapy can be helpful for adults with PTSD./
We all need comfort and we gain it from sharing our burdens, talking about troubles and letting out worries. Listening is more important than talking – let kids talk to you about trauma – we don’t know what they are thinking or are worried about until we let them talk it out. Don’t worry too much about “how to talk about it“, pause, listen, and accept – “yes, there are worries but we’ll stick together and work through it“, is a strong message for all of us to hear.
Children and all of us have “hot” emotional memories centered in the amygdala and milder long term factual memories stored more generally throughout the neocortex. Electrical activity of the brain can be recorded and associated with the topic being considered. The amygdala centered emotional memory can be tied to smells, sounds, places or people and can be unexpectedly triggered leaving the person with panic attack type symptoms unique to the individual’s memories of the early traumatic event.

Neural connections in the brain can be flexible or can be linked together in behavior patterns that might be described as being a bit like playing with a line of toy dominoes. The designers spend hours placing the dominoes in line, each the perfect distance and angle from the last, carefully balanced on end and poised for any slight shock to send the entire chain tumbling down. Emotional memories may be triggered by something like a car door slamming shut. A toddler memory may be submerged regarding something as trivial as mom and dad fighting over who has to carry in the groceries and the car doors were slammed shut violently. To a toddler the words may not mean as much as the tone and the violent sounds. A description of brain cell connections without the dominoes analogy is available on ScienceDaily: Brain pattern flexibility and behavior, (ScienceDaily)

 

After the event, immediately, and maybe later that day, the next day, the next week – the toddler may pester with questions of what is wrong and what did I do to cause that fight? The child’s world is centered around themselves – natural while young but prone to self blame. The memory can be stored with feelings of “I caused that arguement – I am a bad person – I don’t deserve attention or explanation” and so on. If their worries are left unanswered or are denied as real then the hot memory is ignored and is left unprocessed, instead it is pushed down and forgotten at the daily level. A car door slamming with a combination of shouting voices might trigger a panic attack though.

 

The hot memory can be toned down and moved to long term storage if time is allowed to discuss the event – and more than once. It might pop up in the toddler’s chit chat daily, and then weekly, monthly, and maybe even over the years if it was bad enough triggering event. Once the connection is made though, (negative event associated with a negative symptom) and discussed, usually the power of the slamming/shouting sound is reduced and similar events in the future may not trigger a panic attack or it might  be a milder reaction.

 

Children are absorbing knowledge and building their neural pathways – good habits and bad habits are learned by watching the people they love and trust. Spending a few minutes whenever possible to listen to children share their worries allows them to move the memories from the ‘hot’ button zone of the amygdala, to the mellower long-term storage of the neocortex.

 

Symptoms of PTSD, Post Traumatic Stress Disorder, can be effectively reframed  and reduced using cognitive therapy techniques like EMDR. A problem or trigger event is visualized and then a state of deep relaxation is reached and the memory is discussed or pondered with guidance from the therapist. New insights from the perspective of the adult framing of the situation can be considered and then the relaxation method is repeated using the new perspective.  The neural maps of the traumatic events can be reached  from a deeply relaxed state of theta waves. EMDR, attempts to help the patient reach the theta state with rapid stimulation of the right side then left side of the brain, either visually with a moving hand or object, or with sound or a vibration buzz in the palm of the hand. Children under seven are already living in this more meditative level of consciousness. In the zone – flow time – playing like a child – we could all use a little relaxed theta time these days and a chance to free a little worry from the hot zone of the amygdala.

 

The world is changing but denying reality never solves problems it only pushes them down to a submerged hot zone. When we talk about our troubles then we can look for solutions and change. Denying problems, denies a chance for change.

 

Art therapy can be a useful way to give children and anyone freedom to explore feelings – color to feel not to produce. Playdough and other free form play can help reach a relaxed state where gentle talk about hot topics can be released  as they surface. Picking at the problem with needling questions may not be as quick as open ended play time. Adults may find a walk or bike ride their ticket to free flow brain time.

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Disclaimer: Opinions are my own and the information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes.

  1. Terrorism, and talking to kids about catastrophic mass violence, guidance sheets from The National Child Tramatic Stress Network [nctsnet.org/trauma-types/terrorism]
  2. by Carol Boulware, MFT, PhD, “EMDR Therapy, EMDR Therapists, EMDR information, PTSD,” [emdr-therapy.com/].
  3. by Carol Boulware, MFT, PhD, “EMDR-Breakthrough Therapy for Overcoming Anxiety, Stress,Trauma and Self-Sabotage,” [emdr-therapy.com].
  4. by Carol Boulware, MFT, PhD, “Do I Have Anxiety Needing Therapy?” a discussion about anxiety and PTSD focused on adults [emdr-therapy]
  5. The National Child Traumatic Stress Network [nctsnet.org/]
  6. Trauma and Your Family – a guidance factsheet from The National Child Traumatic Stress Network pdf: [nctsn.org]
  7. by Tanya Anderson, PTSD in Children and Adolescents, Great Cities Institute, GCP-05-04, November, 2005  pdf: [uic.edu]
  8. This website is a non-profit 12 step based program for the Adult Children Of Alcoholic (or Dysfunctional) Families. PTSD and neural mapping aren’t discussed but the symptom list includes similar problems: The Laundry List – 14 Traits of an Adult Child of an Alcoholic (or Dysfunctional Family) ,  [adultchildren.org]

Alp Luachra, an old name for edematous malnutrition

Alp Luachra is a Celtic fairy with a pet newt. It was considered dangerous to fall asleep near a stream. Alp Luachra might climb into the victim’s mouth along with his pet newt. They would live in the stomach and gobble up nutrients while the rest of the accursed person shriveled away. No matter how much the victim would eat they would eventually starve – because Alp Luachra leeches all the nutrition away. I learned of him from my new book, Tarot of the Celtic Fairies. The picture on the Tarot card does resemble edematous malnutrition with a very round belly and thin, starved looking arms and legs. Maybe it does exist outside of the tropics. (The 9 of Cauldrons card from  Tarot of the Celtic Fairies 14)

Kwashiorkor, (that rare tropical form of malnutrition in toddlers weaned from breast feeding too rapidly, and/or from lack of introduction of insects to the diet at the appropriate stage), has been in the news. An insurance billing watch dog group found an increased use of the diagnosis code for kwashiorkor/malnutrition in a group of California hospitals. Prime Healthcare Service’s response to the allegations that a diagnosis of malnutrition was used to increase reimbursement states that the facts were distorted in order to mislead the public and gain concessions. It continues that the “relevant (i.e., where the diagnosis affected reimbursement) malnutrition rate at all Prime Healthcare hospitals was 3.6%,which is much less than the rates referenced in the article. For example, their relevant malnutrition rate at Huntington Beach hospital was 5.3% rather than the 39% reported by California Watch.”

That seems reasonable to me. It continues to review the disturbing prevalence of malnutrition and their screening program that Prime Healthcare hospitals use for improving patient care and decreasing morbidity and mortality rates a nutritional screening for their elderly patients is part of their routine care.

Published studies estimate that up to 15% of ambulatory elderly patients, up to 44% of homebound elderly patients, up to 65% of hospitalized elderly patients, and up to 85% of nursing home patients are malnourished. Hajjar, R.R., Kamel, H.K., Denson, K., Malnutrition In Aging, The Internet Journal of Geriatrics and Gerontology, Volume 1, Number 1 (2004); Chen, C.C-H, Schilling, L.S., Lyder, C.H., A Concept Analysis of Malnutrition In The Elderly, Journal of Advanced Nursing, Volume 36(1) (2001).

** Prime Healthcare sounds like a good place for dietitians to work. A nutrition screening by a Registered Dietitian is vital for quality preventative health care. A multidisciplinary team allows a thorough assessment from multiple viewpoints – a stethoscope or a microscope or a little Celtic sparkle – who knows the health solutions that teamwork can bring. However, I was just reading about albumin on RD411, an information website, today [16]. I learned that low albumin is not considered useful to tell if a patient is malnourished because it is easily influenced by many factors besides dietary protein intake. However, at the same time I learn that it is associated with increased mortality and morbidity – so I am left to assume that  I needn’t consider the elderly person with an albumin of 7 or 8 as ‘malnourished’ but just to consider them at increased risk of morbidity and mortality instead. The recommendation is to continue dietary calculations as normal, but instead of pouring another Health Shake to add to the malabsorbtion mess I would rather consider what is causing the shift in fluid and what might be better absorbed than what we already have been trying.

In research by Yi-Chia Huang et al, the elderly Taiwanese population had an intake range of 573.9 to 3191.9 kcal/day and no association between functional status and intake could be made.  Intake of at least 55 grams protein per day was associated with better function but higher levels of protein intake again could not be correlated to improved status. [7] In cases of malabsorption we can pour in 3000 calories per day and there will be no guarantee that it will be more helpful than 573. It would probably be more harmful than low intake. Anything that passes through the body has to be brought into safe balance with the chemical needs of the intestinal lining. Magnesium is a buffer that is taken from the bones to “fix” over acidic conditions. High protein, dairy and sugar intakes add to acidic conditions and coffee, carbonated beverages, black tea, and fruit juices can be very acidic. For strong bones try choosing an herbal or green tea and pass on the extra large glass of pop or milk and the triple shot of alcohol too probably.

There is controversy over using just the albumin level for a diagnosis of malnutrition and it is true that short term edema – puffiness – will cause low albumin levels while puffy. With less fluid in the blood and more fluid in the spaces between cells and organs there will be less albumin. It is a blood protein that acts a little like a sponge to attract and keep fluid around it but where the fluid goes it is also attracted to follow. Circular paths are the way of nature. The albumin level that remains low for months – rather than during an acute week of an illness – I would strongly consider the possibility that an underlying malnutrition problem is the cause of puffiness and low albumin, the reasons for the initial malnutrition can vary but once the poor absorption starts the problems picks up pace and the body deteriorates from feeding on itself – there isn’t a newt but there is a brain, heart and lungs as long as the fingers, toes and remaining peripherals hold out (reminder Buerger’s vasculitis disease [15]).

One lab test can be supported by other labs and observed signs and symptoms of health or weakness. Several studies have found that assessing frailty factors seems more correlated with a variety of quality of life factors and improved surgical recovery rates than BMI. More than 3 of 5 of the following – unintentional weight loss, weakness, self-reported poor energy, slow walking speed, and low physical activity  was found associated with risks of falls and fractures. Hand grip strength, and calf muscle to fat area, mid arm circumference, sarcopenia were mentioned as measurements of improved muscle mass with improved health status. Sit ups and leg lifts or just a walk in the woods – better muscle mass is associated with longer life.

Based on the sensitivity of the autoimmune gut and my review of kwashiorkor research, I would surmise that a gluten free, lactose free, low calcium to magnesium ratio with an increase in glucosamine and other essential sugars (super starches) and plenty of B vitamins, C, A, zinc, selenium might help the catabolic patient with edema. We need to provide building blocks that readily make a strong glycocalcyx to reduce the leakiness of the intestinal lining.

I am glad that Prime Healthcare has had to stand up for malnourished patient’s rights – the right to a diagnosis that is accurate. An albumin of 7 or 8 is tragic and just because it is from excessive dilution due to malabsorption/mal-retention and not due to lack of protein in the diet – doesn’t mean it isn’t leading to cell starvation. Just because we don’t quite understand edematous malnutrition and don’t seem to know how to stop it, doesn’t mean that it doesn’t exist and isn’t killing people in a very costly and agonizingly slow way.

Names matter and the tropics and kwashiorkor is simply where the problem was studied most. Edematous malnutrition is a better name for the condition in my opinion than protein calorie malnutrition. Over the long term edema means that the cells aren’t being well fed or well detoxified. During edema the movement of fluid is reduced and the movement of nutrients and toxins is slowed. Over the long term edema leads to dysfunction and malnourishment. If the fluid in our toilets backed up regularly we would expect the plumber to repair it not just measure the dysfunction. Puffy abdomen and ankles = overflowing waste = better call a doctor on the Prime Healthcare team in case malnutrition is involved (and remember to ask for a referral to a Registered Dietitian); maybe repair is still in the future but recognition is at least a first step.

Kwashiorkor occurs on the same diet as marasmus malnutrition but the children have different metabolic reactions. Recent infection may be associated with the kwashiorkor susceptible population. Their intestinal lining lacked glucosamine and excess fluid movement both directions was the result. An enzyme deficiency for the conversion of glucose or galactose into glucosamine seemed to be a significant difference between the two groups of children and aldosterone levels were also abnormal in the kwashiorkor children but not the maramus group. Edematous malnutrition exists outside of the tropics.
Glucosamine supplements may be crucial for heart disease and other leaky membrane problems (dementia). Zinc and selenium are low in heart disease and B6 and all of the B vitamins are essential for cell growth and energy demands. Vitamin C is also depleted rapidly. Our “health supplement shakes” and complete feeding formulas are not based on ratios that the critically ill can tolerate – they are more harmful than helpful. We need research and development of an isotonic formula with high levels of beneficial nutrients and low levels of a few things that add to the body burden .

In the meantime more magnesium, B complex, zinc, selenium, iodine, glucosamine, taurine, vitamin C, and beta carotene rich dark green and deep orange fruit and vegetables may be helpful to the chronically ill and obese. Mushrooms, aloe vera, fenugreek, slippery elm powder and ginger also have essential sugars – super fiber for building a strong glycocalyx. The intestinal lining is an organ that protects and nourishes our bodies for miles – literally – do we want junk food littering the way or a strong yet fluid, free-form matrix of super starches, trace mineral ions lighting up the place and plenty of strong white blood cells patrolling for trouble.  Cancer wouldn’t stand a chance – or at least reduced chance.

***11-7-11 BTW I figured out what’s happening with the leaky membrane problem – its complicated – call me or read the [bazillion words, “Cantaloupe, listeria, and sea squirts, oh my,” Oct. 5, 2011]

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 /Disclosure: This information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes./
  1. Olubukola O. Nafiu et al., “The Association of Body Mass Index to Postoperative Outcomes in Elderly Vascular Surgery Patients: A Reverse J-Curve Phenomenon,” Anesthesia & Analgesia 112, no. 1 (January 1, 2011): 23 -29.
  2. Ian M Chapman, “Obesity paradox during aging,” Interdisciplinary Topics in Gerontology 37 (2010): 20-36.
  3. S L Miller and R R Wolfe, “The danger of weight loss in the elderly,” The Journal of Nutrition, Health & Aging 12, no. 7 (September 2008): 487-491.
  4. Ian Janssen, “Morbidity and mortality risk associated with an overweight BMI in older men and women,” Obesity (Silver Spring, Md.) 15, no. 7 (July 2007): 1827-1840.
  5. Kristine E. Ensrud et al., “Frailty and Risk of Falls, Fracture, and Mortality in Older Women: The Study of Osteoporotic Fractures,” The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62, no. 7 (July 1, 2007): 744 -751.
  6. Meei-Fang Lou et al., “Nutritional status and health outcomes for older people with dementia living in institutions,” Journal of Advanced Nursing 60, no. 5 (December 2007): 470-477.
  7. Yi-Chia Huang et al., “Nutritional Status of Functionally Dependent and Nonfunctionally Dependent Elderly in Taiwan,” J Am Coll Nutr 20, no. 2 (April 1, 2001): 135-142.  (free article)
  8. Matteo Cesari et al., “Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study,” The American journal of clinical nutrition 83, no. 5 (May 2006): 1142-1148.  (free article)
  9. H K Vincent, K R Vincent, and K M Lamb, “Obesity and mobility disability in the older adult,” Obesity Reviews: An Official Journal of the International Association for the Study of Obesity 11, no. 8 (August 2010): 568-579.
  10. Heppenstall, et al, “Frailty: dominos or deliberation?,” N Z Med J. 2009 Jul 24;122(1299):42-53. http://www.nzma.org.nz/journal/122-1299/3710/.
  11. Fred Chau-Yang Ko, “The clinical care of frail, older adults,” Clinics in Geriatric Medicine 27, no. 1 (February 2011): 89-100.
  12. Stephane M Schneider et al., “Lack of adaptation to severe malnutrition in elderly patients,” Clinical Nutrition (Edinburgh, Scotland) 21, no. 6 (December 2002): 499-504.
  13. Lilian Liang et al., “Nutritional issues in older adults with wounds in a clinical setting” 1: 63-71.
  14. McElroy, Mark, Tarot of the Celtic Fairies, artwork by Eldar Minibaev, (2010, Lo Scarabeo, Via Cigna 110 – 10155 – Torino- Italy _www.loscarabeo.com_ (I hope this will be viewed as a brief extract and recommendation rather than copyright infringement.  I find Tarot cards a meditative cognitive therapy aid – solitaire for the brain.)
  15. http://www.hopkinsvasculitis.org/types-vasculitis/buergers-disease/ ***I discussed it in my article Vasculitis – Withering from Within.The main cause of this type is smoking and the best treatment is to quit smoking. Smoking depletes oxygen and antioxidants and magnesium – malnourishment from within – second best to quitting smoking would be of course to replenish with extra vitamin C and magnesium supplements and foods and some oxygen would help also vitamin A foods – supplements have not been helpful but the food has helped . . . carrots, peaches, sweet potatoes, tomatoes, broccoli and V8, mangos, apricots and cantalope.
  16. http://www.rd411.com/index.php?option=com_content&view=article&id=393:albumin-as-an-indicator-of-nutritional-status&catid=105:professional-refreshers&Itemid=400
  17. see my previous blogs Angelina please don’t risk the knife, and We are what we eat, for more Bibliography on kwashiorkor, insects and perimenopause.
  18. see my previous blogs on the glycocalyx and Electrolytes R Us, for more on leaky membranes and hydration.
  19. http://www.highbeam.com/doc/1G1-250812435.html . “Prime Healthcare Services Review of State Health Data Confirms Normal Malnutrition Rates Among Its Medicare Patients; Recent Studies Debunked.(Clinical report).” PR Newswire. PR Newswire Association LLC. 2011. HighBeam Research. 9 Apr. 2011 http://www.highbeam.com.

From a different list of reading:
7. Yi-Chia Huang et al., “Nutritional Status of Functionally Dependent and Nonfunctionally Dependent Elderly in Taiwan,” J Am Coll Nutr 20, no. 2 (April 1, 2001): 135-142.  (free article)

Excerpt from Conclusions section:
“There were approximately 36% of functionally dependent subjects who consumed energy less than 75% of the Taiwan RDNA in our study. The elderly with functional dependence might have more difficulties in accessing food. However, we could not find an association between energy intake and functional status. This might be due to large variations of energy intake among individuals ranging from 573.9 to 3191.9 kcal/day.
Consistent with Payette and Gray-Donald [24], the elderly had sufficient mean protein intake, but these authors’ association between protein intake and serum albumin concentration was not found. Morgan et al. [6], however, indicated a positive relationship between protein intake and serum albumin concentrations. It is worth noting that the association was valid only up to protein intake of 55 g/day. Since our subjects had a varied protein intake ranging from 23 g/day to 122 g/day and half of the subjects had a protein intake .55 g/day, the dietary protein intake might no longer have an effect on serum albumin concentration. Another possibility was that chronic conditions play a determinant role in affecting the albumin concentration.”

***Note on vitamin D – The chronically ill may have depressed 25-D levels because they have elevated 1,25 D levels resulting in more than enough of the active hormone for preventing fractures even though the vitamin level seems insufficient for the average person.

The enzyme to activate the vitamin to the steroidal hormone is made by white blood cells as part of the stress/inflammation response and in some cancer cell strains. An active D level above 45 means the bones are losing calcium stores. My five year 1,25-D average, while actively avoiding vitamin D foods, supplements and much time in the sun, was 59 pg/ml and my five year average 25-D was 20 ng/ml. The range was 51-71 pg/ml, 1-25-D and 8.0-26.7 ng/ml for 25D. Ex: 3-31-2009 25-D of 9.0 and 1-25D of 53 pg/ml. If I spend a day on the beach I am hurting two days later from the calcium that is drawn out of the bones – muscle spasms, fatigue and irritability symptoms primarily for me but ringing in the ears and a twitching eyelid have been reduced with magnesium. B vitamins and zinc tend to be involved to – magnesium rich foods would provide those as well as iron and iodine only if it was grown in iodine rich soil.

Kwashiorkor Bibliography

  1. http://www.ajcn.org/content/89/2/592.long ***Reduced production of sulfated glycosaminoglycans occurs in Zambian  children with kwashiorkor but not marasmus also good –
  2.  http://www.icmr.nic.in/ijmr/2009/November/1128.pdf  Tahmeed Ahmed, Sabuktagin Rahman and Alejandro Cravioto, Oedematous malnutrition,  Indian J Med Res 130, November 2009, pp 651-654
  3.  http://www.pe.com/localnews/stories/PE_News_Local_D_malnutrition20.27e2afa.htmlWilliams, L., Jewett, C., and Doi, S. K., Hospital chain, under scrutiny, reports rare illness (The Press Enterprise Local News)
  4. http://www.pe.com/localnews/opinion/editorials/stories/PE_OpEd_Opinion_D_op_27_ed_primehealth.1816fbc.html  Shady billing? (The Press Enterprise)
  5. http://www.sacbee.com/2011/02/20/v-print/3414850/medicare-billed-for-exotic-illness.html
  6. Prime Healthcare Should Be Denied New Hospital Licenses Until Federal, State Investigations into Extraordinarily High Septicemia, Malnutrition Rates and Risk to Patients are Complete.Business Wire. Business Wire. 2011. HighBeam Research.
  7. http://online.wsj.com/article/SB10001424052748703293204576106072340020728.html  Marcel Dicke, Arnold Van Huis are professors of entomology at Wageningen University in the Netherlands.  (2-19-11, The Wall Street Journal, pC3)  The Six-Legged Meat of the Future
  8. http://onlinelibrary.wiley.com/doi/10.1111/j.1525-139X.2010.00705.x/abstractEffect of Diabetes Mellitus on Protein–Energy Wasting and Protein Wasting in End-Stage Renal Disease, Nazanin Noori1, Joel D. Kopple1,2Article first  published online:13 APR 2010DOI: 10.1111/j.1525-139X.2010.00705.x
  9. http://www.ncbi.nlm.nih.gov/pubmed/19121473  Semin Nephrol. 2009 Jan;29(1):39-49. Causes and prevention of protein-energy wasting in chronic kidney failure. Dukkipati R, Kopple JD. Division of Nephrology and Hypertension, Los Angeles Biomedical  Research Institute at Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
  10. http://www.ncbi.nlm.nih.gov/pubmed/19121477 Semin Nephrol. 2009 Jan;29(1):75-84. Nutrition support for the chronically wasted or acutely catabolic chronic kidney disease patient.Ikizler  TA.Department of Medicine, Division of Nephrology, Vanderbilt University School of  Medicine,Nashville, TN 37232-2372, USA.
11. http://www.ncbi.nlm.nih.gov/pubmed/16129200Am J Kidney Dis. 2005 Sep;46(3):387-405. Multinutrient oral  supplements and tube feeding in maintenance dialysis: a systematic review and meta-  analysis. StrattonRJ, Bircher G, Fouque D, Stenvinkel P, de Mutsert R, Engfer M, Elia  M.Instituteof Human Nutrition, University of Southampton, UK.

12.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2891019/?tool=pubmed New Insights into the Role of Anabolic Interventions in Dialysis Patients with Protein Energy Wasting Jie Dong and T. Alp Ikizler1 Curr Opin Nephrol Hypertens. Curr Opin Nephrol Hypertens. 2009 November; 18(6): 469–475.doi: 10.1097/MNH.0b013e3283 31489d.

 “Economic Implications of Nutritional interventions It is also important to assess the impact of nutritional supplements not only in terms of changes in nutritional parameters, but to extrapolate these observations to potential improvements in hospitalization, mortality, and cost-effectiveness. In a recent study, Lacson et al showed that a hypothetical increase in serum albumin concentration in the order of 2 g/L in 50%  of the United States dialysis population would be associated with  projections of approximately 1400 lives saved, approximately 6000 hospitalizations  averted, and approximately $36 million in Medicare cost savings resulting  from a reduction of approximately 20,000 hospital days over one year[68]. This is a reasonable estimation since 2 g/L increase in serum albumin is the average improvement reported in most nutritional intervention studies.”

***The above paper is suggesting that giving them growth hormones  and other anabolic steroids along with protein will help them to stop catabolizing and start building albumin. They have had success with the strategy, but wouldn’t magnesium plus protein (ideally combined within the same magnesium foods) be cheaper than hormones and protein?